**6. Shock wave and wound healing**

Although UV protection and antisolars are commonly advised during and after wound healing, it is possible that UV also affects the melanocyte redistribution and prevents the

It has been shown that UVC light *per se* could stimulate wound healing. UVC light enhances fibronectin and growth factors release leading to increase healing cascade and wound contraction [34, 35]. UV can promote endothelial cell proliferation [36] and augment epidermal thickness and reepithelialization or desquamation of the leading edge of periulcer epidermal

UVC (200–280 nm) has a significant antimicrobial effect and can be used as efficient bactericide agent for treatment of acute wound infections and killing pathogens without undesirable injury to host tissue. UVB (280–315 nm) irradiation to the wound has wound healing stimu‐ lating effect and extracorporeal UVB irradiation of blood adds immune system stimulating effects too. Although UVA (315–400 nm) has specific effects on cell biologic events, it has not

An interesting study compared the efficacy of phototherapy on wound healing in rats under the normal and high‐fat diets and revealed increased wound healing by regulating oxidative stress in rats with metabolic disorders under a high‐fat diet [37]. The efficacy of UV therapy on pressure ulcer is not clear due to eventual bias and limited number of trials available for consideration. Further research is recommended to determine possible benefit or drawbacks

While low level laser (or light) and photodynamic therapy both have considerable applications in wound care, but penetration of UV light into tissues and its efficacy is restricted. UVC and UVB can damage DNA in host cells and chronic exposure to UV can be carcinogenic. Accord‐ ingly, additional study of cellular signaling that occurs after UV exposure of tissue is needed

to better indicate the risk and benefits of UV irradiation in wound healing.

**•** Immobility or inability to stand unassisted for 10 min or longer

**•** Past excessive exposure to natural sun light or phototherapy

**•** Very fair skin (skin type 1 and 2, especially PUVA)

normal cutaneous response to injury [33].

366 Wound Healing - New insights into Ancient Challenges

yet been extensively applied to wound treatment [31].

cells [31].

of this treatment [38].

**•** Childhood

**5.1. Contraindication of phototherapy**

**•** Pregnancy and breastfeeding (PUVA)

**•** Immunosuppressive medication

**•** Photosensitizing creams or medications

**•** Past skin cancer, especially melanoma [39]

Although hearing extracorporal shock wave brings the treatment of urinary stones in the mind [40–43] but it also has some benefits in the treatment of acute and chronic wounds [44]. Shock waves are biphasic high‐energy acoustic waves that can be produced by electrohy‐ draulics. Although the exact mechanisms of shock wave therapy are not entirely elucidated, it may harbor eventual immunomedulatory effects, acting by transient micromechanical forces in altering various biologic activities. Shock wave therapy increased expression of macromo‐ lecules in wound healing such as VEGF, proliferating cell nuclear antigen, and endothelial nitric oxide synthesis. Because of the considerable experience in using shock wave in the treatment of urolithiasis and other conditions in humans, it appears to be a safe technology. The clinical effect of this technology in various wound types and the particular mechanisms of action are now beginning to be understood. Shock waves may also stimulate sensory nerve fibers and decrease pain. Clinical studies of shock wave therapy in wound healing suggest that many factors such as wound cause, size, and duration may impact response to shock wave therapy. However, the actual administration of shock wave therapy in current clinical studies varies in type (unfocused versus focused). Primary studies suggest that unfocused shock wave therapy is more effective than focused one in the treatment of superficial soft tissue defects yet, without direct comparison between unfocused and focused shock wave therapy in clinical trials to date [33]. Importantly, additional basic science studies along with randomized controlled trials will be necessary to determine the optimal shock wave therapy settings. Currently, the U.S. Food and Drug Administration has approved devices that administer shock wave therapy for the treatment of plantar fasciitis and lateral epicondylitis. Application of such devices for treatment of acute and chronic wounds has not been approved yet. We look forward to future innovation in this field to find out the accurate mechanisms of action and optimal treatment of specific wound types.

### **6.1. Contraindications**

### *6.1.1. Absolute*

Lungs: Treatments must not be performed across or directed to the lungs and heart.

Eyes: Tissue of the eye could be adversely affected by shock wave.

Brain: The destructive forces seen at transitions could damage and destroy brain matter.

Major blood vessels: Both the major blood vessels in the neck and thigh should be avoided to prevent damage and potential catastrophic bleeding.

Major nerves: Superficial major nerves like the brachial plexus, ulna/radial nerve should not be treated directly (treatment around these areas is acceptable just not directly to the nerve).

Open wounds/postsurgical wounds with or without stabilization (glue, stitches, steristrips): Shock wave damages tissues and local circulation. This could lead to degradation of the wound, further bleeding, and delayed healing.

Implanted devices or hormones.

Epiphysis: Open growth plates could potentially be damaged by shock wave either by using settings that create more growth and close them too quickly or by using settings that delay growth.

*6.1.2. Relative*

Genitals; pregnancy; clotting disorders/anticoagulants; joint replacements, certain settings have been used to loosen previously implanted joints ready for a new implant; infection; and cancer.

Corticosteroid injection: Generally people recommend waiting 1 month before application [45].
