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14 Latest Applications ofNegative Pressure Wound Therapy
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14.2.2 Fat Grafting andNPTW
Regarding NPWT’s new therapeutic lines, it
could be employed with fat grafting to create a
synergistic interaction of regenerative cells and
improve the quality of the underlying tissue. Fat
grafting is a simple and increasingly widespread
technique, with low morbidity and high availability for thickening tissues.
The combination of both techniques according to an animal study [35] could increase the
granulation tissue formation and improve neoangiogenesis. However, so far there is not much literature available on the subject, just animal
studies [35] and clinical reports [36].
New lines of management are being developed as NPWT instillation even though further
studies with a vast number of patients and longterm follow-up are necessary. More studies with
a larger number of patients are required to validate these applications, but the current results are
encouraging.
14.3 Conclusions
NPWT wound dressing is nowadays the standard
of care in complex wounds.
NPWT is a safe, well-tolerated treatment that
has demonstrated clinical benets to reduce the
risk of infection and accelerate the wound healing process. It represented a change in paradigm
in the wound’s treatment improving the quality of
life of patients and reducing the long-term cost
for the health system. Prophylactic use of NPWT
is still not a standard procedure, but its early
results look promising to avoid complications.
No doubt more indications will appear in the near
future to take advantage of the benets offered by
NPWT.
References
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McGuirt W. Vacuum-assisted closure: a new
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2. Gomez TW, Gomez JW, Gopal R. Clinical applications and benets of using closed-incision negative
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closure (VAC)/negative pressure wound therapy
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jcot.2019.06.015.
5. Xia C, Yu A, Qi B, Zhou M, Li Z, Wang W.Analysis
of blood ow and local expression of angiogenesisassociated growth factors in infected wounds treated
with negative pressure wound therapy. Mol Med Rep.
2014;9(5):1749–54.
6. Banwell P, Teot L.Topical negative pressure (TNP):
the evolution of a novel wound therapy. J Wound
Care. 2003;12(1):22–8.
7. Huang C, Leavitt T, Bayer L, Orgill D.Effect of negative pressure wound therapy on wound healing. Curr
Probl Surg. 2014;51(7):301–31.
8. Kloth L. 5 questions and answers about negative
pressure wound therapy. Adv Skin Wound Care.
2002;15:226–9.
9. Desai KK, Hahn E, Pulikkotill B, Lee E. Negative
pressure wound therapy. An Algorithm Clin Plast
Surg. 2012;39(3):311–24. https://doi.org/10.1016/j.
cps.2012.05.002.
10. Armstrong D, Boulton A, Bus S. Diabetic foot
ulcers and their recurrence. N Engl J Med.
2017;376(24):2367–75. https://doi.org/10.1056/
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11. Lipsky B, Berendt A, Cornia P, Pile J, Peters E,
Armstrong D.Infectious Diseases Society of America
clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis.
2012;54(12):e132–73.
12. Isaac A, Armstrong D. Negative pressure wound
therapy and other new therapies for diabetic foot
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mcna.2013.03.015; Epub 2013 May 4.
13. Ji S, Liu X, Huang J, Bao J, Chen Z, Han C, et al.
Consensus on the application of negative pressure wound therapy of diabetic foot wounds. Burns
Trauma. 2021;9(3002):tkab018.
14. Lavery L, Murdoch D, Kim P, Fontaine J, Thakral G,
Davis K.Negative pressure wound therapy with low
pressure and gauze dressings to treat diabetic foot
wounds. J Diabetes Sci Technol. 2014;8(2):346–9.
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15. Lee K, Ben-Nakhi M, Park E, Hong J.Cyclic negative pressure wound therapy: an alternative mode to
intermittent system. Int Wound J. 2015;12(6):686–92.
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16. Randall K, Booth B, Miller A, Russell C, Laughlin
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combination with vacuum-assisted closure therapy for
treatment of a diabetic foot wound. J Foot Ankle Surg.
2008;47(5):430–3.
17. Chiummariello S, Del Torto G, Iera M, Arleo S,
Alfano C. Negative pressure dressing in splitthickness skin grafts: experience with an alternative method. Wounds. 2013;25(11):324–7; pmid:
25867632.
18. Rys P, Borys S, Hohendorff J, Zapala A, Witek P,
Monica M, etal. NPWT in diabetic foot wounds—a
systematic review and meta-analysis of observational
studies. Endocrine. 2020;68(1):44–55. https://doi.
org/10.1007/s12020- 019- 02164- 9.
19. Driver VR, Blume PA.Evaluation of wound care and
health-care use costs in patients with diabetic foot
ulcers treated with negative pressure wound therapy
versus advanced moist wound therapy. J Am Podiatr
Med Assoc. 2014;104(2):147–53.
20. Wurtzer P, Winter R, Stemmer S, Lumenta D. Risk
factors for recurrence of pressure ulcers after
defect reconstruction. Wound Repair Regen.
2018;26(1):664–8.
21. Papp AA.Incisional negative pressure therapy reduces
complications and costs in pressure ulcer reconstruction. Int Wound J. 2019;16:394–400.
22. Madden JJ, Hoffman AN, Kim JS, Thayer WP,
Nanney LB.Flap reconstruction for pressure ulcers:
an outcomes analysis. Plast Reconstr Surg Glob
Open. 2017;5(1):1–8. https://doi.org/10.1097/
GOX.0000000000001187.
23. Boissiere F, Gandol S, Riot S, Kerfant N, Jenzeri
A, Hendriks S, etal. Flap venous congestion and salvage techniques: a systematic literature review. Plast
Reconstr Surg Glob Open. 2021;9(1):e3327.
24. Yu P, Yu N, Yang X, Jin X, Lu H, Qi Z.Clinical efcacy and safety of negative-pressure wound therapy
on aps: a systematic review. J Reconstr Microsurg.
2017;33(5):358–66.
25. Kim TH, Park JH.A novel negative pressure wound
therapy (NPWT) monitoring system for postoperative ap management. Medicine (Baltimore).
2021;100(44):e27671.
26. Number of surgical procedures (per 100,000 population). Lancet Commission on Global Surgery. [cited
2022 Jun 13]. data.worldbank.org/indicator/SH.SGR.
PROC.P5.
27. Blackham AU, Farrah JP, Mccoy TP, etal. Prevention
of surgical site infections in high-risk patients
with laparotomy incisions using negative-pressure
therapy. Am J Surg. 2013;205(6):647. https://doi.
org/10.1016/j.amjsurg.2012.06.007.
28. Emori T, Gaynes R. An overview of nosocomial
infections, including the role of the microbiology
laboratory. Clin Microbiol Rev. 1993;6:428–42.
29. Webster J, Liu Z, Norman G, Jc D, Chiverton L, Scu
P, etal. Negative pressure wound therapy for surgical wounds healing by primary closure (review).
Cochrane Database Syst Rev. 2019;3:151. https://doi.
org/10.1002/14651858.CD009261.pub4/full/es.
30. Sahebally SM, McKevitt K, Stephens I, Fitzpatrick
F, Deasy J, Burke JP, etal. Negative pressure wound
therapy for closed laparotomy incisions in general
and colorectal surgery: a systematic review and metaanalysis. JAMA Surg. 2018;153(11):1–9.
31. Tuuli MG, Liu J, Tita ATN, Longo S, Trudell A,
Carter EB, etal. Effect of prophylactic negative pressure wound therapy vs standard wound dressing on
surgical-site infection in obese women after cesarean delivery: a randomized clinical trial. JAMA.
2020;324(12):1180–9.
32. Antognoli LE, Singh DP, Choudhry S, Turcotte J,
Holton LH.Rinse but don’t repeat: single application
V.A.C.VERAFLO salvages infected breast prostheses.
Plast Reconstr Surg Glob Open. 2021;9(10):e3896.
33. Meybodi F, Sedaghat N, Elder E, French J, Adams
K, Hsu J, etal. Salvaging the unsalvageable: negative
pressure wound therapy for severe infection of prosthetic breast reconstruction. Plast Reconstr Surg Glob
Open. 2021;9:1–6.
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J, Liao EC, Cetrulo CL, et al. Infection following
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success. Plast Reconstr Surg. 2013;131(6):1223–30.
35. Kao H, Hsu H, Chuang W, Chang K, Chen B, Guo
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2015;102:998–1005.
36. Moreira G, De Souza C, Camargos C, Amorim B,
Esteban C, Ii AV, et al. Fat grafting associated with
negative pressure wound therapy. Acta Cir Bras.
2019;34(9):9–11.

Electrical Stimulation inWound
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Care
EliaRicci
15
The denition of electrostimulation (ESTIM) in
wound care is given by Kloth [1]: It is an adjunctive therapy designed to deliver low levels of
electrical current to tissues in and around the
open wound. Electrostimulation is not only of
modern times; the rst report is attributed to
Scribonius Largus in 63AD [2], where he used
electric rays (Torpedo marmorata) and rays
(Rajiformes) for the treatment of headache and
non-healing ulcers. From this derives the term
“torpid ulcers.” From the rst observations of
electricity in living beings with the experiment
on frogs by Luigi Galvagni in 1790, an era of
research began. In the rst half of the 1800s with
the neurophysiology studies of Dubois-Reymond
[3], the understanding of electrical nerve transmission began, especially through the determination of the induced tetanus contraction. In 1834,
the same author reports to have found a perilesional current of less than 1 mA. In 1885,
Guillame Duchenne published how alternating
currents induce effective muscle contractions and
theorized their use in paralysis. Since then, the
diffusion in the medical eld of treatment and
registration systems, just think of ECG, EMG,
etc., has found enormous development.
Today, electrostimulation is widely used,
mainly in rehabilitation, and it has a very high
E. Ricci (*)
Difcult Wound Healing Unit, Policlinico di Monza,
Vercelli, Italia, Italy
level of evidence in terms of EBM in the vulnological eld (Table15.1), but its use is still limited in common clinical practice. Houghton in
2017, [4] after an extensive review of the available studies, points out that there is a strong,
well-constructed literature in favor of ESTIM,
while the works that express doubts would be of
a lower quality level; he also underlines how, in
the diabetic foot, there is a scarcity of literature.
There are some confounding factors: First,
there are different types of current that lead to
different types of treatment, they are often small
producers who have little means to penetrate the
market, and nally, the so-called addition therapies require an extended cultural growth at the
base.
Table 15.2 [5] highlights different types of
current; the lack of knowledge on different types
of currents already leads to a confusion in the
learning phase and therapeutic decision.
Figure15.1 graphically shows the different types
of current. Obviously, different types of electric
current through the methods of administration
lead to different types of treatment. Collins [6]
denes the different types of treatment; the proposed classication is reported in Table 15.3.
Unfortunately, this attempt at rationalization has
not been reected in the literature, and the current works often generate further confusion.
The activities of ESTIM at the cellular and
ultrastructural level, described in the literature,
are multiple: increase of chemotaxis, VEGF,
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_15
155

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ELECTRICAL CURRENTS
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Table 15.1 ESTIM evidence in wound care
Year Society Pathology EBM
2000 Consortium for spinal cord medicine Decubitus A
2005 AAWC Lower limb 1
2006 Wound healing society (USA) Decubitus 1
2006 Wound healing society (USA) Lower limb 1
2006 Wound healing society (USA) Arterial ulcers 2
2006 Wound healing society (USA) Diabetic foot 1
2006 AMWT (GER) Lower limb 1b
2007 RNAO (Canada) Decubitus A
2014 NPUAP-EPUAP-PPPIA Decubitus A
Table 15.2 Various types of currents (Taradaj modied) modied
Current Wave Energy
Pulsed Monophasic
Biphasic Symmetrical
Asymmetrical Balanced
Unbalanced
Alternated Symmetrical
Asymmetrical Balanced
Unbalanced
Direct
E. Ricci
Fig. 15.1 Different
types of current
Volts
blood ow, granulation tissue, macrophage and
broblast activity, wound contraction through an
improvement of myobroblasts, and muscle tone.
There is also a reduction in pain and bacterial
growth. All these activities, the cause of which is
not clearly dened, would derive from the administration of energy at the local level.
The concept of the presence of electrical
activity in the eld of skin lesions has been
known since Galvagni’s studies; the skin is
formed by the epidermal layer, which has a negative electric charge, and the dermis that has a
positive electric charge. A skin lesion puts the
DC AC
two different charges in contact and therefore
can develop a sort of battery with direct current
emission; this is able to originate a signal perceived at a systemic level [7]. Studies now dated
[8–10] have shown this activity and have shown
that, in case of chronicity, the electrical signal is
reduced [11]. Therefore, we can conclude that
the electrical component is present at the local
level of wound, not veried but certainly possible eld of study, is the role of advanced dressings in maintaining electrolytes and therefore
ionic charges at the local level, compared to
drying.
Stochastic (random)
Time

15 Electrical Stimulation inWound Care
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Table 15.3 Different types of ESTIM from Collins modied
Type Acronyms Features
Low-Intensity Direct Current LIDC Low voltages and low current producing a
monophasic waveform
Low-Intensity Pulsed Direct
Current
High-Voltage Pulsed Current HVPC High voltages producing a pulsed
Decubitus Direct Current
Treatment
Simulated Biphasic ES SSES Synthesized biphasic square waveform
Asymmetric Biphasic Electrical
Stimulation
Symmetric Biphasic Electrical
Stimulation
Frequency Rhythmic Electrical
Modulation System
Table 15.4 ESTIM treatment systems found in the literature
Type Acronyms Devices
Low-Intensity Direct Current LIDC PosiFect RD™ DC device (BioFisica)
Low-Intensity Pulsed Direct Current LIDPC UltraStim (north coast)
High-Voltage Pulsed Current HVPC Multifunction devices (Gymna, EMS
Decubitus Direct Current Treatment DDTC BST (LifeWave)
Simulated Biphasic ES SSES Bioactive experimental dressing
Asymmetric Biphasic Electrical
Stimulation
Symmetric Biphasic Electrical
Stimulation
Frequency Rhythmic Electrical
Modulation System
LIDPC Low voltages and low current producing a
pulsed waveform
waveform consisting of pairs of short
pulses separated by long intervals
DDTC Application of a wave form that had been
processed from electrical activity
previously observed and measured around
healing wounds
USELESS Asymmetric biphasic square waveform
result of programmed selection by
clinicians
SBES Symmetric biphasic square waveform
result of programmed selection by
clinicians
FORWARD Producing negative square wave pulses
preset to the maximum value of patient
sensitivity
Wound EL (WoundEL health care)
physio, Chattanooga HPV)
USELESS ABES PosiFect RD (BioFisica)
SBES
FORWARD FREMS (FremsLife)
157
Electrostimulation takes place through the
placement of two electrodes that can be near the
lesion or in contact with it. Connected through
connectors or wireless to the source, they emit
well-dened and preset signals with the different
modes mentioned above: continuous, pulsed or
alternating, and stochastic. An old Israeli engineer friend, Michel Afargan, described the different ways of applying ESTIM as the different
chords we can nd with music, each with different but still perceptible effects. The electric current is obviously determined by a ux of
electrons; these move through the electrodes
(positive ions move toward the cathode, and negative ions move toward the anode) [12]. Sun
reports that different materials and electrode
shapes can affect the therapeutic effect [13].
Recommended in the guidelines of many scientic associations [14–19], it refers to ESTIM in
general.
For educational purposes, we will distinguish
ESTIM into three large groups: treatments based
on direct currents, treatments based on alternating or pulsed currents, and treatments based on
stochastic currents. We will use the classication
dened by Collins for this purpose [6]. Table15.4

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E. Ricci
shows some of the devices available for electrostimulation; it is certainly incomplete, but the
data are not easily available.
15.1 Direct Currents
15.1.1 Low-Intensity Direct Current
(LIDC)
These are microcurrents that simulate the socalled “Galvagni skin battery” and vary between
75 and 800μA [20]. A group of Greek researchers [21] places the maximum effectiveness
between 200 and 800μA and nds no difference
between continuous and pulsed currents.
According to Ismiarto [22], LIDCs act through
the activation of broblasts and the increase of
growth factors, thus having a local effect on the
lesion and surrounding tissues.
15.2 Alternating andPulsed
Currents
the wound bed and reverse the poles to promote
the development of granulation tissue by attracting positively charged broblasts. In the nal
stage, apply the positive pole on the ulcer to
attract the epidermal cells with negative charge
[25]. Goldman has demonstrated an increase in
TpCO2 with HPVC [26]; this would be determined by a mixed effect of vasodilation and neoangiogenesis. In support, Burdge reports a
reduction in amputations and a distalization of
the level [27].
15.2.3 Simulated Biphasic ES (SSES)
The synthesis of this type of ESTIM can be found
in a review by Martinez-Rodriguez [28]; ten
RCTs are analyzed that demonstrate an efcacy
of this type of ES in the treatment of decubitus,
diabetic foot, lower limb ulcers, and surgical
aps. Signicant data were found in ve out of
ten studies and with positive trends in a further
four.
15.2.1 Low-Intensity Pulsed Direct
Current (LIPDC)
Microcurrents (300 to 600 μA) are used, transmitted in pulsed mode directly to the wound bed.
Wood, in a now-dated RCT, reports a statistical
signicance (P < 0.0001) in the treatment of
pressure injuries versus placebo [23].
15.2.2 High-Voltage Pulsed Current
(HVPC)
This type of current, together with the direct currents, is the one most studied by Kloth; his studies have shown a correlation between the
positioning of anode and cathode and the migration of specic cell types in the healing process
[24]. In fact, it proposes to position the positive
pole on the lesion to attract negatively charged
cells (neutrophils and macrophages) to cleanse
15.2.4 Asymmetric Biphasic
Electrical Stimulation
This type of therapy takes place through small
systems that are generally wearable by the
patient. Asra [29] reports a superiority over
direct currents and a greater comfort of therapy.
In a study conducted by Baker [30] in a blind
RCT, statistically signicant healing results were
reported against placebo.
15.2.5 Symmetric Biphasic Electrical
Stimulation (SBES)
Rajendran [31] generally explores ESTIM systems, in particular symmetrical biphasic
stimulation, but does not arrive at conclusive
data, while dening a positive trend.
Even these types of treatment would have a
prevalence of local effects, restoring a situation

15 Electrical Stimulation inWound Care
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159
of acute wound bed through the mechanisms
described in the above activities.
15.3 Stochastic Currents
These currents are asymmetrical as can be seen in
Fig.15.1. The importance of what is dened as
stochastic resonance begins with Collins’ studies
[32]; it is hypothesized that this type of signal
acts as a “noise” disorder, which allows the
spread of nerve signals that, given the minimum
voltage, could not spread normally. Further studies [33, 34] conrmed this assumption. Therefore,
ESTIMs based on stochastic currents would act
as perceived nerve signals at the level of the CNS
[7]. In fact, this could be the famous “neurotrophin” hypothesized by Charcot in the rst half
of the 1800s on pressure injuries.
15.3.1 Decubitus Direct Current
Treatment (DDTC)
The rst studies are due to Adunsky and Ory
showing statistical signicance in pressure injuries in an RCT [35]. The studies conducted by the
present author with Afargan [7, 36] have demonstrated the effective action, not based on local
factors but on the transmission of a systemic signal. Fraccalvieri [37] hypothesizes its use in
long-lasting non-healing lesions. Figure 15.2
shows a clinical case treated with DDTC and
solved in 8weeks.
15.3.2 Frequency Rhythmic Electrical
Modulation System (FREMS)
This type of ESTIM is managed by a programmable computer; it is a system that is mainly used
for the treatment of osteoarticular pathologies in
the psychiatric sector. The activity of FREMS
would be mainly on the vascular compartment
[38, 39]; other authors have used it in the treatment of chronic skin lesions [40, 41] for reparative purposes or for the treatment of pain [42].
At this point, I am certain that I have not dispelled the doubts of the readers, and I would
like to start with an assumption that the ESTIM
in the treatment of chronic skin lesions works. It
is an adjunctive therapy, ancillary, or dene it as
you want, but it is based on solid scientic bases
(Table 15.1), and it is recommended in the
guidelines of numerous scientic associations
[13–18]. It is not a dressing, and therefore, since
this is always necessary, it is sometimes dened
as therapy; in reality, the dressings are not
always deterministic at the level of activation of
the reparative process. Our knowledge at the
ultrastructural level is still limited, but my personal hope is that this type of therapy will nd
the right place in the therapeutic handbook of
chronic skin lesions.
Fig. 15.2 Pressure sores after radiotherapy for neoplastic lesion. Wound aged 5years, healed in 8weeks

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E. Ricci
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Phototherapy inWound Care
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FabrizioMalan
16
The technological evolution of recent years has
brought back a method that is actually quite
ancient: the use of light for therapeutic purposes.
In old times, exposure to sunlight was considered an essential defense to ght diseases and to
maintain a good state of health.
There are different options of treatment with a
light-based therapy:
• Photobiomodulation (PBM): based on a blue
light spectrum (400–430 nm) with low capac-
ity to penetrate the skin, it acts on an endogen
chromophobe (EME group)
• Fluorescence: always based on a blue light
spectrum (400–460 nm) associated with an
exogen chromophobe that works as a photoin-
ductor and photoconverter
• Photodynamic therapy (PDT): based on a red
light spectrum (630 nm) associated with a
photosensitized agent in a gel form, it is able
to reach the deepest layers of the epidermidis
In fact, the bactericidal and virucidal capacity
of sunlight is known; less known is that this effect
is mainly due to the blue component of the visible part of the solar spectrum. The sun’s rays in
the blue region are those that in greatest quantity
reach the earth’s surface, even 10 times higher
than that of UV rays, largely “ltered” by atmo-
F. Malan (*)
Città della Salute, Torino, Italy
e-mail: fmalan@cittadellasalute.to.it
spheric ozone. The germicidal activity of blue
light, corresponding to a wavelength range
between 405 and 470nm, has been the subject of
growing scientic interest in recent years, due to
the current problem of resistance to antibiotics by
numerous bacterial species and the alarming
shortage of new classes of antibiotics available
on the market [1, 2].
Iella Ryberg Finsen was awarded the Nobel
Prize in Medicine in 1903 for demonstrating the
antibacterial capacity and stimulation of healing
of concentrated light rays on wounds.
LASER has brought important advances in the
use of light by dramatically expanding its eld of
application. The use of LASER became a sign of
avant-garde and modernity for many health professionals even beyond the optimal indications.
Another signicant step forward in the use of
light for therapeutic purposes was made with the
introduction of light-emitting diodes (LEDs) as a
light source. LEDs can also allow the emission of
a substantially monochromatic light with therapeutic effects practically superimposable to those
of low-intensity LASERs but with much lower
costs and superior handling.
Since 2014, phototherapy that uses “low
doses” of light for therapeutic purposes was
dened as photobiomodulation by the scientic
community, meaning a use of light that involves a
non-thermal process with endogenous chromophores eliciting photo-physical and photochemical events at various biological scales.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_16
163
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