Climatotherapeutic Treatment of Dermatological Diseases
 
TouristsDead Sea Therapy proved to be of value in treating a number of dermatological, rheumatological and pulmonary diseases, especially psoriasis, atopic dermatitis, vitiligo, psoriatic arthritis, rheumatoid arthritis, osteo-arthritis, and asthma. The first pilot studies were undertaken in 1958, and the remarkably beneficial results reported for psoriasis have been reconfirmed many times over. Now, thousands of people each year seek relief at the Dead Sea for psoriasis and other conditions. 

Articles describing the treatments and their results have been published in both general and specialist scientific journals ( see selected bibliography below), and psoriasis treatment at the Dead Sea is noted in many major dermatological text books and monographs. That the treatment is effective is now beyond doubt. What factors are involved, and the role each factor plays in the treatment of the different diseases, is a matter for investigation. The effect of the Dead Sea therapy on certain other pathological states is also being studied. The Dead Sea Medical Research Center is dedicated to the wider investigation of these factors. 

Psoriasis

Psoriatics were the first patients to be successfully treated by climatotherapy at the Dead Sea, and after 20 years they still form the majority of those seeking relief. Climatotherapy as used in this section includes a combination of sun-bathing, in Dead Sea water, and general exposure to the climatic and other factors of the region.
Psoriasis is a recurrent and usually life-long disease characterized by small or large thickened, red scaly patches on the skin. The patches ( "lesions") tend to be symmetrically distributed and sharply outlined. Itching is usually absent or mild, buy is occasionally severe. The first signs often appear after puberty and during early middle age, buy can develop at any time. Psoriasis is not infectious. In most cases there is no associated disturbance of the general health but 5% or more of the sufferers have, or may develop, mild to severe arthritis (psoriatic arthritis)/ The skin condition is sometimes extremely cosmetically, socially and functionally disabling. The disease is a common one and afflicts 1%-3% of the population of many countries (for example, there are at least 6 million psoriatics in the USA). It accounts for a large percentage of visits to dermatological clinics and of the occupancy in dermatological wards.
The cause of psoriasis is unknown, buy the possibility of developing psoriasis seems to be based on a genetic tendency: one or more blood relations frequently, buy not always, have the disease. This genetic tendency permits some internal or external factors to trigger off immunologic of other changes in the body. The so-called "trigger factors" may differ for different individuals and often go undetected. They include streptococcal infections, a hormonal or metabolic disturbance, physical damage to the skin or certain medicaments. Mental stress often seems to play an important role. The skin reacts by a rapid increase in both the number of its superficial cells (epidermal cells) and of its small blood vessels, as well as by an accumulation of inflammatory cells. These changes are responsible for the clinical signs seen on the skin surface, but even the normal-looking skin shares in the underlying disturbance.
Any therapy designed to clear the skin surface of its psoriatic lesions must reverse the underlying reactions. Although many treatments for psoriasis may induce a partial or complete remission, there is as yet no known cure. Treatment may be by local applications to the skin, by systemic (internal) medication, or by a combination of both. Commonly used are ointments containing tar, sulfur or salicylic acids, dithranol (anthralin), vitamin D3 derivatives and strong corticosteroids ("cortisones").
Ultraviolet radiation, from the sun or an artificial source, is often beneficial. UVB irradiation is sometimes combined with local tar ointment ("Goekermann treatment") or with dithranol ointment ("Ingram treatment") 'PUVA' photochemotherapy combines UVA irradiation with taking a drug called psoralen. In many systemic treatments potent medicaments are used which affect the immune system and cell-proliferation mechanisms.
Treatment for four weeks at the Dead Sea gives results as good as those achieved by any of the above-mentioned therapies and has a number of important advantages over many of them. One major advantage is related to the fact that those treatments which involve drug administration or the use of potent "cortisone" ointments may affect not only the skin, but also the liver, kidneys, blood-forming tissues and metabolic processes, or affect a developing fetus. Some treatments increase the risk of developing cancers. Even if effective, many of these treatments are therefore unsuitable for young children. Effects such as these have not been observed with Dead Sea treatment. Since psoriasis itself is not usually associated with damage to internal organs or to the general health, every effort should be made to avoid treatments which might cause such damage.

Psoriasis Treatment Routine & Results

The Dead Sea treatment of psoriasis is based on a gradual increase of sun-exposure, combined with bathing in the Dead Sea and the application of mild ointments to the skin: skin softeners, lubricating preparations (emollients) such as body oils or vaseline, mild ointments to containing tar, sulfur and salicylic acids or other ingredients. "Cortisone" preparations are not used. The treatment routine is decided upon after a medical examination, and is controlled by a physician and nursing staff. The recommended length of treatment is 4 weeks, although shorter periods sometimes give satisfactory results. Over the years a number of articles on the Dead Sea treatment have been published in scientific journals. Dead Sea treatment is noted in many dermatology textbooks. Typical results reported by various authors are given in the table below.
Table 6: Typical Results of Psoriatic Treatment at the Dead Sea
     
     
    		 Avrach & Scherer 1978  Even-Paz & Shani 1991 Seidl & Harari 1993
    Abels & Katan 1995
    No. of patients
    		 2004 1148 2087 1323
    % Clear
    		 30.0 40.5 60.0 58
    % Almost Clear
    		 21.0 31.0 36.0 14
    % Much Improved
    		 38.0 17.0 36.0 16
    % Partly Improved
    		 9.0 10.8 4.0 11.5
    % No Change
    		 1.3 0.3 0.0 0.5
    % Worse 
    		 0.4 0.4 0.0  
     
These assessments were mainly based on the difference in the percentages of skin area involved before and at the end of treatment. Since authors did not always use identical terms to describe grades of clearing, these are slightly modified. Results of a more precise evaluation, using a special Psoriasis Area and Severity Index ("PASI"), which assesses other factors in addition to the area involved, appear in Table 7.
Table 7: Median % Improvement (PASI Score)
     
    Year 
    		 Sun Exp. Time
    No. Patients
    % Imp.
    		 (P) 
    1994
    		 5.5 32 87.0 <0.001
    1995
    		 3.0-6.0 45 89-92  <0.001
    1996
    		 3.0 78 75-86 (0.00002-0.0018)
     

Remissions and Recurrences:

The length of the remission period after treatment at the Dead Sea similar to that after other treatments for psoriasis. Blick and Angster (1992) reported an average remission period of 5.5 months in 71 patients followed up after their return to Germany. Most information comes from patients themselves on their return to the Dead Sea for repeat treatments. Avrach and Scherer (1978) reported an average of 5.6 months remission in 674 patients after their first course of treatment, and of 6.1 months in 190 patients after their second treatment. Two important observations are that recurrent attacks tend to be less severe than those originally treated, and that almost without exception recurrent attacks continue to respond well to Dead Sea treatment. With many other therapies, and especially with the use of potent "cortisones", the recurrent attack is often not only more severe than before but not infrequently becomes resistant to the treatment.

Side-effects of Dead Sea Treatment:

The most important advantage of the Dead Sea effects or complications. These include sunburn and "sun allergy". Although it is possible to get sunburn, this does not usually occur in individuals who follow treatment instructions, because of the weakened UVB radiation. A form of "sun allergy" occurs on non-psoriatic areas in some individuals, but is usually quickly and easily controlled by the use of simple zinc or calamine lotions or a sun-protective cream. Some predisposed patients may develop an irritation of the hair follicles on the legs, but this is also usually easily controlled.
An important consideration when using UV radiation for extended and repeated sessions is the possibility of long-term damage to the skin which might lead to the development of skin cancers. The weakened UV solar radiation at the Dead Sea would suggest that the risk of this is less there than at sea level or higher altitudes. Over the 20 tear period during which many thousands of patients have been treated, no evidence of skin cancer development attributable to this therapy has been reported. This contrasts with clear evidence of an increased development of skin cancers in patients who have received high doses of PUVA treatment. The total dose of UVB radiation received by a 4-weeks` course of treatment at the Dead Sea is comparable with that usually administered by a course of UV radiation using an artificial source. Skin biopsy specimens from patients who had repeated treatments at the Dead Sea have been studied by ordinary light microscopy and by electromicroscopic examinations. Although the results must be considered preliminary, no definite evidence of sun-induced degenerative or pre-cancerous changes were found.

Factors Related to the Success of the Dead Sea Treatment of Psoriasis:

Dead Sea Sun and Dead Sea Water

The successful results of the Dead Sea treatment of psoriasis may be due to a combination of some or all of those factors already outlined in the introductory section. The most important seems to be exposure to the sun`s ultraviolet rays. A recent study, which compared the results of sunbathing only; Dead Sea water-bathing only; or both treatments combined, revealed a significantly greater effect in those who sunbathed. It also suggested that bathing in Dead Sea water, although having by itself only a minor effect, enhanced treatment because of the sun`s rays (Table 8). Solar radiation might act directly on the skin, or indirectly by affecting immunological or other systems.
Table 8: Mean Group PASI Percentage Improvement
     
     Group (#) 
    Treatment
    		 PASI range at the start of treatment Mean % Improvement
    p values
    I (32) Sun+Dead Sea Water
    		 4-35 83.4 % <0.001
    II (34) Sun 4-36 72.8 % <0.001
    III (15) Dead Sea Water
    5-36
    20%
    0.02
     
In a Belgian study, psoriatic patients treated by artificial UV irradiation whilst being showered with water which contained 20% of salts similar to those in the Dead Sea, improved significantly more than did the patients showered with plain water only. Some physicians have reported improvement or clearing of psoriatic lesions after a series of baths in water containing Dead Sea minerals in lower concentrations than are found in the Dead Sea, and without radiation.
 
Laboratory studies have suggested that certain Dead Sea salts may reduce the proliferative rate of rapidly dividing cells. The application of Dead Sea minerals to the non-affected skin of psoriatic patients was reported as having returned their chemical composition, x-ray fluorescence findings, and the electromicroscopic appearance to a more normal state. It is therefore possible that minerals contained in the Dead Sea water may have a beneficial influence on the disease.
A further study considered the question of how much Dead Sea sun is required in the treatment of psoriasis. During July and August 1994, 45 psoriatic volunteers were treated at the Dead Sea for 28 days, using one of three sun-exposure schedules. The mean percentage improvement in the Psoriasis Area and Severity Index (PASI) was as follows (Table 9):
Table 9: Mean PASI Percentage Improvement
     
    Group
    		 Max Sun Exp. % Improvement
    I
    		 3.0 hours 91
    II 4.5 hours 87
    III 6.0 hours 88
     
One year before, 16 of the patients from groups 1 and 2 had received Dead Sea treatment with a daily sun-exposure time of 5.5 hrs; there was no significant difference in the degree of improvement between the two years. It was concluded that for treatment in July and August the daily sun exposure need not exceed 3 hours. 3 hr exposure time to Dead Sea sun was found to be sufficient in most months of the year as shown in Table 10 (with the exception of Nov-Dec period).
Table 10: PASI % Improvement, Month by Month Comparison

Psychological Factors

During the patient's stay at the Dead Sea, psychological factors may have an important influence. Conditions there are very different from those of a stay in hospital. The psoriatic form a mutually-encouraging social group, which is not only an accepted part of the local scene buy dominates it. In effect they form what is virtually a "Psoriatics Club" They lose much of the feeling of shame and embarrassment, and are able to socialize freely and wear the fashionable clothes they desire. They become hopeful and optimistic after seeing that clearing or improvement is possible without the use of drugs or treatments which they know may have damaging side-effects, and they carry this more positive feeling back home.

Other Factors

Other factors at the Dead Sea may contribute to the excellent results. Among these is the very high bromine content in the air - ten to twenty times more than in Jerusalem. This may be partly responsible for the relaxed feeling experienced by most patients, and contribute to the reduction of stress and tension. Whether the higher atmospheric pressure (which results in the air be10% richer in oxygen than is the air at sea-level) plays a part, is not known.

Psoriasis Treatment - Summary

Dead Sea Treatment is a potent therapy for psoriasis. The results are at least as good as those of any other effective treatment, whilst the lack of serious side-effects give it an advantage over many of them. Most types psoriasis respond. Other advantages are the fact that recurrences are frequently less severe than the previous attack, that resistance to repeated treatment rarely develops, and that the treatment may be given during pregnancy and to young children.
Note: Psoriatic arthritis is dealt with in the next chapter.

Atopic Dermatitis

Patients with atopic dermatitis (neurodermatitis; neurodermitis) form the second largest group of people who come to the Dead Sea for dermatological treatment. The term climatotherapy as used here to include a combination of sun-bathing; bathing in Dead Sea water; and general exposure to the climatic and other factors of the region.
Atopic dermatitis is chronic skin disease of unknown cause with the following main characteristics:
  1. Severe itching. This is an inherent aspect of the disease. Most of the visible skin changes are due to the persistent scratching.
  2. Frequently starts in early infancy. In the early stages the lesions are usually acute, "weeping" and crusted. Later, the skin becomes thickened with an exaggeration of its natural lines ("lichenification"). This occurs especially in the folds of the knees and elbows, and on the wrists, ankles and meck.
  3. A sensitive, reactive skin. The skin is dry, easily irritated by mechanical or chemical stimuli and tends to become allergic to external, ingested or inhaled substances (e.g. pollens, bee stings, house dust, foods, drugs). It is more prone to some bacterial, viral and fungal infections. Psychological and climatic factors sometimes play a dominant role in exacerbating or soothing the disease.
  4. A family history of Atophy. Atophy is a genetic susceptibility to certain diseases, which include atopic dermatitis, asthma and hay fener. The blood of atopic individuals usually has high levels of an antibody called immunoglobulin E, or IgE.
The disease occurs in about 3% of children under 5. It often improves spontaneously in late childhood and early adult life, and the skin signs and symptoms usually, not invariably, clear completely by the age of 30. It may be associated with one of the other atopic diseases, and sometimes also with vitiligo and eye disturbances. The basic requirements of treating atopic dermatitis are to relieve itching and prevent scratching. Factors known to aggravate or irritate the condition should be reduced. Local applications should be mild and soothing. Corticosteroid ("cortisone") ointments and creams are commonly prescribed, buy have the disadvantages described in the section on psoriasis, all the more so because the sufferers are frequently young children. Ultraviolet light as well as local application of tar-containing preparations are often helpful when administered under careful control. Psychological reassurance and encouragement are important to ease feelings of tension and stress and to develop a positive, hopeful attitide. Drugs with a sedative and antipruritic (anti-itching) effect may be required.

The Dead Sea Treatment of Atopic Dermatitis

In general, with some important modifications, the same treatment routine as described for psoriasis is followed and the same climatological factors are at work. Local applications to the skin usually consist of simple emollients, oils and moisturizers, although mild tar preparations may also be oils and emulsions may be added to the bath water. Exposure to the sun is usually postponed for some days, although some early exposure in the shade may be permitted. Dead Sea bathing is also usually delayed, and its frequency controlled by the patient`s reaction.
Corticosteroid preparations are not perscribed. If they were being used before arrival, their application is usually stopped. This may result in some worsening of the skin condition ("rebound phenomenon") during the first week, but good improvement is to be expected later.
Antihistaminesmay be given orally and other measures taken to relieve the itching or exacerbation. Precautionary measures are taken if there is a tendency to herpes simplex or other infections. Similarly, avoidance of known irritants or sensitizing agents is discussed with the patient. After the first week or more of gradual acclimatization to local conditions, patients can usually expose themselves more freely to the sun, avoiding the mid-day period and heat stress. For some patients, treatment at the Dead Sea is best avoided during the hottest months of the year ( July and August).

Results of Dead Sea Treatment

Clearing is usually good to excellent, and for many sufferers undoubtedly exceeds that achieved by other therapies. The severe itching frequently subsides relatively early, even if the skin has not yet shown much response. The process is usually slower and less dramatic than with psoriasis, and for many patients treatment for 6 rather than 4 weeks may be more effective.
The following is an analysis of the results in 535 atopic dermatitis patients who stayed at the Dead Sea for a period of 4-6 weeks:
The best results were achieved with patients treated between March and June or between September and December.
 
The results reported in 177 patients who stayed for a period of 1-4 weeks were less satisfactory: only 50% of them were symptom-free or showed good improvement.

C.Vitiligo

Vitiligo sufferers form the third largest group of dermatological patients who come to the Dead Sea for climatological therapy. Although their number is relatively small compared to those treated for psoriasis and atopic dermatitis, it is increasing yearly and now totals some hundreds. In this section, the term climatotherapy includes exposure to the sun and to Dead Sea water, as well as to the other environmental factors in the area.
Vitiligo is a disease in which small or large areas of skin lose their natural pigment ( melanocytes) which are responsible for producing it. Apart from the white color of the skin, the surface looks normal. The hairs in the affected area usually lose their color. The disease can develop at any time, but it starts before the age of 20 in about halg of the patients. The white patches may expand rapidly or slowly to larger or new areas. It is roughly symmetrical in distribution and commonly involves the backs of the hands and face. The cosmetic and social disability, as well as mental stress, may be considrable.
The cause of vitiligo is unknown, but there is probably an underlying immunological disturbance. It is sometimes associated with certain auto-immunological diseases, such as diabetes and pernicious anemia. Some cases seem to be precipitated by damage to the skin or by stress. In about 40% of patients other members of the family have the same disease.
There is no really satisfactory treatment for vitiligo, and many patients must resort to cosmetic camouflage. In some cases it is easier to repigmentize the surrounding skin, and so obtain a more uniform color on the face or hands. The use of the sun-protection creams is often necessary. There is occasionally partial and temporary improvement in the summer. One of the more recent treatments is PUVA therapy, as described briefly in the section on psoriasis.
The Dead Sea treatment for vitiligo is based mainly on gradually increasing exposure of the skin to the sun`s rays, which apparently stimulates melanocytes to repopulate the affected areas and to function normally. The initial sun exposures must be done gradually and carefully, for vitiliginous skin lacks the natural pigment which protects against the damaging effects of ultaviolet light. However, the skin responds to the sun exposure by thickening its surface layer of horny cells (the stratum corneum, or "horny layer"), and this provides sufficient protection to finally enable the patient to remain in the sun for hours a day. The other climatotherapy factors at the Dead Sea are of minor importance.

Results of Dead Sea Treatment

It is difficult to express the results of the treatment of vitiligo in numerical terms. Repigmentation is usually slow and only partial in any one course of treatment. It begins as separate spots around the hair follicles, and spreads inwards from the margins. Even if improvement only starts towards the end of the 4-week course, it usually continues after returning home, and in most patients the repigmentation is maintained. After repeated courses of treatment, usually over a period of years, excellent results (complete repigmentation of many areas) may be achieved. Occasionally however, a rapid repigmentation of some areas does occur during a single stay at the Dead Sea.

SELECTED BIBLIOGRAPHY

 
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