|
|
|
|
David J. Abels, M.D.,
and Jonathan Kattan-Byron, M.D.
Beer-Sheva, Israel
|
|
|
|
A naturally filtered ultraviolet spectrum of sunlight
along with other natural factors are utilized in the management of psoriasis
at the Dead Sea area in Israel.
In 110 patients with psoriasis, 85.5% achieved complete clearing or excellent
improvement. These results compare favorably with other therapeutic regimens
used today in the treatment of psoriasis. Since systemic medications are avoided,
the potential risks may be considerably lessened. Therefore, this therapeutic
modality may be considered in the management spectrum of psoriasis. (J AM
ACAD DERMATOL 12:639- 643, 1985.)
|
Since the advent of PUVA1, the combination of psoralen (P) and long-wave
ultraviolet radiation (UVA), the management of psoriasis has taken on a new
dimension. Numerous scientific articles have been written discussing this form
of treatment and elucidating the principles involved that are presently being
defined. Concurrent with this knowledge, much more is now understood about
photobiologic mechanisms and the UV spectrum.2.3 Along with this basic knowledge,
phototherapy has progressed today into a well-accepted treatment in most major
medical centers. Selective ultraviolet phototherapy (SUP), first described in
the European literature, is currently gaining popularity and many phototherapy
units are now utilizing this principle.4
Climatotherapy, defined as a treatment combining the natural elements
of a specific geographic location, has been used at the Dead Sea in Israel for
over twenty years.5.6 Because of its unique position, the treatment at the Dead
Sea mainly consists of the patients being exposed to a UV spectrum of long-wave
ultraviolet light found naturally in high intensity7 only in that area of the
world and, in addition, a sea rich in natural minerals and salts. This study
of 110 patients with psoriasis confirms the value of this treatment with the
results comparable to other established treatments used today in the management
of psoriasis.
METHODS
During the period of time from the end of March 1983 to June 1983, we
investigated 110 patients enrolled in a Dermatology Clinic at the Dead Sea in
Israel
sponsored by the Israeli government. Since the study was primarily designed
for the treatment of psoriasis, patients with other skin diagnoses were eliminated
from the study.
|
Table I. Incidence
and improvement with severity of involvement
|
|
Percent involvement Prior to treatment
|
Number (and percentage) of
patients prior to treatment
|
Number (and percentage) of
patients with complete clearing
or excellent improvement
|
|
0-9
|
13 (11.8%)
|
13 (100%)
|
|
10-19
|
24 (21.8%)
|
18 (75%)
|
|
20-29
|
30 (27.3%)
|
28 (93.3%)
|
|
30-100
|
43 (39.1%)
|
35 (81.4%)
|
Ten patients with psoriasis were also excluded: one because excessive
alcoholic intake interfered with treatment compliance; a second patient because
he remained under treatment for only 1 week, which is considered insufficient
time; a third patient was not included because her primary diagnosis was in
doubt; the fourth, because he failed to follow the treatment regimen; the fifth,
because her primary diagnosis was psoriatic arthritis and she had no skin involvement;
and the last five patients, because they left the treatment without a final
examination. All the other patients were randomly included and no selective
basis was utilized.
As mentioned, all patients included in this study had a diagnosis of
psoriasis. The main type was plaque or patchy involvement with six patients
having psoriasis guttata. The psoriatic involvement was visually estimated at
the start and conclusion of treatment and the patients were examined always
by the same two physicians, providing relative consistency to the findings.
The treatment consisted primarily of sun exposure beginning with 10 to 20 minutes,
depending on the skin type, in the morning and the same in the afternoon, with
an increase in increments of 10 minutes each day until a maximum of approximately
6 hours per day was reached. Bathing in the Dead Sea
was highly variable but routinely it began with 5 minutes in the morning and
the same in the afternoon, increasing every 3 days another 5 minutes until 30
minutes in the morning and 30 minutes in the afternoon was obtained. All patients
were examined on a daily basis and treatment was adjusted as required.
Topical medications included petrolatum, body and bath oils, and various
concentrations of sulfur-salicylic acid ointments principally used for keratolytic
purposes. In selected patients, a tar ointment was added toward the end of treatment,
mainly for its UV-enhancing effect. Scalp treatments were administered by a
nurse on a daily basis as needed and consisted mainly of localized applications
of sulfur-salicylic acid ointments. Shampooing of the scalp was with a 5% cetrimide
shampoo with or without tar added. At no time was any other topical or systemic
medication used in the treatment. No topical or systemic corticosteroids were
utilized.
The patients underwent treatment from a minimum of 14 days to a maximum
of 42 days, with the average patient stay at the Dead Sea
being 26 days.
RESULTS
Of the 110 patients included in this study, 56 were male and fifty-four
female. The youngest was 10 and the oldest 76, with the average 43 years of
age.
The range of psoriatic involvement at the beginning of treatment was
from 1% to 90% (Table I) with the average involvement at the start of 29%. The
percentage improvement was classified into groups (Table II) and defined as
minimal improvement, 5% to 20%, no patients; definite improvement, 20% to 50%,
one patient; considerable improvement, 50% to 80%, fifteen patients; excellent
improvement, 80 to 95%, 32 patients; complete clearing, 95% to 100%, sixty-two
patients. The percentage improvement was estimated relative to the original
extent of disease.
Forty-three patients had 30% or greater coverage with psoriasis (Table
I). In analyzing the patients in this group, 81.4% showed complete clearing
or excellent improvement. In the group with 20% to 29% involvement, 93.3% had
complete clearing or excellent improvement. Those with 10% to 19% involvement
had 75% complete clearing or excellent improvement, and all thirteen patients
with 0% to 9% involvement showed complete clearing or excellent improvement.
Included in other findings, thirty-one patients (28%) gave a history
or had evidence of psoriatic arthropathy. Virtually all patients expressed some
degree of improvement in their arthritic symptoms at the time of discharge.
Fifty-two patients (47%) revealed nail changes characteristics of psoriasis.
No significant complications were encountered. Occasionally a patient
experienced transient pustules primarily on the legs that cleared with topical
antibiotics. Unrelated ear or skin infections occurred infrequently and responded
to appropriate therapy. In a few patients, a pruritic sunburn-like erythema
or a sun sensitivity appeared early in treatment but always resolved after several
days avoidance of sun exposure to the affected areas. Only very rarely did blistering
accompany the sunburn-like erythema, and it responded to local treatment.
DISCUSSION
The Dead Sea area, situated 390 meters below sea level, is the lowest
place on earth and consequently has certain characteristic atmospheric and climatic
features present at no other location in the world. First, the Dead Sea itself
has the highest concentration of salts found in any natural body of water. These
salts are present in a total concentration of 33% as compared, for example,
to the Great Salt Lake in Utah at 20% to 27% or the ocean, at 3%. Magnesium
chloride is the salt with the highest concentration at 50%, with sodium chloride,
25%, calcium chloride, 12%, and potassium chloride, 4%.k In the sea, bromides
are also found in significant concentration.
|
Table II.
Treatment response
|
|
Definition
|
Percent Involvement Improved*
|
Number of
patients
|
Percent of
patients25%
|
|
Psoriasis worse
|
0
|
0
|
0
|
|
No change
|
0
|
0
|
0
|
|
Minimal improvement (less scaling and/or
erythema)
|
5-20
|
0
|
0
|
|
Definite improvement (moderate flattening
of plaques; less scaling and erythema)
|
20-50
|
1
|
0.9
|
|
Considerable improvement (considerable
flattening of all plaques; minimal erythema and scaling)
|
50-80
|
15
|
13.6
|
|
Excellent improvement (almost complete
flattening of all plaques; minimal erythema or scaling)
|
80-95
|
32
|
29.1
|
|
Complete clearing (complete flattening
of all plaques; no erythema or scaling but variable pigmentation may remain)
|
95-100
|
62
|
56.4
|
*Compared to original involvement of psoriasis
These elemental properties of the sea are combined with unique photobiologic
characteristics that are also present only in this area. The sunburn spectrum
of ultraviolet light is very weak at the Dead Sea9 because of a continuous
haze that develops over the water. This haze or mist occurs from an extraordinarily
high water evaporation estimated at two billion cubic meters per year. Subsequently,
the majority of UVB sunburning rays are filtered out, thus allowing a greater
exposure to the longer wavelength UVB and penetrating natural UVA rays.
These two major factors, the sea and the sun, have served as a basis
for the management of many different medical illnesses at the Dead Sea, particularly
dermatologic disorders. Psoriasis has been the main skin disease treated, although
atopic dermatitis, neurodermatitis, vitiligo, acne, and ichthyosis have responded
to this treatment. From our experience and also that of others,10 the principal
climatic factor at the Dead Sea accounting for the benefit seen, particularly
in psoriasis, most likely is the naturally filtered spectrum of UVA and the
longer wavelength UVA. Because of this, we are most probably dealing with a
form of natural selective ultraviolet phototherapy (NSUP).
PUVA, the combination of psoralen and long-wave ultraviolet radiation
(UVA), is considered today as one of the major therapeutic modalities in the
management of psoriasis. Since it demonstrates a high clearance rate, nearly
90%,11 it has to be considered as a treatment to which other therapeutic regimens
are compared.12.13 The results in our study of 110 patients with psoriasis treated
with NSUP showed that by classifying the patients according to their percentage
improvement (Table II), 56.4% had complete clearing and 29.1%, excellent improvement.
Grouped together, 85.5% had complete clearing or excellent improvement of their
psoriasis.
This overall figure combining complete clearing and excellent improvement
together would support the treatment value with NSUP and its overall efficacy
would compare favorably with PUVA. All our patients responded to treatment with
just one obtaining less than considerable improvement (Table II). In another
study done at the Dead Sea10 77% had complete clearing or marked improvement,
which is near our finding of 85.5% complete clearing or excellent improvement.
To draw any further comparisons with this study is difficult because of the
lack of quantification of their groups, but their findings generally correlate
with our results.
It should be noted that in addition to NSUP, the treatment schedule in
this study included topical medications mainly used for lubrication and keratolytic
purposes. A tar ointment was added in selected patients toward the termination
of treatment primarily for its UV-potentiating effect. Future data may show
that a combination therapy of NSUP with an active antipsoriatic medication may
significantly enhance the treatment results.
The average stay at the Dead Sea for our patients was 26 days. Even though
the minimum stay was only 14 days, the eleven patients who stayed for this
period of time had an average clearing of 87.5%. Many patients did not show
significant improvement until the third or fourth week; therefore, we usually
suggest that patients undergo treatment for a minimum of 3 weeks and preferably
for a period of 4 weeks. Since some patients did experience substantial improvement
after 14 days, it is likely that future work will demonstrate that on an individual
basis, the period of time to achieve maximum benefit will vary between 14 and
28 days.
Psychotherapeutic influences certainly play a role in the patients?overall
improvement at the Dead Sea. Grouped together for several weeks in a relaxed,
pleasant atmosphere allows those affected with this chronic skin disorder to
share and discuss similar frustrations and apprehensions. Many realize for the
first time that they are not alone in their suffering, and visualizing their
own improvement along with that of others serves as an important psychologic
stimulus to their general progress.
Three additional areas requiring objective confirmation and further study
are the response seen in psoriatic arthritis, possible adverse side effects,
and the recurrence or relapse rate. An added advantage of NSUP was its benefits
with psoriatic arthropathy. Twenty-eight percent of our patients had arthritic
symptoms and all benefited from the treatment. Detailed investigation should
now be undertaken to demonstrate conclusively the benefits of this treatment
in psoriatic arthritis and precisely what part the sea and its minerals may
also play in the therapeutic result.
Other important factors needing evaluation are particularly the long-term
side effects.14 Since NSUP eliminates entirely the taking of systemic medications,
such as psoralens, we are not as concerned, for instance, about the potential
ophthalmologic hazards15 and the patients do not have to wear protective glasses
during or after therapy.
The carcinogenic,16.17 mutagenic,18 and immunologic19 complications of
the other treatments for psoriasis are now just beginning to be recognized.
No investigations of these parameters have as yet been carried out at the Dead
Sea, but currently we are unaware of any skin cancer appearing in any of our
patients who were treated at the Dead Sea prior to this study. This certainly
requires further confirmation with large numbers of patients. In the future,
we also hope to study the problem of premature aging of the skin, which may
possibly be a potential complication.20
The recurrence or relapse rate of the psoriasis is another important
issue that also must be considered. Once more, we have no conclusive data at
this time, but after interviewing several hundreds of patients who have been
at the Dead Sea before, NSUP will frequently give a longer remission than other
modalities without specific maintenance therapy being administered between clearance
courses.10 Patients commonly mention a 3- to 6-month period of time before noticing
the beginning of a relapse and state that the psoriasis frequently does not
appear as severely. Further study and documentation should be forthcoming.
REFERENCES
Parrish JA, Fitzpatrick TB, Tanenbaum L, et al: Photochemotherapy of
psoriasis with oral methoxsalen and long-wave ultraviolet light. N. Engl J Med
291:1207-1211, 1974.
Farber EM, Abel EA, Charuworn A: Recent advances in the treatment of
psoriasis. J AM ACAD DERMATOL, 8:311-321, 1983.
Parrish JA: Phototherapy and photochemotherapy of skin diseases. J Invest
Dermatol 77:167-171, 1981.
Tronnier H, Heidbuchel H: Zur Therapie der psoriasis vulgaris mit ultravioletten
Strahlen. Z Hautkr 51:405-424, 1976.
Dostrovsky A, Sagher F: The therapeutic effects of the Dead Sea on some
skin diseases. Harefuah 57:143-145, 1959.
Dostrovsky A, Sagher J: Influence of helio-balneotherapy at the Hot Spring
of Zohar (Ein Bokek) on psoriasis. Harefuah 64:127-129, 1963.
Goldberg LH, Kushelevsky AP: Ultraviolet light measurements at the Dead
Sea, In: Farber EM, et al, editors: Psoriasis. Proceedings of the Second International
Symposium, 1976, New York, 1977. Yorke Medical Books, pp. 461-463.
Schamberg IL: Treatment of psoriasis at the Dead Sea. Int J Dermatol
17:524-525, 1978.
Kushelevsky AP, Slifkin MA: Ultraviolet light measurements at the Dead
Sea and at Beer-Sheba. Isr J Med Sci 11:488-490, 1975.
Avrach WW: Climatotherapy at the Dead Sea, In: Farber EM, et al, editors:
Psoriasis, Proceedings of the Second International Symposium, 1976. New York,
Yorke Medical Books, pp. 258-261.
Bickers DR: Position paper - PUVA therapy. J AM ACAD DERMATOL 8:265-270,
1983.
Parrish JA: Treatment of psoriasis with long-wave ultraviolet light.
Arch Dermatol 113:1525-1528, 1977.
Van Weelden H, Young E, Van Der Leun JC: Therapy of psoriasis: Comparison
of photochemotherapy and several variants of phototherapy, Br J Dermatol 103:1-9,
1980.
Current status of oral PUVA therapy for psoriasis. J AM ACAD DERMATOL.
1:106-117, 1979.
Lerman S, Megaw J, Willis I: Potential ocular complications from PUVA
therapy and their prevention. J Invest Dermatol 74:197-199, 1980.
Hofmann C, Pelwig G, Braun-Falco O: Bowenoid lesions, Bowens disease
and keratoacanthoma in long-term PUVA-treated patients. Br J Dermatol. 101:685-692,
1979.
Stern RS, Thibodeau LA, Kleinermann RA, et al: Risk of cutancous carcinoma
in patients treated with oral methoxsalen photochemotherapy for psoriasis. N
Engl J Med 300:809-813, 1979.
Bridges B, Strauss G, Possible hazards of photochemotherapy for psoriasis,
Nature 28:523-524, 1980.
Morison WL, Photoimmunology, J Invest Dermatol. 77:71-76, 1981.
Abel EA, Cox AJ, Farber EM: Epidermal dystrophy and actinic keratoses
in psoriasis patients following oral psoralen photochemotherapy (PUVA). J MA
ACAD DERMATOL. 7:333- 340, 1982.
--------------------------------------------------------------------------------
From the Division of Dermatology, Soroka University Hospital and Faculty
of Health Sciences, Ben Gurion University of the Negev.
Accepted for publication Nov. 15, 1984
Reprint requests to: Dr. David J. Abels, 5 Nitza Blvd., Apartment 26,
Netanya, Israel 42269
|
