Document 137885

Psoriasis treatment at the Dead Sea: A natural
selective ultraviolet phototherapy
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 DERMATOL12:639-643, 1985.)
Since the advent of PUVA, ~ 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 spect r a m . 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#
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 nat-
From the Division of Dennatology, 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.
urally 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.
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. 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
Journal of the
American Academyof
Abels and Kattan-Byron
Table I. Incidence and improvement with severity of involvement
Percent involvement
prior to treatment
Number (and percentage) of
patients prior to treatment
13 (11.8%)
24 (21.8%)
30 (27.3%)
43 (39.1%)
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 m6rning 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 the 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.
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% t o 9 0 % (Table
I) with the average involvement at the start of 29%.
The percentage improvement was classified into
groups (Table II) and defined as minimal improve-
Number (and percentage) of
patients with complete clearing
or excellent improvement
ment, 5% to 20%, no patients; definite improvement, 20% to 50%, one patient; considerable im-~
provement, 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 characteristic 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
The Dead Sea area, situated 390 meters below
sea level, is the lowest place on earth and conse-
Volume 12
Number 4
April, 1985
Psoriasis treatment at Dead Sea
Table II. Treatment response
Psoriasis worse
No change
Minimal improvement (less scaling
and/or erythema)
Definite improvement (moderate
flattening of plaques; less scaling
and erythema)
Considerable improvement (considerable flattening of all plaques;
minimal erythema and scaling)
Excellent improvement (almost
complete flattening of all plaques;
minimal erythenaa or scaling)
Complete clearing (complete flattening of all plaques; no erythema
or scaling but variable pigmentation may remain)
Number of
Percent of
*Compared to original involvement of psoriasis.
quently 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%. 8 In the sea, bromides are
also found in significant concentration.
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
D e a d S e a 9 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. 7
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, par-
ticularly 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, t° 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 UVB. Because of this,
we are most probably dealing with a form of natural selective ultraviolet phototherapy (NSUP).
PUVA, the combination of psoralen and longwave 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, z2,~3The 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
Journal of the
American Academy of
Abels and Kattan.Byron
NSUP and its overall efficacy would compare favorably with PUVA. AI! our patients responded to
treatment with just one obtaining less than considerable improvement (Table II). In another study
done at the Dead Sea, 1° 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
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
Three additional areas requiring objective confirrnation and further study are the response seen
in psoriatic arthritis, possible adverse side effects,
and the recurrence or relapse rate. An added ad-
vantage of NSUP was its benefit 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. .4 Since
NSUP eliminates entirely the taking of systemic
medications, such as psoralens, we are not as concerned, for instance, about the potential ophthalmologic hazards 15 and the patients do not have to
wear protective glasses during or after therapy.
The carcinogenic, j6,1v mutagenic, ts and immunologic t9 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. 2°
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, t0 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 reappear as severely. Further
study and documentation should be forthcoming.
1, Parrish JA, Fitzpatrick TB, Tanenbaum L, et al: Photochemotherapy of psoriasis with oral methoxsalen and
long-wave ultraviolet light. N Engl J Med 291:12071211, 1974.
2. Farber EM, Abel EA, Charuworn A: Recent advances in
the treatment of psoriasis. J AM ACADDERMATOL8:311321, 1983.
3. Parrish JA: Phototherapy and photochemotherapy of skin
diseases. J Invest Dermatol 77:167-171, 1981.
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Number 4
April, 1985
Psoriasis treatment at D e a d Sea
4. Tronnier H, Heidbuchel H: Zur therapie der psoriasis
vulgaris mit ultravioletten Strahlen. Z Hautkr 51:405424, 1976.
5. Dostrovsky A, Sagher F: The therapeutic effects of the
Dead Sea on some skin diseases. Harefuah 57:143-145,
6. Dostrovsky A, Shanon J: Influence of helio-balneotherapy at the Hot Spring of Zohar (Ein Bokek) on psoriasis.
Harefuah 64:127-129, 1963.
7. 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.
8. Sehamberg IL: Treatment of psoriasis at the Dead Sea.
Int J Dermatol 17:524-525, 1978.
9. Kushelevsky AP, Slit'kin MA: Ultraviolet light measurements at the Dead Sea and at Beer-Sheba. Isr I Med Sci
11:488-490, 1975.
10. Avrach WW: Climatotherapy 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. 258-261.
11. Bickers DR: Position papermPUVA therapy. J AM ACAD
DERMATOL8:265-270, 1983.
12. Parrish JA: Treatment of psoriasis with long-wave ultraviolet light. Arch Dermatol 113:1525-1528, 1977.
13. Van Weelden H, Young E, Van Der Leun JC: Therapy
of psoriasis: Comparison of photoehemotherapy and several variants of phototherapy. Br J Dermatol 103:1-9,
14. Current status of oral PUVA therapy for psoriasis. J AM
ACAD DERMATOL1:106-117, 1979.
15. Lerman S, Megaw J, Willis I: Potential ocular complications from PUVA therapy and their prevention. J Invest
Dermatol 74:197-199, 1980.
16. Hofman C, Pelwig G, Braun-Falco O: Bowenoid lesions,
Bowens disease and keratoacanthoma in long-term
PUVA-treated patients. Br J Dermatol 101:685-692,
17. Stem RS, Thibodeau LA, Kleinermann RA, et al: Risk
of cutaneous carcinoma in patients treated with oral methoxsalen photochemotherapy for psoriasis. N Engl J Med
300:809-813, 1979.
18. Bridges B, Strauss G: Possible hazards of photochemotherapy for psoriasis. Nature 28:523-524, 1980.
19. Morison WL: Photoimmunology. J Invest Dermatol
77:71-76, 1981.
20. Abel EA, Cox AJ, Farber EM: Epidermal dystrophy and
actinic keratoses in psoriasis patients following oral psoralen photochemotherapy (PUVA). J AM ACAD DERMATOL7:333-340, 1982.
Clonidine treatment in paroxysmal localized
Kuritzky A, Hering R, Goldhammer G, et al: Arch
Neuroi 41:1210-1211, 1984
These neurologists in Israel say that for some types of
localized paroxysmal hyperhidrosis, clonidine may be useful.
Other antianxiety medicines sometimes help too.
Merkel cell carcinoma (endocrine carcinoma of
the skin) of the head and neck
Goepfert H, Remmler D, Silva E, et al: Arch
Otolaryngol 110:707-712, 1984
Merkel cell carcinomas of the skin metastasize early and
often, as shown in this study of forty-one patients. Special
awareness and therapy are needed.
Filaggrin distribution in keratoacanthomas and
squamous cell carcinoma
Klein-Szanto AJ, Barr RJ, Reiners JJ Jr, et al: Arch
Pathol Lab Med 108:888-890, 1984
Filaggrin appears to be absent from squamous cell carcinomas but plentiful in keratoacanthomas. If sustained by
others, this fact may be useful in diagnosis, Filaggrin is a
histidine-rich protein in the normal granular layer of skin.
Cyclic nucleotides and calcium transport in
cultured dermal fibroblasts from progressive
systemic sclerosis and rheumatoid arthritis
Grozdova MD, Khokhlova JV, Panasyuk AF, et al:
Arthritis Rheum 27:1144-1149, 1984
From the USSR comes this report of abnormalities in fibroblasts in scleroderma. Epinephrine-stimulated changes in
calcium-ion uptake were notable. Their choice of controls
may be unsuitable.
Extrapulmonary oat cell carcinoma
Ibrahim NB, Briggs JC, Corbishley CM: Cancer
54:1645-1661, 1984
Extrapulmonary oat cell carcinomas are of interest now
due similarly to endocrine cell tumors and to the view that
these may be poorly formed carcinoid tumors. Some occur
in skin as noted in this review, and the relation to the Merkel
cell tumors is considered. Many questions remain Unanswered
concerning these special neoplasms.