Psoriatics May Gain a Treatment But Lose a Vacation

"Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission."

I used to tell my psoriasis patients to bathe in sea water and get some sun exposure, but don't overdo it because injury to the skin, such as a bad sunburn, may cause new areas of psoriasis to appear. In the office we simulated the sun with ultraviolet treatments and coupled that with various forms of coal tar preparations. This was originally known as the Goekerman treatment, a rather messy procedure, but with time, better tar products were developed and the procedures became known as "modified Goekermans." Studies later showed that the UV-B wavelength of ultraviolet was the most effective and safest way to go. All sorts of variations on what to add to the ultraviolet therapy, if anything, have been proposed over the years. These include such things as improved, lighter colored and less smelly tars in the form of baths, creams or ointments, and just bathing in tap water or salt solutions which supposedly increases photosensitivity of the skin to the UV-B.

Wealthier patients found their psoriasis to be a wonderful excuse for a vacation at the seashore, or better yet, a trip to the Dead Sea, Bad Bentheim in Germany, or perhaps the Blue Lagoon in Iceland where climatotherapy could combine with balneotherapy for gratifying results. Going to spas with selenium-rich water is a more recent addition to the list. Exactly what happens is uncertain. Various theories abound, such as the idea that salt solution may trigger elution of chemotactic and proinflammatory mediators, including elastase, and cytokines. Others feel the immune system may be altered involving such cells as the lymphocytes and Langerhans cells as well as cytokines like interleukin 2 and interferon. Studies have shown increases in levels of bromine, rubidium, calcium, and zinc in the blood serum after Dead Sea bathing. Perhaps the bromine is allowed to penetrate the skin and produce a sedative effect. Psoriasis keratinocytes show higher amounts of minerals, which may alter cell proliferation and differentiation.

Obviously, all this is still up in the air, but it does seem likely that saline spa water might be good for psoriasis. However, according to Léauté-Labrèze et al in a paper entitled "Saline Spa Water or Combined Water and UV-B for Psoriasis vs Conventional UV-B" published in volume 137 of the 2001 Archives of Dermatology on pages 1035-1039, it was found that natural saline spa water with high mineral content found at Salies de Bérn had only a minor therapeutic effect in psoriasis. They also concluded from their randomized, controlled, comparative study with blinded observers performed on 71 adults that bathing showed no beneficial effect on phototherapy.

Writing in the July 2002 issue of the Archives of Dermatology, Boer commented on the Salies de Bérn study because his group had showed in a 1982 study that skin sensitivity to UV-B irradiation is increased by bathing in salt water. They had simply placed the upper forearms of patients in tap water or 4% saline solution. When they increased the salt concentration to near saturation at about 26% or used an imitation known as locum Dead Sea water (LDSW) containing 32.5% salts including 9% sodium chloride, the photosensitivity was not changed. Their conclusion had been that "If bathing prior to UV-B therapy is preferred, then a highly concentrated salt solution, such as LDSW, should be used because it will not increase the UV-B sensitivity of uninvolved skin and therefore will not increase the risk of erythema and blistering of normal skin during UV-B phototherapy for psoriasis." In his commentary Boer also noted that other factors may be at play. For example, the use of moisturizers and emollients in the Salies de Bérn study could have been helpful for several reasons since lubricants may alter the optical properties of the skin, removal of scales by bathing prior to UV-B therapy may be of considerable help, using only UV-B is apparently less efficient than coupling with emollients, and of course relaxation at a spa is likely to improve psoriatics who are well known to get worse under stress.

All of this leads up to a recent observation of my own. Several companies are now offering Dead Sea salts in a cream-like form for sale at places such as beauty parlors. Being non-emulsified they separate out quickly and have to be shaken well before each use. Fortuitously, it was brought to my attention that certain skin lesions on a patient cleared rather rapidly with one of these preparations. The rash turned out to be psoriasis. No form of ultraviolet was involved, and the substance had been applied in the winter so outdoor exposure was not a factor. Those of my readers with psoriasis might like to try this approach for themselves, but I promise nothing.

Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission. Copyright © 2007 by Marvin Ackerman, M.D.

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