Dead sea climatotherapy for psoriasis vulgaris: analysis of short-term results

Background: Psoriasis is a common skin disease which beneficiated lately from many new drugs, acting on immunity. Phototherapy remains however a cornerstone of treatment in moderate-to-severe forms. Patients exhibit a continuous and longstanding interest in Dead Sea Climatotherapy (DSC), a well-known off-label psoriasis treatment which demonstrated high rates of success since decades. Objective: We sought to determine the success rates of DSC and to compare the populations of patients reaching different levels of clearance, in order to correlate results with their respective demographic and clinical variables. We also compare two different criteria of evaluation based on the Psoriasis Area and Severity Index: PASI 75 and PASI 90. Patients and methods: Files of 790 patients suffering from moderate-to-severe Psoriasis vulgaris, who underwent DSC at the Deutsches Medizinisches Zentrum (DMZ) during the past five years were automatically retrieved if PASI at arrival was above 10 and included in this statistical study. In the group of patients who reached 75% and more improvement of PASI (n=719), PASI improvement (PASI%) was first evaluated as a dichotomous variable, as patients were divided in two groups: PASI 75-90 and PASI 90, and secondly was considered as a continuous variable. Results: PASI 75 and PASI 90 reached respectively 91% and 76.8%. Previous treatment at the Dead Sea significantly predicted PASI 90, and age of onset of disease was found inversely correlated to better results. Photo skin type II was found to significantly correlate to PASI 90. Conclusion: Climatotherapy was confirmed as a successful therapy for almost any plaque psoriasis patient. No essential differences were found between patients reaching PASI 75 or PASI 90. PASI 90 seems to be of better value by evaluating immediate results in modern therapeutic trials, while allowing a better therapeutic choice for a specific patient. Introduction Dead Sea Climatotherapy is known for the treatment of psoriasis since more than forty years, with first publications appearing sporadically in the late 70s of the past century [1]. Since, a lot of clinical studies confirmed the spectacular success of the treatment, while reporting its effect of thousands of European sufferers treated in clinics flourishing in Ein Bokek, at the Dead Sea [2,3]. Explanations on the mechanism involved were proposed later on, and were many times exposed, mainly by the team of Kudish [4]. One of these first publications [5] tried to objective which patients can better beneficiate from the sun exposure and the Dead Sea bathes proposed daily, under medical supervision, during 3 weeks or more. More recently, psoriasis at earlier age, which is usually correlated to poor results, was found to be slightly better improved than psoriasis emerging later in life [6]. Thus, it seems important to define which patients hold the best chances to reach total or almost-total clearance through this natural method of treatment, which was demonstrated as free of side effects [7], well accepted and improving largely Quality of Life parameters [8]. PASI (Psoriasis Area Severity Index) is commonly used to quantify psoriasis with an absolute number as a follow-up measure. As an outcome measure in therapeutic trials, PASI is represented as PASI 50, PASI 75, PASI 90 or PASI 100. PASI 90, for example, represents the percentage (or number) of patients who have achieved a 90% or more reduction in their PASI score from the baseline value. Lately PASI 90 has gained more importance over PASI 75, as it correlates better with health-related quality of life measurements and because of the availability of much more potent treatments. Patients and methods We examined the records of the patients suffering from Psoriasis vulgaris, who underwent 3 or 4 weeks of DSC in the past 5 years at the DMZ. 790 patients were automatically selected if their PASI at arrival was higher than 10. As a routine, PASI evaluation for each patient is regularly done immediately before treatment, at arrival at the Dead Sea, and after completion of DSC, by the same dermatologist. Details of the Correspondence to: Marco Harari, DMZ Medical Center, Lot Spa Hotel, Dead Sea, Israel; E-mail: [email protected] Received: March 28, 2016; Accepted: May 03, 2016; Published: May 06, 2016 Harari M (2016) Dead sea climatotherapy for psoriasis vulgaris: analysis of short-term results Glob Dermatol, 2016 doi: 10.15761/GOD.1000177 Volume 3(3): 295-301 individual program administered to the patients were already exposed and discussed in previous publications [2,4]. This study was approved by the ethics committee of the RIDS, Research Institute on Skin Diseases at the Dead Sea. All patients signed an informed consent when entering the clinic and accepted the use of their anonymous data for scientific research. In the records examined, we found that 719 patients (91%) reached PASI improvement of 75% and we choose them as our study population. 70.2% were males, 78.1% were with skin photo type III (following Fitzpatrick classification) and the means of age and Body Mass Index reached respectively 51.2 years and 28.8 Kg/s-m. The demographic variables distributions are presented in Table 1. The PASI values before and after treatment distributions are presented in Table 2. The clinical and treatment variables distributions are presented in Table 3. Results This statistical retrospective cohort study aimed to assess the results of Dead Sea Climatotherapy (DSC) given at the Deutsches Medizinisches Zentrum (DMZ) by several analysis of the Psoriasis Assessment of Severity Index (PASI) recorded before and after treatment while trying to find clinical parameters that predict the PASI improvement (PASI%). From the 790 files of patients included in this study (with an initial PASI reaching at least the value of 10), 91% reached PASI 75, and 76.8% reached PASI 90. As seen in Table 2, the mean PASI at arrival for patients reaching PASI 75 (n=719) dropped from 19.93 to 0.79, defining a mean improvement, after 28 days of treatment, of 96%. • Previous treatments at the Dead Sea were found to be a positive predictor for a better PASI%, as patients who underwent more DSC in the past had higher chances to reach PASI 90: the more DSC the patient underwent in the past, the higher PASI% that was reached. • A positive association was found between the length of the disease, in years, and PASI%: the longer the patient suffered from psoriasis the higher were the chances to reach PASI 90. • A negative association was found between PASI% and age at onset of disease: patients who started earlier in life their diseases were more likely to reach PASI 90. Variable Category N % Range M SD Gender Males 505 70.2