The Benefit of Dead Sea Elements in the

The Benefit of Dead Sea Elements in the Treatment of Psoriasis Jamal Dabbas M. D. Walid Y. Farah M. D. Amman - Jordan

Dead Sea § Fed by the holly river ( Jordan River ) § Bounded on the west by the West Bank and Israel and on the east by Jordan. § The surface of the Dead Sea, 408 m (1, 340 ft) below sea level, it is the lowest water surface on earth. § 55 km long by 17. 5 km. § Moab mountains on the east and Palestinean – Israeli mountains on the west.

History § Historical figures and beauty seekers like Cleopatra and king Herod recognized the natural secret of using the dead sea as the most potent natural skin remedy for the skin. § The modern era for treating skin diseases at the Dead Sea began in 1959 with psoriasis being the principal dermatological disease treated

§ The Dead Sea is a vehicle of minerals and chemicals including Sulfur, Chlorine, Potassium, Sodium, Calcium, Magnesium and Bromine. § Over millions of years, the hot dry air and high evaporation rate have contributed to the high salt concentration present in the Dead Sea, making it one of the saltiest lakes in the world. § The water, ten times saltier than the Mediterranean Sea, has such a high specific weight that one can float effortlessly with no fear of drowning.

Physical Properties § § Temperature 27°C -39°C. Humidity 34% Rainfall 50 mm per year. Very high barometeric pressure – 10% richer in oxygen § Atomosphere pollen free and contains a high concentration of Bromide.

Physical Properties contd. § § UV light UVA > UVB Aerosol haze High degree of buoyancy

Dead Sea Salts Differ from regular sea salt in 3 important ways : 1. Contain 10 times more minerals than sea salt. 2. Absorb essential oils with ease, which enables them to be released into the bath water as they dissolve. 3. Concentration of divalent cations ( Mg & Ca ) is very high compared with monovalent cations (Na & K )

Comparison of Salt Concentration mg/Liter Dead Sea Mediteranian Water Ocean Water Chloride 224. 000 22. 900 19. 000 Magnesium 44. 000 1. 490 1. 350 Sodium 40. 100 12. 700 10. 500 Calcium 17. 200 470 400 Potassium 7. 650 470 390 Bromide 5. 300 76 65

§ In recent years there is much interest in dead sea therapy of variety of dermatological and systemic diseases and has been used in Jordan. § Health resort area, providing Dead Sea therapy, is located a long the eastern shore of the dead sea at the southern end of the Jordan river

§ Studies curried out at the Dead Sea have showed positive results in lengthening the duration of remission and has been recommended as an alternative treatment for psoriasis. The studies have included both exposure to the environment and subdue UV rays at Dead Sea itself together with application of Dead Sea mud and soaking in mineral paths.

Dead Sea Mud in the Treatment of Psoriasis Dr. Jamal Dabbas Dr. Jalal Zubi Dr. Jeries Daoud Dr. Walid Farah

Introduction § Psoriasis represent the largest group of skin disease patients treated at the Dead Sea which have been investigated. § In our study therapy used at home and not at the Dead Sea.

Methods and Materials § March – August 1998. § Patients treated in dermatology clinics outside the Dead Sea above the sea level in Jordan. § 120 patients of psoriasis. § Two groups 60 patients each. § First group assigned to use Dead Sea Mud. § Second group to use wash out mud ( False mud).

Comparison of major ingredients of true mud and washed out mud Ingredients Ca True mud (mg/L) 23556 False mud (mg/L) 64. 5 Na 31727 81. 2 K 6841 56. 3 Cl 190000 1100 Mg 32493 105. 1 Total Scaling 284598 1397. 0

Methods and Materials § § § Age 14 – 61 years. All in good health apart from psoriasis. 2 pts in true mud group and 4 pts in false mud group lost follow up. . Daily activities. § There were no significant difference in demographic and epidemiological variables for the 2 groups

Demographic Data Parameter Race 16 - 61 14 – 58 Male 34 33 Female Sex Mean False mud (n=56) 31 Range Age (years) True mud (n=58) 34 24 23 White 54 53 Black 4 3

Target Area Chest True mud (n=58) 0 False mud (n=56) 0 Abdomen 2 2 Buttocks 3 4 Back 4 3 Upper limbs 12 7 Lower limbs 20 21 Elbow 14 12 Knee 3 7

Disease status and duration True mud (n=58) Disease status at entry Disease duration (yrs) False mud (n=56) Stable 38 35 Worsening 20 21 Mean 6. 3 7. 1

Materials and Methods § Three signs of psoriasis Erythema Induration Scaling § Four sign scores for disease severity 0 = none 1 = slight 2 = moderate 3 = severe

Excluded individuals § § § Systemic steroids within 28 days Antimetabolites within 28 days Topical therapies for psoriasis within 14 days § Any investigational drugs within 1 month

Application Apply the mud to treatment areas twice daily for 1 hour each for a total of three weeks , occlusive dressing may be used when appropriate.

Follow Up Patients returned for evaluation of their response to treatment after 3 , 7 , 14 and 21 days of drug application ( study days 4 , 8 , 15 and 22 )

Criteria for Evaluation § Cleared = 100% clearance of signs (except for residual discoloration) § Marked improvement = 75 – 99% clearance of signs. § Moderate improvement = 50 - < 74% clearance of signs. § Mild improvement = < 50% clearance of signs § No change = no detectable improvement § Exacerbation = flare of sites monitored

Patients Self evaluation § 1 = Excellent § 2 = Good § 3 = Fair § 4 = Poor § 5 = No response § 6 = Exacerbation

Efficacy of Treatement Based on individual and total disease sign scores, the percent improvement in sign scores, the global evaluation of change in disease status and the patient self – evaluation of their response to treatment.

Safety of Treatment Assessed by examination of patients at each visit for local side effects if any.

Visit Rx Pts # 0 M P M P M P 58 56 58 56 Day 4 Day 8 Day 15 Day 21 Mean sign scores MTSS Eryth Scal. Indur. 1. 9 2. 1 1. 9 5. 9 1. 85 2. 15 1. 8 5. 8 2. 0 1. 9 5. 9 1. 9 2. 1 1. 8 5. 8 1. 7 1. 8 5. 2 1. 9 2. 1 1. 9 5. 9 1. 6 1. 3 1. 6 4. 5 1. 8 2. 0 2. 1 5. 9 1. 6 1. 1 1. 3 4. 0 1. 6 2. 0 2. 1 5. 7

Mean Pt. Self Evaluation ( Mean Score ) Visit Day 4 True Mud ( n=58 ) 4. 05 False Mud ( n=56 ) 4. 0 Day 8 3. 0 3. 95 Day 15 2. 95 3. 95 Day 22 3. 05 4. 0

Conclusion § Dead Sea mud applied twice daily for 3 weeks was efficacious in the treatment of psoriasis of variable severity. § Much more effective than placebo. § Rapid onset of action as 1 week of therapy. § Exact mechanisms deserve further efforts… Mechanical ? Thermal ? Chemical ? ?

Conclusion Within the limitations of this study, Dead Sea mud when applied over a 3 weeks treatment period, may be be described SAFE RAPID FAIRLY EFFICACIOUS In the treatment of psoriasis.