The Benefit of Dead Sea The Benefit of Dead Sea Elements in the Treatment of Elements in the Treatment of

PsoriasisPsoriasis

Jamal Dabbas M.D.Jamal Dabbas M.D.

Walid Y. Farah M.D.Walid Y. Farah M.D.

Amman - JordanAmman - Jordan

Dead SeaDead Sea

Fed by the holly river ( Jordan River )Fed by the holly river ( Jordan River ) Bounded on the west by the West Bank and Bounded on the west by the West Bank and

Israel and on the east by Jordan.Israel and on the east by Jordan. The surface of the Dead Sea, 408 m (1,340 ft) The surface of the Dead Sea, 408 m (1,340 ft)

below sea level, it is the lowest water surface on below sea level, it is the lowest water surface on earth.earth.

55 km long by 17.5 km. 55 km long by 17.5 km. Moab mountains on the east and Palestinean – Moab mountains on the east and Palestinean –

Israeli mountains on the west.Israeli mountains on the west.

HistoryHistory

Historical figures and beauty seekers  like Historical figures and beauty seekers  like Cleopatra  and king Herod  recognized the Cleopatra  and king Herod  recognized the natural secret of using the dead sea as the most natural secret of using the dead sea as the most potent natural skin remedy  for the skin.  potent natural skin remedy  for the skin. 

The modern era for treating skin diseases at the The modern era for treating skin diseases at the Dead Sea began in 1959 with psoriasis being Dead Sea began in 1959 with psoriasis being the principal dermatological disease treated the principal dermatological disease treated

The Dead Sea is a vehicle of minerals and The Dead Sea is a vehicle of minerals and chemicals including Sulfur, Chlorine, Potassium, chemicals including Sulfur, Chlorine, Potassium, Sodium, Calcium, Magnesium and Bromine. Sodium, Calcium, Magnesium and Bromine.

Over millions of years, the hot dry air and high Over millions of years, the hot dry air and high evaporation rate have contributed to the high salt evaporation rate have contributed to the high salt concentration present in the Dead Sea, making it concentration present in the Dead Sea, making it one of the saltiest lakes in the world. one of the saltiest lakes in the world.

The water, ten times saltier than the The water, ten times saltier than the Mediterranean Sea, has such a high specific Mediterranean Sea, has such a high specific weight that one can float effortlessly with no fear of weight that one can float effortlessly with no fear of drowning. drowning.

Physical PropertiesPhysical Properties

Temperature 27°C -39°C.Temperature 27°C -39°C. Humidity 34%Humidity 34% Rainfall 50mm per year.Rainfall 50mm per year. Very high barometeric pressure – 10% Very high barometeric pressure – 10%

richer in oxygenricher in oxygen Atomosphere pollen free and contains a Atomosphere pollen free and contains a

high concentration of Bromide.high concentration of Bromide.

Physical Properties contd.Physical Properties contd.

UV light UV light UVA > UVBUVA > UVB Aerosol hazeAerosol haze High degree of buoyancyHigh degree of buoyancy

Dead Sea Salts Dead Sea Salts

Differ from regular sea salt in 3 important ways :Differ from regular sea salt in 3 important ways :

1.Contain 10 times more minerals than sea salt. 1.Contain 10 times more minerals than sea salt.

2. Absorb essential oils with ease, which enables 2. Absorb essential oils with ease, which enables them to be released into the bath water as they them to be released into the bath water as they dissolve. dissolve.

3. Concentration of divalent cations ( Mg & Ca ) is 3. Concentration of divalent cations ( Mg & Ca ) is very high compared with monovalent cations very high compared with monovalent cations

(Na & K )(Na & K )

Comparison of Salt Concentration Comparison of Salt Concentration mg/Liter  mg/Liter 

Dead Sea Dead Sea WaterWater

Mediteranian Mediteranian WaterWater

Ocean Ocean WaterWater

ChlorideChloride 224.000224.000 22.90022.900 19.00019.000

MagnesiumMagnesium 44.00044.000 1.4901.490 1.3501.350

SodiumSodium 40.10040.100 12.70012.700 10.50010.500

CalciumCalcium 17.20017.200 470470 400400

PotassiumPotassium 7.6507.650 470470 390390

BromideBromide 5.3005.300 7676 6565

In recent years there is much interest in In recent years there is much interest in dead sea therapy of variety of dead sea therapy of variety of dermatological and systemic diseases and dermatological and systemic diseases and has been used in Jordan .has been used in Jordan .

Health resort area, providing Dead Sea Health resort area, providing Dead Sea therapy, is located a long the eastern shore therapy, is located a long the eastern shore of the dead sea at the southern end of the of the dead sea at the southern end of the Jordan river Jordan river

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

Dead Sea Mud in the Treatment of Dead Sea Mud in the Treatment of PsoriasisPsoriasis

Dr. Jamal DabbasDr. Jamal Dabbas

Dr. Jalal ZubiDr. Jalal Zubi

Dr. Jeries DaoudDr. Jeries Daoud

Dr. Walid FarahDr. Walid Farah

IntroductionIntroduction

Psoriasis represent the largest group of skin Psoriasis represent the largest group of skin disease patients treated at the Dead Sea disease patients treated at the Dead Sea which have been investigated.which have been investigated.

In our study therapy used at home and not In our study therapy used at home and not at the Dead Sea.at the Dead Sea.

Methods and MaterialsMethods and Materials

March – August 1998.March – August 1998. Patients treated in dermatology clinics outside Patients treated in dermatology clinics outside

the Dead Sea above the sea level in Jordan. the Dead Sea above the sea level in Jordan. 120 patients of psoriasis.120 patients of psoriasis. Two groups 60 patients each.Two groups 60 patients each. First group assigned to use Dead Sea Mud.First group assigned to use Dead Sea Mud. Second group to use wash out mud ( False Second group to use wash out mud ( False

mud).mud).

Comparison of major ingredients of Comparison of major ingredients of true mud and washed out mudtrue mud and washed out mud

IngredientsIngredients True mud (mg/L)True mud (mg/L) False mud (mg/L)False mud (mg/L)

CaCa 2355623556 64.564.5

NaNa 3172731727 81.281.2

KK 68416841 56.356.3

ClCl 190000190000 11001100

MgMg 3249332493 105.1105.1

Total ScalingTotal Scaling 284598284598 1397.01397.0

Methods and MaterialsMethods and Materials

Age 14 – 61 years.Age 14 – 61 years. All in good health apart from psoriasis.All in good health apart from psoriasis. 2 pts in true mud group and 4 pts in false 2 pts in true mud group and 4 pts in false

mud group lost follow up .. Daily activities.mud group lost follow up .. Daily activities. There were no significant difference in There were no significant difference in

demographic and epidemiological variables demographic and epidemiological variables for the 2 groups for the 2 groups

Demographic DataDemographic Data

ParameterParameter True mudTrue mud

(n=58)(n=58)

False mudFalse mud

(n=56)(n=56)

Age (years)Age (years) MeanMean 3434 3131

RangeRange 16 - 6116 - 61 14 – 58 14 – 58

SexSex MaleMale 3434 3333

FemaleFemale 2424 2323

RaceRace WhiteWhite 5454 5353

BlackBlack 44 33

Target AreaTarget AreaTarget AreaTarget Area True mudTrue mud

(n=58)(n=58)

False mudFalse mud

(n=56)(n=56)

ChestChest 00 00

AbdomenAbdomen 22 22

ButtocksButtocks 33 44

BackBack 44 33

Upper limbsUpper limbs 1212 77

Lower limbsLower limbs 2020 2121

ElbowElbow 1414 1212

KneeKnee 33 77

Disease status and durationDisease status and duration

True mudTrue mud

(n=58)(n=58)

False mudFalse mud

(n=56)(n=56)

Disease Disease status at status at

entryentry

StableStable 3838 3535

WorseningWorsening 2020 2121

Disease Disease duration duration

(yrs)(yrs)

MeanMean 6.36.3 7.17.1

Materials and MethodsMaterials and Methods Three signs of psoriasisThree signs of psoriasis

ErythemaErythemaIndurationIndurationScalingScaling

Four sign scores for disease severityFour sign scores for disease severity0 = none0 = none1 = slight1 = slight2 = moderate2 = moderate3 = severe3 = severe

Excluded individualsExcluded individuals

Systemic steroids within 28 daysSystemic steroids within 28 days Antimetabolites within 28 daysAntimetabolites within 28 days Topical therapies for psoriasis within 14 Topical therapies for psoriasis within 14

daysdays Any investigational drugs within 1 monthAny investigational drugs within 1 month

ApplicationApplication

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

Follow UpFollow Up

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

Criteria for EvaluationCriteria for Evaluation Cleared = 100% clearance of signs Cleared = 100% clearance of signs (except for residual discoloration)(except for residual discoloration) Marked improvement = 75 – 99% clearance of Marked improvement = 75 – 99% clearance of

signs.signs. Moderate improvement = 50 - < 74% Moderate improvement = 50 - < 74%

clearance of signs.clearance of signs. Mild improvement = < 50% clearance of signsMild improvement = < 50% clearance of signs No change = no detectable improvement No change = no detectable improvement Exacerbation = flare of sites monitored Exacerbation = flare of sites monitored

Patients Self evaluationPatients Self evaluation

1 = Excellent1 = Excellent 2 = Good2 = Good 3 = Fair3 = Fair 4 = Poor4 = Poor 5 = No response5 = No response 6 = Exacerbation6 = Exacerbation

Efficacy of TreatementEfficacy of Treatement

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

Safety of TreatmentSafety of Treatment

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

VisitVisit RxRx Pts #Pts # Mean sign scoresMean sign scores MTSSMTSS

ErythEryth Scal.Scal. Indur.Indur.

00 MM 5858 1.91.9 2.12.1 1.91.9 5.95.9

PP 5656 1.851.85 2.152.15 1.81.8 5.85.8

DayDay

44

MM 5858 2.02.0 2.02.0 1.91.9 5.95.9

PP 5656 1.91.9 2.12.1 1.81.8 5.85.8

DayDay

88

MM 5858 1.71.7 1.71.7 1.81.8 5.25.2

PP 5656 1.91.9 2.12.1 1.91.9 5.95.9

DayDay

1515

MM 5858 1.61.6 1.31.3 1.61.6 4.54.5

PP 5656 1.81.8 2.02.0 2.12.1 5.95.9

DayDay

2121

MM 5858 1.61.6 1.11.1 1.31.3 4.04.0

PP 5656 1.61.6 2.02.0 2.12.1 5.75.7

Mean Pt. Self Evaluation ( Mean Score )Mean Pt. Self Evaluation ( Mean Score )

VisitVisit True Mud True Mud

( n=58 )( n=58 )

False MudFalse Mud

( n=56 )( n=56 )

Day 4Day 4 4.054.05 4.04.0

Day 8Day 8 3.03.0 3.953.95

Day 15Day 15 2.952.95 3.953.95

Day 22Day 22 3.053.05 4.04.0

ConclusionConclusion

Dead Sea mud applied twice daily for 3 Dead Sea mud applied twice daily for 3 weeks was efficacious in the treatment of weeks was efficacious in the treatment of psoriasis of variable severity.psoriasis of variable severity.

Much more effective than placebo.Much more effective than placebo. Rapid onset of action as 1 week of therapy.Rapid onset of action as 1 week of therapy. Exact mechanisms deserve further efforts…Exact mechanisms deserve further efforts…

Mechanical ? Thermal ? Chemical ????Mechanical ? Thermal ? Chemical ????

ConclusionConclusion

Within the Within the limitationslimitations of this study, Dead Sea of this study, Dead Sea mud when applied over a 3 weeks treatment mud when applied over a 3 weeks treatment period, may be be describedperiod, may be be described

SAFESAFERAPIDRAPIDFAIRLY EFFICACIOUSFAIRLY EFFICACIOUSIn the treatment of psoriasis. In the treatment of psoriasis.