Balneophototherapy of psoriasis: highly concentrated salt water versus tap water--a randomized, one-blind, right/left comparative study

Efficacy of hydrotherapy, spa therapy, and balneotherapy for psoriasis and atopic dermatitis: a systematic review

BACKGROUND

Atopic dermatitis (AD) and psoriasis are chronic inflammatory diseases that have significant skin complications.

OBJECTIVE

The purpose of this systematic study was to evaluate the evidence obtained from human studies on the effects of hydrotherapy, spa therapy, and balneotherapy in psoriasis and atopic dermatitis.

METHODS

The present systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statements. Also, for this study databases such as Embase, PubMed, Scopus ProQuest, and sciences direct database were searched from the beginning to April 2021.

RESULTS

All human studies that examined the effect of balneotherapy, spa therapy, and hydrotherapy on psoriasis and atopic dermatitis were published in the form of a full article in English. In the end, only 22 of the 424 articles met the criteria for analysis. Most studies have shown that balneotherapy, spa therapy, and hydrotherapy may reduce the effects of the disease by reducing inflammation and improving living conditions. In addition, the results of the Downs and Black score show that seven studies received very good scores, three studies received good scores, nine studies received fair scores, and three studies received poor scores.

CONCLUSIONS

The results of studies also showed that hydrotherapy leads to an improvement in the PASI score index. Nevertheless, more clinical trials are needed to determine the mechanism of action of hydrotherapy on these diseases.

Climatotherapy at the Dead Sea for psoriasis is a highly effective anti-inflammatory treatment in the short term; an immunohistochemical study

Climatotherapy is a well‐described treatment of psoriasis. Dead Sea climatotherapy (DSC) in Israel consists of intensive sun and Dead Sea bathing and is very effective in improving clinical and patient‐reported outcomes. However, the effect of DSC has not been widely studied. We aimed to investigate the effect of DSC on psoriasis skin using quantitative immunohistochemistry techniques and analysis of blood samples. Skin punch biopsies from 18 psoriasis patients from a previous cohort study were used. Biopsies were obtained from non‐lesional skin and from a psoriasis target lesion at baseline. A biopsy was acquired from the target lesion after DSC. Among patients who achieved complete visual clearance, a biopsy was also obtained at relapse. Blood samples were obtained at the same time points. We performed haematoxylin and eosin staining and quantitative immunohistochemical analysis of CD3, CD4, CD8, CD11c, CD103, CD163, CD207, forkhead box P3, Ki67 and myeloperoxidase. We performed blood tests of cholesterol, c‐reactive protein, glucose, haemoglobin A1c and triglycerides. All skin biomarkers except for CD207 were decreased after DSC. At relapse, none of the biomarkers were significantly different from the baseline lesional measurements. Total CD207 staining correlated with psoriasis area and severity index at baseline while CD163 staining correlated with psoriasis area and severity index at EOT. No changes were observed in selected blood tests during the study. Consistent with clinical results, DSC is highly effective in the short term almost normalising all investigated biomarkers. However, at relapse, biomarkers were upregulated to the baseline level.

Mind-Body Interventions as Alternative and Complementary Therapies for Psoriasis: A Systematic Review of the English Literature

Objective: Conventional therapeutic methods for psoriasis include topical and systemic drugs, phototherapy, and biologic agents. Despite the fact that these treatment methods, and especially biologic agents, are met with a considerable reduction in disease activity, they can sometimes be costly and are nonetheless accompanied by high risks of adverse events, ranging from mild to debilitating. Therefore, complementary and alternative medicine (CAM), especially mind-and-body interventions, such as acupuncture, psychotherapy, climatotherapy, and cupping may provide a cheaper and potentially beneficial outcome for these patients. Methods: We performed a systematic review of articles pertaining to acupuncture, cupping, psychotherapy and meditation, as well climatotherapy and balneotherapy in the management of psoriasis, by using the PubMED, Medline and Google Academic research databases and reference cross-checking. Results: 12 articles on acupuncture, 9 on dry or wet cupping, 27 concerning meditation, hypnosis or psychotherapy, and 34 regarding climate therapy or balneotherapy were found. Discussion and Conclusions: Currently, there is a lack of evidence in the English literature to support acupuncture as an effective alternative therapy for psoriasis, whereas cupping has been described in the majority of instances to result in Koebner phenomenon and clinical worsening. Stress management therapies such as psychotherapy, hypnosis, and meditation have shown promising results as complementary treatment methods. Climatotherapy and balneotherapy have already been proven as effective means of achieving clinical improvement in psoriasis. Further research is still needed to verify the usefulness of the lesser studied treatment methods.

Salt and skin

The introduction of salt as a therapeutic agent in dermatological disorders has been in use since ancient times. This ubiquitous agent is the most underrated substance after the advent of modern medicine. Though a commonly used agent in both traditional and modern medicine, it is important to understand its relationship to the skin to further enhance the comprehensive benefit. The complex history of the evolution of medicine and its skewed distribution among the countries of the world led to inclusion of locally available and economical agents into therapeutics as it becomes almost an inevitable need. Moreover, an inadequate knowledge about the harmful effects of chronic salt exposure led salt to have a unique role in occupational dermatoses. There is no adequate literature on both detrimental and therapeutic effects of salt and its relation to skin. Hence, a genuine attempt was made to summarize the known and the lesser known facts of this particular common seasoning agent.

[Therapeutic effects of climototherapy: scientomatrical analysis of evidence-based studies]

OBJECTIVE

Scientometrical analysis of studies the use of climatotherapy methods and formulation of guidelines based on the evidence obtained during the analysis.

MATERIAL AND METHODS

The article presents the data of scientometrical analysis of 40 publications on the use of climatotherapy in spa practice.

RESULTS

Clinical effects and proposed mechanisms of action of the proven efficacy climatotherapy methods - aerotherapy, heliotherapy and thalassotherapy for the patients with various chronic diseases are presented. The clinical directions for the using of climatotherapy methods in climatic resorts are highlighted.

CONCLUSIONS

Regular generalization and analysis of existing evidence-based studies is required, as well as the implementation of new high-quality randomized controlled clinical trials to study the effects of climate therapy on a wide range of patients with common socially significant diseases.

Inorganic ions in the skin: Allies or enemies?

Skin constitutes a barrier protecting the organism against physical and chemical factors. Therefore, it is constantly exposed to the xenobiotics, including inorganic ions that are ubiquitous in the environment. Some of them play important roles in homeostasis and regulatory functions of the body, also in the skin, while others can be considered dangerous. Many authors have shown that inorganic ions could penetrate inside the skin and possibly induce local effects. In this review, we give an account of the current knowledge on the effects of skin exposure to inorganic ions. Beneficial effects on skin conditions related to the use of thermal spring waters are discussed together with the application of aluminium in underarm hygiene products and silver salts in treatment of difficult wounds. Finally, the potential consequences of dermal exposure to topical sensitizers and harmful heavy ions including radionuclides are discussed.

Indoor balneophototherapy for chronic plaque psoriasis: Abridged Cochrane Review

Artificial exposure to ultraviolet B light (UVB) while soaking in an indoor salt bath, also called balneophototherapy, could simulate the natural exposure to the sun while bathing in the Dead Sea. We aimed to assess the effects of this intervention on patients with chronic plaque psoriasis. We searched CENTRAL, MEDLINE, Embase, and LILACS up to June 2019. We included randomized controlled trials (RCTs). The primary efficacy outcome was psoriasis area and severity index (PASI)-75 to detect people with a 75% or more reduction in the PASI score from baseline. The primary adverse outcome was treatment-related adverse events requiring withdrawal. We included eight RCTs (2105 participants; 1976 analyzed). With respect to PASI-75, two studies found that salt bath + UVB may improve psoriasis when compared to UVB alone (risk ratio 1.71, 95% confidence interval 1.24 to 2.35; 278 participants). With respect to treatment-related adverse events requiring withdrawal, two other studies found little to no difference when compared to UVB alone (risk ratio 0.96, 95% confidence interval 0.35 to 2.64; 404 participants). Salt bath + UVB could improve psoriasis when compared to UVB alone, though, results are based on a limited number of studies and provide low-certainty evidence.

Saline in Dermatology: A literature review

BACKGROUND

Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience.

METHODS

We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks.

RESULTS

Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

CONCLUSIONS

The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

Indoor salt water baths followed by artificial ultraviolet B light for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is an immune-mediated, chronic, inflammatory skin disease, which can impair quality of life and social interaction. Disease severity can be classified by the psoriasis area and severity index (PASI) score ranging from 0 to 72 points. Indoor artificial salt bath with or without artificial ultraviolet B (UVB) light is used to treat psoriasis, simulating sea bathing and sunlight exposure; however, the evidence base needs clear evaluation.

OBJECTIVES

To assess the effects of indoor (artificial) salt water baths followed by exposure to artificial UVB for treating chronic plaque psoriasis in adults.

SEARCH METHODS

We searched the following databases up to June 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trial registers, and checked the reference lists of included studies, recent reviews, and relevant papers for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of salt bath indoors followed by exposure to artificial UVB in adults who have been diagnosed with chronic plaque type psoriasis. We included studies reporting between-participant data and within-participant data. We evaluated two different comparisons: 1) salt bath + UVB versus other treatment without UVB; eligible comparators were exposure to psoralen bath, psoralen bath + artificial ultraviolet A UVA) light, topical treatment, systemic treatment, or placebo, and 2) salt bath + UVB versus other treatment + UVB or UVB only; eligible comparators were exposure to bath containing other compositions or concentrations + UVB or UVB only.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. The primary efficacy outcome was PASI-75, to detect people with a 75% or more reduction in PASI score from baseline. The primary adverse outcome was treatment-related adverse events requiring withdrawal. For the dichotomous variables PASI-75 and treatment-related adverse events requiring withdrawal, we estimated the proportion of events among the assessed participants. The secondary outcomes were health-related quality of life using the Dermatology Life Quality Index, (DLQI) pruritus severity measured using a visual analogue scale, time to relapse, and secondary malignancies.

MAIN RESULTS

We included eight RCTs: six reported between-participant data (2035 participants; 1908 analysed), and two reported within-participant data (70 participants, 68 analysed; 140 limbs; 136 analysed). One study reported data for the comparison salt bath with UVB versus other treatment without UVB; and eight studies reported data for salt bath with UVB versus other treatment with UVB or UVB only. Of these eight studies, only five reported any of our pre-specified outcomes and assessed the comparison of salt bath with UVB versus UVB only. The one included trial that assessed salt bath plus UVB versus other treatment without UVB (psoralen bath + UVA) did not report any of our primary outcomes. The mean age of the participants ranged from 41 to 50 years of age in 75% of the studies. None of the included studies reported on the predefined secondary outcomes of this review. We judged seven of the eight studies as at high risk of bias in at least one domain, most commonly performance bias. Total trial duration ranged between at least two months and up to 13 months. In five studies, the median participant PASI score at baseline ranged from 15 to 18 and was balanced between treatment arms. Three studies did not report PASI score. Most studies were conducted in Germany; all were set in Europe. Half of the studies were multi-centred (set in spa centres or outpatient clinics); half were set in a single centre in either an unspecified settings, a psoriasis daycare centre, or a spa centre. Commercial spa or salt companies sponsored three of eight studies, health insurance companies funded another, the association of dermatologists funded another, and three did not report on funding. When comparing salt bath plus UVB versus UVB only, two between-participant studies found that salt bath plus UVB may improve psoriasis when measured using PASI 75 (achieving a 75% or more reduction in PASI score from baseline) (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.24 to 2.35; 278 participants; low-certainty evidence). Assessment was conducted at the end of treatment, which was equivalent to six to eight weeks after start of treatment. The two trials which contributed data for the primary efficacy outcome were conducted by the same group, and did not blind outcome assessors. The German Spas Association funded one of the trials and the funding source was not stated for the other trial. Two other between-participant studies found salt bath plus UVB may make little to no difference to outcome treatment-related adverse events requiring withdrawal compared with UVB only (RR 0.96, 95% CI 0.35 to 2.64; 404 participants; low-certainty evidence). One of the studies reported adverse events, but did not specify the type of events; the other study reported skin irritation. One within-participant study found similar results, with one participant reporting severe itch immediately after Dead Sea salt soak in the salt bath and UVB group and two instances of inadequate response to phototherapy and conversion to psoralen bath + UVA reported in the UVB only group (low-certainty evidence).

AUTHORS' CONCLUSIONS

Salt bath with artificial ultraviolet B (UVB) light may improve psoriasis in people with chronic plaque psoriasis compared with UVB light treatment alone, and there may be no difference in the occurrence of treatment-related adverse events requiring withdrawal. Both results are based on data from a limited number of studies, which provided low-certainty evidence, so we cannot draw any clear conclusions. The reporting of our pre-specified outcomes was either non-existent or limited, with a maximum of two studies reporting a given outcome. The same group conducted the two trials which contributed data for the primary efficacy outcome, and the German Spas Association funded one of these trials. We recommend further RCTs that assess PASI-75, with detailed reporting of the outcome and time point, as well as treatment-related adverse events. Risk of bias was an issue; future studies should ensure blinding of outcome assessors and full reporting.

Complementary and alternative medicine for psoriasis: what the dermatologist needs to know

Complementary and alternative medicine (CAM) use is common among patients with psoriasis. CAM modalities include traditional Chinese medicine (TCM), herbal therapies, dietary supplements, climatotherapy, and mind/body interventions. In this review, evidence from clinical trials investigating the efficacy of CAM for psoriasis is reviewed. There is a large amount of evidence from controlled trials that have shown that the combination of TCM with traditional therapies for psoriasis is more efficacious than traditional therapies alone. Herbal therapies that have the most evidence for efficacy are Mahonia aquifolium and indigo naturalis, while there is a smaller amount of evidence for aloe vera, neem, and extracts of sweet whey. Dietary supplementation in patients with psoriasis demonstrates consistent evidence supporting the efficacy of fish oil supplements. Zinc supplementation has not been shown to be effective; however, some evidence is available (albeit conflicting) for vitamin D, vitamin B12, and selenium supplementation. Overwhelming evidence supports the effectiveness of Dead Sea climatotherapy. Finally, mindfulness-based stress reduction can be helpful as adjuvant treatment of psoriasis. There are potential benefits to these modalities, but also potential side issues. Concerns with CAM include, but are not limited to, contamination of TCM products with heavy metals or corticosteroids, systemic toxicity or contact dermatitis from herbal supplements, and ultraviolet light-induced carcinomas from climatotherapy. Dermatologists should be aware of these benefits and side effects to allow for informed discussions with their patients.

Balneotherapy (or spa therapy) for rheumatoid arthritis

BACKGROUND

No cure for rheumatoid arthritis (RA) is known at present, so treatment often focuses on management of symptoms such as pain, stiffness and mobility. Treatment options include pharmacological interventions, physical therapy treatments and balneotherapy. Balneotherapy is defined as bathing in natural mineral or thermal waters (e.g. mineral baths, sulphur baths, Dead Sea baths), using mudpacks or doing both. Despite its popularity, reported scientific evidence for the effectiveness or efficacy of balneotherapy is sparse. This review, which evaluates the effects of balneotherapy in patients with RA, is an update of a Cochrane review first published in 2003 and updated in 2008.

OBJECTIVES

To perform a systematic review on the benefits and harms of balneotherapy in patients with RA in terms of pain, improvement, disability, tender joints, swollen joints and adverse events.

SEARCH METHODS

We searched the Cochrane 'Rehabilitation and Related Therapies' Field Register (to December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 1), MEDLIINE (1950 to December 2014), EMBASE (1988 to December 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to December 2014), the Allied and Complementary Medicine Database (AMED) (1985 to December 2014), PsycINFO (1806 to December 2014) and the Physiotherapy Evidence Database (PEDro). We applied no language restrictions; however, studies not reported in English, Dutch, Danish, Swedish, Norwegian, German or French are awaiting assessment. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing and recently completed trials.

SELECTION CRITERIA

Studies were eligible if they were randomised controlled trials (RCTs) consisting of participants with definitive or classical RA as defined by the American Rheumatism Association (ARA) criteria of 1958, the ARA/American College of Rheumatology (ACR) criteria of 1988 or the ACR/European League Against Rheumatism (EULAR) criteria of 2010, or by studies using the criteria of Steinbrocker.Balneotherapy had to be the intervention under study, and had to be compared with another intervention or with no intervention.The World Health Organization (WHO) and the International League Against Rheumatism (ILAR) determined in 1992 a core set of eight endpoints in clinical trials concerning patients with RA. We considered pain, improvement, disability, tender joints, swollen joints and adverse events among the main outcome measures. We excluded studies when only laboratory variables were reported as outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, performed data extraction and assessed risk of bias. We resolved disagreements by consensus and, if necessary, by third party adjudication.

MAIN RESULTS

This review includes two new studies and a total of nine studies involving 579 participants. Unfortunately, most studies showed an unclear risk of bias in most domains. Four out of nine studies did not contribute to the analysis, as they presented no data.One study involving 45 participants with hand RA compared mudpacks versus placebo. We found no statistically significant differences in terms of pain on a 0 to 100-mm visual analogue scale (VAS) (mean difference (MD) 0.50, 95% confidence interval (CI) -0.84 to 1.84), improvement (risk ratio (RR) 0.96, 95% CI 0.54 to 1.70) or number of swollen joints on a scale from 0 to 28 (MD 0.60, 95% CI -0.90 to 2.10) (very low level of evidence). We found a very low level of evidence of reduction in the number of tender joints on a scale from 0 to 28 (MD -4.60, 95% CI -8.72 to -0.48; 16% absolute difference). We reported no physical disability and presented no data on withdrawals due to adverse events or on serious adverse events.Two studies involving 194 participants with RA evaluated the effectiveness of additional radon in carbon dioxide baths. We found no statistically significant differences between groups for all outcomes at three-month follow-up (low to moderate level of evidence). We noted some benefit of additional radon at six months in terms of pain frequency (RR 0.6, 95% CI 0.4 to 0.9; 31% reduction; improvement in one or more points (categories) on a 4-point scale; moderate level of evidence) and 9.6% reduction in pain intensity on a 0 to 100-mm VAS (MD 9.6 mm, 95% CI 1.6 to 17.6; moderate level of evidence). We also observed some benefit in one study including 60 participants in terms of improvement in one or more categories based on a 4-point scale (RR 2.3, 95% CI 1.1 to 4.7; 30% absolute difference; low level of evidence). Study authors did not report physical disability, tender joints, swollen joints, withdrawals due to adverse events or serious adverse events.One study involving 148 participants with RA compared balneotherapy (seated immersion) versus hydrotherapy (exercises in water), land exercises or relaxation therapy. We found no statistically significant differences in pain on the McGill Questionnaire or in physical disability (very low level of evidence) between balneotherapy and the other interventions. No data on improvement, tender joints, swollen joints, withdrawals due to adverse events or serious adverse events were presented.One study involving 57 participants with RA evaluated the effectiveness of mineral baths (balneotherapy) versus Cyclosporin A. We found no statistically significant differences in pain intensity on a 0 to 100-mm VAS (MD 9.64, 95% CI -1.66 to 20.94; low level of evidence) at 8 weeks (absolute difference 10%). We found some benefit of balneotherapy in overall improvement on a 5-point scale at eight weeks of 54% (RR 2.35, 95% CI 1.44 to 3.83). We found no statistically significant differences (low level of evidence) in the number of swollen joints, but some benefit of Cyclosporin A in the number of tender joints (MD 8.9, 95% CI 3.8 to 14; very low level of evidence). Physical disability, withdrawals due to adverse events and serious adverse events were not reported.

AUTHORS' CONCLUSIONS

Overall evidence is insufficient to show that balneotherapy is more effective than no treatment, that one type of bath is more effective than another or that one type of bath is more effective than mudpacks, exercise or relaxation therapy.

Skin, Inflammation and Sulfurous Waters: What is Known, What is Believed

One could argue that balneotherapy and mud therapy would have not lasted 2,000 years or so If they were not effective. No doubt a long history cannot be taken per se as scientific proof of efficacy. Some empiricism is still present in the field: the concept of spa itself is quite confounding, whereas spring waters are used for leisure purposes but also for non-acute patient therapy and late phases of clinical recovery. These confounding elements ultimately feed the opinion of those who aprioristically reject any potential beneficial effect of balneotherapy: instead, it should at least generate questions that deserve scientific answers. Clinical practices sequentially integrating pharmacological therapy with those natural principles for which a sufficient scientific demonstration is available, would probably cut the costs of public health, generating widespread advantages for the community. Recently, it has become evident that mineral waters may have intrinsic pharmacological properties. Of the numerous salts dissolved in thermal waters that might show pharmacological properties, for certain hydrogen sulfide (H2S) contained in sulfurous waters is the one that has obtained greater scientific attention, to which should be added the extensive scientific effort recently dedicated to H2S as a cellular gasotransmitter, independently from its natural sources. Dermatology and cosmetics are among the most studied applications of sulfurous waters, around which, however, some empiricism still confounds opinions: we therefore considered that a state-of-the-art focus on this topic might be timely and useful for future studies.

Interaction of mineral salts with the skin: a literature survey

There is growing scientific evidence that the health, well-being and the attractiveness of the skin are strongly influenced by nutrition. Consumers recognize this and have supported the creation of a global cosmeceuticals market estimated in 2010 at $27.2 billion. Early in 2011, the US Department of Health and Human Services and Department of Agriculture issued the Dietary Guidelines for Americans, 2010. Twelve vitamins and nine minerals were recognized as essential. The minerals include calcium, copper, iron, magnesium, phosphorus, selenium, zinc, potassium and sodium. Although the topical benefits of several minerals such as zinc, magnesium and iron are recognized and, in some cases, approved by the FDA, the topical benefits of the others to the skin are largely unexplored and unexploited. This review attempts to summarize what has been published in the literature on the interactions of the eight of the nine essential elements with the skin.

Complementary and alternative medicine for psoriasis: a qualitative review of the clinical trial literature

BACKGROUND

Patients with psoriasis often inquire about complementary and alternative medicine in an effort to do everything possible to control the disease.

OBJECTIVE

We sought to review the clinical trial literature regarding complementary and alternative medicine for the treatment of psoriasis.

METHODS

We conducted qualitative systematic review of randomized, clinical trials.

RESULTS

Although many randomized controlled trials were found, both the results and the quality of the studies varied.

LIMITATIONS

The main limitations were the relatively low quality of studies (as assessed by Jadad scores), lack of inclusion of unpublished studies, and the fact that only one author determined inclusion of studies and assignment of Jadad scores.

CONCLUSION

There is a large body of literature in regard to complementary and alternative medicine for the treatment of psoriasis. More work is necessary before these modalities should be recommended to our patients.

Balneotherapy for osteoarthritis

BACKGROUND

Balneotherapy (or spa therapy, mineral baths) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain and as a consequence to relieve patients' suffering and make them feel well. In this update we included one extra study.

OBJECTIVES

To assess the effectiveness of balneotherapy for patients with osteoarthritis (OA).

SEARCH STRATEGY

We searched the following databases up to October 2006: EMBASE, PubMed, the Cochrane 'Rehabilitation and Related Therapies' Field database, PEDro, CENTRAL (Issue 3, 2006) and performed reference checking and communicated with authors to retrieve eligible studies.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing balneotherapy with any intervention or no intervention. At least 90% of the patient population had to be diagnosed with OA.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed quality and extracted data. Disagreements were solved by consensus. In the event of clinical heterogeneity or lack of data we refrained from statistical pooling.

MAIN RESULTS

Seven trials (498 patients) were included in this review. Two studies compared spa-treatment with no treatment. One study evaluated baths as an add-on treatment to home exercises and another compared thermal water from Cserkeszölö with tap water (placebo). Three studies evaluated sulphur or Dead Sea baths with no treatment or mineral baths with tap water baths or no treatment. Only one of the trials performed an intention-to-treat analysis and two studies provided data to perform an intention-to-treat analysis ourselves. A 'quality of life' outcome was reported by one trial. We found: silver level evidence concerning the beneficial effects on pain, quality of life and analgesic intake of mineral baths compared to no treatment (SMD between 1.82 and 0.34). a statistically significant difference in pain and function of Dead Sea + sulphur versus no treatment, only at end of treatment (WMD 5.7, 95%CI 3.3 to 8.1), but not at 3 month follow-up (WMD 2.6, 95%CI -1.1 to 6.3). no statistically significant differences in pain or function at one or three months of Dead Sea baths versus no treatment (WMD 0.5, 95%CI -0.6 to 1.6) or at one or three months of sulphur baths versus no treatment (WMD 0.4, 95%CI -0.9 to 1.7). Adverse events were not measured in the included trials.

AUTHORS' CONCLUSIONS

We found silver level evidence (www.cochranemsk.org) concerning the beneficial effects of mineral baths compared to no treatment. Of all other balneological treatments no clear effects were found. However, the scientific evidence is weak because of the poor methodological quality and the absence of an adequate statistical analysis and data presentation. Therefore, the noted "positive findings" should be viewed with caution.

A pragmatic randomized controlled trial on the effectiveness of low concentrated saline spa water baths followed by ultraviolet B (UVB) compared to UVB only in moderate to severe psoriasis

OBJECTIVE

To evaluate whether low concentrated saline spa water baths followed by ultraviolet B (LC-SSW-UVB) are superior to UVB alone in moderate to severe psoriasis.

BACKGROUND

There is a lack of sufficiently large randomized controlled clinical trial evaluating the additional benefit of saltwater baths followed by UVB compared to UVB only in psoriasis.

STUDY DESIGN

Partly evaluator blind, multicentre, pragmatic, randomized controlled trial.

SETTING

Five German spa centres.

SUBJECTS

One hundred and forty-three adults with stable psoriasis during the last month and a Psoriasis Area and Severity Index (PASI) of > 10 and/or an affected body surface area of > 15%.

INTERVENTIONS

LC-SSW-UVB or UVB thrice a week until remission (PASI < 5) or for a maximum of 6 weeks. Sodium chloride concentrations of natural springs varied between 4.5% and 12%. Conventional UVB (broadband UVB or selective UVB phototherapy) was used as irradiation source.

MAIN OUTCOME

Reduction of PASI and/or affected body surface area of 50% at the end of the intervention period (PASI-50). Only participants receiving at least one intervention were included in the primary analysis.

RESULTS

Patients allocated to LC-SSP-UVB attained a statistically significantly higher rate of PASI-50 at the end of the intervention period than patients allocated to UVB [58/79 (73%) vs. 32/64 (50%); P = 0.01; NNT, 4.3, 95% CI, 2.4-18.1]. Benefit persisted until 3 months only for one of two secondary outcomes considered.

CONCLUSIONS

In routine clinical practice balneophototherapy using conventional UVB is superior to conventional UVB only at the end of a 6-week treatment course.

A 10-day course of SPA therapy is beneficial for people with severe knee osteoarthritis

The objective of this study was to test if spa therapy can play a role in the management of severe knee osteoarthritis (OA). Twenty patients with radiologically and clinically severe knee OA were randomly assigned into spa and drug therapy groups. Spa group (n = 10) traveled to a spa town and stayed at a hotel for a 10-day spa therapy course. They followed a balneotherapy regimen including thermal pool baths at 37 degrees C for 20 min two times daily. Drug therapy group (n = 10) stayed at home and followed their individually prescribed drug therapy (NSAIDs and paracetamol). Patients were assessed at baseline (week 0), after spa therapy at 2 weeks (week 2) and during follow-up period at 12 (week 12) and 24 (week 24) weeks by a blinded investigator. Patients assessed with Lequesne algofunctional index (LAFI), pain (visual analogue scale, VAS), patient's and investigator's global evaluation (VAS), ten-stairs stepping up and down time, 15 m walking time and three times squatting up and down time. Significant improvement in pain and LAFI scores were found at week 2, week 12 and week 24 in the spa therapy group compared to baseline. Comparing the two group differences, spa therapy was superior to drug therapy in pain reduction and in physician's global assessment at all time points. This superiority was also found in LAFI scores and patients' global assessments at week 12 and week 24. A 10-day course of spa therapy may be beneficial in short- and medium-term up to 24 weeks by reducing pain and improving functional status and overall well-being in patients with severe knee OA and may be considered as an effective therapeutic tool for such patients in countries like Turkey where it is widely available and (at least partly) reimbursed.

Exogenous hydrogen sulfide induces functional inhibition and cell death of cytotoxic lymphocytes subsets

The toxic effects of exogenous hydrogen sulfide on peripheral blood lymphocytes have been investigated in detail. Hydrogen sulfide is now considered as a gasotransmitter with specific functional roles in different cell types, like neurons and vascular smooth muscle. Here we show that exogenous hydrogen sulfide induces a caspase-independent cell death of peripheral blood lymphocytes that depends on their intracellular glutathione levels, with a physiologically relevant subset specificity for CD8+ T cells and NK cells. Although lymphocyte activation does not modify their sensitivity to HS-, after 24 h exposure to hydrogen sulfide surviving lymphocyte subsets show a dramatically decreased proliferation in response to mitogens and a reduced IL-2 production. Overall, our data demonstrate that HS- reduces the cellular cytotoxic response of peripheral blood lymphocytes as well as their production of IL-2, therefore de-activating the major players of local inflammatory responses, adding new basic knowledge to the clinically well known anti-inflammatory effects of sulfur compounds.

Phototherapy with narrowband vs broadband UVB

Phototherapy with ultraviolet (UV) radiation of wavelengths between 280 and 320 nm (UVB) is a safe and effective treatment for a variety of diseases. In addition to standard broadband UVB (bUVB), narrowband phototherapy with fluorescent bulbs emitting near monochromatic UV around 311 nm (nUVB) has become an important treatment for diseases such as psoriasis, atopic dermatitis and vitiligo. In addition to these indications, the number of diseases for which nUVB phototherapy is reported to be effective is continuously growing. The differential effects of nUVB phototherapy in comparison to other UV wavelengths as well as established and new indications for this treatment modality are reviewed.

A randomized controlled comparison of the efficacy of Dead Sea salt balneophototherapy vs. narrowband ultraviolet B monotherapy for chronic plaque psoriasis

BACKGROUND

Dead Sea (DS) salt solution soaks are used in combination with narrowband ultraviolet B (NB-UVB) to treat psoriasis in many centres, particularly in continental Europe. No previously published controlled study has assessed DS salt + NB-UVB balneophototherapy.

OBJECTIVES

To compare DS salt balneophototherapy with NB-UVB monotherapy for chronic plaque psoriasis.

METHODS

Sixty patients with chronic plaque psoriasis participated in this paired, controlled study, with pretreatment DS salt soaks randomly allocated to each participant's right or left study limb. Psoriasis severity was assessed with a Scaling, Erythema and Induration score by a blinded observer. Assessments were weekly during the therapy course, and thereafter 8-weekly until relapse or for up to 1 year after clearance.

RESULTS

The mean area under the psoriasis severity-time curves during treatment was not detectably lower with DS salt balneophototherapy than with NB-UVB monotherapy (P = 0.099). The psoriasis severity score fell slightly more from beginning to end of courses with DS salt balneophototherapy than with NB-UVB monotherapy (P = 0.019). There was no detectable difference in times to relapse.

CONCLUSIONS

In this population the addition of pretreatment DS salt soaks to NB-UVB did not result in a clinically important improvement in clearance of psoriasis.

Balneotherapy for rheumatoid arthritis

BACKGROUND

Balneotherapy (spa therapy) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain, improve joint motion and as a consequence to relieve people' suffering and make them feel well.

OBJECTIVES

To perform a systematic review on the effectiveness of balneotherapy for rheumatoid arthritis.

SEARCH STRATEGY

Using the Cochrane search strategy, studies were found by screening: 1) The MEDLINE CD-ROM database from 1966 to June 2002 and 2) the database from the Cochrane 'Rehabilitation and Related Therapies' Field, the Pedro database up to June 2002. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. Date of the most recent literature search: June, 2002

SELECTION CRITERIA

Studies were eligible if they were randomised controlled trials (RCTs) comparing balneotherapy with any other intervention or with no intervention. Included participants all suffered from definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) or by the criteria of Steinbrocker. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be among the main outcome measures.

DATA COLLECTION AND ANALYSIS

The Delphi list was the criteria list used to assess the components of methodological quality. Two reviewers carried out quality assessment and data extraction of the studies. Disagreements were solved by consensus.

MAIN RESULTS

Six trials, representing 355 people, were included in this review. Most trials reported positive findings (the absolute improvement in measured outcomes ranged from 0 to 44%), but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. None of the trials performed an intention-to-treat analysis and only two performed a comparison of effects between groups. Pooling of the data was not performed; because of heterogeneity of the studies, multiple outcome measurements, and the overall data presentation was too scarce.

REVIEWER'S CONCLUSIONS

One cannot ignore the positive findings reported in most trials. However the scientific evidence is insufficient because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, self assessed function, quality of life). Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the apparent effectiveness of balneotherapy cannot be provided at this moment. A large, methodological sound trial is needed.