Clinics in Dermatology (2008) 26, 477485

Climatotherapy of psoriasis
Jana Kazandjieva, MD, Ivan Grozdev, MD,
Razvigor Darlenski, MD, Nikolai Tsankov, MD
Department of Dermatology and Venereology, Medical Faculty, Sofia, Bulgaria, 1431 Sofia, Bulgaria

Abstract In the era when biological treatments for psoriasis are gaining more and more popularity,
climatotherapy represents a safe and efficient alternative to the conventional therapeutic modalities.
Climatotherapy comprises alternative treatment methods, which are based on the healing capacities of
natural resources. This paper provides the reader with relevant information on the different
climatotherapeutic methods, the intimate mechanisms of their action, and the cumulated clinical
experience in the treatment of psoriasis.The positive effect of thalassotherapy for psoriasis has been
known since ancient times. However, in the past decades a number of controlled studies revealed the
efficacy of thalassotherpay in the treatment of psoriasis. Herein, it is exemplified on the experience in
the centers at the Dead Sea and the Black Sea coast.Originating from Europe, balneo- and spa therapy
are becoming popular alternatives for psoriasis treatment worldwide. A short review on the centers
profiled for psoriasis therapy is provided. The unique sites of Blue Lagoon in Iceland and Kangal in
Turkey are selected in this paper. Additionally, alternative nature-based treatments for psoriasis such as
high mountain climatotherapy and naphtalotherapy are discussed.
2008 Elsevier Inc. All rights reserved.

Introduction phrase from one of the tragedies of Euripides.2 During the

Climatotherapy comprises alternative treatment methods
employing the healing capacities of natural resources,
including air, temperature, humidity, barometric pressure
and light.1
Sea and spa water and products have been used for their
healing, curative properties for thousands of years. Even
Hippocrates suggested that the cause of all diseases lays in an
imbalance of the body fluids. To regain the balance, he
advised a change of habits and environment like bathing,
perspiration, walking and massages. In the history of the
Mediterranean people during the ancient Greek and Roman
ages sea water was one of the most widely used therapeutic
agents. Sea water cures all human diseases is a popular
Corresponding author. Tel.: +359 2 923 0684.
E-mail address: tsankn@abv.bg (N. Tsankov).
Roman time Galen (131201 CE) also advocated the use of
water for the treatment of a variety of diseases. He preferred
cold water, a concept that was reconsidered periodically
throughout the following ages. In many cities of the Roman
Empire seawater baths were used for the treatment of
tuberculosis, psoriasis, and rheumatism. Consequently, the
Roman legions built their own baths at mineral and thermal
springs in the newly conquered lands. After the 2nd century
CE, along with the spreading of Christianity and based on
religious dogmas, the use of sea water was largely neglected.
The early Christian Church interdicted ceremonial baths.
Many of the elaborate facilities fell into disrepair, with some
being redeveloped as churches, whereas others survived for
the royalty, who seemed not to be affected by the church
decrees.3
The renaissance of thalassotherapy came in the middle of
the 18th century. It was stimulated by Russo's ideas and the
ideas of the neo-hippocratism which laid the scientific

0738-081X/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2008.05.001
478
foundation of thalassotherapy.2 The work of the English
physician R. Russel in 1749, entitled Dissertatio de tabe
glandular, sive de uso aquae marinae in morbis glandu-
larum and concerning the use of sea water in the treatment
of glandular diseases, was the first approval of thalas-
sotherapy. In 1778, the first Maison de Sant Thermale
Marine (Seawater Bathing Spa) was opened at Dieppe,
France. In 1868, a Florentine doctor named Barellai opened
l'Ospizio Marittimo Veneto, a seawater treatment center, on
the Lido in Venice. The first international congress of sea
bathing and water therapy was held in 1894 in Boulogne-
sur-Mer in France. Seawater therapy was advocated as
being beneficial in treating tuberculosis, gynecological and
dermatological disorders.4
More recently, water-based treatments have been further
specified resulting in novel terms such as balneotherapy, spa
therapy, thalassotherapy, etc. The exact meaning of these
terms is often controversial or overlapping. The aim of this
paper is not to give clear definitions, but to delineate the use
of all water-based treatments involving natural thermal
springs, hot springs, mineral water, and seawater for the
treatment of psoriasis.
Thalassotherapy of psoriasis
Thalassotherapy is a modality of therapeutic and
prophylactic application of sea water, mud, algae, sand and
climate in general. The term stems from the ancient Greek
word ss which means sea. as observed in psoriasis. Clinical studies have revealed
No other skin disease responds to thalassotherapy as
dramatically as psoriasis vulgaris.5 Which are the prerequi-
sites of thalassotherapy?
No corticosteroid preparations are applied
No artificial light sources are used
No systemic therapy is given
No dietary restrictions are imposed
External applications are confined to emollients
In contrast to the conventional therapy for psoriasis,
thalassotherapy is mostly natural and has only few unwanted
side effects. The therapeutic effect is achieved through the
combined action of sun light, sea water, and fresh air and, in
some cases, of combinations with spa water. Some trace
elements such as magnesium, potassium, calcium sulfates,
and sodium, found in seawater, are believed to be absorbed
through the skin and are also beneficial for the good
therapeutic response to thalassotherapy.
Dead Sea
The Dead Sea is a world-famous seaside for climatother-
apy of psoriasis. It is a terminal lake with no outflows. It is
situated in the great Syrian-African rift valley and is the
J. Kazandjieva et al.
lowest point on Earth, 400 m below sea level. The Dead Sea
is a place with unique climatic features, which are beneficial
for certain dermatological conditions, especially for psor-
iasis. Its salt concentration is the highest found in any
natural body of water.6 The salts and minerals are present in
a total concentration of 33%, compared with the total
concentration in the ocean of only 3%. The Dead Sea is rich
in magnesium chloride, calcium chloride, sodium chloride,
potassium chloride, bromine, and calcium sulfate. The
overall UV radiation level at the Dead Sea is lower because
the UV rays pass through additional 400 m of atmosphere
before reaching the Earth's surface. This results in a shift of
the spectrum balance, inasmuch as the ratio of the
intensities of the UVB rays to UVA is lower at the sea
level as compared to higher altitudes.7,8 Furthermore, the
UV spectral measurements vary according to the month of
the year, time of day, cloudiness, and other meteorological
factors.9 The unique spectrum of UV light is thought to be
the principal component responsible for clearing the skin.
A study has demonstrated that the mean improvement in the
psoriatic condition was 28% in patients bathing in the Dead
Sea water only, 72% in patients with only sun bathing and
83% in patients doing both.10,11 In addition, some studies
have shown that the high salt concentrations, similar to the
Dead Sea, can decrease the mitotic rate of epidermal cells.
Solutions of some of the Dead Sea salts were found to
inhibit cell proliferation in culture.12 Laboratory investiga-
tions indicate a possible correlation with the cutaneous
absorption of the major ions in the Dead Sea and a
correction in the abnormal regulation of cell proliferation,
benefit from immersion in the Dead Sea water. Adding
Dead Sea salts to the bath water significantly improved or
cleared 49 of the 50 patients treated.13 In another study a
30% Dead Sea salt solution applied only to the plaques
failed to show a therapeutic response.14 It appears, there-
fore, that the main therapeutic effect of climatotherapy at
the Dead Sea can be attributed primarily to the sunshine and
secondarily to the seawater.
Every year many psoriatic patients from different
countries experience the benefit of the Dead Sea climatother-
apy in Israel. In 1977 Avrach reported several large studies of
patients treated at the Dead Sea according to a standardized
protocol.15 In his studies, approximately 24% of the patients
cleared completely, 53% showed a marked improvement, and
19% a partial improvement. Later on, in 1985, Abels et al.
published a controlled study finding 56% of the patients with
complete clearing, 29% with excellent improvement, and
13% with considerable improvement.16 Several follow-up
studies with larger cohorts of patients have reported almost
identical results.17,18 Although impressive improvements
have been reported for patients with psoriasis, with a
clearance rate of more than 80% after a 4-week climatother-
apy at the Dead Sea, questions regarding the safety of this
treatment have arisen.19 Some authors have reported that the
mean UVB exposure dose at the Dead Sea is one of the lowest
Climatotherapy of psoriasis
still sufficient for clearance of psoriatic plaques. Cohen et al.
evaluated the effectiveness of Dead Sea climatotherapy in
70 psoriatic patients.20 The severity of the disease was
assessed before and after the climatotherapy using the PASI
score and a novel simplified tool for the assessment of
psoriasisthe Beer Sheva Psoriasis Severity Score (BPSS).
The authors concluded that climatotherapy at the Dead Sea is
an effective therapy for patients with psoriasis, as evaluated
by either PASI score or BPSS. Thousands of patients
suffering from psoriasis have been treated successfully in
the Dead Sea area. This high rate of success, measured in
terms of partial to complete plaque clearance and reported to
exceed 85% after 34 weeks of treatment, has been assumed
to be associated with a unique ultraviolet radiation environ-
ment present in the Dead Sea region.21 Harari et al. went
further and reported a 95,5% improvement of the mean PASI
in 64 German psoriatic patients after a 4-week Dead sea
climatotherapy.22 All patients achieved PASI 50, and 75.9%
of the patients achieved PASI 75 after 1 month of treatment.
The median time of remission was 23.1 weeks. The median
time of duration of therapeutic effect was 33.6 weeks.
Statistical multivariable analysis indicated that younger age
of the patients at the time of treatment was associated with a
longer period of remission. Harari has tried to define a
practical approach for patients eligible for Dead Sea
treatment.23 According to this author, Dead Sea treatment
should be considered for psoriasis patients when:
classical phototherapy is not possible for the patient
there is involvement of the joints (psoriatic arthritis)
there is a history of a successful previous stay at the
Dead Sea
there is a history of unsuccessful other treatments
(including phototherapy).
The natural sun light combined with sea baths is widely
used at the Dead Sea in Jordan as well. The percentage and
success of clearance of psoriatic lesions in a large number of
patients were classified according to four stages.24 The
results of the studies conducted at the Dead Sea in Jordan
show that around one third of patients have experienced
complete clearance, between 4050% showed a significant
improvement, and one third showed partial improvement. In
2004, Bisharat reported 431 patients with psoriasis who
underwent thalassotherapy at the Dead Sea medical center in
Jordan. 31% of these patients showed complete clearance,
and 55% of the patients achieved significant improvement.
The author concluded that climatotherapy at the Dead Sea is
an effective therapeutic alternative for psoriatic patients.25
Another study with similar therapeutic results was reported
in 2006.26
Black sea
There is a more than 50-year experience with thalas-
sotherapy for psoriatic patients in Bulgaria.27 The first
479
clinical studies on thalassotherapy were conducted in the
1960s.28 From that time on more than 15,000 patients have
been treated at the Black Sea, and the long-term therapeutic
results have shown good effectiveness, fewer exacerbations
of the disease and prolonged remissions.29-31 Thalassother-
apy in Bulgaria is executed at the Black Sea. The climate at
the Bulgarian seaside is predominantly continental. The
beneficial effect of thalassotherapy is based on the exposure
of the skin to the unique combination of three climatic
factorssunlight, seawater and allergen-free air. The average
summer temperature ranges between 22 and 35C.5 The
average temperature of the seawater is 2728C during
the summer period. Thalassotherapy of psoriatic patients on
the Bulgarian seaside is performed from May to September.
The Black Sea water has pH 8,338,40 and is rich on
mineral and organic substances and colloids such as
chlorides, sodium, potassium, magnesium, sulfur, calcium
and carbonates.32 The salt concentration is 17,318,2 g/l.33
The so called salt mantle has keratolytic action and
increases the skin hydration. The patients undergo a specific
regimen of gradual sun exposure with a stepwise increase to
a maximum of 6h at the 7th day. The good therapeutic
response to heliotherapy is achieved through the direct
action of the natural sun light on the psoriatic lesions
compared to the lack of such an effect in the non-exposed
areas.28,29 Heliotherapy is combined with 610 daily sea
baths with durations of 515 minutes each. The response to
thalassotherapy is achieved through normalization of the
keratopoesis, diminution of the inflammatory infiltrate,
improvement of the capillary permeability and the blood
circulation of the skin.
In a study conducted in 1770 psoriatic patients who
underwent a 28-day thalassotherapy, 30% of the patients
achieved remission of the disease, and 61% of the
patients were recorded with marked or moderate
improvement.34
In another study, 69% of the patients achieved remission
or marked improvement during a 20-day course of
thalassotherapy combined with 515-minute baths in the
sea water per hour.5 Grozdev et al. reported a study
comparing the efficacy of combined topical calcipotriol
treatment and thalassotherapy to the efficacy of thalassother-
apy alone.35 The authors found that the combination of
topical calcipotriol and thalassotherapy was superior to
thalassotherapy alone.35
Further investigations revealed that serum levels of
calcium, potassium and sodium were increased after
thalassotherapy, while those of magnesium and phosphorus
were decreased.34 Helio- and thalassotherapy influence the
serum copper and ceruloplasmin levels in psoriatic
patients.36 The intake of antioxidants during thalassotherapy
lowers the risk of side effects of the UV-radiation.5
Nowadays, psoriasis is considered a chronic and debilitating
inflammatory disease associated with serious comorbidi-
tites.37,38 Psoriatic patients have an increased prevalence of
the components of metabolic syndrome, including obesity,
480
dyslipidemia, and insulin resistance. Thalassotherapy was
shown to have a beneficial effect on the hyperlipidemias with
a frequency of 28,4% before and 3,1% after thalassotherapy,
respectively.29,39
The spectrum of therapeutic modalities for psoriasis
continues to expand, but inadequate attention is devoted to
duration of remission. A remission period for psoriasis has
never been clearly defined. Koo and Lebwohl have tried to
examine the duration of remission of different therapies
currently used for psoriasis.40 They have reported that 41%
of the patients receiving heliotherapy suffer from a relapse of
their disease within a month after discontinuation of the
treatment, and 83% experience a relapse within 6 months.
Koo and Lebwohl have mentioned that 45% of the psoriatic
patients treated at the Dead Sea had relapse in a month after
therapy. In a clinical study performed at the Dead Sea, 45%
of the patients treated had a recurrence of the disease within
one month after heliotherapy. The same recurrence rate was
reported for patients after Goeckerman treatment.15 In the
studies conducted by Basharat at the Dead Sea medical
center in Jordan, the majority of the patients who were
followed-up maintained clearance for a longer time com-
pared to other modalities of therapy (6.1 months on
average).25,26 Harari et al. stated that the period of remission
following Dead Sea climatotherapy compares favorably with
other accepted modalities of treatment.22
Given that psoriasis patients are frequently depressed,
one of the advantages of climatotherapy is increased
optimism and well-being of the patients.6 During clima-
totherapy, patients slowly gain confidence due to the relaxed
atmosphere, and this is thought to contribute to the
favorable overall response. Thalassotherapy considerably
improves the quality of life of patients. In a recent study,
68% of the interviewed psoriatic patients have declared a
high satisfaction from climatotherapy.41 The physical
improvement of the patients was associated with complex
positive psychological influence extending beyond elimina-
tion of everyday stress.
The overall contraindications of thalassotherapy include
tuberculosis, neoplasms, recent myocardial infarcts, athero-
sclerosis, stable high blood pressure, acute infectious
diseases.34 The relative contraindications are thyreotoxico-
sis, arrhythmias, pregnancy, thrombophlebitis, varicosis,
chronic hepatitis, glomerulonephritis, Addison's disease. In
addition, there are certain skin diseases, which preclude
thalassotherapy: photodermatoses, lupus erythematosus,
basal cell and squamous cell carcinomas, pemphigus and
pemphigoid, xeroderma pigmentosum and herpes infections.
The side effects of climatotherapy can be acute or chronic.
Little specific data is available concerning the long-term
changes. The potential side effects, especially the risk of
skin cancer, are unclear. Psoriatic skin is more tolerable to
direct sunlight as compared to healthy skin. In Australia it
has been shown that no psoriatic patient who lived in the
country for more than 20 years developed actinic keratoses.
In contrast, 88% of the patients within the control group
J. Kazandjieva et al.
developed actinic keratoses.42 David et al. determined the
prevalence of solar damage and skin cancer among 1198
patients with psoriasis who underwent Dead Sea clima-
totherapy compared with control patients.43 The authors
concluded that Dead Sea climatotherapy is not associated
with an increased risk of malignant melanoma or non-
melanoma skin cancer for patients with psoriasis in Israel.
However, UV exposure at the Dead Sea may play a role in
the development of solar damage.
Balneo- and spa therapy of psoriasis
Blaneotherapy is referred to as an alternative therapeutic
method based on the use of mineral waters including
bathing.44 In Europe, the word spa has recently gained
popularity, but in some places the term thermal waters is
preferred.45 There are many hypotheses concerning the
origin of the word Spa. The most popular one is for SPA as
acronym of the Latin phrase Sanitas per Aquam (health
through water). According to other authors spa comes from
the Walloon word espa standing for fountain. The Latin
word spagere, which means to scatter, sprinkle or moisten,
also could be a prime source. Later on, the Belgian town Spa
was also pointed out as a possible origin, because of its
curative thermal spring discovered in the 14th century. Spa or
wellness tourism comprises a number of services aimed at
the recreation of the physical and mental health including the
use of water resources.44
Mineral water itself is thought to improve the hydration of
the skin, has cooling and cleansing effects, and exerts
antipruritic activity.46,47 In addition, water increases the
permeability of the stratum corneum to low molecular
agents. Mineral waters are divided into cold (b than 20C),
hot (20-30C), thermal (3040C), and hyper thermal
(N 40C).47 According to the mineral contents they can be
classified as oligomineral (mineral balance b 0.2g/l),
medium mineral (mineral balance 0.21g/l), and true mineral
(mineral balance N 1g/l). Among the arsenical, bromic,
sulfur, iodic, radioactive, carbonic and silica-fluorinated
waters, sulfur waters have been shown to be effective in
psoriasis, especially in combination with UVB.47 Sulfur
waters may have low H2S content (1040 mg/l), medium
H2S content (4080 mg/l), and high H2S content (N 80 mg/l).
The main effect of the sulfur water consists of its keratolytic
properties.48,49 Sulfur waters also possess antibacterial and
antifungal characteristics, and immunomodulating activ-
ity.48,50 It is believed to increase the level of beta-endorphins
in human skin as well, but there are still controversies on this
topic.51 On the immunologic level, sulfurous mineral water
has statistically significant dose-dependent inhibitory effect
on the proliferative response of T-lymphocytes to mito-
gens.52 It inhibits the production and release of cytokines
(IL-2, IFN-gamma). This type of water according to some
authors acts mainly on the T-memory cells subset.52
Climatotherapy of psoriasis
Balneotherapy is generally considered as safe therapeutic
method. However, a number of contraindications for admin-
istering this treatment exist such as acute infection, active
visceral tuberculosis, poorly controlled arterial hypertension,
cardiac arrhythmias, and neoplastic diseases.4
Although the roots of balneotherapy lie in Europe,
alternative treatment with mineral water for psoriasis has
spread around the world.53,54 The scientific approach to the
application of balneotherapy in dermatology has lead to the
establishment of a Council for Balneology for Dermatology
in 1996.55 Herein a brief review on the balneological and
spa therapy of psoriasis worldwide is presented with an
emphasis on the spa centers in Blue Lagoon (Iceland) and
Kangal (Turkey).
Blue lagoon
The Blue Lagoon (Icelandic: Bla Lni") is a unique alternative treatment modality for psoriasis. The thermal
geothermal spa, located in a former lava field in Grindavk
on the Reykjanes Peninsula, southwestern Iceland.56,57 The
Blue Lagoon holds six million liters of geothermal seawater.
It was formed in 1976, when a geothermal power plant was
built in the Reykjanes peninsula. Superheated water is vented
from the ground near a lava flow and used to run turbines that
generate electricity. After going through the turbines, the
steam and hot water pass through a heat exchanger to provide
heat for a municipal hot water heating system. Then the
water is fed into the lagoon for recreational and medicinal
users to bathe in. The fluid is a mixture of 65% seawater and
35% freshwater. The salt content is 2.5%. The mean water
temperature is 37C and the pH7.5. The ecosystem consists
of crystal clear air, unpolluted surroundings, geothermal
water, and the predominant specific algae Lyngbya estuaria
var. thermalis.56
According to Olafsson,56 an employee in the geothermal
plant suffering from psoriasis gradually improved when
rubbing the white mud onto his psoriasis plaques while
bathing in the comfortably warm lagoon. In the following
years many people tried to cure their psoriasis in the lagoon
and this was the beginning of the Blue Lagoon's natural
treatment for psoriasis. The unique healing properties of Blue
Lagoon are based on the silica brine, the specific minerals,
and the blue-green algae.58 It was demonstrated that extracts
based silica mud and two different microalgae species
derived from the Blue Lagoon improved the epidermal
barrier properties and influenced the synthesis of a number of
molecules related to epidermal differentiation.59
The first controlled study was published in 1994.57 The
authors pointed out that bathing has a beneficial effect on
psoriasis. A second study suggested that the combination of
bathing with UVB improves the treatment outcome.60
Nowadays, the treatment involves a combination of bathing
in the Blue Lagoon and UVA /UVB light therapy. The
treatment duration is about 3 weeks. The regimen consists
of 3 times daily rubbing of the silica mud on the skin while
481
bathing in a special lagoon reserved for patients only.
Simultaneously, UVA/UVB light therapy is administered,
and the use of selected Blue Lagoon skin care products
is recommended.4
There is also a study on the combined application of Blue
Lagoon extractions and laser therapy for psoriasis.61 The
patients were bathing and using mud masks, together with
308 nm excimer laser therapy applied to the plaques 23
times weekly. According to the authors, balneotherapy, if
combined with laser, can achieve a more pronounced
reduction of the PASI within a shorter period of time as
compared to control treatments.61
Kangal hot spring ichthyotherapy
Kangal hot spring with fish represents a unique
spring is situated 13 km outside the town of Kangal in
Central Anatolia (Turkey, vicinity of Sivas), an area with an
altitude of 1660 m. The water is isothermal with a mean
temperature of 35C, slightly alkaline (pH approx. 7.2) and
oxygen value of 2.9 ppm.62,63 The mineral and ionic
compounds of the water are well characterized and contain
high levels of selenium (1.3 mg/l). An essential feature of the
Kangal spring water is the inhabitancy of the so called
doctor fish. Two different species can be found in the pools
of the spring, both members of the Cyprinidae family.64
Cyprinion macrostomus macrostomus, also named stri-
kers, and Garra rufa obtusa, known as lickers, are
omnivorous and normally feed on phyto- and zooplankton.64
The high temperature of the spring water is the cause for an
insufficient quantity of plankton for the fish, which makes
them predatory and aggressive in seeking food. The scaly
skin of psoriatic patients offers convenient source of
nutrients for the Kangal doctor fish. Recently, a term for
this therapeutic method was proposedichthyotherapy-
reflecting the nomenclature principle used in other biothera-
pies, e.g. apitherapy and hirudotherapy.65
Although local inhabitants were familiar with the
existence of Kangal spring since the 1800s, pools were
built in 1900 and opened for public use in 1963.63 The first
reports about the unique alternative option for the treatment
of psoriasis originate from the late 1980s and 1990.66,67
Later on, a complex influence on the pathophysiology and
the clinical course of the disease have been suggested,
including the effect of the spring water, the influence of the
natural ultraviolet radiation, the clearing of the scales by the
fish, the reverse Koebner phenomenon, and the reduced
psychological stress during the treatment course.62
The efficacy of Kangal hot spring ichthyotherapy was
investigated in 87 patients with psoriasis vulgaris.62 The
mean duration of the treatment was 11 days, with a mean
length of daily stay in the pools of 7.4 hours. A significant
decrease in PASI score was reported for every time point
482
(day 3, 6, 9, 12, 15, and 21) compared to baseline (prior to
therapy).62 Significantly longer remissions were reported by
35 patients previously treated with this method in compar-
ison to therapy with topical steroids.
A study with 67 psoriatic patients in Austria assessed
whether ichthyotherapy can be effective outside the Kangal
region.65 In contrast to the classical method, the fish
bathing was limited to 2 hours daily in individual tubs. The
therapy was combined with short courses of UVA sunbed
treatment to simulate the natural conditions in Kangal. Three
weeks after the beginning of the therapy, the mean PASI
score was reduced by 71% compared to baseline.65 More-
over, 46% of the patients achieved PASI-75, while 45%
achieved PASI-50. No severe adverse events were observed,
and ichthyotherapy combined with UVA treatments was
described as generally well tolerated. 66% of the patients
stated that they have achieved their treatment goals, and
almost 90% would use the same treatment modality again.
However, the study has certain limitations, as no control
groups of patients taking baths without fish, or without UVA
treatment were included.
The complex mechanism of action of the Kangal
ichthyotherapy is not completely understood. By striking
and licking the skin surface, the fish clear the psoriatic
scales, thus facilitating the penetration of the natural
ultraviolet light.62 The process of squame clearing can be
accompanied by a tingling sensation and formation of
superficial erosions and ulcerations. As fish attack predomi-
nantly the affected sites of the skin, an induction of a reverse
Koebner phenomenon has been proposed, i.e. psoriasis
clearing after injury.62 Former studies showed that reverse
Koebner reactions may be observed in 67% of the patients
with psoriasis.68
Another contributing factor to the beneficial treatment
effect may be the high concentration of selenium in the
Kangal spring water.62 Selenium plasma levels are known to
be low in patients with psoriasis, especially in severe cases
and in longer history of the disease (more than 3 years).69
The misbalanced selenium status contributes to the decreased
antioxidant defense mechanisms in psoriasis.70 Balneother-
apy for psoriasis with selenium-rich waters is reported in the
literature.71 However, ichthyotherapy was efficient in water
with low levels of selenium (less than 5 g/l).65 Hence, the
authors concluded that selenium does not appreciably
contribute to the beneficial effect of ichthyotherapy. The
Jacuzzi effect of the pools as well as the relaxing effect of
the daily thermal bathing might have additional contribution
in ichthyotherapy.62
Spa therapy of psoriasisworldwide
In France, the curative effect for psoriasis of the selenium-
rich La Roche-Posay mineral water is known for decades.72
The positive influence of selenium upon the course of the
J. Kazandjieva et al.
disease is attributed to its antioxidant and anti-inflammatory
properties.71,72 Spa curative centers in France, such as Avne
and Salies de Barn are also renowned for the treatment of
skin disorders including psoriasis.73 In Italy, there are 85 spa
resorts recommended for the treatment of skin diseases.74
Popular sites for psoriasis treatment are the spas of Comano
(Trentino) and Montecatini Terme famous for their sulfur-
rich mineral water, as well the arsenic ferruginous water of
Levico and Vetriolo, and the Dolomite spas with water
containing high levels of calcium, magnesium and sul-
fates.75,76 Recent studies suggested a possible mechanism
mediating the action of Comano`s thermal water on the
molecular level, i.e. interference with TNF-alpha expression,
interleukins-6, -8 and -16 production, and the secretion of
vascular endothelial growth factor-A.77-79 In Southern
Europe, thermal treatment with sulfur waters is performed
in Spain- in the spas of Panticosta, Fuente Amarga, Segura
and Cuntis.80 In addition, Archena, Panticosta and Mar
Menor offer another therapeutic option - peloid treatment,
i.e. the application of different types of mud on the skin
surface. Germany is another example for established
traditions in balneotherapy with more than 340 spa resorts
organized in the German Spas Association, and their number
is constantly increasing.81
In the region of Eastern and Central Europe, there are a
number of balneological centers for the treatment of psoriasis
such as Busko-Zdrj and Ldek-Zdrj in Poland, Jagoda,
Kjustendil, and Marikostinovo in Bulgaria, and Prolom
Banja in Serbia. The combination of high levels of sulfur,
selenium and iodine in the mineral waters of Busko-Zdrj
(Poland) makes it unique in its composition with therapeutic
activity against psoriasis.82 Bathing in radon-containing
water and sulfur water on alternate days for 24 days (Ldek-
Zdrj, Poland) was effective not only for the treatment, but
also for prevention of the psoriasis recurrence.83
There are 520 mineral springs in Bulgaria with 57 sites
registered as balneological resorts.84 Sulfur-rich waters
were shown to be effective in the treatment of psoriasis in
the spa resorts of Jagoda, Kjustendil, and Marikostinovo.47
Combination of bathing in sulfur waters with short-contact
dithranol treatment and selective ultraviolet therapy resulted
in better improvement of psoriatic patients as compared to
the control group treated only with the topical agent and
phototherapy.85 Further studies in 100 patients with psor-
iasis vulgaris demonstrated the beneficial effects of sulfur
baths and accompanying application of warm peloid on
the skin.47
A specific sanatorial treatment for psoriasis has been
established in Naftalan near Ivani Grad, Croatia. The
method is called naphtalotherapy and is based on bathing
in tubs containing naphtalana black-greenish soft sub-
stance produced by distillation from Armenian naphtha.
Chemical analysis revealed that the substance found in
Croatia is identical to the naphthalan from Baku, Azerbai-
jan.86 The substance is used for the treatment of psoriasis
since the beginning of 20th century. 86,87 A possible
Climatotherapy of psoriasis
mechanisms underlying its anti-psoriatic activity has been
suggested in the past decade.88,89 Naphtalan reduces the
angiogenesis,88 the proliferation index, and the CD3, CD4,
and CD8 lymphocyte count in the skin of patients with
psoriasis.89
Although spa culture has been brought by European
settlers to the USA, there is a body of evidence that American
springs have been used by native Americans for centuries.90
Nowadays, balneotherapy is gaining wider popularity in the
US as a method for treatment and recreation.91 Spa resorts
such as Saratoga Springs (New York), Hot Springs
(Arkansas), White Sulfur Springs (West Virginia), Bedford
Springs (Pennsylvania), and a number of springs in the West
offer the possibility for alternative treatment of skin diseases
including psoriasis.91 However, no systematic data is
available on the therapeutic efficacy of balneotherapy of
psoriasis in the USA. Balneotherapy performed in Copahue
Thermal Basin Complex, Argentina, combining daily bath-
ing with volcanic water and application of mud or algae from
the sulfurous lagoons, was evaluated as effective in the
treatment of psoriasis.92
Balneo- and spa therapy of psoriasis are alternative
therapeutic options for the management of psoriasis. The
promising results together with the combination of treat-
ment and complete physical/mental recreation result in the
growing popularity of these therapeutic options amongst the
patients. However, further research and larger controlled
studies are needed to evaluate the mechanism of action as
well as to compare the efficacy of balneological treatment to
conventional therapeutic modalities.
High mountain climatotherapy
In some cases high mountain climatotherapy has been
reported to improve psoriasis. The climate of the high
mountains (1560-2018 m) is thought to be effective for
dermatoses and allergic diseases such as atopic dermatitis
(neurodermatitis), eczema, psoriasis, T-cell lymphoma, and
bronchial asthma.93 In Germany, a similar therapeutic
method was performed at the North Sea islands.94 The
therapeutic immediate and long-term efficacy of the high
mountain climate is proven by excellent follow-up results.
Its superiority to the dermatological therapy applied at
home is evident. Measurement and analysis of climate
efficacy has, however, proven difficult because of its
complexity.94
Conclusion
Conventional treatments of psoriasis can not be replaced
by climatotherapy. As Jean-Jaques Rousseau said more than
a century ago, Back to the Nature, climatotherapy is the
latest confirmation of his appeal.
483
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