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Dermatology Around the World: Despite turbulent times, Dead Sea draws medical tourism

Recent studies show legendary curing pool anything but myth
 
Feb 1, 2002
By: Rebecca Bryant
Dermatology Times
 
 

 Patient before arrival at Dead Sea (top) and 28 days posttreatment. International Journal of Dermatology reported in 1995 that 58 percent of psoriasis patients cleared 100 percent by end of four weeks of treatment, while 30.3 percent had 80 percent to 95 percent clearing. (Photographs courtesy of David Abels, M.D.)
 

Israel doesn't have its usual allure as a travel destination right now, but under the shroud of war, lying placid and peaceful along the Jordanian border, is a dermatologic wonder: the Dead Sea. "There's nothing like it anywhere else in the world," said dermatologist David Abels, M.D., consultant to the Dead Sea Mor Clinic in Ein Bokek.

 

The Dead Sea is the lowest terrestrial point on Earth (approximately 400 meters below mean sea level) and the densest body of water (33 percent mineral salts compared to 3 percent for the oceans). Ancient notables, including Aristotle, the Queen of Sheba, King Solomon, and Cleopatra believed in its healing powers.

In modern times, there is a growing chorus of agreement from healthcare professionals. Indeed, the National Psoriasis Foundation takes the position that, "Eighty percent of the people who get regular daily doses of sunlight enjoy improvement or clearing of their psoriasis. ... For climatotherapy, the best-known location is the Dead Sea in Israel, where each year thousands of people with psoriasis and other skin diseases go for the extensive sun exposure and baths in the unique water."

Over the past two decades, Israel has developed a cluster of modern clinics, spas, and hotels on the southern shore of the Dead Sea at Ein Bokek to serve tourists who want to mix treatment with pleasure. In the vicinity are two World Heritage sites of outstanding global value - the mountain fortress, Masada, and the Nabataean city of Petra in Jordan.

 


The Dead Sea is the lowest terrestrial point on Earth, approximately 400 meters below mean sea level.
 

War-torn economy The country's booming tourism sector went bust in September 2000 when Palestinian Arabs declared an Intifada. Dr. Marco Harari, a climatotherapist and medical director of the Dead Sea Mor Clinic, reported, "The clinic's numbers are down from the peak, but we still see about 2,500 patients a year. Our dermatological patients come between March and November. In other months, there isn't enough sun. Two-thirds of them are suffering from psoriasis. Twenty-five percent from atopic dermatitis." The cornerstone of treatment efficacy is a study of 1,448 patients published by the International Journal of Dermatology in 1995. Dr. Abels summarized, "We found that 58 percent of psoriasis patients cleared 100 percent by the end of 4 weeks of treatment, while 30.3 percent had 80 percent to 95 percent clearing. Those results are as good as any other treatment available today."

 

But just how the Dead Sea worked was a mystery. In 1994 scientists began a long-term study to document ultraviolet radiation at two sites: the Dead Sea basin and a control station near Be'er Sheva, 315 meters above sea level. The goal was to assess whether the basin's ultraviolet environment contributed to clinical results and, if so, how sun exposure protocol might be adjusted accordingly. Due to attenuation caused by atmospheric scattering and absorption, scientists determined that the microclimate of the basin was indeed unique. "The emphasis of the UV spectrum falls within the therapeutic action spectrum for psoriasis - 311 to 313 nanometers," Dr. Abels said. To optimize treatment, he recommended limiting exposure to early morning and late afternoon hours.

 


 Dead Sea water and mud is rich in magnesium, zinc, sodium, calcium, bromide, and rubidium.
 

"I believe the psychotherapeutic influence of the Dead Sea is another important component of treatment," the dermatologist added. "Patients who benefit the most are those with moderate to severe generalized psoriasis that hasn't responded to other treatments. They come to the Dead Sea depressed - even, occasionally, suicidal - due to the seriousness of the disease. Because patients are together in a segregated solarium, not in a sterile environment, they benefit from a support community. There's a natural group psychotherapy going on. I don't know of any place else in the world with a setup like this. I had a patient say, 'It's the only treatment in the world that's a pleasure.' " Climatic factors also alleviate the symptoms of arthritis, which often accompanies psoriasis.

 

In addition to the sun, Israel markets the magnesium, sodium-, calcium-, bromide-, rubidium-, and zinc-rich water and mud of the Dead Sea. Whether trace elements contribute to the treatment of psoriasis is not yet clear. However, Professor Sima Halevy, head of the department of dermatology at Soroka University Medical Center in Be'er Sheva recently completed a double blind controlled study using three groups: 12 psoriasis patients bathed in Dead Sea salts, 11 psoriasis patients bathed in common salt, and 13 healthy individuals served as controls. Before undergoing treatment, the psoriasis patients were found to have significantly higher manganese levels. Bathing in Dead Sea salt led to a reduction in the serum level of manganese and, for some patients, a drop in lithium levels, suggesting that these minerals could influence the pathogenesis and treatment of psoriasis.

While bathing in Dead Sea water and mud does influence the blood concentration of minerals, Dr. Abels admitted, "No one really knows if it's good for healthy skin. We do know that a selenium-dependent enzyme was shown to be elevated after four weeks of treatment. Selenium could affect the immune system and cell proliferation."

 


 Dermatologist David Abels, M.D.: "Because patients are together in a segregated solarium, not in a sterile environment, they benefit from a support community. There's a natural group psychotherapy going on. I don't know of any place else in the world with a setup like this."
 

Further studies Research is conducted under the auspices of the Dead Sea Research Center, part of Ben Gurion University in Be'er Sheva. "There are still some basic studies that need to be done," Dr. Abels said. For example, how long does the psoriasis remission period last? And how does that compare to other treatment modalities? The problem, he said, is that no one has adequately defined remission, so it's difficult to compare existing studies. "Of the thousands of patients we've treated over the past 15 years, the great majority say their psoriasis stays away for a longer time after treatment at the Dead Sea than it does with other treatments, including other types of light treatment and systemic treatments - but that's anecdotal."

 

According to Dr. Michael David, head of the department of dermatology at Rabin Medical Center at Tel Aviv University and past president of the Israel Dermatological Society, photoclimatherapy is accepted widely in Israel. "Most dermatologists are aware of the benefits of the Dead Sea and recommend that their patients go there for treatment of psoriasis, chronic eczema and other types of atopic dermatitis, vitiligo, and mycosis fungoides." Moreover, he believes that this attitude is disseminating through Europe and North America. "Because some of us have been lecturing about this at American Academy of Dermatology meetings and articles have been published, more U.S. dermatologists are aware of the benefits of the Dead Sea."

If exponents of Dead Sea photoclimatherapy have largely redressed the problems of awareness and scientific substantiation, they still face another obstacle: economics. German and Danish insurance companies provide up to 85 percent reimbursement. Europeans travel agents organize and market packages to patients who can pay their own way. For Americans, however, the cost hurdle has been higher, although the cost may be dropping. Dr. Abels recently found that the use of a vitamin D cream prior to and in conjunction with photoclimatherapy accelerates treatment. Two weeks of treatment produced results nearly as good as the standard four week therapy, cutting the cost substantially.

 


 Dermatologists have recommended the Dead Sea for the treatment of psoriasis, dermatitis, vitiligo, and mycosis fungoides.
 

Israeli derm, out of the water The Dead Sea is the most distinctive feature of Israeli dermatology, but overall the profession has more correlates to than differences from U.S. dermatology. "The first medical school - Hadassa Medical Center - was established in Jerusalem in the 20's," Dr. David said. "The first department of dermatology was established there before the second World War by Dr. Dostrovsky, a German who fled from Hitler." Both American and Israeli dermatology, he explained, were influenced by the immigration of Central European Jews. "They were brilliant clinical dermatologists. They brought [knowledge from] the schools of Vienna and Berlin, and pushed forward U.S. dermatology in the 1930s and 1940s and Israeli dermatology in the 1940s and 1950s."

 

Today, with a population of 6 million, Israel has seven university-based departments of dermatology. "At Rambam Medical Center in Haifa, the focus is on genetic and malignant diseases," said Dr. David. "In my center, we are focusing on pemphigus vulgaris. The incidence is higher among Jews than other ethnic origins." Apart from pemphigus, the incidence of most common skin diseases is more or less the same in Israel as in other countries.

In describing the relationship between Israeli and U.S. dermatology, Dr. David reflected. "It's mainly one way," he said. "Young dermatologists go to the United States for clinical fellowships or scientific work. When they come back, they bring new knowledge and ideas." He added that many Israeli dermatologists attend AAD meetings to stay abreast of the field.

Israeli dermatologists faced an unusual challenge over the past decade - not the outbreak of a rare skin disorder but an influx of 100 dermatologists who immigrated from Russia. This swelled the population of physicians from 200 to 300, one per 20,000 of population and led to significant challenges of retraining and assimilation.

For more information and an extensive list of journal citations: www.deadsea-health.org.

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