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

2. Dead Sea  Fed by the holly river ( Jordan River )  Bounded on the west by the West Bank and Israel and on the east by Jordan.  The surface of the Dead Sea, 408 m (1,340 ft) below sea level, it is the lowest water surface on earth.  55 km long by 17.5 km.  Moab mountains on the east and Palestinean – Israeli mountains on the west.

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

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

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

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

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

11. Comparison of Salt Concentration mg/Liter Comparison of Salt Concentration mg/Liter Dead Sea Water Mediteranian Water Ocean Water Chloride224.00022.90019.000 Magnesium44.0001.4901.350 Sodium40.10012.70010.500 Calcium17.200470400 Potassium7.650470390 Bromide5.3007665

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

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

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

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

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

17. Comparison of major ingredients of true mud and washed out mud Ingredients True mud (mg/L) False mud (mg/L) Ca2355664.5 Na3172781.2 K684156.3 Cl1900001100 Mg32493105.1 Total Scaling 2845981397.0

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

19. Demographic Data Parameter True mud (n=58) False mud (n=56) Age (years) Mean3431 Range 16 - 61 14 – 58 SexMale3433 Female2423 RaceWhite5453 Black43

20. Target Area True mud (n=58) False mud (n=56) Chest00 Abdomen22 Buttocks34 Back43 Upper limbs 127 Lower limbs 2021 Elbow1412 Knee37

21. Disease status and duration True mud (n=58) False mud (n=56) Disease status at entry Stable3835 Worsening2021 Disease duration (yrs) Mean6.37.1

22. Materials and Methods  Three signs of psoriasis ErythemaIndurationScaling  Four sign scores for disease severity 0 = none 1 = slight 2 = moderate 3 = severe

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

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

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

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

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

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

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

30. VisitRx Pts # Mean sign scores MTSS ErythScal.Indur. 0M581.92.11.95.9 P561.852.151.85.8 Day4M582.02.01.95.9 P561.92.11.85.8 Day8M581.71.71.85.2 P561.92.11.95.9 Day15M581.61.31.64.5 P561.82.02.15.9 Day21M581.61.11.34.0 P561.62.02.15.7

31. Mean Pt. Self Evaluation ( Mean Score ) Visit True Mud ( n=58 ) False Mud ( n=56 ) Day 4 4.054.0 Day 8 3.03.95 Day 15 2.953.95 Day 22 3.054.0

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

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