Effect of the Dead Sea Climato therapy for Psoriasis on Quality of Life

ABSTRACT: Background: It is well known that quality of life is an integral part in the outcome evaluation process of psoriasis treat- ment. Very few studies, however, examined the effect of climatotherapy at the Dead Sea on quality of life of such chronically ill patients.
Objectives: To determine the effect of the Dead Sea clima- totherapy on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis.
Methods: A total of 119 patients participated in an obser- vational prospective study carried out at the Deutsches Medizinisches Zentrum clinic, a medical skin care center specializing in climatotherapy. The patients completed questionnaires (Skindex-29) to quantify their quality of life at different time points:the day of arrival, the day of departure, and 3 and 6 months after the end of treatment.
Results: Marked improvement in the quality of life scores was measured between the time of arrival to time of departure and to 3 months after the end of treatment.
Conclusions: Dead Sea climatotherapy has a significant positive influence on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis.
key words : climatotherapy, Dead Sea, psoriasis, quality of life, Skindex-29
soriasis vulgaris is a chronic relapsing disease with a status physical only not affects disease The .]1 [worldwide tionspopula various in 4.6% to 0.5 from ranging prevalence and social the including ,wellbeing overall s’patient the also but with disease systemic a is Psoriasis .]2 [life of aspects emotional .[3] diabetes and disease cardiovascular as such nessesill chronic major other to comparable ,disability considerable
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** These authors contributed equally to the studyThis study was performed in partial fulfillment of the MD thesis requirements of the Hebrew University-Hadassah Medical School, Jerusalem, Israel
the patient’s quality of life. Previous studies have demonstrated the importance of addressing quality of life in psoriasis due to its significant effect on patients’ psychosocial wellbeing and functional capabilities [6]. In order to quantify the quality of life aspect of chronic disease such as psoriasis, several quality of life index methods have been constructed in the form of self-reporting questionnaires [7].the patient’s quality of life. Previous studies have demonstrated the importance of addressing quality of life in psoriasis due to its significant effect on patients’ psychosocial wellbeing and functional capabilities [6]. In order to quantify the quality of life aspect of chronic disease such as psoriasis, several quality of life index methods have been constructed in the form of self-reporting questionnaires [7].
PATIENTS AND METHODS Patients participating in this study came to the Deutsches Medizinisches Zen trum clinic, located in the Lot Spa Hotel, Ein Bokek, at the Dead Sea, between March and November 2005. They were sent by their health insurance fund in Germany fol- lowing the failure of other treatments or because of good clinical results during previous therapeutic stays. This prospective study included 119 psoriasis patients of German nationality above the age of 18 years. All participants signed individual written informed consent forms. The recruitment of this group of adult German patients, who did not personally pay for the journey or the treatment and were specifically prefunded for Dead Sea cli- matotherapy, might have reduced various forms of selection bias such as exclusion of patients of lower socioeconomic status or inclusion of patients who came for recreational purposes only. The DMZ clinic, situated at the Dead Sea, is a medical der- matology center specialized in climatotherapy for psoriasis and other skin diseases, as well as arthritis, and is managed by dermatology specialists and a qualified medical team (http:// www.dmz-medical-spa.com/). Treatment at the DMZ clinic

comprises the following:

• medical evaluation by a dermatologist, including medical history, sociodemographic details, physical examination and follow-up during the course of treatment
• a personalized climatotherapy program that includes gradual increase of exposure to sunlight
• sea bathing for 20 minutes twice a day
• topical treatments including emollients and/or salicylic acid specifically prescribed for each patient according to his/her skin condition
• nurse availability to help with any medical issue that might arise
• a relatively secluded, stress-free hotel and spa environment.
  
• designed to provide each patient individually with a calculated therapeutic ultraviolet B radiation dose plan, while taking into consideration the patient’s skin phototype and the minimal erythema dose, which correlates with the patient’s sensitivity to ultraviolet radiation.
• The patients’ parameters of quality of life were evaluated using the Skindex-29 dermatology survey [Figure 1]. This questionnaire was specifically designed to assess quality of life in patients with dermatological conditions. The Skindex-29 was previously tested and validated [10,11] and its German- language version, used in the current study, was also previously validated [12]. Permission to use the Skindex-29 in this study was obtained by E.K. from the original Skindex-29 author (Chren Mary-Margaret MD, personal communication, 2004) and the author of the German version (Augustin Matthias MD, personal communication, 2004).
• Each question in the survey had a 5 point answer scale, ranging between “never” (0) and “all the time” (5); the lower the score (range 0–100) the better the patient’s overall quality of life . The overall quality of life score can be further divided into three subscales: the patient’s emotional state, symptom severity, and functioning state. Unlike the PASI score, the survey does not quantify physical symptoms but assesses the quality of life impact on the symptom severity subscale.
• Patients completed the questionnaires at four follow-up time points: upon arrival, at the end of treatment (departure day), and 3 and 6 months after the end of treatment. The questionnaires on the arrival and departure days were com-
  pleted at the DMZ clinic and the last two were completed in the patients’ homes in Germany and were returned by post. Severity of disease was assessed on arrival at the DMZ clinic by a dermatologist. The assessment was based on the previous treatment received at home and on the disease’s skin involvement. The PASI was recorded only if the lesions covered more than 10% of the body surface area. PASI values were also obtained by the same dermatologist at the end of the treatment.
  STATISTICAL ANALYSIS Statistical analysis was performed using the paired t-test to evaluate quality of life scores before and after treatment and the ANOVA test for assessing the linear trend over the course of the follow-up. The Greenhouse-Geisser method was applied to calculate the Pvalue for trend. All Pvalue calculations were two-sided and considered statistically significant if < 0.05. Statistical analyses were performed using SPSS version 15.0 software (Chicago, IL, USA).
  RESULTS
• The main baseline characteristics of the patients are summa- rized in Table 1. A total of 119 patients arrived at the DMZ clinic for climatotherapy. Their mean age was 46.8 years; 71% of the patients were males; 61% suffered from psoriasis vulgaris (without any joint involvement) and 39% from psoriatic arthri- tis. Mean duration of treatment was 4.1 weeks. At the begin- ning of treatment (arrival day), 71 patients (60%) completed the questionnaires. The response rate gradually decreased at further follow-up points, namely the departure day and 3 and 6 months later [Table 2].
• The overall Skindex-29 score decreased, indicating quality of life improvement, by a mean value of 22.8 points (P < 0.001) between arrival and departure times. Quality of life improve- ment was also measured between the overall mean score at arrival day and the mean scores obtained 3 and 6 months after the end of treatment (-9.2 points, P = 0.008 and -5.2 points, P
  PASI was calculated only if the lesions covered > 10% of the body surface area. PASI = Psoriasis Area and Severity Index
  
• . The mean overall quality of life and PASI scores at departure time (27.6 ± 19.4 and 0.44 ± 0.77, respectively) had a Pearson correlation coefficient r of 0.27 (n = 26 pairs, P = 0.19). = 0.28, not significant, respectively; P for trend = 0.004) [Table 2]. Similarly, the quality of life score differences between arrival and departure times and between arrival and the 3 month follow-up point were statistically significant for the emotional, symptom, and functional scores (data not shown).
• The linear trend of change in quality of life over the entire study period, between arrival time and 6 months after depar- ture, was significant for the overall quality of life score as well as for the three subscales [Figure 2].
• Patients who were over 40 years old had significantly lower mean quality of life improvement than younger patients, ≤ 40 years of age, in the emotional scale (-18.5 ± 21.7 points vs arrival and departure times. Patients who were obese (body mass index ≥ 30 kg/m2) had significantly lower mean quality of life improvement than non-obese patients in the emotional scale (-16.3 ± 21.2 points vs. -28.4 ± 24.8 points, P = 0.04) between arrival and departure times.
• Mean PASI percent improvement, calculated as the differ- ence between arrival and departure values divided by arrival value, reached 96.8%
  Figure 2. Skindex-29 questionnaire scores of the overall, emotional, symptoms and functioning quality of life scales at the study follow- up time points
• Overall score P for trend = 0.004, emotional score P for trend = 0.008, symptoms score P for trend = 0.001, functioning score P for trend = 0.01
• No statistically significant difference in trends over the study period was observed between the overall quality of life score, as well as between the three subscale scores, of patients with psoriasis vulgaris and the corresponding scores of patients with psoriatic arthritis (data not shown).
• DISCUSSION
• as a beneficial therapy that improves patients’ physical condi- tion [13,14]; it is also known to be beneficial for various other chronic illnesses such as those of rheumatic [15,16] and cardio- vascular origin [17,18]. However, little has been documented on the aspect of patients’ quality of life with regard to clima- totherapy. In our study, an improvement in the quality of life of patients with psoriasis vulgaris and psoriatic arthritis who underwent climatotherapy at the DMZ clinic was observed.
• A statistically significant improvement in the overall qual- ity of life score was observed from the day of arrival to the day of departure and further to 3 months after the end of treatment by 45% and 20% respectively. These results rep- resent a marked improvement in the quality of life of the participating patients.
• The quality of life scores obtained 6 months after the end of treatment demonstrated a slight improvement as well. However, this improvement was not statistically significant, possibly due to the lower number of completed question- naires at this time point.
• Notably, two subgroups of patients had lower rates of qual- ity of life improvement, particularly regarding the emotional aspect of quality of life. These patients were older than 40 or were obese. These patients could therefore benefit from lifestyle modification programs such as weight reduction intervention during their therapeutic stay at the Dead Sea in addition to the existing medical and climatotherapy interventions.
• A significant improvement in the quality of life in parallel with a marked improvement in the physical skin condition was reported in our study as well as in others [14]. This composite improvement may pose a challenge for measuring the direct con- tribution of climatotherapy to quality of life versus that of medi- cal treatment alone. In fact, a non-physical outcome of psoriasis, such as its effect on quality of life or depression [19], along with the difficulty to assess the ability of a given therapy to modulate these outcomes directly, can play a major role in the management and prognosis of any chronic morbidity. Further studies may be required to better understand the mechanisms involved in the complex and prolonged interactions between such interventions and outcomes. This concept in psoriasis was recently defined as the cumulative life-course impairment [20].
• Our report and the accumulating medical research evidence could encourage patients and physicians to consider Dead Sea climatotherapy as a routine therapeutic option for psoriasis.
• Climatotherapy for psoriasis was established in recent years Studies with longer follow-up and larger sample size could fur- ther determine the magnitude of various long-term effects of climatotherapy at the Dead Sea on the quality of life
  Acknowledgment We thank Ms. Sabine Gelerstain for the administrative support.
  Corresponding author
  Dr. E. Kopel Dept. of Dermatology, Hadassah University Hospital, P.O Box 12000, Jerusalem 91120, Israel
  Phone : (972-2) 676-4656, Fax: (972-2) 676-9036, email: eran.kopel@mail.huji.ac.il
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