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.

Dead Sea climatotherapy versus topical steroid treatment for atopic dermatitis children: long-term follow-up study.

The aim of this study was to compare long-term results of 4 weeks Dead Sea climatotherapy at the Deutsches Medizinisches Zentrum, Israel to those obtained by classical topical treatment for moderate-to-severe atopic dermatitis. Seventy-two children from the Czech Republic were divided into three groups of 24 and treated during three periods (March 2014, October 2014 and March 2015) with gradually increasing sun exposure during 28 consecutive days. Forty-four children were treated with steroid creams at the Department of Dermatovenereology, Third Faculty of Medicine, Charles University and University Hospital of Kralovske Vinohrady, Prague, Czech Republic. The primary outcome was the change in the SCORing Atopic Dermatitis (SCORAD) index, recorded after 1 month of treatment (immediately after DSC) and 3, 6, 9, 12, and 18 months later in Prague. The mean SCORAD improvement was 87.5 ± 13.4% after 4 weeks at the Dead Sea and 86.1 ± 11.3% after 1 month of treatment with steroid creams in the Czech Republic. All 44 patients treated in Prague participated in this 18-month follow-up study, whereas only 47 patients (65.3%) after DSC treatment. Good clinical results were maintained in both groups and mean SCORAD values were stable and low, around 5.

Skin Microbiome Compositional Changes in Atopic Dermatitis Accompany Dead Sea Climatotherapy.

Dead Sea climatotherapy (DSC) is a well-established therapeutic modality for the treatment of several diseases, including atopic dermatitis. Skin microbiome studies have shown that skin microbiome diversity is anticorrelated with both atopic dermatitis severity and concurrent Staphylococcus aureus overgrowth. This study aimed to determine whether DSC induces skin microbiome changes concurrent with clinical improvements in atopic dermatitis. We sampled 35 atopic dermatitis patients and ten healthy controls on both the antecubital and popliteal fossa. High-resolution microbial community profiling was attained by sequencing multiple regions of the 16S rRNA gene. Dysbiosis was observed in both lesional and nonlesional sites, which was partially attenuated following treatment. Severe AD skin underwent the most significant community shifts, and Staphylococcus epidermidis, Streptococcus mitis and Micrococcus luteus relative abundance were significantly affected by Dead Sea climatotherapy. Our study highlights the temporal shifts of the AD skin microbiome induced by Dead Sea climatotherapy and offers potential explanations for the success of climatotherapy on a variety of skin diseases, including AD.

Multidisciplinary Biopsychosocial Program for Chronic Musculoskeletal Pain at the Dead Sea.

BACKGROUND: Multidisciplinary biopsychosocial rehabilitation for patients presenting with rheumatic diseases has been shown to produce better results in a warm climate. Dead Sea Climatotherapy (DSC) has been successfully used for decades to treat many patients with rheumatic diseases. OBJECTIVES: To evaluate the short-term improvement of Norwegian patients who presented with chronic pain following a multidisciplinary biopsychosocial approach to treatment combined with DSC. Both objective and subjective clinical parameters were evaluated. METHODS: This retrospective study included a statistical analysis of 938 patients presenting with rheumatoid arthritis and ankylosing spondylitis (n=105), osteoarthritis (n=342), fibromyalgia (n=374), and other orthopedic conditions (n=117). Clinical assessments were conducted before and after a 3 week treatment program at the Dead Sea. RESULTS: Six parameters improved significantly in the rheumatoid arthritis and ankylosing spondylitis group as well as in the osteoarthritis group. Five parameters in the fibromyalgia group improved, while two improved in the orthopedic conditions group. Overall, major significant changes occurred in the pain self-assessment, joint motility, and daily activities scores. CONCLUSIONS: A 3-week multidisciplinary biopsychosocial program combined with DSC induced positive changes in the clinical parameters of Norwegian patients presenting with chronic musculoskeletal pain.

Temporal Stability of the Healthy Human Skin Microbiome Following Dead Sea Climatotherapy.

Dead Sea climatotherapy (DSC) is a therapeutic modality for a variety of chronic skin conditions, yet there has been scarce research on the relationship between the cutaneous microbiota and disease states in response to DSC. We characterized the skin bacterial and fungal microbiome of healthy volunteers who underwent DSC. Bacterial community diversity remained similar before and after treatment, while fungal diversity was significantly reduced as a result of the treatment. Individuals showed greater inter-individual than temporal bacterial community variance, yet the opposite was true for fungal community composition. We further identified Malassezia as the genus driving temporal mycobiome variations. The results indicate that the microbiome remains stable throughout DSC, while the mycobiome undergoes dramatic community changes. The results of this study will serve as an important baseline for future investigations of microbiome and mycobiome temporal phenomena in diseased states.

Dead Sea ultraviolet climatotherapy for children with atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common, chronic, and relapsing inflammatory skin disorder. Moderate to severe cases represent an extremely disabling disease, for both children and their parents. Dead Sea climatotherapy (DSC), recognized as a natural treatment for patients with skin diseases, takes advantage of the selectively scattered ultraviolet irradiation (UV) present at the lowest terrestrial site on the earth. OBJECTIVES: To investigate the impact on short-term results of DSC in moderate to severe AD children from the Czech Republic treated 4 weeks at the Deutsches Medizinisches Zentrum (DMZ), Israel, and to correlate their results to the cumulative UVA and UVB irradiation doses received during treatment. PATIENTS AND METHODS: Seventy-two patients aged <19 years were divided into three groups and treated in March 2014, October 2014, and March 2015 with gradually increasing sun exposure during 28 consecutive days. Daily and cumulative exposure doses of UVB and UVA were calculated through patients' recorded sun exposure logs. The SCORing Atopic Dermatitis (SCORAD) index was recorded immediately after DSC and 3 months later by the same dermatologist. RESULTS: Good clinical results were observed in all groups, with overall improvement in SCORAD reaching 87.5 ± 13.4% and 71.3 ± 21.3% immediately after DSC and 3 months later, respectively. No side effects were observed during the treatments. Higher cumulative exposure times correlated with better results and enhanced remission. CONCLUSION: Dead Sea climatotherapy represents a valuable option for the treatment of AD in children. Medically controlled and prescribed sun exposure seems to directly and positively influence the results obtained.

[THE EFFECT OF 5 DAYS IMMERSION IN DEAD SEA WATER ON BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS PATIENTS].

BACKGROUND: Body immersion in plain water or mineral water induces significant and unique physiological changes in most body systems. In a previous pilot study, a significant reduction in blood glucose levels among diabetes mellitus (DM) patients was found following a single immersion in Dead Sea water but not after immersion in plain water. OBJECTIVE: To study the immediate and long term effects of immersion in mineral water for five consecutive days on blood glucose in patients with type 2 DM. METHODS: A total of 34 patients with type 2 DM were divided into 2 groups: The first immersed in a plain water pool and the second immersed in a Dead Sea water pool; both pools were warmed to a temperature of 35°C. Immersions for 20 minutes occurred twice daily: two hours after breakfast and before dinner. Seven samples of capillary blood glucose levels were taken: fasting, before and after every immersion, prior to lunch and before bedtime. Hemoglobin A1C (HbA1c) was taken prior to the study and a re-check was conducted during the 12 weeks following the study. RESULTS: Blood glucose levels significantly decreased immediately after immersion both in Dead Sea water and plain water compared to their values prior to immersion (p<0.001). No significant difference was noted between both types of water. A decrease in fasting glucose levels was observed only in the group immersed in Dead Sea water when compared to plain water (6.83±5.68 mg/dl versus 4.37±1.79 respectively and the difference was close to statistical significance (p=0.071. There were no changes in HbA1c levels. CONCLUSION: Immersion for 20 minutes in water (Dead Sea or plain water) at a temperature of 35°C induced an immediate reduction in glucose levels in patients with type 2 DM.

Dead Sea mud packs for chronic low back pain.

BACKGROUND: Low back pain (LBP) is chronic disease without a curative therapy. Alternative and complementary therapies are widely used in the management of this condition. OBJECTIVES: To evaluate the efficacy of home application of Dead Sea mud compresses to the back of patients with chronic LBP. METHODS: Forty-six consecutive patients suffering from chronic LBP were recruited. All patients were followed at the Soroka University Rheumatic Diseases Unit. The patients were randomized into two groups: one group was treated with mineral-rich mud compresses, and the other with mineral-depleted compresses. Mud compresses were applied five times a week for 3 consecutive weeks. The primary outcome was the patient's assessment of the overall back pain severity. The score of the Ronald & Morris questionnaire served as a secondary outcome. RESULTS: Forty-four patients completed the therapy and the follow-up assessments: 32 were treated with real mud packs and 12 used the mineral-depleted packs. A significant decrease in intensity of pain, as described by the patients, was observed only in the treatment group. In this group, clinical improvement was clearly seen at completion of therapy and was sustained a month later. Significant improvement in the scores of the Roland & Morris questionnaire was observed in both groups. CONCLUSIONS: The data suggest that pain severity was reduced in patients treated with mineral-rich mud compresses compared with those treated with mineral-depleted compresses. Whether this modest effect is the result of a "true" mud effect or other causes can not be determined in this study.

Effect of the Dead Sea climatotherapy for psoriasis on quality of life.

BACKGROUND: It is well known that quality of life is an integral part in the outcome evaluation process of psoriasis treatment. 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 climatotherapy on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis. METHODS: A total of 119 patients participated in an observational 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.

Climatotherapy at the Dead Sea: an effective treatment modality for atopic dermatitis with significant positive impact on quality of life.

BACKGROUND: Atopic dermatitis (AD) has an appreciable effect on quality of life. Improving the quality of life of AD patients is a priority. OBJECTIVE: This study aimed to evaluate the impact of Dead Sea climatotherapy (DSC) as a treatment of AD and its influence on the quality of life of these patients. METHODS: Forty-nine adult patients with AD treated during the years 2009-2010 at the Deutsches Medizinisches Zentrum Medical Center participated in this prospective study. Climatotherapy was administered in accordance with a computer-designed protocol and included gradually increased sun exposure after a sea bath. Severity of AD was evaluated using the Scoring Atopic Dermatitis (SCORAD) index. Patient quality of life was evaluated using Skindex-29. Statistical analysis was performed using a paired t test and Wilcoxon and Mann-Whitney U tests. RESULTS: After treatment, the mean SCORAD value improved by 39 points (P < 0.001). The overall Skindex-29 score improved by a mean value of 33 points (P < 0.001). The pretreatment SCORAD, duration of AD, and maximal daily sun exposure predicted the posttreatment SCORAD values. Pretreatment Skindex-29 and patient age predicted the posttreatment Skindex-29 in a multiple linear regression model. CONCLUSIONS: Dead Sea climatotherapy provides an effective treatment modality for AD by improving the patient's skin condition and quality of life.

[The influence of single immersion in Dead Sea water on glucose, insulin, cortisol and C-peptide levels in type 2 diabetes mellitus patients].

BACKGROUND: Bathing in sweet or mineral water can induce significant physiological changes in several body systems including the endocrine system. To date, there have only been a small number of reports that balneology can reduce blood sugar Levels in patients with type 2 diabetes mellitus (DM]. OBJECTIVE: To compare the effects of a single immersion in sweet or mineral water on blood glucose, insulin, cortisol and c-peptide levels in patients with type 2 DM. METHODS: Fourteen patients with type 2 DM and six healthy volunteers were immersed in water twice, with an interval of two weeks in between immersions. The first immersion was in Dead Sea water and the second in sweet water. In both cases the water was warmed to a temperature of 35 degrees C and the bath continued for 20 minutes. Three blood samples were taken from each of the participants at every immersion. The first sample was taken just prior to the start of immersion, the second sample was taken directly at the end of immersion, and the third sample, one hour later. In each sample the blood was tested for glucose, insulin, cortisol, and c-peptide Levels. RESULTS: A significant reduction was seen in blood glucose levels among DM patients who were immersed in Dead Sea water. The glucose levels dropped from a base Line level of 163 +/- 32.4 mg/dl prior to immersion, to 151 +/- 28.8 at the end of the immersion, and to 141 +/- 34.6 an hour later. All the differences were statistically significant: baseline to end of immersion (P = 0.006), end of immersion to one hour later (P = 0.024), and baseline to one hour after immersion (P=0.005). The difference in blood glucose was much Less following immersion in sweet water and did not reach statistical significance except between the end of immersion and one hour later. No significant differences were found for insulin, cortisol, and c-peptide levels between DM patients and healthy volunteers following immersion. CONCLUSION: One-time immersion in Dead Sea water reduces blood glucose levels in type 2 DM patients compared to healthy volunteers.

Increased vitamin D serum levels correlate with clinical improvement of rheumatic diseases after Dead Sea climatotherapy.

BACKGROUND: Ultraviolet B (UVB) rays are required by the skin for the production of vitamin D. The intensity of UVB at the Dead Sea area is the lowest in the world. Low vitamin D levels are often associated with musculoskeletal symptoms. OBJECTIVES: To assess the effectiveness of climatotherapy at the Dead Sea on the production of vitamin D in Norwegian patients suffering from various rheumatic diseases and to investigate possible associations between increased vitamin D serum levels, musculoskeletal symptoms and disease severity. METHODS: Sixty Norwegian patients who came to the Dead Sea area for 21 days of medical rehabilitation were divided into three groups according to their diagnosis: chronic pain syndromes, i.e., low back pain or fibromyalgia (Group 1, n=33); rheumatoid arthritis (Group 2, n=16); and osteoarthritis (Group 3, n=11). Serum 25-hydroxyvitamin D (25-OH-D) levels were determined at arrival and prior to departure. The treatment protocol included daily sun exposure (climatotherapy), bathing in the Dead Sea and mineral spring water (balneotherapy), mud applications and fitness classes. RESULTS: 25-OH-D serum levels increased significantly from 71.3 +/- 26.6 nM at arrival to 89.3 +/- 23.2 nM prior to departure (P < 0.001). Adjusted for the initial levels of pain (assessed by a visual analog scale) and disease severity, a direct correlation was observed between increased 25-OH-D serum levels and pain reduction (P = 0.012) and reduction of disease severity (P = 0.02). CONCLUSIONS: Climatotherapy at the Dead Sea induces significant changes in vitamin D. Increased 25-OH-D serum levels are associated with reduced musculoskeletal pain and disease severity.

The measurement and analysis of normal incidence solar UVB radiation and its application to the photoclimatherapy protocol for psoriasis at the Dead Sea, Israel.

The broad-band normal incidence UVB beam radiation has been measured at Neve Zohar, Dead Sea basin, using a prototype tracking instrument composed of a Model 501A UV-Biometer mounted on an Eppley Solar Tracker Model St-1. The diffuse and beam fraction of the solar global UVB radiation have been determined using the concurrently measured solar global UVB radiation. The diffuse fraction was observed to exceed 80% throughout the year. The application of the results of these measurements to the possible revision of the photoclimatherapy protocol for psoriasis patients at the Dead Sea medical spas is now under investigation. The suggested revision would enable the sun-exposure treatment protocol to take advantage of the very high diffuse fraction by allowing the patient to receive the daily dose of UVB radiation without direct exposure to the sun, viz. receive the diffuse UVB radiation under a sunshade. This would require an increase in sun-exposure time intervals, as the UVB radiation intensity beneath a sunshade is less than that on an exposed surface.

Intermittent balneotherapy at the Dead Sea area for patients with knee osteoarthritis.

BACKGROUND: Balneotherapy, traditionally administered during a continuous stay at the Dead Sea area, has been shown to be effective for patients suffering from knee osteoarthritis. OBJECTIVES: To evaluate the effectiveness of an intermittent regimen of balneotherapy at the Dead Sea for patients with knee osteoarthritis. METHODS: Forty-four patients with knee osteoarthritis were included in a prospective randomized single-blind controlled study. The patients were divided into two groups: a treatment group (n=24), which were treated twice weekly for 6 consecutive weeks in a sulfur pool heated to 35-36 degrees C, and a control group (n=20) treated in a Jacuzzi filled with tap water heated to 35-36 degrees C. Participants were assessed by the Lequesne index of osteoarthritis severity, the WOMAC index, the SF-36 quality of health questionnaire, VAS scales for pain (completed by patients and physicians), and physical examination. RESULTS: A statistically significant improvement, lasting up to 6 months, was observed in the treatment group for most of the clinical parameters. In the control group the only improvements were in the SF-36 bodily pain scale at 6 months, the Lequesne index at 1 month and the WOMAC pain score at the end of the treatment period. Although the patients in the control group had milder disease, the difference between the two groups was not statistically significant. CONCLUSIONS: Intermittent balneotherapy appears to be effective for patients with knee osteoarthritis.

The percentage of patients achieving PASI 75 after 1 month and remission time after climatotherapy at the Dead Sea.

BACKGROUND: Dead Sea climatotherapy (DSC) is a highly effective treatment for psoriasis; however, there are scanty data concerning the duration of post-therapy remission. OBJECTIVE: Assessment of the duration of remission in patients suffering from plaque-type psoriasis after a 4-week DSC. METHODS: Sixty-four patients from Germany (66% men; average age: 41.5 years) underwent a 4-week course of DSC between September 2001 and November 2002. After returning home, patients were asked to inform their dermatologist immediately when new lesions appeared. In parallel, they were called every 3 months by telephone. All patients who reported new skin lesions underwent a physical examination, including a Psoriasis Assessment Severity Index (PASI). OUTCOMES: (1) Time of recurrence of a psoriatic lesion after complete or almost complete clearance, defined as duration of remission; (2) time that elapsed until a relapse of 50% of the PASI improvement occurred, defined as duration of therapeutic effect. RESULTS: Mean PASI value before and after treatment was 31.7 and 1.42, showing a 95.5% improvement. All patients reached PASI 50, and 75.9% of them reached PASI 75 after 1 month of DSC. 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 a patient's younger age at the time of treatment was associated with a longer period of remission. CONCLUSION: Four-week DSC is an effective remittive treatment for plaque-type psoriasis. The period of remission induced compares favorably with other accepted modalities of treatment.

Rapid initiation of repigmentation in vitiligo with Dead Sea climatotherapy in combination with pseudocatalase (PC-KUS).

BACKGROUND: Low catalase levels and cellular vacuolation in the epidermis of patients with vitiligo support major oxidative stress in this compartment. There is now in vivo evidence for increased epidermal hydrogen peroxide (H(2)O(2)) accumulation in this patient group by utilizing noninvasive Fourier Transform Raman spectroscopy (FT Raman). Epidermal H(2)O(2) can be removed with a topical application of narrow band UVB activated pseudocatalase cream (PC-KUS). (Mn/EDTA-bicarbonate complex, patent No. EPO 58471 1 A), yielding initiation of repigmentation. Dead Sea climatotherapy is another successful treatment modality for vitiligo, but the mode of action has escaped definition so far. METHODS: Epidermal hydrogen peroxide (H(2)O(2)) was assessed in vivo before and after 21 days treatment at the Dead Sea using noninvasive Fourier-Transform Raman spectroscopy. The effectiveness of repigmentation was followed in 59 patients with vitiligo by comparing Dead Sea climatotherapy alone with the combination of Dead Sea climatotherapy/pseudocatalase cream (PC-KUS) as well as Dead Sea climatotherapy/placebo cream. Clinical repigmentation was documented by standardized black/white photography using non-UV coated bulbs as flashlight and by color photography. RESULTS: This study on 59 patients who had vitiligo for an average time of 17 years (range 3-53 years) confirmed in vivo H(2)O(2) accumulation in mM concentrations in the epidermis of untreated patients. Furthermore, we demonstrated a pseudocatalase activity after 15 min of Dead Sea bathing, but the decrease of epidermal H(2)O(2) levels was significantly less compared to narrowband UVB activated pseudocatalase cream (PC-KUS). Initiation of repigmentation was already observed between day 10 and day 16 after a combination of Dead Sea climatotherapy/pseudocatalase cream compared to conventional pseudocatalase monotherapy (8-14 weeks) and Dead Sea climatotherapy alone (5-6 weeks). CONCLUSION: The results of this study show a significantly faster initiation of repigmentation in vitiligo after a combination of short-term climatotherapy (21 days) at the Dead Sea in combination with a pseudocatalase cream (PC-KUS) compared to either conventional climatotherapy at the Dead Sea alone or with placebo cream in combination with climatotherapy. This combined therapy is significantly faster in repigmentation than narrowband UVB activated pseudocatalase cream (PC-KUS) treatment alone. The results of this study support the necessity of epidermal H2O2 removal as well as the influence of solar UV-light in the successful treatment of vitiligo.