|Grade||Level of Evidence|
|A||Multiple double-blind, controlled clinical trials.|
|B||1 double-blind, controlled clinical trial.|
|C||At least 1 controlled or comparative clinical trial.|
|D||Uncontrolled, observational, animal or in-vitro studies only.|
|Grade||Effect||Size of Effect||Comments|
Decreased skin roughness by 40% in atopic individuals and heightened the smoothing effect of an anti-wrinkle gel in healthy but aged skin.
1% Dead Sea water Increased the the smoothing effect of an anti-wrinkle gel by nearly 50%.
Bathing in a 5% Dead Sea salt solution led to a decline in transepidermal water loss of atopic skin, indicative of an improved skin barrier.
Immersion in a 5% Dead Sea salt solution moisturized the skin of subjects with atopic dermatitis
Dead Sea climatotherapy clears psoriatic lesions effectively for many types of psoriasis. Contraindicated in generalized pustular psoriasis.
Dead Sea climatotherapy relieves even severe cases of atopic dermatitis, thereby improving patients' quality of life.
Dead Sea climatotherapy lowered the number of comedones and pustules in all 86 patients who sought treatment for acne at one clinic between 1992 and 1995.
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Table of contents:
- 1. Sources
- 2. Topical bioavailability
- 3. Effects on the skin
- 4. Safety
The Dead Sea, located 410 meters below sea level in the Syrian-East Africa rift valley and surrounded by the Moab mountains on the east and the Judean mountains to the west, is the deepest and most saline lake on earth. Its salt concentration is 345 g/L, about 7-10 times that of the oceans. Yet the water of the Dead Sea is not simply concentrated seawater; it is richer in its proportions of calcium, magnesium, potassium and bromide, and lower in its proportions of sodium, sulfate and carbonate. The bituminous mud of the Dead Sea and the thick haze that overhangs it also contain a wealth of minerals.
2. Topical bioavailability
Some of the minerals in the water of the Dead Sea have been demonstrated to penetrate healthy and psoriatic human skin. Increases in serum levels of bromine, rubidium, calcium and zinc were seen after psoriatic patients bathed daily in the Dead Sea for 4 weeks. When guinea pigs were bathed in simulated Dead Sea bath salt solutions containing calcium, magnesium, potassium and bromine for an hour, traces of each element were detected in the blood and in some internal organs. Magnesium bromide and potassium bromide were also able to pass through healthy rabbit skin after application of the salt-containing varnish.
3. Effects on the skin
3.1 Age-related improvements
Many people have reported experiencing that their skin becomes 'baby-smooth' after bathing in the water of the Dead Sea. To validate this reported feeling, one study employed computer-aided laser prolifometry to assess changes in the skin surface before and after twice-daily applications of 3 cosmetic gels. The first gel contained contained commercial anti-wrinkle agents including locust bean gum, glycoproteins, bilberry extract, sugar maple extract, sugar cane extract, orange extract and lemon extract, the second gel was the same gel as the first but with 1% concentrated Dead Sea water, while the third gel served as a placebo. Each preparation was applied twice daily to the forearms of 20 women volunteers in a double-blinded manner. After 4 weeks, the placebo gel had reduced skin roughness by an average of 10.4%, the anti-wrinkle gel by an average of 27.8%, and the anti-wrinkle gel with Dead Sea water by an average of 40.7%. These changes were significant over baseline values, and significant differences were also observed among the 3 groups.
Concentrated Dead Sea water (AHAVA Dead Sea Osmoter Concentrate) increased the expression of aquaporin-3, a membrane protein that acts as a water/glycerin transporter and therefore contributes to skin hydration, when it was added to human epidermis. A serum containing this concentrate in addition to other active ingredients was also tested in vivo for its moisturizing effect. Briefly, 35 women applied the serum on one area of their forearm, a regular moisturizer in another area and the serum plus the regular moisturizer in a third area. A fourth area was untreated and acted as control. Corneometer measurements confirmed a significant elevation in skin hydration 8 hours later for all 3 treatments compared to the control -- 50% for the serum, 41% for the regular moisturizer and 51% for the combination. After 24 hours, only the areas where the serum and the combination treatment had been applied still showed a significant increase in skin hydration relative to control (17% and 21%, respectively). However, it is important to note that the Dead Sea concentrate also contained other natural actives apart from Dead Sea water such as green tea extract, grape seed extract, olive leaf extract and benzotriazolyl dodecyl p-cresol, which may have hydrating properties in their own right.
Importantly, AHAVA Dead Sea Osmoter Concentrate may be capable of curbing cellular aging. It restored the expression of some senescence markers (p16, involucrin and Bcl-2) in cultured keratinocytes back to their values in non-senescent cells. In in vivo human skin it decreased the expression of p16 but increased that of Fas, which may help limit tumoral proliferation.
A leave-on skin preparation containing Dead Sea mud, Dead Sea water, zinc oxide, aloe vera extract, vitamin E and panthenol (AHAVA Dermud) also reduced the cytotoxicity, antioxidative effect and inflammatory cytokine secretion caused by UVB exposure in samples of human skin fragments, although these effects may be due to the presence of the sunscreen zinc oxide, the antioxidant vitamins, and the aloe vera extract, which contains many biologically active compounds, rather than that of the Dead Sea components.
3.3 Anti-inflammatory effect
Inflammatory disorders such as asthma and arthritis are improved under the conditions at the Dead Sea. The Dead Sea's anti-inflammatory action is thought to originate from its high concentration of magnesium. Magnesium ions have been shown to downregulate the expression of inflammatory mediators such as tumour necrosis factor α (TNFα) and nuclear factor κβ (NFκβ). This may be because it suppresses the function of human epidermal Langerhans cells in vitro, since the decreased antigen-presenting capacity of the Langerhans cells is associated with an inhibition of the constitutive tumor necrosis factor-alpha production by epidermal cells.
3.4 Anti-microbial action
Dead Sea mud has antibacterial and antifungal properties, probably because of its hypersaline nature, low pH and high concentration of sulfide. Test microorganisms including Escherichia coli, Staphylococcus aureus, Propionibacterium acnes and Candida albicans rapidly lost their viability when added to the mud, and zones of growth inhibition were observed around discs of Dead Sea mud placed on agar plates inoculated with Aspergillus niger, Candida albicans, Escherichia coli and Propionibacterium acnes (but not with Staphylococcus aureus).
3.5 Acne treatment
All 86 patients treated for acne at the Dead Sea between 1992-1995 experienced significant improvement in the form of reduced comedos and pustules, putting to rest concerns that the high bromine concentration in the haze overhanging the Dead Sea would provoke brom-acne.
3.6 Psoriasis treatment
Dead Sea water balneotherapy, phototherapy and climatotherapy have been used to treat psoriasis for decades. Chronic plaque-type , guttate, flexural and palmoplantar psoriasis respond well, but in generalized pustular psoriasis Dead Sea water climatotherapy is contraindicated. Pediatric-onset psoriasis also benefits from Dead Sea climatotherapy, with the treatment effect correlating inversely with patient age at disease onset.
In a retrospective analysis of 1448 records of patients who were treated consecutively at a Dead Sea psoriasis clinic, clearing of 80-100% was observed in 88% of the patients, including almost 55% who had complete clearing. In another study, 85.5% of 110 patients with psoriasis achieved excellent improvement or complete clearance of psoriatic lesions.
Although the treatment length is usually 4 weeks, 2-week treatments are also beneficial, albeit with remission rates that are lower than those achieved in treatments of longer duration.
Bathing in a solution of Dead Sea salt can be combined with device-administered phototherapy to simulate treatment conditions at the Dead Sea for outpatient use. This treatment is termed synchronous balneophototherapy, and it is as effective as, if not superior, to phototherapy alone.
Skin biopsies show Dead Sea climatotherapy leads to a reversal of both pathologic epidermal and immunologic activation. Keratinocyte hyperplasia and the thickness of the malphigian layer are dramatically reduced, keratin 16 expression is normalized, and the number of activated T-lymphocytes in the epidermis is depleted. Further, the level of methionine-enkephalin is increased, which has been hypothesized to be the result of a direct stimulatory effect of UVA irradiation.
Selected Dead Sea salts such as potassium bromide, magnesium bromide and magnesium chloride have demonstrated anti-proliferative effects in vitro, which may be helpful in psoriasis, where excessive cellular proliferation is implicated. The trace elements selenium, manganese and lithium in Dead Sea water may also contribute to the effectiveness of psoriasis treatments.
3.7 Dermatitis treatment
In 2000, an estimated 21% of patients who went to the Dead Sea for treatment suffered from atopic dermatitis. In a prospective study of 49 such patients, Dead Sea climatotherapy significantly diminished the severity of atopic dermatitis in addition to improving patients' quality of life. It is effective even for severe cases of atopic dermatitis. Artificial balneophototherapy consisting of narrowband UVB and bathing in Dead Sea salt solution has also been recommended for patients with chronic atopic dermatitis.
2 Dead Sea water-enriched creams (AHAVA Dermud containing 1.9% Dead Sea mud + 1% Dead Sea water and AHAVA Clineral Topic Body Cream containing 2.5% Dead Sea water + 1.8% Dead Sea mud) have been evaluated in a randomized, controlled, double-blind trial involving 86 children with mild or moderate atopic dermatitis. The children applied either the active cream or the control emollient cream to the whole body skin area twice daily after bathing for 12 weeks. While all 3 creams improved stratum corneum hydration and lessened the severity of atopic dermatitis, neither of the active creams significantly improved the SCORAD scores relative to that seen with the control cream.
The magnesium content in Dead Sea water may be responsible for its beneficial effects on atopic dermatitis. When volunteers with atopic dry skin submerged one forearm in a bath solution containing 5% Dead Sea salt for 15 minutes, skin hydration was enhanced and transepidermal water loss was decreased, indicating that the Dead Sea salt solution had improved the skin barrier function. Skin roughness and redness, markers for inflammation, were reduced as well.
3.8 Other effects and uses
Dead Sea products have also decreased skin and mucosal toxicity in head and neck cancer patients receiving radiochemotherapy, relieved cutaneous dryness, itching, peeling and tightness in hemodialysis patients and accelerated the healing of full-thickness excision cutaneous wounds in BALB/c mice.
4.1 Presence of toxic elements
Analyses of Dead Sea black mud deposits and commercial Dead Sea mud cosmetics have revealed no enrichment of toxic elements to cause concern, and appear to be safe for consumers.
4.2 Side effects of climatotherapy
The UV radiation at the Dead Sea is attenuated as a result of the increased optical path length and consequent enhanced scattering. The shorter erythematous UVB rays are the most greatly attenuated, while the longer therapeutic UVB wavelengths are only mildly attenuated, thus leading to a greater proportion of the therapeutic wavelengths. Hence, only 3 hours of daily sun exposure is needed for the heliotherapy of psoriasis at the Dead Sea, half the time originally recommended, and the mean UVB exposure dose at the Dead Sea is among the lowest reported for clearance of psoriatic plaques.
In a study of 1738 Danish patients with psoriasis who were subject to climatotherapy at the Dead Sea during the years 1972-1993, their overall risk of cancer was higher than that expected in Danish general population, presumably due to the excess UV exposure. A slightly smaller study of 460 patients with psoriasis and 738 control patients however found that Dead Sea climatotherapy was not associated with an increased risk of malignant melanoma or nonmelanoma skin cancer, though symptoms of photodamage (elastosis, solar lentigines, poikiloderma and facial wrinkles) were significantly more common and showed a dose response with increased Dead Sea exposure time.
4.3 Bromide toxicity
A case of bromide toxicity from consumption of Dead Sea salt has been reported.
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