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Balneotherapy

Author: Dr Cathlyna Saavedra, House Officer, Middlemore Hospital, Auckland, New Zealand. DermNet Chief Editor in Chief: Adjunct A/Prof Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. May 2020.


What is balneotherapy?

Balneotherapy is the treatment of disease by bathing in thermal mineral waters. Balneotherapy has been used all over the world for centuries, particularly for the treatment of chronic skin and musculoskeletal conditions. It experienced a decline in popularity in the last century due to the emergence of new pharmacological agents but is now regaining interest as an alternative or complementary treatment option [1,2].

It can also be combined with other treatments such as physical therapy or exercise and mud packs. When combined with exposure to ultraviolet (UV) radiation (phototherapy), the treatment is known as balneophototherapy [2,3].

Mud and balneotherapy

Who uses balneotherapy?

Balneotherapy is used by patients with a wide range of medical conditions, particularly illnesses related to chronic inflammation. These include skin conditions such as psoriasis and atopic dermatitis and rheumatological conditions such as osteoarthritis.

How is balneotherapy done?

Balneotherapy involves bathing in waters of naturally-occurring mineral springs; traditional sites include the Dead Sea in Israel and Jordan, the Kangal Hot Springs in Turkey, and the Blue Lagoon in Iceland. More recently, balneotherapy is also offered by spas or treatment centres through naturally-sourced mineral water or synthetic salt solutions. Balneotherapy is also occasionally done at home by dissolving minerals or salts in baths, such as sea salts and Epsom salts (magnesium sulfate).

Dead Sea balneotherapy

How is balneotherapy carried out?

The practice of balneotherapy is centre-specific with no standardised treatment regimen. The waters used for balneotherapy can vary greatly in terms of temperature (from 30 to 40°C) and mineral and chemical composition (bicarbonate, sulfate, sulphide, chloride, magnesium, and other metals and minerals) [1]. There is no standard duration or frequency of immersion, but some centres offer treatment cycles lasting weeks to months [1].

Balneophototherapy combines bathing followed by sunbathing or UVB phototherapy.  Immersion in thermal spring water is thought to produce a synergistic effect of both treatments [3].  Bbalneophotochemotherapy or bathwater PUVA combines bathing in a psoralens solution followed by exposure to an artificial source of UVA.

When is balneotherapy effective as a treatment?

The heterogeneity of treatment regimens (different water composition, temperature, and duration of therapy), small study sample sizes, and lack of blinded randomised controlled trials (and therefore bias and possible placebo effect) make it difficult to determine the true efficacy and benefit of balneotherapy. The waters of the Dead Sea are below sea level, where there is relatively less UVB and correspondingly more UVA, which may also enhance the value of exposure to natural sunlight (while somewhat reducing the risk of sunburn). 

Some studies have shown that the use of balneotherapy in addition to conventional medical treatment (as opposed to conventional medical treatment alone) can improve symptom control and quality of life in conditions such as:

Some studies have also shown that balneotherapy may be beneficial in other conditions such as:

How does balneotherapy work?

The underlying therapeutic mechanism of balneotherapy is not fully understood. It is thought to encompass chemical, thermal, mechanical, and immunomodulatory processes.

Multiple in-vitro studies analysing the effects of different mineral/salt solutions on different cell types (keratinocytes, chondrocytes, synoviocytes, osteoblasts, and blood cells) have demonstrated a wide range of immune and cellular responses after immersion [16]. These responses range from:

  • The suppression of inflammatory cytokines
  • Increased cell viability and reduced apoptosis
  • Prevention of DNA mutations after UV exposure [1,16].

These are thought to contribute to the anti-inflammatory, anticatabolic, and the angiogenic effects thought to be associated with balneotherapy.

What are the contraindications to balneotherapy?

Balneotherapy is contraindicated in the following dermatological conditions [1]:

Other general contraindications to balneotherapy include [2,17]:

  • Epilepsy
  • Cardiovascular diseases, including arrhythmias and congestive heart failure
  • Recent stroke or heart attack
  • Severe hypertension or hypotension
  • Severe anaemia
  • Open wounds, skin ulcers, or active bleeding
  • Hypersensitivity to mineral baths
  • Severe psychiatric disorder
  • Drug or alcohol intoxication.

What are the benefits of balneotherapy?

Compared to standard treatments (oral, intravenous, or topical anti-inflammatory medications and systemic therapy), there are minimal side-effects to balneotherapy. If balneotherapy is effective in symptom control, it can reduce the number or dose of medications required and thus the side-effects of these medications.

Balneotherapy can be used in conjunction with conventional medical treatment and other therapies, such as physical therapy or phototherapy. Psychological and physical benefits include relaxation, stress management, and improvements in sleep and mood [7].

What are the disadvantages of balneotherapy?

Balneotherapy is usually privately-funded, as it is not considered a conventional medical treatment option. Access to out-of-home balneotherapy is dependent on the availability of local treatment centres and natural springs.

What are the side effects and risks of balneotherapy?

Balneotherapy is generally safe with minimal side-effects. These side effects can include:

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References

  1. Huang A, Seité S, Adar T. The use of balneotherapy in dermatology. Clin Dermatol 2018; 36: 363–8. doi: 10.1016/j.clindermatol.2018.03.010. PubMed
  2. Nasermoaddeli A, Kagamimori S. Balneotherapy in medicine: A review. Environ Health Prev Med 2005; 10: 171–9. doi: 10.1007/BF02897707. PubMed Central
  3. Gambichler T. Balneophototherapy for Psoriasis Using Saltwater Baths and UV-B Irradiation, Revisited. Arch Dermatol 2007; 143: 647–9. doi: 10.1001/archderm.143.5.647. PubMed
  4. Cozzi F, Ciprian L, Carrara M, Galozzi P, Zanatta E, Scanu A, et al. Balneotherapy in chronic inflammatory rheumatic diseases — a narrative review. Int J Biometeorol 2018; 62: 2065–71. doi: 10.1007/s00484-018-1618-z. PubMed
  5. Leaute-Labreze C, Saillour F, Chene G, et al. Saline spa water or combined water and UV-B for psoriasis vs conventional UV-B: lessons from the Salies de Bearn randomized study. Arch Dermatol 2001; 137: 1035–9. PubMed
  6. Borroni G, Brazzelli V, Fornara L, et al. Clinical, pathological and immunohistochemical effects of arsenical-ferruginous spa waters on mild-to-moderate psoriatic lesions: a randomized placebo-controlled study. Int J Immunopathol Pharmacol 2013; 26: 495–501. doi: 10.1177/039463201302600223. PubMed
  7. Farina S, Gisondi P, Zanoni M, Pace M, Rizzoli L, Baldo E et al. Balneotherapy for atopic dermatitis in children at Comano spa in Trentino, Italy. Journal of Dermatological Treatment 2011; 22: 366–71. doi: 10.3109/09546634.2010.512950. PubMed
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  10. van Tubergen A, Landewé R, van der Heijde D, Hidding A, Wolter N, Asscher M, Falkenbach A, Genth E, Thè HG, van der Linden S. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis Rheum 2001; 45: 430–8. doi: 10.1002/1529-0131(200110)45:5<430::aid-art362>3.0.co;2-f. PubMed
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  13. Naumann J, Sadaghiani C. Therapeutic benefit of balneotherapy and hydrotherapy in the management of fibromyalgia syndrome: a qualitative systematic review and meta-analysis of randomized controlled trials. Arthritis Res Ther 2014; 16: R141. DOI: 10.1186/ar4603. PubMed
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