55 Climatotherapy in Atopic Eczema 55

Chapter 55 Climatotherapy in Atopic Eczema 55

E. Vocks

55.1 have a clear impact on the disease. A number of epide- Influence of Climate on Atopic Eczema miological studies showed a direct correlation between pollutant parameters such as air pollution, ozone, etc. Environmental climatic factors have a significant influ- and the prevalence of allergic diseases and symptoms ence on the prevalence and course of atopic eczema [44, 47, 78, 82]. In animal experiments, it was demon- (Fig. 55.1). strated, for example, that the IgE sensitization with Aeroallergens, such as house dust mites, pollen, ovalbumin succeeded more easily when the animals molds, and animal dander as well as food allergens can were exposed simultaneously to diesel exhaust parti- elicit or aggravate the disease conspicuously. The cles (DEPs) or ozone [63, 94], and in sensitized animals induction of atopic eczema by aeroallergens was veri- the reaction to allergens was stronger if they had fied in numerous studies [23, 57]. In correspondingly breathed in corresponding air pollutants before [59, predisposed and sensitized subjects, by means of spe- 64]. Likewise, the nonspecific immune response was cific IgE antibodies, the allergens turn on a switch strengthened by pollutants [26, 63]. Furthermore, it from a Th1-dominated immunity situation to an was shown in vitro that air pollutants can increase the intensified Th2 response and thereby a pathological allergenicity of relevant aeroallergens [6]. Thus, pollut- inflammation cascade in the skin [77]. The aeroaller- ants intensify allergic reactions by modifying the epi- genic house dust mite Dermatophagoides pteronyssi- thelium, influencing the immune system, and increas- nus ranks as the most important allergen that leads in ing the allergenicity of relevant allergens [81]. Aller- this way to a significant release or aggravation of atop- gens and pollutants are effective, not only additively, as ic eczema; however, other aeroallergens – besides we now know, but environmental pollutants also allergenic foods – can also distinctly worsen atopic potentize the allergic reaction [22]. eczema [77]. Thus allergenic and toxic environmental substances Airpollutantssuchasozone,nitrogenoxide,volatile can induce or amplify IgE- and Th2 cell-mediated organic compounds, tobacco smoke, fine and ultrafine immunological reactions and lead to an aggravation or particulate matter, and diesel exhaust particles also acute episode of atopic eczema.

Aeroallergens Air pollutants

Air temperature Global solar radiation Atopic eczema Air humidity Air movement

Fig. 55.1. Multiple climatic Entire climate Atmospheric conditions, weather influences on the course of atopic eczema (geographical) (seasons) 508 55 Climatotherapy in Atopic Eczema

Physical meteorological properties of the environ- sure of the altitude, as well as highly variable weather. ment also play a part in atopic eczema. The activity and These stimulating factors cause a general neurovegeta- severity of the disease can change drastically in certain tive and neuroendocrine stimulation and thereby lead seasons of the year, during travel, or after a change in to a lasting immunological stabilization [86]. residence [46, 74]. In previous studies, changeable In atopic eczema, such a climatically determined weather,asuddenfallintemperature,thecoldseason, nonspecific immune modulation is of special thera- high sultriness, and geographical regions lacking sun peutic importance, because the disease is accompanied are considered to be factors detrimental to the condi- by constitutional disturbances of immunological function [15, 40, 55, 74, 91, 104]. On the other hand, in cer- tions, in particular by a weakness of the Th1 immune tain climatic zones a definite improvement of atopic system and by intensified pathological Th2 reactions eczema is observed, for example in particular mari- [77]. The biotropy of the stimulating climate produces time climate zones and in specific high-altitude areas a persistent normalization of the disturbed immuno- [74]. Possible explanations for this particular depen- logical condition, a nonspecific downregulation of the dence of atopic eczema on weather and climate, espe- pathological immune response, and thereby long-term cially with regard to the physical part played by the stabilization [34]. meteorological environment – apart from variations in allergenic and pollutant exposure – could be seen in the disturbed barrier function of the stratum corneum, the 55.2 altered cutaneous vasoreactivity, and sweating dysre- History of Climatotherapy gulation in atopic eczema [54, 75], leading to impaired adaptation to different weather conditions and Remedial effects of climatic factors on the human increased irritability [32, 96] (Table 55.1). organism were recognized early in history. Natural Given that multiple allergenic, toxic, and physical cli- mineral and thermal springs were cult sites for the matic environmental factors can lead to an aggravation Indo-Europeans (3000–500 B.C.); the Celts and Ger- of atopic eczema,it is evident thata climate lackingaller- mans also revered source deities. Furthermore, one gens and pollutants with favorable physical and meteo- encounters a well-defined sun cult in many prehistoric rological qualities has a significantly positive influence cultures. In antiquity, references to the favorable effects on the disease. The indication for climatotherapy in case of sun baths were already found in the writings of the of atopic eczema results from these findings. pre-Socratics; in ancient China, the sun was also Thus, climatotherapy for atopic eczema is based on reportedagainandagaintohaveaneffectinthetreat- the one hand on the concept of specific protection from ment of very different diseases. The Romans applied environmental factors that significantly worsen the ill- sun baths as a therapy for gout, paralysis, bladder and ness. On the other hand, genuine climatotherapy of kidney illnesses, general strength decline, rheumatic atopic eczema aims at a nonspecific immunological illnesses, and bronchitis and carried out bathing cures stimulation and modulation through further so-called [1, 4]. biotropic climate factors [85, 100]. This requires a cer- Already Hippocrates (ca. 460 B.C.) pointed out very tain number of climatic stimulating factors, such as sun impressively in his work Concerning air, water and and light, wind and cold, reduced oxygen partial pres- localities the dependence of health on weather and climate influences. Soranus of Ephesus described for the firsttime(secondcenturyA.D.)thepersuasiveeffectof Table 55.1. Features of atopic eczema dependent on environmental climate the sea water. Roman scholars considered changes in the air and climate (mutatio caeli, alteratio aeris)to Immunological abnormalities have a remedial effect; particularly in case of tubercu- IgE-mediated allergenic presentation losis, wound-healing disturbances, and general conva- TcellsinAD Role of superantigens and bacteria lescence, they recommended long sea voyages [1, 92]. Impaired skin barrier function A systematic climatotherapy developed in the middle of the eighteenth century with the first seaside Vascular and sweating dysregulation resorts in England. The English physician R. Russel Itch (1700–1771) founded this discipline in his scientific 55.2 History of Climatotherapy 509 writings on the healing effect of sea water and established the well-known seaside resort of Brighton. Initi- ated by J.C. Lettsom (1744–1815), the first seaside hospital was built in 1796 in Margate (southern England). Thereafter, seaside hospices and pediatric hospitals were built on the sea coast in almost all European countries [1]. In Germany, S.G. Vogel (1750–1830) introduced seaside resorts into therapy for the first time. Hufeland (1762–1836) declared the establishment of a seaside resort to be the most important national issue. In 1794, the first German seaside bath was built in Heiligen- damm/Doberan at the Baltic Sea; in 1797 the spa Nord- erney was founded on the east Frisian North Sea island Fig. 55.2. Open air rest cure in Davos around 1900 (Courtesy of Norderney: these are the oldest German seaside the Archives of the Alexanderhausklinik Davos) resorts. The next maritime climate health resorts followed: in 1819 Wyk on Föhr, 1826 Helgoland, 1850 Bor- theinhalationofpuredrywinterairofthehighmoun- kum, and 1855 Westerland-on-Sylt, and in 1913 a sea- tainsaswellasofgoodnutrition,butdidnotmention side hospice in St.-Peter-Ording. In 1881/1882, F.W. solar radiation in his publications (Fig. 55.2). Thus, it Benecke (1824–1882), the founder of thalassotherapy was in fact Dr. Oskar Bernhard (1861–1939) from in Germany, conducted the first climate therapeutic Samedan near St. Moritz, who introduced heliotherapy investigations in Norderney. Indications for climato- in the Swiss high mountains and documented the treat- therapy were at that time particularly tuberculosis and ment successes in 1899. Thanks to the physician Dr. scrofulosis [4, 86]. Auguste Rollier (1874–1958) from Leysin, in the Ber- Concerning the therapeutic importance of natural nese Alps, heliotherapy in the high-altitude mountains solar radiation, the first scientific studies of modern was further developed as a global therapy for the treat- times by Edwards (in 1824) and Winslow (in 1867) ment of tuberculosis and was verified in numerous came from England [92]. Also in Switzerland, the phy- writings [93]. In 1894, the author Maximilian Mehl sician of natural medicine Arnold Rikli, in the middle designed the so-called Mehl heliotherapy in Germany of the 18th century (1823–1906), followed Rousseau’s and was regarded as the founder of the Sun Sanatorium call for a retouralanature ` and opened a sanatorium for Skin and Lupus Diseased in Oranienburg near Ber- for natural medicine in 1855 in Velden/Slovenia. With lin [92]. light and sun baths, Rikli wanted to achieve milder and In the twentieth century, climatotherapy lost impor- more organic healing effects than those obtained with tance initially in the course of medical investigation the cold water treatments customary at that time. In his and pharmacological therapeutic possibilities. As no opinion, the sun bath was superior to the air bath. He satisfactory therapeutic success could be achieved for wrote, “Water does it certainly, air, however, stands the increasingly occurring chronic skin and pulmo- higher, and light the highest.” In 1841, a congenial col- nary diseases, a first “revival” of climatotherapy came league and kindred spirit, the physician Dr. Luzius about in the 1950s, particularly for the treatment of Ruedi (1804–1869), founded a health resort for chil- atopic eczema and bronchial asthma. Then the already dren suffering from scrofulosis in the Swiss high acquired findings recommended climate zones with a mountain valley of Davos and achieved amazing strong stimulating effect for these diseases. Conse- results. Unfortunately, at first they fell into oblivion, quently, in 1953 on Norderney, the first dermatologi- when Dr. Ruedi left Davos in 1849 without having pub- cal/allergological specialized clinic was founded by Jo lished the healing success of his treatments. In 1862, Hartung. At the Baltic Sea, particularly Linser and Har- Dr. Alexander Spengler (1827–1901) began with treat- nack were engaged in the climatotherapy of atopic ment of tuberculosis and thus continued Ruedi’s work eczema [41, 42]. They also administered thalassothera- in Davos [30]; however, he emphasized more clearly the py aboard ship [56]. On the initiative of Popchristov in therapeutic effect of movement in the fresh air and of 1962, the Symposium Primum Dermatologicum Bulga- 510 55 Climatotherapy in Atopic Eczema

Table 55.2. History of climatotherapy for skin diseases and allergies Century Climate factors Main indications Prehistory and antiquity 3000–500 Indo-Europeans Source deities Various B.C. Sun cults Ca. 460 Hippocrates Weather and climatic Var ious B.C. influences on health 2ndcentury Soranus of Ephesus Healing effect of sea water Gout, paralysis, bladder and kidney A.D. diseases, general strength loss, rheumatic diseases, bronchitis, Until ca. Ancient Rome Sun baths tuberculosis, wound healing 400 A.D. Balneotherapy disturbances, skin injuries, general Sea voyages as therapy convalescence (change of climate) Until ca. China Climatotherapy and helio- 500 A.D. therapy

From the middle of the eighteenth century 1753 R. Russel Seaside resorts and maritime Tuberculosis, scrofulosis Foundation of the seaside resort of climate Brighton, England 1794 First German seaside clinic in Heiligen- damm/ Doberan bath, Baltic Sea, Germany 1797 Foundation of the North Sea resort of Norderney, Germany 1824 J. Edwards, England Natural heliotherapy Tuberculosis, scrofulosis, general 1867 H. Winslow, England strength loss, wound healing disturbances 1841 Luzius Ruedi Health resort in Davos, Switzerland 1855 Arnold Rikli Natural medicine sanatorium in Velden, Slovenia 1862 Alexander Spengler High-altitude climatotherapy Tuberculosis, scrofulosis Sanatorium in Davos, Switzerland 1899 Oskar Bernhard Heliotherapy in the Swiss Tuberculosis, scrofulosis Samedan near St. Moritz, Switzerland high-altitude mountains from 1904 Auguste Rollier Leysin, Switzerland 1894 Maximilian Mehl Mehl’s heliotherapy Tuberculosis, scrofulosis Sun sanatorium for skin and lupus diseased patients, Oranienburg near Berlin, Germany

Twentieth century 1953 Jo Hartung Seaside stimulating climato- Atopic eczema, allergic rhino- Dermatologic/allergologic specialized therapy conjunctivitis, bronchial asthma, clinic on Norderney, North Sea eczema, psoriasis, and other chronic constitutional dermatoses 1961 Siegfried Borelli High-altitude stimulating Dermatological/allergological high- climatotherapy altitude clinic of Davos, Swiss Alps 55.3 Climate and Weather, Climate Adaptation 511 riae, dedicated exclusively to dermatological climato- Table 55.3. Multiple climatic effecting factors therapy, took place in Sofia. In addition to thalassothe- Geographic factors Changing weather elements rapy, dermatological high-altitude climatotherapy was Geographic latitude Solar radiation developed, particularly through the studies of A. Mar- Sea level Cloudiness chionini and S. Borelli, initially on the basis of clinical Distance from the sea Fog, rainfall mails with atopic eczema patients in Turkey on Mount Position in relation to moun- Air temperature, air pressure Olympus, later in the Swiss high-altitude valley of tain ranges (orography) Air humidity Composition of the ground, Air movement Davos (1560 m above sea level). In 1961 Siegfried vegetation Air current Borelli founded a dermatological/allergological high- Aerosol (chemical, biological) altitude clinic in Davos, the Alexanderhausklinik [11] (natural-anthropogenic) (Table 55.2). In the course of the following decades, numerous publications were produced in those clinics at the It is distinguished between greater area climate of the North Sea and in Davos concerning the effect of clima- different continents, macroclimate of the larger areas, totherapy on chronic skin diseases and allergies, espe- and microclimate at individual places [18, 58]. From a cially on atopic eczema and atopic airway diseases, but biometeorological point of view, the climatic condi- also on other dermatoses, particularly chronic contact tions in central Europe comprise a maritime climate, a eczemas and psoriasis [7–12, 21, 29, 31, 34, 68–71, 89, flat land climate, a low mountain-range climate, and a 90, 99]. high-altitude climate [85]. Faced with the ever-increasing incidence of envi- The term “weather” means the instantaneous coop- ronmentally triggered skin and airway diseases in the eration of the meteorological entities prevailing at a last few decades, the value of natural climatotherapy specific place on a specific date. Thus, the weather is the was rediscovered and reformulated. Today one knows current state of the atmosphere at a specific place [106]. that healing climatic factors have adjuvant effects that The weather stages are determined by the alternation of are not achieved by pharmacotherapeutic or other itinerant high-pressure areas (cyclones) and low-pres- monotherapies in these chronic, multifactorially deter- sure areas (anticyclones) [1, 49]. Special weather and mined diseases. atmospheric phenomena with high biotropy are inversions, thunderstorms, and foehn wind [86]. Humans adapt continuously to the climatic and 55.3 weather-conditional atmospheric environmental con- Climate and Weather, Climate Adaptation ditions.Thisoccursasshort-orlong-termadapta- tion to permanently changing weather elements and According to Alexander von Humboldt, climate is “all unchangeable geographic factors of a specific climate atmospheric state changes that noticeably affect our [86]. human organism.” Modern meteorology defines the The adaptation of humans to different atmospheric term “climate” as the average state of the atmosphere conditions is urgently necessary for the preservation of aboveaspecificplaceaswellastheaveragecourseof the integrity of the body. Temperature regulation, for weather, characteristic for this place [18, 86]. On the example, is one of the most important adaptation pro- onehand,theclimateresultsfromgeographicfactors cesses. This process is used for the preservation of such as geographic latitude, sea level, distance from the homoiothermia of the human organism, which in turn sea, position in relation to mountain ranges (orogra- is a basic requirement for all physiological functions [3, phy), composition of the ground and vegetation, the 106]. Climatic adaptation makes demands on the ma- latter particularly influencing the composition of the nifold regulation systems of the organism, including air. On the other hand, it results from the changing the immunological system [48, 86]. The adaptation weather elements, to which sun and sky radiation, processes, also called weather reactions, occur within cloudiness, fog, rainfall, air temperature, humidity, air physiological boundaries, usually autonomously and pressure, air movement, air current, and the chemical unnoticed [36]. The healthy organism is characterized and biological composition of the air, the aerosol, by trained vegetative, humoral, and immunological belong [24, 48, 106] (Table 55.3). regulatory mechanisms. 512 55 Climatotherapy in Atopic Eczema

55.4 Table 55.4. Climate effecting complexes with influence on the Human Biometeorological Research human organism (according to [3], [49]) Photo-actinic complex The entire spectrum of Human biometeorological research deals with the solar radiation affecting reciprocal action between the atmospheric environ- the earth’s surface ment and the human organism [25, 36, 48]. It was long Thermic-hygric complex Heat, cold, moisture, air neglected scientifically and remained for the most part movement dependent on empirical knowledge, because methodo- Relative oxygen deficiency From about 1500m in logic problems in this field made progress extremely altitude relevant slow. The exploration of climatic effects on the organ- Air-chemical complex Aerosols ism was always considered to be especially difficult, Degree of ionization of the air because it deals in this case with relationships between Air-electric complex Changing electromagnetic two very extremely complex systems [45, 48]. fields and field strengths Therefore, older studies in which meteorological influences on atopic eczema were examined often failed and/or were inconsistent. They were done in the sources of errors made during the analysis of biological 1950s, 1960s, and 1970s and were carried out in the relationships [48]. Davos high-altitude valley in the Swiss Alps [37, 51], at Therefore, in modern human biometeorological the North Sea [21, 65, 66, 69], the Baltic Sea [41, 88], in research, correlation analyses with individual climato- Bulgarian mountain range areas [67], and in Germany logical and medical parameters were chosen, measured in Giessen [52]. Some of the investigations were based andrecordedinlargeseries,inordertouncoverpossi- on very few cases, examined in part only a few and dif- ble relationships, now possible with modern statistical ferent meteorological parameters (besides air temper- methods [25]. A further investigational approach is the ature, air pressure, humidity, wind velocity, and solar correlation of medical data with weather stages. radiation they also examined parameters such as Weather stages show a relatively good coincidence with ozone, cyclones and anticyclones, weather, and tidal biological data; therefore they are used particularly in wave). In addition they were based partly on different the investigation of weather sensitivity [48]. Finally, and unclearly defined clinical parameters for the evalu- epidemiological investigations on the incidence and ationofthecourseofatopiceczema.Thus,theycannot prevalence of certain diseases in different geographical be compared, do not fulfill statistical study conditions, areas provide a great amount of material for the explo- and result in inconsistent results, in particular with ration of climatic influences on human disease. regard to the role of the duration of sunshine, air tem- In the field of allergic disease, biometeorological perature, humidity, wind relationships, and weather research has attained special importance in the last few disturbances (cyclones) on the course of atopic ecze- years, since a multifactorial pathogenesis of allergic ma. diseases is now assumed. In spite of enormous progress Since the effect of an individual climate parameter in immunological research, the cause for the increase such as air temperature depends on the quality of other of allergies has still not been clarified [79]. The statisti- conditions prevailing at the same time, such as air cal recording of natural and artificial environmental humidity and air movement, in biometeorology an impacts on allergic diseases has led to the first infor- attempt was also made to record correlations with bio- mative findings. logical data by defining so-called meteorological com- Thus, the dependence of allergenic air pollen con- plex entities (entities defined in mathematical formu- centrations can be verified on the one hand by air lae such as effective temperature, chilling effect, etc.) humidity, air temperature, and atmospheric condi- [24, 106]. In the course of this systematization, six cli- tions,andontheotherhandbyanthropogenicandcli- mate effect complexes were defined (Table 55.4). matic (ultraviolet radiation) conditional modifications Although this division retained fundamental validi- of the natural vegetation [33]. House dust mite and ty, it is not applicable for precise scientific analyses. mold contamination of the air increases with air mois- Similarly, the artificially defined physical complex enti- ture and temperature and in cases of insufficient venti- ties proved to be unsuitable, since they represented lation. Some studies presume general urbanization in 55.6 Climatotherapy in Atopic Eczema 513 this connection as a cause of the increase in allergen- Table 55.5. Basic principles of climatotherapy polluted microclimates [61]. Protection and/or Air pollution ↓ In our own investigation, a significant influence of relief Sultriness ↓ Relief weather factors on pruritus of atopic eczema was veri- Inversions ↓ + fied. With increased air temperature (to approximately Adaptation to natu- Sun ↑ 20°C) and wind rate and with decreased air humidity, ral environmental Light ↑ ↑ pruritus decreased. Possible causes are to be found in factors Wind Cold ↑ an atmospherically dependent nonspecific skin irrita- ↓ ﬂ O2 partial pressure tion due to the faulty epidermal barrier function and Rough, changeable Stimulation vegetative dysregulations [32, 103, 104]. Weather sensi- (biotropic) weather ↑ tivity is disturbed in patients with atopic eczema [102]. As for the effects of environmental noxiousness on 1. Protection from and/or relief from burdening allergic diseases, interesting experimental and epidemi- atmospheric conditions ological data have been collected. Accordingly, sulfur 2. Adaptation to natural environmental factors dioxide, soot particles, tobacco smoke, volatile gases, ozone, aromatic hydrocarbons, small molecular parti- In this case, the meteorological elements can be divid- cles, nitrogen oxides, and diesel particles are some of the ed based on their most frequent effects into so-called most important pollutants. They can have both an im- stimulating and protective factors [2, 106], where some mune-stimulating and immune-suppressing effect [6]. climatic elements that usually produce a stimulating AfterthereunioninGermany,theso-calledEast-West effect can also lead to removal of this effect. This studies were very informative, according to which the depends on the entire climatic situation and the type classical type I smog, mainly SO2 and dust (in the East) and length of the climatic exposure, which determines led to less allergic sensitization than the modern type II the dose, as well as on the individual sensitivity and/or smog, especially organic components, fine particles, and illness of the patient [85] (Table 55.5). ozone (in the West), but a frequent occurrence of atopic eczema correlated with the classical smog [62, 83]. Thus, essential findings concerning the influence of 55.6 modern climatic and environmental factors on the Climatotherapy in Atopic Eczema prevalence of allergic illnesses could be established by biometeorological and allergotoxicological investiga- Atopic eczema is one of the oldest and most important tions, in particular for atopic eczema. The correspond- indications for climatotherapeutic measures [10, 100], ing therapeutic measures such as protection can be as demonstrated by the historical evolution of climato- implemented most consistently within the framework therapy in the last 100 years. This is also understand- of climatotherapeutic measures [2, 85]. The effects of able in that it is a disease that manifests on the skin, the climatotherapies for atopic eczema have been verified, boundary organ of the organism to the environment, furthermore, in numerous clinical studies [34, 100]. the organ that is influenced more strongly than any other by the surrounding climatic atmosphere. Indi- vidual climate elements, which are necessary for an 55.5 effective climatotherapy of atopic eczema, can be sum- Basic Principles of Climatotherapy marized as follows. The corresponding healing climate must be charac- Climatotherapy is defined as “the treatment of patients terized by a low content of aeroallergens (house dust by modification of their exposure to physical and mites, pollens, molds) and air pollutants, which in chemical effects of the atmosphere, through which dur- many cases drastically reduces disease maintenance or ing simultaneous isolation from harmful environmen- worsening allergic reactions in atopic eczema [34, 99]. talconditionsanadaptationtonaturalenvironmental A sufficiently high atmospheric chilling effect, in par- factors is attained” [86]. ticular the absence of any sultriness, leads to the nor- Thefundamentalprincipleofclimatotherapyis malization of the abnormal sweating function [87] and based on two aspects: has an anti-inflammatory and antipruriginous effect 514 55 Climatotherapy in Atopic Eczema

Table 55.6 Climatic assump- Low aeroallergen content House dust mites, pollen, mould spores tions for a climatotherapy of Low air pollutant content Sulfur dioxide, soot particles, tobacco smoke, volatile gases, atopic eczema ozone, aromatic hydrocarbons, small molecular particles, nitrogen oxides, and diesel particles Low oppressive sultriness Low air humidity, medial air temperatures Sufficient chilling-effect Medial temperatures, air movement Intense solar radiation Littlevaporandfog,highsunshinedurationthroughouttheyear Climatic stimulating factors Sun and light [Climate stimulating stages Wind and cold 2-(3)] Decreased oxygen partial pressure of the altitude Surf aerosol of the sea Increased biotropy of the weather course

[104]. Furthermore, the climate must have intense nat- [80]. According to Drosner, significant rise in the cuta- ural solar irradiation, which achieves in addition to neous reaction to microbial recall antigens (Multitest bactericidal effects, an anti-inflammatory and antipro- Merieux) occurred following high-altitude climatothe- liferative immunological effect directly on the skin rapy for atopic eczema. The number of anergic and organ [53], and thus contributing to normalization of hyperergic reactions decreased with a simultaneous the faulty barrier function [98] (Table 55.6). increase in normergic reactions [27]. In addition to these basic requirements, which first For German patients, this specific climatic constel- protect and isolate the skin from detrimental climatic lation required for climatotherapy of atopic eczema is factors, the therapeutic climate must also possess suffi- found in an ideal form in the maritime climate of the cient biotropic stimulating factors essential for an North Sea islands, particularly the islands lacking grass effective climatotherapy of atopic eczema [2, 86, 100]. and vegetation, and in the high mountain valley of On a scale of 0 (protective climate) to 3 (very strong Davos in the Swiss Alps, because these climate zones stimulating climate), climatic zones of the stimulating have sufficient climatic stimulating factors vital for the stages 2–3 are suitable [11, 85, 99]. Climatic stimulat- lasting effect in addition to a lack of allergens and pol- ing factors are sun and light, wind and coldness, lutants and intense solar radiation [99]. Here the best reduced oxygen partial pressure of the altitude, surf therapeutic experience has been recorded. aerosol of the sea, as well as an increased biotropy of Climate therapies on the Baltic Sea islands are only the weather with an increase in the stimulus level, stim- relatively suitable for atopic eczema due to the vegeta- ulus frequency, and environmental stimulus variability tion and the frequent land breezes on these islands [86]. with aperiodic variations [36, 49, 86] (Table 55.6). In Outside of the German-speaking countries, climatothe- the climatotherapy of atopic eczema, solar radiation rapy for atopic eczema is carried out on the French therefore represents not only a disease-specific thera- Atlantic and Mediterranean coasts, on the Canary peutic, but also a nonspecific immunological stimulus. Islands [5] as well as in the Eastern areas in Poland (Bal- These nonspecific climatic stimulating factors affect tic Sea coast, southern coast of the Crimea, and the – often via an initial irritation, also accompanied by dis- Caspian Sea), in Bulgaria, in the former Yugoslavia, in ease deterioration – training of the thermoregulatory, Russia, and on the Turkish coasts; however, few validat- vegetative, and endocrine adaptation processes of the ed scientific findings are available [86]. Thalassotherapy organism and a raised tolerance toward climatic stimu- on the Dead Sea is specialized in the treatment of psoria- li. A decrease in sensitivity to cold [97] has physiological sis, and combined applications with artificial selective results, a metabolism increase [20], and an increase in UV spectra [84] are not effective as climatotherapy. performance [19], but also decreased infection vulnera- The maritime climate is characterized by a number bility. The precise effects of a climate’s stimulus on the of particular climatic qualities; the climatotherapeuti- immune system have not yet been clarified sufficiently. cally important characteristics are considerably more An investigation conducted by Ring et al. demonstrated effective on the corresponding islands than in the coast the influence on humoral and cellular immunity, for climate [49]. Particularly in the maritime surf zone, we example by using a hydrotherapeutic Kneipp treatment find markedly fewer allergens and/or a complete lack 55.6 Climatotherapy in Atopic Eczema 515

Table 55.7. Biometeorological characteristics of (North Sea) atures and the distinct dryness of the air, house dust maritime climate (according to [86]) mites are basically not present roughly 1200 m above Protecting Allergens ↓ (particularly North Sea islands, sea level, because they do not survive under these con- more effective than the Baltic Sea) ditions [60]. These thermic-hygric conditions reduce Air pollutants ↓ the concentration of allergenic pollens and the pollen ↓ Sultriness season in comparison to the lowland regions [38]. The Strongly Air temperature ↓ proportion of mold spores is reduced for the same rea- ↑ stimulating Wind sons or is missing altogether. The wind conditions Ultraviolet and global radiation ↑ Aerosols of the sea water should be such that no air allergens are carried in from Biotropic (changeable) weather ↑ elsewhere. This is, for example, ideal in the high-altitude valley of Davos, where mountain ranges in all main wind directions stop the stronger air movements of allergens. The pronounced maritime aerosol contains [11]. It can be assumed that pollutants specific of resi- salt and iodine. Furthermore, the maritime climate is dential and/or industrial sites are lacking to a large characterized by a particularly well-developed photo- extent. According to Drzimalla, there is also a pro- actinic complex, since the wide horizon provides unlim- nounced lack of air bacteria in the Davos area, with on ited sky radiation [86]. Heliotherapy is very effective, the average 400/m3 air; in cities bacteria are often mea- above all from spring until fall for atopic eczema [71]. sured at 50,0000–100,000/m3 air[28].Furthermore,the Furthermore, we find a relative coolness in the case of high mountains are characterized by a lack of sultri- strong winds and high humidity. In order not to over- ness, meaning that sweat and heat oppressiveness is dose the cold stimulation, wind protection is often nec- absent. In particular, vapor and fog rarely occur in essary. Furthermore, the weather is changeable (Table Davos [104]. 55.7). Since the climate of the North Sea is very stimulat- Thestimulatingclimaticeffectsofhighaltitudecon- ing (climatic stimulating stage 3), it is perhaps too much sist in intense solar radiation, cooling stimuli, in par- soforsmallchildrenanditcanleadtoalastingdeterio- ticular fluctuations in temperature, reduced oxygen ration of the condition for certain individuals. partial pressure, and an abundance of atmospheric In the high-altitude climate beginning at 1000 m smallionsaswellasvariableweather(Table55.9).The above sea level, a special climatic situation occurs in high-altitude valley of Davos is a climate zone of the that with an increase in altitude a change in meteoro- stimulating stage 2 and for that reason an ideal climate logical factors is to be found (Table 55.8). for the treatment of atopic eczema. The special climatic situation in the high mountains By the increase in the duration of sunshine above above 1000 m first of all relieves symptoms because of 800 m in the fall and winter, the specific radiation cli- thepurityoftheair.Theallergenicpollutionoftheair mate in the high-altitude mountains is characterized is clearly reduced. Due to the low annual mean temper- by higher global solar radiation, at times 100% stron-

Table 55.8. Change in meteorological factors with increase in altitude (according to [3], [36]) Table 55.9. Biometeorological characteristics of high-altitude climate above 1,000 m (according to [86]) Decrease Inhalant allergens Protecting Allergens ↓ (also house dust mites from Air pollution 1,200 m above sea level) Air temperature – Approximately 6°C Air pollutants ↓ Air pressure – Approximately 12% Air bacteria ↓ Water vapor pressure of the air – Approximately 25% Air humidity and sultriness ↓ Oxygen partial pressure – Approximately 12% Strongly Ultraviolet and global radiation ↑ Increase stimulating Air temperature ↓ Global solar radiation + 10%–20% Air dryness ↑ Ultraviolet radiation + 20%–30% Wind ↑ (according to mountain range Electromagnetic radiation constellation) ↓ Snow coverage O2 partial pressure Wind rate Biotropic (changeable) weather ↑ 516 55 Climatotherapy in Atopic Eczema

gerthaninlowlandregions,andbyanincreasein Table 55.10. Different types of climate exposure procedures intensity of the biologically particularly effective spec- Climate exposure Definition trum between 290 and 350 nm. On the one hand, the procedure global solar radiation of the altitude is effective as a Heliotherapy Therapeutic exposure to the natural nonspecific endocrine immunological stimulus; on the sun under controlled conditions other hand it is a specific therapeutic for the diseased Open-air rest cure Rest in the open air with body clothed skin in atopic eczema [98]. Heliotherapy at altitudes of and protected against cooling about 1500 m is particularly effective and in a wind- Terrain therapy Hiking (ergotherapy) under cool protected geographical position possible virtually conditions throughout the year, because even with an overcast sky, Thalassotherapy, Effect of the maritime climate, ultraviolet radiation reaches the ground. In the winter sea bath combined with sea baths months, global solar radiation is even more intensified by the snow covering the ground [36]. Here it should be pointed out that the radiation conditions in Davos provide an especially favorable therapeutic effect with an accumulation of 295 nm in the ultraviolet-B range, comparable to artificial UVA-B phototherapy, in addition to the immunological and endocrine effects of visible light [34, 98]. Because of its special radiation conditions, Davos was selected to be the site of the Physi- cal-Meteorological Observatory (PMOD) of the Swiss Research Institute and the World Radiation Center (WRC). The climatotherapy of atopic eczema also has a positive effect on atopic airway diseases, allergic rhinocon- junctivitis, and allergic and/or mixed forms of bronchial asthma. These diseases are often coupled with Fig. 55.3. Heliotherapy in Davos (Courtesy of the Archives of atopic eczema. However, patients who suffer exclusive- the Alexanderhausklinik Davos) ly from these airway diseases are subjected to an analo- gous climatotherapy. The climate zones mentioned are the same. peutic sunbathing periods should not exceed 15 to a maximum of 60 min daily (Fig. 55.3). Based on our investigation, the effective cumulative UVB doses in 55.7 high-altitude heliotherapy were established far below Application of Climatotherapy the cumulative UVB doses that are commonly applied using artificial dermatological UVB phototherapy [98], For successful climate therapy treatment, the body because in the case of global solar radiation, high doses must be exposed for several weeks to the biometeoro- of visible light also participate among the other spec- logical conditions [2]. The climate exposure proce- tra, whose precise endocrine and immunological dures during the treatment of atopic eczema still con- effects remain unknown at this time. sist essentially in heliotherapy, open-air rest cure and The open-air rest cure in the form of resting in the terrain therapy, at the sea and in thalassotherapy [34, open air with the body clothed and protected against 86] (Table 55.10). In heliotherapy, at the seaside area cooling has an invigorating effect and leads to general and in high-altitude mountains, the immune-modulat- vegetative and immunological stabilization. This free ing effect of UV and visible light radiation of the sun air cure is ideally supported by climatic terrain thera- are used therapeutically under controlled conditions. py, whose therapeutic effects are enhanced by hiking The dose depends on the individual ultraviolet skin under cool conditions and by the favorable influences type according to Fitzpatrick and on the initial suntan of the climate [49] (Fig. 55.4). Schuh was able to verify and is always generally suberythematous. The thera- that in atopic eczema a 4-week terrain training in the 55.8 Therapy Results 517

Table 55.11. Climatotherapy in atopic eczema: complex therapy program Climate exposure procedure Stage-appropriate dermatological treatment with externa Balneotherapy Where appropriate, systemic medicamentous treatment Where appropriate, diets Where appropriate, concurrent psychotherapeutic procedures Recreation and sport therapy Where appropriate, concurrent treatment of airway disease Enhanced allergological diagnostic Education including social-medical advice and care Where appropriate, child care Fig. 55.4. Terraintraining during climatotherapy in Davos For children and adolescents, kindergarten and school (Courtesy of the Archives of the Alexanderhausklinik Davos), instruction in winter also cross-country skiing is performed high-altitude mountains of Davos led to a significant able eczema therapy (as free of corticosteroids as possi- improvement in the faulty sweating behavior parallel to ble), where appropriate elimination diet regimes, how- the improvement of skin symptoms, which was a long- ever, concurrent with psychological behavioral thera- lasting effect and still found as high as 38% after pies (relaxing training sessions) and general recreation- 6 months. In parallel, a decrease in the illness phases al therapies with sport and physical therapy. Enhanced and in the severity of atopic eczema as well as in the itch allergological diagnostic and patient education belong was found in up to 50% of the subjects 6 months after to the complex therapy program [50, 76] (Table 55.11). endurance training [87]. Thalassotherapy exploits the This requires the following facilities: in addition to a curative effects of the sea water and the maritime aero- variable selection of dermatological internally and sol in combination with ultraviolet radiation [49]. The externally active substances and corresponding appli- sea bath in the stimulating climate of the North Sea is cation aids, equipment for general and emergency one of the strongest stimulating factors available, since treatment, phototherapy devices for adjuvant irradia- the water temperature even in the summer rarely tion (UVAand UVB), bath equipment for single whole- reaches more than 20°C. It is increasingly dosed, in gen- body and partial baths, community pools (hydrothera- eral with swimming for 3–7 min in the beginning [86]. py), inhalation device, general lab, allergy lab (allergy Simultaneously, an antimicrobic, astringent, and kera- tests), pulmonary functional devices, as well as further tolytic effect of the salt water on the diseased skin facilities such as a kitchen for patient instruction, occurs, which is tolerated, however, only in the subacute rooms and equipment for physical therapy, community and interval stage; in acutely exacerbated atopic eczema sport, ergotherapy, relaxation therapy, patient groups, the salt water can be too irritative, since the salinity of specialized lectures, and where appropriate the neces- the North Sea is relatively high, averaging about 3.4%. sary kindergarten and school facilities [101]. The treatment duration of the climatotherapy for atopic eczema should last at least 4, or better 6 weeks. The climatic adaptation goes through stages of improve- 55.8 ment and deterioration and lasts several weeks. At the Therapy Results earliest, stabilization occurs in the 3rd week and the actual therapeutic effect begins [49, 69]. Furthermore, With a dermatological, at least 6-week climatotherapy repeated climatotherapy procedures are clearly suitable in the North Sea stimulating climate on the island to decrease acuity and to prevent relapse inclination [34]. Norderney, 92% of the patients with atopic eczema Climatotherapy is carried out under inpatient condi- became symptom free, 8% improved, but still had tions, under which, in addition to the actual climate remaining focuses [71]. Initially, the number of eosino- exposure procedures, necessary dermatological and al- phils that had increased in the peripheral blood and the lergological therapies can take place, such as stage-suit- sharply raised entire and specific IgE values decreased 518 55 Climatotherapy in Atopic Eczema

[73]. Fischer demonstrated a significant decrease in the considerably improved skin condition resulted (Figs. T helper-suppressor ratio after North Sea climatothe- 55.5–55.8); in 2.8% it remained unchanged, and in rapy [35]. High pathologically lowered serum cortisol 0.5% an impaired skin state was shown at dismissal values normalized during the treatment in the sea cli- [34]. With 4,324 patients (1995–2000), a drop in the mate [71]. Pathologically lowered alkali resistance, SCORAD (score index for atopic dermatitis) was thermal conductivity, and skin circulation improved reached, on average from 52.0 to 15.3 (71%) (Fig. 55.9). significantly [69, 72]. In 98% of the patients, the long- In vitro, the number of eosinophils in the peripheral term corticoid treatment was reduced [71]. The effect blood and total IgE decreased. Also, a significant re- was continuous: repeated climate therapies led to ductionwasfoundintheserumECP,from33µg/lto increasingly longer relapse-free intervals [71]. 17.5 µg /l in 41 examined patients [90] (Fig. 55.10). The The therapy results after high-altitude climatothe- sIL2R was determined in 27 patients with atopic eczema, rapy in the Alexanderhausklinik in Davos were docu- who were treated as inpatients for an average of approxi- mented by the evaluation of patient data from 1961 to mately 7 weeks in the Zürcher high-altitude clinic 1995 in 31,438 patients with atopic eczema. According- Davos-Clavadel. All patients showed raised output val- ly, in 96.7% of these patients a symptom-free and/or ues and a significant drop at the end of the therapy [34].

Fig. 55.5. Atopic eczema before 4-week climatotherapy in Davos, Alexanderhausklinik (Courtesy of the Archives of the Alexanderhausklinik Davos)

Fig. 55.6. Atopic eczema after 4-week climatotherapy in Davos, Figs. 55.7. Severe prurigoform atopic eczema before 6-week cli- Alexanderhausklinik (Courtesy of the Archives of the Alexan- matotherapy in Davos, Alexanderhausklinik (Courtesy of the derhausklinik Davos) Archives of the Alexanderhausklinik Davos) 55.8 Therapy Results 519

µg/l ECP Fig. 55.10. Serum ECP 40 35 (eosinophilic cationic 33 protein) levels in 30 patients with atopic 25 20 17,5 eczema before and 15 after climatotherapy 10 in the Alexanderhaus- 5 klinik Davos (n = 41) 0 (Data from [90]) before after

During the high-altitude climatotherapy in Davos, two-thirds of the patients were able to stop taking their long-term topically applied corticoid, in one-third in the 1st week of therapy [31, 43]. In most patients, the follow-up treatment was also without corticosteroids [29]. Out of 375 children treated, two-thirds did not need any external cortisone within the 1st year after the high-altitude climatotherapy (before treatment 50% had needed external cortisone), and from those in whom a cortisone externum was used again, approximately 60% received weaker corticoid preparations and smaller amounts than before climatotherapy [43]. Still 12 months after therapy, two-thirds of the patients showed an improved, stable course without exacerbations in comparison with the condition before treatment at Davos [28, 29]. Similar results were documented in 97 patients with atopic eczema who had been treated between 1990 and 1994 in the Zürcher alti- Fig. 55.8. Severe prurigo atopic eczema after 6-week climato- tude clinic Davos-Clavadel [68]. The long-lasting effect therapy in Davos, Alexanderhausklinik (Courtesy of the was also shown in a recording of work disability peri- Archives of the Alexanderhausklinik Davos) ods in 3,211 patients of the Alexanderhausklinik: in the year before the high-altitude climatotherapy, 24% of thepatientswereunabletoworkbecauseofatopic before after climatotherapy eczema once or several times, 14.2% of them longer than 4 weeks, whereas in the year after the therapy in 100 Davos, only 10% of the patients were absent from 80 work, and only 2.4% longer than 4 weeks [29]. 67.5 D Theeffectivenessofthehigh-altitudeclimatotherapy 60 51.5 44.5 inDavosinatopiceczemawasalsodocumentedonthe 40 basis of further clinical experimental studies. Borelli S C O R A R A O S C 22,1 and Chlebarov examined the influence of high-altitude 15 20 12.7 climatotherapy on the neurovegetative and histamine 0 reactivity of the skin. Of the atopic dermatitis patients < 4 weeks 4-6 weeks > 6 weeks examined, 96 of 100 showed an increased sympathetic n = 502 n = 3428 n = 394 skin response at presentation. This decreased to 81% Fig. 55.9. Decrease in the Score Index for Atopic Dermatitis during one 4- to 10-week stay; in 24% it normalized (SCORAD) after high-altitude climatotherapy in the Alexan- derhausklinik Davos, depending on the duration of treatment completely [13]. Also, the histamine response of the (longer treatment for more severe cases) (n = 4,324, 1995– skin, which was high in 81 of 119 patients at presenta- 2000) tion, declined during one at least 4-week stay in about 520 55 Climatotherapy in Atopic Eczema

Table 55.12. Observed effects Neurovegetative regulation Normalization of sympathetic skin response of climatotherapy in atopic Normalization of skin response to histamine eczema (according to [89]) Improved skin perfusion and oxygen release Normalization of thermoregulation Adaptation of sweat secretion Reduction of transepidermal water loss (TEWL) Immunologic parameters Decrease in eosinophilia Decrease in eosinophilic cationic protein (ECP) Decrease in T cell activation Rehabilitation, Drastic resolution of skin symptoms socioeconomic effects Decrease in SCORAD Resolution of itch Sustained asymptomatic interval Relief of symptoms and reduction of rashes and aggravation frequency after return home Cessation or reduction of corticosteroid use Enhancement of working ability Reduction of disease activity after repeated climatotherapeutic measures

halfofthepatients[14].Incomparison,adecreasein Under these protective conditions, for the first time the skin’s reactivity to intracutaneously applied hista- regeneration of the organ damage that has already mine, serotonin, acetylcholine, and bradykinin was occurred can begin. In addition, the climatic stimula- observed after climatotherapy, parallel to clinical im- tion causes a downregulation of what is in atopic eczema provement [17]. An improved skin circulation after an enhanced – specific and nonspecific – immune high-altitude climatotherapy was verified both fluvo- response. Immunological stabilization occurs and graphically [16] and by means of transcutaneous CO2 thereby a prognosis of lasting improvement in the entire measurement [39]. Investigations of the thermophysio- clinical picture. In view of this environmentally trig- logical responsiveness of the skin showed normalized gered skin disease, natural climatotherapy is an indis- thermoregulation,improvedskincirculation,aswellas pensable adjuvant therapy which is particularly effec- an adaptation of sweat production in atopic eczema tive, and largely exceeds the effect of other therapies. patients after physical training under high-altitude climatic conditions; a decisive influence was attributed to the cool ambient temperatures [87]. Measurements of References transepidermal water loss (TEWL), which is high in 1. Amelung W (1986) Zur Geschichte der Bäder- und Klima- atopic eczema patients in comparison to normal sub- heilkunde. In: Amelung W, Hildebrandt G (eds) Balneologie jects and indicates a disturbed barrier function of the und medizinische Klimatologie. Springer, Berlin Heidel- skin, showed a significant drop after therapy in the berg New York, pp 197–201 high-altitude climate [95] (Table 55.12). 2. Amelung W (1986) Wesen der Klimabehandlung. In: Ame- lung W, Hildebrandt G (eds) Balneologie und medizinische Klimatologie. Springer, Berlin Heidelberg New York, pp 701– 717 55.9 3. Amelung W, Hildebrandt G (1986) Balneologie und medizi- Conclusion nische Klimatologie. Springer, Berlin Heidelberg New York 4. Amelung W, Hildebrandt G (1998) Zur Geschichte der Bäder- und Klimaheilkunde. In: Gutenbrunner Ch, Hilde- Climatotherapy in atopic eczema must be considered as brandt G (eds) Handbuch der Balneologie und medizini- the most comprehensive integral rehabilitation measure schen Klimatologie. Hrsg: Springer, Berlin Heidelberg New of its kind [95]. On the one hand, it is lastingly effective, York, pp 753–758 5. Autio P, Komulainen P, Larni HM (2002) Heliotherapy in given the climatically determined lack of allergens and atopic dermatitis: a prospective study on climatotherapy pollution and with that, the interruption of the allergic using the SCORAD index. Acta Derm Venereol. 82:436–440 reaction and improvement of the current symptoms. 6. Behrendt H, Becker WM, Fritzsche C, Sliwa-Tomszok W, References 521

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