Side-effects of Side-effects of balneotherapybalneotherapy- survey of the - survey of the

literatureliterature

Pál Géher MDPál Géher MD

Survey of the literatureSurvey of the literature

PubMedPubMed: „balneotherapy” : „balneotherapy” or „hydrotherapy”.1966-or „hydrotherapy”.1966-2005.2005. 9237 citations incl. 307 9237 citations incl. 307

review articles - review articles - 17271727 citations with abstract citations with abstract incl.117 review articles.incl.117 review articles.

CochraneCochrane Collaboration: Collaboration: 7 reviews.7 reviews.

How safe is it?How safe is it?

The Cochrane Database of The Cochrane Database of Systematic ReviewsSystematic Reviews 2005 Issue 42005 Issue 4Copyright © 2005 The Copyright © 2005 The Cochrane Collaboration.Cochrane Collaboration.

Balneotherapy for Balneotherapy for rheumatoid arthritisrheumatoid arthritis

Verhagen AP, Bierma-Verhagen AP, Bierma-Zeinstra SMA, Cardoso Zeinstra SMA, Cardoso JR, de Bie RA, Boers M, JR, de Bie RA, Boers M, de Vet HCWde Vet HCW

„„The studies did The studies did not test for side not test for side effects or safety effects or safety of of balneotherapy.”balneotherapy.”

PSORIASIS AND PSORIASIS AND OTHER OTHER KERATINISING KERATINISING DISORDERS DISORDERS

- - Alternative/complementary Alternative/complementary treatmentstreatments

- psychological approaches- psychological approaches

- dietary fish supplements- dietary fish supplements

- - balneotherapy including balneotherapy including spa waters and Dead Sea spa waters and Dead Sea therapytherapy

- laser therapy- laser therapy

- combinations of the above- combinations of the above

- Chinese herbs- Chinese herbs

WaterbirthWaterbirth

1600 deliveries over 8 1600 deliveries over 8 years.years.

Shorter first stage of Shorter first stage of labor.labor.

Lower episiotomy Lower episiotomy rate.rate.

The rate of neonatal The rate of neonatal infection was infection was notnot increased with a increased with a water birth (1.22% vs. water birth (1.22% vs. 2.64%)2.64%)

Thoeni A et al.: Matern Fetal Neonatal Med 2005;17:357-61.

Spa infectionsSpa infections

Okada M et al.: Kansenshogaku Zasshi 2005;79:365-74.

June 2002: the largest outbreak of legionellosis in Japan:• 295 patients infected,• 37 % of them hospitalized,• 7 died.

Causes:1.Legionella pneumophila,2.L. dumoffii,3.L. londiniensis.

Legionella sp. in thermal waterLegionella sp. in thermal water

Samples from thermal Samples from thermal bath in Brescia from bath in Brescia from February till October February till October 2000.2000.

34.8% of the samples 34.8% of the samples contained Legionella contained Legionella pneumophila; the pneumophila; the predominant isolates predominant isolates (30%) belonged to (30%) belonged to Legionella pneumophila Legionella pneumophila serogroup 1. serogroup 1.

Indicates a Indicates a potential riskpotential risk of infection to patients.of infection to patients.

Martinelli F et al.: New Microbiol 2001;24:259-64.

Brescia

Folliculitis after bathFolliculitis after bath

A healthy 10-year-old boy A healthy 10-year-old boy presented with a presented with a widespread, nonpruritic, widespread, nonpruritic, pustular rash of 3 days' pustular rash of 3 days' duration after thermal duration after thermal bath (JCA).bath (JCA).

Treated with erythromycin Treated with erythromycin tablets, 250 mg twice tablets, 250 mg twice daily for 10 days.daily for 10 days.

Within 1 week the rash Within 1 week the rash had had completely resolvedcompletely resolved..

Bhatia A, Brodell RT.: Postgrad Med 1999;106:43-6.

Fungi in thermal bathFungi in thermal bath

Samples of Samples of bathwater from 22 bathwater from 22 public baths.public baths.

The samples The samples produced 12 isolates produced 12 isolates of Exophiala of Exophiala jeanselmei, 2 of E. jeanselmei, 2 of E. dermatitidis and 1 of dermatitidis and 1 of E. moniliae. E. moniliae.

Lowe NJ et al.: J Am Acad Dermatol 1986;14:754-60.

HypHypoothyroidism after sea bath thyroidism after sea bath saltssalts

A case of a 32 year old woman with a iodine-A case of a 32 year old woman with a iodine-induced hypothyroidism without goitre due to induced hypothyroidism without goitre due to an excessive trans-cutaneous/trans-mucous an excessive trans-cutaneous/trans-mucous absorption of iodine in sea-bath salts.absorption of iodine in sea-bath salts.

Iodized sea-bath salts have been used for Iodized sea-bath salts have been used for three months in a hot water bath for a three months in a hot water bath for a slimming effect.slimming effect.

A A complete regressioncomplete regression is noticed after 1 year. is noticed after 1 year.

Nifosi G.: Minerva Endocrinol 1998;23:93-7.

Mud bathMud bath

A case of 74 year old A case of 74 year old woman with a long-woman with a long-lasting, extensive lasting, extensive eczematous and eczematous and bullous bullous dermatitisdermatitis due to a mud bath due to a mud bath with cinnamon with cinnamon essential oil in a spa.essential oil in a spa.

Garcia-Abujeta JL et al.: Contact Dermatitis 2005;52:234.

Mud packMud pack

Mud samples were analysed before and Mud samples were analysed before and 80 after application.80 after application.

Pseudomonas aeruginosa was found in Pseudomonas aeruginosa was found in about 11% of the samples of about 11% of the samples of both both groups. groups. Coliforms were also found in Coliforms were also found in bothboth groups. groups.

Slight faecal contamination is possible.Slight faecal contamination is possible. Mud can be considerably contaminated Mud can be considerably contaminated

with faecal germs even before application. with faecal germs even before application.

Seefelder A. et al.: Offentl Gesundheitswes 1991;53:338-43.

SaunaSauna

A case of excessive A case of excessive rhabdomyolysis rhabdomyolysis and acute renal and acute renal failure triggered by failure triggered by a sauna visit in a a sauna visit in a 29 year-old African 29 year-old African American with American with sickle cell trait.sickle cell trait.

Eisenbach Ch et al.: Clin Nephrol 2005;63:229-31.

SaunaSauna

Sauna bathing is safe.Sauna bathing is safe. Very few acute myocardial infarctions and Very few acute myocardial infarctions and

sudden deaths occur in saunas.sudden deaths occur in saunas. Alcohol consumption during sauna bathing Alcohol consumption during sauna bathing

increases the risk of hypotension, increases the risk of hypotension, arrhythmia, and sudden death.arrhythmia, and sudden death.

Hannuksela ML, Ellahham S.: Am J Med 2001;110:118-26.

Sauna abuseSauna abuse

14 patients with 14 patients with bulimia bulimia nervosanervosa who regularly who regularly spent long periods of time spent long periods of time in saunas as a weight-in saunas as a weight-control technique. control technique.

Many of these patients Many of these patients also engaged in other also engaged in other behaviors that resulted in behaviors that resulted in dehydration, such as dehydration, such as diuretic abuse and diuretic abuse and laxative abuse.laxative abuse.

Mitchell JE et al.: Psychosomatics 1991;32:417-9.

Dead Sea resort treatment for Dead Sea resort treatment for psoriasispsoriasis

460 patients with 460 patients with psoriasis 760 control.psoriasis 760 control.

Elastosis, solar Elastosis, solar lentigines, poikiloderma, lentigines, poikiloderma, and facial wrinkles and facial wrinkles more more commoncommon among among psoriasis patients.psoriasis patients.

No difference between No difference between cancer rates.cancer rates.

David M et al:J Am Acad Dermatol 2005;52:445-50.

Elastosis

Solar lentigines Poikiloderma

Facial wrinkles

Dead Sea treatment of atopic Dead Sea treatment of atopic dermatitisdermatitis

Balneophototherapy: UVB + bathing in Balneophototherapy: UVB + bathing in Dead Sea salt containing water.Dead Sea salt containing water.

615 intention-to-treat and 143 according-615 intention-to-treat and 143 according-to-protocol undergo 3-5 treatment to-protocol undergo 3-5 treatment sessions per week up to 35 in total. sessions per week up to 35 in total.

Withdrawn because of side effects (3%). Withdrawn because of side effects (3%). Most frequentMost frequent side effects were: erythema side effects were: erythema

in 7.3%, burning of skin due to salt in 7.3%, burning of skin due to salt solution in 3.6%. solution in 3.6%.

Schieffner R et al.: Eur J Dermatol 2002;12:543-8.

BalneophototherapyBalneophototherapy

There were There were no systemic side effectsno systemic side effects in the in the patients treated by bath-water delivery; patients treated by bath-water delivery; however, some patients did develop however, some patients did develop phototoxic erythema.phototoxic erythema.

The minimal phototoxic dose threshold The minimal phototoxic dose threshold after psoralen bath delivery gradually after psoralen bath delivery gradually declined over five treatments from 5.3 +/- declined over five treatments from 5.3 +/- 0.6 joules/cm0.6 joules/cm22 to 2.8 +/- 0.3 joules/cm to 2.8 +/- 0.3 joules/cm22..

Lowe NJ et al.: J Am Acad Dermatol 1986;14:754-60.

Hyperthermia in hot bath Hyperthermia in hot bath

A case of a 47-year-old black man with a A case of a 47-year-old black man with a history of history of multiple sclerosismultiple sclerosis died in a bath. died in a bath.

Individuals with multiple sclerosis, if Individuals with multiple sclerosis, if immersed in hot water, develop motor immersed in hot water, develop motor weakness, which may be so severe as to weakness, which may be so severe as to prevent them from getting out of the water. prevent them from getting out of the water.

Kohlmeyer RE et al.: Am J Forensic Med Pathol 2000;21:201-3.

Bath related headache I.Bath related headache I. 7 cases, Far-Orient, 7 cases, Far-Orient,

mean age: 51 years.mean age: 51 years. Uniphasic cluster of Uniphasic cluster of

severe headache severe headache recurrently triggered by recurrently triggered by bathing (30 min-30 h).bathing (30 min-30 h).

Self-limitingSelf-limiting course; course; remission within three remission within three months after onset.months after onset.

Nimodipine may shorten Nimodipine may shorten the duration.the duration.

Mak W et al.: Cephalalgia 2005;25:191-8.

Bath related headache II.Bath related headache II.

Three cases of women with hot bath-Three cases of women with hot bath-related severe paroxysmal headache.related severe paroxysmal headache.

Neurological examination, routine Neurological examination, routine laboratory tests, EEG, and brain imaging laboratory tests, EEG, and brain imaging showed no abnormality in any of the showed no abnormality in any of the patients.patients.

Hot bath-related headache is a Hot bath-related headache is a benign benign headacheheadache unassociated with a structural unassociated with a structural lesion.lesion.

Negoro K et al.: Headache 2000;40:173-5.

Epilepsy caused by bathing Epilepsy caused by bathing

Incecik F et al.: Indian Pediatr 2004;41:731-3.

Three cases with hot water epilepsy in childrenwith normal psychomotordevelopment .

A favorable prognosis.

Treatment: -avoiding warm water,-using oral prophylaxiswith benzodiazepinesor conventional AEDs.

Hot water epilepsy (HWE) I.Hot water epilepsy (HWE) I.

21 patients with HWE – form of reflex 21 patients with HWE – form of reflex epilepsy (male:female=3:1; age:1,5-27 ys)epilepsy (male:female=3:1; age:1,5-27 ys)

6 patients reported self-induction, 9 6 patients reported self-induction, 9 patients expressed feeling pleasure during patients expressed feeling pleasure during the seizures.the seizures.

20 patients had partial seizures, 8 of 20 patients had partial seizures, 8 of whom also had sec. generalized whom also had sec. generalized seizures;1patient had generalized seizures seizures;1patient had generalized seizures only.only.

Bebek N et al.: Epilepsia. 2001;42:1180-4.

Hot water epilepsy (HWE) II.Hot water epilepsy (HWE) II.

The major sites of epileptogenic activity The major sites of epileptogenic activity were over the unilateral temporal regions were over the unilateral temporal regions (in 40% of patients). (in 40% of patients).

Seizure control was achieved by reducing Seizure control was achieved by reducing the temperature or the duration of the the temperature or the duration of the bath; several of the patients required bath; several of the patients required medication.medication.

Bebek N et al.: Epilepsia. 2001;42:1180-4.

AquadyniaAquadynia

2 women in whom bathing was regularly 2 women in whom bathing was regularly followed by intense, widespread followed by intense, widespread burningburning painpain that lasted 15 to 45 minutes. that lasted 15 to 45 minutes.

Pain was not caused by any skin or Pain was not caused by any skin or systemic diseases.systemic diseases.

A type of noradrenergic pain induced by A type of noradrenergic pain induced by contact with water, because it can be contact with water, because it can be blocked with clonidine or propranolol.blocked with clonidine or propranolol.

Shelley WB, Shelley ED: J Am Acad Dermatol 1998;38:357-8.

PneumonitisPneumonitis

2 patients who 2 patients who developed acute developed acute pneumonitis after pneumonitis after bathing for OA.bathing for OA.

Bromine and Bromine and hydrobromic acid hydrobromic acid generated from a generated from a widely used widely used water water disinfectantdisinfectant were were implicated as the implicated as the underlying cause. underlying cause.

Burns MJ, Linden CH: Chest 1997;111:816-9.

Accidents in the bathAccidents in the bath

Survey in Japan over 5 years.Survey in Japan over 5 years. The incidence rates for accidents per The incidence rates for accidents per

10,000 bathings in councils were 10,000 bathings in councils were 1.33 and 1.33 and 0.28.0.28.

Hayasaka S et al:Nippon Koshu Eisei Zasshi 2002;49:1070-5.

Bath related sudden deathBath related sudden death

cardiovascular cardiovascular disease (60.4%),disease (60.4%),

cerebrovascular cerebrovascular disease (18.7%)disease (18.7%)

drowning (11.2%). drowning (11.2%). Risk factors:Risk factors: Elderly people,Elderly people, Patients with Patients with

cardiovascular cardiovascular diseases.diseases.

Kido M et al:Nippon Rinsho. 2005; 63:1239-42.

Thank you for your attentionThank you for your attention