55 Climatotherapy in Atopic Eczema

Aeroallergens Air pollutants

Air temperature Global solar radiation Atopic eczema Air humidity

Air movement Entire climate Atmospheric conditions, weather (geographical) (seasons)

55 Climatotherapy in Atopic Eczema

E. Vocks

55.1

Influence of Climate on Atopic Eczema

Environmental climatic factors have a significant influ- ence on the prevalence and course of atopic eczema (Fig. 55.1).

Aeroallergens, such as house dust mites, pollen, molds, and animal dander as well as food allergens can elicit or aggravate the disease conspicuously. The induction of atopic eczema by aeroallergens was veri- fied in numerous studies [23, 57]. In correspondingly predisposed and sensitized subjects, by means of spe- cific IgE antibodies, the allergens turn on a switch from a Th1-dominated immunity situation to an intensified Th2 response and thereby a pathological inflammation cascade in the skin [77]. The aeroaller- genic house dust mite Dermatophagoides pteronyssi-

this way to a significant release or aggravation of atop- ic eczema; however, other aeroallergens – besides allergenic foods – can also distinctly worsen atopic eczema [77].

Air pollutants such as ozone, nitrogen oxide, volatile organic compounds, tobacco smoke, fine and ultrafine particulate matter, and diesel exhaust particles also

Fig. 55.1. Multiple climatic influences on the course of atopic eczema

have a clear impact on the disease. A number of epide- miological studies showed a direct correlation between pollutant parameters such as air pollution, ozone, etc.

and the prevalence of allergic diseases and symptoms [44, 47, 78, 82]. In animal experiments, it was demon- strated, for example, that the IgE sensitization with ovalbumin succeeded more easily when the animals were exposed simultaneously to diesel exhaust parti- cles (DEPs) or ozone [63, 94], and in sensitized animals the reaction to allergens was stronger if they had breathed in corresponding air pollutants before [59, 64]. Likewise, the nonspecific immune response was strengthened by pollutants [26, 63]. Furthermore, it was shown in vitro that air pollutants can increase the allergenicity of relevant aeroallergens [6]. Thus, pollut- ants intensify allergic reactions by modifying the epi- thelium, influencing the immune system, and increas- ing the allergenicity of relevant allergens [81]. Aller- gens and pollutants are effective, not only additively, as we now know, but environmental pollutants also potentize the allergic reaction [22].

Thus allergenic and toxic environmental substances can induce or amplify IgE- and Th2 cell-mediated immunological reactions and lead to an aggravation or acute episode of atopic eczema.

Chapter 55

Physical meteorological properties of the environ- ment also play a part in atopic eczema. The activity and severity of the disease can change drastically in certain seasons of the year, during travel, or after a change in residence [46, 74]. In previous studies, changeable weather, a sudden fall in temperature, the cold season, high sultriness, and geographical regions lacking sun are considered to be factors detrimental to the condi- tion [15, 40, 55, 74, 91, 104]. On the other hand, in cer- tain climatic zones a definite improvement of atopic eczema is observed, for example in particular mari- time climate zones and in specific high-altitude areas [74]. Possible explanations for this particular depen- dence of atopic eczema on weather and climate, espe- cially with regard to the physical part played by the meteorological environment – apart from variations in allergenic and pollutant exposure – could be seen in the disturbed barrier function of the stratum corneum, the altered cutaneous vasoreactivity, and sweating dysre- gulation in atopic eczema [54, 75], leading to impair- ed adaptation to different weather conditions and increased irritability [32, 96] (Table 55.1).

Given that multiple allergenic, toxic, and physical cli- matic environmental factors can lead to an aggravation of atopic eczema, it is evident that a climate lacking aller- gens and pollutants with favorable physical and meteo- rological qualities has a significantly positive influence on the disease. The indication for climatotherapy in case of atopic eczema results from these findings.

Thus, climatotherapy for atopic eczema is based on the one hand on the concept of specific protection from environmental factors that significantly worsen the ill- ness. On the other hand, genuine climatotherapy of atopic eczema aims at a nonspecific immunological stimulation and modulation through further so-called biotropic climate factors [85, 100]. This requires a cer- tain number of climatic stimulating factors, such as sun and light, wind and cold, reduced oxygen partial pres-

Table 55.1. Features of atopic eczema dependent on environ- mental climate

Immunological abnormalities IgE-mediated allergenic presentation T cells in AD

Role of superantigens and bacteria Impaired skin barrier function Vascular and sweating dysregulation Itch

sure of the altitude, as well as highly variable weather.

These stimulating factors cause a general neurovegeta- tive and neuroendocrine stimulation and thereby lead to a lasting immunological stabilization [86].

In atopic eczema, such a climatically determined nonspecific immune modulation is of special thera- peutic importance, because the disease is accompanied by constitutional disturbances of immunological func- tions, in particular by a weakness of the Th1 immune system and by intensified pathological Th2 reactions [77]. The biotropy of the stimulating climate produces a persistent normalization of the disturbed immuno- logical condition, a nonspecific downregulation of the pathological immune response, and thereby long-term stabilization [34].

55.2

History of Climatotherapy

Remedial effects of climatic factors on the human organism were recognized early in history. Natural mineral and thermal springs were cult sites for the Indo-Europeans (3000 – 500 B.C.); the Celts and Ger- mans also revered source deities. Furthermore, one encounters a well-defined sun cult in many prehistoric cultures. In antiquity, references to the favorable effects of sun baths were already found in the writings of the pre-Socratics; in ancient China, the sun was also reported again and again to have an effect in the treat- ment of very different diseases. The Romans applied sun baths as a therapy for gout, paralysis, bladder and kidney illnesses, general strength decline, rheumatic illnesses, and bronchitis and carried out bathing cures [1, 4].

Already Hippocrates (ca. 460 B.C.) pointed out very impressively in his work Concerning air, water and

mate influences. Soranus of Ephesus described for the first time (second century A.D.) the persuasive effect of the sea water. Roman scholars considered changes in the air and climate (mutatio caeli, alteratio aeris) to have a remedial effect; particularly in case of tubercu- losis, wound-healing disturbances, and general conva- lescence, they recommended long sea voyages [1, 92].

A systematic climatotherapy developed in the mid-

dle of the eighteenth century with the first seaside

resorts in England. The English physician R. Russel

(1700 – 1771) founded this discipline in his scientific

writings on the healing effect of sea water and estab- lished the well-known seaside resort of Brighton. Initi- ated by J.C. Lettsom (1744 – 1815), the first seaside hos- pital was built in 1796 in Margate (southern England).

Thereafter, seaside hospices and pediatric hospitals were built on the sea coast in almost all European coun- tries [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 Norderney: these are the oldest German seaside resorts. The next maritime climate health resorts fol- lowed: in 1819 Wyk on Föhr, 1826 Helgoland, 1850 Bor- kum, and 1855 Westerland-on-Sylt, and in 1913 a sea- side hospice in St.-Peter-Ording. In 1881/1882, F.W.

Benecke (1824 – 1882), the founder of thalassotherapy in Germany, conducted the first climate therapeutic investigations in Norderney. Indications for climato- therapy were at that time particularly tuberculosis and scrofulosis [4, 86].

Concerning the therapeutic importance of natural solar radiation, the first scientific studies of modern times by Edwards (in 1824) and Winslow (in 1867) came from England [92]. Also in Switzerland, the phy- sician of natural medicine Arnold Rikli, in the middle of the 18th century (1823 – 1906), followed Rousseau’s call for a retour `a la nature and opened a sanatorium for natural medicine in 1855 in Velden/Slovenia. With light and sun baths, Rikli wanted to achieve milder and more organic healing effects than those obtained with the cold water treatments customary at that time. In his opinion, the sun bath was superior to the air bath. He wrote, “Water does it certainly, air, however, stands higher, and light the highest.” In 1841, a congenial col- league and kindred spirit, the physician Dr. Luzius Ruedi (1804 – 1869), founded a health resort for chil- dren suffering from scrofulosis in the Swiss high mountain valley of Davos and achieved amazing results. Unfortunately, at first they fell into oblivion, when Dr. Ruedi left Davos in 1849 without having pub- lished the healing success of his treatments. In 1862, Dr. Alexander Spengler (1827 – 1901) began with treat- ment of tuberculosis and thus continued Ruedi’s work in Davos [30]; however, he emphasized more clearly the therapeutic effect of movement in the fresh air and of

Fig. 55.2. Open air rest cure in Davos around 1900 (Courtesy of the Archives of the Alexanderhausklinik Davos)

the inhalation of pure dry winter air of the high moun- tains as well as of good nutrition, but did not mention solar radiation in his publications (Fig. 55.2). Thus, it was in fact Dr. Oskar Bernhard (1861 – 1939) from Samedan near St. Moritz, who introduced heliotherapy in the Swiss high mountains and documented the treat- ment successes in 1899. Thanks to the physician Dr.

Auguste Rollier (1874 – 1958) from Leysin, in the Ber- nese Alps, heliotherapy in the high-altitude mountains was further developed as a global therapy for the treat- ment of tuberculosis and was verified in numerous writings [93]. In 1894, the author Maximilian Mehl designed the so-called Mehl heliotherapy in Germany and was regarded as the founder of the Sun Sanatorium for Skin and Lupus Diseased in Oranienburg near Ber- lin [92].

In the twentieth century, climatotherapy lost impor- tance initially in the course of medical investigation and pharmacological therapeutic possibilities. As no satisfactory therapeutic success could be achieved for the increasingly occurring chronic skin and pulmo- nary diseases, a first “revival” of climatotherapy came about in the 1950s, particularly for the treatment of atopic eczema and bronchial asthma. Then the already acquired findings recommended climate zones with a strong stimulating effect for these diseases. Conse- quently, in 1953 on Norderney, the first dermatologi- cal/allergological specialized clinic was founded by Jo Hartung. At the Baltic Sea, particularly Linser and Har- nack were engaged in the climatotherapy of atopic eczema [41, 42]. They also administered thalassothera- py aboard ship [56]. On the initiative of Popchristov in 1962, the Symposium Primum Dermatologicum Bulga-

55.2 History of Climatotherapy 509

Table 55.2. History of climatotherapy for skin diseases and allergies

Century Climate factors Main indications

Prehistory and antiquity 3000 – 500

B.C.

Indo-Europeans Source deities Various

Sun cults Ca. 460

B.C.

Hippocrates Weather and climatic

influences on health

Various

2^ndcentury A.D.

Soranus of Ephesus Healing effect of sea water Gout, paralysis, bladder and kidney diseases, general strength loss, rheumatic diseases, bronchitis, tuberculosis, wound healing disturbances, skin injuries, general convalescence

Until ca.

400 A.D.

Ancient Rome Sun baths

Balneotherapy Sea voyages as therapy (change of climate) Until ca.

500 A.D.

China Climatotherapy and helio-

therapy From the middle of the eighteenth century

1753 R. Russel Seaside resorts and maritime

climate

Tuberculosis, scrofulosis Foundation of the seaside resort of

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 strength loss, wound healing disturbances

1867 H. Winslow, England 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

high-altitude mountains

Tuberculosis, scrofulosis Samedan near St. Moritz, Switzerland

from 1904 Auguste Rollier Leysin, Switzerland

1894 Maximilian Mehl Mehl’s heliotherapy Tuberculosis, scrofulosis

Sun sanatorium for skin and lupus dis- eased patients, Oranienburg near Berlin, Germany

Twentieth century

1953 Jo Hartung Seaside stimulating climato-

therapy

Atopic eczema, allergic rhino- conjunctivitis, bronchial asthma, eczema, psoriasis, and other chronic constitutional dermatoses Dermatologic/allergologic specialized

clinic on Norderney, North Sea

1961 Siegfried Borelli High-altitude stimulating

climatotherapy Dermatological/allergological high-

altitude clinic of Davos, Swiss Alps

riae, dedicated exclusively to dermatological climato- therapy, took place in Sofia. In addition to thalassothe- rapy, dermatological high-altitude climatotherapy was developed, particularly through the studies of A. Mar- chionini and S. Borelli, initially on the basis of clinical mails with atopic eczema patients in Turkey on Mount Olympus, later in the Swiss high-altitude valley of Davos (1560 m above sea level). In 1961 Siegfried Borelli founded a dermatological/allergological high- altitude clinic in Davos, the Alexanderhausklinik [11]

(Table 55.2).

In the course of the following decades, numerous publications were produced in those clinics at the North Sea and in Davos concerning the effect of clima- totherapy on chronic skin diseases and allergies, espe- cially on atopic eczema and atopic airway diseases, but also on other dermatoses, particularly chronic contact eczemas and psoriasis [7 – 12, 21, 29, 31, 34, 68 – 71, 89, 90, 99].

Faced with the ever-increasing incidence of envi- ronmentally triggered skin and airway diseases in the last few decades, the value of natural climatotherapy was rediscovered and reformulated. Today one knows that healing climatic factors have adjuvant effects that are not achieved by pharmacotherapeutic or other monotherapies in these chronic, multifactorially deter- mined diseases.

55.3

Climate and Weather, Climate Adaptation

According to Alexander von Humboldt, climate is “all atmospheric state changes that noticeably affect our human organism.” Modern meteorology defines the term “climate” as the average state of the atmosphere above a specific place as well as the average course of weather, characteristic for this place [18, 86]. On the one hand, the climate results from geographic factors such as geographic latitude, sea level, distance from the sea, position in relation to mountain ranges (orogra- phy), composition of the ground and vegetation, the latter particularly influencing the composition of the air. On the other hand, it results from the changing weather elements, to which sun and sky radiation, cloudiness, fog, rainfall, air temperature, humidity, air pressure, air movement, air current, and the chemical and biological composition of the air, the aerosol, belong [24, 48, 106] (Table 55.3).

Table 55.3. Multiple climatic effecting factors

Geographic factors Changing weather elements Geographic latitude

Sea level

Distance from the sea Position in relation to moun-

tain ranges (orography) Composition of the ground,

vegetation

Solar radiation Cloudiness Fog, rainfall

Air temperature, air pressure Air humidity

Air movement Air current

Aerosol (chemical, biological) (natural-anthropogenic)

It is distinguished between greater area climate of the different continents, macroclimate of the larger areas, and microclimate at individual places [18, 58]. From a biometeorological point of view, the climatic condi- tions in central Europe comprise a maritime climate, a flat land climate, a low mountain-range climate, and a high-altitude climate [85].

The term “weather” means the instantaneous coop- eration of the meteorological entities prevailing at a specific place on a specific date. Thus, the weather is the current state of the atmosphere at a specific place [106].

The weather stages are determined by the alternation of itinerant high-pressure areas (cyclones) and low-pres- sure areas (anticyclones) [1, 49]. Special weather and atmospheric phenomena with high biotropy are inver- sions, thunderstorms, and foehn wind [86].

Humans adapt continuously to the climatic and weather-conditional atmospheric environmental con- ditions. This occurs as short- or long-term adapta- tion to permanently changing weather elements and unchangeable geographic factors of a specific climate [86].

The adaptation of humans to different atmospheric conditions is urgently necessary for the preservation of the integrity of the body. Temperature regulation, for example, is one of the most important adaptation pro- cesses. This process is used for the preservation of homoiothermia of the human organism, which in turn is a basic requirement for all physiological functions [3, 106]. Climatic adaptation makes demands on the ma- nifold regulation systems of the organism, including the immunological system [48, 86]. The adaptation processes, also called weather reactions, occur within physiological boundaries, usually autonomously and unnoticed [36]. The healthy organism is characterized by trained vegetative, humoral, and immunological regulatory mechanisms.

55.3 Climate and Weather, Climate Adaptation 511

55.4

Human Biometeorological Research

Human biometeorological research deals with the reciprocal action between the atmospheric environ- ment and the human organism [25, 36, 48]. It was long neglected scientifically and remained for the most part dependent on empirical knowledge, because methodo- logic problems in this field made progress extremely slow. The exploration of climatic effects on the organ- ism was always considered to be especially difficult, because it deals in this case with relationships between two very extremely complex systems [45, 48].

Therefore, older studies in which meteorological influences on atopic eczema were examined often failed and/or were inconsistent. They were done in the 1950s, 1960s, and 1970s and were carried out in the Davos high-altitude valley in the Swiss Alps [37, 51], at the North Sea [21, 65, 66, 69], the Baltic Sea [41, 88], in Bulgarian mountain range areas [67], and in Germany in Giessen [52]. Some of the investigations were based on very few cases, examined in part only a few and dif- ferent meteorological parameters (besides air temper- ature, air pressure, humidity, wind velocity, and solar radiation they also examined parameters such as ozone, cyclones and anticyclones, weather, and tidal wave). In addition they were based partly on different and unclearly defined clinical parameters for the evalu- ation of the course of atopic eczema. Thus, they cannot be compared, do not fulfill statistical study conditions, and result in inconsistent results, in particular with regard to the role of the duration of sunshine, air tem- perature, humidity, wind relationships, and weather disturbances (cyclones) on the course of atopic ecze- ma.

Since the effect of an individual climate parameter such as air temperature depends on the quality of other conditions prevailing at the same time, such as air humidity and air movement, in biometeorology an attempt was also made to record correlations with bio- logical data by defining so-called meteorological com- plex entities (entities defined in mathematical formu- lae such as effective temperature, chilling effect, etc.) [24, 106]. In the course of this systematization, six cli- mate effect complexes were defined (Table 55.4).

Although this division retained fundamental validi- ty, it is not applicable for precise scientific analyses.

Similarly, the artificially defined physical complex enti- ties proved to be unsuitable, since they represented

Table 55.4. Climate effecting complexes with influence on the human organism (according to [3], [49])

Photo-actinic complex The entire spectrum of solar radiation affecting the earth’s surface Thermic-hygric complex Heat, cold, moisture, air

movement

Relative oxygen deficiency From about 1500m in altitude relevant Air-chemical complex Aerosols Degree of ionization of the air

Air-electric complex Changing electromagnetic fields and field strengths

sources of errors made during the analysis of biological relationships [48].

Therefore, in modern human biometeorological research, correlation analyses with individual climato- logical and medical parameters were chosen, measured and recorded in large series, in order to uncover possi- ble relationships, now possible with modern statistical methods [25]. A further investigational approach is the correlation of medical data with weather stages.

Weather stages show a relatively good coincidence with biological data; therefore they are used particularly in the investigation of weather sensitivity [48]. Finally, epidemiological investigations on the incidence and prevalence of certain diseases in different geographical areas provide a great amount of material for the explo- ration of climatic influences on human disease.

In the field of allergic disease, biometeorological research has attained special importance in the last few years, since a multifactorial pathogenesis of allergic diseases is now assumed. In spite of enormous progress in immunological research, the cause for the increase of allergies has still not been clarified [79]. The statisti- cal recording of natural and artificial environmental impacts on allergic diseases has led to the first infor- mative findings.

Thus, the dependence of allergenic air pollen con-

centrations can be verified on the one hand by air

humidity, air temperature, and atmospheric condi-

tions, and on the other hand by anthropogenic and cli-

matic (ultraviolet radiation) conditional modifications

of the natural vegetation [33]. House dust mite and

mold contamination of the air increases with air mois-

ture and temperature and in cases of insufficient venti-

lation. Some studies presume general urbanization in

this connection as a cause of the increase in allergen- polluted microclimates [61].

In our own investigation, a significant influence of weather factors on pruritus of atopic eczema was veri- fied. With increased air temperature (to approximately 20°C) and wind rate and with decreased air humidity, pruritus decreased. Possible causes are to be found in an atmospherically dependent nonspecific skin irrita- tion due to the faulty epidermal barrier function and vegetative dysregulations [32, 103, 104]. Weather sensi- tivity is disturbed in patients with atopic eczema [102].

As for the effects of environmental noxiousness on allergic diseases, interesting experimental and epidemi- ological data have been collected. Accordingly, sulfur dioxide, soot particles, tobacco smoke, volatile gases, ozone, aromatic hydrocarbons, small molecular parti- cles, nitrogen oxides, and diesel particles are some of the most important pollutants. They can have both an im- mune-stimulating and immune-suppressing effect [6].

After the reunion in Germany, the so-called East-West studies were very informative, according to which the classical type I smog, mainly SO

and dust (in the East) led to less allergic sensitization than the modern type II smog, especially organic components, fine particles, and 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 modern climatic and environmental factors on the prevalence of allergic illnesses could be established by biometeorological and allergotoxicological investiga- tions, in particular for atopic eczema. The correspond- ing therapeutic measures such as protection can be implemented most consistently within the framework of climatotherapeutic measures [2, 85]. The effects of climatotherapies for atopic eczema have been verified, furthermore, in numerous clinical studies [34, 100].

55.5

Basic Principles of Climatotherapy

Climatotherapy is defined as “the treatment of patients by modification of their exposure to physical and chemical effects of the atmosphere, through which dur- ing simultaneous isolation from harmful environmen- tal conditions an adaptation to natural environmental factors is attained” [86].

The fundamental principle of climatotherapy is based on two aspects:

Table 55.5. Basic principles of climatotherapy Protection and/or

relief

Air pollution↓ Sultriness↓

Inversions↓ Relief

Adaptation to natu- ral environmental factors

Sun↑ Light↑ Wind↑ Cold↑

O2partial pressure↓ Rough, changeable

(biotropic) weather↑ Stimulation

+ fl

1. Protection from and/or relief from burdening atmospheric conditions

2. Adaptation to natural environmental factors In this case, the meteorological elements can be divid- ed based on their most frequent effects into so-called stimulating and protective factors [2, 106], where some climatic elements that usually produce a stimulating effect can also lead to removal of this effect. This depends on the entire climatic situation and the type and length of the climatic exposure, which determines the dose, as well as on the individual sensitivity and/or illness of the patient [85] (Table 55.5).

55.6

Climatotherapy in Atopic Eczema

Atopic eczema is one of the oldest and most important indications for climatotherapeutic measures [10, 100], as demonstrated by the historical evolution of climato- therapy in the last 100 years. This is also understand- able in that it is a disease that manifests on the skin, the boundary organ of the organism to the environment, the organ that is influenced more strongly than any other by the surrounding climatic atmosphere. Indi- vidual climate elements, which are necessary for an effective climatotherapy of atopic eczema, can be sum- marized as follows.

The corresponding healing climate must be charac- terized by a low content of aeroallergens (house dust mites, pollens, molds) and air pollutants, which in many cases drastically reduces disease maintenance or worsening allergic reactions in atopic eczema [34, 99].

A sufficiently high atmospheric chilling effect, in par- ticular the absence of any sultriness, leads to the nor- malization of the abnormal sweating function [87] and has an anti-inflammatory and antipruriginous effect

55.6 Climatotherapy in Atopic Eczema 513

Table 55.6 Climatic assump- tions for a climatotherapy of atopic eczema

Low aeroallergen content House dust mites, pollen, mould spores

Low air pollutant content Sulfur dioxide, soot particles, tobacco smoke, volatile gases, 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 Little vapor and fog, high sunshine duration throughout the year Climatic stimulating factors Sun and light

[Climate stimulating stages 2-(3)]

Wind and cold

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- ural solar irradiation, which achieves in addition to bactericidal effects, an anti-inflammatory and antipro- liferative immunological effect directly on the skin organ [53], and thus contributing to normalization of the faulty barrier function [98] (Table 55.6).

In addition to these basic requirements, which first protect and isolate the skin from detrimental climatic factors, the therapeutic climate must also possess suffi- cient biotropic stimulating factors essential for an effective climatotherapy of atopic eczema [2, 86, 100].

On a scale of 0 (protective climate) to 3 (very strong stimulating climate), climatic zones of the stimulating stages 2 – 3 are suitable [11, 85, 99]. Climatic stimulat- ing factors are sun and light, wind and coldness, reduced oxygen partial pressure of the altitude, surf aerosol of the sea, as well as an increased biotropy of the weather with an increase in the stimulus level, stim- ulus frequency, and environmental stimulus variability with aperiodic variations [36, 49, 86] (Table 55.6). In the climatotherapy of atopic eczema, solar radiation therefore represents not only a disease-specific thera- peutic, but also a nonspecific immunological stimulus.

These nonspecific climatic stimulating factors affect – often via an initial irritation, also accompanied by dis- ease deterioration – training of the thermoregulatory, vegetative, and endocrine adaptation processes of the organism and a raised tolerance toward climatic stimu- li. A decrease in sensitivity to cold [97] has physiological results, a metabolism increase [20], and an increase in performance [19], but also decreased infection vulnera- bility. The precise effects of a climate’s stimulus on the immune system have not yet been clarified sufficiently.

An investigation conducted by Ring et al. demonstrated the influence on humoral and cellular immunity, for example by using a hydrotherapeutic Kneipp treatment

[80]. According to Drosner, significant rise in the cuta- neous reaction to microbial recall antigens (Multitest Merieux) occurred following high-altitude climatothe- rapy for atopic eczema. The number of anergic and hyperergic reactions decreased with a simultaneous increase in normergic reactions [27].

For German patients, this specific climatic constel- lation required for climatotherapy of atopic eczema is found in an ideal form in the maritime climate of the North Sea islands, particularly the islands lacking grass and vegetation, and in the high mountain valley of Davos in the Swiss Alps, because these climate zones have sufficient climatic stimulating factors vital for the lasting effect in addition to a lack of allergens and pol- lutants and intense solar radiation [99]. Here the best therapeutic experience has been recorded.

Climate therapies on the Baltic Sea islands are only relatively suitable for atopic eczema due to the vegeta- tion and the frequent land breezes on these islands [86].

Outside of the German-speaking countries, climatothe- rapy for atopic eczema is carried out on the French Atlantic and Mediterranean coasts, on the Canary Islands [5] as well as in the Eastern areas in Poland (Bal- tic Sea coast, southern coast of the Crimea, and the Caspian Sea), in Bulgaria, in the former Yugoslavia, in Russia, and on the Turkish coasts; however, few validat- ed scientific findings are available [86]. Thalassotherapy on the Dead Sea is specialized in the treatment of psoria- sis, and combined applications with artificial selective UV spectra [84] are not effective as climatotherapy.

The maritime climate is characterized by a number

of particular climatic qualities; the climatotherapeuti-

cally important characteristics are considerably more

effective on the corresponding islands than in the coast

climate [49]. Particularly in the maritime surf zone, we

find markedly fewer allergens and/or a complete lack

Table 55.7. Biometeorological characteristics of (North Sea) maritime climate (according to [86])

Protecting Allergens↓(particularly North Sea islands, more effective than the Baltic Sea) Air pollutants↓

Sultriness↓ Strongly

stimulating

Air temperature↓ Wind↑

Ultraviolet and global radiation↑ Aerosols of the sea water Biotropic (changeable) weather↑

of allergens. The pronounced maritime aerosol contains salt and iodine. Furthermore, the maritime climate is characterized by a particularly well-developed photo- actinic complex, since the wide horizon provides unlim- ited sky radiation [86]. Heliotherapy is very effective, above all from spring until fall for atopic eczema [71].

Furthermore, we find a relative coolness in the case of strong winds and high humidity. In order not to over- dose the cold stimulation, wind protection is often nec- essary. Furthermore, the weather is changeable (Table 55.7). Since the climate of the North Sea is very stimulat- ing (climatic stimulating stage 3), it is perhaps too much so for small children and it can lead to a lasting deterio- ration of the condition for certain individuals.

In the high-altitude climate beginning at 1000 m above sea level, a special climatic situation occurs in that with an increase in altitude a change in meteoro- logical factors is to be found (Table 55.8).

The special climatic situation in the high mountains above 1000 m first of all relieves symptoms because of the purity of the air. The allergenic pollution of the air is clearly reduced. Due to the low annual mean temper-

Table 55.8. Change in meteorological factors with increase in altitude (according to [3], [36])

Decrease Inhalant allergens Air pollution

Air temperature – Approximately 6 °C

Air pressure – Approximately 12 %

Water vapor pressure of the air – Approximately 25 % Oxygen partial pressure – Approximately 12 % Increase

Global solar radiation + 10 % – 20 % Ultraviolet radiation + 20 % – 30 % Electromagnetic radiation

Snow coverage Wind rate

atures and the distinct dryness of the air, house dust mites are basically not present roughly 1200 m above sea level, because they do not survive under these con- ditions [60]. These thermic-hygric conditions reduce the concentration of allergenic pollens and the pollen season in comparison to the lowland regions [38]. The proportion of mold spores is reduced for the same rea- sons or is missing altogether. The wind conditions should be such that no air allergens are carried in from elsewhere. This is, for example, ideal in the high-alti- tude valley of Davos, where mountain ranges in all main wind directions stop the stronger air movements [11]. It can be assumed that pollutants specific of resi- dential and/or industrial sites are lacking to a large extent. According to Drzimalla, there is also a pro- nounced lack of air bacteria in the Davos area, with on the average 400/m

air; in cities bacteria are often mea- sured at 50,0000 – 100,000/m

air [28]. Furthermore, the high mountains are characterized by a lack of sultri- ness, meaning that sweat and heat oppressiveness is absent. In particular, vapor and fog rarely occur in Davos [104].

The stimulating climatic effects of high altitude con- sist in intense solar radiation, cooling stimuli, in par- ticular fluctuations in temperature, reduced oxygen partial pressure, and an abundance of atmospheric small ions as well as variable weather (Table 55.9). The high-altitude valley of Davos is a climate zone of the stimulating stage 2 and for that reason an ideal climate for the treatment of atopic eczema.

By the increase in the duration of sunshine above 800 m in the fall and winter, the specific radiation cli- mate in the high-altitude mountains is characterized by higher global solar radiation, at times 100 % stron-

Table 55.9. Biometeorological characteristics of high-altitude climate above 1,000 m (according to [86])

Protecting Allergens↓(also house dust mites from 1,200 m above sea level)

Air pollutants↓ Air bacteria↓

Air humidity and sultriness↓ Strongly

stimulating Ultraviolet and global radiation↑ Air temperature↓

Air dryness↑

Wind↑(according to mountain range constellation)

O2partial pressure↓

Biotropic (changeable) weather↑

55.6 Climatotherapy in Atopic Eczema 515

ger than in lowland regions, and by an increase in intensity of the biologically particularly effective spec- trum between 290 and 350 nm. On the one hand, the global solar radiation of the altitude is effective as a nonspecific endocrine immunological stimulus; on the other hand it is a specific therapeutic for the diseased skin in atopic eczema [98]. Heliotherapy at altitudes of about 1500 m is particularly effective and in a wind- protected geographical position possible virtually throughout the year, because even with an overcast sky, ultraviolet radiation reaches the ground. In the winter 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 pro- vide an especially favorable therapeutic effect with an accumulation of 295 nm in the ultraviolet-B range, comparable to artificial UVA-B phototherapy, in addi- tion to the immunological and endocrine effects of vis- ible light [34, 98]. Because of its special radiation con- ditions, 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 posi- tive effect on atopic airway diseases, allergic rhinocon- junctivitis, and allergic and/or mixed forms of bron- chial asthma. These diseases are often coupled with atopic eczema. However, patients who suffer exclusive- ly from these airway diseases are subjected to an analo- gous climatotherapy. The climate zones mentioned are the same.

55.7

Application of Climatotherapy

For successful climate therapy treatment, the body must be exposed for several weeks to the biometeoro- logical conditions [2]. The climate exposure proce- dures during the treatment of atopic eczema still con- sist essentially in heliotherapy, open-air rest cure and terrain therapy, at the sea and in thalassotherapy [34, 86] (Table 55.10). In heliotherapy, at the seaside area and in high-altitude mountains, the immune-modulat- ing effect of UV and visible light radiation of the sun are used therapeutically under controlled conditions.

The dose depends on the individual ultraviolet skin type according to Fitzpatrick and on the initial suntan and is always generally suberythematous. The thera-

Table 55.10. Different types of climate exposure procedures Climate exposure

procedure

Definition

Heliotherapy Therapeutic exposure to the natural sun under controlled conditions Open-air rest cure Rest in the open air with body clothed

and protected against cooling Terrain therapy Hiking (ergotherapy) under cool

conditions Thalassotherapy,

sea bath

Effect of the maritime climate, combined with sea baths

Fig. 55.3. Heliotherapy in Davos (Courtesy of the Archives of the Alexanderhausklinik Davos)

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 high-altitude heliotherapy were established far below the cumulative UVB doses that are commonly applied using artificial dermatological UVB phototherapy [98], because in the case of global solar radiation, high doses of visible light also participate among the other spec- tra, whose precise endocrine and immunological effects remain unknown at this time.

The open-air rest cure in the form of resting in the

open air with the body clothed and protected against

cooling has an invigorating effect and leads to general

vegetative and immunological stabilization. This free

air cure is ideally supported by climatic terrain thera-

py, whose therapeutic effects are enhanced by hiking

under cool conditions and by the favorable influences

of the climate [49] (Fig. 55.4). Schuh was able to verify

that in atopic eczema a 4-week terrain training in the

Fig. 55.4. Terraintraining during climatotherapy in Davos (Courtesy of the Archives of the Alexanderhausklinik Davos), in winter also cross-country skiing is performed

high-altitude mountains of Davos led to a significant improvement in the faulty sweating behavior parallel to the improvement of skin symptoms, which was a long- lasting effect and still found as high as 38 % after 6 months. In parallel, a decrease in the illness phases and in the severity of atopic eczema as well as in the itch was found in up to 50 % of the subjects 6 months after endurance training [87]. Thalassotherapy exploits the curative effects of the sea water and the maritime aero- sol in combination with ultraviolet radiation [49]. The sea bath in the stimulating climate of the North Sea is one of the strongest stimulating factors available, since the water temperature even in the summer rarely reaches more than 20°C. It is increasingly dosed, in gen- eral with swimming for 3 – 7 min in the beginning [86].

Simultaneously, an antimicrobic, astringent, and kera- tolytic effect of the salt water on the diseased skin occurs, which is tolerated, however, only in the subacute and interval stage; in acutely exacerbated atopic eczema the salt water can be too irritative, since the salinity of the North Sea is relatively high, averaging about 3.4 %.

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- ment and deterioration and lasts several weeks. At the earliest, stabilization occurs in the 3rd week and the actual therapeutic effect begins [49, 69]. Furthermore, repeated climatotherapy procedures are clearly suitable to decrease acuity and to prevent relapse inclination [34].

Climatotherapy is carried out under inpatient condi- tions, under which, in addition to the actual climate exposure procedures, necessary dermatological and al- lergological therapies can take place, such as stage-suit-

Table 55.11. Climatotherapy in atopic eczema: complex thera- py program

Climate exposure procedure

Stage-appropriate dermatological treatment with externa Balneotherapy

Where appropriate, systemic medicamentous treatment Where appropriate, diets

Where appropriate, concurrent psychotherapeutic proce- dures

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

For children and adolescents, kindergarten and school instruction

able eczema therapy (as free of corticosteroids as possi- ble), where appropriate elimination diet regimes, how- ever, concurrent with psychological behavioral thera- pies (relaxing training sessions) and general recreation- al therapies with sport and physical therapy. Enhanced allergological diagnostic and patient education belong to the complex therapy program [50, 76] (Table 55.11).

This requires the following facilities: in addition to a variable selection of dermatological internally and externally active substances and corresponding appli- cation aids, equipment for general and emergency treatment, phototherapy devices for adjuvant irradia- tion (UVA and UVB), bath equipment for single whole- body and partial baths, community pools (hydrothera- py), inhalation device, general lab, allergy lab (allergy tests), pulmonary functional devices, as well as further facilities such as a kitchen for patient instruction, rooms and equipment for physical therapy, community sport, ergotherapy, relaxation therapy, patient groups, specialized lectures, and where appropriate the neces- sary kindergarten and school facilities [101].

55.8

Therapy Results

With a dermatological, at least 6-week climatotherapy in the North Sea stimulating climate on the island Norderney, 92 % of the patients with atopic eczema became symptom free, 8 % improved, but still had remaining focuses [71]. Initially, the number of eosino- phils that had increased in the peripheral blood and the sharply raised entire and specific IgE values decreased

55.8 Therapy Results 517

[73]. Fischer demonstrated a significant decrease in the T helper-suppressor ratio after North Sea climatothe- rapy [35]. High pathologically lowered serum cortisol values normalized during the treatment in the sea cli- mate [71]. Pathologically lowered alkali resistance, thermal conductivity, and skin circulation improved significantly [69, 72]. In 98 % of the patients, the long- term corticoid treatment was reduced [71]. The effect was continuous: repeated climate therapies led to increasingly longer relapse-free intervals [71].

The therapy results after high-altitude climatothe- rapy in the Alexanderhausklinik in Davos were docu- mented by the evaluation of patient data from 1961 to 1995 in 31,438 patients with atopic eczema. According- ly, in 96.7 % of these patients a symptom-free and/or

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, Alexanderhausklinik (Courtesy of the Archives of the Alexan- derhausklinik Davos)

considerably improved skin condition resulted (Figs.

55.5 – 55.8); in 2.8 % it remained unchanged, and in 0.5 % an impaired skin state was shown at dismissal [34]. With 4,324 patients (1995 – 2000), a drop in the SCORAD (score index for atopic dermatitis) was reached, on average from 52.0 to 15.3 (71 %) (Fig. 55.9).

In vitro, the number of eosinophils in the peripheral blood and total IgE decreased. Also, a significant re- duction was found in the serum ECP, from 33 µg/l to 17.5 µg /l in 41 examined patients [90] (Fig. 55.10). The sIL2R was determined in 27 patients with atopic eczema, who were treated as inpatients for an average of approxi- mately 7 weeks in the Zürcher high-altitude clinic Davos-Clavadel. All patients showed raised output val- ues and a significant drop at the end of the therapy [34].

Figs. 55.7. Severe prurigoform atopic eczema before 6-week cli- matotherapy in Davos, Alexanderhausklinik (Courtesy of the Archives of the Alexanderhausklinik Davos)

44.5

12.7

51.5

15

67.5

22,1

0 20 40 60 80 100

< 4 weeks 4-6 weeks > 6 weeks before after

n = 502 n = 3428 n = 394

S C O R A D

c limatotherapy

33

17,5

0 5 10 15 20 25 30 35 40

before after

µg/l ECP

Fig. 55.8. Severe prurigo atopic eczema after 6-week climato- therapy in Davos, Alexanderhausklinik (Courtesy of the Archives of the Alexanderhausklinik Davos)

Fig. 55.9. Decrease in the Score Index for Atopic Dermatitis (SCORAD) after high-altitude climatotherapy in the Alexan- derhausklinik Davos, depending on the duration of treatment (longer treatment for more severe cases) (n = 4,324, 1995 – 2000)

Fig. 55.10. Serum ECP (eosinophilic cationic protein) levels in patients with atopic eczema before and after climatotherapy in the Alexanderhaus- klinik Davos (n = 41) (Data from [90])

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, approxi- mately 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 docu- mented in 97 patients with atopic eczema who had been treated between 1990 and 1994 in the Zürcher alti- tude clinic Davos-Clavadel [68]. The long-lasting effect was also shown in a recording of work disability peri- ods in 3,211 patients of the Alexanderhausklinik: in the year before the high-altitude climatotherapy, 24 % of the patients were unable to work because of atopic eczema once or several times, 14.2 % of them longer than 4 weeks, whereas in the year after the therapy in Davos, only 10 % of the patients were absent from work, and only 2.4 % longer than 4 weeks [29].

The effectiveness of the high-altitude climatotherapy in Davos in atopic eczema was also documented on the basis of further clinical experimental studies. Borelli and Chlebarov examined the influence of high-altitude climatotherapy on the neurovegetative and histamine reactivity of the skin. Of the atopic dermatitis patients examined, 96 of 100 showed an increased sympathetic skin response at presentation. This decreased to 81 % during one 4- to 10-week stay; in 24 % it normalized completely [13]. Also, the histamine response of the skin, which was high in 81 of 119 patients at presenta- tion, declined during one at least 4-week stay in about

55.8 Therapy Results 519

Table 55.12. Observed effects of climatotherapy in atopic eczema (according to [89]) Neurovegetative regulation Normalization of sympathetic skin response

Normalization of skin response to histamine 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, socioeconomic effects

Drastic resolution of skin symptoms 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

half of the patients [14]. In comparison, a decrease in the skin’s reactivity to intracutaneously applied hista- mine, serotonin, acetylcholine, and bradykinin was observed after climatotherapy, parallel to clinical im- provement [17]. An improved skin circulation after high-altitude climatotherapy was verified both fluvo- graphically [16] and by means of transcutaneous CO

measurement [39]. Investigations of the thermophysio- logical responsiveness of the skin showed normalized thermoregulation, improved skin circulation, as well as an adaptation of sweat production in atopic eczema patients after physical training under high-altitude cli- matic conditions; a decisive influence was attributed to the cool ambient temperatures [87]. Measurements of transepidermal water loss (TEWL), which is high in atopic eczema patients in comparison to normal sub- jects and indicates a disturbed barrier function of the skin, showed a significant drop after therapy in the high-altitude climate [95] (Table 55.12).

55.9 Conclusion

Climatotherapy in atopic eczema must be considered as the most comprehensive integral rehabilitation measure of its kind [95]. On the one hand, it is lastingly effective, given the climatically determined lack of allergens and pollution and with that, the interruption of the allergic reaction and improvement of the current symptoms.

Under these protective conditions, for the first time regeneration of the organ damage that has already occurred can begin. In addition, the climatic stimula- tion causes a downregulation of what is in atopic eczema an enhanced – specific and nonspecific – immune response. Immunological stabilization occurs and thereby a prognosis of lasting improvement in the entire clinical picture. In view of this environmentally trig- gered skin disease, natural climatotherapy is an indis- pensable adjuvant therapy which is particularly effec- tive, and largely exceeds the effect of other therapies.

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