Sulfur to alleviate skin affected by psoriasis?

Psoriasis is a chronic inflammatory and proliferative disorder of the skin , which clinically manifests itself through the formation of well-defined erythematous plaques , covered with persistent scales. Psoriatic skin lesions are typically located on the elbows, scalp, face, fold areas, palms of the hands, and soles of the feet. As a chronic disease, psoriasis has a cyclical course, including periods of remission.

The causes of psoriasis are not yet fully understood. However, several factors have been identified as playing a role in the development of psoriasis. Recent research suggests that an excessive activation of the immune system in the context of a genetic predisposition may be involved in the onset of the disease. Although specific systemic and environmental factors are known to influence the disease (stress, intake of certain medications, excessive alcohol, etc.), its progression is unpredictable and generally develops spontaneously with an increase and worsening of lesions without discernible causes.

Psoriasis is considered a lifelong disease, and there is not yet a causal treatment for the condition. The systemic treatments for psoriasis depend on the severity of the dermatosis and the location of the physical symptoms, and may include local topical agents (keratolytics, corticosteroids, D3 vitamin analogues, retinoids, etc.), systemic medications administered orally or percutaneously (ciclosporin, methotrexate, acitretin, apremilast, etc.) and alternative and complementary therapeutic methods (thermal cures, laser, phototherapy (PUVA), etc.).

However, rare but serious safety issues have been observed (impairment of kidney function, infections, cancers, cardiovascular risks, liver damage, hematological disorders, depressive episodes, exacerbation of chronic inflammatory bowel diseases, etc.).

Considering the potential for side effects from long-term exposure to various systemic treatments for psoriasis, sulfur balneotherapy could represent a useful alternative for the treatment of mild to moderate psoriatic lesions. Indeed, sulfur-based remedies have been used for centuries to treat various dermatological conditions such as psoriasis.

A small clinical trial revealed that all 10 patients suffering from psoriatic plaques showed a significant improvement in the elasticity of skin components (elastic fibers, etc.) and a restoration of its hydration level, after a bath at a temperature of about 34˚C - 35˚C in thermal water containing a high level of sulfur (173 mg/L) for a duration of 20 minutes over 12 days, compared to the skin of controls with no obvious skin lesions. They thus reported a reduction in psoriasis symptoms, namely a decrease in the thinning of psoriatic plaques and a reduction in the intensity of redness.

By what mechanisms?

The action of sulfur on the skin is believed to be due to its interaction with cysteine and its catabolites contained in keratinocytes. The sulfur that penetrates the skin is oxidized into hydrogen sulfide and triggers various physiological responses.

• Anti-inflammatory: Sulfurous water has demonstrated its ability to inhibit the proliferation of T lymphocytes, as well as the production and/or release of pro-inflammatory cytokines (IL-2, IFN-γ), thereby deactivating the main players of the inflammatory response in keratinocytes. It can also inhibit the expression of immune system mediators induced by TNF-α (E-selectin and ICAM-1).

• Anti-proliferative: It has been demonstrated that the exogenous application of hydrogen sulfide (H2S) reduces the proliferation of human keratinocytes by decreasing the expression of the vascular endothelial growth factor (VEGF), through a cascade of intracellular reactions.

In a 2023 study, researchers sought to assess the effect of hydrotherapy on the skin microbiome in 16 patients with plaque psoriasis. The composition of microbial communities was similar on psoriatic plaques and unaffected healthy skin, before and after balneotherapy. The study reveals that balneotherapy sessions over a period of 3 weeks (sulfur content of 3.2 mg/L; bath temperature at 36°C; neutral pH; five times per week) significantly increased the level of the genus Leptolyngbya (potential antioxidants, anti-inflammatory, anti-proliferative), and decreased the quantity of the genus Flavobacterium genus (enhance the growth of Cyanobacteria, such as Leptolyngbya), whether on non-lesioned skin or on skin affected by psoriasis.

Limitations to Studies?

While the trend observed confirmed the effects of balneotherapy on psoriasis, these studies notably have limitations. The sample size in the studies is not sufficient for a detailed statistical analysis. Moreover, the characteristics of mineral spring waters differ from one study to another, with varying sulfur contents and the presence of other minerals (magnesium, calcium, iron, hydrogen carbonate, etc.). Therefore, it is not straightforward to determine the effects of sulfur on psoriasis.

However, sulfur-rich water bath therapy appears to have proven itself as a promising therapeutic strategy for clinically improving plaque psoriasis, not to mention that serious adverse effects resulting from this type of therapy are rare. On the other hand, the effects and efficacy of sulfur thermal therapy on psoriasis are only partially understood. Further studies are needed.

• SESTI S. & al. In vivo study of biomechanical properties in psoriasis vulgaris: Effectiveness of sulfur spa therapy. Open Journal of Molecular and Integrative Physiology (2013).

• NÉMETH B. & al. Balneotherapy in psoriasis rehabilitation. In Vivo (2017).

• TSANKOV N. & al. Disease severity, patient-reported outcomes and skin hydration improve during balneotherapy with hydrocarbonate- and sulphur-rich water of psoriasis. Journal of the European Academy of Dermatology and Venereology (2021).

• BENDER T. & al. Evaluation of the effects of Lake Hévíz sulfur thermal water on skin microbiome in plaque psoriasis: An open label, pilot study. International Journal of Biometeorology (2023).