The Effect of Geothermal Water on Skin Condition and Body Fat

Balneotherapy for therapeutic purposes has been used since ancient times, and was based on empirical experience carried forward from generation to generation. There is scientific evidence about the positive effects of the thermal water on the skin and on body weight, but studies with the mineral water from a borehole are missing. Objective: To investigate the effect of high mineralization geothermal water on the skin and body fat. Methods: The study included 50 women who received geothermal water baths for than before the treatment (p<0,01). After 20 minutes of balneotherapy treatment, there were fewer skin complaints (p=0,003), a decreased BMI (p<0,001) and a lower body fat percentage (p=0,017); as well as greater skin moisture (p<0,05) and skin elasticity (p=0,016). Conclusions: High mineralization geothermal baths of a duration of 15-20 minutes improve the skin condition and reduce the amount of fat in the body; the effect lasts up to 4 months after the treatment. As a result, geothermal water treatments should be integrated into the treatment programs for skin diseases and should take a significant place among beauty procedures.


INTRODUCTION
The healing effect of thermal water has been mentioned from the times of the Roman Empire [1]. In recent decades, several fields of medicine have undergone a great transformation because of the evidence of the effects of natural scientific factors. The result of the effects of neuroreflexive and humoral mechanisms is a complex series of reactions involving the adaptations of the human body, caused by the stimulation of mechano-, thermo-, baro-and chemo-receptors. It is difficult to attribute the measured effects to specific parameters. The scientific reports suggesting that the chemical and thermal properties of spa water have an impact on skin cell physiology [2], trigger physiological changes in the renal and cardiovascular systems with potentially beneficial effects on skin diseases. Whereas the benefits of the external use of several minerals (zinc, magnesium and iron) are known well, and have been confirmed by the FDA; the benefits of other minerals to the skin are still under investigation [3]. The efficacy of spa therapy for inflammatory skin diseases and the mechanisms are only partly understood, and incorporate chemical, thermal, mechanical and immunomodulatory effects. Minerals in spring water (sulfur, magnesium, calcium, selenium) induce anti-inflammatory, keratolytic, antibacterial or antifungal effects [4]. For antiinflammatory effects, the inhibition of Th1, Th2, Th17 differentiation, inhibition of keratinocytes cytokine (IL-6, IL-8, IL-1α, TNFα and GM-CSF) production, and modulatory effects on epidermal Langerhans cells have been reported [4]. Also studies with animal models showed bicarbonatecalcium-magnesium mineral water improve in skin regeneration, not only by increasing keratinocyte proliferation and migration but also favorably modulating the regenerated collagen and elastic fibers in the dermis [5]. Experimental in vitro studies on cell cultures and human keratinocyte cell lines showed that thermal springs reduce parameters associated with inflammation [6]. Scientific works by various authors have revealed that direct contact with thermal water has a beneficial therapeutic effect in the treatment of skin diseases (psoriasis, dermatitis, eczema, various infections and injuries) [7][8][9][10][11][12][13][14][15][16][17].
In addition to the diverse positive effects on the body, obesity is a specific target of balneotherapy, where treatments have also shown a positive result [18][19][20]. Overweightness and obesity are the main risk factors in coronary heart disease, strokes, type II diabetes, osteoarthritis, and certain types of cancer (uterus, breast, intestine) [21], and thereby worsen the quality of life, increase mortality and add to health-related costs. The mechanisms for this effect is under investigation. Water immersion is believed to induce cardiac, blood flow, and temperature changes to the body. The displacement of body fluid to the central cavity causes an increase in interstitial fluid transfer into the vascular space reducing exerciseinduced swelling and increasing cardiac output and blood flow, which accelerates the removal of metabolites and waste products, reduction of muscle oedema and fatigue, and enhances delivery of oxygen [22,23]. Hot water temperatures are associated with an increase in peripheral vasodilatation, which also results in increased blood flow thus decreasing blood pressure, regulating autonomic nervous system [24]. Impact on the plasma level of the adipocytokines leptin and adiponectin [25] as antioxidant and metabolic activities matters [19]. Different studies data show that the effectiveness of balneotherapy on weight loss is similar to the results obtained by drug treatment, commercial weight management programs, and comprehensive lifestyle modification programs. Some scientific human studies showed reduced excessive body mass, correction of blood lipid spectrum, normalization of metabolic processes in the liver [26,27,18]. The healing effects of thermal spring water are well known, but further studies of its biological properties and its therapeutic benefits are necessary [28].
Although there is a proven positive effect of the Dead Sea and other natural mineral water sources on the skin and on body weight, there is a lack of studies on the effect of water extracted from boreholes. The objective of our study is to explore the effect of geothermal water of a high degree of mineralization on the skin and on body fat.

MATHERIALS AND METHODS
The study, involving 50 women (average age 35), was carried out in Klaipeda, at the spa centre in February-June 2015. All subjects were informed about the purpose, conditions, and course of the study prior to the inclusion, and signed a participant's agreement. This openlabel trial was implemented in observance of the rules of good clinical practice; protocol was approved by the Ethics Committee of Vilnius University. The voluntary participants randomly were divided into 2 groups (25 in both), which received geothermal water treatments of a different duration of procedure (Group I-15 and Group II-20 min). Randomization into two different treatment groups was performed by an individual who was not involved in the implementation of the study using a randomnumber table. A professional performing the statistical analysis was aware of the randomization.
The inclusion criteria were: women 18-55 years of age, had not received any rehabilitation procedures during the last 3 months, and who wished to participate in the study. Exclusion criteria: current acute skin or infectious disease, active tuberculosis, severe asthma, malignant tumours, severe nervous system disorders (psychosis, neurosis, epilepsy), liver failure, kidney failure, severe heart deficiency, severe hypertension, angina at rest, non-corrected serious endocrinological diseases (thyroid, pancreas), heart rhythm disorders, bleeding, severe allergic reactions, severe obesity in the absence of pregnancy. All of the participants were examined by a general practitioner.
Geothermal water of an indifferent temperature (34°C), with a high mineralization of 27,6 g/l (supplied by borehole from Klaipeda region) was used for the study. The chemical composition of the water is presented in Table 1. The geothermal water was slightly alkaline, pH was 7.24, specific electric conductivity was 42800 μS/cm at 25°C, total water hardness 173, carbonate 1.35, and with a cation/anion balance +5998 mg-eq/l. The subjects received 15 balneoprocedures in geothermal water baths daily five times a week for 3 weeks. The participants were immersed to below the armpits in warm water of 34°C. The exposure time for balneoprocedure for Group I was 15 minutes; and for Group II was 20 minutes. It was recommended that the subjects slightly moved around while in the bath. In case of unpleasant sensations, weakness or heart problems, they could seek medical attention, and their behavior and changes in appearance were monitored and observed during the treatment. The enrolled patients completed the balneotherapy treatment as outpatients, with no change in their daily routine or work attendance.
According to the methodology a questionnaire about the health and about the skin condition of the women were used; the skin moisture and elasticity was measured with a Soft 55 Catellani 1930 measurer; the BMI and skin fat were measured with an Omron body fat measurer and with scales; the skin ridge was measured with a caliper; and the other sizes were measured with a tape-measure. The participants were examined before the procedures and immediately after the treatment; while the remnant effect of the 15-min treatment was evaluated 1 and 4 months after the treatment.
In describing the data, we calculated of the readings, as well as the deviations (SD). To determine the reliability of the statistical ev calculated the confidence inte confidence level (CI) 0,95. The graphs are given using the averag During the verification of the hypothes the normality of the distribut parameters, the Kolmogorov-Smirnov used. Student criteria was us comparison of the data averages independent groups when some s the conditions of normality; nonparametric Mann-Whitney criterion when the distributions in the studied did not satisfy the conditions of norm comparison of the two dependent signs, we used a pairwise Student used a nonparametric Wilcoxon, McNemar's test when the distributions satisfy the conditions of normality. 4 of height (168,5 cm in Group I and 166,6 cm in Group II), the status of general health (both 7,7, VAS), wellbeing (7,9 and 7,7, VAS), pain (3,3 and 3,5, VAS), stress (4 and 4,6, VAS), fatigue (4,8 and 4,7, VAS), alcohol (14 and 19%) and 5 and 29%). The Group I participants were younger (30 and 39 years), less in weight (64 and 67 kg), had more complaints (2 and 1,2), smoked every day (40 and 14%), their incidence of morbidity was higher ted the average the standard accuracy and aluation, we ervals at a data in the ge of 95% CI. potheses about ution of the rnov test was sed for the s of the two some signs satisfied ; and the rion was used died population normality. For the nt quantitative tudent's t-test; and on, Sign and ributions did not The pairwise comparisons of the averages of the variable estimates were perform Sidak criterion. The significance lev verification of the statistical hypothe 0.05. For the accumulation of the readings, MS Excel tables wer calculations were performed using software package SPSS 20.

The Effect of Geothermal Skin
The effect of the geothermal water the general skin condition was stud its moisture, elasticity, individual of the skin and the use of skin produ The Group I participants evaluat condition in a 10-point scale (VAS after the 3 weeks of geothermal w as well as after 1 and 4 months. Posi the 15-minute geothermal water ba elasticity, moisture content, cellulite skin condition were recorded, a results were not statistically signific 0,766) ( Fig. 1). The evaluation amount of skin condition complain statistically significant positive (average before the treatment w and after the treatment was 1,9 p=0,001). After 4 months, the skin condition was inute treatment on the subjective condition of the ; Article no.BJMMR.29892 the dependent med using the level during the potheses was on of the study re used. The g the statistical l Bath on the ter treatment on studied, such as vidual characteristics of skin products. luated their skin S) immediately water treatment, ositive results of ath on the skin te and general although these cant (p=0,062luation of the total ints showed a ve variation as 3 (SD 1,8) 1,9 (SD 1,3), p=0,001). After 4 months, the skin condition was ion of the skin significantly better than the initial condi average of 0,41 point, p=0,010). result was statistically unreliabl elasticity remained increased in compa the initial condition (0,2 point), and the fewer signs of cellulitis (0,4 point) (F The evaluation of the effect of the geothermal water treatment (II G subjective skin condition and its improv well as the frequency of the prod before and after the treatment, show result for almost all signs (except (p=0,156-0,741), and statisticall amount of skin complaints

ondition (by an
Although the ly, the skin omparison with nd there were (Fig. 1). the 20-minute Group) on the provement, as products used showed a positive pt for cellulite) ly, the total decreased significantly (by an average of 0,8, 9 0,327 to 1,357, p=0,003) (Fig. 2).
The study of the 15-minute geothe treatment on the objective body content and elasticity showed significant increase in the skin mo (average increase of 7,5, 95% CI f 0,1; p=0,047), and this result still month of treatment. However, relevant change in the body skin not observed (Fig. 3). After 4 months treatment, the body skin moi remained at a negligibly inc (p=0,073). The study of the objective change skin condition after the 20-minute revealed a reliable improvement moisture content and elasticity (F The skin moisture content improv (p=0,05) and the elasticity by 3 units (p To evaluate the effect of the geothe treatment on the skin condition, questions were asked that all describe the current situation The evaluation of the changes a minute treatment using the McNem that 16 of the participants had comp skin before the treatment, and for (31%) the skin was no longer dry; had itchy skin, and the itching dis 3 of them (75%); allergic skin disapp 1 out of 1 participant (100%); disappeared in 3 out of 4 participants vascular networks decreased in participants (29%); 2 out of 4 parti slack skin that disappeared (50% participants had skin soreness and disappeared; and 5 out of 12 partic reduction in skin cellulitis (42%). Ho results did not reach the limits of the statistical test. In the evaluation reliability using the Wilcoxon test, positive change was received with itchy skin and cellulite (both p=0,046). no significant changes in the eruption elements were found (p=0,317 lesions after the 20was observed nges were not statistically significant by the W and McNemar tests. The following changes were observed: 36% participants stopped using moistur 50% had reduced itchy skin; 67% skin sensitivity; 71% had reduced 72% had reduced skin dryness reduced cellulitis; and 100% had low skin fatness, scaling, redness vascular networks, rashes, spots, pus and the use of fatty creams and ser Additionally, the effect of the 15-minute treatment on the use of skincare products, as a measure for the skin condition improvement, was studied. It was found that both immediately after the treatment and 1 month after the treatment, a statistically significant reduction in the frequency of skincare product usage was seen (average, VAS, before the treatment 7,14 (SD 2,78) and after the treatment 4,81 (3,11), p Immediately after the treatment, the p did not find it necessary to use so personal care products (p=0,083 to 0,666 after 1 month, the total consumpt improvement products remained si lower (average, VAS, 5,1 (SD 3,4 After 4 months, 50% used fewer f 40% used fewer nourishing serums, and 8% used less (McNemar's test, p=0,5-1). Thr study, the frequency of the use remained at a decreased level (p=0,213). After the 20 minutes tr frequency of the use of creams also by an average of 1,6 points (p=0,156); 100% of the participants did not use minute treatment on the use of skincare products, as a measure for the skin condition improvement, was studied. It was found that both immediately after the month after the treatment, a statistically significant reduction in the frequency of skincare product usage was seen (average, VAS, before the treatment 7,14 (SD 2,78) and after the treatment 4,81 (3,11), p=0,001).

Fig. 5. Change in the limb skin
the participants so many other to 0,666), and onsumption of skin d significantly 42), p=0,001). r fatty creams, creams and moisturizers roughout the use of creams by 1 point nutes treatment, the lso decreased 156); whereas use fatty creams and serums, and 36% used less mo (Figs. 1-2).

The Effect of the Geother Body Fat
In order to determine the effect of the water treatment on body fat, the si limbs, the thickness of the hypode BMI and the body fat content were me It was found that, after 15 m geothermal bath treatment, the volu limbs, BMI and fat content a Furthermore, after the treatment, significant (p<0,05) decrease in a volumes (at 8 measuring points) w 1 month following the treatment, the increase was statistically signifi evaluation of the volume after 4 mon a positive impact on all volumes of (p<0,05) (Fig. 5). The analysis of the water treatment on the hypode found that, after the treatment, the both the upper and lower limbs (at points) decreased in a statistica manner (p≤ 0.001). After 1 month treatment, the fat layer in the area (left) and the forearm (right) of the and the calf (right) area of a low significantly lower (p<0,05). The remaining skin areas also remaine comparison to the initial measure negligibly. After 4 months treatment, the hypodermic fat measurements) of the limbs wa lower than before the treatment (p≤ skin ridge (mm) and the volume of the limbs (cm) aft minute treatment  (Fig. 5).

fter the 15-
It was found that the limb volume of participants did not change significa treatment. The analysis of the geothermal water treatment on the fat layer found that there was a d dimensions, but a statistical signifi decrease was only reached in the right forearm (p=0,016) and the ri (p=0,038). The total changes in ridges and volumes are given in Fig The study sought to determine wh minute treatment would affect the index (BMI) and the variation in content. The results obtained show of these signs decreased: the significantly reduced (on average 0 from 0,07 to 0,57, p=0,015); and percentage decrease was not si average 0,57; 95% CI from -3, p=0,224) (Fig. 7). After 4 months, fat content remained lower tha measurement (0,28, respectively ( 0,52).
At the end of the 20-minute geothe bath treatment, a significant reducti and fat content was determine decreased by 0,5 (p<0,001) and percentage decreased by 2 (0,017)

Comparison of the Treatm in the Groups
The quantitative study results of the and 20-minute treatment groups compared. In all cases, calcul performed to determine whethe 8 of the Group II cantly after the effect of the the hypodermic decrease in all nificance of the the ridge of the the right thigh the limb skin g. 6.
whether the 15the body mass the body fat wed that both the BMI was 0,32, 95% CI the body fat significant (on 3,76 to 1,51, the BMI and an the initial (p=0,088) and othermal water ion in the BMI ed. The BMI the body fat (Fig. 8).

ment Effects
the 15-minute roups were also lculations were er the data satisfied the conditions of norm parametric or non-parametric methods applied. The verification of the obje data by the Kolmogorov-Smirnov Wilk tests showed that part of satisfied the condition of norma moisture content); whereas anoth data has some reservations. As a r methods were needed for the compa groups.
In applying the t-test, a statistica difference of the skin elasticity betw and II was obtained (p=0,039). Acc Mann-Whitney test results, it can be following statistically significant re the groups were found: differenc content (p=0,008) and differen elasticity (p=0,012). The body significantly decreased and the increased more in Group treatment).
In comparing the subjective between the groups after the trea found, when comparing Group I that no essential differences betwe were found (p=0,072 to 0,905).
The analysis of the data concerni volumes between the study groups they are not distributed according distribution, so we applied a nonpa the result. We can conclude that between the treatment groups (in points: both upper arms and fo thighs and calfs) were significant, a in favour of the Group I (15-minute) (p<0,001 to 0,014).

limb skin ridge and volume of the limbs after the 20-minute
; Article no. BJMMR.29892 of normality, and tric methods were objective study rnov and Shapirothe data fully ality (the skin nother part of the result, different omparison of the cally significant tween Groups I ccording to the be said that the esults between ces in body fat nces in skin y fat content skin elasticity II (20-minute skin changes atment, it was with Group II, een the groups rning the limb oups found that ing to a normal arametric test to all differences (in 8 measuring forearms, both and were more nute) treatment nute treatment

. Change in
According to the Kolmogorov-S Shapiro-Wilk tests, the results of the results tend more to normality, with some reservations. In applying the t-test, si differences were determined between Groups I and II, except on side of the right thigh and the (p=0,001 to 0,034). Since the data meet normality, we also applied anoth -the Mann-Whitney test. Based on received, significant differences found everywhere between Group I with the exception of the right biceps 0,036). Results were more in favor (15-minute) treatment.

BMI and fat content after the 15-minute treatmen in the BMI and fat content after the treatment
Smirnov and the skin ridge , with some test, significant everywhere on the lateral right biceps a did not fully nother criterion on the data we were again I and Group II, ps (p<0,001 to of the Group I in the study this, it can be summarized that the 15-minute tr more useful for the reduction volumes; and the 20-minute treatm useful for weight and fat loss increase in skin elasticity, as w improvement in skin moisture content geothermal water treatment.

DISCUSSION
The study found that the geotherm a high mineralization (27,6 g/l) ha impact on the reduction of skin complaints, as well as increasi moisture content and elasticity, hypodermic fat and the fat content 15-minute treatment was more reduction of the body size; and ; Article no.BJMMR.29892 nt nute treatment was of the body ment was more and for the well as for the ontent after the rmal water with as a significant skin condition sing the skin and reducing tent in the body. A useful for the nd a 20-minute treatment was beneficial for weight loss and for fat reduction. After 1 month following the end of the treatment, significant changes in the reduction of the complaints remained the same (76%) for some indicators such as the skin ridge thickness, reduction of itching, and reduced vascular networks and skin cellulite. After 4 months following the treatment, the skin condition still remained significantly better than the initial measurement (on average, by 0,41 point), a positive effect on all of the limb volumes was observed (p<0,05), and the hypodermic limb fat layer (all measurements) was significantly lower than before the treatment (p≤0,01). The Cl-Na-SO4-Ca water we analyzed produces effects that are specific to the main minerals. Of course, the chloride in the water improves the cellular metabolism, tissue regeneration, and blood and lymph circulation, as well as stimulating the organic and metabolic functions [29]. In 34-36°C water, the muscle tone decreases, contractures remises, peripheral arterial blood flow is stimulated, tissue trophic improves, and swelling and pain lessens; while in a 20-30 g/l of water mineralization the adrenal cortex function is stimulated and there are improvements in the oxidation and reduction processes in the tissues, the skin vascular tone is regulated, and there is a positive effect on the adaptive mechanisms. Additionally, the functional ratio of the cerebral cortex and the hypothalamus is changed, and the sympathetic nervous system tone increases; the ribonucleic acid content in the skin cells increases; the glycogen and ascorbic acid content decreases; and the tone of the peripheral veins increases as well [29].
There are more and more studies emerging that deal with the biochemical mechanisms of the positive effects of mineral water. Studies by Venier and Larese Filon show that some (not all) metal ions can easily pass through the skin, and in particular, are stimulated by sweat [30]. Additionally, trends to increase the minerals such as copper, zinc, calcium, magnesium and iron levels during the mineral baths, and to decrease in the levels of cadmium are found [3]. Icelanders found that the Blue Lagoon extracts could induce the expression of involucrin, loricrin, transglutaminase -1 and the filaggrin gene in human epidermal keratinocytes and could affect the dermal fibroblasts [7,11]. It is believed that magnesium and calcium play a key role in regulating the proliferation and differentiation of keratinocytes, and also in activating the migration of keratinocytes, inhibiting E-cadherin and stimulating the α1β2-integrin functions [31].
In Japan, balneotherapy is now being successfully applied in the treatment of atopic dermatitis, because the acidic medium and the active manganese and iodine ions cause a strong bactericidal effect and can successfully treat purulent skin lesions. Proksch et al. found that significant changes in the skin (a reduction in transepidermal water loss, roughness and redness, as well as an increased skin moisture content) occurred after daily 5% Dead Sea baths when compared with tap water [12]. There are not many studies related to the balneotherapy treatment of obesity. However, a study by Hahn et al. found a significant 1,91 kg/m (2) BMI decrease in a balneotherapy group that was compared with the use of a motivational dietary interview (0,20 kg/m2) (P < 0,001). The one-year benefit, compared to matched interview patients, was 4,6 kg [18]. Some broad commercial weight loss programs for one year can reach 6,65 kg as standards only 3,16 kg [34]. It is also known that thermal therapy for obese people can reduce body weight and body fat without any change in plasma ghrelin concentrations [26]. It has been found that carbon dioxide arsenic mineral baths improve the microcirculation and fat metabolism, and thus have a beneficial effect on arterial hypertension, obesity and hyperlipidaemia [35]. Kang Ki Yeon study with obese children shows that hot spring bath could be an effective way of managing and treating obesity (BMI after 4 procedures lowered (from 25,99 to 25,06), as body fat mass (from 21,83 to 19,55) and percent body fat (from 38,24 to 34,20) [36]. Furthermore, an experimental study on rats showed that mineral water with arsenic could reduce excessive body weight, adjust the spectrum of blood lipids and normalize the metabolic processes of the liver [27]. Is balneotherapy more effective than hydrotherapy in our research field? The common things and differences of both therapies where discussed by MZ Karagulle in 2006 [37]. Lot of studies were made to compare both water therapies for the treatment of knee osteoarthritis, lower back pain, inflammatory and metabolic diseases [38] with magnitude of improvement in thermal water group (pain, tenderness, mobility, quality of life and etc) however no scientific balneotherapy studies involving tap water control group on skin and obesity were not found. Skin status changes because of thermal fresh water effects (stimulation of vasodilation, enhancing of blood circulation, some anti-inflammatory effect) definitely are [2,24,23] but major neuroreflexive, humoral mechanisms are involved during balneotherapy [1,3,12,19,29]. There is a need for further research for comparison of geothermal vs tap water treatment to clarify complex balneotherapy mechanism regarding thermal effect of hydrotherapy with tap water on the effect on skin and fat distribution.
Balneotherapy has a long history of applications and research, and the number of published studies that analyse the mechanisms of balneological substances and interventions is increasing. Judging from the available scientific data, balneotherapeutic treatments can improve the recipient's physical and psychological state, and can successfully treat the disorders of the skin and internal organs. If the safety and efficacy of geothermal water therapy is proven further, it could gain a more meaningful place in integrative medical treatments and in the promotion of health.

A 15-20 minute baths in geothermal water
improves the skin condition and reduce the hypodermic fat content in the body. 2. The positive effect of the geothermal water remains for up to 4 months after the treatment. 3. Geothermal water treatments could be integrated into the programs for skin disease treatment and should take a significant place among beauty treatment procedures.