Analysis of the data from the study showed a significant improvement. However, many different factors may contribute to the beneficial effects of spa therapy. Only a few of the patients using the spa were controlled well. Some of the patients were not followed up after they left the spa, and no information could be collected about their condition. Information taken from patients who were treated in the spa previously showed that recurrences occur later than those of patients treated with drugs.

The patients allow the fish to attack their bodies, as they are thought to be holy. Although they attack areas with lesions they may also invade normal skin. The cause of this behavior is the lack of food in the pools. Garra rufa obtusa can clean the squams of a patient in a few hours. Continuous cleansing of squams increases the effectivity of ultraviolet light. The quick cleaning of the squams also creates a positive psychological condition.

The fish especially clean squams. Superficial ulcerations may occur over the lesions for a very short period. We think that the fish prefer squamous areas because of their softness. During the follow-up, no new psoriatic plaques associated with Koebner phenomenon may play a role in the treatment of psoriasis ( Fig. 5).

It is generally reported that selenium in the water may be effective either via absorption through the skin or oral ingestion (3-5). Selenium is also used in pitriasis versicolor and seborrheic dermatitis. Selenium is a cofactor of glutathion peroxidase, an enzyme that protects cells against free radicals (3, 4). This cofactor also has an antimiotic activity and protects against malignancies and viral diseases (3-6).

The score of water in the spa is at the bottom of the pools so we also believe that the jacuzzi effect may play a role in the treatment.

First degree sunburn occurred in two patients at the beginning of the therapy. Thus ,avoidance of the sun is recommended. No other side effects were seen. Out of the study, two patients with pustular and erythrodermic psoriasis did not recover from their illnesses. These patients could not continue the spa therapy because of pain.

Information taken from patients showed that recurrences began late after spa therapy. These patients declared that they did not use any drugs. The majority of the patients who came to the spa have the belief that recurrences may be prevented.

In conclusion, factors outlined below are therapeutic:

·         The short period of (4-8 hours) decapitage of squams by fish

·         The effect of selenium

·         The effect of the natural ultraviolet radiation

·         Jacuzzi effect of pools

·         Reverse Koebner phenomenon

The aim of this study is not to substitute spa therapy for medical therapy. It may be an alternative therapy in addition to medical therapy. Spa therapy with the help of a dermatologist would be more effective.