Influence of alpine mountain climate of Bavaria on patients with atopic diseases: studies at the Environmental Research Station Schneefernerhaus (UFS - Zugspitze) – a pilot study
- Bernadette Eberlein1, 2Email author,
- Johannes Huss-Marp2,
- Florian Pfab2,
- Rainald Fischer3,
- Regina Franz1,
- Michele Schlich1,
- Maria Leibl1,
- Veronika Allertseder1,
- Jarmila Liptak1,
- Marie Kriegisch2,
- Romain Hennico2,
- Julia Latotski2,
- Cordula Ebner von Eschenbach2,
- Ulf Darsow1,
- Jeroen Buters2,
- Heidrun Behrendt2,
- Rudolf Huber3 and
- Johannes Ring1
© Eberlein et al.; licensee BioMed Central Ltd. 2014
Received: 3 March 2014
Accepted: 25 March 2014
Published: 8 May 2014
Mountain and maritime climate therapy takes advantage of specific climatic conditions to treat chronic allergic diseases. It was the aim of the study to investigate effects of a 5 day sojourn on atopic diseases at the highest German mountain. In this pilot study 18 patients with grass pollen-induced rhinoconjunctivitis, atopic ezcema or asthma and 11 non-allergic controls were included. Skin physiology parameters, changes of the respiratory and nasal functions, subjective symptoms and blood parameters were measured during a 5-day observation period in the Environmental Research Station Schneefernerhaus (UFS) at the moderate altitude mountain region (Zugspitze; 2650 m alt.) compared to a low altitude area (Munich; 519 m alt.). Several of the skin physiology parameters changed significantly during the observation period (decrease of skin hydration, increase of skin smoothness, skin roughness, skin scaliness and pH-value). In patients with atopic eczema, the SCORAD (Severity Scoring of Atopic Dermatitis) and the scores of the DIELH (Deutsches Instrument zur Erfassung der Lebensqualität bei Hauterkrankungen) did not change significantly. Histamine induced itch decreased significantly. Parameters of nasal function did not change significantly. Several lung parameters showed a slight, but statistically significant improvement (forced expiratory volume in one second/volume capacity [FEV1/VC], peak expiratory flow [PEF], maximum expiratory flow at 50% of vital capacity [MEF 50], maximal mid-expiratory flow between 25% and 75% of vital capacity [MMFEF 25/75]), whereas the vital capacity (VC) decreased significantly. ECP (eosinophil cationic protein) in the serum and parameters of blood count changed significantly. These results show that the benefit of a moderate altitude mountain climate sojourn over a period of 5 days differs in depending on the atopic disease. Especially asthma parameters and itching of the skin improved. It would be interesting to assess the parameters during longer observation periods in alpine climate.
Climate therapy comprises the use of certain climatic conditions in the treatment of chronic diseases. In allergy, maritime and moderate altitude mountain zones are of interest [1, 2]. It was the aim of this pilot study to follow objective and subjective parameters in patients suffering from rhinoconjunctivitis and/or atopic eczema and asthma over a 5 days sojourn in the Environmental Research Station Schneefernerhaus (UFS) at the Zugspitze (2650 m alt.) in the alpine mountain climate of Bavaria compared to lowland in Munich (518 m alt.).
Clinical characteristics, skin tests, determination of total and specific lgE in the patient group
Total IgE (IU/ml)
Specific IgE (CAP-class)
Birch, grass, cat, celery
D. pter. 2, cat 2, dog 3, hazelnut 2, celery 1, grass 4, birch 4, hazel 3
D. pter., birch, grass, mugwort
D. pter. 3, celery 3, grass 6, birch 4, hazel 5, wheat flour 3, rye 5, mugwort 3
D. pter., cat, grass, mugwort
D. pter. 3, cat 1, grass 2, rye 2, mugwort 2
Hazel, celery, Alt. alternata
D. pter., birch, dog, cat
D. pter. 4, cat 2, dog 2, grass 3
AE, Asthma, AR
D. pter. 5, grass 2, mugwort 1, Ambrosia 1
Trees, mugwort, birch, D. pter., alder, grass, hazel
D. pter. 4, cat 3, celery 3, grass 3, birch 5, wheat flour 3, mugwort 3, Ambrosia 3, latex 2
Trees, birch, D. pter., alder, grass, hazel, dog, cat
D. pter. 6, cat 4, grass 5, birch 3, wheat flour 1, mugwort 1, milk 2
Trees, mugwort, birch, Blatella, D. far., D. pter., alder, grass, hazel, dog, cat, ambrosia, herbage
D. pter. 4, cat 2, hazel nut 3, grass 2, birch 3, mugwort 2, Ambrosia 1
Grass, cat, herbage
Cat 3, grass 4
D. far., D. pter., grass
D. pter. 2, grass 5, Ambrosia 1
AE, Asthma, AR
Trees, birch, D. far., D. pter., alder, hazel, Aspergillus, Ambrosia
D. pter., 3, birch 3
AE, Asthma, AR
Trees, birch, D. pter., alder, grass, hazel, dog, cat, horse, Alternaria tenuis, Ambrosia
D. pter. 3, cat 5, grass 3, birch 6, wheat flour 2, mugwort 3, egg white 2, codfish 2, Cladosporium herbarum 3
AE, Asthma, AR
Trees, birch, D. far., D. pter., alder, grass, hazel, dog, cat, herbage, horse
D. pter. 4, cat 2, grass 2, birch 3
Mugwort, grass, herbage
Trees, birch, alder, grass, herbage, Ambrosia
D. pter. 1, cat 2, grass 4, birch 2, wheat flour 1, Ambrosia 2
Trees, birch, D. far., D. pter., alder, grass, hazel, herbage,
D. pter. 3, celery 1, grass 3, birch 4, Ambrosia 2
Five-day observation periods at the Environmental Research Station Schneefernerhaus (UFS) were performed at the following time points with groups up to 10 patients and/or controls: July/August 2008, March 2009 and July 2009. All parameters were measured 3 to 4 days in Munich before the sojourn at the UFS (t1), at the first and second day (t2) and at the fourth and fifth (t3) day during the sojourn at the UFS as well as about 4 weeks later in Munich (t4). The local Ethical Committee approved the study (Ethik-Kommission der Bayerischen Landesärztekammer, No. 08054). All participants had given informed consent. All parameters were measured in all patients (exception: SCORAD only in patients with atopic eczema) and controls (exceptions: skin prick test titration, SCORAD, conjunctival provocation).
The severity of the atopic eczema was graded according to the SCORAD . A skin prick test titration with different concentrations of the grass pollen extract was performed in patients at all time points and the wheal and flare reactions were measured. Itch intensity after prick testing of histamine was rated on a computerized visual analogue scale (VAS).
Parameters of skin physiology (surface pH, sebum, skin hydration) were measured on the flexor side of the forearm with a Corneometer (CORNEOMETER CM825/SEBUMETER SM 810/SKIN-pH-METER PH 900 KOMBI, Courage and Khazaka electronic GmbH, Köln, Germany).
Transepidermal water loss (Tewameter TM 300; CK electronic GmbH, Köln, Germany) was measured in unexposed skin and 10 min after exposure to a 0.5 M NaOH solution (alkali resistance test) and 0.9% NaCl solution 2 times for 10 min with an interval of 10 min in between. Laser Doppler imaging (Moor Instruments, Axminster, England) was applied to monitor dermal blood flow.
Application of skin replicas was done according to previous publications . Replicas were measured by means of the optical skin measuring system VisioScan VC98 with the software SELS 2000 (Courage and Khazaka electronic GmbH, Köln, Germany) calculating skin surface parameters.
In all subjects rhinomanometric and pulmonary function parameters were determined with a spirometer (Flowscreen Pro, Jaeger GmbH, Hoechberg, Germany) and a methacholine challenge test was performed with a bodyplethysmograph (Master Screen Body, Jaeger GmbH, VIASYS Healthcare, Hoechberg, Germany) as previously described . Peak-flow monitoring was done with peak-flow-meters (Mini-Wright-Peak-Flow-Meter, Clemente Clark, Essex, England). FENO measurements (NIOX MINO; Aerocrine, Solna, Sweden) were performed at the different time points as previously described .
Nasal secretions were collected by placing small cotton wool pieces into the middle meatus ot the nose for 20 minutes, followed by centrifugation (3000 R, 20 min) of the cotton wool pieces. In all samples ECP was analyzed (CAP ECP FEIA, Pharmacia, Uppsala, Sweden).
In the conjunctival provocation test five serial dilutions (1:10) of grass pollen extracts were created. A single drop (20 μl) of the lowest concentration was placed in the conjunctival sac followed by the next concentration at 10-min intervals switching from one eye to the other until symptoms appeared. Symptoms were scored as absent (0,) mild (1), moderate (2) or severe (3) 5 and 10 min after challenge.
The following questionnaires were used: Deutsches Instrument zur Erfassung der Lebensqualität bei Hauterkrankungen (DIELH), a questionnaire for health related quality of life (SF-36), The Eppendorf Itch Questionnaire (EIQ) in adults) and the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) [7–10].
The following blood parameters were determined: complete blood count (Sysmex XT-2000 i/XT-1800i; Sysmex Corporation, Japan), eosinophil cationic protein (CAP ECP FEIA, Pharmacia, Uppsala, Sweden), human IL-16 (DuoSet ELISA Development System, R&D Systems Europe, Abingdon, United Kingdom) and IL-33 (Human IL-33 ELISA Quantitation Kit, Gentaur, Brussels, Belgium).
Data were analyzed using SPSS. For statistical analysis of the whole study population the Friedman’s one-way analysis of variance by ranks was used for paired samples and the Wilcoxon test for unpaired samples. For the disease-related analysis the univariate analysis of variance (ANOVA) was used. The critical value for significance was set at P < 0.05 for all analyses.
Significant results of skin, nasal, conjunctival and lung parameters, questionnaires and blood parameters at the beginning (t1) in Munich, at time point 2 (t2) and 3 (t3) in the UFS and time point 4 (T4) in Munich in the different groups: data are means ± SD
Str. corneum hydration (arb. units)
Skin roughness (arb. units)
Skin scaliness (arb. units)
Skin smoothness (arb. units)
Blood flow (right) (arb. units)
Blood flow (left) (arb. units)
↑AE t1/t3 ↓AEt3/t4
Wheal diluted 1:10 (mm)
Wheal diluted 1:100 (mm)
Flare diluted 1:10 (mm)
Nasal and conjunctival parameters
Resistance (after prov.) (ml/s)
Conjunctival provocation (score) Allergen 1/100 (5min)
↑Asthma t1/t2 ↓Asthma t2/t3
**t1/t2 **t2/t3 *t3/t4
MMEF 25/75 (l/s)
Resistance after 0.1% methacholine (kPA*s/l)
↓Asthma t1/t2 ↑AE t1/t2
↓Asthma t2/t3 ↑AE t2/t3
**t1/t2 **t2/t3 **t3/t4
This study shows, that a 5-day-sojourn at the Environmental Research Station Schneefernerhaus (UFS Zugspitze) at an altitude of 2650 m alt. exerts different effects on atopic diseases. A limitation of the study is the small number of participants.
Despite benefits of climate therapy in patients with atopic eczema during treatment in specialized in-patient facilities in the alpine mountain climate of Bavaria [11, 12] or in mountain altitude conditions like Davos  we didn’t find a clinical amelioration of atopic eczema skin lesions using the SCORAD. Moreover some skin physiology parameters worsened (e.g. stratum corneum hydration, pH, skin roughness). On the one hand this might be due to the fact that topical glucocorticosteroids were withdrawn 1 week before time point 1, on the other hand side low air humidity at this altitude might have negative influences on the skin. Only histamine-induced itching showed a significant improvement during the observation period at the UFS. It is known that in the Swiss mountain area of Davos itch intensity was found to be correlated with some meteorological variables, especially air temperature .
An improvement of several lung parameters was observed, only the forced vital capacity decreased. There are several studies showing that FVC decreases with increasing altitude. It is assumed that this effect is related to pulmonary interstitial changes due to pulmonary artery enlargement and interstitial edema . Improvement of other lung function disturbances had also been reported in previous studies with children and adolescents in in-patient rehabilitation programs [15–18] in moderately and high mountain climate. This may be due to a reduced allergen exposure in the altitude. House dust mites allergens haven’t been measured during this study, but it is known that mites can not survive in alpine mountain climate above 1500 m. Furthermore it could be shown that in general the amount of pollen (birch, grass) at the UFS is considerably lower than the amount in Munich (unpublished observations, Buters J et al.). Decrease of exhaled NO as a parameter of lung inflammation was also seen in asthmatic patients under mountain climate therapy , but not in our study. This may be due to the short time period at the UFS.
In the AURA (Allergien und Umweltkrankheiten in der Rehabilitation) study we found a significant increase of the SF-36 questionnaire confirming the benefit of the therapy in Pfronten , but in our study at the UFS there were no significant differences at the different time points. Also the skin specific questionnaires emphazising the pruritus (The Eppendorf Itch Questionnaire) and the quality of life (DIELH) showed a significant drop of the total score in the DIELH in the AURA study , but in our study these scores did not differ significantly. This discrepancy may be due to additional therapies (e.g. optimized therapy with glucocorticosteroids and systemic drugs) and trainings (e.g. special trainings for patients with asthma and atopic eczema) offered in a clinical department.
As expected exposure to moderate altitude had significant effects on red blood cells . We could show an increase of eosinophils during the stay at the UFS. This is in contrast to other studies during hospital treatment of atopic eczema in the mountain climate  and the North Sea climate with decreased eosinophils .
Elevated ECP levels are regarded as markers of inflammation in asthma and atopic eczema . A decrease of ECP had been shown in the mountain climate of Davos . In our study, in patients with atopic diseases ECP decreased significantly from time point t1 to time point t2, but increased again at time point t3. This may reflect the aggravation of the skin parameters. It could be shown that circulating Il-16 levels are correlated with the SCORAD in adult patients with atopic eczema  and decreased significantly in these patients after successful treatment . According to this, we did not find a decrease in our patients with atopic diseases.
The 5 day observation period in the mountain climate of the Zugspitze in Bavaria showed favourable results only for a limited number of parameters. Especially patients with asthma had a benefit from this stay, whereas skin physiology parameters worsened. This might be due to the short duration of the sojourn and typical environmental factors at this altitude. This pilot study suggests that it would be of interest to assess the skin parameters and characteristics of atopic eczema over a longer period of observations.
The statistical analysis was performed by the Institut für Medizinische Statistik und Epidemiologie, Technische Universität München (Bernhard Haller).
The authors also want to thank the Free State of Bavaria (Bayerisches Staatsministerium für Umwelt und Gesundheit) for funding and the Christine Kühne Center for allergy research and education (CK – CARE) for support in data evaluation.
- Steiger T, Borelli S: Significance of climatic factors in the treatment of atopic eczema (Atopic Constitutional Neurodermitis). Handbook of Atopic Eczema. Edited by: Ruzicka T, Ring J, Przybilla B. 1991, Berlin, Heidelberg, New York: Springer, 420-428.Google Scholar
- Karagiannidis C, Hense G, Rueckert B, Mantel PY, Ichters B, Blaser K, Menz G, Schmidt-Weber CB: High-altitude climate therapy reduces local airway inflammation and modulates lymphocyte activation. Scand J Immunol. 2006, 63: 304-310. 10.1111/j.1365-3083.2006.01739.x.View ArticlePubMedGoogle Scholar
- Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, Taieb A: Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology. 1997, 195: 10-19.View ArticlePubMedGoogle Scholar
- Eberlein-König B, Schäfer T, Huss-Marp J, Darsow U, Möhrenschlager M, Herbert O, Abeck D, Krämer U, Behrendt H, Ring J: Skin surface pH, stratum corneum hydration, trans-epidermal water loss and skin roughness related to atopic eczema and skin dryness in a population of primary school children. Acta Derm Venereol. 2000, 80: 188-191. 10.1080/000155500750042943.View ArticlePubMedGoogle Scholar
- Fischer R, Lang SM, Bergner A, Huber RM: Monitoring of expiratory flow rates and lung volume during a high altitude expedition. Eur J Med Res. 2005, 10: 469-474.PubMedGoogle Scholar
- Huss-Marp J, Krämer U, Eberlein B, Pfab F, Ring J, Behrendt H, Gulyas AF: Reduced exhaled oxide values in children with asthma after inpatient rehabilitation at high altitude. J Allergy Clin Immunol. 2007, 120: 471-472. 10.1016/j.jaci.2007.03.039.View ArticlePubMedGoogle Scholar
- Schäfer T, Staudt A, Ring J: German instrument for the assessment of quality of life in skin diseases (DIELH). Internal consistency, reliability, convergent and discriminant validity and responsiveness. Hautarzt. 2001, 52: 624-628. 10.1007/s001050170102.View ArticlePubMedGoogle Scholar
- Ware JJ, Snow KK, Kosinski M, Gandek B: SF-36 Health Survey. Manual and interpretation guide. 1993, Boston: The Health Institute, New England Medical CenterGoogle Scholar
- Darsow U, Mautner VF, Bromm B, Scharein E, Ring J: The Eppendorf Pruritus Questionnaire. Hautarzt. 1997, 48: 730-733. 10.1007/s001050050651.View ArticlePubMedGoogle Scholar
- Juniper EF, Guyatt GH: Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clin Exp Allergy. 1991, 21: 77-83. 10.1111/j.1365-2222.1991.tb00807.x.View ArticlePubMedGoogle Scholar
- Eberlein B, Gulyas A, Schultz K, Lecheler J, Flögel S, Wolfmeyer C, Thiessen K, Gass S, Kroiss M, Huss-Marp J, Darsow U, Hollweck R, Schuster T, Behrendt H, Ring J: Benefits of alpine mountain climate of Bavaria in patients with allergic diseases and chronic obstructive pulmonary disease: results from the AURA study. J Investig Allergol Clin Immunol. 2009, 19: 159-161.PubMedGoogle Scholar
- Eberlein B, Gulyas A, Schultz K, Lecheler J, Flögel S, Wolfmeyer C, Thiessen K, Jakob T, Hollweck R, Ring J, Behrendt H: Domestic allergens and endotoxin in three hospitals offering in-patient rehabilitation for allergic diseases in the alpine mountain climate of Bavaria – the AURA study. Int J Environ Health. 2009, 212: 21-26. 10.1016/j.ijheh.2007.09.003.View ArticleGoogle Scholar
- Vocks E, Busch R, Fröhlich C, Borelli S, Mayer H, Ring J: Influence of weather and climate on subjective symptom intensity in atopic eczema. Int J Biometeorol. 2001, 45: 27-33. 10.1007/s004840000077.View ArticlePubMedGoogle Scholar
- Ziaee V, Alizadeh A, Movafegh A: Pulmonary function parameters changes at different altitudes in healthy athletes. Iran J Allergy Asthma Immunol. 2008, 7: 79-84.PubMedGoogle Scholar
- Petermann F, Gulyas A, Niebank K, Stübing K, Warschburger P: Rehabilitationserfolge bei Kindern und Jugendlichen mit Asthma und Neurodermitis. Allergologie. 2000, 23: 492-502.Google Scholar
- Grootendorst DC, Dahlen SE, van den Bos JW, Duiverman EJ, Veselic-Charvat M, Vrijlandt EJLE, O’Sullivan S, Kumlin M, Sterk PJ, Roldaan AC: Benefits of high altitude allergen avoidance in atopic adolescents with moderate to severe asthma, over and above treatment with high dose inhaled steroids. Clin Exp Allergy. 2001, 31: 400-408. 10.1046/j.1365-2222.2001.01022.x.View ArticlePubMedGoogle Scholar
- van Velzen E, van den Bos JW, Benckhuijsen JA, van Essel T, de Bruijn R, Aalbers R: Effect of allergen avoidance at high altitude on direct and indirect bronchial hyperresponsiveness and markers of inflammation in children with allergic asthma. Thorac. 1996, 51: 582-584.Google Scholar
- Rijssenbeek-Nouwens LH, Bel EH: High-altitude treatment: a therapeutic option for patients with severe, refractory asthma?. Clin Exp Allergy. 2011, 41: 775-782. 10.1111/j.1365-2222.2011.03733.x.View ArticlePubMedGoogle Scholar
- Schmidt W: Effects of intermittent exposure to high altitude on blood volume and erythropoietic activity. High Alt Med Biol. 2002, 3: 167-176. 10.1089/15270290260131902.View ArticlePubMedGoogle Scholar
- Simon HU, Grotzer M, Nikolaizik K, Blaser M, Schöni H: High altitude climate therapy reduces peripheral blood T-lymphocyte activation, eosinophilia and bronchial abstruction in children with house-dust mite allergic asthma. Pediatr Pulmonol. 1994, 17: 302-311.View ArticleGoogle Scholar
- Pürschel W, Pahl O: Behaviour of eosinophilic granulocytes, total IgE and allergen specific IgE antibodies in atopic neurodermitis during hospital treatment of the North Sea climate. Z Hautkr. 1985, 60: 661-670.PubMedGoogle Scholar
- Remes S, Korppi M, Remes K, Savolainen K, Mononen I, Pekkanen J: Serum eosinophil cationic protein (ECP) and eosinophil protein X (EPX) in childhood asthma: the influence of atopy. Pediatr Pulmonol. 1998, 25: 167-174. 10.1002/(SICI)1099-0496(199803)25:3<167::AID-PPUL6>3.0.CO;2-J.View ArticlePubMedGoogle Scholar
- Engst R, Vocks E: High-mountain climate therapy for skin diseases and allergy: Mode of action, therapeutic results, and immunologic effects. Rehabilitation (Stutg). 2000, 39: 215-222. 10.1055/s-2000-5897.View ArticleGoogle Scholar
- Angelova-Fischer I, Hipler UC, Bauer A, Fluhr JW, Tsankov N, Fischer TW, Elsner P: Significance of interleukin-16, macrophage-derived chemokine, eosinophil cationic protein and soluble E-selectin in reflecting disease activity of atopic dermatitis – from laboratory parameters to clinical score. Br J Dermatol. 2006, 154: 1112-1117. 10.1111/j.1365-2133.2006.07201.x.View ArticlePubMedGoogle Scholar
- Masuda K, Katoh N, Okuda F, Kishimoto S: Increased levels of serum interleukin-16 in adult type atopic dermatitis. Acta Derm Venereol. 2003, 83: 249-253. 10.1080/00015550310016472.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.