Clinical Effects of Regular Dry Sauna Bathing: A Systematic Review by Dr. J. Hussain & Dr M. Cohen
Regular infrared and/or Finnish sauna bathing has the potential to provide many beneficial health effects, especially for those with cardiovascular-related and rheumatological disease, as well as athletes seeking improved exercise performance. The mechanisms for these effects may include increased bioavailability of NO (nitric oxide) to vascular endothelium, heat shock protein-mediated metabolic activation, immune and hormonal pathway alterations, enhanced excretions of toxicants through increased sweating, and other hormetic stress responses.
Currently there is insufficient evidence to recommend specific types of sauna bathing for specific clinical conditions. While regular sauna bathing appears to be well-tolerated in the clinical setting with only minor and infrequent adverse effects reported, further data on the frequency and extent of adverse effects is required. Further studies are also required to explore the mechanisms by which sauna bathing exerts physiological, psychological, and metabolic effects, as well as to better define the benefits and risks of distinct types of saunas and the optimal frequency and duration of sauna bathing for beneficial health effects.
Many health benefits are claimed by individuals and facilities promoting sauna bathing; however the medical evidence to support these claims is not well established. This paper aims to systematically review recent research on the effects of repeated dry sauna interventions on human health.
A systematic search was made of medical databases for studies reporting on the health effects of regular dry sauna bathing on humans from 2000 onwards. Risk of bias was assessed according to the Cochrane Collaboration guidelines.
Forty clinical studies involving a total of 3855 participants met the inclusion criteria. Only 13 studies were randomized controlled trials and most studies were small (n < 40). Reported outcome measures were heterogeneous with most studies reporting beneficial health effects. Only one small study (n = 10) reported an adverse health outcome of disrupted male spermatogenesis, demonstrated to be reversible when ceasing sauna activity.
Regular dry sauna bathing has potential health benefits. More data of higher quality is needed on the frequency and extent of adverse side effects. Further study is also needed to determine the optimal frequency and duration of distinct types of sauna bathing for targeted health effects and the specific clinical populations who are most likely to benefit.
Sauna bathing is a form of whole-body thermotherapy that has been used in various forms (radiant heat, sweat lodges, etc.) for thousands of years in many parts of the world for hygiene, health, social, and spiritual purposes. Modern day sauna use includes traditional Finnish-style sauna, along with Turkish-style Hammam, Russian Banya, and other cultural variations, which can be distinguished by the style of construction, source of heating, and level of humidity. Traditional Finnish saunas are the most studied to date and generally involve short exposures (5−20 minutes) at temperatures of 80°C–100°C with dry air (relative humidity of 10% to 20%) interspersed with periods of increased humidity created by the throwing of water over heated rocks . In the past decade, infrared sauna cabins have become increasingly popular. These saunas use infrared emitters at different wavelengths without water or additional humidity and generally run at lower temperatures (45–60°C) than Finnish saunas with similar exposure times . Both traditional Finnish and infrared sauna bathing can involve rituals of cooling-off periods and rehydration with oral fluids before, during, and/or after sauna bathing.
Sauna bathing is inexpensive and widely accessible with Finnish-style saunas more often used in family, group, and public settings and infrared saunas more commonly built and marketed for individual use. Public sauna facilities can be located within exercise facilities and the relationship between saunas and exercise, which may include synergistic hormetic responses, is an area of active research [3–8]. The use of private saunas, especially involving infrared saunas, is also increasing and saunas are used for physical therapy in massage clinics, health spas, beauty salons, and domestic homes. This trend is capitalising on the call for additional lifestyle interventions to enhance health and wellness particularly in populations that have difficulty exercising (e.g., obesity, chronic heart failure, chronic renal failure, and chronic liver disease) . Facilities offering sauna bathing often claim health benefits that include detoxification, increased metabolism, weight loss, increased blood circulation, pain reduction, antiaging, skin rejuvenation, improved cardiovascular function, improved immune function, improved sleep, stress management, and relaxation. However, rigorous medical evidence to support these claims is scant and incomplete, as emphasized in a recent multidisciplinary review of sauna studies .
There is considerable evidence to suggest that sauna bathing can induce profound physiological effects [4, 11–17]. Intense short-term heat exposure elevates skin temperature and core body temperature and activates thermoregulatory pathways via the hypothalamus  and CNS (central nervous system) leading to activation of the autonomic nervous system. The activation of the sympathetic nervous system, hypothalamus-pituitary-adrenal hormonal axis, and the renin-angiotensin-aldosterone system leads to well-documented cardiovascular effects with increased heart rate, skin blood flow, cardiac output, and sweating [1, 11]. The resultant sweat evaporates from the skin surface and produces cooling that facilitates temperature homeostasis. In essence, sauna therapy capitalises on the thermoregulatory trait of homeothermy, the physiological capability of mammals and birds to maintain a relatively constant core body temperature with minimal deviation from a set point . It is currently unclear whether steam saunas invoke the same degree of physiological responses as dry saunas , as the higher humidity results in water condensation on the skin and reduced evaporation of sweat .
On a cellular level, acute whole-body thermotherapy (both wet and dry forms) induces discrete metabolic changes that include production of heat shock proteins, reduction of reactive oxygenated species, reduced oxidative stress and inflammation pathway activities, increased NO (nitric oxide) bioavailability, increased insulin sensitivity, and alterations in various endothelial-dependent vasodilatation metabolic pathways . It has been suggested that heat stress induces adaptive hormesis mechanisms similar to exercise, and there are reports of cellular effects induced by whole-body hyperthermia in conjunction with oncology-related interventions (i.e., chemotherapy and radiotherapy) ; however the mechanisms by which the physiological and cellular changes induced by sauna bathing contribute to enhanced health and/or therapeutic effects is still being explored [4, 7, 8, 24–27].
The following systematic review was undertaken to explore recent research on the clinical effects of repeated dry sauna bathing (Finnish-style, infrared, or other dry sauna forms) to document the full range of medical conditions saunas have been used for, as well as any associated health benefits and/or adverse effects observed. While a small number of reviews of sauna bathing and health have been conducted in the past [1, 2, 28–30], as far as we know, this is the first systematic review of sauna and health to include both Finnish and infrared saunas. Furthermore, this review only considers effects related to regular, multiple sessions of sauna activity rather than single sauna sessions, to better reflect the use of sauna bathing as a regular lifestyle intervention.
2.1. Eligibility Criteria
Studies of humans undergoing repeated dry sauna bathing that reported on health measures were included in the review. Studies were included for initial review if they were published in English language from January 2000 onwards and involved research in humans undergoing repeated dry sauna sessions with at least one reported health outcome. Studies involving predominantly high-humidity (>50%) wet/steam “sauna” or immersion hydrotherapy were excluded for the potential confounding mechanisms of differential sweating rates and explicit focus of this review limited to “dry sauna” interventions. Studies of partial body heating were excluded since proposed mechanisms of action may or may not be the same as whole-body heating. Studies reporting primarily animal-based, nonhuman findings were excluded given the recognized differences in end-organ (skin) structure and responses (sweating mechanisms) between animals and humans. Studies of “sauna” as a recruitment venue for potential sexual activity, primarily regarding men who have sex with men (MSM), were excluded since these studies lacked details of sauna interventions, confounding whether wet or dry interventions, and measured health metrics focused to sexual activity but not necessarily to sauna activity.
2.2. Search Strategy
PubMed, Web of Science, Scopus, and Proquest were initially searched with keyword “sauna” and date restrictions of January 2000–April 2017. Search dates were chosen to focus on updated findings reflecting advancing technology in both diagnostics and physiological monitoring to build upon the foundational literature of prior nonsystematic clinical reviews of sauna activity published in the early 2000s. After further restrictions of English language and humans, records were then expanded using Google Scholar, with searches for other research by key authors, searches of citations and reference lists of original and review articles, and other “related articles”. Additional searches with expanded keywords relating to sauna including “interventional study”, “whole body hyperthermia”, and “whole body thermotherapy” were also conducted with the same initial restrictions.
2.3. Data Extraction
Abstracts of initially identified studies were screened by investigator JH and then the complete full-text articles of potentially eligible studies were carefully screened by both investigators JH and MC for research design, population descriptive data, timing and physical details of dry sauna intervention, outcome measures, key results, and adverse effects. Discrepancies regarding inclusion of studies or data extraction were discussed until consensus was reached.
2.4. Assessment for Risk of Bias
Included randomized controlled trials (RCTs) were assessed for risk of bias according to the Cochrane Collaboration's tool for assessing bias and calculated Jadad et al. scores . Domains of bias assessed were selection bias (by looking for random sequence generation and allocation concealment), performance bias (by published mention of blinding of participants and personnel), detection bias (by documented attempts to blind outcome assessment), attrition bias (by evaluating for incomplete outcome data), reporting bias (by any indication of selective reporting of outcomes), and other bias (e.g., conclusions not clearly supported by reported outcomes). Risk of bias was initially assessed by investigator JH as “low”, “unclear”, or “high” and then confirmed by investigator MC. Any discrepancies were discussed until consensus was reached.
For the full paper please refer to this link: