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Probiotics Cannot Replace Standard of Care Atopic Dermatitis Therapies, Research Letter Argues

April 11, 2024

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In one study, researchers were unable to detect any changes in the gut microbiome of patients treated with tapering dose of steroids or a probiotic mixture.

While probiotics may serve a role in the management of atopic dermatitis, they cannot and should not replace standard of care therapies, argued Gamal et al, authors of a research letter recently published in Skin Health and Disease.¹

Pile of capsules with probiotic powder inside on white background

Romario Ien/Adobe Stock

Researchers cited previous studies exploring the role of the gut microbiome in the pathogenesis and progression of atopic dermatitis as a basis for their research. In 2022, authors of a review published in Cells found several studies demonstrating that gut dysbiosis in the skin and gut, also known as attenuation of microbiota diversity, is capable of interfering with the mechanism of itch in atopic dermatitis. The review also found that microbiota-derived treatments, including probiotics, have demonstrated relief of itch in some patients with atopic dermatitis.²

Furthermore, past research has also demonstrated that gut dysbiosis frequently exists in patients with atopic dermatitis and is characterized by lowered microbiota diversity, increased pathobionts, and a decreased relative abundance of short chain fatty acid producers.³Despite this existing research, authors of the research letter note that there has been inconsistency within these studies regarding crucial factors such as the duration of treatment, age of patients, the strain of probiotics administered, and whether or not probiotics were utilized as an adjunctive therapy to topical steroids.

In this recent study, researchers conducted a prospective controlled pilot study to assess the feasibility of probiotics as a standalone treatment for acute exacerbation of atopic dermatitis compared to standard of care therapy, typically involving the use of topical steroids. This study, conducted in an Egyptian patient cohort, aimed to shed light on the efficacy of probiotics and their impact on the gut microbiome in atopic dermatitis management and care.

Patients with moderate to severe atopic dermatitis were enrolled and randomized into one of 2 groups, with one patient group receiving standard of care therapy with tapering doses of steroids and the other receiving a probiotic mixture comprised of 2 lactobacilli strains (Lactobacillus delbruekii and Lactobacillus fermentum). The primary outcome assessed was clinical improvement measured by the change in SCORing Atopic Dermatitis, or SCORAD, score after a 3-week intervention period.

Results revealed that patients in the steroid group achieved significantly higher clinical response rates and exhibited a more substantial decrease in SCORAD compared to those in the probiotic treatment group.

Review Previous Coverage of the Gut Microbiome in AD

After 3 weeks of treatment, all patients in the steroid treatment group showed a clinical response, whereas only 36.36% of patients in the probiotic group responded. Additionally, patients in the steroid group exhibited a significantly higher magnitude of response, measured by the percentage change in SCORAD score.

A sub-group analysis of gut microbiome diversity revealed no significant changes in alpha diversity post-treatment in either treatment group, although there was a trend towards increased average alpha diversity. Similarly, beta-diversity analysis showed no significant clustering of microbiome communities between the different treatment groups.

While acknowledging its limitations, such as a higher dropout rate in the probiotic group and the inability to identify subgroups benefiting more from probiotics, Gamal et al concluded that probiotics alone cannot replace standard of care therapies for acute atopic dermatitis management. Instead, probiotics may hold potential as adjunctive or maintenance therapy, particularly in the context of favorable gut microbiome changes.

"We could finally conclude that probiotics cannot be used as a solo treatment for management of acute AD, and where administration of probiotics is considered, it should be for prolonged time and as an adjunctive or maintenance therapy," according to Gamal et al. "In addition, where probiotics are to be expected to provide any additional benefit in AD, this has to be in the context of a favourable gut microbiome change as concluded from our study and other previous contradictory studies."

References

Gamal NA, Shoaib MA, Farag MA, Farag AG, Stark R, Tso S. A non-inferiority clinical trial comparing probiotics and oral corticosteroids for the management of acute exacerbation of atopic dermatitis patients. Skin Health Dis. April 6, 2024. Accessed April 10, 2024. https://doi.org/10.1002/ski2.373
Moniaga CS, Tominaga M, Takamori K. An altered skin and gut microbiota are involved in the modulation of itch in atopic dermatitis. Cells. 2022. Accessed April 10, 2024. https://doi.org/10.3390/cells11233930
Song H, Yoo Y, Hwang J, Na YC, Kim HS. Faecalibacterium prausnitzii subspecies–level dysbiosis in the human gut microbiome underlying atopic dermatitis. J Allergy Clin Immunol. 2016. Accessed April 10, 2024. https://doi.org/10.1016/j.jaci.2015.08.021