Probiotics, which are helpful bacteria that protect the body from harmful bacteria, are literally everywhere. In light of increasing antibiotic resistance due to over- and misuse, coupled with patients’ preferences for more holistic, natural approaches to healing, are we entering an era of anti-antibiotics and pro-probiotics?
Probiotics, which are helpful bacteria that protect the body from harmful bacteria, are literally everywhere. Strolling through the aisles of any grocery store, we can find yogurts, milks, juices, and other consumables that contain naturally-occurring probiotics such as lactobacillus or bifidobacterium, or foodstuffs that are artificially teeming with these celebrated organisms. Upon further probing we even encounter “prebiotics,” or nondigestible food ingredients (such as cellulose) that promote the growth of beneficial microorganisms in the intestines-i.e., sustenance for our symbionts.
In light of increasing antibiotic resistance due to over- and misuse, coupled with patients’ preferences for more holistic, natural approaches to healing, are we entering an era of anti-antibiotics and pro-probiotics? Replacing the drugs with the bugs, if you will? There is, in fact, interesting literature on the various applications of probiotics in skin health, and for integrative practitioners striving to combine the best of allopathy with nature’s bounty, several of these studies are here mentioned.
In 2014, Bowe et al reviewed a theory from 1930 known as the “gut-brain-skin axis”-essentially, the idea that disturbed emotional states such as stress, anxiety and depression can reciprocally contribute to altered gut flora (SIBO: small intestinal bacterial overgrowth) and GI leakage, which in turn recruits a systemic inflammatory response with skin manifestations such as acne.1 While this theory has not been directly studied with respect to acne, Parodi and colleagues showed in 2008 that patients with rosacea had a ten-fold greater incidence of SIBO as compared to healthy controls.2 Additionally, studies examining the therapeutic benefit of oral and topical probiotic administration in mild acne patients within the last decade have been promising, with mechanistic theories including decreased release of inflammatory mediators as well as increased production of ceramide and skin barrier restoration.3,4
Stapholococcus colonization of skin compromised by eczema is a common and known phenomenon, as is the inflammatory basis of atopic dermatitis. As such, probiotics theoretically confer a dual benefit of antimicrobial as well as anti-inflammatory therapy. In practice, however, the data is mixed. Initial studies of different strains of oral lactobacillus for both prevention and treatment of atopic dermatitis were encouraging,5,6 but follow-up reviews and meta-analyses have been conflicting.7,8,9 Another difficulty in reviewing the literature is the lack of standardization in which probiotic strains are tested, in what dosages, and administered to which study subject (pregnant/lactating mother vs. affected child). Overall, the risk of oral probiotic supplementation appears to be low (except for a theoretical risk of infection in immunocompromised patients), so until more convincing evidence emerges in either direction, use may be encouraged in the interested patient. And, of further significance, topical probiotics are another emerging approach to atopic dermatitis and barrier repair, with the additional benefit of increasing local ceramide production.4,10,11
More on atopic dermatitis
Wound healing / MRSA
Although slightly tongue-in-cheek, the word “kefir” in the title of this article has a legitimate place in the wound-healing literature. Kefirs are natural probiotic compounds (yeast/bacteria fermentation starters) with anti-inflammatory and anti-microbial properties, which are typically packaged into drinkable yogurts and labeled as such. Huseini and colleagues researched the application of kefir-based gels of varying durations of incubation/potency on mice with cutaneous burns. The kefir gels were compared to no intervention, gel vehicle alone, or silver sulfadiazine (conventional therapy). Overall, the kefir gel with 96 hours of incubation (longest) yielded superior results in terms of inflammation, scar formation, and wound re-epithelialization.12 As a purported mechanism in wound healing, Wong and colleagues suggested that probiotics may help to normalize disruptions in human microbial communities and bacteria-host interactions that contribute to non-healing wounds.13
As patients with chronic wounds can become colonized with MRSA (methicillin-resistant staphylococcus aureus), researchers have also studied what, if any, role probiotics may play in preventing or treating MRSA infections. Shu’s group in 2013 found that supplementing mice with a skin-commensal bacterium (P.Acnes) resulted in both in vitro / vivo growth suppression of the most prevalent strain of community-acquired MRSA.14 Another study looking at species-specific inhibition of various probiotics and MRSA found inhibitory activity of lactobacillus plantarum both in cell culture and mouse models.15
Probiotics may also protect the skin against photoaging. A recent study examined the impact of orally supplementing mice with a bifidobacterium strain prior to UVB radiation, three times weekly for 7 weeks. Compared to controls, supplementation significantly suppressed changes in transepidermal water loss, skin hydration, epidermal thickening, and attenuated the damage to the tight junction structure and basement membrane induced by chronic UVB irradiation, possibly via measurably-decreased interleukin-1-beta production in the skin.16 This study confirmed prior research from 2014, where mouse supplementation with a bifidobacterium strain attenuated UV-induced barrier perturbation and oxidative stress of the skin,17 possibly via reduced generation of reactive oxygen species (ROS).
Glow of health
As the old adage goes, “You are what you eat.” So can consuming probiotics induce a “glow of health,” or even a fountain of youth? Levkovich’s study in aged mice demonstrated an epithelial follicular anagen-phase shift with sebocytogenesis, resulting in thick lustrous fur – all from eating probiotic-supplemented yogurt.18 Vegan needs are covered by kimchi, a fermented Korean cruciferous dish with naturally-occuring lactobacillus species.19 The fermented tea beverage known as kombucha confers four main properties: detoxification, antioxidation, energizing potencies, and promotion of depressed immunity.20 At every turn, we are confronted with consumables teeming with bacteria, the Good Guys of the New Frontier.
It thus appears that the potential applications of probiotics in skin disease are vast, as evidenced by the sampling of studies above. Like any popular It-Girl, probiotics are popping up everywhere, ranging from therapeutics to cosmetics, foods and beverages. Yet, also like “old wine in a new bottle,”21 probiotics merit a closer look and further study to determine which strains confer tangible benefits in which applications, among what patient populations, and at which dosages. While it is tempting to jump on the bandwagon of broad utility, such enthusiasm must be tempered with careful study and consideration.
1. Bowe W, Patel NB, Logan AC. Acne vulgaris, probiotics and the gut-brain-skin axis: from anecdote to translational medicine. Benef Microbes. 2014;5(2):185-99.
2. Parodi A, Paolino S, Greco A, et al. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008;6(7):759-64.
3. Muizzuddin N, Maher W, Sullivan M, Schnittger S, Mammone T. Physiological effect of a probiotic on skin. J Cosmet Sci. 2012;63(6):385-95.
4. Di marzio L, Cinque B, De simone C, Cifone MG. Effect of the lactic acid bacterium Streptococcus thermophilus on ceramide levels in human keratinocytes in vitro and stratum corneum in vivo. J Invest Dermatol. 1999;113(1):98-106.
5. Kalliomäki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet. 2001;357(9262):1076-9.
6. Weston S, Halbert A, Richmond P, Prescott SL. Effects of probiotics on atopic dermatitis: a randomised controlled trial. Arch Dis Child. 2005;90(9):892-7.
7. Van der aa LB, Heymans HS, Van aalderen WM, Sprikkelman AB. Probiotics and prebiotics in atopic dermatitis: review of the theoretical background and clinical evidence. Pediatr Allergy Immunol. 2010;21(2 Pt 2):e355-67.
8. Pelucchi C, Chatenoud L, Turati F, et al. Probiotics supplementation during pregnancy or infancy for the prevention of atopic dermatitis: a meta-analysis. Epidemiology. 2012;23(3):402-14.
9. Boyle RJ, Bath-hextall FJ, Leonardi-bee J, Murrell DF, Tang ML. Probiotics for treating eczema. Cochrane Database Syst Rev. 2008;(4):CD006135.
10. Di marzio L, Centi C, Cinque B, et al. Effect of the lactic acid bacterium Streptococcus thermophilus on stratum corneum ceramide levels and signs and symptoms of atopic dermatitis patients. Exp Dermatol. 2003;12(5):615-20.
11. Di marzio L, Cinque B, Cupelli F, De simone C, Cifone MG, Giuliani M. Increase of skin-ceramide levels in aged subjects following a short-term topical application of bacterial sphingomyelinase from Streptococcus thermophilus. Int J Immunopathol Pharmacol. 2008;21(1):137-43.
12. Huseini HF, Rahimzadeh G, Fazeli MR, Mehrazma M, Salehi M. Evaluation of wound healing activities of kefir products. Burns. 2012;38(5):719-23.
13. Wong VW, Martindale RG, Longaker MT, Gurtner GC. From germ theory to germ therapy: skin microbiota, chronic wounds, and probiotics. Plast Reconstr Surg. 2013;132(5):854e-861e.
14. Shu M, Wang Y, Yu J, et al. Fermentation of Propionibacterium acnes, a commensal bacterium in the human skin microbiome, as skin probiotics against methicillin-resistant Staphylococcus aureus. PLoS ONE. 2013;8(2):e55380.
15. Sikorska H, Smoragiewicz W. Role of probiotics in the prevention and treatment of meticillin-resistant Staphylococcus aureus infections. Int J Antimicrob Agents. 2013;42(6):475-81.
16. Satoh T, Murata M, Iwabuchi N, et al. Effect of Bifidobacterium breve B-3 on skin photoaging induced by chronic UV irradiation in mice. Benef Microbes. 2015;:1-8.
17. Ishii Y, Sugimoto S, Izawa N, Sone T, Chiba K, Miyazaki K. Oral administration of Bifidobacterium breve attenuates UV-induced barrier perturbation and oxidative stress in hairless mice skin. Arch Dermatol Res. 2014;306(5):467-73.
18. Levkovich T, Poutahidis T, Smillie C, et al. Probiotic bacteria induce a 'glow of health'. PLoS ONE. 2013;8(1):e53867.
19. Park KY, Jeong JK, Lee YE, Daily JW. Health benefits of kimchi (Korean fermented vegetables) as a probiotic food. J Med Food. 2014;17(1):6-20.
20. VÄ«na I, Semjonovs P, Linde R, DeniÅa I. Current evidence on physiological activity and expected health effects of kombucha fermented beverage. J Med Food. 2014;17(2):179-88.
21. Kumar S, Mahajan BB, Kamra N. Future perspective of probiotics in dermatology: an old wine in new bottle. Dermatol Online J. 2014;20(9).