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Topical Probiotics: the Unknowns Behind Their Rising Popularity Volume 25 Number 5| May 2019| Dermatology Online Journal || Commentary 25(5):5 Topical probiotics: the unknowns behind their rising popularity Griffin R Lee1 BA, Melody Maarouf2 MHS, Aleksi J Hendricks3 BS, Dylan E Lee4 MD, Vivian Y Shi3 MD Affiliations: 1John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA, 2College of Medicine, University of Arizona, Tucson, Arizona, USA, 3Division of Dermatology, Department of Medicine, University of Arizona, Tucson, Arizona, USA, 4Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA Corresponding Author: Vivian Y. Shi3 MD, Division of Dermatology, Department of Medicine, University of Arizona, 7165 North Pima Canyon Drive, Tucson, Arizona 85718, Email: [email protected] Introduction Abstract The cutaneous microbiome is a diverse microbial Objective: Topical probiotics have been used for skin community that plays a critical role in the innate and th care and treatment since the early 20 century. Over adaptive immune responses and maintenance of the past decade, there has been a dramatic surge of skin barrier function [1, 2]. The hygiene hypothesis commercially-available topical probiotic products. proposes that a lack of early childhood pathogen We conducted a systematic search of clinical data relating to the use of topical probiotics and identified exposure related to over-cleansing and antimicrobial relevant clinical and regulatory gaps. use limits natural immune development, including Methods: PubMed and Google Scholar searches that of the skin barrier, and predisposes one to were conducted for trials and reviews of probiotics. develop allergic conditions [3-5]. Additionally, FDA definitions of cosmetics, drugs, and regulation of cutaneous dysbiosis alters the immune milieu and topical probiotics were reviewed. has been implicated in a number of skin diseases, Results: Topical probiotics have shown efficacy in a including atopic dermatitis (AD), psoriasis, acne number of limited trials, particularly those involving vulgaris, and seborrheic dermatitis [1, 6]. In the past the treatment of acne, atopic dermatitis, and rosacea. decade, commercially available topical probiotics However, there is a paucity of literature on the safety have gained tremendous popularity — a Google profiles, mechanistic action, and therapeutic search of “topical probiotics” yields over 3 million potential of topical probiotic products. Several results. Despite their rising popularity amongst the regulatory gaps exist, including approval and general public, how much information is the medical classification of topical probiotic products by the community equipped with regarding the safety and FDA; currently there are no topical probiotic products efficacy of topical probiotics? the FDA has approved as drugs. Conclusion: With increasing popularity among the general public, but insufficient clinical data to Discussion demonstrate large-scale effectiveness and a In contrast to topical bacteriotherapy, the transplant thorough understanding of side effects, there is a of skin microbiota from one person to another, need for further mechanistic and clinical topical probiotics involve the transfer of laboratory- investigation, as well as improved regulation and cultured bacteria. Use of topical bacteriotherapy was standardization of topical probiotic products. first proposed as a treatment for cutaneous diseases in 1912, when topical application of Lactobacillus Keywords: topical probiotics, probiotics, hygiene hypothesis, bulgaricus was reported to improve acne and skin, microbiome seborrhea [7]. Following the boom of oral probiotics, - 1 - Volume 25 Number 5| May 2019| Dermatology Online Journal || Commentary 25(5):5 numerous topical probiotic formulations have been depending on bacterial speciation. A 2017 study of proposed to correct skin dysbiosis and establish 14 topical probiotic species found that each species immune homeostasis by equilibrating the skin had a unique spectrum of characteristics, including microbiota [3]. Topical probiotics have keratin adhesion, inhibitory action, organic acid demonstrated notable efficacy in limited clinical production, and inhibition of biofilm formation [6]. trials in acne, atopic dermatitis, and rosacea [8-13]. The isolation of probiotics from their natural Although the exact mechanism of probiotics remains environments inhibits quorum sensing and may unknown, they are hypothesized to exert anti- produce behavior distinct from that exhibited in inflammatory effects by stimulating regulatory T- their native microbial communities. cells and release of anti-inflammatory cytokines such Currently, the FDA categorizes probiotics into as IL-10, competing with pathogens for nutrients and different product categories such as foods, food aggregating and displacing pathogens [14]. additives, cosmetics, dietary supplements, medical Probiotic strains containing commensal skin devices, or drugs on a case-by-case basis, but does microbes such as Lactobacillus, Bifidobacterium, or not have a regulatory definition or agency that Streptococcus have demonstrated cutaneous specifically addresses topical probiotics [17]. At this immuno-regulatory effects through inhibition of time, there are no probiotics approved as drugs by biofilm formation, reduction of systemic the FDA [17]. Although topical probiotic products are inflammatory cytokines, and direct, competitive used to mitigate skin pathologies, their utilization inhibition of binding sites [6, 7]. Lactobacilli applies more towards the product category of specifically exhibit antimicrobial activity against skin “cosmetics,” which the FDA defines as products used pathogens including Escherichia coli, Pseudomonas to cleanse or beautify the body [17]. The FDA does aeruginosa, and pathobionts (resident microbes with not require cosmetic products and ingredients to pathogenic potential), such as Cutibacterium have FDA approval prior to marketing [18]. (formerly Propionibacterium) acnes [6]. Recently, a Therefore, probiotic labeling by manufacturers may small open label study of 10 adults and 5 pediatric include unsubstantiated therapeutic claims, and AD patients treated with topical microbiome consumer use in pursuit of these unproven benefits transplantation (Roseomonas mucosa lysate cultured is a growing concern. from healthy volunteers) led to a >50% Future investigations should evaluate the efficacy improvement in SCORing Atopic Dermatitis and safety of topical probiotics, as the need for (SCORAD) index in 10 patients (P=0.016). R. mucosa is improved regulations and labeling will be an believed to improve AD symptoms by restoring ongoing dialogue. Should probiotics and epithelial barrier function and innate/adaptive bacteriotherapy become approved as immune balance as well as via inhibition of S. aureus biotherapeutics, these investigations will pave the growth [15]. way for more appropriate regulation and Despite promising findings in preliminary standardization of effective clinical use. Additionally, bacteriotherapy studies, the mechanism and side further investigations in dermatologic conditions for effects of topical probiotics remain largely unknown. which probiotics have demonstrated efficacy (AD, Transfer of antibiotic resistance among pathogens, acne, rosacea) will help to elucidate the mechanisms bacteremia, and allergic reactions to inactive by which probiotics are able to ameliorate disease ingredients have been proposed as potential symptoms. adverse effects. However, a recent review by the Agency for Healthcare Research and Quality (AHRQ) Conclusion concluded that the available literature is not Although emerging evidence holds promise, the sufficiently equipped to determine the safety of current view of topical probiotics among probiotic use with confidence [16]. Furthermore, the dermatologists is one of excitement and cautious clinical effects of topical probiotics also vary optimism. Further investigations are needed to more - 2 - Volume 25 Number 5| May 2019| Dermatology Online Journal || Commentary 25(5):5 thoroughly evaluate their benefits and safety. probiotic formulations should be undertaken to Additional efforts by the FDA to better define topical broaden our understanding of their potential bacteriotherapy will help to establish guidelines for therapeutic applications. Topical probiotics are a product safety and intended use. Patients seeking promising therapeutic option for inflammatory information about the use of over-the-counter cutaneous pathologies and future clinical trials and topical probiotics should be advised about their reports regarding their efficacy will be eagerly potential clinical benefits but should also be awaited. informed of the remaining unknowns regarding their mechanism of action and potential adverse effects. Larger scale clinical trials evaluating efficacy and Potential conflicts of interest further research into the mechanisms of topical The authors declare no conflicts of interests. References 1. Schommer NN, Gallo RL. Structure and function of the human skin Allergy Asthma Immunol. 2014;113(2):209-16 e7. [PMID: microbiome. Trends Microbiol. 2013;21(12):660-8. [PMID: 24893766]. 24238601]. 11. Blanchet-Réthoré S, Bourdès V, Mercenier A, et al. Effect of a lotion 2. Grice EA, Segre JA. The skin microbiome. Nat. Rev. Microbiol. containing the heat-treated probiotic strain. Clin Cosmet Investig 2011;9:244. [PMID: 21407241] Dermatol. 2017;10:249-57. [PMID: 28721083]. 3. Romagnani S. Coming back to a missing
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