Atopic Dermatitis and the Role of the Skin Microbiome in Choosing Prevention, Treatment, and Maintenance Options

October 2020 | Volume 19 | Issue 10 | Original Article | 935 | Copyright © October 2020

Published online October 2, 2020

Hilary Baldwin MDa, Crystal Aguh MDb, Anneke Andriessen PhDc, Latanya Benjamin MD FAAP FAADd, Aaron S. Ferberg MDe, Deirdre Hooper MD FAADf, Joseph L. Jarizzo MDg, Peter A. Lio MDh, Brook Tlougan MD FAADI, Heather C. Woolery-Lloyd MDj, Joshua Zeichner MD FAADk

aAcne Treatment and Research Center, Brooklyn, NY bEthnic Skin Program, Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD cRadboud University Medical Center, Nijmegen, The Netherlands; Andriessen Consultants, Malden, The Netherlands dFlorida Atlantic University, Boca Raton, FL eArkansas Dermatology Skin Cancer Center, Arkansas Research Trials, Little Rock, AR; Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY fAudubon Dermatology; Tulane and Louisiana State Universities, New Orleans, LA gWake Forest School of Medicine and Weill Cornell Medical College, Winston Salem, NC, and New York, NY hDepartment of Dermatology, Feinberg School of Medicine, Northwestern University; Medical Dermatology Associates of Chicago, Chicago, IL iWestmed Medical Group, Purchase, NY; Columbia University Irving Medical Center, Manhattan, New York, NY jFrost Department of Dermatology and Cutaneous Surgery, Miller University of Miami School of Medicine, Miami, FL kDepartment of Dermatology, Mount Sinai Hospital, New York, NY; Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY

they recommend that skincare products targeting AD should be developed with a focus on maintaining the balance of healthy skin microbiome. Overall, board members were in agreement that maintaining microbial homeostasis is a crucial component of AD therapies. Currently, an AD management program that includes reducing pathogenic organisms, optimizing the re-population of the (healthy diversified) microbiome, and restoring the skin barrier is needed. As the microbiome plays a role in the prevention of AD and also in the active phase of the disease,39,50 a product displaying pre- and post-biotic activity may prove beneficial.

Given the biological properties of LRP-TSW and of the biomass of Vitreoscilla filiformis, its use in a LRP-TSW and APF emollient for treating AD warrants consideration as a new strategy for treating inflammatory skin conditions.52,53 This process combines the beneficial effects of an emollient containing the lysate of nonpathogenic bacteria Vitreoscilla filiformis, to target a significant factor in the pathogenesis of AD. LRP-TSW displays anti-free radical, immunomodulatory, anti-inflammatory properties. It also introduces selenium and strontium to reduce the production of inflammatory cytokines.53 Furthermore, the biomass contained in the LRP-TSW and APF emollient releases lysates that normalize dysbiosis, re-balancing the bacterial content of lesions and nonlesional areas of AD skin.55 Given these findings, investigators approved of the use of this selenium-rich TSW as an active ingredient in topical, irritant-reducing formulations.53 Overall, these findings suggest that a new strategy for managing inflammatory skin diseases may be to combine the use of pre- and post-biotics into a moisturizer. Such a treatment may help restore homeostasis of the skin, re-populate the diversity of the microbiome, encourage the growth of commensal bacteria, and improve barrier function and symptoms of AD.


Enhancement of skin microbiome richness and diversity with a combination of LRP-TSW and APF in an emollient base may offer a valuable option for the treatment and maintenance of inflammatory skin diseases. Clinicians should discuss the benefits of such a product in the context of a full AD management program that covers prevention, active treatment, and maintenance. Future Directives Given that AD progresses through various stages of development, the use of a product that is specially formulated to target a particular phase of the disease may warrant further investigation. For example, future investigations may evaluate a LRP-TSW/APF containing moisturizer during the pre-flare period of AD. The moisturizer is approved for application on children as young as 2 weeks.


The authors disclosed receipt of an unrestricted educational grant from La Roche-Posay Dermatological Laboratories, USA, for support with the research of this work. All authors participated in the development, writing, and reviewing the manuscript and disclosed to have no conflict of interest with the content.

Funding: This review was supported by an unrestricted educational grant from La Roche-Posay Dermatological Laboratories, USA.


1. Silverberg JI. Public health burden and epidemiology of atopic dermatitis. Dermatol Clin. 2017;35(3):283-289.
2. Kabashima K. New concept of the pathogenesis of atopic dermatitis: interplay among the barrier, allergy, and pruritus as a trinity. J Dermatol Sci. 2013;70(1):3-11.
3. Cork MJ, Danby SG, Vasilopoulos Y, et al. Epidermal barrier dysfunction in atopic dermatitis. J Invest Dermatol. 2009;129(8):1892-1908.
4. Lyons JJ, Milner JD, Stone KD. Atopic dermatitis in children: clinical features, pathophysiology, and treatment. Immunol Allergy Clin North Am. 2015;35(1):161-183.
5. Garg N, Silverberg JI. Epidemiology of childhood atopic dermatitis. Clin Dermatol. 2015;33(3):281-288.
6. Eichenfield LF, Ellis CN, Mancini AJ, Paller AS, Simpson EL. Atopic dermatitis: epidemiology and pathogenesis update. Semin Cutan Med Surg. 2012;31(3 Suppl):S3-S5.
7. Del Rosso JQ, Harper J, Kircik L, et al. Consensus recommendations on adjunctive topical management of atopic dermatitis. J Drugs Dermatol. 2018;17(10):1070-1076.
8. Wollenberg A, Oranje A, Deleuran M, et al. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients. J Eur Acad Dermatol Venereol. 2016;30(5):729-747. 9. Bieber T. Atopic dermatitis. N Engl J Med. 2008;358(14):1483-1494.
10. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-2196.
11. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223.
12. Lapidus CS, Schwarz DF, Honig PJ. Atopic dermatitis in children: Who cares? Who pays? Journal of the American Academy of Dermatology. 1993;28(5, Part 1):699-703.
13. Emerson RM, Williams HC, Allen BR. Severity distribution of atopic dermatitis in the community and its relationship to secondary referral. Br J Dermatol. 1998;139(1):73-76.
14. Schultz Larsen F, Diepgen T, Svensson A. The occurrence of atopic dermatitis in north Europe: an international questionnaire study. J Am Acad Dermatol. 1996;34(5 Pt 1):760-764.
15. Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI, Group IPTS. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124(6):1251-1258.e1223.