Dr. Raja Sivamani talks probiotics, including evidence, products, and indications for dermatologic conditions.
Raja Sivamani, MD, is a board certified dermatologist at Pacific Skin Institute, Sacramento, California, and Senior Medical Editor for LearnSkin.
“There’s two kinds of probiotics: there’s… spore-based probiotics and there’s non-spore,” said Raja Sivamani, MD, who discussed probiotics in dermatology at the 2021 Dermatology PEARLS symposium.
“The big concern is, are these probiotics alive when they get in—because you have the stomach acids and you have bile, which is very harsh… so if you put in a live probiotic that you’re giving for health benefit, it actually is probably dead by the time it gets to the intestines.”
The World Health Organization defines probiotics as “live microorganisms which when administered in adequate amounts confer a health benefit on the host”—a definition that is shifting given the clinical success of spore-based probiotics, said Dr. Sivamani.
“The spores, which are technically not alive…get past everything. And then when they get to the gut, that’s when they germinate.”
There are two probiotic products currently available with good clinical data, said Dr. Sivamani. One is spore based (SereneSkin; Microbiome Labs) and one is non-spore based (Healthy Trinity; Natren).
“The studies show they both work. The spore-based one though, the SereneSkin, was a much bigger study, and it was placebo controlled. The other one (Healthy Trinity) was not placebo controlled. It was controlled against antibiotics, and it worked just as well as an antibiotic.”
Probiotics for Acne
Probiotics may offer an alternative to antibiotics for acne patients, according to Dr.
Sivimani.
“Taking people people off antibiotics is not as simple, especially if your next option is isotretinoin.”
Although probiotics can be given in addition to antibiotics, he said, “We’re starting to see that perhaps we can do it in lieu of—as a replacement. And they still have anti-inflammatory effect, which is great, because then you’re impacting the gut and you’re doing other things to the biome that are probably positive beyond just trying to treat the skin.”
Importantly, said Dr. Sivimani, probiotics are not a replacement for standard of care.
“You want to be sure you have topical therapies that are directly on the skin and, if necessary, systemic therapies. However, I don’t like to do the ‘in addition to’ antibiotics. I just don’t do antibiotics if at all possible.”
And, added Dr. Sivamani who was part of the studies, there are additional benefits not related to acne.
“I make it a point to talk about nutrition with every single patient that comes for acne… someone is committing to a probiotic [is] committing to a new way of thinking about nutritional supplementation, and in many cases they’re also willing to change their nutrition as part of it.”
Other Conditions
Most chronic skin conditions are believed to have a connection with the gut, including rosacea, psoriasis, and vitiligo, said Dr. Sivimani.
“Rosacea is where we’re looking at the role of gut health and can probiotics impact the gut. There are some studies that are being planned for [rosacea] and… psoriasis. When when you look at gut health in general, we see that there are some links now being made to conditions like vitiligo.”
Atopic dermatitis is the only condition other than acne that currently has “robust” probiotic data available, said Dr. Sivimani.
The 3 strains that have shown at least some clinical evidence, said Dr. Sivimani include:
- Lactobacillus rhamnosus GG
- Bifidobacterium breve
- Lactobacillus salivarius
“…that doesn’t meant that you need to have all 3 of those. The studies have shown that if you can have at least a mix of 2 of those, it seems to be more effective.”
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