Development and clinical assessment of new topical cream containing postbiotic in the treatment of pediatric atopic dermatitis

Development and clinical assessment of new topical cream containing postbiotic in the treatment of pediatric atopic dermatitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and clinical assessment of new topical cream containing postbiotic in the treatment of pediatric atopic dermatitis Nasrin Moazzen, Hamid Ahanchian, Shiva Golmohammadzadeh, Kiana Delaram, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3680536/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Atopic dermatitis (AD) is the major common chronic inflammatory dermatologic disorder in children. Postbiotics are bioactive compounds derived from probiotics, inanimate microorganisms, and/or their components. In the current study, we aimed to prepare, characterize, and clinically evaluate postbiotic cream in pediatric patients. Methods After preparing different formulations, the formulations were evaluated for stability and physicochemical properties for semi-solids, such as physical properties, viscosity, temperature cycle, and pH. Finally, a formulation that showed better physical properties was chosen for further investigation. The study was performed on patients with AD referred to the outpatient allergy clinic. The primary outcomes were assessed with the SCORAD index and changes in the proportion of children with clinical improvement/no improvement, deterioration, and recurrence rate. Results The final formulation's pH was 6.00 ± 0.02. In addition, the centrifugation test showed that this formulation was completely homogeneous after centrifugation. The temperature cycle test indicated no change in the structure of the cream. After a two-month follow-up, the mean SCOARD score was 50 ± 14.5 at baseline and 27.8 ± 10 at the final visit in the postbiotic group. It was also 43 ± 12 at baseline and 28.2 ± 6 at the final visit in the placebo group. After four months, eleven patients had a recurrence in lesions: 2 in the postbiotic group, 6.9% versus 9 in the placebo group, 30%). Conclusion This study demonstrated that postbiotic formulation is cutaneously acceptable and showed a clinically significant improvement, especially in long-term follow-up. Probiotic Postbiotic Lactobacillus plantarum Atopic dermatitis Recurrence Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction Atopic dermatitis (AD) as the most common chronic skin disorder in childhood, has a high impact on well being and quality of life of children and their parents [1]. Its prevalence has been rising all over the world during the past few decades, especially in countries with higher adherence to Western diet and lifestyle [2]. Numerous studies have been conducted to explore new treatment modalities for reducing disease burden. Avoidance of irritants together with daily proper skin care like hydrating and moisturizing lead to better symptom control and improved quality of life [3]. Different irritants and allergens can trigger the recurrence. So affected children may frequently need topical corticosteroid therapy [4]. As a result of frequent use of topical corticosteroids, some adverse effects like thinning of the skin, hypopigmentation, acne, steria, secondary infection, and even steroid addiction may occur [5]. These adverse events besides the psychological implications of uncontrolled disease or frequent recurrence have led to calls for new therapeutic alternatives [4]. There is some evidence that shows that early microbial exposure can prevent atopic redmatitis [6, 7]. Probiotics as live microorganisms that if administered in appropriate doses and duration can have positive effects on various diseases, attract the most interest. However, the results of clinical trials are variable and we need more power with larger samples to identify the effective strains, right dose, and duration, but a meta-analysis found a 20% reduction in atopic dermatitis incidence after using probiotics [8]. The World Allergy Organization guideline panel suggests using probiotics for the prevention of allergies in high-risk pregnant women for have an allergic child, in women who breastfeed these infants, and also in high-risk infants for developing allergies [9]. There is less consensus about using probiotics in atopic dermatitis treatment. In a meta-analysis that included 25 RCTs, probiotics were effective in more severe AD after infancy [10]. However, there is scarce data on the use of topical probiotics in the treatment or prevention of AD. In a recent trial, the topical application of Rosemonas mucosa on the skin of AD patients in different age groups was investigated. They aimed to modify the skin microbiome safely. The result was reduced disease severity and increased quality of life for children as young as 3 years of age. These improvements persisted for up to eight months after treatment stopped [11]. Topical application of probiotics has been indicated to improve the skin's barrier function and ameliorate staphylococcus aureus colonization in the skin, which might contribute to reducing the severity of AD [12]. Due to rising concern about applying live strains in certain patients such as neonates and vulnerable participants, the use of non-viable and heated probiotics is interesting [13, 14]. Additionally, there has been various evidence that the effectiveness of some of the bioactive responses of probiotics is not directly related to the viability of the microorganism, as dead cells can show their biological properties equal or superior to their live counterparts. Therefore, these compounds/molecules derived from the inactivated probiotics have been known as postbiotics, which are defined as a “preparation of inanimate microorganisms and/or their components that confers a health benefit on the host” [15–18]. Postbiotics can be obtained from metabolites generated during fermentation or disruption and fragmentation of living cells. Generally, the bioactive properties are related to several components such as bacteriocins, lipoteichoic acids (LTA), surface layer proteins, bioactive peptides, polysaccharides, short-chain fatty acids, and organic acids. The lysates or microbial fractions of non-viable probiotics can be released upon inactivation methods such as thermal treatments, ultraviolet rays, high pressure, irradiation, and sonication [19, 20]. Many authors have demonstrated that certain bacterial lysates showed promising anti-adhesion and anti-microbial properties when applied to cutaneous and mucosal surfaces. Therefore, these non-replicating bacteria forms seemed to be interesting for topical preparations for cosmeceutical purposes [21–25]. In the current study, we aimed to evaluate the effect of a new topical cream containing Lactobacillus plantarum lysate on atopic dermatitis in pediatric patients. 2 Materials and Methods 2.1 Materials MRS (de Man, Rogosa, and Sharpe) broth and agar media were prepared from Difco (Detroit, USA). 2.2 Methods 2.2.1 Preparation of Probiotic Lysates The probiotic bacteria of L. plantarum (ATCC 1058) strain was used in the experiment. The Lactobacilli bacteria were cultured using MRS broth medium for 48 h at 37°C under microaerophilic conditions until the stationary phase was achieved. An inoculum of bacteria containing approximately 1×108 to 109 CFU/ml was prepared. The number of viable bacteria was estimated by plate counts using MRS agar [26]. For probiotic lysate preparation, the fermentation broth was centrifuged at 8600×g to harvest the bacteria. Then, the pellet was resuspended in 10 ml of PBS and sonicated (5 min, alternating 60 s of sonication and 15 s of pause) using a Vibracell sonicator (Sonic and Materials, Danbury, CT, USA). The absorbance of samples was evaluated at 590 nm to verify the disruption of bacterial cells before and after every sonication step (Eppendorf Hamburg, Germany) [27]. 2.2.2 Preparation cream containing L. plantarum lysate The composition used for topical formulation is listed in Table 1 . Oil-in-water emulsion-based topical cream was formulated. The amount of Stearic acid, Span, Isopropyl myristate, Cetostearyl alcohol, Eucerin, Caprylic/capric triglyceride, Glyceryl monostearate, Shea butter, Poloxamer 188, and Oleic Acid were dissolved in the oil phase and heated up to 70ºC. Distilled water, Triethanolamine, Tween 80, and Glycerin were added to the separate beaker and heated up to 70ºC. After heating, the water-soluble phase was added to the oil phase slowly with continuous mixing till a uniform, smooth emulsion was obtained. Then, the mixture was kept aside to cool at 45ºC. The measured amount of probiotic lysate was added before the finished product was transferred into a suitable container. Then the emulsion was cooled to room temperature. Four different formulations F1, F2, F3, and F4 were prepared with different concentrations of some ingredients up to a certain limit to obtain the final formulations. Blends of Tween 80 (HLB 15.0), Span 60 (HLB 4.7), and Span 80 (HLB 4.3) in different ratios were chosen as emulsifiers at 5% concentration. Table 1 the composition used for topical cream formulation Compound F1 F2 F3 F4 Stearic acid 7 7 7 7 Span 80 1.23 1.23 1.07 ---- Span 60 ----- ----- ----- 1.12 Isopropyl myristate 2 2 2 2 Cetostearyl alcohol 2.5 2.5 2.5 2.5 Eucerin 3 3 3 3 Caprylic/capric triglyceride 2 2 2 2 Glyceryl monostearate 3 3 2 2 Shea butter 2 2 2 2 Oleic Acid 4 4 4 4 Poloxamer 188 0.1 0.1 0.1 0.1 Triethanolamine 0.4 0.75 0.75 0.75 Tween 80 3.77 3.77 3.93 3.88 Glycerin 1.25 1.25 1.25 1.25 Lactobacillus plantarum lysate 0.5 0.5 0.5 0.5 Distilled water 67.25 66.9 67.9 67.9 2.2.3 Postbiotic Cream Characterization 2.2.3.1 Organoleptic and Physical Properties All the formulations were visually examined after preparation and the results of physical appearance were reported. 2.2.3.2 Viscosity determination The viscosity measurement and rheologic behavior of the final formulations were carried out with Brookfield (model DV-I with No. 6 spindle). The values of each formulation were determined in triplicate. 2.2.3.3 Optical microscopy analysis The O/W cream formulations were examined by using a polarized light microscope (Olympus BX51, Olympus Optical Co. Ltd., Tokyo, Japan). An appropriate amount of each formulation sample was placed on a glass slide. The samples were observed under crossed polars at 100× magnification. 2.2.3.4 Determination of pH A 10 g portion of each formulation was suspended in 100 mL of deionized water and its pH was determined. A magnetic stirrer was used to produce homogeneity. 2.2.3.5 Physical Stability The physical stability of the formulations was evaluated by two conventional methods, centrifugation and freezing and thawing methods. For the centrifugation method, A 10 g portion of each formulation was placed in a centrifuge tube (1 cm diameter) and centrifuged at 3000 rpm for 30 min. Then the phase separation and solid sedimentation of the samples were observed. In the case of the freezing and thawing method, a twenty-gram portion of each formula was stored periodically at 25°C and − 20°C for 48 h each. The procedure was repeated six times and then the samples were checked regarding their appearance and stability. 2.2.4 Design This was a randomized double-blind, placebo-controlled, parallel-group, phase 3 clinical trial study, which was performed on patients with AD referred to the outpatient allergy clinic of Akbar Hospital, Mashhad, Iran between May 2019 and June 2021. The study had been approved by the ethical committee of Mashhad University of Medical Sciences (ethical code: IR.MUMS.MEDICAL.REC.1398.796). The subjects’ parents/guardians had been informed about the study objectives and design, and those who agreed to participate were required to provide written consent before enrollment. The study was conducted following the ethical principles set out in the Declaration of Helsinki Guideline on Good Clinical Practice. The trial was registered in the IRCT.ir database (IRCT20200117046164N1). The patients were randomly assigned to one of the two study groups: 1. Cream containing postbiotic lysate 2. Placebo group (vehicle cream without postbiotic lysate) 2.3 Study population sample size was calculated based on 80% power, α = .05 and Effect size d = .76, by formula difference between two independent means (two groups) and it was estimated that at least 23 patients were required for each group; the final sample size assuming a 20% dropout out was set as 30 individuals in each group. Patients between 6 months and 5 years old with moderate to severe AD were enrolled. Diagnosis of atopic dermatitis was based on the presence of at least three out of Hanifin and Rajka’s four major diagnostic criteria for this disease: chronic or recurrent, pruritic lesions with characteristic distribution, and positive family history of allergic conditions[28]. AD severity was based on the SCORAD index, and scores above 25 were considered moderate and severe [28, 29]. Patients who had other skin disorders at the same time or were acutely infected, patients with skin lesions, systemic corticosteroid treatment and recently using postbiotics within the 6 weeks, were excluded. Protocol All participants were asked about detailed medical history. Out of 80 children, 60 met the inclusion criteria. After signing the written informed consent by the parents or guardian, they were educated on how to use the creams and avoid the common triggers. The participants were allocated into the postbiotic and placebo groups randomly. Patients, their parents, and researchers were blind to the group allocation. Assessment of AD severity and other demographic characteristics documented. The postbiotic or placebo cream is administered alongside the standard treatments. The patients and their parents were asked about any adverse events during the intervention by phone call every two weeks. The participating children visited an allergy clinic after 4 weeks. A severity assessment was done by the SCORAD index. They also investigated the use of topical steroids in the recurrence of symptoms. Recurrence was defined as the need to use topical steroids for skin lesions for at least three days. After four months, all participants were asked about any atopic dermatitis symptoms by phone call. They also investigated the use of topical steroids in the recurrence of symptoms. Recurrence was defined as the need to use topical steroids for skin lesions for at least three days. 2.4 Outcomes The primary outcomes included changes in AD symptom severity assessed with the SCORAD index and changes in the proportion of children with clinical improvement/no improvement or deterioration. Also, we assessed the number of flare-ups that needed topical corticosteroids. All subjects were assessed for clinical improvement, no improvement, or exacerbation at 0, 2, and 4 weeks after treatment after a two-month follow-up. 2.5 Statistics The collected data were analyzed using IBM SPSS statistics version 25 software. The differences between the postbiotic and placebo groups were evaluated with the use of the Chi-square test and Student's t -test. The intergroup and intragroup differences in age, physical development parameters, and SCORAD index data were evaluated with paired t-tests, t-tests , and repeated measures ANOVA after checking for equality of variances and normality using a Shapiro–Wilk test. The p-value was considered less than 0.05. 2.6 Ethics This study was approved by the ethical committee of Mashhad University of Medical Sciences (Ethical code: IR.MUMS.MEDICAL.REC.1398.796). 3 Results 3.1 Organoleptic properties of O/W cream formulations The O/W cream formulations were white and opaque, with a smooth and semi-solid texture, and any bleeding and phase separation were not shown. The cream formulation was also easily spread on the skin. A few minutes after applying the cream on the skin, the formulation did not show any undesirable textures and also could be easily washed with water. 3.2 HLB and cream formulation All selected ingredients for developing the final formulation are acceptable grades for cosmeceuticals/pharmaceuticals. The chosen emulsifier system in the formulation included Tween 80 and Span 60, while the stiffening agent was also added to the formula composed of stearic acid and glyceryl monostearate. To preserve the formulation from contamination; phenoxyethanol (1%), sodium benzoate (0.25%), and potassium sorbate (0.3%) were used as a preservative. According to the previous reports, the best stable emulsions are formulated with emulsifiers or a mixture of emulsifiers, which possess HLB values close to the required HLB (rHLB) of the oil phase in the formula. The concept of rHLB was employed to design emulsion-based stable formulations. The HLB values of both the oil phase and emulsifier system were determined according to the defined method. To develop a stable cream formulation, the quantities of emulsifiers to reach the rHLB for the oil phase were calculated. After the homogenization of the oil and aqueous phase, all formulations, F1-F4, were able to form the stable emulsion system. These formulations had a suitable emulsifier combination with desirable rHLB values that equal the oil phase. The results, Table 1 , showed the overall rHLB values contributed by the oil phase of formulations F1-F4 were 12.37, 12.37, 12.70, and 12.70, respectively, and the overall HLB value contributed by the emulsifier combination of formulations F1-F4 was 12.37, 12.37, 12.70 and 12.70, respectively. 3.3 Viscosity The viscosity of each formula is shown in Fig. 2. The viscosity values were 14, 4.7, 4.2, and 6.8 Pa.s for formulation F1, F2, F3, and F4, respectively. Based on these results, F1 showed the highest viscosity values among all the formulations. Besides, F2 exhibited the highest viscosity variations between the formulas. Figure 2: viscosity of formulations. 3.4 Optical microscopy analysis The results of the optical microscopy analysis are shown in Fig. 3. All emulsion systems have a “foam-like” appearance (the oil droplets are separated by a thin film of continuous phase). However, F3 and F4 were more uniform and F1 and F2 were less uniform dispersed oil droplets; also, the particle sizes were different from one sample to another. Figure 3: Optical microscopy analysis of formulations. 3.5 pH measurement The pH values of the different formulations F1-F4 were 5.40 ± 0.01, 5.31 ± 0.02, 5.61 ± 0.01, and 6.00 ± 0.02, respectively. 3.6 Physical stability The freeze–thaw, and centrifugation tests were used to assay the cream formulation stability in temperature and mechanical stress. Among all of the formulations, F4 was not separated and showed it was a stable formula. 3.7 Clinical outcome Sixty patients were enrolled in the study and eight of them were excluded because of adverse events. Finally, 52 patients (27 in the intervention group and 25 in the placebo group) were included in to analysis. The mean age was 28.89 ± 17.77 months and the median age was 24 months (range: 6 months- 6 years). The baseline characteristics of participants in the two groups are summarized in Table 2 . Table 2 Baseline characteristics of participants in two groups. Variables Postbiotic (n = 27) Placebo (n = 25) P value Age (mean ± S.D) months 30.03 ± 23.25 27.86 ± 19.35 0.696 Gender (n, %) Male (11, 40.75) Female(16, 59.25) Male (15, 60.00) Female(10, 40.00) 0.065* Familial history (n, %) 16, 59.25 16, 64.00 0.99* Antibiotic use (n, %) 12, 44.44 8, 32.00 0.26* Time from the occurrence of symptoms (mean ± S.D) months 15.21 ± 16.23 12.44 ± 9.34 0.45** Weight (mean ± S.D) kg 12.62 ± 5.55 11.62 ± 4.65 0.41** * Chi-square test ** T-Test After a two-month follow-up, three patients had a recurrence and needed topical corticosteroids (all of them were in the placebo group) which has no significant difference in comparison with the postbiotic group (P = 0.23). After four months, eleven patients had a recurrence in lesions (2 in the postbiotic group, 6.9% versus 9 in the placebo group, 31%; P = 0.01). The mean of the SCOARD score is listed in Table 3 in postbiotic and placebo groups at baseline and final visit. Table 3 The comparison of SCOARD score in patients of placebo versus postbiotic groups Indices Phase Postbiotic (n = 27) Placebo (n = 25) Mean Difference p-value* SCORAD- A Baseline 58.77 ± 21.71 56.28 ± 21.61 2.49 0.543* 6th week 28.98 ± 15.86 37.12 ± 18.05 -8.13 p-value* < 0.001** < 0.001** SCORAD- B Baseline 8.77 ± 2.77 6.72 ± 1.69 .411 0.016* 6th week 4.85 ± 2.10 4.44 ± 1.41 2.05 p-value* < 0.001** < 0.001** SCORAD- C Baseline 9.18 ± 2.49 7.52 ± 1.75 .388 0.046* 6th week 5.63 ± 2.23 5.24 ± 1.42 1.66 p-value < 0.001** < 0.001** SCORAD total Baseline 51.88 ± 13.67 42.31 ± 7.29 9.56 0.048* 6th week 27.81 ± 10.44 28.28 ± 5.74 − .46 p-value < 0.001** < 0.001** *Between-group (intervention * time effect) significance **Within-group (time effect) significance The details of the SCOARD score are seen in Table 3 according to A score, B score, and C score. The mean of A score was 58.77 ± 21.71 in the postbiotic group and 56.28 ± 21.61 in the placebo group at baseline (P = 0.88) and 28.98 ± 15.86 in postbiotic and 37.12 ± 18.05 in placebo groups after treatment (P = 0.543). The mean B score was 8.77 ± 2.77 in the postbiotic group and 6.72 ± 1.69 in the placebo group at baseline (P = 0.589) and 4.85 ± 2.10 in postbiotic and 4.44 ± 1.41 in placebo groups after treatment (P = 0.016). The mean C score was 9.18 ± 2.49 in the postbiotic group and 7.52 ± 1.75 in the placebo group at baseline (P = 0.780) and 5.63 ± 2.23 in postbiotic and 5.24 ± 1.42 in placebo groups after treatment (P = 0.049). The mean score of SCOARD was compared at two time points before the intervention and 6 weeks later. The total score of SCOARD was in the placebo group (51.88 ± 13.67) and the postbiotic group (42.31 ± 7.29). In comparing the changes of the two groups using the analysis of Repeated Measures ANOVA, this difference was significant (p = 0.048). In the visited patients, physicians were examined immediately after stopping using the cream and 4 months later for the relapse of the disease. In the placebo group, 10% of the disease relapsed on the first visit after stopping using the cream. In the fourth month visit, 30% of patients in the placebo group relapsed. The frequency of disease relapse in both postbiotic and placebo groups was statistically significant (p = 0.020). 4 Discussion The topical application of postbiotics as a promising therapeutic approach for treating patients has recently attracted great attention [15, 18, 30, 31]. The composition of skin care products contains different ingredients that are necessary to provide the intended efficacy, quality, and safety. So, choosing the appropriate ingredients is crucial for improving the performance of the final formulation. Surfactants, as amphiphilic substances, are important ingredients in cream formulations. They can reduce the surface tension between liquids with different polarities due to the presence of both hydrophilic and hydrophobic moieties in their chemical structure, and therefore provide a homogeneous and uniform texture to the final formulations [32, 33]. To complete the emulsification of two immiscible phases, a suitable emulsifier system with an rHLB value is very crucial [34, 35]. Consequently, the HLB of each ingredient of the oil phase needs to be determined before proceeding with the emulsification process. The results of HLB values are presented in Table 1 , which shows that the mixture of Tween 80 and Span 80 and Tween 80 and Span 60 provided the HLB for a stable o/w emulsion. The suitability of the contributed HLB values of the oil phase and rHLB obtained by the combination of the emulsifier system was the reason for the formulation stability [36]. It should be noted that a certain amount of emulsifier system is necessary to stabilize the formulation. Based on the previous study, maximum stability was achieved at 5% emulsifier content due to compact films around each oil droplet cannot be formed at surfactant concentrations less than 5%, which finally destabilized the emulsion. Also, emulsifier concentration higher than 5% leads to destabilizing the emulsion [37]. The role of poloxamer 188 as a surfactant along with a suitable emulsifier system in improving the stability was previously described [38]. It was shown that a gel-cream formulation that was emulsified by non-ionic emulsifiers, which are Tween 20, poloxamer 188, and soy lecithin showed steric stabilization [39]. This observation is in line with our results that showed the chosen emulsifier system is enough good for the stability of the final formulation. The rheological parameters of the topical formulation play an important role in the quality control of the cosmeceutical emulsions. The viscosity of different formulations is illustrated in Fig. 2. As seen, the F1 showed the highest value of viscosity among the formulations. The viscosity variation of emulsions could be related to the variation of ingredients, especially to the emulsifier concentration and the rheology modifier [40]. Additionally, all the rheograms showed a pseudoplastic flow which is a desirable rheological behavior for preparations. In this case, the shear rate increases upon shear stress decrease. This kind of behavior leads to a reduction in the apparent viscosity of the formula [41]. Low viscosity in the formula indicated that the preparations showed good rheology during handling and also attributed to better emulsification of stearic acid in the presence of the emulsifier and co-emulsifier system [42]. Despite the improvement of instrumental analysis techniques, the optical microscopy method remains the most widely used analytical method for characterizing the microstructure of topical formulations [43]. Based on the results of the present study (Fig. 3), formulations F3 and F4 exhibited monodisperse and a uniform roundness of drops, which indicated the stability of the system. The foam-like structure of these samples created during shear blending confers them a viscoelastic rheological behavior, which is responsible for their appearances [40]. The pH values of different formulations were obtained. Skin pH is one of the most important biophysical features. Natural skin pH varies between 4.5 to 6.5 due to various parameters such as race, skin tone or color, and exposure to sunlight. This interval has been considered to be optimal for cosmeceuticals that contact directly with the skin [44]. The values obtained for our formulations were in this interval, indicating that they can be safely applied to the skin. The F4 was the most stable formulation during colloidal and thermal stabilities assessment and did not show any sign of separation. This observation indicated the proper ratio of non-ionic surfactants that were used in the formulation. So, this formulation was selected for further in vivo studies. Probiotics are agents that potentially can be promising approaches in the treatment of allergic conditions, including AD. The aim of the current randomized, double-blind, placebo-controlled trial was to determine whether the topical L. Plantarum lysate, would be an effective treatment in children with AD. The results of our study showed that the topical formulation is not superior to placebo in terms of primary outcomes. Despite of lower SCOARD score in the postbiotic group rather than placebo, the results of this clinical trial are not in line with previous studies on oral probiotics [45, 46]. However, we showed that in long-term follow-up, the recurrence of lesions in the postbiotic group was significantly lesser than in the placebo group. While atopic dermatitis is a chronic relapsing disorder, finding new treatment modalities that reduce the recurrence of the disease will be promising [47]. Atopic dermatitis has a very complex pathophysiology. Genetic predisposition besides various exogenous factors leads to clinical manifestations like pruritus, erythema, and skin dryness [48]. Recent studies have shown that an imbalance of skin microbiome and abundance of staphylococcus aureus link to T-cell dysfunction, reduced AMPs, and impairment of skin barrier , , [49, 50]. These findings suggest that manipulating the environmental milieu can modulate the immunologic reaction. So trials have begun aiming to change the skin microflora of AD patients. Recent evidence has shown that topical probiotics as a promising treatment can increase skin ceramides and attenuate the colony count of pathogenic S. aureus . However, this ability was largely linked to the dose, duration, and probiotic strains that were used. Common studied probiotic strains are S. thermophiles , V. filiformis , S. hominis , S. epidermidis , and L. johsonii [10, 51, 52]. In our study, we showed no significant difference in the severity of AD in patients who received topical postbiotic treatment rather than control. There are limited studies in the field of using probiotics as topical for the treatment of AD. Oral use of probiotics in children with AD has shown favorable results [53–55].In several studies, it is demonstrated that topical administration of probiotics are safe [56, 57]. In one study, topical ointment containing Lactobacillus reuteri DSM 17938 in adult patients with AD led to significant improvement in the SCORAD index. They have used this complementary treatment for 8 weeks [58]. They didn’t evaluate the recurrence rate of the disease. Despite no statistical difference in primary outcomes in groups receiving placebo or postbiotics, clinical improvement was shown in our study and, the recurrence rate significantly decreased. Our sample size was too small and generalizing the results should be done with precautions. Further studies with large-scale and multi-center trial is recommended for better analytical outcomes. A trial for different strains of probiotics is suggested, too. 5 Conclusion This study showed that the postbiotic cream containing L. plantarum lys is safe and acceptable. Also, we have shown a significantly reduced recurrence rate of AD. In conclusion, the results suggest that the postbiotic product, containing L. plantarum lysate as an extra ingredient, shows promise as a novel topical cosmetic formulation and with further testing could be a standard topical product for the management of AD or other conditions associated with the skin. We also showed that in long-term follow-up, the recurrence of lesions in the postbiotic group was significantly lesser than in the placebo group. Declarations Conflict of interest There is no conflict of interest. Funding This study is funded by Mashhad University of Medical Sciences. Author’s contributions Nasrin Moazzen collaborated in the original idea, concept, design, and writing and drafting the article. Hamid Ahanchian and Tahereh Sadeghi contributed with data interpretation, writing, and drafting of the article. Bahman Khameneh contributed to all stages of the process and mainly participated in drafting the article, writing, and editing the final version to be published. Kiana Delaram and Amir Hossein Masrour contributed to cream preparing, and writing the original draft. All the authors read and approved the final version of the manuscript. Competing interests The authors declare that they have no competing interests. References T. Torres, E. Ferreira, M. Gonçalo, P. Mendes-Bastos, M. Selores, P. Filipe, Update on atopic dermatitis, Acta medica portuguesa 2019 , 32 , 606–613. G. Sanclemente, N. Hernandez, D. Chaparro, L. Tamayo, A. Lopez, Á. López, A. Cortes, Á. Seidel, C.I. Ortiz, C. Arenas, Epidemiologic features and burden of atopic dermatitis in adolescent and adult patients: A cross-sectional multicenter study, World Allergy Organization Journal 2021 , 14 , 100611. L. Schneider, S. Tilles, P. Lio, M. Boguniewicz, L. Beck, J. LeBovidge, N. Novak, D. Bernstein, J. Blessing-Moore, D. Khan, Atopic dermatitis: a practice parameter update 2012, Journal of Allergy and Clinical Immunology 2013 , 131 , 295–299. e227. V. Aoki, D. Lorenzini, R.L. Orfali, M.C. Zaniboni, Z.N.P.d. Oliveira, M.C. Rivitti-Machado, R. Takaoka, M.B. Weber, T. Cestari, B. Gontijo, Consensus on the therapeutic management of atopic dermatitis-Brazilian Society of Dermatology, Anais Brasileiros de Dermatologia 2019 , 94 , 67–75. T. Hajar, Y.A. Leshem, J.M. Hanifin, S.T. Nedorost, P.A. Lio, A.S. Paller, J. Block, E.L. Simpson, A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses, Journal of the American Academy of Dermatology 2015 , 72 , 541–549. e542. A. Lluis, B. Schaub, Lesson from the farm environment, Current opinion in allergy and clinical immunology 2012 , 12 , 158–163. D. Martino, S.L. Prescott, Silent mysteries: epigenetic paradigms could hold the key to conquering the epidemic of allergy and immune disease, Allergy 2010 , 65 , 7–15. S. Kianmehr, M. Jahani, N. Moazzen, H. Ahanchian, B. Khameneh, The potential of Probiotics for treating skin Disorders: a concise review, Current Pharmaceutical Biotechnology 2022 , 23 , 1851–1863. A. Fiocchi, R. Pawankar, C. Cuello-Garcia, K. Ahn, S. Al-Hammadi, A. Agarwal, K. Beyer, W. Burks, G.W. Canonica, M. Ebisawa, World allergy organization-McMaster University guidelines for allergic disease prevention (GLAD-P): probiotics, World Allergy Organization Journal 2015 , 8 , 1–13. S.-O. Kim, Y.-M. Ah, Y.M. Yu, K.H. Choi, W.-G. Shin, J.-Y. Lee, Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials, Annals of Allergy, Asthma & Immunology 2014 , 113 , 217–226. I.A. Myles, C.R. Castillo, K.D. Barbian, K. Kanakabandi, K. Virtaneva, E. Fitzmeyer, M. Paneru, F. Otaizo-Carrasquero, T.G. Myers, T.E. Markowitz, Therapeutic responses to Roseomonas mucosa in atopic dermatitis may involve lipid-mediated TNF-related epithelial repair, Science translational medicine 2020 , 12 , eaaz8631. M. Marcinkowska, A. Zagórska, N. Fajkis, M. Kolaczkowski, P. Pasko, A Review of Probiotic Supplementation and Feasibility of Topical Application for the Treatment of Pediatric Atopic Dermatitis, Current pharmaceutical biotechnology 2018 , 19 , 827–838. R.J. Boyle, R.M. Robins-Browne, M.L. Tang, Probiotic use in clinical practice: what are the risks?, The American journal of clinical nutrition 2006 , 83 , 1256–1264. J.Z. Goldenberg, C. Yap, L. Lytvyn, C.K.F. Lo, J. Beardsley, D. Mertz, B.C. Johnston, Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children, Cochrane Database of Systematic Reviews 2017 . A. da Silva Vale, G.V. de Melo Pereira, A.C. de Oliveira, D.P. de Carvalho Neto, L.W. Herrmann, S.G. Karp, V.T. Soccol, C.R. Soccol, Production, Formulation, and Application of Postbiotics in the Treatment of Skin Conditions, Fermentation 2023 , 9 . M.J. Lee, Z.L. Zang, E.Y. Choi, H.K. Shin, G.E. Ji, Cytoskeleton reorganization and cytokine production of macrophages by bifidobacterial cells and cell-free extracts, 2002 . S. Salminen, M.C. Collado, A. Endo, C. Hill, S. Lebeer, E.M.M. Quigley, M.E. Sanders, R. Shamir, J.R. Swann, H. Szajewska, G. Vinderola, The International Scientific Association of Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of postbiotics, Nat Rev Gastroenterol Hepatol 2021 , 18 , 649–667. C. Gelmetti, C. Rigoni, A.M. Cantù, A. Agolzer, A. Agrusa, M. Brena, F. Dall’Oglio, P. Demichelis, S. Farina, L.A. Frasin, S. Lorenzi, G. Mazzola, M. Praticò, S. Robotti, A. Tedeschi, L. Villa, P. Ananiadis, E. Arkoumani, I. Astashonok, E. Baselga Torres, S. Borici, E. Cano, R. Cela, A. Cengo, F. Corella, X. Cubiro Raventos, M.A. De Jesus Silva, E. Demiraj, E. Dhima, X. Doci, A. Domarad, M. Didyk, A. Dyli, O. Efthimiou, G. Filippi, V.A. Flores Climente, M.P. Garcia Muret, J.G. Navarro, M. Gega, A.N. Giakoub, V. Giakoubis, A. Gica, M. Gjomema, B. Guri, E. Janushaj, A. Kanelleas, G. Kanelopoulou, E. Kapaj, D. Kapoukranidou, K. Karadima, A. Katsavou, L. Kotrulja, A. Kyriakou, G. Larios, A. Lopez, C. Lopez, S.M. Manoli, T. Matvienko, L. Mervic, K. Mileounis, D. Muja, M. Nadezhda, D. Panagioti, M. Papakonstantis, M. Papanikou, D. Papathemeli, K. Papigkioti, V. Pivak, D. Preza, E. Roé, M. Rogl Butina, E. Serra Baldrich, D. Sgouros, A. Shilova, E. Shllaku, N. Sideris, E. Sina, A. Sinani, F. Sourli-Chasioti, M. Stankaj, D. Tasioula, A. Tsalmadoupis, F. Tsatsou, E. Tsenebi, A. Tsitlakidou, P. Vassis, E. Vilarrassa, O. Vorobey, N. Voutsakis, S. Yakovleva, S. Yakubovskaya, E. Yerygina, A. Zarras, V. Zenelaj, O. Zenko, Topical prebiotics/postbiotics and PRURISCORE validation in atopic dermatitis. International study of 396 patients, J. Dermatol. Treat. 2023 , 34 . C.N. de Almada, C.N. Almada, R.C.R. Martinez, A.S. Sant'Ana, Paraprobiotics: Evidences on their ability to modify biological responses, inactivation methods and perspectives on their application in foods, Trends Food Sci Technol 2016 , 58 , 96–114. G. Vinderola, M.E. Sanders, S. Salminen, The Concept of Postbiotics, Foods 2022 , 11 . V. Salo, A. Remitz, A. Lauerma, A. Salava, Treatment of atopic dermatitis with probiotic L. lactis lysate-A double-blinded, placebo-controlled pilot study, 2023 . A. Guéniche, P. Bastien, J.M. Ovigne, M. Kermici, G. Courchay, V. Chevalier, L. Breton, I. Castiel-Higounenc, Bifidobacterium longum lysate, a new ingredient for reactive skin, Exp Dermatol 2010 , 19 , e1-8. A.C. Ouwehand, A. Båtsman, S. Salminen, Probiotics for the skin: a new area of potential application?, Lett Appl Microbiol 2003 , 36 , 327–331. K.L. Rodrigues, L.R. Caputo, J.C. Carvalho, J. Evangelista, J.M. Schneedorf, Antimicrobial and healing activity of kefir and kefiran extract, Int J Antimicrob Agents 2005 , 25 , 404–408. L. Di Marzio, B. Cinque, C. De Simone, M.G. Cifone, 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 , 98–106. Y. Ashoori, M. Mohkam, R. Heidari, S.N. Abootalebi, S.M. Mousavi, S.A. Hashemi, N. Golkar, A. Gholami, Development and in Vivo Characterization of Probiotic Lysate-Treated Chitosan Nanogel as a Novel Biocompatible Formulation for Wound Healing, BioMed Res. Int. 2020 , 2020 . F. Lombardi, F.R. Augello, S. Artone, B. Bahiti, J.M. Sheldon, M. Giuliani, M.G. Cifone, P. Palumbo, B. Cinque, Efficacy of probiotic Streptococcus thermophilus in counteracting TGF-β1-induced fibrotic response in normal human dermal fibroblasts, Journal of Inflammation 2022 , 19 , 27. J.M. HanifIn, Diagnostic features of atopic dermatitis, Acta Derm. Venereol. 1980 , 92 , 44–47. A. Oranje, E. Glazenburg, A. Wolkerstorfer, F. De Waard-van der Spek, Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score, British Journal of Dermatology 2007 , 157 , 645–648. M. Majeed, S. Majeed, K. Nagabhushanam, L. Lawrence, S. Arumugam, L. Mundkur, Skin protective activity of lactosporin-the extracellular metabolite from bacillus coagulans mtcc 5856, Cosmetics 2020 , 7 , 1–14. S. Kianmehr, M. Jahani, N. Moazzen, H. Ahanchian, B. Khameneh, The Potential of Probiotics for Treating Skin Disorders: A Concise Review, Current pharmaceutical biotechnology 2022 , 23 , 1851–1863. N. Lourith, M. Kanlayavattanakul, Natural surfactants used in cosmetics: glycolipids, Int J Cosmet Sci 2009 , 31 , 255–261. S. Golmohammadzadeh, N. Farhadian, A. Biriaee, F. Dehghani, B. Khameneh, Preparation, characterization and in vitro evaluation of microemulsion of raloxifene hydrochloride, Drug Dev Ind Pharm 2017 , 43 , 1619–1625. N. Wangpradit, S. Macha, N. Phooteh, N. Yusohyo, A. Waedoloh, S. Manee, Determination of required hydrophilic-lipophilic balance of Amesiodendron chinense (Merr.) Hu oil and development of stable cream formulation?, OCL 2022 , 29 , 29. H. Kim, S. Jung, S. Yeo, D. Kim, Y.C. Na, G. Yun, J. Lee, Characteristics of Skin Deposition of Itraconazole Solubilized in Cream Formulation, Pharmaceutics 2019 , 11 . P.B. Ximango, E.B.D. da Rocha, A.M.F. de Sousa, C.F. Scofield, M.L.L. Paredes, E.R.d.A. Lima, Preparation and characterization of patauá and pracaxi Brazilian vegetable oil emulsions, Journal of Dispersion Science and Technology 2022 , 1–11. A.R. Rahate, J.M. Nagarkar, Emulsification of Vegetable Oils using a Blend of Nonionic Surfactants for Cosmetic Applications, Journal of Dispersion Science and Technology 2007 , 28 , 1077–1080. C.C. Chu, K.L. Nyam, Kenaf (Hibiscus cannabinus L.) seed oil: Application as cosmetic product ingredients, Industrial Crops and Products 2020 , 156 , 112871. T.B. Tan, W.C. Chu, N.S. Yussof, F. Abas, H. Mirhosseini, Y.K. Cheah, I.A. Nehdi, C.P. Tan, Physicochemical, morphological and cellular uptake properties of lutein nanodispersions prepared by using surfactants with different stabilizing mechanisms, Food & Function 2016 , 7 , 2043–2051. E. Danila, Z. Moldovan, M.G.A. Kaya, M.V. Ghica, Formulation and characterization of some oil in water cosmetic emulsions based on collagen hydrolysate and vegetable oils mixtures, Pure and Applied Chemistry 2019 , 91 , 1493–1507. V.M. Di Mambro, M.F. Borin, M.J.V. Fonseca, Topical formulations with superoxide dismutase: influence of formulation composition on physical stability and enzymatic activity, Journal of Pharmaceutical and Biomedical Analysis 2003 , 32 , 97–105. K. Kaur, G. Rath, Formulation and evaluation of UV protective synbiotic skin care topical formulation, J Cosmet Laser Ther 2019 , 21 , 332–342. A.Z.M. Badruddoza, T. Yeoh, J.C. Shah, T. Walsh, Assessing and Predicting Physical Stability of Emulsion-Based Topical Semisolid Products: A Review, Journal of Pharmaceutical Sciences 2023 , 112 , 1772–1793. S. Smaoui, H.B. Hlima, R. Jarraya, N.G. Kamoun, R. Ellouze, M. Damak, Cosmetic emulsion from virgin olive oil: Formulation and bio-physical evaluation, Afr. J. Biotechnol 2012 , 11 , 9664–9671. B. Cukrowska, A. Ceregra, I. Rosiak, E. Klewicka, K. Slizewska, I. Motyl, The influence of probiotic Lactobacillus casei and paracasei strains on clinical status of atopic eczema in children with food allergy on cow's milk proteins, Pediatria Wspolczesna 2008 , 10 , 67–70. B. Cukrowska, A. Ceregra, E. Klewicka, K. Slizewska, I. Motyl, Z. Libudzisz, PROBIOTYCZNE SZCZEPY LACTOBACILLUS CASEI I LACTOBACILLUS PARACASEI W LECZENIU ALERGII POKARMOWEJ U DZIECI, Przeglad Pediatryczny 2010 , 40 . A.W. Burks, L.B. Bacharier, G.K.K. Hershey, R.S. Peebles, R.E. O'Hehir, D.H. Broide, S.T. Holgate, Middleton's allergy E-Book: principles and practice, Elsevier Health Sciences2019. E.L. Simpson, Atopic dermatitis: a review of topical treatment options, Current medical research and opinion 2010 , 26 , 633–640. M. Sieprawska-Lupa, P. Mydel, K. Krawczyk, K. Wójcik, M. Puklo, B. Lupa, P. Suder, J. Silberring, M. Reed, J. Pohl, Degradation of human antimicrobial peptide LL-37 by Staphylococcus aureus-derived proteinases, Antimicrobial agents and chemotherapy 2004 , 48 , 4673–4679. M.D. Howell, M. Boguniewicz, S. Pastore, N. Novak, T. Bieber, G. Girolomoni, D.Y. Leung, Mechanism of HBD-3 deficiency in atopic dermatitis, Clinical immunology 2006 , 121 , 332–338. B. Cinque, C. La Torre, E. Melchiorre, G. Marchesani, G. Zoccali, P. Palumbo, L. Di Marzio, A. Masci, L. Mosca, P. Mastromarino, Use of probiotics for dermal applications, Probiotics: biology, genetics and health aspects 2011 , 221–241. A. Guéniche, A.C. Cathelineau, P. Bastien, J. Esdaile, R. Martin, C. Queille Roussel, L. Breton, Vitreoscilla filiformis biomass improves seborrheic dermatitis, Journal of the European Academy of Dermatology and Venereology 2008 , 22 , 1014–1015. H.-J. Yang, T.K. Min, H.W. Lee, B.Y. Pyun, Efficacy of probiotic therapy on atopic dermatitis in children: a randomized, double-blind, placebo-controlled trial, Allergy, asthma & immunology research 2014 , 6 , 208–215. I.A. Rather, V.K. Bajpai, S. Kumar, J. Lim, W.K. Paek, Y.-H. Park, Probiotics and Atopic Dermatitis: An Overview, Front Microbiol 2016 , 7 , 507–507. N.Y. Kim, G.E. Ji, Effects of probiotics on the prevention of atopic dermatitis, Korean J Pediatr 2012 , 55 , 193–201. P.Y. Ong, T. Ohtake, C. Brandt, I. Strickland, M. Boguniewicz, T. Ganz, R.L. Gallo, D.Y. Leung, Endogenous antimicrobial peptides and skin infections in atopic dermatitis, New England Journal of Medicine 2002 , 347 , 1151–1160. L. Di Marzio, C. Centi, B. Cinque, S. Masci, M. Giuliani, A. Arcieri, L. Zicari, C. De Simone, M.G. Cifone, Effect of the lactic acid bacterium Streptococcus thermophilus on stratum corneum ceramide levels and signs and symptoms of atopic dermatitis patients, Experimental dermatology 2003 , 12 , 615–620. É. Butler, C. Lundqvist, J. Axelsson, Lactobacillus reuteri DSM 17938 as a Novel Topical Cosmetic Ingredient: A Proof of Concept Clinical Study in Adults with Atopic Dermatitis, Microorganisms 2020 , 8 , 1026. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3680536","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":254642432,"identity":"cb2a0136-b488-4d34-917e-31ce515caa18","order_by":0,"name":"Nasrin Moazzen","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nasrin","middleName":"","lastName":"Moazzen","suffix":""},{"id":254642434,"identity":"54d9f0a0-6788-4487-9038-950b94827249","order_by":1,"name":"Hamid Ahanchian","email":"","orcid":"","institution":"Mashhad University of 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1","display":"","copyAsset":false,"role":"figure","size":405447,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the study\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3680536/v1/5460f9d9a00d27234459d350.jpeg"},{"id":47469772,"identity":"5ede88bb-4655-494b-a91a-433dab9870a4","added_by":"auto","created_at":"2023-12-02 01:56:41","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":261423,"visible":true,"origin":"","legend":"\u003cp\u003eViscosity of formulations.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3680536/v1/3b283fb5e90e2587a56f4534.jpeg"},{"id":47469966,"identity":"0e0a99e0-6a8a-476f-a721-7625d22c9bd2","added_by":"auto","created_at":"2023-12-02 02:04:41","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":116708,"visible":true,"origin":"","legend":"\u003cp\u003eOptical microscopy analysis of formulations.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3680536/v1/5900758cf2c60dde4f9d9cf6.jpeg"},{"id":47469967,"identity":"78056826-c020-46c6-82e5-12c4d9b60b30","added_by":"auto","created_at":"2023-12-02 02:04:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":7191,"visible":true,"origin":"","legend":"\u003cp\u003eThe comparison of relapse disease in two groups of placebo and postbiotic.\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3680536/v1/678795ada85f852f2d679828.png"},{"id":49156167,"identity":"445c7926-4caa-410e-9270-667765090a14","added_by":"auto","created_at":"2024-01-04 03:52:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":718833,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3680536/v1/d846df8f-cb9c-4086-bd53-0a324f0c05ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and clinical assessment of new topical cream containing postbiotic in the treatment of pediatric atopic dermatitis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAtopic dermatitis (AD) as the most common chronic skin disorder in childhood, has a high impact on well being and quality of life of children and their parents [1]. Its prevalence has been rising all over the world during the past few decades, especially in countries with higher adherence to Western diet and lifestyle [2]. Numerous studies have been conducted to explore new treatment modalities for reducing disease burden. Avoidance of irritants together with daily proper skin care like hydrating and moisturizing lead to better symptom control and improved quality of life [3]. Different irritants and allergens can trigger the recurrence. So affected children may frequently need topical corticosteroid therapy [4]. As a result of frequent use of topical corticosteroids, some adverse effects like thinning of the skin, hypopigmentation, acne, steria, secondary infection, and even steroid addiction may occur [5]. These adverse events besides the psychological implications of uncontrolled disease or frequent recurrence have led to calls for new therapeutic alternatives [4]. There is some evidence that shows that early microbial exposure can prevent atopic redmatitis [6, 7]. Probiotics as live microorganisms that if administered in appropriate doses and duration can have positive effects on various diseases, attract the most interest. However, the results of clinical trials are variable and we need more power with larger samples to identify the effective strains, right dose, and duration, but a meta-analysis found a 20% reduction in atopic dermatitis incidence after using probiotics [8]. The World Allergy Organization guideline panel suggests using probiotics for the prevention of allergies in high-risk pregnant women for have an allergic child, in women who breastfeed these infants, and also in high-risk infants for developing allergies [9]. There is less consensus about using probiotics in atopic dermatitis treatment. In a meta-analysis that included 25 RCTs, probiotics were effective in more severe AD after infancy [10]. However, there is scarce data on the use of topical probiotics in the treatment or prevention of AD. In a recent trial, the topical application of Rosemonas mucosa on the skin of AD patients in different age groups was investigated. They aimed to modify the skin microbiome safely. The result was reduced disease severity and increased quality of life for children as young as 3 years of age. These improvements persisted for up to eight months after treatment stopped [11].\u003c/p\u003e \u003cp\u003eTopical application of probiotics has been indicated to improve the skin's barrier function and ameliorate staphylococcus aureus colonization in the skin, which might contribute to reducing the severity of AD [12]. Due to rising concern about applying live strains in certain patients such as neonates and vulnerable participants, the use of non-viable and heated probiotics is interesting [13, 14].\u003c/p\u003e \u003cp\u003eAdditionally, there has been various evidence that the effectiveness of some of the bioactive responses of probiotics is not directly related to the viability of the microorganism, as dead cells can show their biological properties equal or superior to their live counterparts.\u003c/p\u003e \u003cp\u003eTherefore, these compounds/molecules derived from the inactivated probiotics have been known as postbiotics, which are defined as a \u0026ldquo;preparation of inanimate microorganisms and/or their components that confers a health benefit on the host\u0026rdquo; [15\u0026ndash;18]. Postbiotics can be obtained from metabolites generated during fermentation or disruption and fragmentation of living cells. Generally, the bioactive properties are related to several components such as bacteriocins, lipoteichoic acids (LTA), surface layer proteins, bioactive peptides, polysaccharides, short-chain fatty acids, and organic acids. The lysates or microbial fractions of non-viable probiotics can be released upon inactivation methods such as thermal treatments, ultraviolet rays, high pressure, irradiation, and sonication [19, 20]. Many authors have demonstrated that certain bacterial lysates showed promising anti-adhesion and anti-microbial properties when applied to cutaneous and mucosal surfaces. Therefore, these non-replicating bacteria forms seemed to be interesting for topical preparations for cosmeceutical purposes [21\u0026ndash;25].\u003c/p\u003e \u003cp\u003eIn the current study, we aimed to evaluate the effect of a new topical cream containing \u003cem\u003eLactobacillus plantarum\u003c/em\u003e lysate on atopic dermatitis in pediatric patients.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Materials\u003c/h2\u003e \u003cp\u003eMRS (de Man, Rogosa, and Sharpe) broth and agar media were prepared from Difco (Detroit, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Methods\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Preparation of Probiotic Lysates\u003c/h2\u003e \u003cp\u003eThe probiotic bacteria of \u003cem\u003eL. plantarum\u003c/em\u003e (ATCC 1058) strain was used in the experiment. The Lactobacilli bacteria were cultured using MRS broth medium for 48 h at 37\u0026deg;C under microaerophilic conditions until the stationary phase was achieved. An inoculum of bacteria containing approximately 1\u0026times;108 to 109 CFU/ml was prepared. The number of viable bacteria was estimated by plate counts using MRS agar [26]. For probiotic lysate preparation, the fermentation broth was centrifuged at 8600\u0026times;g to harvest the bacteria. Then, the pellet was resuspended in 10 ml of PBS and sonicated (5 min, alternating 60 s of sonication and 15 s of pause) using a Vibracell sonicator (Sonic and Materials, Danbury, CT, USA). The absorbance of samples was evaluated at 590 nm to verify the disruption of bacterial cells before and after every sonication step (Eppendorf Hamburg, Germany) [27].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Preparation cream containing \u003cem\u003eL. plantarum\u003c/em\u003e lysate\u003c/h2\u003e \u003cp\u003eThe composition used for topical formulation is listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Oil-in-water emulsion-based topical cream was formulated. The amount of Stearic acid, Span, Isopropyl myristate, Cetostearyl alcohol, Eucerin, Caprylic/capric triglyceride, Glyceryl monostearate, Shea butter, Poloxamer 188, and Oleic Acid were dissolved in the oil phase and heated up to 70\u0026ordm;C. Distilled water, Triethanolamine, Tween 80, and Glycerin were added to the separate beaker and heated up to 70\u0026ordm;C. After heating, the water-soluble phase was added to the oil phase slowly with continuous mixing till a uniform, smooth emulsion was obtained. Then, the mixture was kept aside to cool at 45\u0026ordm;C. The measured amount of probiotic lysate was added before the finished product was transferred into a suitable container. Then the emulsion was cooled to room temperature. Four different formulations F1, F2, F3, and F4 were prepared with different concentrations of some ingredients up to a certain limit to obtain the final formulations. Blends of Tween 80 (HLB 15.0), Span 60 (HLB 4.7), and Span 80 (HLB 4.3) in different ratios were chosen as emulsifiers at 5% concentration.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ethe composition used for topical cream formulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompound\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStearic acid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpan 80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e----\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpan 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsopropyl myristate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCetostearyl alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEucerin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaprylic/capric triglyceride\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlyceryl monostearate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShea butter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOleic Acid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoloxamer 188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriethanolamine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTween 80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycerin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLactobacillus plantarum lysate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistilled water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Postbiotic Cream Characterization\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section4\"\u003e \u003ch2\u003e2.2.3.1 Organoleptic and Physical Properties\u003c/h2\u003e \u003cp\u003eAll the formulations were visually examined after preparation and the results of physical appearance were reported.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section4\"\u003e \u003ch2\u003e2.2.3.2 Viscosity determination\u003c/h2\u003e \u003cp\u003eThe viscosity measurement and rheologic behavior of the final formulations were carried out with Brookfield (model DV-I with No. 6 spindle). The values of each formulation were determined in triplicate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section4\"\u003e \u003ch2\u003e2.2.3.3 Optical microscopy analysis\u003c/h2\u003e \u003cp\u003eThe O/W cream formulations were examined by using a polarized light microscope (Olympus BX51, Olympus Optical Co. Ltd., Tokyo, Japan). An appropriate amount of each formulation sample was placed on a glass slide. The samples were observed under crossed polars at 100\u0026times; magnification.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section4\"\u003e \u003ch2\u003e2.2.3.4 Determination of pH\u003c/h2\u003e \u003cp\u003eA 10 g portion of each formulation was suspended in 100 mL of deionized water and its pH was determined. A magnetic stirrer was used to produce homogeneity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section4\"\u003e \u003ch2\u003e2.2.3.5 Physical Stability\u003c/h2\u003e \u003cp\u003eThe physical stability of the formulations was evaluated by two conventional methods, centrifugation and freezing and thawing methods. For the centrifugation method, A 10 g portion of each formulation was placed in a centrifuge tube (1 cm diameter) and centrifuged at 3000 rpm for 30 min. Then the phase separation and solid sedimentation of the samples were observed. In the case of the freezing and thawing method, a twenty-gram portion of each formula was stored periodically at 25\u0026deg;C and \u0026minus;\u0026thinsp;20\u0026deg;C for 48 h each. The procedure was repeated six times and then the samples were checked regarding their appearance and stability.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Design\u003c/h2\u003e \u003cp\u003eThis was a randomized double-blind, placebo-controlled, parallel-group, phase 3 clinical trial study, which was performed on patients with AD referred to the outpatient allergy clinic of Akbar Hospital, Mashhad, Iran between May 2019 and June 2021. The study had been approved by the ethical committee of Mashhad University of Medical Sciences (ethical code: IR.MUMS.MEDICAL.REC.1398.796). The subjects\u0026rsquo; parents/guardians had been informed about the study objectives and design, and those who agreed to participate were required to provide written consent before enrollment. The study was conducted following the ethical principles set out in the Declaration of Helsinki Guideline on Good Clinical Practice. The trial was registered in the IRCT.ir database (IRCT20200117046164N1).\u003c/p\u003e \u003cp\u003eThe patients were randomly assigned to one of the two study groups:\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e1. Cream containing postbiotic lysate\u003c/h3\u003e\n\n\u003ch3\u003e2. Placebo group (vehicle cream without postbiotic lysate)\u003c/h3\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study population\u003c/h2\u003e \u003cp\u003esample size was calculated based on 80% power, α\u0026thinsp;=\u0026thinsp;.05 and Effect size d\u0026thinsp;=\u0026thinsp;.76, by formula difference between two independent means (two groups) and it was estimated that at least 23 patients were required for each group; the final sample size assuming a 20% dropout out was set as 30 individuals in each group. Patients between 6 months and 5 years old with moderate to severe AD were enrolled. Diagnosis of atopic dermatitis was based on the presence of at least three out of Hanifin and Rajka\u0026rsquo;s four major diagnostic criteria for this disease: chronic or recurrent, pruritic lesions with characteristic distribution, and positive family history of allergic conditions[28]. AD severity was based on the SCORAD index, and scores above 25 were considered moderate and severe [28, 29]. Patients who had other skin disorders at the same time or were acutely infected, patients with skin lesions, systemic corticosteroid treatment and recently using postbiotics within the 6 weeks, were excluded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eProtocol All participants were asked about detailed medical history. Out of 80 children, 60 met the inclusion criteria. After signing the written informed consent by the parents or guardian, they were educated on how to use the creams and avoid the common triggers. The participants were allocated into the postbiotic and placebo groups randomly. Patients, their parents, and researchers were blind to the group allocation. Assessment of AD severity and other demographic characteristics documented. The postbiotic or placebo cream is administered alongside the standard treatments. The patients and their parents were asked about any adverse events during the intervention by phone call every two weeks. The participating children visited an allergy clinic after 4 weeks. A severity assessment was done by the SCORAD index. They also investigated the use of topical steroids in the recurrence of symptoms. Recurrence was defined as the need to use topical steroids for skin lesions for at least three days. After four months, all participants were asked about any atopic dermatitis symptoms by phone call. They also investigated the use of topical steroids in the recurrence of symptoms. Recurrence was defined as the need to use topical steroids for skin lesions for at least three days.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcomes included changes in AD symptom severity assessed with the SCORAD index and changes in the proportion of children with clinical improvement/no improvement or deterioration. Also, we assessed the number of flare-ups that needed topical corticosteroids. All subjects were assessed for clinical improvement, no improvement, or exacerbation at 0, 2, and 4 weeks after treatment after a two-month follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistics\u003c/h2\u003e \u003cp\u003eThe collected data were analyzed using IBM SPSS statistics version 25 software. The differences between the postbiotic and placebo groups were evaluated with the use of the Chi-square test and Student's \u003cem\u003et\u003c/em\u003e-test. The intergroup and intragroup differences in age, physical development parameters, and SCORAD index data were evaluated with paired t-tests, \u003cem\u003et-tests\u003c/em\u003e, and repeated measures ANOVA after checking for equality of variances and normality using a Shapiro\u0026ndash;Wilk test. The p-value was considered less than 0.05.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethics\u003c/h2\u003e \u003cp\u003e This study was approved by the ethical committee of Mashhad University of Medical Sciences (Ethical code: IR.MUMS.MEDICAL.REC.1398.796).\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Organoleptic properties of O/W cream formulations\u003c/h2\u003e \u003cp\u003eThe O/W cream formulations were white and opaque, with a smooth and semi-solid texture, and any bleeding and phase separation were not shown. The cream formulation was also easily spread on the skin. A few minutes after applying the cream on the skin, the formulation did not show any undesirable textures and also could be easily washed with water.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.2 HLB and cream formulation\u003c/h2\u003e \u003cp\u003eAll selected ingredients for developing the final formulation are acceptable grades for cosmeceuticals/pharmaceuticals. The chosen emulsifier system in the formulation included Tween 80 and Span 60, while the stiffening agent was also added to the formula composed of stearic acid and glyceryl monostearate. To preserve the formulation from contamination; phenoxyethanol (1%), sodium benzoate (0.25%), and potassium sorbate (0.3%) were used as a preservative. According to the previous reports, the best stable emulsions are formulated with emulsifiers or a mixture of emulsifiers, which possess HLB values close to the required HLB (rHLB) of the oil phase in the formula. The concept of rHLB was employed to design emulsion-based stable formulations. The HLB values of both the oil phase and emulsifier system were determined according to the defined method. To develop a stable cream formulation, the quantities of emulsifiers to reach the rHLB for the oil phase were calculated. After the homogenization of the oil and aqueous phase, all formulations, F1-F4, were able to form the stable emulsion system. These formulations had a suitable emulsifier combination with desirable rHLB values that equal the oil phase. The results, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, showed the overall rHLB values contributed by the oil phase of formulations F1-F4 were 12.37, 12.37, 12.70, and 12.70, respectively, and the overall HLB value contributed by the emulsifier combination of formulations F1-F4 was 12.37, 12.37, 12.70 and 12.70, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Viscosity\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe viscosity of each formula is shown in Fig.\u0026nbsp;2. The viscosity values were 14, 4.7, 4.2, and 6.8 Pa.s for formulation F1, F2, F3, and F4, respectively. Based on these results, F1 showed the highest viscosity values among all the formulations. Besides, F2 exhibited the highest viscosity variations between the formulas.\u003c/p\u003e \u003cp\u003eFigure 2: viscosity of formulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Optical microscopy analysis\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe results of the optical microscopy analysis are shown in Fig.\u0026nbsp;3. All emulsion systems have a \u0026ldquo;foam-like\u0026rdquo; appearance (the oil droplets are separated by a thin film of continuous phase). However, F3 and F4 were more uniform and F1 and F2 were less uniform dispersed oil droplets; also, the particle sizes were different from one sample to another.\u003c/p\u003e \u003cp\u003eFigure 3: Optical microscopy analysis of formulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.5 pH measurement\u003c/h2\u003e \u003cp\u003eThe pH values of the different formulations F1-F4 were 5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01, 5.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02, 5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01, and 6.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Physical stability\u003c/h2\u003e \u003cp\u003eThe freeze\u0026ndash;thaw, and centrifugation tests were used to assay the cream formulation stability in temperature and mechanical stress. Among all of the formulations, F4 was not separated and showed it was a stable formula.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Clinical outcome\u003c/h2\u003e \u003cp\u003eSixty patients were enrolled in the study and eight of them were excluded because of adverse events. Finally, 52 patients (27 in the intervention group and 25 in the placebo group) were included in to analysis. The mean age was 28.89\u0026thinsp;\u0026plusmn;\u0026thinsp;17.77 months and the median age was 24 months (range: 6 months- 6 years). The baseline characteristics of participants in the two groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants in two groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostbiotic (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlacebo (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D) months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.03\u0026thinsp;\u0026plusmn;\u0026thinsp;23.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.86\u0026thinsp;\u0026plusmn;\u0026thinsp;19.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (11, 40.75)\u003c/p\u003e \u003cp\u003eFemale(16, 59.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale (15, 60.00)\u003c/p\u003e \u003cp\u003eFemale(10, 40.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.065*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamilial history (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16, 59.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16, 64.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.99*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotic use (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12, 44.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8, 32.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.26*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from the occurrence of symptoms\u003c/p\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D) months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.21\u0026thinsp;\u0026plusmn;\u0026thinsp;16.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.44\u0026thinsp;\u0026plusmn;\u0026thinsp;9.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D) kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.41**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e** T-Test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter a two-month follow-up, three patients had a recurrence and needed topical corticosteroids (all of them were in the placebo group) which has no significant difference in comparison with the postbiotic group (P\u0026thinsp;=\u0026thinsp;0.23). After four months, eleven patients had a recurrence in lesions (2 in the postbiotic group, 6.9% versus 9 in the placebo group, 31%; P\u0026thinsp;=\u0026thinsp;0.01). The mean of the SCOARD score is listed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e in postbiotic and placebo groups at baseline and final visit.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe comparison of SCOARD score in patients of placebo versus postbiotic groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndices\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostbiotic\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePlacebo\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSCORAD- A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.77\u0026thinsp;\u0026plusmn;\u0026thinsp;21.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.28\u0026thinsp;\u0026plusmn;\u0026thinsp;21.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.543*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.98\u0026thinsp;\u0026plusmn;\u0026thinsp;15.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.12\u0026thinsp;\u0026plusmn;\u0026thinsp;18.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-8.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSCORAD- B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSCORAD- C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.046*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSCORAD total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.88\u0026thinsp;\u0026plusmn;\u0026thinsp;13.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.048*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.81\u0026thinsp;\u0026plusmn;\u0026thinsp;10.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Between-group (intervention * time effect) significance\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e**Within-group (time effect) significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe details of the SCOARD score are seen in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e according to A score, B score, and C score. The mean of A score was 58.77\u0026thinsp;\u0026plusmn;\u0026thinsp;21.71 in the postbiotic group and 56.28\u0026thinsp;\u0026plusmn;\u0026thinsp;21.61 in the placebo group at baseline (P\u0026thinsp;=\u0026thinsp;0.88) and 28.98\u0026thinsp;\u0026plusmn;\u0026thinsp;15.86 in postbiotic and 37.12\u0026thinsp;\u0026plusmn;\u0026thinsp;18.05 in placebo groups after treatment (P\u0026thinsp;=\u0026thinsp;0.543). The mean B score was 8.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77 in the postbiotic group and 6.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69 in the placebo group at baseline (P\u0026thinsp;=\u0026thinsp;0.589) and 4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10 in postbiotic and 4.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 in placebo groups after treatment (P\u0026thinsp;=\u0026thinsp;0.016). The mean C score was 9.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49 in the postbiotic group and 7.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75 in the placebo group at baseline (P\u0026thinsp;=\u0026thinsp;0.780) and 5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23 in postbiotic and 5.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42 in placebo groups after treatment (P\u0026thinsp;=\u0026thinsp;0.049). The mean score of SCOARD was compared at two time points before the intervention and 6 weeks later. The total score of SCOARD was in the placebo group (51.88\u0026thinsp;\u0026plusmn;\u0026thinsp;13.67) and the postbiotic group (42.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29). In comparing the changes of the two groups using the analysis of Repeated Measures ANOVA, this difference was significant (p\u0026thinsp;=\u0026thinsp;0.048).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the visited patients, physicians were examined immediately after stopping using the cream and 4 months later for the relapse of the disease. In the placebo group, 10% of the disease relapsed on the first visit after stopping using the cream. In the fourth month visit, 30% of patients in the placebo group relapsed. The frequency of disease relapse in both postbiotic and placebo groups was statistically significant (p\u0026thinsp;=\u0026thinsp;0.020).\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe topical application of postbiotics as a promising therapeutic approach for treating patients has recently attracted great attention [15, 18, 30, 31]. The composition of skin care products contains different ingredients that are necessary to provide the intended efficacy, quality, and safety. So, choosing the appropriate ingredients is crucial for improving the performance of the final formulation. Surfactants, as amphiphilic substances, are important ingredients in cream formulations. They can reduce the surface tension between liquids with different polarities due to the presence of both hydrophilic and hydrophobic moieties in their chemical structure, and therefore provide a homogeneous and uniform texture to the final formulations [32, 33]. To complete the emulsification of two immiscible phases, a suitable emulsifier system with an rHLB value is very crucial [34, 35]. Consequently, the HLB of each ingredient of the oil phase needs to be determined before proceeding with the emulsification process. The results of HLB values are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which shows that the mixture of Tween 80 and Span 80 and Tween 80 and Span 60 provided the HLB for a stable o/w emulsion. The suitability of the contributed HLB values of the oil phase and rHLB obtained by the combination of the emulsifier system was the reason for the formulation stability [36]. It should be noted that a certain amount of emulsifier system is necessary to stabilize the formulation. Based on the previous study, maximum stability was achieved at 5% emulsifier content due to compact films around each oil droplet cannot be formed at surfactant concentrations less than 5%, which finally destabilized the emulsion. Also, emulsifier concentration higher than 5% leads to destabilizing the emulsion [37].\u003c/p\u003e \u003cp\u003eThe role of poloxamer 188 as a surfactant along with a suitable emulsifier system in improving the stability was previously described [38]. It was shown that a gel-cream formulation that was emulsified by non-ionic emulsifiers, which are Tween 20, poloxamer 188, and soy lecithin showed steric stabilization [39]. This observation is in line with our results that showed the chosen emulsifier system is enough good for the stability of the final formulation.\u003c/p\u003e \u003cp\u003eThe rheological parameters of the topical formulation play an important role in the quality control of the cosmeceutical emulsions. The viscosity of different formulations is illustrated in Fig.\u0026nbsp;2. As seen, the F1 showed the highest value of viscosity among the formulations. The viscosity variation of emulsions could be related to the variation of ingredients, especially to the emulsifier concentration and the rheology modifier [40]. Additionally, all the rheograms showed a pseudoplastic flow which is a desirable rheological behavior for preparations. In this case, the shear rate increases upon shear stress decrease. This kind of behavior leads to a reduction in the apparent viscosity of the formula [41]. Low viscosity in the formula indicated that the preparations showed good rheology during handling and also attributed to better emulsification of stearic acid in the presence of the emulsifier and co-emulsifier system [42].\u003c/p\u003e \u003cp\u003eDespite the improvement of instrumental analysis techniques, the optical microscopy method remains the most widely used analytical method for characterizing the microstructure of topical formulations [43]. Based on the results of the present study (Fig.\u0026nbsp;3), formulations F3 and F4 exhibited monodisperse and a uniform roundness of drops, which indicated the stability of the system. The foam-like structure of these samples created during shear blending confers them a viscoelastic rheological behavior, which is responsible for their appearances [40].\u003c/p\u003e \u003cp\u003eThe pH values of different formulations were obtained. Skin pH is one of the most important biophysical features. Natural skin pH varies between 4.5 to 6.5 due to various parameters such as race, skin tone or color, and exposure to sunlight. This interval has been considered to be optimal for cosmeceuticals that contact directly with the skin [44]. The values obtained for our formulations were in this interval, indicating that they can be safely applied to the skin.\u003c/p\u003e \u003cp\u003eThe F4 was the most stable formulation during colloidal and thermal stabilities assessment and did not show any sign of separation. This observation indicated the proper ratio of non-ionic surfactants that were used in the formulation. So, this formulation was selected for further in vivo studies.\u003c/p\u003e \u003cp\u003eProbiotics are agents that potentially can be promising approaches in the treatment of allergic conditions, including AD. The aim of the current randomized, double-blind, placebo-controlled trial was to determine whether the topical \u003cem\u003eL. Plantarum\u003c/em\u003e lysate, would be an effective treatment in children with AD. The results of our study showed that the topical formulation is not superior to placebo in terms of primary outcomes. Despite of lower SCOARD score in the postbiotic group rather than placebo, the results of this clinical trial are not in line with previous studies on oral probiotics [45, 46]. However, we showed that in long-term follow-up, the recurrence of lesions in the postbiotic group was significantly lesser than in the placebo group. While atopic dermatitis is a chronic relapsing disorder, finding new treatment modalities that reduce the recurrence of the disease will be promising [47]. Atopic dermatitis has a very complex pathophysiology. Genetic predisposition besides various exogenous factors leads to clinical manifestations like pruritus, erythema, and skin dryness [48]. Recent studies have shown that an imbalance of skin microbiome and abundance of staphylococcus aureus link to T-cell dysfunction, reduced AMPs, and impairment of skin barrier \u003csup\u003e, ,\u003c/sup\u003e[49, 50]. These findings suggest that manipulating the environmental milieu can modulate the immunologic reaction. So trials have begun aiming to change the skin microflora of AD patients. Recent evidence has shown that topical probiotics as a promising treatment can increase skin ceramides and attenuate the colony count of pathogenic \u003cem\u003eS. aureus\u003c/em\u003e. However, this ability was largely linked to the dose, duration, and probiotic strains that were used. Common studied probiotic strains are \u003cem\u003eS. thermophiles\u003c/em\u003e, \u003cem\u003eV. filiformis\u003c/em\u003e, \u003cem\u003eS. hominis\u003c/em\u003e, \u003cem\u003eS. epidermidis\u003c/em\u003e, and \u003cem\u003eL. johsonii\u003c/em\u003e [10, 51, 52]. In our study, we showed no significant difference in the severity of AD in patients who received topical postbiotic treatment rather than control. There are limited studies in the field of using probiotics as topical for the treatment of AD. Oral use of probiotics in children with AD has shown favorable results [53\u0026ndash;55].In several studies, it is demonstrated that topical administration of probiotics are safe [56, 57]. In one study, topical ointment containing Lactobacillus reuteri DSM 17938 in adult patients with AD led to significant improvement in the SCORAD index. They have used this complementary treatment for 8 weeks [58]. They didn\u0026rsquo;t evaluate the recurrence rate of the disease. Despite no statistical difference in primary outcomes in groups receiving placebo or postbiotics, clinical improvement was shown in our study and, the recurrence rate significantly decreased. Our sample size was too small and generalizing the results should be done with precautions. Further studies with large-scale and multi-center trial is recommended for better analytical outcomes. A trial for different strains of probiotics is suggested, too.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study showed that the postbiotic cream containing \u003cem\u003eL. plantarum\u003c/em\u003e lys is safe and acceptable. Also, we have shown a significantly reduced recurrence rate of AD. In conclusion, the results suggest that the postbiotic product, containing \u003cem\u003eL. plantarum\u003c/em\u003e lysate as an extra ingredient, shows promise as a novel topical cosmetic formulation and with further testing could be a standard topical product for the management of AD or other conditions associated with the skin. We also showed that in long-term follow-up, the recurrence of lesions in the postbiotic group was significantly lesser than in the placebo group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by Mashhad University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNasrin Moazzen collaborated in the original idea, concept, design, and writing and drafting the article. Hamid Ahanchian and Tahereh Sadeghi contributed with data interpretation, writing, and drafting of the article. Bahman Khameneh contributed to all stages of the process and mainly participated in drafting the article, writing, and editing the final version to be published.\u0026nbsp;Kiana Delaram\u0026nbsp;and Amir Hossein Masrour contributed to cream preparing, and writing the original draft. All the authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eT. Torres, E. Ferreira, M. Gon\u0026ccedil;alo, P. Mendes-Bastos, M. Selores, P. Filipe, Update on atopic dermatitis, \u003cem\u003eActa medica portuguesa\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e32\u003c/em\u003e, 606\u0026ndash;613.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eG. Sanclemente, N. Hernandez, D. Chaparro, L. Tamayo, A. Lopez, \u0026Aacute;. L\u0026oacute;pez, A. Cortes, \u0026Aacute;. Seidel, C.I. Ortiz, C. Arenas, Epidemiologic features and burden of atopic dermatitis in adolescent and adult patients: A cross-sectional multicenter study, \u003cem\u003eWorld Allergy Organization Journal\u003c/em\u003e \u003cstrong\u003e2021\u003c/strong\u003e, \u003cem\u003e14\u003c/em\u003e, 100611.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eL. Schneider, S. Tilles, P. Lio, M. Boguniewicz, L. Beck, J. LeBovidge, N. Novak, D. Bernstein, J. Blessing-Moore, D. Khan, Atopic dermatitis: a practice parameter update 2012, \u003cem\u003eJournal of Allergy and Clinical Immunology\u003c/em\u003e \u003cstrong\u003e2013\u003c/strong\u003e, \u003cem\u003e131\u003c/em\u003e, 295\u0026ndash;299. e227.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eV. Aoki, D. Lorenzini, R.L. Orfali, M.C. Zaniboni, Z.N.P.d. Oliveira, M.C. Rivitti-Machado, R. Takaoka, M.B. Weber, T. Cestari, B. Gontijo, Consensus on the therapeutic management of atopic dermatitis-Brazilian Society of Dermatology, \u003cem\u003eAnais Brasileiros de Dermatologia\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e94\u003c/em\u003e, 67\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eT. Hajar, Y.A. Leshem, J.M. Hanifin, S.T. Nedorost, P.A. Lio, A.S. Paller, J. Block, E.L. Simpson, A systematic review of topical corticosteroid withdrawal (\u0026ldquo;steroid addiction\u0026rdquo;) in patients with atopic dermatitis and other dermatoses, \u003cem\u003eJournal of the American Academy of Dermatology\u003c/em\u003e \u003cstrong\u003e2015\u003c/strong\u003e, \u003cem\u003e72\u003c/em\u003e, 541\u0026ndash;549. e542.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. Lluis, B. Schaub, Lesson from the farm environment, \u003cem\u003eCurrent opinion in allergy and clinical immunology\u003c/em\u003e \u003cstrong\u003e2012\u003c/strong\u003e, \u003cem\u003e12\u003c/em\u003e, 158\u0026ndash;163.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eD. Martino, S.L. Prescott, Silent mysteries: epigenetic paradigms could hold the key to conquering the epidemic of allergy and immune disease, \u003cem\u003eAllergy\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e65\u003c/em\u003e, 7\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS. Kianmehr, M. Jahani, N. Moazzen, H. Ahanchian, B. Khameneh, The potential of Probiotics for treating skin Disorders: a concise review, \u003cem\u003eCurrent Pharmaceutical Biotechnology\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e23\u003c/em\u003e, 1851\u0026ndash;1863.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. Fiocchi, R. Pawankar, C. Cuello-Garcia, K. Ahn, S. Al-Hammadi, A. Agarwal, K. Beyer, W. Burks, G.W. Canonica, M. Ebisawa, World allergy organization-McMaster University guidelines for allergic disease prevention (GLAD-P): probiotics, \u003cem\u003eWorld Allergy Organization Journal\u003c/em\u003e \u003cstrong\u003e2015\u003c/strong\u003e, \u003cem\u003e8\u003c/em\u003e, 1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS.-O. Kim, Y.-M. Ah, Y.M. Yu, K.H. Choi, W.-G. Shin, J.-Y. Lee, Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials, \u003cem\u003eAnnals of Allergy, Asthma \u0026amp; Immunology\u003c/em\u003e \u003cstrong\u003e2014\u003c/strong\u003e, \u003cem\u003e113\u003c/em\u003e, 217\u0026ndash;226.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eI.A. Myles, C.R. Castillo, K.D. Barbian, K. Kanakabandi, K. Virtaneva, E. Fitzmeyer, M. Paneru, F. Otaizo-Carrasquero, T.G. Myers, T.E. Markowitz, Therapeutic responses to Roseomonas mucosa in atopic dermatitis may involve lipid-mediated TNF-related epithelial repair, \u003cem\u003eScience translational medicine\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e12\u003c/em\u003e, eaaz8631.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM. Marcinkowska, A. Zag\u0026oacute;rska, N. Fajkis, M. Kolaczkowski, P. Pasko, A Review of Probiotic Supplementation and Feasibility of Topical Application for the Treatment of Pediatric Atopic Dermatitis, \u003cem\u003eCurrent pharmaceutical biotechnology\u003c/em\u003e \u003cstrong\u003e2018\u003c/strong\u003e, \u003cem\u003e19\u003c/em\u003e, 827\u0026ndash;838.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eR.J. Boyle, R.M. Robins-Browne, M.L. Tang, Probiotic use in clinical practice: what are the risks?, \u003cem\u003eThe American journal of clinical nutrition\u003c/em\u003e \u003cstrong\u003e2006\u003c/strong\u003e, \u003cem\u003e83\u003c/em\u003e, 1256\u0026ndash;1264.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJ.Z. Goldenberg, C. Yap, L. Lytvyn, C.K.F. Lo, J. Beardsley, D. Mertz, B.C. Johnston, Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children, \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. da Silva Vale, G.V. de Melo Pereira, A.C. de Oliveira, D.P. de Carvalho Neto, L.W. Herrmann, S.G. Karp, V.T. Soccol, C.R. Soccol, Production, Formulation, and Application of Postbiotics in the Treatment of Skin Conditions, \u003cem\u003eFermentation\u003c/em\u003e \u003cstrong\u003e2023\u003c/strong\u003e, \u003cem\u003e9\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM.J. Lee, Z.L. Zang, E.Y. Choi, H.K. Shin, G.E. Ji, Cytoskeleton reorganization and cytokine production of macrophages by bifidobacterial cells and cell-free extracts, \u003cstrong\u003e2002\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS. Salminen, M.C. Collado, A. Endo, C. Hill, S. Lebeer, E.M.M. Quigley, M.E. Sanders, R. Shamir, J.R. Swann, H. Szajewska, G. Vinderola, The International Scientific Association of Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of postbiotics, \u003cem\u003eNat Rev Gastroenterol Hepatol\u003c/em\u003e \u003cstrong\u003e2021\u003c/strong\u003e, \u003cem\u003e18\u003c/em\u003e, 649\u0026ndash;667.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eC. Gelmetti, C. Rigoni, A.M. Cant\u0026ugrave;, A. Agolzer, A. Agrusa, M. Brena, F. Dall\u0026rsquo;Oglio, P. Demichelis, S. Farina, L.A. Frasin, S. Lorenzi, G. Mazzola, M. Pratic\u0026ograve;, S. Robotti, A. Tedeschi, L. Villa, P. Ananiadis, E. Arkoumani, I. Astashonok, E. Baselga Torres, S. Borici, E. Cano, R. Cela, A. Cengo, F. Corella, X. Cubiro Raventos, M.A. De Jesus Silva, E. Demiraj, E. Dhima, X. Doci, A. Domarad, M. Didyk, A. Dyli, O. Efthimiou, G. Filippi, V.A. Flores Climente, M.P. Garcia Muret, J.G. Navarro, M. Gega, A.N. Giakoub, V. Giakoubis, A. Gica, M. Gjomema, B. Guri, E. Janushaj, A. Kanelleas, G. Kanelopoulou, E. Kapaj, D. Kapoukranidou, K. Karadima, A. Katsavou, L. Kotrulja, A. Kyriakou, G. Larios, A. Lopez, C. Lopez, S.M. Manoli, T. Matvienko, L. Mervic, K. Mileounis, D. Muja, M. Nadezhda, D. Panagioti, M. Papakonstantis, M. Papanikou, D. Papathemeli, K. Papigkioti, V. Pivak, D. Preza, E. Ro\u0026eacute;, M. Rogl Butina, E. Serra Baldrich, D. Sgouros, A. Shilova, E. Shllaku, N. Sideris, E. Sina, A. Sinani, F. Sourli-Chasioti, M. Stankaj, D. Tasioula, A. Tsalmadoupis, F. Tsatsou, E. Tsenebi, A. Tsitlakidou, P. Vassis, E. Vilarrassa, O. Vorobey, N. Voutsakis, S. Yakovleva, S. Yakubovskaya, E. Yerygina, A. Zarras, V. Zenelaj, O. Zenko, Topical prebiotics/postbiotics and PRURISCORE validation in atopic dermatitis. International study of 396 patients, \u003cem\u003eJ. Dermatol. Treat.\u003c/em\u003e \u003cstrong\u003e2023\u003c/strong\u003e, \u003cem\u003e34\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eC.N. de Almada, C.N. Almada, R.C.R. Martinez, A.S. Sant\u0026apos;Ana, Paraprobiotics: Evidences on their ability to modify biological responses, inactivation methods and perspectives on their application in foods, \u003cem\u003eTrends Food Sci Technol\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e58\u003c/em\u003e, 96\u0026ndash;114.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eG. Vinderola, M.E. Sanders, S. Salminen, The Concept of Postbiotics, \u003cem\u003eFoods\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e11\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eV. Salo, A. Remitz, A. Lauerma, A. Salava, Treatment of atopic dermatitis with probiotic L. lactis lysate-A double-blinded, placebo-controlled pilot study, \u003cstrong\u003e2023\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. Gu\u0026eacute;niche, P. Bastien, J.M. Ovigne, M. Kermici, G. Courchay, V. Chevalier, L. Breton, I. Castiel-Higounenc, Bifidobacterium longum lysate, a new ingredient for reactive skin, \u003cem\u003eExp Dermatol\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e19\u003c/em\u003e, e1-8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.C. Ouwehand, A. B\u0026aring;tsman, S. Salminen, Probiotics for the skin: a new area of potential application?, \u003cem\u003eLett Appl Microbiol\u003c/em\u003e \u003cstrong\u003e2003\u003c/strong\u003e, \u003cem\u003e36\u003c/em\u003e, 327\u0026ndash;331.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eK.L. Rodrigues, L.R. Caputo, J.C. Carvalho, J. Evangelista, J.M. Schneedorf, Antimicrobial and healing activity of kefir and kefiran extract, \u003cem\u003eInt J Antimicrob Agents\u003c/em\u003e \u003cstrong\u003e2005\u003c/strong\u003e, \u003cem\u003e25\u003c/em\u003e, 404\u0026ndash;408.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eL. Di Marzio, B. Cinque, C. De Simone, M.G. Cifone, Effect of the lactic acid bacterium Streptococcus thermophilus on ceramide levels in human keratinocytes in vitro and stratum corneum in vivo, \u003cem\u003eJ Invest Dermatol\u003c/em\u003e \u003cstrong\u003e1999\u003c/strong\u003e, \u003cem\u003e113\u003c/em\u003e, 98\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eY. Ashoori, M. Mohkam, R. Heidari, S.N. Abootalebi, S.M. Mousavi, S.A. Hashemi, N. Golkar, A. Gholami, Development and in Vivo Characterization of Probiotic Lysate-Treated Chitosan Nanogel as a Novel Biocompatible Formulation for Wound Healing, \u003cem\u003eBioMed Res. Int.\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e2020\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eF. Lombardi, F.R. Augello, S. Artone, B. Bahiti, J.M. Sheldon, M. Giuliani, M.G. Cifone, P. Palumbo, B. Cinque, Efficacy of probiotic Streptococcus thermophilus in counteracting TGF-\u0026beta;1-induced fibrotic response in normal human dermal fibroblasts, \u003cem\u003eJournal of Inflammation\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e19\u003c/em\u003e, 27.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJ.M. HanifIn, Diagnostic features of atopic dermatitis, \u003cem\u003eActa Derm. Venereol.\u003c/em\u003e \u003cstrong\u003e1980\u003c/strong\u003e, \u003cem\u003e92\u003c/em\u003e, 44\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. Oranje, E. Glazenburg, A. Wolkerstorfer, F. De Waard-van der Spek, Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score, \u003cem\u003eBritish Journal of Dermatology\u003c/em\u003e \u003cstrong\u003e2007\u003c/strong\u003e, \u003cem\u003e157\u003c/em\u003e, 645\u0026ndash;648.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM. Majeed, S. Majeed, K. Nagabhushanam, L. Lawrence, S. Arumugam, L. Mundkur, Skin protective activity of lactosporin-the extracellular metabolite from bacillus coagulans mtcc 5856, \u003cem\u003eCosmetics\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e7\u003c/em\u003e, 1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS. Kianmehr, M. Jahani, N. Moazzen, H. Ahanchian, B. Khameneh, The Potential of Probiotics for Treating Skin Disorders: A Concise Review, \u003cem\u003eCurrent pharmaceutical biotechnology\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e23\u003c/em\u003e, 1851\u0026ndash;1863.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eN. Lourith, M. Kanlayavattanakul, Natural surfactants used in cosmetics: glycolipids, \u003cem\u003eInt J Cosmet Sci\u003c/em\u003e \u003cstrong\u003e2009\u003c/strong\u003e, \u003cem\u003e31\u003c/em\u003e, 255\u0026ndash;261.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS. Golmohammadzadeh, N. Farhadian, A. Biriaee, F. Dehghani, B. Khameneh, Preparation, characterization and in vitro evaluation of microemulsion of raloxifene hydrochloride, \u003cem\u003eDrug Dev Ind Pharm\u003c/em\u003e \u003cstrong\u003e2017\u003c/strong\u003e, \u003cem\u003e43\u003c/em\u003e, 1619\u0026ndash;1625.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eN. Wangpradit, S. Macha, N. Phooteh, N. Yusohyo, A. Waedoloh, S. Manee, Determination of required hydrophilic-lipophilic balance of Amesiodendron chinense (Merr.) Hu oil and development of stable cream formulation?, \u003cem\u003eOCL\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, \u003cem\u003e29\u003c/em\u003e, 29.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eH. Kim, S. Jung, S. Yeo, D. Kim, Y.C. Na, G. Yun, J. Lee, Characteristics of Skin Deposition of Itraconazole Solubilized in Cream Formulation, \u003cem\u003ePharmaceutics\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e11\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eP.B. Ximango, E.B.D. da Rocha, A.M.F. de Sousa, C.F. Scofield, M.L.L. Paredes, E.R.d.A. Lima, Preparation and characterization of patau\u0026aacute; and pracaxi Brazilian vegetable oil emulsions, \u003cem\u003eJournal of Dispersion Science and Technology\u003c/em\u003e \u003cstrong\u003e2022\u003c/strong\u003e, 1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.R. Rahate, J.M. Nagarkar, Emulsification of Vegetable Oils using a Blend of Nonionic Surfactants for Cosmetic Applications, \u003cem\u003eJournal of Dispersion Science and Technology\u003c/em\u003e \u003cstrong\u003e2007\u003c/strong\u003e, \u003cem\u003e28\u003c/em\u003e, 1077\u0026ndash;1080.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eC.C. Chu, K.L. Nyam, Kenaf (Hibiscus cannabinus L.) seed oil: Application as cosmetic product ingredients, \u003cem\u003eIndustrial Crops and Products\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e156\u003c/em\u003e, 112871.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eT.B. Tan, W.C. Chu, N.S. Yussof, F. Abas, H. Mirhosseini, Y.K. Cheah, I.A. Nehdi, C.P. Tan, Physicochemical, morphological and cellular uptake properties of lutein nanodispersions prepared by using surfactants with different stabilizing mechanisms, \u003cem\u003eFood \u0026amp; Function\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e7\u003c/em\u003e, 2043\u0026ndash;2051.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eE. Danila, Z. Moldovan, M.G.A. Kaya, M.V. Ghica, Formulation and characterization of some oil in water cosmetic emulsions based on collagen hydrolysate and vegetable oils mixtures, \u003cem\u003ePure and Applied Chemistry\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e91\u003c/em\u003e, 1493\u0026ndash;1507.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eV.M. Di Mambro, M.F. Borin, M.J.V. Fonseca, Topical formulations with superoxide dismutase: influence of formulation composition on physical stability and enzymatic activity, \u003cem\u003eJournal of Pharmaceutical and Biomedical Analysis\u003c/em\u003e \u003cstrong\u003e2003\u003c/strong\u003e, \u003cem\u003e32\u003c/em\u003e, 97\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eK. Kaur, G. Rath, Formulation and evaluation of UV protective synbiotic skin care topical formulation, \u003cem\u003eJ Cosmet Laser Ther\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, \u003cem\u003e21\u003c/em\u003e, 332\u0026ndash;342.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.Z.M. Badruddoza, T. Yeoh, J.C. Shah, T. Walsh, Assessing and Predicting Physical Stability of Emulsion-Based Topical Semisolid Products: A Review, \u003cem\u003eJournal of Pharmaceutical Sciences\u003c/em\u003e \u003cstrong\u003e2023\u003c/strong\u003e, \u003cem\u003e112\u003c/em\u003e, 1772\u0026ndash;1793.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eS. Smaoui, H.B. Hlima, R. Jarraya, N.G. Kamoun, R. Ellouze, M. Damak, Cosmetic emulsion from virgin olive oil: Formulation and bio-physical evaluation, \u003cem\u003eAfr. J. Biotechnol\u003c/em\u003e \u003cstrong\u003e2012\u003c/strong\u003e, \u003cem\u003e11\u003c/em\u003e, 9664\u0026ndash;9671.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eB. Cukrowska, A. Ceregra, I. Rosiak, E. Klewicka, K. Slizewska, I. Motyl, The influence of probiotic Lactobacillus casei and paracasei strains on clinical status of atopic eczema in children with food allergy on cow\u0026apos;s milk proteins, \u003cem\u003ePediatria Wspolczesna\u003c/em\u003e \u003cstrong\u003e2008\u003c/strong\u003e, \u003cem\u003e10\u003c/em\u003e, 67\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eB. Cukrowska, A. Ceregra, E. Klewicka, K. Slizewska, I. Motyl, Z. Libudzisz, PROBIOTYCZNE SZCZEPY LACTOBACILLUS CASEI I LACTOBACILLUS PARACASEI W LECZENIU ALERGII POKARMOWEJ U DZIECI, \u003cem\u003ePrzeglad Pediatryczny\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e40\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA.W. Burks, L.B. Bacharier, G.K.K. Hershey, R.S. Peebles, R.E. O\u0026apos;Hehir, D.H. Broide, S.T. Holgate, Middleton\u0026apos;s allergy E-Book: principles and practice, Elsevier Health Sciences2019.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eE.L. Simpson, Atopic dermatitis: a review of topical treatment options, \u003cem\u003eCurrent medical research and opinion\u003c/em\u003e \u003cstrong\u003e2010\u003c/strong\u003e, \u003cem\u003e26\u003c/em\u003e, 633\u0026ndash;640.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM. Sieprawska-Lupa, P. Mydel, K. Krawczyk, K. W\u0026oacute;jcik, M. Puklo, B. Lupa, P. Suder, J. Silberring, M. Reed, J. Pohl, Degradation of human antimicrobial peptide LL-37 by Staphylococcus aureus-derived proteinases, \u003cem\u003eAntimicrobial agents and chemotherapy\u003c/em\u003e \u003cstrong\u003e2004\u003c/strong\u003e, \u003cem\u003e48\u003c/em\u003e, 4673\u0026ndash;4679.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM.D. Howell, M. Boguniewicz, S. Pastore, N. Novak, T. Bieber, G. Girolomoni, D.Y. Leung, Mechanism of HBD-3 deficiency in atopic dermatitis, \u003cem\u003eClinical immunology\u003c/em\u003e \u003cstrong\u003e2006\u003c/strong\u003e, \u003cem\u003e121\u003c/em\u003e, 332\u0026ndash;338.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eB. Cinque, C. La Torre, E. Melchiorre, G. Marchesani, G. Zoccali, P. Palumbo, L. Di Marzio, A. Masci, L. Mosca, P. Mastromarino, Use of probiotics for dermal applications, \u003cem\u003eProbiotics: biology, genetics and health aspects\u003c/em\u003e \u003cstrong\u003e2011\u003c/strong\u003e, 221\u0026ndash;241.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eA. Gu\u0026eacute;niche, A.C. Cathelineau, P. Bastien, J. Esdaile, R. Martin, C. Queille Roussel, L. Breton, Vitreoscilla filiformis biomass improves seborrheic dermatitis, \u003cem\u003eJournal of the European Academy of Dermatology and Venereology\u003c/em\u003e \u003cstrong\u003e2008\u003c/strong\u003e, \u003cem\u003e22\u003c/em\u003e, 1014\u0026ndash;1015.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eH.-J. Yang, T.K. Min, H.W. Lee, B.Y. Pyun, Efficacy of probiotic therapy on atopic dermatitis in children: a randomized, double-blind, placebo-controlled trial, \u003cem\u003eAllergy, asthma \u0026amp; immunology research\u003c/em\u003e \u003cstrong\u003e2014\u003c/strong\u003e, \u003cem\u003e6\u003c/em\u003e, 208\u0026ndash;215.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eI.A. Rather, V.K. Bajpai, S. Kumar, J. Lim, W.K. Paek, Y.-H. Park, Probiotics and Atopic Dermatitis: An Overview, \u003cem\u003eFront Microbiol\u003c/em\u003e \u003cstrong\u003e2016\u003c/strong\u003e, \u003cem\u003e7\u003c/em\u003e, 507\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eN.Y. Kim, G.E. Ji, Effects of probiotics on the prevention of atopic dermatitis, \u003cem\u003eKorean J Pediatr\u003c/em\u003e \u003cstrong\u003e2012\u003c/strong\u003e, \u003cem\u003e55\u003c/em\u003e, 193\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eP.Y. Ong, T. Ohtake, C. Brandt, I. Strickland, M. Boguniewicz, T. Ganz, R.L. Gallo, D.Y. Leung, Endogenous antimicrobial peptides and skin infections in atopic dermatitis, \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e \u003cstrong\u003e2002\u003c/strong\u003e, \u003cem\u003e347\u003c/em\u003e, 1151\u0026ndash;1160.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eL. Di Marzio, C. Centi, B. Cinque, S. Masci, M. Giuliani, A. Arcieri, L. Zicari, C. De Simone, M.G. Cifone, Effect of the lactic acid bacterium Streptococcus thermophilus on stratum corneum ceramide levels and signs and symptoms of atopic dermatitis patients, \u003cem\u003eExperimental dermatology\u003c/em\u003e \u003cstrong\u003e2003\u003c/strong\u003e, \u003cem\u003e12\u003c/em\u003e, 615\u0026ndash;620.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u0026Eacute;. Butler, C. Lundqvist, J. Axelsson, Lactobacillus reuteri DSM 17938 as a Novel Topical Cosmetic Ingredient: A Proof of Concept Clinical Study in Adults with Atopic Dermatitis, \u003cem\u003eMicroorganisms\u003c/em\u003e \u003cstrong\u003e2020\u003c/strong\u003e, \u003cem\u003e8\u003c/em\u003e, 1026.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Probiotic, Postbiotic, Lactobacillus plantarum, Atopic dermatitis, Recurrence","lastPublishedDoi":"10.21203/rs.3.rs-3680536/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3680536/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAtopic dermatitis (AD) is the major common chronic inflammatory dermatologic disorder in children. Postbiotics are bioactive compounds derived from probiotics, inanimate microorganisms, and/or their components. In the current study, we aimed to prepare, characterize, and clinically evaluate postbiotic cream in pediatric patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAfter preparing different formulations, the formulations were evaluated for stability and physicochemical properties for semi-solids, such as physical properties, viscosity, temperature cycle, and pH. Finally, a formulation that showed better physical properties was chosen for further investigation. The study was performed on patients with AD referred to the outpatient allergy clinic. The primary outcomes were assessed with the SCORAD index and changes in the proportion of children with clinical improvement/no improvement, deterioration, and recurrence rate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe final formulation's pH was 6.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02. In addition, the centrifugation test showed that this formulation was completely homogeneous after centrifugation. The temperature cycle test indicated no change in the structure of the cream. After a two-month follow-up, the mean SCOARD score was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 at baseline and 27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10 at the final visit in the postbiotic group. It was also 43\u0026thinsp;\u0026plusmn;\u0026thinsp;12 at baseline and 28.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6 at the final visit in the placebo group. After four months, eleven patients had a recurrence in lesions: 2 in the postbiotic group, 6.9% versus 9 in the placebo group, 30%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrated that postbiotic formulation is cutaneously acceptable and showed a clinically significant improvement, especially in long-term follow-up.\u003c/p\u003e","manuscriptTitle":"Development and clinical assessment of new topical cream containing postbiotic in the treatment of pediatric atopic dermatitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-02 01:56:37","doi":"10.21203/rs.3.rs-3680536/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c35b4d3-b13e-42fd-bd02-18b79971db70","owner":[],"postedDate":"December 2nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-13T03:06:02+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-02 01:56:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3680536","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3680536","identity":"rs-3680536","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}