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Allergy Asthma Immunol Res. 2018 Jul;10(4):354-362. English.
Published online February 26, 2018.
Copyright © 2018 The Korean Academy of Asthma, Allergy and Clinical Immunology • The Korean Academy of Pediatric Allergy and Respiratory Disease
Microbiome in the Gut-Skin Axis in Atopic Dermatitis
So-Yeon Lee,1 Eun Lee,2 Yoon Mee Park,3 and Soo-Jong Hong1
1Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
2Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.
3Asan Institute for Life Science, University of Ulsan College of Medicine, Seoul, Korea.

Corresponding author: Soo-Jong Hong, MD, PhD, Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3379; Fax: +82-2-473-3725; Email:
Received November 15, 2017; Revised December 16, 2017; Accepted December 29, 2017.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


The microbiome is vital for immune system development and homeostasis. Changes in microbial composition and function, termed dysbiosis, in the skin and the gut have recently been linked to alterations in immune responses and to the development of skin diseases, such as atopic dermatitis (AD). In this review, we summarize the recent findings on the gut and skin microbiome, highlighting the roles of major commensals in modulating skin and systemic immunity in AD. Although our understanding of the gut-skin axis is only beginning, emerging evidence indicates that the gut and skin microbiome could be manipulated to treat AD.

Keywords: Atopic dermatitis; gut microbiota; skin; microbiome


Atopic dermatitis (AD) is a chronic inflammatory skin condition with a drastic impact on pediatric health. The multifactorial pathogenesis of AD is still somewhat of an enigma. Its development involves multiple potential genes, an altered innate and adaptive immune response, and epidermal epithelial dysfunction and is influenced by several environmental risk factors.1, 2 The increased prevalence of AD, particularly in industrialized regions, has been hypothesized to be due to the excessive hygiene accompanying the Western lifestyle reduces exposure of the host's immune system to the education provided by beneficial microbes.3, 4 In particular, infancy and early childhood have been identified as important and vulnerable periods in the development of the gut microbiome, which shapes an individual's disposition to AD.5 This is exemplified by germ-free mice, which lack an appropriately developed immune system and show mucosal alterations, both of which can be restored through colonization with the gut microbiome.6 In this ever-expanding field, researchers are now investigating how the local microbiome influences immunity at distal sites, particularly how the gut microbiome influences other organs, such as the lung, brain, and skin. This has led to the coining of terms, such as the “gut-brain axis” and “gut-lung axis.”

Research into the effects of probiotics has revealed how gut microbiome can affect other organs. Several studies have demonstrated that probiotics can influence the composition of the gut microbiome and may even exert immunomodulatory effects.7, 8 In response to these promising results, the possible application of probiotics to the therapeutic management of allergic diseases has been investigated in many studies.9, 10 In particular, a considerable body of literature has been published on the effects of probiotics in patients with AD.11 More recently, interest in dissecting the gut-skin axis has been revived by the finding that the consumption of certain lactobacilli by mice can markedly change their overall skin phenotypes.12 The mechanisms by which the gut microbiome affects the immune responses in the skin, and vice versa, are being uncovered, but many questions remain.

In this review article, we summarize the recent findings on the gut and skin microbiome, highlighting the roles of major commensals in modulating skin and systemic immunity in AD.


Gut microbiome and AD

The gut microbiome might play a crucial role in the development of AD by regulating immune system maturation through cross-talk between the microbiome and the host, especially in early life.13, 14 Alterations in the gut microbiome affect the immune system balance via the production of metabolites, which can cause an inflamed microenvironment in the presence of specific microbiome in the gut.15 The established dysbiosis of the gut microbiome combined with the immune system imbalance persists into adulthood and thereby contributes to the natural courses of diseases, such as AD.16

Various environmental factors, such as stress, diet, and pollutants, affect microbial composition and profiling, particularly in early life.16 In combination with these diverse factors, the gut microbiome contributes to the development and natural course of AD. Previous studies have found that the gut microbiome in early life is associated with age of onset, severity, remission, flares, and even phenotype of AD (e.g., atopic vs non-atopic AD) (Table 1). Although some studies suggested that gut microbiome diversity is inversely related to the development of AD,17 the association between gut microbiome diversity and AD development remains contradictory.17, 18, 19 The development of AD might be promoted not only by gut microbiome diversity in itself, but also by interactions between specific gut microbiome, established immune systems, and harmonization of the gut microbiome and the host.

Table 1
Summary of the previous studies of the gut microbiome in AD
Click for larger imageClick for full tableDownload as Excel file

In patients with AD, the proportion of Clostridia, Clostridium difficile, Escherichia coli, and Staphylococcus aureus (S. aureus) in the gut microbiome is higher than in healthy controls, whereas that of Bifidobacteria, Bacteroidetes, and Bacteroides is decreased.17, 18, 19, 20, 21 Butyrate-producing bacteria, such as Coprococcus eutactus, are increased in infants with milder AD or healthy infants than in those with severe AD.21 Short-chain fatty acids (SCFAs), including butyrate, propionate, and acetate, have antiinflammatory and immunomodulatory effects, regardless of their interaction with the gut epithelium barrier.22 In addition, the gut microbiome involved in the SCFA pathway was identified to be present at a higher proportion in patients with AD.23 In association with the mechanisms underlying the development of AD, Clostridia and Escherichia coli in the intestine might be associated with AD via eosinophilic inflammation.19

In another study, the presence of specific gut microbiome, such as Akkermansia muciniphila and Ruminococcus gnavus, was associated with alterations in functional genes, which affected the development of the host immune system.23 It is still unclear whether compositional changes in the gut microbiome precede the development of AD, and thereby shift the immune system and disrupt the gut epithelial barrier, making it amenable to the development of AD, or how the pathogenic role of the established gut microbiome contributes to the development of AD. Gut microbiome and its metabolites might manipulate the local immune responses as well as those of the systemic immune system.19, 23

One of the effective therapeutic options for AD involves probiotics, although previous studies on the effects of probiotics in the treatment and prevention of the development of AD failed to draw any firm conclusions.25 However, the restoration of gut microbiome dysbiosis can be considered a therapeutic target for AD from the aspect of the harmonization of the gut microbiome with the subsequent immune responses. Both the independent effect of each environmental factor and the combination of the diverse factors involved might shape the immune system, so that it is liable to develop AD. Therefore, studies of the combined effects of the diverse environmental factors and dynamics of the gut microbiome might be more useful to evaluate the impact of gut microbiome in the development of AD.


Immunologic pathway

AD is a common clinical manifestation that involves 2 major biological pathways: barrier dysfunction and immune response. AD is associated with a T helper (Th) 1/Th2 imbalance, which induces secretion of Th2 cytokines, such as interleukin (IL)-4, IL-5, and IL-13, and leads to higher production of immunoglobulin E (IgE) and increased binding of S. aureus to AD skin.26

The gut microbiome has been studied as an important contributing factor to the immunologic pathway of AD via probiotics. Orally administered probiotics could interact with gastrointestinal mucosa and gut-associated lymphoid tissue (GALT), where more than 70% of immune cells are located.7 Probiotics interact with epithelial cells, mucosal dendritic cells (DCs), and macrophages through diverse ways. Depending on the probiotic strain, they can either induce immune activation signaling by producing IL-12, IL-18, and tumor necrosis factor (TNF)-α or trigger tolerance signaling by stimulating anti-inflammatory cytokines, such as IL-10 and TGF-β.8, 27 In the IL-10/TGF-β-enriched cytokine milieu, DCs and macrophages can enhance the generation of the induced regulatory T (Treg) cells that play key roles in maintaining peripheral immune tolerance by balancing the ratio of effector and Treg cells. Apart from probiotics, alterations in the gut microbiome might affect the development of host immune cell function through differences in gut microbiome genes, particularly in infants with AD.24

S. aureus is the most common pathogen grown from AD skin, and AD flares are associated with S. aureus superantigens. However, a recent birth cohort study showed that gut colonization by S. aureus strains carrying a certain combination of superantigen and adhesion genes was negatively associated with the subsequent development of AD in infancy.28 Such strains may stimulate and promote the maturation of the infant immune system. Even though skin S. aureus may aggravate already established AD, this does not preclude the possibility that commensal mucosal colonization by gut S. aureus prior to the “atopic march” could have a protective effect through the broad immune stimulation afforded by this bacterium.

Studies in humans also indicate the ability of the gut microbiome to enhance skin health outside the context of AD. In a human study, Lactobacillus paracasei supplementation reduced skin sensitivity and transepidermal water loss in healthy adults.29 The authors attributed these effects to an increase in circulating TGF-β because this cytokine has been shown to affect barrier integrity.30 Thus, all of these studies support the concept that the skin and the gut are linked via modulation of the immune environment through the microbiome.

Metabolite pathway

SCFAs produced by the gut microbiome, such as Akkermansia muciniphila,31 play important roles in inflammatory diseases, such as AD, which might explain the association between dietary feeding, microbiome, and the skin immune system.23, 32 Oral administration of metabolites can affect skin disease by influencing their anti-allergic and anti-inflammatory effects.33 In a mouse study, linoleic acid and 10-hydroxy-cis-12-octadecenoic acid alleviated AD and modulated the gut microbiome. In another study, administration of probiotic Bifidobacterium animalis subsp. lactis (LKM512) increased the levels of the metabolite kynurenic acid, which reduced scratching behavior in AD mice.34

A recently published report showed 3 different states of neonatal gut microbiome (NGM) and metabolite function in early allergic sensitization.35 The so-called NGM3 state in that study was related to multiple allergic sensitizations in asthma and lower relative abundance of Bifidobacterium, Akkermansia, and Facalibacterium. In addition, the metabolite 12,13-dihydroxy-9Z-octadecenoic acid (12,13-DiHome), which has proinflammatory immunomodulatory effects in vitro, was enriched in NGM3. Moreover, 12, 13-DiHome was increased in vernix caseosa as a protective layer in human skin.36 The diverse evidence may support the existence of metabolite-mediated gut-skin axis communications (Figure).

Mechanisms of the interaction between the gut and skin microbiomes on AD. AD, atopic dermatitis; GABA, γ-aminobutyric acid; SCFA, short-chain fatty acid; 12,13-DiHome, 12,13-dihydroxy-9Z-octadecenoic acid; Treg, regulatory T; IFN, interferon; IL, interleukin.
Click for larger imageDownload as PowerPoint slide

Neuroendocrine pathway

The emerging data support the presence of a gut-skin axis that is mediated by neuroendocrine molecules produced by the gut microbiome.37, 38 The data suggest that compositional and proportional differences in the gut microbiome are linked to the generation of diverse favorable neurotransmitters and neuromodulators, which are associated with the degree of AD symptoms. They can also affect skin barrier dysfunction and immune system dysregulation, which are the key pathophysiologies in the development of AD.

The gut microbiome can modulate the gut-skin axis through direct and indirect pathways.39 Tryptophan produced by the gut microbiome causes an itching sensation in the skin,37 whereas Lactobacillus species and Bifidobacterium species can produce γ-aminobutyric acid (GABA), which inhibits skin itch.37, 40 Escherichia species and Enterococcus species can produce serotonin, which is involved in skin pigmentation.38, 41

Indirectly, the gut microbiome can modulate cytokine levels in the bloodstream and thereby affect brain function, anxiety, and stress.39 Cortisol, usually released under stress conditions, can change gut epithelium permeability and barrier function by altering the composition of the gut microbiome.38 This also alters the levels of circulating neuroendocrine molecules, such as tryptamine, trimethylamine, and serotonin, and thereby modifies the skin barrier and skin inflammation.37, 42 These neuroendocrine molecules might be considered future therapeutics for AD (Figure).


Skin microbiome and AD

Chronic inflammation in the skin, such as in AD, exacerbates skin barrier impairment and is associated with abnormalities in the functions of skin barrier-associated genes.43, 44, 45 Skin microbiomes can influence the skin barrier by controlling ecological factors, such as humidity, temperature, pH, and lipid content.46 Previous research has shown that a compositional change in the skin microbiome influences the development and degree of symptoms of AD via allergic inflammation.47 Dysbiosis of the skin commensal microbiome may contribute to the disruption of immune homeostasis in the skin and promote the development of skin diseases, such as AD.48 Previous studies have found that the skin microbiome is associated with age, lesion of AD, and bacterial composition rate of AD lesion (Table 2). Therefore, determination of whether the skin microbiome plays a role in the initiation of AD could help reduce its development.

Table 2
Summary of the previous studies on the skin microbiome in AD
Click for larger imageClick for full tableDownload as Excel file

In general, the skin microbiome comprises up to 107 microorganisms per cm2, primarily Propionibacteria, Streptococcus, Staphylococcus, and Corynebacterium.49 Above all, the results of many studies have shown that AD patients have a higher proportion of S. aureus in the skin microbiome compared with healthy controls.48, 50, 51 In AD patients frequently inflamed with S. aureus, the expression levels of proinflammatory cytokine genes, including IL-4, IL-13, and thymic stromal lymphopoietin (TSLP), are stimulated and the Th1/Th2 immune response is induced.50, 52 Colonization with S. aureus could impair the suppressive activity of Treg cells.53, 54 In addition, the presence of S. aureus in the skin is related to a high IgE response.53 These findings show that S. aureus flares in the skin exacerbate the skin disease by further promoting inflammation. In addition, in patients with AD, marked reductions in skin microbial diversity occur during disease flares and effective treatment restores diversity to the skin bacterial community. Flares are characterized by increased abundance of pathogenic S. aureus.55, 56

Most studies of the skin microbiome in AD have focused on S. aureus, and a few studies have shown that Staphylococcus epidermidis can inhibit the growth of S. aureus; additionally, colonization with S. epidermidis and S. cohnii reduced the development of AD in children at age 1.56, 57

However, in recent studies, skin immunity was differentially affected by the time of S. aureus appearance. In a mouse model, cutaneous exposure to commensal bacteria early in life induced tolerance to S. aureus.58 Another birth cohort study showed a difference in staphylococcal colonization, namely fewer Staphylococcus species, at a site of AD predilection that was later affected by AD.47 These observations suggesting that the timing of exposure to commensal bacteria influences the development of tolerance prompted us to explore how neonatal and adult skin differs with respect to the resident immune cell populations. Neonatal skin Treg cells are more activated and abundant than their adult counterparts, constitute the majority of T cells in the skin during this key developmental window, and are unique to the skin versus another key barrier site, the gut.59 As long as exposure to various food antigens at younger ages causes tolerance, exposure to S. aureus at an early age on the skin may help induce tolerance because gut exposure to diverse food antigens at a younger age causes tolerance.

To confirm the characterization of community function and genomes, metagenome shotgun analysis of human skin was needed. A skin metagenome shotgun study showed an interaction between biogeography and individuality shape function in human skin60 as well as a cross-modulated interaction between skin microbial communities, the skin surface microenvironment, and the immune system in AD flares.61 AD-associated microbiomes can increase the risk of flares by influencing the skin surface microenvironment and through an interaction with the host immune system. Future functional studies of the skin microbiome at the metatranscriptomic, metaproteomic, and metabolic levels are vital for our understanding of AD mechanisms and may identify future therapeutic targets of the microbiome in AD and skin health maintenance.

The effects of skin immunity on systemic and intestinal immunity

Studies of the effects of skin immunity on the gut and systemic immunity have been performed in the food allergy field, but not for AD. Food allergy and AD are closely related, and, epidemiologic studies have shown that AD-associated cutaneous inflammation is a significant risk factor for the development of food allergy.62, 63 Exposure to food allergens via the cutaneous route and its extremely efficient antigen-presenting cells, before exposure via the oral route, bypasses oral tolerance. Thus, when the gut does get exposed to food allergens, this previous sensitization by the cutaneous route leads to symptoms associated with food allergy.64 The immunologic mechanisms by which antigen sensitization in the skin can predispose the gut to allergic inflammation are incompletely understood, but a recent animal study showed that epicutaneous sensitization on a disrupted skin barrier is associated with accumulation of TSLP-elicited basophils and DCs, which are necessary and sufficient to promote antigen-induced food allergies.65 Injured epithelial cells may also release IL-33 to activate ST2-expressing skin DCs.66 TSLP-activated DCs migrate to draining lymph nodes, which in turn induce naïve CD4+ T cells to differentiate into CD4+ Th2 cells and maintain CD4+ Th2 effector/memory pools.67 Gut IL-25 propagates the allergic immune response by enhancing collaborative interactions between resident type 2 innate lymphoid cells and CD4+ Th2 cells expanded by ingested antigens in the gut.68 IL-4 signaling provided by CD4+ Th2 cells induces emigrated mast cell progenitors to become multifunctional IL-9-producing mucosal mast cells, which then expand greatly after repeated food antigen exposure.69

On the other hand, cutaneous exposure, such as epicutaneous immunotherapy (EPIT), may be used to treat food allergy. EPIT is a novel experimental method that attempts to induce tolerance in allergic patients by delivering low concentrations of food allergens through healthy skin. In milk-sensitized mice, EPIT induced milk-specific Treg cells that subsequently promoted tolerance to cutaneously administered peanuts and house dust mites.70 The results are similar to those of subcutaneous and sublingual routes of inhalant allergen exposure, where allergen tolerance is attributed to the induction of Treg cells and IL-10.71

How the same skin exposure can either induce intestinal sensitization or cause immune tolerance has not been elucidated. However, differences in exposure time and the presence of microorganisms in the skin or gut are likely to be involved and need to be examined further.


Here, we explored the current evidence for the existence of a translationally relevant gut-skin axis. The roles played by the gut and skin microbiome have recently been revisited and abundant evidence suggests that host-microbiome interactions can actually determine the status of health and AD. It is unclear whether changes in the microbiome at one organ site affect distal organs or different organ sites and whether these systemic effects might be specific for certain tissues or organs, and the mechanisms involved. To date, no broad study investigating these systemic widespread effects has been performed.

S. aureus species of the skin microbiome play key roles in the development and establishment of AD, but the proportional differences among other skin microbes are implicated in AD development. Therefore, extensive research is required to identify the interactions between the skin microbiomes or between the gut and skin microbiomes and how the mechanisms involved influence the development of AD dysbiosis. Moreover, additional investigations are needed to confirm that AD dysbiosis through the skin microbiome affects the skin response and systemic immune response in AD. It is also unclear whether S. aureus species or other microbes may have some function in the gut.

The compositional and proportional differences in the gut microbiome are associated with the development of AD via an immunomodulatory effect of the gut microbiome. The gut microbiome may contribute to the development, persistence, and severity of AD via immunologic, metabolic, and neuroendocrine pathways. To identify the in-depth role of the gut or skin microbiome in the development of AD, studies should investigate both the gut and skin microbiome and the diverse pathways involved in cross-talk between the gut or skin microbiome and the immune system.

Metagenomic analyses in humans and animals clearly demonstrated that AD is associated with the dysbiosis of the gut and skin microbiome. However, causal relationships between microbiome and AD have rarely been elucidated. In this regard, microbiome, metatranscriptomic, metagenomic, and metabolomic analyses can be promising tools for understanding the etiology and increasing prevalence of AD in recent decades. Furthermore, identification of novel microbial genes and molecular pathways capable of modulating mucosal Th responses might be immensely helpful in achieving in-depth understanding of the origin of AD.


There are no financial or other issues that might lead to conflict of interest.


This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2014R1A2A1A10050687) and a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI14C2687).

1. Dharmage SC, Lowe AJ, Matheson MC, Burgess JA, Allen KJ, Abramson MJ. Atopic dermatitis and the atopic march revisited. Allergy 2014;69:17–27.
2. Flohr C, Mann J. New insights into the epidemiology of childhood atopic dermatitis. Allergy 2014;69:3–16.
3. Lee SY, Yu J, Ahn KM, Kim KW, Shin YH, Lee KS, et al. Additive effect between IL-13 polymorphism and cesarean section delivery/prenatal antibiotics use on atopic dermatitis: a birth cohort study (COCOA). PLoS One 2014;9:e96603
4. Lee JY, Seo JH, Kwon JW, Yu J, Kim BJ, Lee SY, et al. Exposure to gene-environment interactions before 1 year of age may favor the development of atopic dermatitis. Int Arch Allergy Immunol 2012;157:363–371.
5. Kim BJ, Lee SY, Kim HB, Lee E, Hong SJ. Environmental changes, microbiota, and allergic diseases. Allergy Asthma Immunol Res 2014;6:389–400.
6. Al-Asmakh M, Zadjali F. Use of germ-free animal models in microbiota-related research. J Microbiol Biotechnol 2015;25:1583–1588.
7. Lebeer S, Vanderleyden J, De Keersmaecker SC. Host interactions of probiotic bacterial surface molecules: comparison with commensals and pathogens. Nat Rev Microbiol 2010;8:171–184.
8. Ueno N, Fujiya M, Segawa S, Nata T, Moriichi K, Tanabe H, et al. Heat-killed body of lactobacillus brevis SBC8803 ameliorates intestinal injury in a murine model of colitis by enhancing the intestinal barrier function. Inflamm Bowel Dis 2011;17:2235–2250.
9. Peng Y, Li A, Yu L, Qin G. The role of probiotics in prevention and treatment for patients with allergic rhinitis: a systematic review. Am J Rhinol Allergy 2015;29:292–298.
10. Kim SO, Ah YM, Yu YM, Choi KH, Shin WG, Lee JY. Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials. Ann Allergy Asthma Immunol 2014;113:217–226.
11. Rather IA, Bajpai VK, Kumar S, Lim J, Paek WK, Park YH. Probiotics and atopic dermatitis: an overview. Front Microbiol 2016;7:507
12. Levkovich T, Poutahidis T, Smillie C, Varian BJ, Ibrahim YM, Lakritz JR, et al. Probiotic bacteria induce a ‘glow of health’. PLoS One 2013;8:e53867
13. Olszak T, An D, Zeissig S, Vera MP, Richter J, Franke A, et al. Microbial exposure during early life has persistent effects on natural killer T cell function. Science 2012;336:489–493.
14. Arpaia N, Campbell C, Fan X, Dikiy S, van der Veeken J, deRoos P, et al. Metabolites produced by commensal bacteria promote peripheral regulatory T-cell generation. Nature 2013;504:451–455.
15. Zeng MY, Inohara N, Nuñez G. Mechanisms of inflammation-driven bacterial dysbiosis in the gut. Mucosal Immunol 2017;10:18–26.
16. Gensollen T, Blumberg RS. Correlation between early-life regulation of the immune system by microbiota and allergy development. J Allergy Clin Immunol 2017;139:1084–1091.
17. Abrahamsson TR, Jakobsson HE, Andersson AF, Björkstén B, Engstrand L, Jenmalm MC. Low diversity of the gut microbiota in infants with atopic eczema. J Allergy Clin Immunol 2012;129:434–440. 440.e1–440.e2.
18. Penders J, Stobberingh EE, Thijs C, Adams H, Vink C, van Ree R, et al. Molecular fingerprinting of the intestinal microbiota of infants in whom atopic eczema was or was not developing. Clin Exp Allergy 2006;36:1602–1608.
19. Lee E, Lee SY, Kang MJ, Kim K, Won S, Kim BJ, et al. Clostridia in the gut and onset of atopic dermatitis via eosinophilic inflammation. Ann Allergy Asthma Immunol 2016;117:91–92.e1.
20. Kirjavainen PV, Arvola T, Salminen SJ, Isolauri E. Aberrant composition of gut microbiota of allergic infants: a target of bifidobacterial therapy at weaning? Gut 2002;51:51–55.
21. Nylund L, Nermes M, Isolauri E, Salminen S, de Vos WM, Satokari R. Severity of atopic disease inversely correlates with intestinal microbiota diversity and butyrate-producing bacteria. Allergy 2015;70:241–244.
22. Smith PM, Howitt MR, Panikov N, Michaud M, Gallini CA, Bohlooly-Y M, et al. The microbial metabolites, short-chain fatty acids, regulate colonic Treg cell homeostasis. Science 2013;341:569–573.
23. Song H, Yoo Y, Hwang J, Na YC, Kim HS. Faecalibacterium prausnitzii subspecies-level dysbiosis in the human gut microbiome underlying atopic dermatitis. J Allergy Clin Immunol 2016;137:852–860.
24. Lee MJ, Kang MJ, Lee SY, Lee E, Kim K, Won S, et al. Perturbations of the gut microbiome genes in infants with atopic dermatitis according to feeding type. J Allergy Clin Immunol 2018;141:1310–1319.
25. Chang YS, Trivedi MK, Jha A, Lin YF, Dimaano L, García-Romero MT. Synbiotics for prevention and treatment of atopic dermatitis: a meta-analysis of randomized clinical trials. JAMA Pediatr 2016;170:236–242.
26. Huang YJ, Marsland BJ, Bunyavanich S, O'Mahony L, Leung DY, Muraro A, et al. The microbiome in allergic disease: current understanding and future opportunities-2017 PRACTALL document of the American Academy of Allergy, Asthma & Immunology and the European Academy of Allergy and Clinical Immunology. J Allergy Clin Immunol 2017;139:1099–1110.
27. Smits HH, Engering A, van der Kleij D, de Jong EC, Schipper K, van Capel TM, et al. Selective probiotic bacteria induce IL-10-producing regulatory T cells in vitro by modulating dendritic cell function through dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin. J Allergy Clin Immunol 2005;115:1260–1267.
28. Nowrouzian FL, Lina G, Hodille E, Lindberg E, Hesselmar B, Saalman R, et al. Superantigens and adhesins of infant gut commensal Staphylococcus aureus strains and association with subsequent development of atopic eczema. Br J Dermatol 2017;176:439–445.
29. Gueniche A, Philippe D, Bastien P, Reuteler G, Blum S, Castiel-Higounenc I, et al. Randomised double-blind placebo-controlled study of the effect of Lactobacillus paracasei NCC 2461 on skin reactivity. Benef Microbes 2014;5:137–145.
30. Hashimoto K. Regulation of keratinocyte function by growth factors. J Dermatol Sci 2000;24 Suppl 1:S46–S50.
31. Reichardt N, Duncan SH, Young P, Belenguer A, McWilliam Leitch C, Scott KP, et al. Phylogenetic distribution of three pathways for propionate production within the human gut microbiota. ISME J 2014;8:1323–1335.
32. Thorburn AN, Macia L, Mackay CR. Diet, metabolites, and “western-lifestyle” inflammatory diseases. Immunity 2014;40:833–842.
33. Kaikiri H, Miyamoto J, Kawakami T, Park SB, Kitamura N, Kishino S, et al. Supplemental feeding of a gut microbial metabolite of linoleic acid, 10-hydroxy-cis-12-octadecenoic acid, alleviates spontaneous atopic dermatitis and modulates intestinal microbiota in NC/nga mice. Int J Food Sci Nutr 2017;68:941–951.
34. Matsumoto M, Ebata T, Hirooka J, Hosoya R, Inoue N, Itami S, et al. Antipruritic effects of the probiotic strain LKM512 in adults with atopic dermatitis. Ann Allergy Asthma Immunol 2014;113:209–216.e7.
35. Fujimura KE, Sitarik AR, Havstad S, Lin DL, Levan S, Fadrosh D, et al. Neonatal gut microbiota associates with childhood multisensitized atopy and T cell differentiation. Nat Med 2016;22:1187–1191.
36. Checa A, Holm T, Sjödin MO, Reinke SN, Alm J, Scheynius A, et al. Lipid mediator profile in vernix caseosa reflects skin barrier development. Sci Rep 2015;5:15740
37. Jin UH, Lee SO, Sridharan G, Lee K, Davidson LA, Jayaraman A, et al. Microbiome-derived tryptophan metabolites and their aryl hydrocarbon receptor-dependent agonist and antagonist activities. Mol Pharmacol 2014;85:777–788.
38. Cryan JF, Dinan TG. Mind-altering microorganisms: the impact of the gut microbiota on brain and behaviour. Nat Rev Neurosci 2012;13:701–712.
39. Yokoyama S, Hiramoto K, Koyama M, Ooi K. Impairment of skin barrier function via cholinergic signal transduction in a dextran sulphate sodium-induced colitis mouse model. Exp Dermatol 2015;24:779–784.
40. Akiyama T, Iodi Carstens M, Carstens E. Transmitters and pathways mediating inhibition of spinal itch-signaling neurons by scratching and other counterstimuli. PLoS One 2011;6:e22665
41. Lee HJ, Park MK, Kim SY, Park Choo HY, Lee AY, Lee CH. Serotonin induces melanogenesis via serotonin receptor 2A. Br J Dermatol 2011;165:1344–1348.
42. O'Neill CA, Monteleone G, McLaughlin JT, Paus R. The gut-skin axis in health and disease: A paradigm with therapeutic implications. BioEssays 2016;38:1167–1176.
43. Eyerich K, Novak N. Immunology of atopic eczema: overcoming the Th1/Th2 paradigm. Allergy 2013;68:974–982.
44. Smith FJ, Irvine AD, Terron-Kwiatkowski A, Sandilands A, Campbell LE, Zhao Y, et al. Loss-of-function mutations in the gene encoding filaggrin cause ichthyosis vulgaris. Nat Genet 2006;38:337–342.
45. Seite S, Bieber T. Barrier function and microbiotic dysbiosis in atopic dermatitis. Clin Cosmet Investig Dermatol 2015;8:479–483.
46. Grice EA, Kong HH, Conlan S, Deming CB, Davis J, Young AC, et al. Topographical and temporal diversity of the human skin microbiome. Science 2009;324:1190–1192.
47. Kennedy EA, Connolly J, Hourihane JO, Fallon PG, McLean WH, Murray D, et al. Skin microbiome before development of atopic dermatitis: early colonization with commensal staphylococci at 2 months is associated with a lower risk of atopic dermatitis at 1 year. J Allergy Clin Immunol 2017;139:166–172.
48. Nakatsuji T, Chen TH, Narala S, Chun KA, Two AM, Yun T, et al. Antimicrobials from human skin commensal bacteria protect against Staphylococcus aureus and are deficient in atopic dermatitis. Sci Transl Med 2017;9:eaah4680
49. Thomas CL, Fernández-Peñas P. The microbiome and atopic eczema: more than skin deep. Australas J Dermatol 2017;58:18–24.
50. Jun SH, Lee JH, Kim SI, Choi CW, Park TI, Jung HR, et al. Staphylococcus aureus-derived membrane vesicles exacerbate skin inflammation in atopic dermatitis. Clin Exp Allergy 2017;47:85–96.
51. Oh J, Freeman AF, Park M, Sokolic R, Candotti F, Holland SM, et al. The altered landscape of the human skin microbiome in patients with primary immunodeficiencies. Genome Res 2013;23:2103–2114.
52. Nakatsuji T, Chen TH, Two AM, Chun KA, Narala S, Geha RS, et al. Staphylococcus aureus exploits epidermal barrier defects in atopic dermatitis to trigger cytokine expression. J Invest Dermatol 2016;136:2192–2200.
53. Laborel-Préneron E, Bianchi P, Boralevi F, Lehours P, Fraysse F, Morice-Picard F, et al. Effects of the Staphylococcus aureus and Staphylococcus epidermidis secretomes isolated from the skin microbiota of atopic children on CD4+ T cell activation. PLoS One 2015;10:e0141067
54. Martin H, Laborel-Préneron E, Fraysse F, Nguyen T, Schmitt AM, Redoulès D, et al. Aquaphilus dolomiae extract counteracts the effects of cutaneous S. aureus secretome isolated from atopic children on CD4+ T cell activation. Pharm Biol 2016;54:2782–2785.
55. Kim MH, Rho M, Choi JP, Choi HI, Park HK, Song WJ, et al. A Metagenomic Analysis Provides a Culture-Independent Pathogen Detection for Atopic Dermatitis. Allergy Asthma Immunol Res 2017;9:453–461.
56. Kong HH, Oh J, Deming C, Conlan S, Grice EA, Beatson MA, et al. Temporal shifts in the skin microbiome associated with disease flares and treatment in children with atopic dermatitis. Genome Res 2012;22:850–859.
57. Iwase T, Uehara Y, Shinji H, Tajima A, Seo H, Takada K, et al. Staphylococcus epidermidis Esp inhibits Staphylococcus aureus biofilm formation and nasal colonization. Nature 2010;465:346–349.
58. Kobayashi T, Glatz M, Horiuchi K, Kawasaki H, Akiyama H, Kaplan DH, et al. Dysbiosis and Staphylococcus aureus colonization drives inflammation in atopic dermatitis. Immunity 2015;42:756–766.
59. Scharschmidt TC, Vasquez KS, Truong HA, Gearty SV, Pauli ML, Nosbaum A, et al. A wave of regulatory T cells into neonatal skin mediates tolerance to commensal microbes. Immunity 2015;43:1011–1021.
60. Oh J, Byrd AL, Deming C, Conlan S, Kong HH, Segre JA. NISC Comparative Sequencing Program. Biogeography and individuality shape function in the human skin metagenome. Nature 2014;514:59–64.
61. Chng KR, Tay AS, Li C, Ng AH, Wang J, Suri BK, et al. Whole metagenome profiling reveals skin microbiome-dependent susceptibility to atopic dermatitis flare. New Microbiol 2016;1:16106.
62. Lack G, Fox D, Northstone K, Golding J. Avon Longitudinal Study of Parents and Children Study Team. Factors associated with the development of peanut allergy in childhood. N Engl J Med 2003;348:977–985.
63. Kelleher MM, Dunn-Galvin A, Gray C, Murray DM, Kiely M, Kenny L, et al. Skin barrier impairment at birth predicts food allergy at 2 years of age. J Allergy Clin Immunol 2016;137:1111–1116.e8.
64. Bartnikas LM, Gurish MF, Burton OT, Leisten S, Janssen E, Oettgen HC, et al. Epicutaneous sensitization results in IgE-dependent intestinal mast cell expansion and food-induced anaphylaxis. J Allergy Clin Immunol 2013;131:451–460.e1-6.
65. Noti M, Kim BS, Siracusa MC, Rak GD, Kubo M, Moghaddam AE, et al. Exposure to food allergens through inflamed skin promotes intestinal food allergy through the thymic stromal lymphopoietinbasophil axis. J Allergy Clin Immunol 2014;133:1390–1399. 1399.e1–1399.e6.
66. Galand C, Leyva-Castillo JM, Yoon J, Han A, Lee MS, McKenzie AN, et al. IL-33 promotes food anaphylaxis in epicutaneously sensitized mice by targeting mast cells. J Allergy Clin Immunol 2016;138:1356–1366.
67. Wang Q, Du J, Zhu J, Yang X, Zhou B. Thymic stromal lymphopoietin signaling in CD4(+) T cells is required for TH2 memory. J Allergy Clin Immunol 2015;135:781–791.e3.
68. Lee JB, Chen CY, Liu B, Mugge L, Angkasekwinai P, Facchinetti V, et al. IL-25 and CD4(+) TH2 cells enhance type 2 innate lymphoid cellderived IL-13 production, which promotes IgE-mediated experimental food allergy. J Allergy Clin Immunol 2016;137:1216–1225.e5.
69. Chen CY, Lee JB, Liu B, Ohta S, Wang PY, Kartashov AV, et al. Induction of interleukin-9-producing mucosal mast cells promotes susceptibility to IgE-mediated experimental food allergy. Immunity 2015;43:788–802.
70. Mondoulet L, Dioszeghy V, Puteaux E, Ligouis M, Dhelft V, Plaquet C, et al. Specific epicutaneous immunotherapy prevents sensitization to new allergens in a murine model. J Allergy Clin Immunol 2015;135:1546–1557.e4.
71. Akbari O, DeKruyff RH, Umetsu DT. Pulmonary dendritic cells producing IL-10 mediate tolerance induced by respiratory exposure to antigen. Nat Immunol 2001;2:725–731.
72. Watanabe S, Narisawa Y, Arase S, Okamatsu H, Ikenaga T, Tajiri Y, et al. Differences in fecal microflora between patients with atopic dermatitis and healthy control subjects. J Allergy Clin Immunol 2003;111:587–591.
73. Mah KW, Björkstén B, Lee BW, van Bever HP, Shek LP, Tan TN, et al. Distinct pattern of commensal gut microbiota in toddlers with eczema. Int Arch Allergy Immunol 2006;140:157–163.
74. Penders J, Thijs C, van den Brandt PA, Kummeling I, Snijders B, Stelma F, et al. Gut microbiota composition and development of atopic manifestations in infancy: the KOALA Birth Cohort Study. Gut 2007;56:661–667.
75. van Nimwegen FA, Penders J, Stobberingh EE, Postma DS, Koppelman GH, Kerkhof M, et al. Mode and place of delivery, gastrointestinal microbiota, and their influence on asthma and atopy. J Allergy Clin Immunol 2011;128:948–955.e1-3.
76. Penders J, Gerhold K, Stobberingh EE, Thijs C, Zimmermann K, Lau S, et al. Establishment of the intestinal microbiota and its role for atopic dermatitis in early childhood. J Allergy Clin Immunol 2013;132:601–607.e8.
77. Shi B, Bangayan NJ, Curd E, Taylor PA, Gallo RL, Leung DY, et al. The skin microbiome is different in pediatric versus adult atopic dermatitis. J Allergy Clin Immunol 2016;138:1233–1236.
78. Drago L, De Grandi R, Altomare G, Pigatto P, Rossi O, Toscano M. Skin microbiota of first cousins affected by psoriasis and atopic dermatitis. Clin Mol Allergy 2016;14:2