PROBIOTIC PHARMACEUTICAL COMPOSITION

Description

[0001] The invention relates to a pharmaceutical composition, a water bath containing the pharmaceutical composition, and a method for producing the water bath. Background of the invention

[0002] Both the intestinal and dermal microbiomes are important for human health. The intestinal microbiome influences numerous immune functions and is likely involved in the development of atopic diseases. Furthermore, interactions between dermal microorganisms and the specific immune system are also known. In recent years, the effects of probiotics and prebiotics have been extensively studied. It has been shown that both internal and external application of probiotic or prebiotic preparations could be effective in the treatment of atopic diseases.

[0003] Atopic dermatitis (AD) is a chronic or chronically relapsing, non-contagious skin disease whose classic morphology and location vary depending on age and which is usually accompanied by intense itching. The course of the disease is variable, and symptoms often occur in flare-ups that can vary in duration and severity. They are characterized by dry skin with reddened, inflamed areas (eczema), widespread thickening and coarsening of the skin (lichenification), as well as nodules and pustules (prurito nodules).

[0004] In infancy, eczema typically appears on the extensor surfaces of the arms and legs, face, and head. Older children and adults often develop flexural eczema in the elbows or behind the knees. Depending on activities that put stress on the skin, hand eczema can also occur.

[0005] According to healthcare epidemiology analyses from Germany, around 23% of infants and toddlers, 8% of school children and 2-4% of adults use healthcare services due to atopic dermatitis.

[0006] Atopic dermatitis (AD) is a complex disease with diverse causes. Various genetic factors can act as predisposing factors, with alterations in genes associated with the skin's barrier function playing a particularly important role, such as loss-of-function mutations of the filaggrin gene. The gene product filaggrin plays a crucial role in the transformation of keratinocytes into corneocytes. Filaggrin cleavage products also ensure water retention and maintain the low pH of the stratum corneum.

[0007] Furthermore, environmental influences resulting from life in industrialized countries, especially in urbanized areas, are discussed, including the influence of air pollution such as car exhaust, but also the predominant living in enclosed and heated spaces, the lower microbial exposure and an excessive use of soaps and cleansing cosmetics.

[0008] The interplay of the different factors leads to an impairment of the skin's barrier function and a dysregulation of the immune system, although it is not entirely clear how the two effects mutually influence each other.

[0009] A disease flare is likely triggered when antigen-presenting cells (Langerhans cells) bind antigens to their cell membrane and then present them to CD4+ T cells via MHC class 2 receptors. The activated APCs (antigen-presenting cells) secrete interleukin 4 (IL-4), which induces the differentiation of TH0 cells into TH2 cells and their clonal proliferation. Subsequently, TH2 cells synthesize the characteristic cytokines IL-4 and IL-13, which in turn cause the differentiation of naïve B cells into IgG4 / IgE-producing memory B cells and their clonal expansion. AD patients have an increased number of activated T cells in their blood. The circulating T cells are predominantly CD4+ T cells; the number of CD8+ cells is not elevated or is even slightly reduced.

[0010] The induction of the cytokines IL-4, IL-13, and also IL-31 leads to the downregulation of the expression of filaggrin and the keratinocyte protein loricin, which further impairs corneocyte function and the skin barrier.

[0011] The dermal microbiome interacts with skin immune cells, thereby modulating the function of the dermal immune system. Like other inflammatory skin diseases such as acne, atopic dermatitis (AD) is also associated with dermal dysbiosis. During an acute flare-up, a significantly reduced diversity and altered species distribution of the dermal microbiome can be observed, which is then frequently dominated by Staphylococcus aureus. The degree of colonization correlates with the severity of the disease (Geoghegan et al., Staphylococcus aureus and Atopic Dermatitis: A Complex and Evolving Relationship, Trends Microbiol., 2018; 26(6): 484-97).

[0012] Atopic dermatitis has a high prevalence and is often associated with a significant reduction in quality of life. In many patients, the condition persists beyond childhood, necessitating long-term therapy.

[0013] Against this backdrop, the search for innovative therapies and supportive measures with few side effects is urgently needed. Probiotics represent a promising approach in this regard, because, like other inflammatory skin diseases such as acne, atopic dermatitis is also associated with dermal and intestinal dysbiosis.

[0014] In recent years, an increasing number of studies have been conducted on the oral administration of pre-, pro- and synbiotics, which, according to meta-analyses, have shown predominantly positive effects.

[0015] The topical application of probiotic preparations has been far less thoroughly investigated. An open-label phase I / II study demonstrated that the topical application of Roseomonas mucosa isolated from healthy donors resulted in a significant improvement in symptoms. The need for steroid use and the colonization of the skin with S. aureus were also reduced (Myles et al., First-in-human topical microbiome transplantation with Roseomonas mucosa for atopic dermatitis, JCI Insight, 2018, 3(9)).

[0016] In a single-blind, randomized, placebo-controlled study, the topical application of a probiotic dietary supplement, administered as a bath or partial bath, was investigated. Study participants assessed their overall skin condition as well as the symptoms of itching, scaling, dryness, and the severity of fissures / excoriations. Furthermore, participants rated the limitations in their daily lives resulting from the condition. Improvement was observed for all parameters after 7 days and throughout the entire 14-day treatment period. However, it was noted that further studies are needed to identify suitable bacterial strains and to obtain more information on dosage and mechanisms of action (Axt-Gadermann, Significant Improvement of Skin Conditions in Atopic Dermatitis by Synbiotic Bath Additives, Akt Dermatol, 2018, 44: 1-8).

[0017] EP 2 228 067 A1 discloses a pharmaceutical composition for use in the prevention and treatment of atopic dermatitis, which contains probiotic microorganisms from the group consisting of Lactobacillus, Bifidobacterium and Streptococcus, and also a prebiotic compound.

[0018] EP 3 484 585 B1 also describes a probiotic composition with bacteria of the genera Lactobacillus and Bifidobacter, which is used to treat neurodermatitis and may additionally contain maltodextrin.

[0019] EP 3 176 175 A1 discloses compositions containing L-arabinogalactosides and probiotic bacterial strains such as bifidobacteria, which can also be used to treat atopic dermatitis.

[0020] BR 1020 1900 6837 A2 describes a cosmetic composition for the treatment of neurodermatitis, comprising lactobacilli.

[0021] WO 2016 / 149687 A1 discloses a pharmaceutical composition for topical use in the treatment of atopic dermatitis. The composition may contain Lactobacillus and Streptococcus and prebiotics such as pectin or inulin.

[0022] WO 2019 / 180748 A1 describes a probiotic formulation for topical application as an anti-acne agent. These are used in concentrations between 10⁶ < kbE and 10¹⁴ < kbE.

[0023] CN 111 374 896 A further discloses a prebiotic and probiotic composition for the treatment of acne. The composition contains bacterial strains of the genera Bifidobacterium, Lactobacillus, and Streptococcus, and a prebiotic component such as inulin.

[0024] CN 104 839 654 A concerns a composition containing a prebiotic such as inulin or starch, as well as a probiotic from the genera Bifidobacterium and Lactobacillus, and which can also be used to treat acne.

[0025] CN 111 568 846 A describes inulin as a prebiotic for the treatment of acne.

[0026] WO 2020 / 234867 A1 discloses compositions that can be used to treat acne and atopic dermatitis and include probiotic microorganisms such as Lactobacillus, Bifidobacterium and Streptococcus.

[0027] WO 2020 / 120670 A1 concerns a topical formulation also for the treatment of acne or atopic dermatitis, which may contain probiotic bacteria from the genera Lactobacillus, Bifidobacterium or Streptococcus.

[0028] Therefore, there is a need for the development of topically applicable probiotic, prebiotic, and synbiotic compositions that can be used to treat skin diseases. Accordingly, the object of the present invention is to provide a pharmaceutical composition that can be used to treat skin diseases such as atopic dermatitis or acne and that leads to a significant improvement in the respective symptoms. Summary of the invention

[0029] The above-mentioned problem is solved by the present invention as defined in the pending claims 1-7.

[0030] The present invention relates to a pharmaceutical composition for use in the treatment of atopic dermatitis, comprising a probiotic, wherein the probiotic comprises the microorganisms Lactobacillus paracasei, Bifidobacterium longum, Streptococcus thermophilus, Lactobacillus johnsonii, Lactobacillus reuteri, Lactobacillus plantarum, Lactobacillus gasseri, Lactobacillus rhamnosus, and Bifidobacterium lactis. Furthermore, the total concentration of the microorganisms in the composition can be in the range of 0.2 x 10⁹ CFU / g to 3.0 x 10⁹ CFU / g (CFU = colony-forming units), optionally in the range of 0.6 x 10⁹ CFU / g to 2.4 x 10⁹ CFU / g, and further optionally in the range of 1.0 x 10⁹ The number of KbE / g should be between 2.0 x 10 9< KbE / g or approximately 1.8 x 10 9< KbE / g.

[0031] Furthermore, the pharmaceutical composition may include a prebiotic, preferably selected from the group consisting of inulin, maltodextrin, pectin, and resistant starch. The prebiotic in the pharmaceutical composition is particularly preferred to be inulin and / or maltodextrin.

[0032] Also disclosed is a pharmaceutical composition comprising a synbiotic, wherein the synbiotic comprises a probiotic and a prebiotic as defined above.

[0033] The aforementioned pharmaceutical compositions may be available as topical dosage forms, in particular as creams, ointments or oils, or as bath additives.

[0034] The invention further relates to a water bath comprising 0.5 g to 10 g, optionally 1.0 g to 8.0 g, further optionally 2.0 g to 6.0 g, or optionally 2.5 g or 5.0 g of a pharmaceutical composition as defined above per liter of water.

[0035] Furthermore, a method for producing the water bath is provided, comprising mixing the pharmaceutical composition defined above with water, such that the bath has a concentration of the composition of 0.5 g to 10 g per liter of water.

[0036] Furthermore, the pharmaceutical composition or water bath defined above can be used in the treatment of atopic dermatitis.

[0037] It is also revealed that the pharmaceutical composition defined above can be used in the treatment of atopic dermatitis, wherein the microorganisms are selected from the group consisting of Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium lactis, Bifidobacterium longum, Bifidobacterium longum subsp. Infantis, Lactobacillus johnsonii, Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus bulgaricus, Lactobacillus casei, Lactobacillus fermentum, Lactobacillus gasseri, Lactobacillus paracasei, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rhamnosus (ATCC 53103), Lactobacillus rhamnosus, Lactobacillus salivariusLs, Lactococcus lactis, Streptococcus thermophilus, Streptococcus salivarius, Enterococcus faecalis, Enterococcus faecium, Saccharomyces boulardii, Saccharomyces cerevisiae and / or E. coli.Furthermore, the microorganisms may be selected from the group consisting of Lactobacillus paracasei, Bifidobacterium longum, Streptococcus thermophilus, Lactobacillus johnsonii, Lactobacillus reuteri, Lactobacillus plantarum, Lactobacillus gasseri, Lactobacillus rhamnosus and Bifidobacterium lactis.

[0038] It is also revealed that the pharmaceutical composition defined above can be used in the treatment of acne, wherein the microorganisms are selected from the group consisting of Streptococcus salivarius, Lactococcus spp., Streptococcus thermophilus, Lactobacillus delbrueckii, Lactobacillus plantarum, Lactobacillus paracasei, Lactobacillus acidophilus, Bifidobacterium adolescentis, and / or Bifidobacterium animalis. Description of the characters

[0039] For all figures, the means were compared using one-way ANOVA, and significant changes over time (p < 0.05) are marked with an asterisk. The descriptive statistics can be found in the respective tables in the example. Figure 1 : Representation of the SCORAD on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B), and for the total population (C). Figure 2 : Representation of the local SCORAD on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B), respectively, and for the total population of 25 (C). Figure 3 : Assessment of the symptom erythema on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 4: Assessment of the symptom excoriation on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 5 : Assessment of the symptom edema on days 0, 7 and 14 for the treatment groups who received a partial bath at low dose (A) or high dose (B) or for the total population (C). Figure 6 : Assessment of the symptom of crust formation on days 0, 7 and 14 for the treatment groups that received a partial bath in low dosage (A) or high dosage (B) or for the total population (C). Figure 7 : Assessment of the symptom lichenification on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 8: Assessment of the symptom of dryness on days 0, 7 and 14 for the treatment groups who received a partial bath at low dose (A) or high dose (B) or for the total population (C). Figure 9 : Participant questionnaire: Assessment of skin condition on days 0, 7 and 14 for the treatment groups who received a partial bath in low dosage (A) or high dosage (B) or for the total population (C). Figure 10 : Participant questionnaire: Assessment of redness of the affected skin areas on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 11 : Participant questionnaire: Assessment of scaling of the affected skin areas on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 12: Participant questionnaire: Assessment of the dryness of the affected skin areas on days 0, 7 and 14 for the treatment groups who received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 13 : Participant questionnaire: Assessment of itching on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 14 : Participant questionnaire: Assessment of limitations in everyday life on days 0, 7 and 14 for the treatment groups who received a partial bath in low dosage (A) or high dosage (B) or for the total population (C). Figure 15 Participant questionnaire: Assessment of sleep disturbances on days 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 16: SCORAD (A) localSCORAD (B) for the subgroup of children on days 0, 7 and 14. Figure 17 : 21 Participant questionnaires: Assessment of the general skin condition (A), dryness (B), scaling (C) and redness (D) on days 0, 7 and 14 for the subgroup of children. Figure 18 : Quantification of the gene copy number of S. aureus on day 0, 7 and 14 for the treatment groups that received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 19 : Quantification of the gene copy number of S. aureus on day 0, 7 and 14 for the subgroup of children who received a partial bath in low dose (A) or high dose (B) or for the total population (C). Figure 20 Correspondence analysis of bacterial community structures from skin swabs of the two treatment groups and the total population as mean values ​​at the respective time points with standard error. Detailed description of the invention

[0040] Unless otherwise defined, technical and scientific terms used herein shall have the same meaning as they are generally understood by a person skilled in the field of the invention.

[0041] Prebiotics are indigestible food components that favorably influence the activity and growth of one or more microorganisms, thereby improving the health of the host.

[0042] Probiotics are live microorganisms that, alone or as an additive in foods and dietary supplements, exert health-promoting effects that go beyond the level of basic nutritional effects.

[0043] Synbiotics are products that contain both prebiotics and probiotics. The added prebiotic fiber is intended to ensure the growth and survival of the probiotic bacteria.

[0044] Dietary fiber consists of carbohydrate polymers with ten or more monomer units that are not hydrolyzed by the body's own enzymes in the human small intestine.

[0045] The inventors discovered that the topical application of a probiotic, comprising a combination of microorganisms from the Streptococcus genus with microorganisms from the Lactobacillus and / or Bifidobacterium genera, leads to significant improvements in the symptoms of skin diseases such as atopic dermatitis (eczema). This is because atopic dermatitis is often characterized by a deficiency of ceramides. Microorganisms of the Streptococcus genus, particularly the Streptococcus thermophilus species, are able to increase the ceramide content of the epidermis due to their possession of an active "neutral sphingomyelinase."

[0046] Furthermore, the total concentration of microorganisms in the composition can range from 0.2 x 10⁹ CFU / g to 3.0 x 10⁹ CFU / g, optionally from 0.6 x 10⁹ CFU / g to 2.4 x 10⁹ CFU / g, and optionally from 1.0 x 10⁹ CFU / g to 2.0 x 10⁹ CFU / g. Additionally, the total concentration of microorganisms in the pharmaceutical composition can be approximately 1.8 x 10⁹ CFU / g. The inventors were able to demonstrate that when the pharmaceutical composition containing microorganisms in this concentration range was used, the symptoms of skin diseases could be significantly alleviated.

[0047] The invention relates to a pharmaceutical composition for use in the treatment of atopic dermatitis, wherein the pharmaceutical composition may comprise a prebiotic selected from the group consisting of inulin, maltodextrin, pectin, and resistant starch. The dietary fiber may be present in equal proportions by weight. The microorganisms already present on the skin can be increased by the use of the prebiotic.

[0048] Furthermore, the prebiotic pharmaceutical composition may be inulin and / or maltodextrin.

[0049] Also disclosed is a pharmaceutical composition comprising a synbiotic, wherein the synbiotic comprises a probiotic and a prebiotic as defined above. The prebiotic comprises microorganisms selected from the bacterial genera Lactobacillus and / or Bifidobacterium, and Streptococcus. The total concentration of the microorganisms in the composition may be in the range of 0.2 x 10⁹ CFU / g to 3.0 x 10⁹ CFU / g, optionally in the range of 0.6 x 10⁹ CFU / g to 2.4 x 10⁹ CFU / g, and further optionally in the range of 1.0 x 10⁹ CFU / g to 2.0 x 10⁹ CFU / g, or approximately 1.8 x 10⁹ CFU / g. The prebiotic is selected from the group consisting of inulin, maltodextrin, pectin, resistant starch and / or related dietary fibers, or it may be inulin and / or maltodextrin. By weight, the prebiotic may be the main component of the pharmaceutical composition and / or the synbiotic.Furthermore, the prebiotic may be present in an amount of approximately 98% by weight of the total weight of the pharmaceutical composition. The prebiotic may also be present in an amount of at least 98% by weight of the total weight of the pharmaceutical composition. The prebiotic may consist of or comprise inulin, maltodextrin, pectin, resistant starch, and / or related dietary fibers, which may be present in approximately equal proportions by weight. Alternatively, the prebiotic may be composed of approximately equal parts by weight of inulin and maltodextrin, such that the amount of inulin and maltodextrin may each be approximately 49% by weight of the total weight of the pharmaceutical composition. Finally, the amount of inulin and maltodextrin may each be at least 49% by weight of the total weight of the pharmaceutical composition.The prebiotic can serve as a nutrient source not only for the bacteria already present on the skin, but also for the probiotics contained in the pharmaceutical composition.

[0050] The aforementioned pharmaceutical compositions may be available as topical dosage forms, in particular as creams, ointments or oils, or as bath additives.

[0051] Another aspect of the invention relates to a water bath containing 0.5 g to 10 g, optionally 1.0 g to 8.0 g, further optionally 2.0 g to 6.0 g, or optionally 2.5 g or 5.0 g of a pharmaceutical composition as defined above per liter of water. The pharmaceutical composition comprises a probiotic, prebiotic, or synbiotic as defined above.

[0052] Furthermore, a method for preparing the water bath is provided, comprising mixing the pharmaceutical composition defined above with water such that the bath has a concentration of the composition of 0.5 g to 10 g per liter of water. Optionally, the target concentration of the composition can be 1.0 g to 8.0 g, further optionally 2.0 g to 6.0 g, or optionally 2.5 g or 5.0 g.

[0053] To use the water bath, the affected body parts are placed in the water bath so that they are completely submerged. The bath lasts for 10 minutes. Afterwards, the area is air-dried.

[0054] Another aspect of the invention is the use of the pharmaceutical composition or the water bath defined above in the treatment of atopic dermatitis. The pharmaceutical composition comprises a probiotic, prebiotic, or synbiotic as defined above. The inventors have demonstrated that the use of the pharmaceutical composition clearly improves the general condition of the skin as well as symptoms such as redness, scaling, itching, dryness, erythema, excoriation, edema / papule formation, lichenification, and weeping / crusting. Furthermore, the use of the pharmaceutical composition according to the invention leads to a reduction in limitations in daily life and an improvement in sleep disturbances caused by the skin changes.

[0055] It is also revealed that the pharmaceutical composition defined above can be used in the treatment of atopic dermatitis, wherein the microorganisms are selected from the group consisting of Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium lactis, Bifidobacterium longum, Bifidobacterium longum subsp. Infantis, Lactobacillus johnsonii, Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus bulgaricus, Lactobacillus casei, Lactobacillus fermentum, Lactobacillus gasseri, Lactobacillus paracasei, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rhamnosus (ATCC 53103), Lactobacillus rhamnosus, Lactobacillus salivariusLs, Lactococcus lactis, Streptococcus thermophilus, Streptococcus salivarius, Enterococcus faecalis, Enterococcus faecium, Saccharomyces boulardii, Saccharomyces cerevisiae and / or E. coli.Furthermore, the microorganisms may be selected from the group consisting of Lactobacillus paracasei, Bifidobacterium longum, Streptococcus thermophilus, Lactobacillus johnsonii, Lactobacillus reuteri, Lactobacillus plantarum, Lactobacillus gasseri, Lactobacillus rhamnosus, and Bifidobacterium lactis. The total concentration of microorganisms in the composition may be in the range of 0.2 x 10⁹ CFU / g to 3.0 x 10⁹ CFU / g, optionally in the range of 0.6 x 10⁹ CFU / g to 2.4 x 10⁹ CFU / g, and further optionally in the range of 1.0 x 10⁹ CFU / g to 2.0 x 10⁹ CFU / g, or approximately 1.8 x 10⁹ CFU / g. The pharmaceutical composition may also contain a prebiotic, which is selected from the group consisting of inulin, maltodextrin, pectin, resistant starch and / or related dietary fibers, or is inulin and / or maltodextrin. The prebiotic may be the main component of the pharmaceutical composition by weight.Furthermore, the prebiotic may be present in an amount of approximately 98% by weight of the total weight of the pharmaceutical composition. The prebiotic may also be present in an amount of at least 98% by weight of the total weight of the pharmaceutical composition. In this case, the prebiotic may consist of inulin, maltodextrin, pectin, resistant starch, and / or related dietary fibers, which may be present in approximately equal proportions by weight. Alternatively, the prebiotic may be composed of approximately equal parts by weight of inulin and maltodextrin, such that the amount of inulin and maltodextrin may each be approximately 49% by weight of the total weight of the pharmaceutical composition. Finally, the amount of inulin and maltodextrin may each be at least 49% by weight of the total weight of the pharmaceutical composition.The pharmaceutical composition can also be used to prepare a water bath as defined above.

[0056] It is also evident that the pharmaceutical composition defined above can be used in the treatment of acne, wherein the microorganisms are selected from the group consisting of Streptococcus salivarius, Lactococcus spp., Streptococcus thermophilus, Lactobacillus delbrueckii, Lactobacillus plantarum, Lactobacillus paracasei, Lactobacillus acidophilus, Bifidobacterium adolescentis, and / or Bifidobacterium animalis. These microorganisms are particularly effective against P. acnes / Cutibacterium acnes and / or exhibit anti-inflammatory effects. Example of implementation

[0057] A two-arm, randomized, and blinded study was conducted. 1. Overview of the test plan

[0058] The study included four visits, an optional 7-day "washout period" and a 14-day application period.

[0059] The first visit (V1) involved screening of study participants. Following enrollment, a seven-day washout period ensued, during which no external or internal medications were permitted. If the participant was not on medication at V1, the examinations at visit 2 could proceed directly.

[0060] Visit 2 (V2) corresponded to day 0. Symptoms were assessed by the physician using the validated symptom score SCORAD (SCORing Atopic Dermatitis) and by the study participant using a questionnaire. Superficial skin swabs were also taken for microbiological examination, and the test products were distributed and their use explained. Visits 3 (V3) and 4 (V4) took place on day 7 (+ / - 1 day) and day 14 (+ / - 1 day), respectively. The same examinations were performed and parameters collected as in V2. 1.1 Visits and examinations Visit 1 (V1) - Screening

[0061] a. Informing the study participant b. Obtaining the participant's informed consent form c. Verifying inclusion and exclusion criteria, including symptom-related examination and SCORAD assessment d. Documenting medical history, comorbidities, and concomitant medication e. Documenting demographic data f. Distributing the investigational products and providing instructions for use Visit 2 (V2) - Day 0

[0062] a. Handing out and completing the participant questionnaire. 1. The study participant assesses their general skin condition as well as the symptoms of redness, scaling, itching, and dryness. In addition, limitations in daily life and sleep disturbances caused by the skin changes are evaluated. All parameters are rated on a scale of 0-10. b. Collection of the SCORAD score by the investigator. c. Skin swab for subsequent microbiological examination. The skin swab is taken using the VWR Transport Swabs Amies sampling system from Mibius. This is moistened with nuclease-free water immediately before use. Then, the swab is applied to the eczema with light pressure for 30 seconds. The sampling system is then frozen at -20°C. Visit 3 (V3) Day 7 (± 1)

[0063] a. Handing out and completing the participant questionnaire. 2. The study participant assesses their general skin condition as well as the symptoms redness, scaling, itching, and dryness. In addition, limitations in daily life and sleep disturbances due to the skin changes are evaluated. All parameters are rated on a scale of 0-10. b. Collection of the SCORAD score by the investigator. c. Skin swab for subsequent microbiological examination. The skin swab is taken using the VWR Transport Swabs Amies sampling system from Mibius. This is moistened with nuclease-free water immediately before use. Then, with light pressure, it is swabbed over the eczema for 30 seconds. The sampling system is then frozen at -20°C. Visit 4 (V4) Day 14 (± 1)

[0064] a. Handing out and completing the participant questionnaire. 3. The study participant assesses their general skin condition as well as the symptoms of redness, scaling, itching, and dryness. In addition, limitations in daily life and sleep disturbances caused by the skin changes are evaluated. All parameters are rated on a scale of 0-10. b. Collection of the SCORAD score by the investigator. c. Skin swab for subsequent microbiological examination. The skin swab is taken using the VWR Transport Swabs Amies sampling system from Mibius. This is moistened with nuclease-free water immediately before use. Then, the swab is applied to the eczema with light pressure for 30 seconds. The sampling system is then frozen at -20°C. 1.2 Inclusion criteria

[0065] Study participants must be at least 5 years old. For children and adolescents under 16 years of age, the questionnaire will be completed by or together with the parents. Signed informed consent form for participation in the study. Atopic eczema on hands / arms and feet / legs: SCORAD baseline score > 10. The criteria erythema + excoriation or crusting should be present as markers for an acute event. Topical medications containing active ingredients must be discontinued at least 7 days prior to the start of the study: corticosteroids, immunosuppressants such as pimecrolimus or tacrolimus, and disinfectant or antibiotic topical medications (disinfectant baths, ointments). 1.3 Exclusion criteria

[0066] Required systemic therapy for atopic eczema: Use of cortisone preparations, antihistamines, therapy with agents that can affect the skin microbiome, such as antibiotics. Immunosuppression: Individuals with severe immunodeficiency (after organ or stem cell transplants, undergoing chemotherapy or high-dose cortisone therapy). Pregnancy and breastfeeding. 2. Application

[0067] A bath additive containing nine probiotic bacterial strains was used. The bath additive was tested in two different dosages. 2.1 Composition of the ActivaDerm bath additive and the bath

[0068] Table 1: Bacterial strains used in the bath additive bacterial strain Colony-forming units per gram Lactobacillus plantarum 0.2 x 10 9 < KbE / g Lactobacillus gasseri 0.2 x 10 9 < KbE / g Lactobacillus rhamnosum 0.2 x 10 9 < KbE / g Lactobacillus paracasei 0.2 x 10 9 < KbE / g Bifidobacterium longum 0.2 x 10 9 < KbE / g Streptococcus thermophilus 0.2 x 10 9 < KbE / g Lactobacillus johnsonii 0.2 x 10 9 < KbE / g Lactobacillus reuteri 0.2 x 10 9 < KbE / g Bifidobacterium lactis 0.2 x 10 9 < KbE / g

[0069] The total concentration (activity) is: 1.8 x 10⁹ < CFU / g

[0070] Other ingredients: Inulin and maltodextrin in equal parts by weight. dosage

[0071] 1) 5 grams per liter, corresponding to 9 x 10⁹ < CFU / liter (1 x 10⁹ < CFU / L per strain) 2) 2.5 grams per liter, corresponding to 4.5 x 10⁹ < CFU / liter (0.5 x 10⁹ < CFU / L per strain)

[0072] The affected skin areas were bathed daily for 10 minutes. 2.2 Randomization and Blinding

[0073] Study participants were assigned using randomization. Blinding was ensured by the indistinguishable packaging of the test products. 2.3 Instructions for the study participant on how to use the study medication

[0074] The study participant did not administer the probiotic bath at the test center, but rather at home. He received detailed instructions for this purpose, which included the following information: Fill a small tub, bucket, or similar container with lukewarm water enough to cover the affected areas (the water should not be too hot). Please use a measuring cup to measure the water so you know how many liters are in your bath. Add one scoop of powder per liter of water and stir well. Soak for 10 minutes. Afterward, allow the area to air dry; do not rinse off the bathwater. If the skin feels very dry, you can apply a basic, non-medicated moisturizer after at least one hour. Do not use anything else (no cortisone, Protopic, etc.). You should not shower until at least eight hours after the bath. Do not wash your hands during this time if they have been treated with the probiotic bath. Therefore, it is recommended to use the bath in the evening.Please fill out the enclosed checklist daily after using the bath and hand it in to the study physician at the end of the study. 2.4 Storage conditions

[0075] The probiotic bath additive was stored at room temperature in its original packaging. To minimize moisture absorption, the packaging should be tightly resealed immediately after each use. The measuring spoon should not come into contact with the bathwater. 2.5 Concomitant medication during the study

[0076] Any concomitant medication (including OTC preparations, dietary supplements and herbal medicines) taken during the study was documented in the observation form. 2.6 Compliance

[0077] A checklist was used to verify whether the study participant used the bath daily. This checklist documented daily usage as well as any unusual occurrences. 3. Examination of clinical efficacy parameters

[0078] Changes in clinical symptoms were analyzed using the SCORAD score by the investigator, as well as through the assessment of the study participant using a questionnaire. 3.1 SCORAD

[0079] The validated symptom score SCORAD was used for evaluation (Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology. 1993;186(1):23-31.). 3.2 Participant Questionnaire

[0080] The following parameters were documented by the study participant in the participant questionnaire on a numerical scale of 0-10: Assessment of general skin condition; assessment of redness; assessment of scaling; assessment of itching; assessment of dryness; limitations in daily life; sleep disturbances due to skin changes 4. Microbiological investigations

[0081] Since the literature describes a correlation between the severity of atopic dermatitis symptoms, the diversity of the bacterial skin microbiome, and the quantity of S. aureus, skin swabs were taken from the study participants. The skin swabs were taken using the VWR Transport Swabs Amies sampling system from Mibius. The sampling systems were stored at -20°C until nucleic acid extraction. Nucleic acid extraction using phenol / chloroform was performed with minor modifications according to the publication by Noll et al. (Noll et al., Succession of bacterial community structure and diversity in a paddy soil oxygen gradient, Environ Microbiol, 2005, 7(3): 382-395). 4.1 Taking skin samples

[0082] The skin swab was taken using the VWR Transport Swabs Amies sampling system from Mibius. This system was moistened with nuclease-free water immediately before use. It was then swabbed over the eczema with light pressure for 30 seconds. The sampling system was subsequently frozen at -20°C and remained at the testing center until refrigerated shipment to the microbiological laboratory. 4.2 DNA isolation from skin samples

[0083] The following are modifications to the protocol according to Noll et al. 2005. A spatula tip of zirconium beads (approx. 0.2 g), 400 µL of cold TPM buffer, 200 µL of NaPO4 buffer, and 600 µL of SDS-aquaphenol mixture were added to all samples. The samples were then vortexed and incubated at 65°C for 10 minutes. Each mixture was then homogenized in FastPrep 24 for 60 s at 4.5 m / s and subsequently frozen at -80°C for 5 minutes. The samples were then centrifuged at 21,500 x g and 4°C for 15 minutes. 800 µL of the supernatant was mixed with the same volume of TPM buffer, vortexed, and centrifuged again (21,500 x g, 4°C, 15 minutes). The maximum volume of supernatant (approx. 800 µL) was removed and mixed with the same volume of cold phenol-chloroform-isoamyl alcohol and centrifuged (21,500 x g, 4°C, 15 min). 1300 µL of PEG buffer and 2 µL of glycogen were added to 650 µL of supernatant. The mixture was vortexed and incubated for 45 min at 4°C and 21,500 x g.500 x g were centrifuged. The supernatant was discarded. The nucleic acid pellet was washed twice with 500 µL of ethanol and dried at 37°C. The purified DNA pellet was then resuspended in 50 µL of TE buffer.

[0084] Subsequently, the quantity (A260) and quality (A260 / 280, A260 / 230) of the DNA were determined photometrically using the µDropTM Plate according to the manufacturer's instructions. 4.3 qPCR Staphylococcus aureus

[0085] Subsequently, a quantitative polymerase chain reaction (qPCR) was performed using the Bio-Rad CFX96 real-time system. The quantitative change (V2, V3, and V4) in the gene copy number of S. aureus was determined using qPCR.

[0086] To quantify the gene copy number, an external standard of S. aureus (DSMZ 346), previously acquired from the German Collection of Microorganisms and Cell Cultures, was generated, as described by Noll et al., 2019 (Noll et al., Copper containing wood preservatives shifted bacterial and fungal community compositions in pine sapwood in two field sites, Int Biodeter Biodegr, 2019, 142: 26-35). Using nucleic acid extracts with defined DNA concentrations and total cell counts, the gene copy number of individual skin swabs can be determined. The external standard was generated from the bacterial species S. aureus. For this purpose, an overnight culture of S. aureus was prepared in BHI medium. The cell count of the culture was then determined using a Neubauer counting chamber according to Nieschlag et al., 2012 (Nieschlag E.(WHO Laboratory Manual: Examination and Processing of Human Semen, 2012, Springer-Verlag) and subsequently, nucleic acids (see 4.3) were extracted from a volume of 500 µL of the culture. Using a dilution series of the nucleic acid extracts (see 4.3), the gene copy number of S. aureus was determined by qPCR in comparison with the microscopically counted microorganisms and used as an external quantification standard. The species-specific qPCR protocol, based on the nucA gene, was performed without modifications according to the description by Brakstad et al., 1992 (Brakstad, Aasbakk et al., Detection of Staphylococcus aureus by polymerase chain reaction amplification of the nuc gene, J Clin Microbiol, 1992, 30(7): 1654-1660). The polymerase used was iTaq Universal SYBR Green Supermix (Biorad ®< ).

[0087] The nucA gene and its length exhibit high specificity for the bacterium S. aureus. The nucA gene represents the precursor of the thermonuclease of S. aureus. Due to the rarity of the nucA gene sequence motif in other bacterial species, it is highly likely that only the genomic DNA of S. aureus will be amplified during qPCR (Barouei, Moussavi et al., Effect of maternal probiotic intervention on HPA axis, immunity and gut microbiota in a rat model of irritable bowel syndrome, PLoS One, 2012, 7(10): e46051). The sequence-specific primer pair for S. aureus also binds the nucA fragment with high specificity (Brakstad, Aasbakk et al., Detection of Staphylococcus aureus by polymerase chain reaction amplification of the nuc gene, J Clin Microbiol, 1992, 30(7): 1654-1660). 4.4 16S rRNA gene and ITS-specific high-throughput sequencing

[0088] Bacterial 16S rRNA gene- and ITS (internal transcribed spacer region)-specific high-throughput sequencing was performed using Illumina MiSeq high-throughput sequencing technology based on the publication by Caproso et al., 2012 (Caproso, Lauber et al., Ultra-high-throughput microbial community analysis on the Illumina HiSeq and MiSeq platforms., 2012, ISME J 6(8): 1621-1624) with the primer set from Noll et al. 2019 (Noll et al., Copper containing wood preservatives shifted bacterial and fungal community compositions in pine sapwood in two field sites, 2019, 142: 26-35). The processing of the resulting sequence data and their statistical analysis were performed according to Noll et al. 2019 (Noll et al., Copper containing wood preservatives shifted bacterial and fungal community compositions in pine sapwood in two field sites, 2019, 142: 26-35). 5. Statistics

[0089] All statistical analyses were performed using the statistical software R version 3.5.2 or RStudio version 1.1.463. The experimental data from the SCORAD study were tested for normality using the Shapiro-Wilk test. Assuming a normal distribution, and since the samples are independent, a non-connected ANOVA was chosen. Subsequently, a pairwise t-test was used to determine between which groups the significant difference existed. The p-value was then subjected to a Bonferroni correction. The significance level was set at α = 0.05.

[0090] In the absence of a normal distribution, a significant difference in the means was sought using the Kruskal-Wallis test. A pairwise Wilcoxon test was then used to determine between which groups the significant difference existed. The p-value was then subjected to a Bonferroni correction. 6. Results 6.1 Assessment by the examining physician 6.1.1 SCORAD

[0091] The SCORAD evaluation shows that in both treatment groups there is a clear trend towards improvement in clinical symptoms during the course of the study (see Figure 1and Table 2). On both day 7 and day 14, the mean SCORAD value decreased compared to the previous time point. This trend was somewhat more pronounced in the lower-dose treatment group; compared to the baseline value on day 0, the difference in SCORAD was already statistically significant on day 7. In the higher-dose treatment group, statistical significance was reached on day 14. Since the results do not indicate a difference in efficacy between the two dosages, all participants can be grouped together as part of the overall population corresponding to a dosage of 4.5 to 9 x 10⁹ < CFU / L. This resulted in a significant reduction in the mean SCORAD from 63.04 on day 0 to 47.09 (-15.95) on day 7 and 35.26 (-27.78) on day 14. Table 2: Results of the SCORAD analysis of both treatment groups and the total population SCORAD A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 62,68 43,68 31,81 63,48 51,17 39,41 63,04 47,09 35,26 Standard deviation 11,88 17,50 17,26 14,20 19,87 24,48 12,67 18,55 20,69 minimum 38,90 21,40 11,40 41,30 20,30 10,50 38,90 20,30 10,50 Lower quartile 57,10 27,65 18,15 47,50 37,80 20,00 56,90 28,90 18,90 median 60,10 43,10 31,25 68,80 55,95 37,35 65,85 46,60 32,25 Upper quartile 69,75 58,10 42,35 69,80 66,20 68,20 69,80 63,00 44,30 maximum 82,80 75,80 65,80 83,10 75,30 75,30 83,10 75,80 75,30 N (number) 12 12 12 10 10 10 22 22 22

[0092] 6.1.2 Part B of SCORAD - local SCORAD

[0093] Section B of the SCORAD assesses the intensity of symptoms in the treated skin areas. Therefore, a partial evaluation of this section, in the form of a local SCORAD, provides additional information about the treatment effect.

[0094] The results here are consistent with the results of the entire SCORAD study (see Figure 2 For the overall population and for the lower-dose treatment group, the improvement was significant on day 7 and day 14 compared to baseline on day 0. For the higher-dose group, the difference was significant on day 14 (p<0.05). Table 3: Results of the localSCORAD analysis of both treatment groups and the total population local SCORAD A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 14,75 10,25 7,75 14,60 11,80 9,40 14,68 10,99 8,54 Standard deviation 2,86 4,61 3,93 3,10 4,24 5,33 2,91 4,41 4,62 minimum 8 4 3 9 5 2 8 4 2 Lower quartile 13,5 5,5 3,5 12 8 5 13 6 5 median 15 10,5 9 15 12 9 15 11,8 9 Upper quartile 17 14 11 17 15 14 17 15 11 maximum 18 17 14 18 18 18 18 18 18 N (number) 12 12 12 10 10 10 22 22 22

[0095] To analyze whether the improvement in the SCORAD score can be attributed to specific parameters or is equally supported by all individual symptoms, Part B of the SCORAD was analyzed for the individual parameters: erythema, excoriation, edema / papule formation, lichenification, weeping / crusting, and dryness.

[0096] Analysis of the erythema scores shows that they improve in accordance with the change in the total SCORAD score and Part B of the SCORAD score during the course of treatment (see Figure 3 (and Table 4). The documented improvements are more pronounced in the lower-dose treatment group. For the overall population as well as the lower-dose treatment group, the differences compared to baseline on day 0 are statistically significant on day 7 and day 14. Table 4: Results of the analysis of the parameter erythema for both treatment groups and the total population Erythema A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 2,83 2,00 1,67 2,60 2,00 1,70 2,73 2,00 1,68 Standard deviation 0,58 0,95 0,65 0,70 0,82 0,95 0,63 0,87 0,78 minimum 1 1 1 1 1 0 1 1 0 Lower quartile 3 1 1 2 1 1 2 1 1 median 3 2 2 3 2 2 3 2 2 Upper quartile 3 3 2 3 3 2 3 3 2 maximum 3 3 3 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22

[0097] The clinical symptom of excoriation also improves consistently throughout the course of the negotiations, in line with the change in the overall SCORAD score and the course of the local SCORAD score (see Figure 4 and Table 5). Significant differences compared to baseline can be documented for the total population on day 7 and day 14, as well as for the treatment group with the lower dose. Table 5: Results of the analysis of the parameter excoriation for both treatment groups and the total population Excoriation A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 2,08 1,25 0,92 2,40 1,80 1,40 2,23 1,50 1,14 Standard deviation 0,67 0,87 1,00 0,97 1,03 1,17 0,81 0,96 1,08 minimum 1 0 0 0 0 0 0 0 0 Lower quartile 2 1 0 2 1 1 2 1 0 median 2 1 1 3 2 1 2 1 1 Upper quartile 2,5 2 1,5 3 3 3 3 3 2 maximum 3 3 3 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22

[0098] Edema and papule formation also decreased on average in both study populations during the course of the study (see Figure 5(and Table 6). The differences are also more pronounced in the treatment group with the lower dosage. For the entire study population, significant differences were found at both further examination time points (day 7 and day 14) compared to the baseline value. Table 6: Results of the analysis of the parameter edema for both treatment groups and the total population Edema A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 2,33 1,67 1,00 2,60 2,10 1,50 2,45 1,86 1,23 Standard deviation 0,78 0,98 0,85 0,52 0,74 1,08 0,67 0,89 0,97 minimum 1 0 0 2 1 0 1 0 0 Lower quartile 2 1 0 2 2 1 2 1 0 median 2,5 1,5 1 3 2 1,5 3 2 1 Upper quartile 3 2,5 2 3 3 2 3 3 2 maximum 3 3 2 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22

[0099] On average, crust formation improved in both treatment groups during the course of the study ( Figure 6and Table 7). The difference is particularly pronounced in the group receiving the lower dosage. With a mean reduction of 0.5 score points on day 14, this group showed the most significant change for all documented symptoms. A statistically significant improvement in crust formation was observed for the lower-dose treatment group as well as for the overall population on both day 7 and day 14. Table 7: Results of the analysis of the parameter crust formation for both treatment groups and the total population crust formation A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 2,25 1,08 0,50 2,10 1,70 1,00 2,18 1,36 0,73 Standard deviation 0,87 1,08 0,67 1,10 1,06 1,25 0,96 1,09 0,98 minimum 1 0 0 0 0 0 0 0 0 Lower quartile 1,5 0 0 1 1 0 1 0 0 median 2,5 1 0 2,5 2 0,5 2,5 1 0 Upper quartile 3 1,5 1 3 2 2 3 2 1 maximum 3 3 2 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22

[0100] The signs of lichenification also tend to improve on average in the study participants ( Figure 7and Table 8). However, the differences are less pronounced than for the parameters described previously. The change in the mean value from day 0 to day 14 is less than one score point for the overall population (-0.69), while the corresponding changes for erythema, excoriation, edema, and crusting were -1.05, -1.09, -1.22, and -1.45 points, respectively. Nevertheless, the differences in the overall population as well as in the lower-dose treatment group reach statistical significance on day 14 compared to day 0. Table 8: Results of the analysis of the parameter lichenification for both treatment groups and the total population Lichenification A low dose B high dose C Total population 0 7 14 0 7 14 0 7 14 mean 2,33 1,83 1,42 1,90 1,60 1,50 2,14 1,73 1,45 Standard deviation 0,78 0,72 0,67 0,88 0,84 1,08 0,83 0,77 0,86 minimum 1 1 0 0 0 0 0 0 0 Lower quartile 2 1 1 2 1 1 2 1 1 median 2,5 2 1,5 2 2 1,5 2 2 1,5 Upper quartile 3 2 2 2 2 2 3 2 2 maximum 3 3 2 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22

[0101] The mean values ​​for the skin dryness parameter of the study participants tend to improve over the course of the study ( Figure 8and Table 9). Similar to lichenification, the change here is weaker than with the other analyzed parameters. The difference is significant for the total population on day 14 compared to the baseline value on day 0 (-0.68). Table 9: Results of the analysis of the parameter drought for both treatment groups and the total population dryness A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 2,92 2,42 2,25 3,00 2,60 2,30 2,95 2,50 2,27 Standard deviation 0,29 0,79 0,87 0,00 0,70 0,95 0,21 0,74 0,88 minimum 2 1 1 3 1 1 2 1 1 Lower quartile 3 2 1,5 3 2 1 3 2 1 median 3 3 2,5 3 3 3 3 3 3 Upper quartile 3 3 3 3 3 3 3 3 3 maximum 3 3 3 3 3 3 3 3 3 N (number) 12 12 12 10 10 10 22 22 22 6.2 Evaluation by the study participant 6.2.1 Questionnaire on symptoms

[0102] In addition to the SCORAD assessment by the investigator, the study participants also evaluated their symptoms themselves. On average, the participants rated their overall skin condition better at both examination time points than at the preceding time point ( Figure 9and Table 10). This applies to both treatment groups, although the differences are somewhat more pronounced in the lower-dose group. Here, the difference on day 14 compared to the baseline value on day 0 is significant. This general trend is consistent with the investigator's assessment using SCORAD. Table 10: Assessment of skin condition by study participants: Descriptive statistical parameters for both treatment groups and the total population General skin findings A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 6,75 6,08 4,75 7,40 5,90 6,10 7,05 6,00 5,36 Standard deviation 1,54 2,02 2,30 1,84 2,60 2,69 1,68 2,25 2,52 minimum 4 3 1 4 2 2 4 2 1 Lower quartile 5,5 4,5 3 6 4 5 6 4 3 median 7 6 4,5 7,5 5,5 5,5 7 5,5 5 Upper quartile 8 7,5 6,5 8 8 8 8 8 7 maximum 9 9 8 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22

[0103] The assessment of redness of the treated skin areas by the study participants is comparable to the assessment of the overall skin condition: there is a tendency towards improvement in redness in both treatment groups and consequently in the overall population ( Figure 10 and Table 11). However, statistical significance cannot be achieved - unlike the assessment of erythema by the examining physician within the framework of SCORAD. Table 11: Assessment of redness of the affected skin areas by the study participants: descriptive statistical parameters for both treatment groups and the total population Redness A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 5,92 4,92 4,00 6,70 6,50 5,70 6,27 5,64 4,77 Standard deviation 1,51 2,11 2,41 2,11 2,37 2,87 1,80 2,32 2,71 minimum 3 2 1 4 3 3 3 2 1 Lower quartile 5 4 2 5 5 3 5 4 3 median 6 4,5 3,5 7 6,5 5 6 5 4,5 Upper quartile 7 6 6 8 8 8 8 7 7 maximum 8 9 8 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22

[0104] The assessment of the scaling of the treated skin areas by the study participants also shows, on average, a trend toward improvement in these symptoms ( Figure 11 and Table 12) in accordance with the improvement in skin condition according to the participant questionnaire and the SCORAD. Here too, no statistical significance was achieved. Table 12: Assessment of scaling of the affected skin areas by the study participants: descriptive statistical parameters for both treatment groups and the total population Scaling A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 5,58 4,67 3,83 6,00 5,20 4,60 5,77 4,91 4,18 Standard deviation 2,54 1,97 2,52 2,11 3,26 3,13 2,31 2,58 2,77 minimum 0 1 0 3 1 0 0 1 0 Lower quartile 4 3 2 4 2 3 4 3 3 median 6,5 4,5 4 6 5 4 6 5 4 Upper quartile 7 6,5 5,5 7 8 7 7 7 6 maximum 9 7 9 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22

[0105] In contrast to the results of the doctor's assessment, the patient himself perceived and rated the improvement in skin dryness as more significant ( Figure 12and Table 13). In the treatment group with the lower dose, the differences were significant compared to day 0, as were they in the entire study population. Table 13: Assessment of dryness of the affected skin areas by the study participants: descriptive statistical parameters for both treatment groups and the total population dryness A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 7,00 6,00 4,92 7,30 6,80 6,30 7,14 6,36 5,55 Standard deviation 1,65 2,09 2,35 2,00 1,93 2,50 1,78 2,01 2,46 minimum 5 3 2 4 4 3 4 3 2 Lower quartile 5,5 4 3 6 5 4 6 5 3 median 7 6 4,5 7 6,5 6 7 6,5 5 Upper quartile 8 7,5 7 9 8 8 8 8 8 maximum 10 9 9 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22

[0106] On average, according to participant assessments, the itching was alleviated over the course of the study ( Figure 13 and Table 14). For the total population, the difference was statistically significant compared to the baseline value. Table 14: Assessment of itching of the affected skin areas by the study participants: Descriptive statistical parameters for both treatment groups and the total population itching A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 6,42 5,67 4,33 6,90 5,50 5,10 6,64 5,59 4,68 Standard deviation 2,27 2,42 2,27 2,60 2,80 3,54 2,38 2,54 2,87 minimum 2 2 1 2 0 0 2 0 0 Lower quartile 5 4 2,5 5 4 3 5 4 3 median 6 5,5 4,5 7 5 4,5 7 5 4,5 Upper quartile 8,5 7 5,5 9 7 8 9 7 7 maximum 10 10 8 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22

[0107] The quality of life of the study participants was also assessed using the questionnaire. This included information on limitations in daily life ( Figure 14and Table 15) as well as sleep disturbances caused by the skin disease documented ( Figure 15 and Table 16).

[0108] Both parameters tended to improve over the course of the study. However, a statistically significant difference could only be observed for limitations in daily life for the participant group receiving the higher dosage on day 14 compared to day 0. Table 15: Assessment of the limitations in everyday life of the affected skin areas by the study participants: Descriptive statistical parameters for both treatment groups and the total population Restrictions in everyday life A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 6,17 4,75 3,67 5,90 5,10 4,70 6,05 4,91 4,14 Standard deviation 1,85 2,34 2,19 2,88 3,51 3,34 2,32 2,86 2,75 minimum 2 1 0 1 0 1 1 0 0 Lower quartile 6 3 2 4 4 2 4 3 2 median 7 4,5 3,5 5,5 4 4 6,5 4 3,5 Upper quartile 7 6,5 5,5 8 9 6 7 7 6 maximum 8 9 7 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22 Table 16: Assessment of sleep disturbances caused by the skin disease by the study participants: Descriptive statistical parameters for both treatment groups and the total population Sleep disorders A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 3,92 3,50 2,58 5,70 4,40 3,60 4,73 3,91 3,05 Standard deviation 2,84 2,61 2,75 3,16 3,78 3,78 3,06 3,15 3,21 minimum 0 0 0 0 0 0 0 0 0 Lower quartile 2,5 2,5 0 4 1 0 3 1 0 median 3,5 3 1,5 6,5 5 3 4 3,5 2 Upper quartile 5,5 4,5 4,5 8 8 7 7 5 5 maximum 10 10 8 10 10 10 10 10 10 N (number) 12 12 12 10 10 10 22 22 22 6.3 Analysis of the subgroup of children

[0109] Since the prevalence of atopic dermatitis is significantly higher in childhood than in adulthood, the efficacy of the test product was additionally evaluated for the subgroup of children (5 to 11 years). The results show that the probiotic bath demonstrates comparably good efficacy in this age group as in the general population.

[0110] SCORAD and localSCORAD can be significantly reduced at both examination time points compared to the previous time point ( Figure 16 and Table 17). The differences are significant on day 14 compared to the baseline on day 0, although the subgroup comprised only a small number of participants (n=7). Table 17: Results of the analysis of the SCORAD and the local SCORAD of the subgroup of children A SCORAD B local SCORAD day 0 7 14 0 7 14 mean 55,39 42,63 27,16 12,71 9,86 6,29 Standard deviation 11,25 15,96 14,60 2,87 4,18 3,95 minimum 38,90 21,40 11,80 8 5 2 Lower quartile 43,60 26,40 12,40 10 5 3 median 56,90 43,60 21,50 14 10 5 Upper quartile 66,80 61,90 42,30 15 15 11 maximum 69,80 63,00 44,30 16 15 11 N (number) 7 7 7 7 7 7

[0111] The evaluation of the participant questionnaires also showed an improvement in skin dryness, scaling, and redness in the subgroup of children during the course of the study. Consequently, the overall skin condition was also rated better on average at both follow-up examinations than at the previous time point. Figure 17 and Table 18). Table 18: Assessment of the general skin condition (A), dryness (B), scaling (C), and redness (D) by the study participants. Descriptive statistical parameters for the subgroup of children. A skin condition B. Dryness day 0 7 14 0 7 14 mean 5,29 4,43 3,71 5,71 5,00 4,00 Standard deviation 1,11 1,99 1,80 1,11 1,63 1,41 minimum 4 2 2 4 3 2 Lower quartile 4 3 2 5 4 3 median 5 4 3 6 5 4 Upper quartile 6 6 5 7 6 5 maximum 7 8 7 7 8 6 N (number) 7 7 7 7 7 7 C Scaling The redness mean 4,14 3,57 2,57 5,00 3,71 3,00 Standard deviation 2,12 2,23 1,90 1,53 1,50 1,29 minimum 0 1 0 3 2 1 Lower quartile 3 1 1 4 2 2 median 5 3 3 5 4 3 Upper quartile 6 5 4 7 5 4 maximum 6 7 5 7 6 5 N (number) 7 7 7 7 7 7 maximum 6 7 5 7 6 5 N (number) 7 7 7 7 7 7

[0112] Parameters relating to quality of life, such as limitations in daily life and sleep disorders, also improved during the study ( Figure 18 and Table 19). However, no significant differences were achieved. Table 19: Assessment by study participants of the limitations in daily life (A), itching (B), and sleep disturbances (C) caused by the skin condition. Descriptive statistical parameters. A limitations in everyday life B Itching C Sleep disorders day 0 7 14 0 7 14 0 7 14 mean 4,43 2,86 2,57 5,29 4,57 3,00 3,71 2,86 1,29 Standard deviation 1,72 1,46 1,51 1,89 1,51 1,73 2,63 1,95 2,21 minimum 2 1 0 2 2 1 0 0 0 Lower quartile 3 1 2 4 4 1 2 1 0 median 4 4 3 5 5 3 4 3 0 Upper quartile 6 4 3 7 5 5 7 5 4 maximum 7 4 5 7 7 5 7 5 5 N (number) 7 7 7 7 7 7 7 7 7 6.4 Microbiological investigations

[0113] From participants who completed the study, skin swabs were taken on days 0, 7, and 14 from areas of atopic eczema. Nucleic acids were extracted from these skin swabs (see 4.1 and 4.2), and the gene copy number of S. aureus (4.3) was determined from the respective nucleic acid extract using quantitative PCR. These same nucleic acid extracts were also used for bacterial 16S rRNA gene and fungal ITS sequencing (see 4.4). Some extracts showed an insufficient quantity of nucleic acids. This insufficient quantity of nucleic acids resulted in these extracts having an extremely low gene copy number of S. aureus, and only a small number of sequences could be obtained from the sequencing.Therefore, the sample from subject 15 on day 7 was not used for characterizing the bacterial community, and the samples from subject 6 (day 7, 68 sequence reads), 14 (day 0, 16 sequence reads), subject 16 (day 14, 1 sequence reads) and subject 27 (day 0 and 7, 6 and 0 sequence reads) were not used for quantifying the gene copy number of S. aureus and characterizing the fungal community. 6.4.1 Quantification of gene copy number in S. aureus

[0114] The evaluation of the gene copy number quantification in S. aureus showed that in both treatment groups there was a clear trend towards a reduction in the gene copy number of S. aureus (see Figure 18and Table 20). On both day 7 and day 14, the mean gene copy number decreased compared to the previous time point. This trend was somewhat more pronounced in the lower-dose treatment group and in the overall population; compared to the baseline value on day 0, the difference in gene copy number was statistically significant on day 14. Table 20: Quantification of the gene copy number of S. aureus: Descriptive statistical parameters for both treatment groups and for the total population. S. aureus Gene copy number A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 22580400 12641800 863744 11104600 13725600 4621598 15546000 13134500 2571859 Standard deviation 26201200 22600700 1008075 6512114 23468500 5465113 19750800 22447900 4123173 minimum 848083 23030 0 1476833 356683 38948 848083 23030 0 Lower quartile 2524250 297475 48428 6475000 611917 531767 3416250 513717 183600 median 11034500 2322917 437808 9789742 2019167 2403750 9617211 2113583 1078833 Upper quartile 44979600 10671700 1263000 17926200 12036700 6620000 17926200 12036700 2763833 maximum 80200000 70850000 2773500 22062500 65066700 17136700 80200000 70850000 17136700 N (number) 12 12 12 10 10 10 22 22 22 6.4.2 Quantification of gene copy number in S. aureus in the subgroup of children

[0115] The subgroup of children comprised only a few study participants: 4 children were included in the lower-dose treatment group and 3 children in the high-dose treatment group (see also 6.3).

[0116] The gene copy number of S. aureus decreased over time in the treatment group with the higher dose and in the overall population, while in the treatment group with the lower dose a decrease in gene copy number could only be detected on day 14 ( Figure 19 The differences in gene copy number did not reach statistical significance in any treatment group over the course of the treatment. Table 21: Quantification of the gene copy number of S. aureus: Descriptive statistical parameters for both treatment groups and the total population of the subgroup of children. S. aureus Gene copy number children A low dose B high dose C Total population day 0 7 14 0 7 14 0 7 14 mean 4428012 14041700 627383 16880400 17277200 1660033 9764745 15428300 1069948 Standard deviation 5485269 22450400 711271 6470125 27803900 1304185 8561635 22642600 1060469 minimum 848083 23030 0 9628667 513717 183600 848083 23030 0 Lower quartile 916233 247515 25600 9628667 513717 183600 984383 472000 51200 median 2200317 4466000 548100 18950000 1946167 2141333 9628667 1946167 1045000 Upper quartile 7939792 27835800 1229167 22062500 49371700 2655167 18950000 47211700 2141333 maximum 12463300 1413333 47211700 22062500 49371700 2655167 22062500 49371700 2655167 N (number) 4 4 4 3 3 3 7 7 7 6.4.3 Characterization of the bacterial skin microbiome

[0117] Based on the calculation of ecological indices, no significant difference in α-diversity was found between the two treatment groups (see Table 22). Bacterial diversity (richness) was slightly increased in the higher-dose treatment group compared to the lower-dose group at the start of the study. Bacterial diversity (richness) increased in both groups and in the overall population over the course of treatment. All other indices showed no significant differences between the treatment groups or over time. Table 22: Mean values ​​of the ecological indices Richness, Shannon Index, Simpson Index, and Pielou's Evenness with standard deviation (SD) and standard error (SE) for both treatment groups and the total population. The indices were calculated using the microbiome and phyloseq packages. ANOVA was used to determine whether there was a significant difference between the treatment groups and the duration of treatment. Treatment group Richness Shannon Simpson Evans SD SE Time Day 0 High dose 130 2,15 0,62 0,45 152,19 14,96 low dose 109 2,18 0,64 0,48 131,01 13,91 Total population 119 2,17 0,63 0,47 140,64 14,39 Time of day 7 High dose 160 1,96 0,55 0,40 182,67 12,84 low dose 151 2,27 0,63 0,45 171,20 12,12 Total population 155 2,13 0,60 0,43 176,12 12,43 Time of day 14 High dose 157 2,43 0,68 0,49 182,45 15,12 low dose 148 2,23 0,63 0,46 170,50 14,27 Total population 152 2,32 0,66 0,48 175,93 14,65

[0118] The composition of the bacterial community structure did not change significantly over time in either treatment group or the overall population ( Figure 20However, a difference in the temporal evolution of the composition of the bacterial community structure was observed between the two treatment groups with different dosages ( Figure 20 ).

[0119] The relative abundance and phylogenetic composition of the bacterial community structure changed over time. In both treatment groups, as well as in the overall population, the proportions of the genera Lactobacillus and Bifidobacterium increased, particularly during the first 7 days of treatment. By the time of the examination on day 14, these proportions appeared to stabilize at this higher level. The genus Streptococcus also tended to increase. However, in the low-dose treatment group, the proportions on day 14 were below the baseline values ​​on day 0. Representatives of all three genera are included in the probiotic test product.

[0120] Furthermore, over the course of the treatment, the relative abundances of the Corynebacterium family and some families of the Proteobacteria division increased compared to day 0, even though these were not part of the bath. At the same time, the sequence read frequency of the genus Staphylococcus decreased over the course of the treatment, although this decrease was not statistically significant. 7. Discussion of the results 7.1 Clinical efficacy parameters

[0121] Both the SCORAD evaluation and the participant questionnaires show that, on average, an improvement occurred for all parameters. This applies to both dosages of the test product, which differed only slightly in terms of the efficacy determined within this study. It can be assumed that a slight bias towards the lower dosage arose by chance due to the small number of participants per group. According to these results, the lower dosage of the probiotic bath is therefore sufficient to achieve a clinical improvement in symptoms.

[0122] The evaluation of the SCORAD and the so-called local SCORAD (Part B of the SCORAD) revealed a significant improvement in clinical symptoms during the course of the study. A partial analysis of the individual parameters of the SCORAD (Part B) shows that this change is supported by all parameters, and no single symptom remained completely unchanged or worsened during the study. However, the parameters lichenification and dry skin improved less significantly within the 14-day application period than the symptoms erythema, excoriation, and crusting. While the latter are more indicative of an acute inflammatory process and therefore subside more quickly, lichenification represents a change in skin structure. This changes more slowly, and it takes several weeks to months for the leathery changes to regress.From this perspective, the slight tendency to improve lichenification under treatment with the test product can be interpreted as the first phase of regression.

[0123] The reduced effect of the probiotic bath on skin dryness, documented in the SCORAD study, may be due to the bath method itself, particularly with regard to daily use. However, it should be noted that the overall dryness improved, not worsened. Furthermore, in this case, the physician's assessment differs from that of the study participants, who rated the change in skin dryness more favorably.

[0124] Overall, the results of the participant questionnaire confirm the improvement in symptoms documented by the physician using SCORAD. Here, too, a trend toward improvement, in some cases significant, can be observed for all parameters: redness, scaling, dryness, itching, and general skin condition.

[0125] However, the relief of symptoms—with the exception of dry skin—was generally rated somewhat less clearly by the study participants than by the physician. Subjective skepticism towards the new application method may play a role here. It should also be considered that all topical preparations containing active ingredients were discontinued seven days prior to the start of the treatment, and the patient may therefore have expected a worsening of their symptoms.

[0126] Nevertheless, the assessment of quality of life, i.e. limitations in everyday life and sleep disorders, also shows a trend towards improvement.

[0127] Of particular practical relevance is the efficacy of the probiotic for the subgroup of children, who, due to the high prevalence of atopic dermatitis in this age group, represent the main users of the product. Even here, despite the small group size (n=7), statistically significant improvements were achieved with SCORAD and local SCORAD.

[0128] As previously mentioned, all results of the clinical analysis must be evaluated in light of the study design, which included discontinuing all active medications seven days prior to the start of the test phase. This strict requirement was chosen to ensure that the observed effects could be clearly attributed to the test product and that all participants were treated under comparable conditions.

[0129] Under these circumstances, there was naturally a risk that discontinuing the medication containing the active ingredients would lead to a worsening of symptoms, which could not be alleviated by the bath. This approach may also have contributed to a correspondingly critical expectation among study participants who trusted the effectiveness of their existing therapy, while perhaps being more skeptical of the unfamiliar test product.

[0130] It is therefore noteworthy that an improvement in symptoms could be documented on average for the entire study population as well as for both treatment groups. 7.2 Microbiological examination

[0131] The gene copy number of S. aureus decreased in both treatment groups. In the lower-dose treatment group, as well as in the overall population, these differences between day 0 and day 14 were statistically significant. Simultaneously, analysis of the bacterial microbiomes showed a trend toward a reduction in the relative abundance of the genus Staphylococcus, although this was not statistically significant. Since different PCR conditions and primers were used for qPCR (primer for the nucA gene) and for amplicon sequencing (primer for the bacterial 16S rRNA gene), the gene copy number is more informative than the relative abundance generated by amplicon high-throughput sequencing due to the higher specificity of the chosen qPCR approach. Nevertheless, the result of the decrease in Staphylococcus can be confirmed using both independent PCR-based methods.The results of amplicon sequencing do not allow for phylogenetic resolution below the genus level of Staphylococcus. Therefore, shifts in the quantity of S. aureus to other species within the genus Staphylococcus, such as S. epidermidis, which is very common on healthy skin, can only be assumed theoretically.

[0132] The concentration of S. aureus on the skin has long been interpreted as a significant factor in the severity of atopic dermatitis. Therefore, a reduction in the gene copy number of S. aureus is consistent with the improvement in clinical symptoms as assessed by SCORAD and the participant questionnaire. This correlation suggests that a reduction in S. aureus—along with potentially other parameters—may have contributed to the clinical improvement in symptoms.

[0133] A unique feature of the test preparation compared to other probiotic dermatological products is the use of live microorganisms. These were subsequently found in the microbiological analysis of skin swabs: The sequence motifs of bacterial components of the probiotic bath additive were detected with increasing frequency in the bacterial skin microbiomes of participants in both treatment groups over time. The proportions of the genera Lactobacillus and Bifidobacterium increased within the first few days of treatment and appeared to stabilize at this higher level thereafter.This result indicates that the bacteria in the probiotic bath additive not only influenced the existing diversity and thus interacted with the existing skin microbiome on different levels (commensalism, competition, mutualism), but also became part of the skin microbiome themselves—at least during the treatment period. As a component of the skin microbiome, these bacteria can independently interact with the dermal skin cells and the host's immune system, achieving a higher proportion of interactions with the existing skin microbiome in terms of both quantity and quality. Since the relative abundance of these genera increased during the application period, it can be postulated that this level of interaction with the skin microbiome and skin epithelial cells can be quantitatively and temporally sustainably developed and expanded.

[0134] Overall, the treatment showed a positive effect on bacterial richness (diversity) and also increased the relative abundance of members of the bacterial microbiome that were not part of the probiotic bath additive. It is possible that these additional members of the bacterial skin microbiome were previously suppressed and reduced below the detection limit by other components of the skin microbiome, particularly S. aureus. Furthermore, the treatment with the probiotic bath additive could also have increased the colonization success of microorganisms from other skin areas, clothing, air, or water. Since there was no control or placebo group with whom the same analyses were performed at the same time, no clear reason for the increase in richness can be identified. However, it can be assumed that the dysbiosis associated with atopic dermatitis was alleviated.

[0135] In healthy skin, there is a synergistic interaction between the skin microbiome and the human host, in which the immune response and the defense against pathogens are coordinated. The more dysbiosis prevails, the less these functions can be fulfilled. According to the study results, treatment with the probiotic bath additive therefore promotes the regeneration of the richness and diversity of the skin microbiome and thus supports its function in host interaction.

[0136] Analysis of the temporal evolution of the bacterial skin microbiome composition shows that samples from participants in both treatment groups deviated from their baseline composition. Subjects treated with the lower dose tended to exhibit a more stable bacterial community composition than those treated with the higher dose. The partial baths thus have a temporal effect, and the development of greater diversity can occur within as little as seven days of treatment. Since this study did not obtain higher temporal resolution data on microbiome changes, a shorter treatment duration could theoretically be used to achieve this effect. Further experiments and analyses could provide higher temporal resolution data.

[0137] The analysis of the subgroup of children confirms the trends observed in the overall population with regard to microbiological results as well as clinical symptoms. Therefore, comparable efficacy can be assumed in children, although the results are not statistically significant due to the small number of participants in this subgroup. 7.3 Conclusion

[0138] In summary, the application of the probiotic bath in subjects with atopic dermatitis resulted in an average reduction in S. aureus colonization of the skin and simultaneously led to greater diversity of the bacterial skin microbiome. These effects were already observed at the first examination point after seven days of application and, with only minor differences, affected both study groups, which were treated with different dosages of the probiotic bath. Due to the study design, which excluded the use of other active ingredient preparations during the study period and within a preceding seven-day washout phase, all documented changes can be attributed relatively clearly to the test product.

[0139] The results of the microbiological investigations are consistent with the statistically significant improvement in clinical symptoms, which was documented by the study physicians using the SCORAD and a participant questionnaire.

[0140] Based on the correlation between clinical and microbiological results, it can be postulated that the clinical effect of the probiotic bath is at least partially due to influencing an existing dermal dysbiosis. At the same time, the results underscore the importance of the skin microbiome for the pathogenesis of atopic dermatitis.

Claims

1. A pharmaceutical composition for use in the treatment of atopic dermatitis, comprising a probiotic, wherein the probiotic comprises the microorganisms Lactobacillus paracasei, Bifidobacterium longum, Streptococcus thermophilus, Lactobacillus johnsonii, Lactobacillus reuteri, Lactobacillus plantarum, Lactobacillus gasseri, Lactobacillus rhamnosus and Bifidobacterium lactis.

2. A pharmaceutical composition for use according to claim 1, wherein the total concentration of microorganisms in the composition ranges from 0.2 x 109 CFU / g to 3.0 x 109 CFU / g (CFU = colony-forming units), optionally from 0.6 x 109 CFU / g to 2.4 x 109 CFU / g, furthermore optionally from 1.0 x 109 CFU / g to 2.0 x 109 CFU / g.

3. A pharmaceutical composition for use according to claim 2, wherein the total concentration of microorganisms in the composition is approximately 1.8 x 109 CFU / g.

4. A pharmaceutical composition for use according to claim 1, wherein the composition comprises a prebiotic which is preferably selected from the group consisting of inulin, maltodextrin, pectin and resistant starch, particularly preferably is inulin and / or maltodextrin.

5. A pharmaceutical composition for use according to any of the preceding claims 1-4, wherein the composition exists as a topical dosage form, in particular as a cream, ointment or oil, or as a bath additive.

6. A water bath comprising 0.5 g to 10 g, optionally 1.0 g to 8.0 g, furthermore optionally 2.0 g to 6.0 g, or optionally 2.5 g or 5.0 g of a pharmaceutical composition according to any of claims 1-4 per litre of water.

7. A method of producing a water bath according to claim 6, comprising mixing the pharmaceutical composition according to any of claims 1-4 with water so that the bath has a concentration of the composition of 0.5 g to 10 g per litre of water.