Clinical evidence of benefits of a dietary supplement containing probiotic and carotenoids on ultraviolet-induced skin damage

The Role of Probiotics in Skin Care: Advances, Challenges, and Future Needs

The skin, being the largest organ in the human body, plays a pivotal role in safeguarding the body against invasive pathogens. Therefore, it is essential to reinforce and protect this vital organ. Current research supports the impact of probiotics on skin health and their ability to alleviate various skin disorders. However, the effectiveness and probable side effects of probiotics in skin care remain a subject of debate, necessitating further investigation and analysis. Hence, this study aims to highlight existing gaps and future needs in the current research on probiotics in skin care and pave the way for future investigations. Therefore, we scrutinized the effects of oral (fermented foods and dietary supplements) and non-oral/topical probiotics on skin care, and the mechanism of probiotics that affect skin health. The results of most studies showed that fermented foods containing probiotics, particularly dairy products, positively impact skin health. The research results regarding the efficacy of probiotic supplements and live strains in treating skin disorders show promising potential. However, safety evaluations are crucial, to identify any potential adverse effects. While research has identified numerous potential mechanisms by which probiotics may influence skin health, a complete understanding of their precise mode of action remains elusive. However, it seems that probiotics can exert their positive effects through the gut-skin and gut-skin-brain axis on the human body. Therefore, following the identification of safe probiotics, additional studies should be carried out to establish optimal dosages, potential side effects, suitable regulatory guidelines, and validation methods.

Exploring the impact of solar radiation on skin microbiome to develop improved photoprotection strategies

The skin microbiome undergoes constant exposure to solar radiation (SR), with its effects on health well-documented. However, understanding SR's influence on host-associated skin commensals remains nascent. This review surveys existing knowledge on SR's impact on the skin microbiome and proposes innovative sun protection methods that safeguard both skin integrity and microbiome balance. A team of skin photodamage specialists conducted a comprehensive review of 122 articles sourced from PubMed and Research Gateway. Key terms included skin microbiome, photoprotection, photodamage, skin cancer, ultraviolet radiation, solar radiation, skin commensals, skin protection, and pre/probiotics. Experts offered insights into novel sun protection products designed not only to shield the skin but also to mitigate SR's effects on the skin microbiome. Existing literature on SR's influence on the skin microbiome is limited. SR exposure can alter microbiome composition, potentially leading to dysbiosis, compromised skin barrier function, and immune system activation. Current sun protection methods generally overlook microbiome considerations. Tailored sun protection products that prioritize both skin and microbiome health may offer enhanced defense against SR-induced skin conditions. By safeguarding both skin and microbiota, these specialized products could mitigate dysbiosis risks associated with SR exposure, bolstering skin defense mechanisms and reducing the likelihood of SR-mediated skin issues.

Immunological aspects of probiotics for improving skin diseases: Influence on the Gut-Brain-Skin Axis

The interplay between gut microbiota and human health, both mental and physical, is well-documented. This connection extends to the gut-brain-skin axis, linking gut microbiota to skin health. Recent studies have underscored the potential of probiotics and prebiotics to modulate gut microbiota, supported by in vivo and clinical investigations. In this comprehensive review, we explore the immunological implications of probiotics in influencing the gut-skin axis for the treatment and prevention of skin conditions, including psoriasis, acne, diabetic ulcers, atopic dermatitis, and skin cancer. Our analysis reveals that probiotics exert their effects by modulating cytokine production, whether administered orally or topically. Probiotics bolster skin defenses through the production of antimicrobial peptides and the induction of keratinocyte differentiation and regeneration. Yet, many questions surrounding probiotics remain unanswered, necessitating further exploration of their mechanisms of action in the context of skin diseases.

A narrative review of the impact of ultraviolet radiation and sunscreen on the skin microbiome

BACKGROUND

The human skin microbiome is a dynamic ecosystem that plays an important role in skin health. The skin microbiome has been implicated in numerous diseases, and our knowledge surrounding it continues to evolve. A better understanding of the interactions between the environment and the skin microbiome will lead to improvements in skin health.

METHODS

This article reviews the published literature surrounding the impact of ultraviolet radiation (UVR) and sunscreen on the skin microbiome.

RESULTS

Skin microbes are differentially impacted by UVR, and alterations in the microbiome can be detected following UVR exposure. These changes are related to direct bactericidal effects, alterations in the cutaneous metabolome, and changes in the cutaneous immune system. UV filters used in sunscreen have been shown to have bactericidal effects, and many compounds used in sunscreen emulsions can also negatively impact cutaneous microbes.

CONCLUSION

A healthy microbiome has been shown to produce compounds that help protect the skin from UVR, and sunscreen has the potential to reduce the diversity of the skin microbiome. This indicates that designing sunscreen products that both provide protection against UVR and preserve the skin microbiome may offer additional benefits to skin health when compared with traditional sunscreen products.

Effects of probiotics supplementation on skin photoaging and skin barrier function: A systematic review and meta-analysis

BACKGROUND

Ultraviolet (UV) irradiation is one of the major causes of skin aging. To date, there remains limited evidence on using oral probiotics for skin anti-photoaging.

OBJECTIVES

This systematic review and meta-analysis aims to assess the effects of probiotics on skin photoaging.

METHODS

We searched the PubMed and Embase databases for studies published until August 31, 2021, and included randomized controlled trials, murine randomized controlled experiments, and in vitro studies. Skin barrier function was compared between UV irradiated probiotics and controls.

RESULTS

After given oral probiotics supplements, a significant reduction was shown in all types of measured MMPs in both murine and in vitro studies. Oral probiotics supplementation significantly reversed UV-induced increase of epidermal thickness (standardized mean differences [SMD] = -1.76; 95% confidence interval [CI] = -3.04 to -0.49; p = .007; I²  = 81%), UV-induced increase trans-epidermal water loss (SMD = -1.72; 95% CI = -2.76 to -0.67; p = .001; I²  = 57%), and UV-induced skin dehydration (SMD = 1.85; 95% CI = 1.16 to 2.55; p < .00001; I²  = 4%).

CONCLUSIONS

Probiotics are effective against skin photoaging in terms of MMP pathways and reversing skin barrier function from murine randomized data. Further randomized controlled trials on humans are required to warrant these results.

Probiotics in dermatological and cosmetic products – application and efficiency

The term “probiotics” has first been used in 1907 by Elie Metchnikoff. Since then, probiotics have been part of research not only in regards of digestive health, but also inflammatory diseases. Lately, there has been an increased interest of probiotic’s effects in skincare. The management of atopic dermatitis, acne, psoriasis, photo aging, skin cancer, intimate care, oral care, wound healing is getting harder each passing day, due to increased antibiotic resistance and other side effects of conventional therapy. Therefore, new ingredients have been investigated and probiotics have been proved to be effective in treating various skin conditions. This review aims to evaluate the scientific evidence on topical and oral probiotics, and to evaluate the efficacy of cosmetic and dermatological products containing probiotics. Many studies have shown that skin and gut microbiome alterations have an important role in skin health. Although this is a new topic in dermatology and cosmetology, there have been some promising results in lots of research studies that the use of probiotics in cosmetic products may help improve the patient’s outcome. While oral probiotics have been shown to promote gut health, which influences the host immune system and helps treat different skin diseases, the mechanism of action of topical probiotics is not yet fully understood. Although the number of commercial probiotic cosmetic products released in the market is increasing and most of the studies have not shown any serious side effect of probiotics, further studies, in larger and heterogeneous groups are needed.

The Role of Probiotics in Skin Photoaging and Related Mechanisms: A Review

Solar ultraviolet radiation (UVR) is the primary pathogenetic factor in skin photoaging. It can disrupt cellular homeostasis by damaging DNA, inducing an inflammatory cascade, immunosuppression, and extracellular matrix (ECM) remodeling, resulting in a variety of dermatologic conditions. The skin microbiome plays an important role in the homeostasis and maintenance of healthy skin. Emerging evidence has indicated that highly diverse gut microbiome may also have an impact on the skin health, referred to as the gut-skin axis (GSA). Oral and topical probiotics through modulating the skin microbiome and gut-skin microbial interactions could serve as potential management to prevent and treat the skin photoaging by multiple pathways including reducing oxidative stress, inhibiting ECM remodeling, inhibiting the inflammatory cascade reaction, and maintaining immune homeostasis. In this review, the effects of oral and topical probiotics in skin photoaging and related mechanisms are both described systematically and comprehensively.

Modulating effects of oral administration of Lycii Fructus extracts on UVB‑induced skin erythema: A Randomized, placebo‑controlled study

Severe UV exposure induces skin inflammation, causing erythema. Lycii Fructus (Lycium barbarum and Lycium chinense) is a potential antioxidant agent with a high content of polyphenols, including rutin and chlorogenic acid. This study examined the effects of Lycii Fructus extract (LFE) on UVB-induced skin erythema in humans. Healthy volunteers were randomly assigned to one of two groups and received UVB irradiation at 1.5 minimal erythemal dose (MED) on day 0 at three designated sites on their backs, and the skin color was measured until day 7. After an 8-week treatment with LFE (900 mg/day) or placebo, UVB irradiation (l.5 MED) was applied again at different sites on day 63. Skin color was continuously measured in each group until day 69. LFE tablet administration for 8 weeks significantly inhibited UVB-induced erythema formation and increased the MED by 13%. Erythema formation peaked on the first day after UVB irradiation, but gradually dissipated over the next several days. LFE tended to accelerate erythema disappearance. To determine the polyphenol responsible for the protection against UVB-induced skin damage, the effects of LFE-derived polyphenols and their metabolites on UVB-induced cytotoxicity were examined in vitro. The major intestinal metabolite of rutin and LFE significantly attenuated phototoxicity and in human keratinocyte HaCaT cells. Quercetin enhanced intracellular glutathione levels in HaCaT cells, even though LFE did not increase it. Together, the results showed that LFE inhibited erythema formation and accelerated erythema dissipation, possibly through its direct antioxidative action.

Advances in Microbiome-Derived Solutions and Methodologies Are Founding a New Era in Skin Health and Care

The microbiome, as a community of microorganisms and their structural elements, genomes, metabolites/signal molecules, has been shown to play an important role in human health, with significant beneficial applications for gut health. Skin microbiome has emerged as a new field with high potential to develop disruptive solutions to manage skin health and disease. Despite an incomplete toolbox for skin microbiome analyses, much progress has been made towards functional dissection of microbiomes and host-microbiome interactions. A standardized and robust investigation of the skin microbiome is necessary to provide accurate microbial information and set the base for a successful translation of innovations in the dermo-cosmetic field. This review provides an overview of how the landscape of skin microbiome research has evolved from method development (multi-omics/data-based analytical approaches) to the discovery and development of novel microbiome-derived ingredients. Moreover, it provides a summary of the latest findings on interactions between the microbiomes (gut and skin) and skin health/disease. Solutions derived from these two paths are used to develop novel microbiome-based ingredients or solutions acting on skin homeostasis are proposed. The most promising skin and gut-derived microbiome interventional strategies are presented, along with regulatory, safety, industrial, and technical challenges related to a successful translation of these microbiome-based concepts/technologies in the dermo-cosmetic industry.

A combination of Vitreoscilla filiformis extract and Vichy volcanic mineralizing water strengthens the skin defenses and skin barrier

Probiotics are live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host. Semiactive, non-replicating bacteria or extracts used in dermocosmetics have interesting properties for skin quality. Vitreoscilla filiformis is cultured by a fermentation process to obtain an extract. It is considered as a probiotic fraction and topical application of this extract has shown activity to strengthen the skin physical barrier function and maintain good homeostasis of skin defenses. Vichy volcanic mineralizing water (VVMW) is a pure, highly mineralized water that has been shown to strengthen the skin against exposome aggressions. This manuscript reviews properties of probiotic fractions used in skin care, especially studies on an extract of V. filiformis grown in a medium containing VVMW (VfeV) and evaluated in combination with VVMW. Skin barrier function: In normal human epidermal keratinocyte cultures, the combination of 10% VVMW and 0.002% VfeV significantly increased transglutaminase, filaggrin, involucrin, claudin-1, and zonula occludens-1 in comparison with the controls. Antimicrobial peptide defenses: The combination of 16.7% VVMW and 0.1% VfeV increased the expression of β-defensin-4A and S100A7. Skin immune defense functions: In lipopolysaccharide-stimulated peripheral blood mononuclear cells, the combination of 16.7% VVMW and 0.1% VfeV down-regulated IL-8, TNF-α, IL-12/IL-23p40, and increased IL10 and IL-10/IL-12 ratio compared to the control. Additionally, the combination of 79% VVMW plus 5% VfeV protected Langerhans cells in skin explants exposed to ultraviolet radiation. In conclusion, the combination of VfeV plus VVMW has properties to strengthen the skin barrier by stimulating skin differentiation and tight junctions, biochemical defenses by stimulating antimicrobial peptides, and cellular immune defenses by increasing the IL-10/IL-12 ratio and by protecting Langerhans cells challenged by ultraviolet radiation.

Microbiota Targeted Interventions of Probiotic Lactobacillus as an Anti-Ageing Approach: A Review

With the implementation of modern scientific protocols, the average human lifespan has significantly improved, but age-related problems remain a challenge. With the advent of ageing, there are alterations in gut microbiota and gut barrier functions, weak immune responses, increased oxidative stress, and other age-related disorders. This review has highlighted and discussed the current understanding on the significance of gut microbiota dysbiosis and ageing and its inherent effects against age-related oxidative stress as well as on the gut health and gut-brain axis. Further, we have discussed the key mechanism of action of Lactobacillus strains in the longevity of life, alleviating gut dysbiosis, and improving oxidative stress and inflammation to provide an outline of the role of Lactobacillus strains in restoration of gut microbiota dysbiosis and alleviating certain conditions during ageing. Microbiota-targeted interventions of some characterized strains of probiotic Lactobacillus for the restoration of gut microbial community are considered as a potential approach to improve several neurological conditions. However, very limited human studies are available on this alarmed issue and recommend further studies to identify the unique Lactobacillus strains with potential anti-ageing properties and to discover its novel core microbiome-association, which will help to increase the therapeutic potential of probiotic Lactobacillus strains to ageing.

Plant-Based Foods for Skin Health: A Narrative Review

The potential role of plant-based foods in the promotion of skin health is an emerging area of nutrition research. Plant-based foods are rich in bioactive compounds, including vitamin C, vitamin E, beta carotene, polyphenols, and phenolic acids, which can contribute to oxidant defense, lower inflammation, and promote structural support of the skin. Epidemiological studies have associated higher intakes of select fruits and vegetables with positive skin health. Beneficial effects of certain fruits, vegetables, nuts, legumes, and polyphenolic-rich beverages on the skin have been reported, with each of these providing a unique phytochemical composition. Although most studies use extracts, this review will focus on data from whole foods and minimally processed products. Collectively, the evidence to date suggests a promising future for plant-based dietary interventions that promote skin barrier health and function. However, additional research is required to address issues such as the optimal quality and duration of intake as well as potential mechanisms. Studies in the above areas will help formulate specific targeted dietary recommendations.

The Effect of Probiotics on Various Diseases and their Therapeutic Role: An Update Review

Probiotic bacteria play a critical and functional role in clinical and nutritional applications. In the present study, the ability of various probiotics and their metabolites in the prevention and treatment of different diseases, infections and disorders was reviewed. The issues that were noticed are included: Fibrocystic, diabetes, acne, colon cancer, cardiovascular, urinary tract infections, atopic eczema syndrome, food allergies and obesity. Enhancement in using drug treatment has led to the appearance of drug-resistance concern, thus probiotics can be a suitable choice. This review focuses on the effect of probiotic bacteria and their metabolites on immune-boosting, prevention and treatment of these diseases. For this purpose, after a short glance at each disease, infection and disorder, the mechanism of probiotic action and recent studies about that disease are reviewed. It could be recommended that probiotics consumption, perhaps from birth to all stages of life, would be effective in the life-long, development of health effects and disease treatments.

Role of ingestible carotenoids in skin protection: A review of clinical evidence

Carotenoids, a class of phytonutrients, have been well established to boost skin's innate resistance against ultraviolet (UV) B-induced erythema (sunburn). Many of the published clinical studies thus far have focused on the measurement of erythema as the primary clinical indicator of skin protection against UVB radiation. More recent studies have shown that carotenoid supplementation provides even more skin protection than previously shown as new clinical and molecular endpoints beyond UVB-induced erythema have been reported. These recent studies have demonstrated that carotenoids also provide photoprotection against UVA-induced pigmentation and inhibit molecular markers of oxidative stress such as intercellular adhesion molecule 1, heme oxygenase-1, and matrix metalloproteinases 1 and 9. This article provides a comprehensive review of the published clinical evidence on skin benefits of carotenoids in the last five decades and indicates new perspectives on the role of ingestible carotenoids in skin protection.

Extracts of Jasminum sambac flowers fermented by Lactobacillus rhamnosus inhibit H2 O2 - and UVB-induced aging in human dermal fibroblasts

Ultraviolet (UV) irradiation is a crucial factor that leads to skin photoaging and results in increased DNA damage, oxidative stress, and collagen degradation. Jasmine flowers have been utilized as a traditional medicine in Asia to treat various diseases, including dermatitis, diarrhea, and fever. Furthermore, the fermented broth of Lactobacillus rhamnosus has been reported to exert protective effects on the skin. In the present study, jasmine flower extract was fermented with L. rhamnosus. We investigated the antioxidant and collagen-promoting effects on UVB/H₂ O₂ -induced HS68 dermal fibroblast cell damage. The results indicated that treatment with the fermented flower extracts of Jasminum sambac (F-FEJS) could enhance the viability of HS68 cells. Furthermore, the UVB/H₂ O₂ -induced excessive production of reactive oxygen species, degradation of collagen, activation of MAPKs, including P38, ERK, and JNK, and premature senescence were remarkably attenuated by F-FEJS in dermal fibroblast cells. The nuclear accumulation of p-c-jun, which is downstream of MAPK, and the inactivation of p-smad2/3, which is one of the crucial transcription factors that enhance collagen synthesis, were reversed in response to F-FEJS treatment in UVB/H₂ O₂ -exposed cells. Notably, the expression of antioxidant genes, such as HO-1, and the nuclear translocation of Nrf2 were further enhanced by F-FEJS in UVB/H₂ O₂ -treated cells. Interestingly, the F-FEJS-induced increase in ARE luciferase activity indicated the activation of Nrf2/ARE signaling. In conclusion, our findings demonstrated that F-FEJS can effectively ameliorate UVB/H₂ O₂ -induced dermal cell aging and may be considered a promising ingredient in skin aging therapy.

Synbiotics supplement is effective for Melasma improvement

BACKGROUND

Melasma is a disorder of melanogenesis among humans causing localized, chronic acquired hypermelanosis of the skin requiring a combination of treatments. Related studies have shown probiotics contribute distinct advantages for skin disorders possibly including melasma because of its anti-inflammatory activities, anti-oxidation properties, ultraviolet protection, and tyrosinase activity inhibition.

AIMS

The study aimed to investigate the effects of synbiotics supplement on improving melasma (evaluated from mMASI score).

METHODS

This research comprised an experimental study employing a prospective, double-blind, randomized controlled trial among 57 Thai participants divided in 2 groups (29 for the experimental and 28 for the placebo groups). The participants were aged 30-50 years old, had Fitzpatrick skin type III-VI, with facial melasma on both sides of the face and attending Mae Fah Luang University Hospital, Bangkok from January-December 2019. Participants were randomly treated with oral synbiotics or placebo, 1 sachet daily for 12 weeks. Melasma severity and skin health were evaluated at 4 visits for each participant (baseline, weeks 4, 8, and 12, respectively).

RESULTS

Severity of melasma scored by mMASI of the synbiotics group was 7.54 ± 0.79, 7.36 ± 0.80, 7.16 ± 0.73, and 6.98 ± 0.72 at baseline, weeks 4, 8, and 12, respectively, and 7.51 ± 0.86, 7.52 ± 0.88, 7.54 ± 0.86, and 7.54 ± 0.89 at baseline, weeks 4, 8, and 12, respectively, in the placebo group. Comparing between two groups at week 12, melasma score in the synbiotics supplement group was significantly lower than that in the placebo group (P = .008).

CONCLUSION

Oral synbiotics supplementation for 12 weeks improved the severity of melasma score.

Non-Melanoma Skin Cancer: news from microbiota research

Recently, research has been deeply focusing on the role of the microbiota in numerous diseases, either affecting the skin or other organs. What it is well established is that its dysregulation promotes several cutaneous disorders (i.e. psoriasis and atopic dermatitis). To date, little is known about its composition, mediators and role in the genesis, progression and response to therapy of Non-Melanoma Skin Cancer (NMSC). Starting from a bibliographic study, we classified the selected articles into four sections: i) normal skin microbiota; ii) in vitro study models; iii) microbiota and NMSC and iv) probiotics, antibiotics and NMSC. What has emerged is how skin microflora changes, mainly represented by increases of Staphylococcus aureus, Streptococcus pyogenes and Pseudomonas aeruginosa strains, modifications in the mutual quantity of β-Human papillomavirus genotypes, of Epstein Barr Virus and Malassezia or candidiasis, may contribute to the induction of a state of chronic self-maintaining inflammation, leading to cancer. In this context, the role of S. aureus and that of specific antimicrobial peptides look to be prominent. Moreover, although antibiotics may contribute to carcinogenesis, due to their ability to influence the microbiota balance, specific probiotics, such as Lacticaseibacillus rhamnosus GG, Lactobacillus johnsonii NCC 533 and Bifidobacteria spp., may be protective.

Flexible Self-Powered Real-Time Ultraviolet Photodetector by Coupling Triboelectric and Photoelectric Effects

The portable UV photodetector is used to timely remind humans of overexposure to UV radiation. However, the traditional UV photodetector cannot meet the practical demands, and the power supply problem hinders its further development. In this work, we demonstrated a flexible, transparent, and self-powered UV photodetector by coupling of triboelectric and photoelectric effects. The device integrates a flexible ZnO nanoparticle (NP) UV photodetector, a transparent- and flexible-film-based TENG (TFF-TENG), commercial chip resistors, and LEDs on the PET thin film. The TFF-TENG could harvest mechanical energy from finger tapping and sliding motion and power the ZnO NP UV photodetector to realize self-powered detection. The voltage of the constant resistors connected with the UV photodetector in series changes from 0.5 to 19 V under the UV light with power intensities increasing from 0.46 to 21.8 mW/cm², and the voltage variation is reflected by the number of LEDs directly. The excellent flexibility and transparency of the device could extend its application scenarios; for example, such a portable device could be applied to real-time monitoring of the UV radiation to remind humans of intense UV light.

Seven-day Green Tea Supplementation Revamps Gut Microbiome and Caecum/Skin Metabolome in Mice from Stress

Green tea supplementation has beneficial health effects. However, its underlying mechanisms, such as effects on modulating the intestinal microbiome and endogenous metabolome, particularly following short-term supplementation, are largely unclear. We conducted an integrative metabolomics study to evaluate the effects of short-term (7-day) supplementation of green tea extract (GTE) or its components, epigallocatechin gallate, caffeine, and theanine, on the caecum microbiota and caecum/skin metabolome in mice. Further, we established an integrative metabolome-microbiome model for correlating gut and skin findings. The effects of short-term supplementation with dietary compounds were evaluated with respect to UV stress response, with GTE showing the most remarkable effects. Biplot analysis revealed that Bifidobacteria and Lactobacillus spp. were considerably influenced by short-term GTE supplementation, while Clostridium butyricum was significantly increased by UV stress without supplementation. GTE supplementation helped the skin metabolome defend against UV stress. Interestingly, a significant positive correlation was observed between caecum bacteria (Bifidobacteria, Lactobacillus spp.) and metabolites including skin barrier function-related skin metabolites, caecal fatty acids, and caecal amino acids. Overall, 7-day GTE supplementation was sufficient to alter the gut microbiota and endogenous caecum/skin metabolome, with positive effects on UV stress response, providing insight into the mechanism of the prebiotic effects of GTE supplementation.

Fermentation of Blackberry with L. plantarum JBMI F5 Enhance the Protection Effect on UVB-Mediated Photoaging in Human Foreskin Fibroblast and Hairless Mice through Regulation of MAPK/NF-κB Signaling

Chronic and extensive exposure of ultraviolet (UV)-irradiation causes human skin sunburn, inflammation, or photoaging, which is associated with downregulated collagen synthesis. This study investigated the effects of fermented blackberry (Rubus fruticosus B., FBB) by Lactobacillus plantarum JBMI F5 (LP) on UVB-induced photoaging in human foreskin fibroblast (Hs68) as well as in SKH-1 hairless mice. FBB pretreatment inhibited UVB-mediated type-1 procollagen degradation, matrix metalloproteinase (MMP)-1 and MMP-2 protein expression, and suppressed nuclear factor-κB (NF-κB) activation as well as mitogen-activated protein kinase (MAPK) phosphorylation in Hs68. In addition, FBB administration diminished the wrinkle formation in dorsal skin and epidermal thickening in UVB-irradiated hairless mice. Moreover, UVB-induced Type-1 procollagen reduction and antioxidant enzyme inactivation were reversed by FBB administration. These results suggest that FBB may have antiphotoaging effects on UVB-induced wrinkle formation by maintaining the extracellular matrix density in the dermis, which occurs via regulation of reactive oxygen species and related MAPK and NF-κB signaling. Therefore, FBB can be a potential candidate for protecting skin aging against UV irradiation.

Protective effects of tyndallized Lactobacillus acidophilus IDCC 3302 against UVB‑induced photodamage to epidermal keratinocytes cells

Photoaging is a consequence of chronic exposure to ultraviolet (UV) radiation and results in skin damage. In this study, whether tyndallizate of the probiotic bacterium Lactobacillus acidophilus IDCC 3302 (ACT 3302) can protect against UVB‑induced photodamage to the skin was investigated. For this, HaCaT keratinocytes were used as a model for skin photoaging. HaCaT cells were treated with ACT 3302 prior to UVB exposure and skin hydration factors and matrix metalloproteinase (MMP)‑1, MMP‑2, and MMP‑9 levels in the culture supernatant were evaluated by ELISA. The protective effects of ACT 3302 against UVB‑induced oxidative stress in HaCaT cells was also assessed by measuring superoxide dismutase and catalase activity and detecting the expression of pro‑inflammatory cytokine‑encoding genes and mitogen‑activated protein kinase (MAPK) signaling components by reverse transcription‑quantitative polymerase chain reaction and western blotting, respectively. UVB exposure increased MMP expression and MAPK activation; these changes were attenuated by pretreatment with ACT 3302. Treatment with ACT 3302 prior to UVB exposure also attenuated inflammation. These results demonstrate that tyndallized ACT 3302 can mitigate photodamage to the skin induced by UVB radiation through the suppression of MMPs and could therefore be used clinically to prevent wrinkle formation.

Probiotics in Extraintestinal Diseases: Current Trends and New Directions

Probiotics are defined as live microorganisms that when administered in adequate amounts confer a health benefit to the host. Their positive supplementation outcomes on several gastrointestinal disorders are well defined. Nevertheless, their actions are not limited to the gut, but may also impart their beneficial effects at distant sites and organs. In this regard, in this review article we: (i) comprehensively describe the main mechanisms of action of probiotics at distant sites, including bones, skin, and brain; (ii) critically present their therapeutic potential against bone, skin, and neuronal diseases (e.g., osteoporosis, non-healing wounds and autoimmune skin illnesses, mood, behavior, memory, and cognitive impairments); (iii) address the current gaps in the preclinical and clinical research; and (iv) indicate new research directions and suggest future investigations.

Cutaneous Photoprotective Activity of a Short-term Ingestion of High-Flavanol Cocoa: A Nutritional Intervention Study

In vivo and in vitro studies have shown that prolonged oral administration of flavanol-rich cocoas extracts have photoprotective effects. The aim of the present study was to assess the photoprotective activity of short-time administration of a new variety of naturally selected cocoa extract rich in bioactive compounds. We selected a cocoa powder particularly rich in polyphenols, flavanols, caffeine, theobromine and theophylline. We then investigated, in 10 healthy subjects, the photoprotective effects of one week of daily oral administration of two doses of such powder. Phototesting with solar simulated radiation was performed at baseline and after cocoa supplementation. Visual assessment of the minimal erythema dose and spectrophotometric measurement of the "a" parameter were done after 24 h from the irradiation. Oral daily supplementation of 1 g of high-flavanol cocoa was not effective but a one-week administration of 4-6 g of cocoa induced a statistically significant increase in the visual erythema threshold and a significant reduction in the "a" parameter. We demonstrated that a new variety of naturally selected cocoa extract, even when administered for a short time, retains a dose-dependent photoprotective effect. These results are also indicative of the fact that topical sunscreens could be supplemented by a specific diet.

Ultraviolet radiation, both UVA and UVB, influences the composition of the skin microbiome

BACKGROUND

Studies have begun to investigate the complex relationship between host and microorganisms in non-infectious pathologies such as acne, atopic dermatitis and psoriasis. Though the skin is exposed to environmental stressors such as ultraviolet radiation (UVR), no studies exist examining the effects of both UVA and UVB on the skin microbiome.

OBJECTIVE

To test the effect of UVA and UVB on human skin microbiome.

METHODS

To test whether UV will alter the cutaneous microbiome, participants were exposed to doses of UVA (22-47 J/cm² ) or UVB (100-350 mJ/cm² ) and samples were collected. DNA was isolated and sequenced to identify the microbial composition of each sample.

RESULTS

There was vast intra- and inter-subject variation at all time points, and phylum and species-level differences were identified. These included an increase in the phylum Cyanobacteria and a decrease in the family Lactobacillaceae and Pseudomonadaceae. The sensitivity of microbes to UVR and their re-colonization potential following exposure differed in UVA vs UVB samples.

LIMITATIONS

The sample size was small, and the study was limited to males.

CONCLUSION

The results demonstrate that UVR has profound qualitative and quantitative influences on the composition of the skin microbiome, possibly effecting skin pathology in which UVR is a factor.

Skin Moisturizing and Antiphotodamage Effects of Tyndallized Lactobacillus acidophilus IDCC 3302

Photoaging is generally the result of chronic exposure to the sun and ultraviolet (UV) radiation, which causes skin damage. In this study, we developed a UVB-induced hairless mouse model to determine whether Lactobacillus acidophilus IDCC 3302 tyndallizate (ACT3302) can enhance photodamaged skin repair. Mice (6 weeks old) were divided into six groups containing normal, UVB-treated vehicle, and UVB-treated ACT3302 (1 × 10⁵, 1 × 10⁶, 1 × 10⁷, and 1 × 10⁸ cells). Epidermal thickness was increased by UVB, but the thickening was lessened by ACT3302 as was the transepidermal water loss (TEWL). However, ACT3302 increased capacitance and decreased TEWL. Skin tissue staining to evaluate skin collagen increases in the number of skin collagen bundles in UVB-treated ACT3302 mice. UVB irradiation increased matrix metalloproteinase (MMP) and proinflammatory cytokine expression and activated mitogen-activated protein kinases in hairless mice; these changes were also attenuated by ACT3302. We conclude that ACT3302 effectively suppressed wrinkle formation induced by UVB irradiation through MMP downregulation. Therefore, ACT3302 potentially prevents skin photoaging and wrinkle formation.

Oral Photoprotection: Effective Agents and Potential Candidates

Electromagnetic radiation in the ultraviolet, visible, and infrared ranges produces biologic effects in humans. Where some of these effects are beneficial, others are harmful to the skin, particularly those stemming from ultraviolet radiation (UVR). Pharmacological photoprotection can be topical or systemic. Systemic photoprotection is often administered orally, complementing topical protection. New and classic oral agents (e.g., essential micronutrients as vitamins, minerals, polyphenols, carotenoids) are endowed with photoprotective and anti-photocarcinogenic properties. These substances bear the potential to increase systemic protection against the effects of electromagnetic radiation in the UV, visible, and infrared ranges. Protective mechanisms vary and include anti-oxidant, anti-inflammatory, and immunomodulatory effects. As such, they provide protection against UVR and prevent photo-induced carcinogenesis and aging. In this review, we present state of the art approaches regarding the photoprotective effects of vitamins and vitamin derivatives, dietary botanical, and non-botanical agents. A growing body of data supports the beneficial effects of oral photoprotection on the health of the skin. More studies will likely confirm and expand the positive impact of oral dietary botanicals as complementary measures for photoprotection.

Nutraceuticals for Skin Care: A Comprehensive Review of Human Clinical Studies

The skin is the body’s largest organ, it participates in sensitivity and offers protection against microorganisms, chemicals and ultraviolet (UV) radiation. Consequently, the skin may suffer alterations such as photo-ageing, immune dysfunction and inflammation which may significantly affect human health. Nutraceuticals represent a promising strategy for preventing, delaying, or minimising premature ageing of the skin and also to alleviate certain skin disorders. Among them, bioactive peptides and oligosaccharides, plant polyphenols, carotenoids, vitamins and polyunsaturated fatty acids are the most widely used ingredients. Supplementation with these products has shown evidence of having an effect on the signs of ageing and protection against UV radiation ageing in several human trials. In this review, the most relevant human studies on skin nutraceuticals are evaluated and the statistical resolution, biological relevance of their results, and, the trial protocols are discussed. In conclusion, quality and rigorousness of the trials must be improved to build credible scientific evidence for skin nutraceuticals and to establish a cause-effect relationship between the ingredients the beneficial effects for the skin.

Probiotics-mediated suppression of cancer

PURPOSE OF REVIEW

Probiotics can be used as an adjuvant for cancer prevention or/and treatment through their abilities to modulate intestinal microbiota and host immune response. Although most of the recent reviews have focused on the potential role of probiotics against colon cancer, only few of them include the probiotic effect on extraintestinal cancers. The present review covers the most important findings from the literature published during the past 20 months (from January 2015 to August 2016) regarding the probiotics-mediated suppression of both gastrointestinal and extraintestinal cancers and the underlying mechanisms.

RECENT FINDINGS

A comprehensive literature search in Pubmed, Science direct and Google scholar databases was conducted to locate all relevant articles that investigated the effect of probiotics on prevention/treatment of both gastrointestinal and extraintestinal cancers. Different mechanisms for the beneficial effects of probiotics against cancer were also discussed, mainly via modulation of gut microbiota which thereby influences host metabolism and immunity.

SUMMARY

Despite laboratory-based studies having demonstrated encouraging outcomes that probiotics possess antitumor effects, the benefits should not be exaggerated before we get more results from human clinical trials. These are very important before the medical community can accept the use of probiotics as an alternative therapy for cancer control.

The role of microbiota, and probiotics and prebiotics in skin health

During the past decade, scientists have made great strides in understanding the microbiome's role in human health. Today, the microbiome has become key in scientific research, therapeutic development, medical treatment, and as a news feature in the media. Most studies have focused on the microbiome of our gut, but recently researchers have turned their attention to other microbiomes, including that of the skin. These studies of gut and skin microbiomes are yielding very informative results, new treatment strategies, and the development of new prebiotic and probiotic products for the treatment of many skin conditions.

Message in a Bottle: Dialog between Intestine and Skin Modulated by Probiotics

At the beginning, probiotics were used exclusively for gastrointestinal conditions. However, over the years, evidence has shown that probiotics exert systemic effects. In this review article, we will summarize recent reports that postulate probiotic treatment as an efficient one against skin pathologies, such as cancer, allergy, photoaging and skin infections. The focus will be restricted to oral probiotics that could potentially counteract the ultraviolet irradiation-induced skin alterations. Moreover, the possible underlying mechanisms by which probiotics can impact on the gut and exert their skin effects will be reviewed. Furthermore, how the local and systemic immune system is involved in the intestine-cutaneous crosstalk will be analyzed. In conclusion, this article will be divided into three core ideas: (a) probiotics regulate gut homeostasis; (b) gut and skin homeostasis are connected; (c) probiotics are a potentially effective treatment against skin conditions.

Health effects of probiotics on the skin

Skin is the largest organ of the body and is constantly exposed to physical, chemical, bacterial, and fungal challenges. It is well known that probiotics are helpful for specific disorders and different clinical studies have indicated that probiotics have special effects in cutaneous apparatus directly or indirectly that can be considerable from versatile aspects. Probiotic bacteriotherapy can have great potential in preventing and treating the skin diseases including eczema, atopic dermatitis, acne, and allergic inflammation or in skin hypersensitivity, UV-induced skin damage, wound protection, and as a cosmetic product. The current paper comprehensively reviews the different health effects of probiotics on the skin.

The administration of probiotics and synbiotics in immune compromised adults: is it safe?

This study aimed to systematically evaluate safety of probiotics and synbiotics in immune compromised adults (≥18 years). Safety was analysed using the Common Terminology Clinical Adverse Events (CTCAE version 4.0) classification, thereby providing an update on previous reports using the most recent available clinical data (2008-2013). Safety aspects are represented and related to number of participants per probiotic strain/culture, study duration, dosage, clinical condition and selected afflictions. Analysis of 57 clinical studies indicates that probiotic and/or synbiotic administration in immune compromised adults is safe with regard to the current evaluated probiotic strains, dosages and duration. Individuals were considered immune compromised if HIV-infected, critically ill, underwent surgery or had an organ- or an autoimmune disease. There were no major safety concerns in the study, as none of the serious adverse events (AE)s were related, or suspected to be related, to the probiotic or synbiotic product and the study products were well tolerated. Overall, AEs occurred less frequent in immune compromised subjects receiving probiotics and/or synbiotics compared to the control group. In addition, the results demonstrated a flaw in precise reporting and classification of AE in most studies. Furthermore, generalisability of conclusions are greatly limited by the inconsistent, imprecise and potentially incomplete reporting as well as the variation in probiotic strains, dosages, administration regimes, study populations and reported outcomes. We argue that standardised reporting on adverse events (CTCAE) in 'food' studies should be obligatory, thereby improving reliability of data and re-enforcing the safety profile of probiotics.

Brazilian consensus on photoprotection

Brazil is a country of continental dimensions with a large heterogeneity of climates and massive mixing of the population. Almost the entire national territory is located between the Equator and the Tropic of Capricorn, and the Earth axial tilt to the south certainly makes Brazil one of the countries of the world with greater extent of land in proximity to the sun. The Brazilian coastline, where most of its population lives, is more than 8,500 km long. Due to geographic characteristics and cultural trends, Brazilians are among the peoples with the highest annual exposure to the sun. Epidemiological data show a continuing increase in the incidence of non-melanoma and melanoma skin cancers. Photoprotection can be understood as a set of measures aimed at reducing sun exposure and at preventing the development of acute and chronic actinic damage. Due to the peculiarities of Brazilian territory and culture, it would not be advisable to replicate the concepts of photoprotection from other developed countries, places with completely different climates and populations. Thus the Brazilian Society of Dermatology has developed the Brazilian Consensus on Photoprotection, the first official document on photoprotection developed in Brazil for Brazilians, with recommendations on matters involving photoprotection.

The effect of probiotics on immune regulation, acne, and photoaging

Probiotics are live micro-organisms that provide a health benefit to the host. The role of probiotics in the management of disease, as well as immune modification, has recently experienced a renewed interest in society, as probiotics can be found in products ranging from yogurt to facial creams. In this article, we discuss the role of probiotics in the development of the immune system, the treatment of acne and rosacea, and protection against aging and photodamage.

Gastrointestinal Tract Commensal Bacteria and Probiotics: Influence on End-Organ Physiology

Bacteria represent the earliest form of independent life on this planet. Bacterial development has included cooperative symbiosis with plants (e.g., Leguminosae family and nitrogen fixing bacteria in soil) and animals (e.g., the gut microbiome). It is generally agreed upon that the fusion of two prokaryotes evolutionarily gave rise to the eukaryotic cell in which mitochondria may be envisaged as a genetically functional mosaic, a relic from one of the prokaryotes. This is expressed by the appearance of mitochondria in eukaryotic cells (an alpha-proteobacteria input), a significant endosymbiotic evolutionary event. As such, the evolution of human life has been complexly connected to bacterial activities. Hence, microbial colonization of mammals has been a progressively driven process. The interactions between the human host and the microbiome inhabiting the gastrointestinal tract (GIT) for example, afford the human host the necessary cues for the development of regulated signals that in part are induced by reactive oxygen species (ROS). This regulated activity then promotes immunological tolerance and metabolic regulation and stability, which then helps establish control of local and extraintestinal end-organ (e.g., kidneys) physiology. Pharmacobiotics, the targeted administration of live probiotic cultures, is an advancing area of potential therapeutics, either directly or as adjuvants. Hence the continued scientific understanding of the human microbiome in health and disease may further lead to fine tuning the targeted delivery of probiotics for a therapeutic gain.

Can dietary intake influence perception of and measured appearance? A systematic review

Appearance-based interventions have had some success in reducing smoking and sun exposure. Appearance may also motivate dietary behavior change if it was established that dietary improvement had a positive impact on appearance. The aims of this review are to evaluate the current evidence examining the relationship between dietary intake and appearance and to determine the effectiveness of dietary interventions on perceived or actual appearance. An electronic search of English-language studies up to August 2012 was conducted using Cochrane, MEDLINE, Embase, CINAHL, Web of Science, SCOPUS, and PsycINFO databases. Studies that included participants aged at least 18 years, that observed or altered dietary intake from actual food or dietary supplement use, and assessed appearance-related outcomes were considered eligible. Data from 27 studies were extracted and assessed for quality using standardized tools. Nineteen studies were assessed as being of "positive" and 4 of "neutral" quality. All observational studies (n = 4741 participants) indicated that there was a significant association between various aspects of dietary intake and skin coloration and skin aging. The majority (16 studies, 769 participants) evaluated the effect of dietary supplements on skin appearance among women. Only 1 study examined the effect of actual food intake on appearance. Significant improvements in at least 1 actual or perceived appearance-related outcome (facial wrinkling, skin elasticity, roughness, and skin color) following dietary intervention were shown as a result of supplementation. Further studies are needed in representative populations that examine actual food intake on appearance, using validated tools in well-designed high-quality randomized control trials.

The overarching influence of the gut microbiome on end-organ function: the role of live probiotic cultures

At the time of birth, humans experience an induced pro-inflammatory beneficial event. The mediators of this encouraged activity, is a fleet of bacteria that assault all mucosal surfaces as well as the skin. Thus initiating effects that eventually provide the infant with immune tissue maturation. These effects occur beneath an emergent immune system surveillance and antigenic tolerance capability radar. Over time, continuous and regulated interactions with environmental as well as commensal microbial, viral, and other antigens lead to an adapted and maintained symbiotic state of tolerance, especially in the gastrointestinal tract (GIT) the organ site of the largest microbial biomass. However, the perplexing and much debated surprise has been that all microbes need not be targeted for destruction. The advent of sophisticated genomic techniques has led to microbiome studies that have begun to clarify the critical and important biochemical activities that commensal bacteria provide to ensure continued GIT homeostasis. Until recently, the GIT and its associated micro-biometabolome was a neglected factor in chronic disease development and end organ function. A systematic underestimation has been to undervalue the contribution of a persistent GIT dysbiotic (a gut barrier associated abnormality) state. Dysbiosis provides a plausible clue as to the origin of systemic metabolic disorders encountered in clinical practice that may explain the epidemic of chronic diseases. Here we further build a hypothesis that posits the role that subtle adverse responses by the GIT microbiome may have in chronic diseases. Environmentally/nutritionally/and gut derived triggers can maintain microbiome perturbations that drive an abnormal overload of dysbiosis. Live probiotic cultures with specific metabolic properties may assist the GIT microbiota and reduce the local metabolic dysfunctions. As such the effect may translate to a useful clinical treatment approach for patients diagnosed with a metabolic disease for end organs such as the kidney and liver. A profile emerges that shows that bacteria are diverse, abundant, and ubiquitous and have significantly influenced the evolution of the eukaryotic cell.

Active ingredients against human epidermal aging

The decisive role of the epidermis in maintaining body homeostasis prompted studies to evaluate the changes in epidermal structure and functionality over the lifetime. This development, along with the identification of molecular mechanisms of epidermal signaling, maintenance, and differentiation, points to a need for new therapeutic alternatives to treat and prevent skin aging. In addition to recovering age- and sun-compromised functions, proper treatment of the epidermis has important esthetic implications. This study reviews active ingredients capable of counteracting symptoms of epidermal aging, organized according to the regulation of specific age-affected epidermal functions: (1) several compounds, other than retinoids and derivatives, act on the proliferation and differentiation of keratinocytes, supporting the protective barrier against mechanical and chemical insults; (2) natural lipidic compounds, as well as glycerol and urea, are described as agents for maintaining water-ion balance; (3) regulation of immunological pathogen defense can be reinforced by natural extracts and compounds, such as resveratrol; and (4) antioxidant exogenous sources enriched with flavonoids and vitamin C, for example, improve solar radiation protection and epidermal antioxidant activity. The main objective is to provide a functional classification of active ingredients as regulatory elements of epidermal homeostasis, with potential cosmetic and/or dermatological applications.

Lipoteichoic acid from Lactobacillus rhamnosus GG as an oral photoprotective agent against UV-induced carcinogenesis

Probiotics are live micro-organisms that when administered in adequate amounts confer a health benefit on the host. Cell surface molecules of these micro-organisms are being studied in relation to their ability to interact with the host. The cell wall of lactobacilli possesses lipoteichoic acids (LTA) which are molecules with immunomodulatory properties. UV radiation (UVR) has been proposed as the main cause of skin cancer because of its mutagenic and immunosuppressive effects. Photoprotection with some nutrition interventions including probiotics has recently been shown. The aim of the present study was to investigate whether the oral administration of purified LTA from Lactobacillus rhamnosus GG can modulate the immune-suppressive effect of UVR and skin tumour development in female Crl:SKH-1-hrBR mice. For this purpose, two irradiation models were studied: (1) a chronic irradiation scheme consisting of daily irradiations during twenty consecutive days and (2) a long-term irradiation schedule, irradiating the animals three times per week, during 34 weeks for tumour development. The results showed that T-cells in the inguinal lymph node of LTA-treated mice produced higher levels of (1) interferon-γ and (2) a number of total, helper and cytotoxic T-cells compared with non-treated mice. Moreover, a significant delay in tumour appearance was found in LTA-treated mice. An increased IgA+ cell number was found in the small intestine together with a higher number of activated dendritic cells in the mesenteric lymph nodes. The latter results might be indicative of a direct effect of LTA in the gut, affecting the cutaneous immune system and restoring homeostasis through the gut–skin axis.

You are what you eat: within-subject increases in fruit and vegetable consumption confer beneficial skin-color changes

BACKGROUND

Fruit and vegetable consumption and ingestion of carotenoids have been found to be associated with human skin-color (yellowness) in a recent cross-sectional study. This carotenoid-based coloration contributes beneficially to the appearance of health in humans and is held to be a sexually selected cue of condition in other species.

METHODOLOGY AND PRINCIPAL FINDINGS

Here we investigate the effects of fruit and vegetable consumption on skin-color longitudinally to determine the magnitude and duration of diet change required to change skin-color perceptibly. Diet and skin-color were recorded at baseline and after three and six weeks, in a group of 35 individuals who were without makeup, self-tanning agents and/or recent intensive UV exposure. Six-week changes in fruit and vegetable consumption were significantly correlated with changes in skin redness and yellowness over this period, and diet-linked skin reflectance changes were significantly associated with the spectral absorption of carotenoids and not melanin. We also used psychophysical methods to investigate the minimum color change required to confer perceptibly healthier and more attractive skin-coloration. Modest dietary changes are required to enhance apparent health (2.91 portions per day) and attractiveness (3.30 portions).

CONCLUSIONS

Increased fruit and vegetable consumption confers measurable and perceptibly beneficial effects on Caucasian skin appearance within six weeks. This effect could potentially be used as a motivational tool in dietary intervention.

Photoprotective potential of Cordyceps polysaccharides against ultraviolet B radiation-induced DNA damage to human skin cells

BACKGROUND

Ultraviolet (UV) radiation causes DNA damage resulting in photoageing and skin cancer. UVB (290-320 nm) interacts directly with DNA, inducing two major photoproducts: cyclobutane-pyrimidine dimers (CPDs) and (6-4) pyrimidine-pyrimidone photoproducts. Cordyceps sinensis (Berk.) Sacc. is a medicinal fungus with reported anticancer and cytoprotective effects.

OBJECTIVES

To investigate genoprotective effects of polysaccharide-rich Cordyceps mycelial components against UVB-induced damage in normal human fibroblast cells.

METHODS

Cultured human fibroblasts (BJ cells) were treated for 30 min and, separately, for 24 h with hot water extract of Cordyceps fungal mycelia or exopolysaccharides. Cells were washed, irradiated with UVB (302 nm), and immediately lysed, after which DNA damage, as strand breaks, was measured using an enzyme-assisted comet assay that detects CPDs.

RESULTS

DNA damage in UVB-irradiated cells was significantly lowered (P < 0·01) with Cordyceps pretreatment. Similar results were seen with 30 min and 24 h pretreatment. Specifically, and in comparison with irradiated cells with no Cordyceps pretreatment, there was a 27% reduction in CPDs in irradiated cells with 24 h pretreatment with 200 μg mL(-1) of the hot water Cordyceps extract, and a 34% reduction with 24 h pretreatment with 200 μg mL(-1) of the exopolysaccharide extract.

CONCLUSIONS

Clear evidence of protection against UVB-induced CPDs was seen with Cordyceps mycelial extracts. Results indicate that Cordyceps may offer photoprotection and lower the risk of basal cell carcinoma, the main skin cancer caused by CPDs. Further study is needed to identify protective mechanisms.