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Elevated skin surface pH has been reported in patients with atopic dermatitis (AD). Here we explored the role of skin pH in the pathogenesis of AD using the NC/Tnd murine AD model. Alkalinization of the skin of asymptomatic NC/Tnd mice housed in specific pathogen-free (SPF) conditions induced KLK5 and activated the protease-activated receptor 2 (PAR2), resulting in thymic stromal lymphopoietin (TSLP) secretion and a cutaneous T-helper 2 allergic response. This was associated with increased trans-epidermal water loss and development of eczematous lesions in these SPF NC/Tnd mice, which normally do not suffer from AD. Injection of recombinant TSLP also induced scratching behavior in the SPF NC/Tnd mice. TSLP production and dermatitis induced by alkalinization of the skin could be blocked by the PAR2 antagonist ENMD-1068. In contrast, weak acidification of eczematous skin in conventionally housed NC/Tnd mice reduced kallikrein (KLK) 5　activity and ameliorated the dermatitis. Onset of the dermatitis was associated with increased epidermal filaggrin expression and impaired activity of the sodium/hydrogen exchanger NHE1, a known regulator of skin pH. We conclude that alterations in skin pH directly modulate KLK5 activity leading to skin barrier dysfunction, itch, and dermatitis via the PAR2-TSLP pathway.Journal of Investigative Dermatology accepted article preview online, 22 September 2015. doi:10.1038/jid.2015.363.

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