Update on the Malassezia associated skin diseases.

A. Velegraki Dept. of Microbiology

Medical School National and Kapodistrian University of Athens

25/11/2016

Disclaimer

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Unrestricted research grants & honoraria Astellas Gilead L’Oréal, Paris (R&D) MSD Pfizer Procter & Gamble, USA (R&D)

One health Concept

• Unites Human Health, Animal Health, and the Environment • Promotes communication and collaboration

among people working in different fields

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On that premise

• Fungal infections of skin, hair and nails affect

~1 billion people globally. • In the US studies estimated 4M outpatient

medical visits.

Vos et al. Lancet 2012; 380:2163–2196 Panackal et al. Int J Dermatol. 2009 Jul;48(7):704-12.

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Non-inflammatory condition

pityriasis versicolor (PV)

PLoS Pathog 11(1): e1004523. doi:10.1371/journal.ppat.1004523 http://journals.plos.org/plospathogens/article?id=info:doi/10.1371/journal.ppat.1004523

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Inflammatory conditions I

Folliculitis Seborrhoeic dermatitis

PLoS Pathog 11(1): e1004523. doi:10.1371/journal.ppat.1004523 http://journals.plos.org/plospathogens/article?id=info:doi/10.1371/journal.ppat.1004523

Courtesy E. Guého, in Malassezia and the Skin, Springer 2010

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Seborrheic Dermatitis and Dandruff

Schwartz et al. Acta Derm Venereol. 2013 27;93:131-7

Seborrhoeic blepharitis Demodex blepharitis

Inflammatory conditions II (Malssezia and its . . skin microbiome “ally?”)

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Atopic dermatitis

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Malassezia yeasts seem to participate in the extrinsic and intrinsic forms of AD

Bieber T. N Engl J Med 2008;358:1483-94; Sugita T. et al. J Clin Microbiol 2001; 39: 3486–3490 Saunders et al. PLoS Pathog. 2012;8(6):e1002701. doi: 10.1371/journal.ppat.1002701. Gaitanis et al. Clinics in Dermatol. 2013; 31, 445-463

Gathering evidence on the presence of Malassezia in lesions and healthy skin

Culture on non- culture?

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Skin specimen test procedures

Updating the old question

• Swabs • Scrapings • Washing • Scotch tape • Transparent dressing,

Opsite™ (Smith & Nephew)

• Microscopy (KOH, fluorescence, gram stain)

• Culture media modified Dixon (mDIX), Leeming and Notman agar (LNA)

• Real time PCR

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Sampling with Opsite™ and testing by real time PCR

Sugita et al. In Malassezia and the Skin, Springer Verlag, Berlin-Heidelberg 2010 25/11/2016

But need strain

Kolecka et al. Brit J Dermatol. 2014; 170: 332-341

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Malassezia pachydermatis • Thus far the most polymorphic lipophilic yeast (phenonotypically and genotypically. • In constant interaction with animal skin microenvironment • Isolated from the skin of diverse range of carnivore animals and the skin of humans (dog owners) • Become pathogenic under the influence of predisposing factors

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Midreuil et al. Int J Syst Bacteriol 1999; 49: 1287–1294 Cafarchia et al. J Clin Microbiol 2004; 42: 4868–4869 Bond et al. In: Malassezia and the Skin 2010. Springer. pp 271–299.

Human skin Malassezia yeasts

Genetic variations

Environmentalfactors

Genetic variations

Environmentalfactors

Susceptible individuals - genetic predisposition

Pathogenic strains Pathogenicity traits

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In extreme environments Sugita et al. Med. Mycol. 2015, 53, 717-724; Med. Mycol 2016,

doi 10.1093/mmy/myv121

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Interactions with the epidermis and properties

of the Malassezia metabolome:

25/11/2016 Gaitanis et al. Clinics in Dermatol. (2013) 31,455-436

Enzymes & allergens sensitize susceptible hosts. Indole metabolites modify the function of melanocytes & dendritic cells

The Malassezia metabolome and its properties

Melanin production

Tryptophan as sole nitrogen source indole alkaloid production

Mayser P et al, Arch Dermatol Res. 1998;290(5):277-82. Gaitanis et al. J Clin Microbiol. 2005; 43: 4147-51

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Extracts from L-tryptophan grown M. furfur strains isolated by HPLC & characterized by NMR

and Mass spectroscopy

Healthy skin isolates Seborrheic dermatitis isolates

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Gaitanis et al. J Invest Dermatol. 2008 Jul;128(7):1620-5. Mexia et al. Arch Biochem Biophys. 2015 Apr 1;571:16-20 Giatanis et al. Med Hypotheses. 2011 Jul;77(1):47-51

Indicative Extracts

• M. furfur extracts from SD and healthy skin

• A: indolo-3-carboxaldehyde

• M: Malassezin • ICZ: indolo[3,2-b]

carbazole (Novel isolate)

• P: pityriacitrin

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Malassezin

Indicative bioactive properties • Reduces melanin synthesis

and inhibits transfer of melanin from melanocytes to keratocytes

• Induces the apoptosis of melanocytes

• It is an AhR ligand although it does not fulfill the basic structural characteristics.

No sunburn?

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Model showing the putative interactions of Malassezia yeasts with the skin.

Velegraki A, Cafarchia C, Gaitanis G, Iatta R, Boekhout T (2015) Malassezia Infections in Humans and Animals: Pathophysiology, Detection, and Treatment. PLoS Pathog 11(1): e1004523. doi:10.1371/journal.ppat.1004523 http://journals.plos.org/plospathogens/article?id=info:doi/10.1371/journal.ppat.1004523

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indolo[3,2-b] carbazole (ICZ)

Bioactivity • One of the most active AhR

agonists (dioxin receptor) in vitro (EC50=2.6x10-7M)

• Regulates AhR expression depended genes like dioxin but it is removed from the body and does not exhibit the dioxin toxic

• Induces transientCYP1A1 in the liver

Are Malassezia metabolites active against other fungi of the skin microbiota or oter pathogenic fungi? What is the concentration of these metabolites in the skin?

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Malassezia indole inhibitory activity

• Against Aspergillus, Candida Cryptococcus, Rhizopus, Fusarium spp. and Exophiala dermatitidis

• These concentrations are significant as they are detectible in loco (diseased skin)

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Velegraki et al. Spring EADV, 2016

Conclusions

• Malassezia infections are of public health significance • Human and other vertabrate Malassezia commencals interact with

the environment leading to increased colonization and disease. • Malassezia L-tryptophan alkaloids are statistically correlated with

disease severity: seborrhoic dermatitis > pityriasis versicolor > dandruff > healthy

• Malassezia inflammatory conditions may be risk factors for other skin diseases due to their metabolite interactions with the host and response to the UV intensity and dosimetry

• Malassezia metabolites show activity against other fungi.

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26

Malassezia and the skin. Springer-Verlag, 2010

Τα ινδολικά παράγωγά τους διεγείρουν τον

υποδοχέα διοξίνης (AhR) in loco (δέρμα)

Journal of Investigative Dermatology advance online publication, 4 April 2013