Ioannis D. Bassukas

The Malassezia Genus in Skin and Systemic Diseases

SUMMARY In the last 15 years, the genus Malassezia has been a topic of intense basic research on taxonomy, physiology, biochemistry, ecology, immunology, and metabolomics. Currently, the genus encompasses 14 species. The 1996 revision of the genus resulted in seven accepted taxa: M. furfur, M. pachydermatis, M. sympodialis, M. globosa, M. obtusa, M. restricta, and M. slooffiae. In the last decade, seven new taxa isolated from healthy and lesional human and animal skin have been accepted: M. dermatis, M. japonica, M. yamatoensis, M. nana, M. caprae, M. equina, and M. cuniculi. However, forthcoming multidisciplinary research is expected to show the etiopathological relationships between these new species and skin diseases. Hitherto, basic and clinical research has established etiological links between Malassezia yeasts, pityriasis versicolor, and sepsis of neonates and immunocompromised individuals. Their role in aggravating seborrheic dermatitis, dandruff, folliculitis, and onychomycosis, though often supported by histopathological evidence and favorable antifungal therapeutic outcomes, remains under investigation. A close association between skin and Malassezia IgE binding allergens in atopic eczema has been shown, while laboratory data support a role in psoriasis exacerbations. Finally, metabolomic research resulted in the proposal of a hypothesis on the contribution of Malassezia-synthesized aryl hydrocarbon receptor (AhR) ligands to basal cell carcinoma through UV radiation-induced carcinogenesis.

Melanin absorption spectroscopy: new method for noninvasive skin investigation and melanoma detection

We present a new method for studying melanin in vivo based on diffuse reflectance spectroscopy of human skin. We find that the optical absorption spectrum of in vivo melanin exhibits an exponential dependence on wavelength, consistent with, but with a higher decay slope than, in vitro results. We offer theoretical justification for this exponential dependence on the basis of a recently proposed model for the structure of eumelanin protomolecules. Moreover, we report on a new method for analysis of diffuse reflectance spectra, which identifies intrinsic differences in absorption spectra between malignant melanoma and dysplastic nevi in vivo. These preliminary results are confirmed both by analysis of our own clinical data as well as by analysis of data from three independent, previously published studies. In particular, we find evidence that the histologic transition from dysplastic nevi to melanoma in situ and then to malignant melanoma is reflected in the melanin absorption spectra. Our results are very promising for the development of techniques for the noninvasive detection of melanoma and, more generally, for the study and characterization of pigmented skin lesions. It is also a promising approach for a better understanding of the biological role, structure, and function of melanin.

AhR Ligands, Malassezin, and Indolo[3,2-b]Carbazole are Selectively Produced by Malassezia furfur Strains Isolated from Seborrheic Dermatitis

Malassezia yeasts are connected with seborrheic dermatitis (SD) whereas M. furfur pathogenicity is associated with the production of bioactive indoles. In this study, the production of indoles by M. furfur isolates from healthy and diseased skin was compared, the respective HPLC patterns were analyzed, and substances that are preferentially synthesized by strains isolated from SD lesions were isolated and characterized. Malassezin, pityriacitrin, indole-3-carbaldehyde, and indolo[3,2-b]carbazole (ICZ) were isolated by HPLC from extracts of M. furfur grown in L-tryptophan agar, and identified by nuclear magnetic resonance and mass spectroscopy. Of these, ICZ, a potent ligand of the aryl hydrocarbon receptor (AhR), is described for the first time to our knowledge as a M. furfur metabolite. HPLC-photodiode array detection analysis of strain extracts from 7 healthy subjects and 10 SD patients showed that M. furfur isolates from only SD patients consistently produce malassezin and ICZ. This discriminatory production of AhR agonists provides initial evidence for a previously unreported mechanism triggering development of SD and indicates that the variable pathogenicity patterns recorded for M. furfur-associated SD conditions may be attributed to selective production (P<0.001) of measurable bioactive indoles.

Skin diseases associated with Malassezia yeasts: Facts and controversies

The implication of the yeast genus Malassezia in skin diseases has been characterized by controversy, since the first description of the fungal nature of pityriasis versicolor in 1846 by Eichstedt. This is underscored by the existence of Malassezia yeasts as commensal but also by their implication in diseases with distinct absence of inflammation despite the heavy fungal load (pityriasis versicolor) or with characteristic inflammation (eg, seborrheic dermatitis, atopic dermatitis, folliculitis, or psoriasis). The description of 14 Malassezia species and subsequent worldwide epidemiologic studies did not reveal pathogenic species but rather disease-associated subtypes within species. Emerging evidence demonstrates that the interaction of Malassezia yeasts with the skin is multifaceted and entails constituents of the fungal wall (melanin, lipid cover), enzymes (lipases, phospholipases), and metabolic products (indoles), as well as the cellular components of the epidermis (keratinocytes, dendritic cells, and melanocytes). Understanding the complexity of their interactions will highlight the controversies on the clinical presentation of Malassezia-associated diseases and unravel the complexity of skin homeostatic mechanisms.

Drug-induced bullous pemphigoid in diabetes mellitus patients receiving dipeptidyl peptidase-IV inhibitors plus metformin

Background  Preclinical data and reports of adverse skin reactions in patients treated with dipeptidyl peptidase‐IV inhibitors (gliptins) have increased awareness towards skin‐targeting side‐effects of these anti‐hyperglycaemic drugs. Bullous pemphigoid (BP), sometimes drug‐induced, is the most commonly acquired autoimmune blistering dermatosis in western countries, typically a disease of the elderly people with significant morbidity and excess mortality.

Cryosurgery during topical imiquimod: a successful combination modality for lentigo maligna

Background  Either cryosurgery or topical imiquimod have been used to treat patients with lentigo maligna in cases where surgery is not feasible.

Tuberculin Skin Test Overestimates Tuberculosis Hypersensitivity in Adult Patients with Psoriasis

Background: Tuberculin skin testing (TST) is still the reference method for the diagnosis of latent tuberculosis infection (LTBI). Objective: To evaluate the effect of psoriasis on TST. Methods: Comparison of TST results of consecutive dermatology (n = 91) and internal medicine (n = 615) inpatients. TST was uniformly ordered, performed and evaluated according to the Mantoux method using purified protein derivative. Results: (a) Significantly larger TST indurations were measured in dermatology (median: 7 mm) compared to internal medicine inpatients (median: <1 mm; p < 0.0001). More dermatology inpatients showed ‘positive’ (>5 mm) and ‘strongly positive’ (≥15 mm) TST results (53 vs. 29% and 22 vs. 13%, respectively). (b) Among dermatology inpatients, the TST reactions were significantly larger (p < 0.01) in psoriatics (n = 28) compared to the remaining patients (n = 63). (c) In psoriatics, the TST correlated positively with the psoriasis area and severity index score (p = 0.015). Conclusion: Overt psoriasis is associated with increased TST measurements. This observation is suggestive of a possible overtreatment of these patients for LTBI.

The range of molecular methods for typing Malassezia.

Purpose of review The recent sequencing of the whole genome of Malassezia globosa and M. restricta forms the basis for molecular epidemiology studies and instigates investigations into their respective virulence factors. Thus, reviewing current knowledge on Malassezia molecular typing methods would reveal the pros and cons of each method and would highlight potential scarcity of epidemiological data regarding this ubiquitous fungal commensal and pathogen. Recent findings Methods employed for Malassezia molecular typing can be categorized into those detecting sequence variations of strains and those that selectively amplify polymorphic DNA markers for discriminating Malassezia species subtypes. The former exploit rRNA gene sequence variations in order to trace M. globosa, M. restricta and M. pachydermatis subtypes associated with specific skin diseases, or detect M. furfur geographical variations. Polymorphic DNA amplification methods, such as amplified fragment length polymorphism analysis, demonstrated association of M. furfur subtypes with the origin of the strain (skin or systemic isolate), whereas PCR-fingerprinting of the mini-satellite DNA clustered M. furfur strains according to their geographic origin and disease origin. Moreover, much typing work has already been performed regarding the zoophilic species M. pachydermatis and the relevant methods can be adapted for studying the anthropophilic Malassezia species. Summary In the near future, molecular typing will be a powerful tool in epidemiological studies that could be employed for the elucidation of the pathobiology of Malassezia species in associated skin diseases.

Immunocryosurgery for basal cell carcinoma: results of a pilot, prospective, open-label study of cryosurgery during continued imiquimod application.

Background/aim  Theoretical considerations support the combination of cryosurgery and topical imiquimod to treat basal cell carcinomas (BCC). The aim of the present study was to test the feasibility and efficacy of ‘cryosurgery during continued imiquimod application’ (‘immunocryosurgery’) to treat ‘high‐risk‐for‐recurrence’ BCCs.

Comparative evaluation of two simple diffuse reflectance models for biological tissue applications

We present a comparative evaluation of two simple diffuse reflectance models for biological tissue applications. One model is based on a widely accepted and used in biomedical optics implementation of diffusion theory, and the other one is based on a semiempirical approach derived from basic physical principles. We test the models on tissue phantoms and on human skin, utilizing a standard six-around-one optical fiber probe for light delivery and collection. We show that both models are suitable for use with an optical fiber probe and illustrate the potential, applicability, and validity range of the models.