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Chen M, Wang R, Wang T. Gut microbiota and skin pathologies: Mechanism of the gut-skin axis in atopic dermatitis and psoriasis. Int Immunopharmacol 2024; 141:112658. [PMID: 39137625 DOI: 10.1016/j.intimp.2024.112658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/01/2024] [Accepted: 07/07/2024] [Indexed: 08/15/2024]
Abstract
Atopic dermatitis (AD) and psoriasis are chronic skin diseases with a global impact, posing significant challenges to public health systems and severely affecting patients' quality of life. This review delves into the key role of the gut microbiota in these diseases, emphasizing the importance of the gut-skin axis in inflammatory mediators and immune regulation and revealing a complex bidirectional communication system. We comprehensively assessed the pathogenesis, clinical manifestations, and treatment strategies for AD and psoriasis, with a particular focus on how the gut microbiota and their metabolites influence disease progression via the gut-skin axis. In addition, personalized treatment plans based on individual patient microbiome characteristics have been proposed, offering new perspectives for future treatment approaches. We call for enhanced interdisciplinary cooperation to further explore the interactions between gut microbiota and skin diseases and to assess the potential of drugs and natural products in modulating the gut-skin axis, aiming to advance the treatment of skin diseases.
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Affiliation(s)
- Meng Chen
- Department of Dermatology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, China
| | - Rui Wang
- Department of Dermatology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, China.
| | - Ting Wang
- Department of Dermatology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou 318000, China.
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Deodhar A, Blauvelt A, Lebwohl M, Feely M, Kronbergs A, Eberhart N, Zhu D, Inman E, Grace E, Holzkaemper T, Rahman P, Marzo-Ortega H, Papp KA, Merola JF, Gottlieb AB, Schwartzman S. Long-term safety of Ixekizumab in adults with psoriasis, psoriatic arthritis, or axial spondyloarthritis: a post-hoc analysis of final safety data from 25 randomized clinical trials. Arthritis Res Ther 2024; 26:49. [PMID: 38347650 PMCID: PMC10860236 DOI: 10.1186/s13075-023-03257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/27/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND We report long-term, end-of-study program safety outcomes from 25 randomized clinical trials (RCTs) in adult patients with psoriasis (PsO), psoriatic arthritis (PsA), or axial spondyloarthritis (axSpA) [including ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA)] who received ≥ 1 dose of Ixekizumab (IXE) over 5 years (PsO) or up to 3 years (PsA, axSpA). METHODS This integrated safety analysis consists of data from patients who received any dose of IXE, across 25 RCTs (17 PsO, 4 PsA, 4 axSpA). Rates of treatment-emergent adverse events (TEAEs), serious adverse events (SAEs) and selected adverse events (AEs) of interest were analyzed for all pooled studies by years of therapy and overall, through March 2022. Results were reported as exposure-adjusted incidence rates (IRs) per 100 patient-years (PY) overall and at successive year intervals. RESULTS Six thousand eight hundred ninety two adult patients with PsO, 1401 with PsA, and 932 with axSpA (including AS and nr-axSpA), with a cumulative IXE exposure of 22,371.1 PY were included. The most commonly reported TEAE across indications was nasopharyngitis (IRs per 100 PY: 8.8 (PsO), 9.0 (PsA), 8.4 (axSpA)). SAEs were reported by 969 patients with PsO (IR 5.4), 134 patients with PsA (IR 6.0), and 101 patients with axSpA (IR 4.8). Forty-five deaths were reported (PsO, n = 36, IR 0.2; PsA, n = 6, IR 0.3; axSpA, n = 3, IR 0.1). TEAEs did not increase during IXE exposure: IRs per 100 PY, PsO: 88.9 to 63.2 (year 0-1 to 4-5), PsA: 87 to 67.3 (year 0-1 to 2-3), axSpA: 82.1 to 55.4 (year 0-1 to > = 2). IRs per 100 PY of discontinuation from IXE due to AE were 2.9 (PsO), 5.1 (PsA), and 3.1 (axSpA). IRs per 100 PY of injection site reactions were 5.9 (PsO), 11.6 (PsA) and 7.4 (axSpA); Candida: 1.9 (PsO), 2.0 (PsA), and 1.2 (axSpA); depression, major adverse cerebro-cardiovascular events and malignancies: ≤ 1.6 across all indications. Adjudicated IRs per 100 PY of inflammatory bowel disease were ≤ 0.8 across indications (0.1 [PsO]; 0.1 [PsA]; 0.8 [axSpA]). CONCLUSIONS In this integrated safety analysis, consisting of over 22,000 PY of exposure, the long-term safety profile of IXE was found to be consistent with previous, earlier reports, with no new safety signals identified. TRIAL REGISTRATION NCT registration numbers for RCTs included in this integrated analysis can be found in Additional File 1.
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Affiliation(s)
- Atul Deodhar
- Oregon Health & Science University, Portland, OR, USA
| | | | | | - Meghan Feely
- Mount Sinai Hospital, New York, NY, USA
- Eli Lilly and Company, Indianapolis, IN, USA
- Mount Sinai West and Mount Sinai Morningside, New York, NY, USA
| | | | | | - Danting Zhu
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Elsa Inman
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Elsie Grace
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Proton Rahman
- Memorial University of Newfoundland, St. John's, NL, Canada
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds Institute for Rheumatic and Musculoskeletal Medicine, The University of Leeds, Leeds, UK
| | - Kim A Papp
- Probity Medical Research and Alliance Clinical Trials, Waterloo, ON, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joseph F Merola
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Peng XP, Al-Ddafari MS, Caballero-Oteyza A, El Mezouar C, Mrovecova P, Dib SE, Massen Z, Smahi MCE, Faiza A, Hassaïne RT, Lefranc G, Aribi M, Grimbacher B. Next generation sequencing (NGS)-based approach to diagnosing Algerian patients with suspected inborn errors of immunity (IEIs). Clin Immunol 2023; 256:109758. [PMID: 37678716 DOI: 10.1016/j.clim.2023.109758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/23/2023] [Accepted: 09/02/2023] [Indexed: 09/09/2023]
Abstract
The advent of next-generation sequencing (NGS) technologies has greatly expanded our understanding of both the clinical spectra and genetic landscape of inborn errors of immunity (IEIs). Endogamous populations may be enriched for unique, ancestry-specific disease-causing variants, a consideration that significantly impacts molecular testing and analysis strategies. Herein, we report on the application of a 2-step NGS-based testing approach beginning with targeted gene panels (TGPs) tailored to specific IEI subtypes and reflexing to whole exome sequencing (WES) if negative for Northwest Algerian patients with suspected IEIs. Our overall diagnostic yield of 57% is comparable to others broadly applying short-read NGS to IEI detection, but data from our localized cohort show some similarities and differences from NGS studies performed on larger regional IEI cohorts. This suggests the importance of tailoring diagnostic strategies to local demographics and needs, but also highlights ongoing concerns inherent to the application of genomics for clinical IEI diagnostics.
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Affiliation(s)
- Xiao P Peng
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany; Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
| | - Moudjahed Saleh Al-Ddafari
- Laboratory of Applied Molecular Biology and Immunology, W0414100, University of Tlemcen, Algeria; Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - Andres Caballero-Oteyza
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Germany
| | - Chahrazed El Mezouar
- Laboratory of Applied Molecular Biology and Immunology, W0414100, University of Tlemcen, Algeria; Pediatric Department, Medical Center University of Tlemcen, Faculty of Medicine, University of Tlemcen, Algeria
| | - Pavla Mrovecova
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - Saad Eddin Dib
- Pediatric Department, Medical Center University of Tlemcen, Faculty of Medicine, University of Tlemcen, Algeria
| | - Zoheir Massen
- Pediatric Department, Medical Center University of Tlemcen, Faculty of Medicine, University of Tlemcen, Algeria
| | - Mohammed Chems-Eddine Smahi
- Laboratory of Applied Molecular Biology and Immunology, W0414100, University of Tlemcen, Algeria; Specialized Mother-Child Hospital of Tlemcen, Department of Neonatology, Faculty of Medicine, University of Tlemcen, Algeria
| | - Alddafari Faiza
- Department of Internal Medicine, Medical Center University of Tlemcen, Faculty of Medicine, University of Tlemcen, Tlemcen, Algeria
| | | | - Gérard Lefranc
- Institute of Human Genetics, UMR 9002 CNRS-University of Montpellier, France
| | - Mourad Aribi
- Laboratory of Applied Molecular Biology and Immunology, W0414100, University of Tlemcen, Algeria.
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany; DZIF - German Center for Infection Research, Satellite Center Freiburg, Germany; CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Germany.
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Patini R, Gioco G, Rupe C, Contaldo M, Serpico R, Giuliani M, Lajolo C. Oral Candida and psoriasis: Is there association? A systematic review and trial sequential analysis. Oral Dis 2023; 29:3121-3135. [PMID: 36324299 DOI: 10.1111/odi.14422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 12/07/2023]
Abstract
To assess (i) the prevalence of oral colonization by Candida spp. in patients with psoriasis and (ii) the prevalence of oral lesions associated with Candida spp. in patients with psoriasis and identify the risk factors for oral lesions. A systematic review was conducted in accordance with PRISMA criteria. The PROSPERO registration code is CRD42019127178. PubMed, Scopus and Web of Science were used as search engines. Meta-analyses and trial sequential analyses were performed. Among the 5805 retrieved records, nine articles were included. Among 530 psoriatic patients, 255 patients had an oral Candida spp. colonisation with an odds ratio (OR) = 3.44 (95% CI:2.38-5.00). Among 490 psoriatic patients, 43 patients developed oral Candida spp. lesions with an OR = 5.31 (95% CI:1.04-27.23). Among the patients without the main predisposing factors for infections, psoriatic patients had a higher OR (3.48, 95% CI: 2.0-6.0) for Candida spp. colonization, but not for Candida spp. infection, when compared with healthy controls (p-value > 0.05). Meta-analysis showed a higher risk of Candida spp. colonisation in patients with psoriasis. Patients who received immunosuppressive therapies were also at higher risk of developing oral lesions. Further studies are needed to understand these associations.
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Affiliation(s)
- Romeo Patini
- Head and Neck Department, "Fondazione Policlinico Universitario A. Gemelli - IRCCS", School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gioele Gioco
- Head and Neck Department, "Fondazione Policlinico Universitario A. Gemelli - IRCCS", School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cosimo Rupe
- Head and Neck Department, "Fondazione Policlinico Universitario A. Gemelli - IRCCS", School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Contaldo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rosario Serpico
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Giuliani
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Carlo Lajolo
- Head and Neck Department, "Fondazione Policlinico Universitario A. Gemelli - IRCCS", School of Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy
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de Aguiar Cordeiro R, Reis AT, Lima XTV, de Andrade ARC, Aguiar ALR, Portela FVM, Pereira LMG, Moura SGB, da Silva BN, de Lima-Neto RG, Maia DCBSC, Rocha MFG, Sidrim JJC. Malassezia spp. and Candida spp. from patients with psoriasis exhibit reduced susceptibility to antifungals. Braz J Microbiol 2023; 54:169-177. [PMID: 36480120 PMCID: PMC9944151 DOI: 10.1007/s42770-022-00883-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Psoriasis is a chronic inflammatory disease that affects over 125 million people worldwide. Many studies have shown the importance of the microbiome for psoriasis exacerbation. AIM Explore the fungal load and species composition of cultivable yeasts on the skin of psoriatic patients (PP) and healthy volunteers living in a tropical area and evaluate the susceptibility to antifungals. METHODOLOGY A cross-sectional study with 61 participants (35 patients and 26 healthy controls) was performed during August 2018 and May 2019. Clinical data were collected from patient interviewing and/or medical records review. Samples were collected by swabbing in up to five anatomic sites. Suggestive yeast colonies were counted and further identified by phenotypical tests, PCR-REA, and/or MALDI-TOF. Susceptibility of Malassezia spp. and Candida spp. to azoles, terbinafine, and amphotericin B was evaluated by broth microdilution. RESULTS Nearly 50% of the patients had moderate to severe psoriasis, and plaque-type psoriasis was the most common clinical form. Yeast colonies count was significantly more abundant among PP than healthy controls. Malassezia and Candida were the most abundant genus detected in all participants. Higher MIC values for ketoconazole and terbinafine were observed in Malassezia strains obtained from PP. Approximately 42% of Candida isolates from PP showed resistance to itraconazole in contrast to 12.5% of isolates from healthy controls. MIC values for fluconazole and amphotericin B were significantly different among Candida isolates from PP and healthy individuals. CONCLUSION This study showed that Malassezia and Candida strains from PP presented higher MIC values to widespread antifungal drugs than healthy individuals.
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Shaheen MA, Dakhli AO, Hassen SI. Comparison between the Efficacy of Intense Pulsed Light (I.P.L.) versus Photo-dynamic Therapy (P.D.T.) with Methylene-Blue in the Treatment of Psoriatic nails. Photodiagnosis Photodyn Ther 2023; 41:103298. [PMID: 36682430 DOI: 10.1016/j.pdpdt.2023.103298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/12/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Nail affection is seen in up to 50 % of patients with skin psoriasis, although up to 5% of nail psoriatic patients do not complain of skin affection. Various treatment options are emerging for nail psoriasis such as intense pulsed light [1]. Methylene-blue (M.B) is a phenothiazine dye which is suggested to mediate cell cyto-toxicity by the generation of hydroxyl-radicals which change the intra-cellular calcium homeo-static mechanisms [2]. OBJECTIVES Evaluation and comparing the efficacy of I.P.L. and methylene-blue assisted photo-dynamic therapy for treating psoriatic nails. PATIENTS AND METHODS 20 patients with mild to moderate psoriasis with nail involvement. Sessions were performed once every 2 weeks on all the affected nails for a maximum of 3 months (6 sessions). Nail Psoriasis Severity Index (N.A.P.S.I.) score and photo-documentation were done for all the patients to assess the nail status at the first visit, after two, six sessions and three months after finishing the six session (0 m., 1 m., 3 m. and 6 m.). Nails of the right hand were treated with methylene-blue mediated photo-dynamic therapy using the Intense Pulsed Light (IPL) as the light source, while the left hand received conventional IPL (430-1200 nm) alone. RESULTS The present study showed that both treatments were effective on nail psoriasis, but MB-PDT was more effective in nail-bed lesions. There was no significant difference regarding patient satisfaction. CONCLUSION Both Intense Pulsed Light and methylene-blue assisted photo-dynamic therapy were safe, nearly pain-free, easy to use, and effective for treating nail psoriasis. MB-PDT is a new promising strategy for the treatment of nail psoriasis.
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Affiliation(s)
- Maha Adel Shaheen
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine - Ain Shams University
| | | | - Samah Ibrahim Hassen
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine - Ain Shams University.
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Lopes JP, Lionakis MS. Pathogenesis and virulence of Candida albicans. Virulence 2022; 13:89-121. [PMID: 34964702 PMCID: PMC9728475 DOI: 10.1080/21505594.2021.2019950] [Citation(s) in RCA: 128] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/08/2021] [Accepted: 12/14/2021] [Indexed: 12/18/2022] Open
Abstract
Candida albicans is a commensal yeast fungus of the human oral, gastrointestinal, and genital mucosal surfaces, and skin. Antibiotic-induced dysbiosis, iatrogenic immunosuppression, and/or medical interventions that impair the integrity of the mucocutaneous barrier and/or perturb protective host defense mechanisms enable C. albicans to become an opportunistic pathogen and cause debilitating mucocutaneous disease and/or life-threatening systemic infections. In this review, we synthesize our current knowledge of the tissue-specific determinants of C. albicans pathogenicity and host immune defense mechanisms.
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Affiliation(s)
- José Pedro Lopes
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Michail S. Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
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8
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Sachen KL, Arnold Greving CN, Towne JE. Role of IL-36 cytokines in psoriasis and other inflammatory skin conditions. Cytokine 2022; 156:155897. [DOI: 10.1016/j.cyto.2022.155897] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 12/15/2022]
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Sobecka-Frankiewicz M, Rudnicka J, Iwanicka-Grzegorek E, Mielczarek A. Oral changes in patients with psoriasis. Int J Dermatol 2022; 62:604-610. [PMID: 35834660 DOI: 10.1111/ijd.16350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/31/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
Psoriasis is one of the most frequent skin diseases. The cause of psoriasis is not fully expained as there are many factors (infectious, traumatic, hormonal, and chemical) that may play a role in the manifestation of its symptoms. One of the factors that may contribute to the appearance of psoriatic lesions may be the lesions in the oral cavity. The occurrence of lesions in the oral cavity is defined as rare, what can be explained by their nonspecific clinical image, and also by the possibility of being overlooked. Most characteristic symptoms of psoriasis occurring in the oral cavity are the geographic tongue and fissured tongue. It is also believed that there is a correlation between psoriasis and oral health- the periodontal and teeth condition as well as changes in saliva secretion. The psoriasis arthritis changes can also affect temporomandibular joint and impair the function of stomatognathic system. Because of these reports, cooperation of dermatologists and dentists in psoriasis care seems to be necessary.
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Affiliation(s)
| | - Joanna Rudnicka
- Department of Conservative Dentistry and Endodontics, Warsaw Medical University, Warsaw, Poland
| | - Ewa Iwanicka-Grzegorek
- Department of Conservative Dentistry and Endodontics, Warsaw Medical University, Warsaw, Poland
| | - Agnieszka Mielczarek
- Department of Conservative Dentistry and Endodontics, Warsaw Medical University, Warsaw, Poland
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Holzknecht J, Dubrac S, Hedtrich S, Galgóczy L, Marx F. Small, Cationic Antifungal Proteins from Filamentous Fungi Inhibit Candida albicans Growth in 3D Skin Infection Models. Microbiol Spectr 2022; 10:e0029922. [PMID: 35499318 PMCID: PMC9241769 DOI: 10.1128/spectrum.00299-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022] Open
Abstract
The emerging resistance of human-pathogenic fungi to antifungal drugs urges the development of alternative therapeutic strategies. The small, cationic antifungal proteins (AFPs) from filamentous ascomycetes represent promising candidates for next-generation antifungals. These bio-molecules need to be tested for tolerance in the host and efficacy against fungal pathogens before they can be safely applied in humans. Testing of the efficacy and possible adverse effects of new drug candidates in three-dimensional (3D) human-cell based models represents an advantageous alternative to animal experiments. In, this study, as a proof-of-principle, we demonstrate the usefulness of 3D skin infection models for screening new antifungal drug candidates for topical application. We established a cutaneous infection with the opportunistic human-pathogenic yeast Candida albicans in a commercially available 3D full-thickness (FT) skin model to test the curative potential of distinct AFPs from Penicillium chrysogenum (PAFopt, PAFB, and PAFC) and Neosartorya (Aspergillus) fischeri (NFAP2) in vitro. All tested AFPs were comparably well tolerated by the skin models. The infected 3D models exhibited reduced epidermal permeability barriers, allowing C. albicans to colonize the epidermal and dermal layers, and showed increased secretion of the pro-inflammatory cytokine IL-6 and the chemokine IL-8. AFP treatment diminished the fungal burden and penetration depth of C. albicans in the infected models. The epidermal permeability barrier was restored and the secretion of IL-8 was decreased following AFP treatment. In summary, our study proves that the tested AFPs exhibit antifungal potential against cutaneous C. albicans infection in a 3D FT skin model. IMPORTANCE Candida albicans represents one of the most prevalent opportunistic fungal pathogens, causing superficial skin and mucosal infections in humans with certain predisposing health conditions and life-threatening systemic infections in immunosuppressed patients. The emerging drug resistance of this human-pathogenic yeast and the limited number of antifungal drugs for prevention and treatment of infections urgently demands the identification of new antifungal compounds with novel mechanisms of action. Small, cationic antifungal proteins (AFPs) from filamentous fungi represent promising candidates for next-generation antifungals for topical application. These bio-molecules need to be tested for tolerance by the host and efficacy in pathogen clearance prior to being involved in clinical trials. In a proof-of-principle study, we provide evidence for the suitability of 3D human-cell based models as advantageous alternatives to animal experiments. We document the tolerance of specific AFPs and their curative efficacy against cutaneous C. albicans infection in a 3D skin model.
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Affiliation(s)
- Jeanett Holzknecht
- Biocenter, Institute of Molecular Biology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sandrine Dubrac
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sarah Hedtrich
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - László Galgóczy
- Department of Biotechnology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
- Institute of Biochemistry, Biological Research Centre, Eötvös Loránd Research Network, Szeged, Hungary
| | - Florentine Marx
- Biocenter, Institute of Molecular Biology, Medical University of Innsbruck, Innsbruck, Austria
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Zhou S, Yao Z. Roles of Infection in Psoriasis. Int J Mol Sci 2022; 23:ijms23136955. [PMID: 35805960 PMCID: PMC9266590 DOI: 10.3390/ijms23136955] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 02/08/2023] Open
Abstract
Psoriasis is a chronic, immune-mediated disorder with cutaneous and systemic manifestations. Genetic predisposition, environmental factors, and immune dysfunction all contribute to the pathogenesis of psoriasis with host-microbe interaction governing the progression of this disease. Emerging evidence has indicated that infection is an environmental trigger for psoriasis and plays multiple roles in its maintenance as evidenced by the frequent association between guttate psoriasis onset and acute streptococcal infection. Different infectious factors act on immune cells to produce inflammatory cytokines that can induce or aggravate psoriasis. In addition to bacterial infections, viral and fungal infections have also been shown to be strongly associated with the onset or exacerbation of psoriasis. Intervention of skin microbiota to treat psoriasis has become a hot research topic. In this review, we summarize the effects of different infectious factors (bacteria, viruses, and fungi) on psoriasis, thereby providing insights into the manipulation of pathogens to allow for the identification of improved therapeutic options for the treatment of this condition.
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Affiliation(s)
- Shihui Zhou
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China;
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Zhirong Yao
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China;
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Correspondence:
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Elsner K, Holstein J, Hilke FJ, Blumenstock G, Walker B, Schmidt S, Schaller M, Ghoreschi K, Meier K. Prevalence of Candida species in Psoriasis. Mycoses 2021; 65:247-254. [PMID: 34787934 DOI: 10.1111/myc.13399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Psoriasis patients are more frequently colonised with Candida species. The correlation between fungal colonisation and clinical severity is unclear, but may exacerbate psoriasis and the impact of antipsoriatic therapies on the prevalence of Candida is unknown. OBJECTIVES To examine the prevalence of C species in psoriasis patients compared to an age- and sex-matched control population, we investigated the influence of Candida colonisation on disease severity, immune cell activation and the interplay on psoriatic treatments. METHODS The prevalence of C species was examined in 265 psoriasis patients and 200 control subjects by swabs and stool samples for fungal cultures. Peripheral mononuclear blood cells (PBMCs) were collected from 20 fungal colonised and 24 uncolonised patients and stimulated. The expression of interferon (IFN)-γ, IL-17A, IL-22 and tumour necrosis factor (TNF)-α from stimulated PBMCs was measured by quantitative real-time polymerase chain reaction (qPCR). RESULTS A significantly higher prevalence for Candida was detected in psoriatic patients (p ≤ .001) compared to the control subjects; most abundant in stool samples, showing Candida albicans. Older participants (≥51 years) were more frequent colonised, and no correlation with gender, disease severity or systemic treatments like IL-17 inhibitors was found. CONCLUSIONS Although Candida colonisation is significantly more common in patients with psoriasis, it does not influence the psoriatic disease or cytokine response. Our study showed that Candida colonisation is particularly more frequent in patients with psoriasis ≥51 years of age. Therefore, especially this group should be screened for symptoms of candidiasis during treatment with IL-17 inhibitors.
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Affiliation(s)
- Kevin Elsner
- Department of Dermatology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Julia Holstein
- Department of Dermatology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Franz Joachim Hilke
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gunnar Blumenstock
- Deptartment of Clinical Epidemiology and Biostatistics, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Birgit Walker
- Department of Dermatology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Sybille Schmidt
- Department of Dermatology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Martin Schaller
- Department of Dermatology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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13
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Liang X, Ou C, Zhuang J, Li J, Zhang F, Zhong Y, Chen Y. Interplay Between Skin Microbiota Dysbiosis and the Host Immune System in Psoriasis: Potential Pathogenesis. Front Immunol 2021; 12:764384. [PMID: 34733291 PMCID: PMC8558530 DOI: 10.3389/fimmu.2021.764384] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022] Open
Abstract
Psoriasis is a multifactorial immune-mediated disease. The highly effective and eligible treatment for psoriasis is limited, for its specific pathogenesis is incompletely elucidated. Skin microbiota is a research hotspot in the pathogenesis of immune-mediated inflammatory skin diseases nowadays, and it may have significant involvement in the provocation or exacerbation of psoriasis with broadly applicable prospects. It is postulated that skin microbiota alternation may interplay with innate immunity such as antimicrobial peptides and Toll-like receptors to stimulate T-cell populations, resulting in immune cascade responses and ultimately psoriasis. Achieving a thorough understanding of its underlying pathogenesis is crucial. Herein, we discuss the potential immunopathogenesis of psoriasis from the aspect of skin microbiota in an attempt to yield insights for novel therapeutic and preventive modalities for psoriasis.
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Affiliation(s)
- Xiaoqian Liang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Caixin Ou
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jiayi Zhuang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jinsheng Li
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Fangfei Zhang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Yuanqiu Zhong
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Yongfeng Chen
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
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14
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Fungal Infections among Psoriatic Patients: Etiologic Agents, Comorbidities, and Vulnerable Population. Autoimmune Dis 2021; 2021:1174748. [PMID: 34567800 PMCID: PMC8461225 DOI: 10.1155/2021/1174748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Psoriasis is a chronic inflammatory disorder of the skin and joint, affecting nearly 2-3% of the general population. It is assumed that imbalance between the types of natural microflora can accelerate the onset of the disease. Some fungi can play the role of superantigens and prolong chronic inflammation in the skin of psoriatic patients. The aim of the present investigation was to identify fungal species isolated from patients with psoriasis. Methods From March 2016 to May 2019, 289 patients with prior diagnosis of psoriasis were included in this survey. Direct microscopy with potassium hydroxide (KOH 10%), culture, urea hydrolysis, hair perforation test, and growth on rice grains were used to identify clinical isolates, phenotypically. For molecular identification of Candida species and Malassezia species, PCR-RFLP and PCR-sequencing were used, respectively. Results Forty-six out of 289 psoriatic patients had fungal infections (15.9%). Dermatophytes (54.3%), Candida spp. (19.5%), Malassezia spp. (15.2%), Aspergillus spp. (6.5%), and Fusarium spp. (4.3%) were the causative agents of fungal infections. Among Malassezia and Candida species, M. restricta (10.8%) and C. glabrata (8.7%) were the most prevalent species, respectively. Conclusion Our findings suggested that fungal pathogens, particularly dermatophytes, may play an important role in the pathogenicity of psoriasis. Also, due to the high rate of yeast colonization in the clinical samples of psoriatic patients, concomitant use of anti-inflammatory drugs and antifungals may represent an effective therapeutic approach for better management of chronic lesions among these patients. Mycological tests should be applied to indicate the incidence of fungal diseases in psoriatic patients.
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15
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Ji C, Wang H, Bao C, Zhang L, Ruan S, Zhang J, Gong T, Cheng B. Challenge of Nail Psoriasis: An Update Review. Clin Rev Allergy Immunol 2021; 61:377-402. [PMID: 34478047 DOI: 10.1007/s12016-021-08896-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/11/2022]
Abstract
Nail psoriasis is a refractory disease that affects 50-79% skin psoriasis patients and up to 80% of patients with psoriatic arthritis (PsA). The pathogenesis of nail psoriasis is still not fully illuminated, although some peculiar inflammatory cytokines and chemokines seems to be the same as described in psoriatic skin lesions. Psoriatic nail involving matrix can cause pitting, leukonychia, red spots in lunula, and nail plate crumbling, while nail bed involvement can result in onycholysis, oil-drop discoloration, nail bed hyperkeratosis, and splinter hemorrhages. The common assessment methods of evaluating nail psoriasis includes Nail Psoriasis Severity Index (NAPSI), Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA), Nail Psoriasis Quality of life 10 (NPQ10), and so on. Treatment of nail psoriasis should be individualized according to the number of involving nail, the affected site of nail and presence of skin and/or joint involvement. Generally, topical therapies are used for mild nail psoriasis, while biologic agents such as etanercept are considered for severe nail disease and refractory nail psoriasis. Even though the current literature has shown some support for the pathogenesis, clinical presentation, or therapies of nail psoriasis, systemic review of this multifaceted disease is still rare to date. We elaborate recent developments in nail psoriasis epidemiology, pathogenesis, anatomy, clinical manifestation, diagnosis, differential diagnosis, and therapies to raise better awareness of the complexity of nail psoriasis and the need for early diagnosis or intervention.
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Affiliation(s)
- Chao Ji
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Haiqing Wang
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Chengbei Bao
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Liangliang Zhang
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Shifan Ruan
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Jing Zhang
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China
| | - Ting Gong
- Central Laboratory, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China.
| | - Bo Cheng
- Department of Dermatology, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, Fujian, China.
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16
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Ricardo JW, Lipner SR. Nail Psoriasis in Older Adults: Intralesional, Systemic, and Biological Therapy. Dermatol Clin 2021; 39:195-210. [PMID: 33745633 DOI: 10.1016/j.det.2020.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Psoriasis may affect the skin, scalp, joints, and nails and is common in older adults. Intramatrical injections with triamcinolone acetonide are safe and effective in older individuals. Conventional systemic medications are relatively effective, but side effects, including laboratory abnormalities and drug interactions, are particularly common among older adults. Biologic medications have shown excellent efficacy in treating nail psoriasis. Their safety profile is favorable, but data assessing long-term safety are lacking. Randomized controlled trials in older adults exclusively are necessary to develop evidence-based treatment guidelines in this population.
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Affiliation(s)
- Jose W Ricardo
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA.
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17
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de Jesús-Gil C, Sans-de San Nicolàs L, Ruiz-Romeu E, Ferran M, Soria-Martínez L, García-Jiménez I, Chiriac A, Casanova-Seuma JM, Fernández-Armenteros JM, Owens S, Celada A, Howell MD, Pujol RM, Santamaria-Babí LF. Interplay between Humoral and CLA + T Cell Response against Candida albicans in Psoriasis. Int J Mol Sci 2021; 22:ijms22041519. [PMID: 33546306 PMCID: PMC7913574 DOI: 10.3390/ijms22041519] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/15/2022] Open
Abstract
Candida albicans (CA) infections have been associated with psoriasis onset or disease flares. However, the integrated immune response against this fungus is still poorly characterized in psoriasis. We studied specific immunoglobulins in plasma and the CA response in cocultures of circulating memory CD45RA- cutaneous lymphocyte antigen (CLA)+/- T cell with autologous epidermal cells from plaque and guttate psoriasis patients (cohort 1, n = 52), and also healthy individuals (n = 17). A complete proteomic profile was also evaluated in plaque psoriasis patients (cohort 2, n = 114) regarding their anti-CA IgA levels. Increased anti-CA IgA and IgG levels are present in the plasma from plaque but not guttate psoriasis compared to healthy controls. CA cellular response is confined to CLA+ T cells and is primarily Th17. The levels of anti-CA IgA are directly associated with CLA+ Th17 response in plaque psoriasis. Proteomic analysis revealed distinct profiles in psoriasis patients with high anti-CA IgA. C-C motif chemokine ligand 18, chitinase-3-like protein 1 and azurocidin were significantly elevated in the plasma from plaque psoriasis patients with high anti-CA levels and severe disease. Our results indicate a mechanism by which Candida albicans exposure can trigger a clinically relevant IL-17 response in psoriasis. Assessing anti-CA IgA levels may be useful in order to evaluate chronic psoriasis patients.
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Affiliation(s)
- Carmen de Jesús-Gil
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
| | - Lídia Sans-de San Nicolàs
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
| | - Ester Ruiz-Romeu
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
| | - Marta Ferran
- Department of Dermatology, Hospital del Mar, 08003 Barcelona, Spain; (M.F.); (R.M.P.)
| | - Laura Soria-Martínez
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
| | - Irene García-Jiménez
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
| | - Anca Chiriac
- Department of Dermatophysiology, Apollonia University, 700613 Iasi, Romania;
| | - Josep Manel Casanova-Seuma
- Department of Dermatology, Hospital Universitari Arnau de Vilanova, 25198 Lleida, Spain; (J.M.C.-S.); (J.M.F.-A.)
| | | | - Sherry Owens
- Translational Sciences, Incyte Corporation, Wilmington, DE 19803, USA; (S.O.); (M.D.H.)
| | - Antonio Celada
- Macrophage Biology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain;
| | - Michael D. Howell
- Translational Sciences, Incyte Corporation, Wilmington, DE 19803, USA; (S.O.); (M.D.H.)
| | - Ramòn María Pujol
- Department of Dermatology, Hospital del Mar, 08003 Barcelona, Spain; (M.F.); (R.M.P.)
| | - Luis Francisco Santamaria-Babí
- Translational Immunology, Department of Cellular Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Spain; (C.d.J.-G.); (L.S.-d.S.N.); (E.R.-R.); (L.S.-M.); (I.G.-J.)
- Correspondence: ; Tel.: +34-677375160
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18
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Immunity to commensal skin fungi promotes psoriasiform skin inflammation. Proc Natl Acad Sci U S A 2020; 117:16465-16474. [PMID: 32601220 DOI: 10.1073/pnas.2003022117] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Under steady-state conditions, the immune system is poised to sense and respond to the microbiota. As such, immunity to the microbiota, including T cell responses, is expected to precede any inflammatory trigger. How this pool of preformed microbiota-specific T cells contributes to tissue pathologies remains unclear. Here, using an experimental model of psoriasis, we show that recall responses to commensal skin fungi can significantly aggravate tissue inflammation. Enhanced pathology caused by fungi preexposure depends on Th17 responses and neutrophil extracellular traps and recapitulates features of the transcriptional landscape of human lesional psoriatic skin. Together, our results propose that recall responses directed to skin fungi can directly promote skin inflammation and that exploration of tissue inflammation should be assessed in the context of recall responses to the microbiota.
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19
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Campione E, Cosio T, Lanna C, Mazzilli S, Ventura A, Dika E, Gaziano R, Dattola A, Candi E, Bianchi L. Predictive role of vitamin A serum concentration in psoriatic patients treated with IL-17 inhibitors to prevent skin and systemic fungal infections. J Pharmacol Sci 2020; 144:52-56. [PMID: 32565006 DOI: 10.1016/j.jphs.2020.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/01/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
The use of biological drugs in psoriasis is replacing traditional therapies due to their specific mechanism and limited side effects. However, the use of Interleukin 17 inhibitors and the modification of its cytokine pathway could favor the risk of fungal infections. All-trans retinoic acid is an active metabolite of vitamin A with anti-inflammatory and immunoregulatory properties through its capacity to stimulate both innate and adaptive immunity and to its effects on proliferation, differentiation and apoptosis in a variety of immune cells. Furthermore, it has been recently discovered that All-trans retinoic acid has a direct fungistatic effect against Candida and Aspergillus Fumigatus. On the basis of these new insights, in the current review, we suggest that the evaluation of serum level of All-trans retinoic acid or vitamin A should be considered as a predictive marker for the development of fungal infections among psoriatic patients treated with Interleukin 17 inhibitors. In clinical practice, vitamin A test could be added in the routine hospital diagnostic management for a better selection of psoriatic patients eligible to Interleukin 17 inhibitors.
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Affiliation(s)
- Elena Campione
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Terenzio Cosio
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Caterina Lanna
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Sara Mazzilli
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Emi Dika
- Dermatology Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Roberta Gaziano
- Microbiology Section, Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Annunziata Dattola
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Candi
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luca Bianchi
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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20
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Buhl AL, Wenzel J. Interleukin-36 in Infectious and Inflammatory Skin Diseases. Front Immunol 2019; 10:1162. [PMID: 31191535 PMCID: PMC6545975 DOI: 10.3389/fimmu.2019.01162] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022] Open
Abstract
Interleukin-36 (IL-36) comprises to a cytokine family consisting of four isoforms IL-36α, IL-36β, IL-36γ, and IL-36 receptor antagonist (IL-36 Ra). These IL-36 cytokines, in turn, belong to the IL-1 superfamily. The IL-36 receptor (IL-1R6) is functional as a heterodimer formed of IL-1R6 and IL-1 receptor accessory protein (IL-1RAcP). IL-36α, IL-36β, and IL-36γ are regarded as pro-inflammatory ligands and IL-36 Ra as well as IL-38 as anti-inflammatory ligands of IL-1R6. IL-36 cytokines are mainly expressed on the barrier sites of the body e.g., bronchial, intestinal, and dermal epithelium. One of their most important biological functions is the bridging of innate and adaptive immune responses. A disturbed balance between pro-inflammatory and anti-inflammatory branches easily leads to inflammation of the corresponding tissue. The most prominent example for an altered IL-36 expression is the spectrum of psoriasis. In addition to inflammatory dermatoses, IL-36 also seems to play a role in infectious dermatoses. Microbial triggers, especially Staphylococcus aureus infection, increase the production of pro-inflammatory IL-36 cytokines and initiate/promote the inflammation of skin lesions. Due to the discovery of IL-36 as an important immune mediator, it has already been possible to develop important diagnostic tools for dermatitis. Not only in the field of inflammatory skin diseases, but also in pulmonary and intestinal inflammation, there is evidence that IL-36 cytokines might have diagnostic and/or therapeutic relevance.
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Affiliation(s)
- Anna-Lena Buhl
- Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
| | - Joerg Wenzel
- Department of Dermatology and Allergy, University Hospital of Bonn, Bonn, Germany
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21
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Papini M, Natalini Y. Candida infections in psoriatic patients on anti-IL17 therapy: a case series. J DERMATOL TREAT 2018; 29:3-4. [DOI: 10.1080/09546634.2018.1530437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Manuela Papini
- Dipartimento di Scienze Chirurgiche e Biomediche, Clinica Dermatologica di Terni, Università degli Studi di Perugia, Perugia, Italy
| | - Ylenia Natalini
- Dipartimento di Scienze Chirurgiche e Biomediche, Clinica Dermatologica di Terni, Università degli Studi di Perugia, Perugia, Italy
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22
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Rademaker M, Agnew K, Anagnostou N, Andrews M, Armour K, Baker C, Foley P, Gebauer K, Gupta M, Marshman G, Rubel D, Sullivan J, Wong LC. Psoriasis and infection. A clinical practice narrative. Australas J Dermatol 2018; 60:91-98. [PMID: 30079566 DOI: 10.1111/ajd.12895] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/30/2018] [Indexed: 12/13/2022]
Abstract
The Australasian Psoriasis Collaboration has developed a clinical practice narrative with respect to the relationship between psoriasis, its treatment and infection. The cutaneous microbiome of patients with psoriasis is different to those without psoriasis, although the significance of this is unclear. Whilst a wide range of microorganisms has been associated with psoriasis (including β-haemolytic streptococci, Staphylococcus aureus, Porphyromonas gingivalis, Candida albicans, Chlamydia psittaci, human immunodeficiency virus and hepatitis C virus), there is limited evidence that antimicrobial therapy is of direct benefit in preventing flares of psoriasis. Psoriasis is independently associated with an increased risk of serious infection, but the absolute risk is low. The risk of serious infections is further increased with immune-modulatory treatments. The decision whether to, and when to, stop or resume immune-modulatory treatment after a serious infection has occurred depends on risk assessment for that patient, taking into account the infection being treated, the risk of recurrent infection, any interventions that can modify the risk and the need for psoriasis control. Live vaccines (e.g. MMR, varicella, zoster and yellow fever) are generally contraindicated in patients with psoriasis on immune-modulatory agents, but this depends on the degree of immune suppression and individual risk factors. Wound healing in psoriasis is normal. Treatment with infliximab, adalimumab, etanercept, methotrexate and ciclosporin can safely be continued through low-risk surgical procedures. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient's individual risk factors and comorbidities.
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Affiliation(s)
- Marius Rademaker
- Waikato Clinical School, Auckland University Medical School, Hamilton, New Zealand
| | - Karen Agnew
- Dermatology Department, Greenlane Clinical Centre & Starship Children's Hospital, Auckland, New Zealand
| | - Nicholas Anagnostou
- Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | | | | | - Christopher Baker
- Skin & Cancer Foundation Inc., Melbourne, Victoria, Australia.,St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Foley
- Skin & Cancer Foundation Inc., Melbourne, Victoria, Australia.,St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kurt Gebauer
- University of Western Australia, Perth, Western Australia, Australia.,Probity Medical Research, Freemantle, Western Australia, Australia
| | - Monisha Gupta
- Department of Dermatology, Liverpool Hospital, Sydney, New South Wales, Australia.,The Skin Hospital, Darlinghurst, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Gillian Marshman
- Flinders Medical Centre, Bedford Park, South Australia, Australia.,Flinders University Medical School, Adelaide, South Australia, Australia
| | - Diana Rubel
- Woden Dermatology, Phillip, Australian Capital Territory, Australia.,Australian National University, Canberra, Australian Capital Territory, Australia
| | - John Sullivan
- Kingsway Dermatology, Miranda, New South Wales, Australia
| | - Li-Chuen Wong
- Dermatology Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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23
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Galluzzo M, Talamonti M, De Simone C, D'Adamio S, Moretta G, Tambone S, Caldarola G, Fargnoli MC, Peris K, Bianchi L. Secukinumab in moderate-to-severe plaque psoriasis: a multi-center, retrospective, real-life study up to 52 weeks observation. Expert Opin Biol Ther 2018; 18:727-735. [PMID: 29798698 DOI: 10.1080/14712598.2018.1481503] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate efficacy and safety of the anti-IL-17 drug secukinumab in a real-life large cohort of patients with moderate-to-severe plaque psoriasis in Central Italy. METHODS Multicenter, retrospective study with an observation period of up to 52 weeks. Efficacy was assessed by Psoriasis Area and Severity Index (PASI) score; clinical and laboratory examinations were performed at baseline and at weeks 4, 12, 24, 36, and 52. RESULTS A 90% and a 100% PASI score reduction (PASI90 and PASI100) were reported in 67.5% and 55% of patients at week 12, respectively. A rapid improvement of skin lesions was observed particularly in young patients and in patients naïve to biologics: at week 4, the achievement of PASI90 and PASI100 was higher in younger patients (odds ratio [OR] 0.95, and 0.95; p = 0.003, and 0.005, respectively); PASI90 was achieved by 42.0% of patients naïve to biologics and by 17.0% of patients with prior exposure to biologics (PBT) (OR 0.24; p = 0.001); and PASI100 was reached by 25.5% of naïve patients and 9.8% of PBT (OR 0.28; p = 0.015).The drug was well tolerated. CONCLUSION Secukinumab was effective in this real-life analysis, with rapid clinical improvement and long-term maintenance of results.
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Affiliation(s)
- Marco Galluzzo
- a Dermatology, Department of "Medicina dei Sistemi" , University of Rome Tor Vergata , Rome , Italy
| | - Marina Talamonti
- a Dermatology, Department of "Medicina dei Sistemi" , University of Rome Tor Vergata , Rome , Italy
| | - Clara De Simone
- b Institute of Dermatology , Catholic University of the Sacred Heart , Rome , Italy
| | - Simone D'Adamio
- a Dermatology, Department of "Medicina dei Sistemi" , University of Rome Tor Vergata , Rome , Italy
| | - Gaia Moretta
- b Institute of Dermatology , Catholic University of the Sacred Heart , Rome , Italy
| | - Sara Tambone
- c Department of Dermatology , University of L'Aquila , L'Aquila , Italy
| | - Giacomo Caldarola
- b Institute of Dermatology , Catholic University of the Sacred Heart , Rome , Italy
| | | | - Ketty Peris
- b Institute of Dermatology , Catholic University of the Sacred Heart , Rome , Italy
| | - Luca Bianchi
- a Dermatology, Department of "Medicina dei Sistemi" , University of Rome Tor Vergata , Rome , Italy
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Pietrzak A, Grywalska E, Socha M, Roliński J, Franciszkiewicz-Pietrzak K, Rudnicka L, Rudzki M, Krasowska D. Prevalence and Possible Role of Candida Species in Patients with Psoriasis: A Systematic Review and Meta-Analysis. Mediators Inflamm 2018; 2018:9602362. [PMID: 29853795 PMCID: PMC5960518 DOI: 10.1155/2018/9602362] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/08/2018] [Indexed: 12/15/2022] Open
Abstract
Although fungal colonization is implicated in the pathogenesis of psoriasis, its prevalence remains unclear. The aim of this systematic review and meta-analysis was to provide an overview on the prevalence of Candida species in patients with psoriasis. We searched databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and http://clinicaltrials.gov) to identify studies involving subjects of any age with an established diagnosis of psoriasis and healthy controls, who were tested for carriage of Candida spp. on the skin or mucosal membranes (or saliva and stool), or presented with clinical candidiasis with microbiologically confirmed etiology. We identified nine cross-sectional studies including a total of 1038 subjects with psoriasis (psoriatics) and 669 controls. We found Candida species detection rates for psoriatics were significantly higher than those in the controls, especially in the oral mucosa milieux. These results suggest psoriasis may be one of the systemic diseases that predispose to oral Candida spp. carriage and infection.
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Affiliation(s)
- Aldona Pietrzak
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Ul. Radziwillowska 13, 20-080 Lublin, Poland
| | - Ewelina Grywalska
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Ul. Chodźki 4a, 20-093 Lublin, Poland
| | - Mateusz Socha
- Department of Internal Medicine and Cardiology, First Military Clinical Hospital with the Outpatient Clinic, Al. Racławickie 23, 20-048 Lublin, Poland
| | - Jacek Roliński
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Ul. Chodźki 4a, 20-093 Lublin, Poland
| | | | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Ul. Koszykowa 82a, 02-008 Warsaw, Poland
| | - Marcin Rudzki
- Chair and Department of Jaw Orthopaedics, Medical University of Lublin, Ul. Karmelicka 7, 20-081 Lublin, Poland
| | - Dorota Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Ul. Radziwillowska 13, 20-080 Lublin, Poland
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25
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Braegelmann J, Braegelmann C, Bieber T, Wenzel J. Candida induces the expression of IL-36γ in human keratinocytes: implications for a pathogen-driven exacerbation of psoriasis? J Eur Acad Dermatol Venereol 2018; 32:e403-e406. [PMID: 29633390 DOI: 10.1111/jdv.14994] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Braegelmann
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany
| | - C Braegelmann
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany
| | - T Bieber
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany
| | - J Wenzel
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany
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26
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Ventura A, Mazzeo M, Gaziano R, Galluzzo M, Bianchi L, Campione E. New insight into the pathogenesis of nail psoriasis and overview of treatment strategies. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2527-2535. [PMID: 28919705 PMCID: PMC5587086 DOI: 10.2147/dddt.s136986] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Psoriasis is a chronic inflammatory disease affecting up to 3% of the general population. The prevalence of nail involvement in psoriasis patients varies between 15% and 79%. While the nails represent a small portion of the body surface area, psoriasis in these areas can have a disproportionate influence on a patient’s physical and psychosocial activities. Differential diagnosis between an onychomycosis and a psoriatic nail could be challenging; nevertheless, coexistence of onychomycosis and nail psoriasis also occurs and both are common disorders in the general population. Nail psoriasis can be difficult to treat. Treatment of nail psoriasis should consider the body surface area of skin disease, psoriatic arthritis, severity of nail disease, and the impairment in the quality of life. All patients should be tested for onychomycosis before starting a therapy. This recommendation is underlined by the fact that nail psoriasis is mostly treated by immunosuppressive drugs, like steroids, methotrexate, or biologics, which may aggravate mycotic nail infections. Conventional systemic therapy, such as use of steroids, cyclosporine, methotrexate, and retinoid in the long term, can cause organ toxicities. Currently, use of apremilast and tofacitinib favors an early healing of nail psoriasis because they act directly on the pathogenic targets, distressing the inflammatory signals associated with the initiation and maintenance of the disease activity, and as with several conventional synthetic disease modifying antirheumatic drugs, they are characterized by the convenience of oral administration. The number of treatment options has increased considerably in recent years; however, given the heterogeneity of the disease, the therapy should be personalized to individual cases.
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Affiliation(s)
- Alessandra Ventura
- Department of Dermatology, University of Rome "Tor Vergata", Rome, Italy
| | - Mauro Mazzeo
- Department of Dermatology, University of Rome "Tor Vergata", Rome, Italy
| | - Roberta Gaziano
- Department of Experimental Medicine and Surgery, Rome, Italy
| | - Marco Galluzzo
- Department of Dermatology, University of Rome "Tor Vergata", Rome, Italy
| | - Luca Bianchi
- Department of Dermatology, University of Rome "Tor Vergata", Rome, Italy
| | - Elena Campione
- Department of Dermatology, University of Rome "Tor Vergata", Rome, Italy
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27
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Management of Moderate to Severe Plaque Psoriasis: The Emerging Role of IL-17 Inhibition. J Cutan Med Surg 2017; 21:2S-40S. [DOI: 10.1177/1203475417722552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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28
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Interaction of Candida Species with the Skin. Microorganisms 2017; 5:microorganisms5020032. [PMID: 28590443 PMCID: PMC5488103 DOI: 10.3390/microorganisms5020032] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/30/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022] Open
Abstract
The human skin is commonly colonized by diverse fungal species. Some Candida species, especially C. albicans, do not only reside on the skin surface as commensals, but also cause infections by growing into the colonized tissue. However, defense mechanisms at the skin barrier level are very efficient, involving residential non-immune and immune cells as well as immune cells specifically recruited to the site of infection. Therefore, the skin is an effective barrier against fungal infection. While most studies about commensal and pathogenic interaction of Candida species with host epithelia focus on the interaction with mucosal surfaces such as the vaginal and gastrointestinal epithelia, less is known about the mechanisms underlying Candida interaction with the skin. In this review, we focus on the ecology and molecular pathogenesis of Candida species on the skin and give an overview of defense mechanisms against C. albicans in this context. We also discuss new research avenues in dermal infection, including the involvement of neurons, fibroblasts, and commensal bacteria in both mouse and human model systems.
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29
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Saunte D, Mrowietz U, Puig L, Zachariae C. Candida
infections in patients with psoriasis and psoriatic arthritis treated with interleukin-17 inhibitors and their practical management. Br J Dermatol 2017; 177:47-62. [DOI: 10.1111/bjd.15015] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2016] [Indexed: 12/13/2022]
Affiliation(s)
- D.M. Saunte
- Department of Dermatology; Zealand University Hospital; Roskilde Denmark
| | - U. Mrowietz
- Psoriasis Center; Department of Dermatology; University Medical Center Schleswig-Holstein; Campus Kiel Germany
| | - L. Puig
- Department of Dermatology; Hospital de la Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Barcelona Spain
| | - C. Zachariae
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
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30
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Abstract
Many of the molecular pathways associated with psoriasis pathogenesis are also involved in host defense mechanisms that protect against common pathogens. Candida can stimulate the production of cytokines that trigger or exacerbate psoriasis, and many systemic psoriasis treatments may put patients at increased risk for developing oral, cutaneous, and genitourinary candidiasis. Therefore, dermatologists should regularly screen patients with psoriasis for signs of Candida infection, and take steps to effectively treat these infections to prevent worsening of psoriasis symptoms. This review provides an overview of candidiasis epidemiology in patients with psoriasis, followed by a primer on the diagnosis and treatment of superficial Candida infections, with specific guidance for patients with psoriasis. Candidiasis in patients with psoriasis typically responds to topical or oral antifungal therapy. While biologic agents used to treat moderate-to-severe psoriasis, such as tumor necrosis factor-α inhibitors and interleukin-17 inhibitors, are known to increase patients’ risk of developing localized candidiasis, the overall risk of infection is low, and candidiasis can be effectively managed in most patients while receiving systemic psoriasis therapies. Thus, the development of candidiasis does not usually necessitate changes to psoriasis treatment regimens.
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31
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Ayala-Fontánez N, Soler DC, McCormick TS. Current knowledge on psoriasis and autoimmune diseases. PSORIASIS-TARGETS AND THERAPY 2016; 6:7-32. [PMID: 29387591 PMCID: PMC5683130 DOI: 10.2147/ptt.s64950] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Psoriasis is a prevalent, chronic inflammatory disease of the skin, mediated by crosstalk between epidermal keratinocytes, dermal vascular cells, and immunocytes such as antigen presenting cells (APCs) and T cells. Exclusive cellular “responsibility” for the induction and maintenance of psoriatic plaques has not been clearly defined. Increased proliferation of keratinocytes and endothelial cells in conjunction with APC/T cell/monocyte/macrophage inflammation leads to the distinct epidermal and vascular hyperplasia that is characteristic of lesional psoriatic skin. Despite the identification of numerous susceptibility loci, no single genetic determinant has been identified as responsible for the induction of psoriasis. Thus, numerous other triggers of disease, such as environmental, microbial and complex cellular interactions must also be considered as participants in the development of this multifactorial disease. Recent advances in therapeutics, especially systemic so-called “biologics” have provided new hope for identifying the critical cellular targets that drive psoriasis pathogenesis. Recent recognition of the numerous co-morbidities and other autoimmune disorders associated with psoriasis, including inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus suggest common signaling elements and cellular mediators may direct disease pathogenesis. In this review, we discuss common cellular pathways and participants that mediate psoriasis and other autoimmune disorders that share these cellular signaling pathways.
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Affiliation(s)
- Nilmarie Ayala-Fontánez
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.,The Murdough Family Center for Psoriasis, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - David C Soler
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.,The Murdough Family Center for Psoriasis, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Thomas S McCormick
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.,The Murdough Family Center for Psoriasis, University Hospitals Case Medical Center, Cleveland, OH, USA
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