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The Role of Yeast in Atopic Dermatitis Revisited: a Critical Appraisal

  • Atopic Dermatitis (C Flohr, Section Editor)
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Abstract

Atopic dermatitis (AD) is the commonest chronic inflammatory skin disorder. In a subset of patients, particularly those with symptoms predominating on the head and neck, the yeast Malassezia is thought to be an important driver of AD of a more recalcitrant nature. Mechanistically, sensitization to Malassezia appears mediated by antigen-presenting cells in eczematous skin that promote cutaneous inflammation, partly through cross-reactivity with auto-antigens. This is consistent with evidence that patients with head and neck dermatitis (HND) have higher rates of sensitization to Malassezia versus healthy controls. However, to prove that Malassezia is a causative factor in HND, we should evaluate evidence on whether efforts to reduce Malassezia actually improve disease activity. We therefore performed a systematic review of randomized controlled trials (RCTs) investigating antifungal treatments in AD/HND. The majority of RCTs concluded that antifungals were superior to placebo or standard treatment in terms of reducing AD severity, supporting the notion that yeast can contribute to eczematous skin inflammation. Recognising and treating yeast colonization in AD patients can result in a significant reduction in disease severity, in addition to anti-inflammatory therapy alone.

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Abbreviations

AD:

Atopic dermatitis

ALT:

Alanine aminotransferase

APT:

Atopy patch test

C. albicans :

Candida albicans

EASI:

Eczema area and severity index

FLG:

Filaggrin

HND:

Head and neck dermatitis

IGA:

Investigator Global Assessment

ILC:

Innate lymphoid cell

sIgE:

Specific immunoglobulin E

M :

Malassezia

MHC:

Major histocompatibility complex

MnSOD:

Manganese superoxide dismutase

PGA:

Patient Global Assessment

RAST:

Radioallergosorbent test

RCT:

Randomized controlled trial

S. aureus :

Staphylococcus aureus

SCORAD:

Scoring atopic dermatitis

SPT:

Skin prick test

TEWL:

Transepidermal water loss

Treg:

Regulatory T cell

TSLP:

Thymic stromal lymphopoietin

U/ml:

International units per millilitre

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Acknowledgments

We would like to thank Dr Susan Howell, mycologist at Guy’s and St Thomas’ NHS Foundation Trust, as well as Library Information Specialists Sarah Lawson (University College London) and John Woodcock (King’s College London) for their support in developing the systematic search strategy.

Compliance with Ethics Guidelines

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Conflict of Interest

Teresa Tsakok, Heike Schulenburg, Catherine Smith, Stephen Till and Carsten Flohr declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. St John′s Institute of Dermatology, King′s College London, Guy′s Hospital, Great Maze Pond, London, SE1 9RT, UK

    Teresa Tsakok

  2. St John′s Institute of Dermatology, Guy′s Hospital, Great Maze Pond, London, SE1 9RT, UK

    Heike Schulenburg

  3. St John′s Institute of Dermatology, Guy′s and St Thomas′ NHS Foundation Trust & King′s College London, Guy′s Hospital, Great Maze Pond, London, SE1 9RT, UK

    Catherine Smith & Carsten Flohr

  4. Division of Asthma, Allergy and Lung Biology, King′s College London, Guy′s Hospital, Great Maze Pond, London, SE1 9RT, UK

    Stephen Till

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  1. Teresa Tsakok
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  3. Catherine Smith
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Corresponding author

Correspondence to Carsten Flohr.

Additional information

This article is part of the Topical Collection on Atopic Dermatitis

Appendix: Search Strategies

Appendix: Search Strategies

  1. I.

    CENTRAL (Cochrane library) search strategy

    1. #1

      MeSH descriptor: [Fungi] explode all trees

    2. #2

      (fungi)

    3. #3

      (#1 or #2)

    4. #4

      (yeasts) or (‘not dermatophyte’) or (‘no dermatophyte’) or (‘non dermatophyte’)

    5. #5

      (malassezia) or (pityrosporum)

    6. #6

      (candida)

    7. #7

      (#3 or #4 or #5 or #6)

    8. #8

      MeSH descriptor: [Dermatitis, Atopic] explode all trees

    9. #9

      MeSH descriptor: [Eczema] explode all trees

    10. #10

      ('atopic dermatitis') or ('atopic eczema') or eczema

    11. #11

      (#8 or #9 or #10)

    12. #12

      (#7 and #11)

  2. II.

    Systematic MEDLINE (OVID) and EMBASE search strategy

    1. 1.

      fungi.mp. or exp Fungi/

    2. 2.

      fungus.mp.

    3. 3.

      fungal.mp.

    4. 4.

      yeast.mp. or exp Yeasts/

    5. 5.

      Malassezia.mp.

    6. 6.

      pityrosporum.mp.

    7. 7.

      candida.mp.

    8. 8.

      or/1-7

    9. 9.

      atopic dermatitis.mp. or exp Dermatitis, Atopic/

    10. 10.

      atopic eczema.mp.

    11. 11.

      eczema.mp.

    12. 12.

      neurodermatitis.mp.

    13. 13.

      or/9-12

    14. 14.

      8 and 13

/ after an index term indicates that all subheadings were selected. exp before an index term indicates that the term was exploded. mp. indicates a free text search for a term (title, abstract, original title, subject heading word, keyword heading word; cas registry/ec number word, mesh subject heading, chemical abstracts (cas) registry/enzyme commission number (ec number) word, MESH subject heading).

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Tsakok, T., Schulenburg, H., Smith, C. et al. The Role of Yeast in Atopic Dermatitis Revisited: a Critical Appraisal. Curr Derm Rep 4, 228–240 (2015). https://doi.org/10.1007/s13671-015-0123-4

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