Atopic dermatitis is a chronic multifactorial inflammatory skin disease, which has had a marked increase in prevalence during the last decades. Recently, a new nomenclature was recommended where the term ‘atopic eczema/dermatitis syndrome’ (AEDS) should be used to reflect the heterogeneity in this group of patients and where those patients without measurable IgE reactivity should be classified as either ‘nonallergic AEDS’ or ‘non-IgE-associated allergic AEDS’. For nearly 20 years it has been discussed whether the opportunistic yeast Malassezia, previously designated Pityrosporum, is a contributing factor to AEDS. Today there are several reports that demonstrate specific serum IgE or positive skin prick test and/or atopy patch test reactions to Malassezia in patients with AEDS. Several IgE-binding components have been identified in extracts of Malassezia ranging in molecular mass between 10 and 100 kD. The genes for nine Malassezia allergens with molecular weights ranging from 14 to 36 kD have hitherto been identified and cloned. Six of them are now produced by recombinant techniques and used in diagnostic tests. At present the genus Malassezia is subdivided into seven different species, which all have been isolated from human skin. The respective contribution of different Malassezia spp. to AEDS and in what proportion they share allergens remains to be clarified. We summarize here data that Malassezia can play a role in eliciting and maintaining eczema in patients with AEDS.

Atopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients.Johansson, C.; Sandström, M.H.; Bartosik, Jacek; Särnhult, T.; Christiansen, J; Zargari, A.; Bäck, Ove; Wahlgren, C.F.; Faergemann, J.; Scheynius, A.; Tengvall Linder, M. Link to publication Citation for published version (APA): Johansson, C., Sandström, M. H., Bartosik, J., Särnhult, T., Christiansen, J., Zargari, A., ... Tengvall Linder, M. (2003). Atopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients. British Journal of Dermatology, 148(3), 479-488. DOI: 10.1046479-488. DOI: 10. /j.1365479-488. DOI: 10. -2133479-488. DOI: 10. .2003 General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.• Users may download and print one copy of any publication from the public portal for the purpose of private study or research.• You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal Clinical and Laboratory InvestigationsAtopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients SummaryBackground The yeast Malassezia is considered to be one of the factors that can contribute to atopic dermatitis (AD).Objectives To investigate the reactivity to Malassezia allergens, measured as specific serum IgE, positive skin prick test and positive atopy patch test (APT), in adult patients with AD. Methods In total, 132 adult patients with AD, 14 with seborrhoeic dermatitis (SD) and 33 healthy controls were investigated for their reactions to M. sympodialis extract and three recombinant Malassezia allergens (rMal s 1, rMal s 5 and rMal s 6).Results Sixty-seven per cent of the AD patients, but only one of the SD patients and none of the healthy controls, showed a positive reaction to at least one of the Malassezia allergens (extract and ⁄ or recombinant allergens) in at least one of the tests. The levels of M. sympodialis-specific IgE in serum correlated with the total serum IgE levels. Elevated serum levels of M. sympodialis-specific IgE were found in 55% and positive APT reactions in 41% of the AD patients with head and neck dermatitis. A relatively high proportion of patients without head and neck dermatitis and patients with low total serum IgE levels had a positive APT for M. sympodialis, despite lower proportions of individuals with M. sympodialis-specific IgE among these groups of patients.Conclusions These results support that Malassezia can play a role in eliciting and maintaining eczema in patients with AD. The addition of an APT to the test battery used in this study reveals a previously overlooked impact of Malassezia hypersensitivity in certain subgroups of AD patie...

The opportunistic yeast Malassezia sympodialis belongs to the normal cutaneous flora but can also cause IgE-mediated sensitization in patients suffering from atopic eczema (AE). We investigated 706 individuals by ImmunoCAPm70 and skin-prick tests with a crude M. sympodialis extract. In AE patients, we further performed skin prick tests, atopy patch tests, ELISA, and peripheral blood mononuclear cells proliferation assays with recombinant M. sympodialis allergens (rMala s 1 and 5-9). In 52/97 patients with AE-specific IgE against M. sympodialis was detectable. Almost no reactivity to M. sympodialis was seen in patients suffering from other allergic diseases (4/571) and no reactivity at all was seen in healthy controls (0/38). Skin tests showed variable recognition patterns against the different molecular structures with a predominant sensitization to rMala s 1, 5, 6, and 9, confirmed also by specific serum IgE to these allergens. Interestingly, IgE- and T-cell-mediated reactivity against M. sympodialis was also found in patients with the intrinsic form of AE. Thus, sensitization to M. sympodialis is specific for AE patients and occurs in both the extrinsic and intrinsic variant of eczema. Recombinant yeast allergens represent a useful tool to study molecular structures and differential sensitization patterns in the pathogenesis of AE.

Cultures for Malassezia yeasts were taken from both normal-looking skin and lesional skin in 124 patients with atopic dermatitis, 16 patients with seborrhoeic dermatitis and from normal skin of 31 healthy controls. Positive Malassezia growth was found in fewer patients with atopic dermatitis (56%) than in patients with seborrhoeic dermatitis (88%) or in healthy controls (84%, p<0.01). In the patients with atopic dermatitis, fewer positive cultures were found in lesional (28%) than in non-lesional skin (44%, p<0.05), while positive cultures were found in 75% of both lesional and non-lesional skin of patients with seborrhoeic dermatitis (not significant). M. sympodialis dominated in patients with atopic dermatitis (46%) and in healthy controls (69%). In patients with seborrhoeic dermatitis both M. sympodialis and M. obtusa were cultured in 43%. A Malassezia species extract mixture would increase the possibility of detecting IgE sensitization to Malassezia in patients with atopic dermatitis.

To explore the pruritogenic and inflammatory effects of cytokines, a single dose of 20 micrograms recombinant human interleukin-2 was injected intradermally into eight patients with atopic dermatitis and eight healthy controls. The study was double-blind and randomized with glucose as a negative control. The effects were evaluated by recording local itch and erythema over 72 h and by examining skin biopsies taken at 24 h and 72 h. In patients and controls, interleukin-2 provoked a low-intensity local itch with maximal intensity between 6 h and 48 h and erythema with maximal extension between 12 h and 72 h. In the atopic dermatitis patients, these reactions tended to appear earlier and were less pronounced than in the healthy controls. Interleukin-2 induced dermal mononuclear cell infiltrates consisting mainly of CD3+ cells. A majority of the T cells were CD4+. The number of dermal CD25+, HLA-DR+ and ICAM-1+ cells was also increased at the interleukin-2 induced spongiosis and exocytosis as well as HLA-DR+ and ICAM-1+ keratinocytes. The microscopic findings tended to be more prominent at 72 h than at 24 h in both groups, but with a somewhat slower onset in the atopic dermatitis patients. In conclusion, a single intradermal injection of interleukin-2 induced local itch, erythema, dermal T-cell infiltrates, spongiosis, exocytosis and activation of keratinocytes both in atopic dermatitis patients and in healthy controls.

The yeast Malassezia furfur belongs to the normal cutaneous flora, but is also a triggering allergen that can contribute to atopic dermatitis. To illuminate the effect of circulating allergen-specific T cells in atopic dermatitis, the peripheral mononuclear cell response was correlated with the in vivo skin prick test and atopy patch test reactivity to M. furfur. None of 16 healthy controls showed any positive in vivo reaction. The 40 atopic dermatitis patients, of whom 18 had serum IgE reactivity to M. furfur, were subdivided according to their in vivo reaction to M. furfur extract into three groups: skin prick test positive/atopy patch test positive (n = 12), skin prick test positive/atopy patch test negative (n = 12), and skin prick test negative/atopy patch test negative (n = 16). The skin prick test positive/atopy patch test positive and the skin prick test positive/atopy patch test negative groups had a significantly higher peripheral mononuclear cell stimulation index than the healthy controls. Interestingly, the stimulation index values in the skin prick test positive/atopy patch test positive group were significantly higher than in the skin prick test positive/atopy patch test negative group. In the M. furfur skin prick test positive atopic dermatitis patients (n = 24) a correlation was found between stimulation index and the M. furfur atopy patch test reactions, but not between stimulation index and M. furfur-specific serum IgE levels. Skin prick test positive and/or atopy patch test positive reactions to the recombinant M. furfur allergens rMal f 1, rMal f 5, and rMal f 6 were observed in 7, 14, and 16 of the 40 atopic dermatitis patients, respectively. Further, there was a correlation between production of the T helper 2-related cytokines interleukins 4, 5, and 13 and stimulation index to M. furfur extract, but not between the T helper 1-related interferon-gamma and stimulation index to M. furfur extract. Our data strongly suggest a relationship between circulating specific T cells with a T helper 2-like cytokine profile and positive atopy patch test reactions.

Our data suggest that P. orbiculare can induce a T-cell response in AD patients. The Th2-like profile of P. orbiculare-reactive TCC derived from lesional skin indicates that P. orbiculare may play a role in maintaining IgE-mediated skin inflammation in AD.

To investigate whether the CD30 molecule, expressed only by a minority of T and B cells, defines a subtype of T helper cells, Pityrosporum orbiculare-specific CD4+ T cell clones were assessed for CD30 protein and gene expression. The clones were defined as Th1, Th0, and Th2 according to their cytokine mRNA profile detected by reverse transcription PCR (RT-PCR). The kinetics of CD30 expression after OKT3 (anti-CD3) stimulation was analyzed by flow cytometry, immunocytochemistry, and RT-PCR. OKT3 activation induced a high expression of CD30 in cells of both Th1 and Th0 as well as Th2 type after 1-3 days. A difference between the clones was noted in that the Th2 clones remained highly positive in CD30 expression, whereas expression in the other clones started to decline from day 3. These data indicate that CD30 is expressed in activated CD4+ T cells of all three subtypes, and that the expression is sustained in Th2 cells.