Expression of epidermal antimicrobial peptides is increased in tinea pedis.

BACKGROUND: Tinea pedis is often chronic or recurrent, but not all individuals are equally susceptible to this infection. Dermatophytes are able to induce the expression of antimicrobial peptides and proteins (AMPs) in human keratinocytes and certain AMPs can inhibit the growth of dermatophytes. OBJECTIVE: The focus of this study was to analyse the secretion of relevant AMPs, especially RNase 7, human beta-defensin-2 (hBD-2) and the S-100 protein psoriasin (S100A7), in patients with confirmed tinea pedis. METHODS: To verify the diagnosis, skin scales were obtained from all patients (n = 13) and the dermatophytes were identified by potassium hydroxide mount, culture and molecular analysis. To determine the AMP concentrations, the lesional skin area of the foot was rinsed with a buffer that was subsequently analysed by ELISA. The corresponding area of the other unaffected foot as well as defined healthy skin areas of the forearm and forehead and samples from age and gender-matched healthy volunteers served as controls. RESULTS: In tinea pedis patients the AMP concentrations were higher in lesional skin than in non-lesional skin and in healthy skin of controls. In particular, concentrations of hBD-2 and psoriasin were significantly elevated. CONCLUSIONS: The induction of AMPs in tinea pedis might be triggered directly by the dermatophytes; furthermore, attendant inflammation and/or differentiation processes may play a role. Our results indicate that there is no defect in the constitutive expression and induction of the analysed AMPs by dermatophytes in the epidermis of affected patients. However, it is not known why the elevated AMP concentrations fail to efficiently combat dermatophyte growth.

Human primary epidermal organoids enable modeling of dermatophyte infections.

Technology of generating human epidermal derivatives with physiological relevance to in vivo epidermis is continuously investigated for improving their effects on modeling of human natural dermatological status in basic and clinical studies. Here, we report a method of robust establishment and expansion of human primary epidermal organoids (hPEOs) under a chemically defined condition. hPEOs reconstruct morphological, molecular, and functional features of human epidermis and can expand for 6 weeks. Remarkably, hPEOs are permissive for dermatophyte infections caused by Trichophyton Rubrum (T. rubrum). The T. rubrum infections on hPEOs reflect many aspects of known clinical pathological reactions and reveal that the repression on IL-1 signaling may contribute to chronic and recurrent infections with the slight inflammation caused by T. rubrum in human skin. Thus, our present study provides a new insight into the pathogenesis of T. rubrum infections and indicates that hPEOs are a potential ex vivo model for both basic studies of skin diseases and clinical studies of testing potential antifungal drugs.

Skin Immunity to Dermatophytes: From Experimental Infection Models to Human Disease.

Dermatophytoses (ringworms) are among the most frequent skin infections and are a highly prevalent cause of human disease worldwide. Despite the incidence of these superficial mycoses in healthy people and the compelling evidence on chronic and deep infections in immunocompromised individuals, the mechanisms controlling dermatophyte invasion in the skin are scarcely known. In the last years, the association between certain primary immunodeficiencies and the susceptibility to severe dermatophytosis as well as the evidence provided by novel experimental models mimicking human disease have significantly contributed to deciphering the basic immunological mechanisms against dermatophytes. In this review, we outline the current knowledge on fungal virulence factors involved in the pathogenesis of dermatophytoses and recent evidence from human infections and experimental models that shed light on the cells and molecules involved in the antifungal cutaneous immune response. The latest highlights emphasize the contribution of C-type lectin receptors signaling and the cellular immune response mediated by IL-17 and IFN-γ in the anti-dermatophytic defense and skin inflammation control.

Burden of Chronic Dermatophytosis in a Tertiary Care Hospital: Interaction of Fungal Virulence and Host Immunity.

Dermatophytosis is caused by keratinophilic dermatophytes and affects the superficial skin and its appendages. The nature of infection and response to treatment is influenced by host-pathogen factors like duration and severity of disease, prior drug history and type of causative organism. In our study, the burden of dermatophytosis affecting glabrous skin saw a rise in recalcitrant and reinfection cases with only 1.6% achieving complete cure. Chronicity of dermatophytic infection was reflected in the high serum IgE levels and immediate hypersensitivity reactions. Hence, it becomes pertinent for clinicians to identify the non-responders and modify therapy to achieve clinical cure with fungal clearance confirmed by mycological tools.

New insights in dermatophyte research.

Dermatophyte research has renewed interest because of changing human floras with changing socioeconomic conditions, and because of severe chronic infections in patients with congenital immune disorders. Main taxonomic traits at the generic level have changed considerably, and now fine-tuning at the species level with state-of-the-art technology has become urgent. Research on virulence factors focuses on secreted proteases now has support in genome data. It is speculated that most protease families are used for degrading hard keratin during nitrogen recycling in the environment, while others, such as Sub6 may have emerged as a result of ancestral gene duplication, and are likely to have specific roles during infection. Virulence may differ between mating partners of the same species and concepts of zoo- and anthropophily may require revision in some recently redefined species. Many of these questions benefit from international cooperation and exchange of materials. The aim of the ISHAM Working Group Dermatophytes aims to stimulate and coordinate international networking on these fungi.

Dermatophyte Antigen Kit.

The dermatophyte antigen kit uses monoclonal antibodies that react with polysaccharides present in the dermatophyte cell wall to detect dermatophyte antigens in specimens based on the principle of immunochromatography. Clinical studies showed that the kit was very useful in the diagnosis of tinea unguium but not tinea pedis. The kit was therefore further developed as an in vitro diagnostic tool for tinea unguium and was approved by the Pharmaceuticals and Medical Devices Agency of Japan. The kit's extraction solution can extract antigens from nail specimens quickly and efficiently. When direct microscopy fails to detect fungal elements in a specimen of suspected tinea unguium, the kit can be used so that positive samples are re-examined by direct microscopy, in order to reduce the likelihood of false-negative detection. In addition, in settings where direct microscopy is unavailable, the kit can be used so that treatment for dermatophytes is withheld when results are negative. Such an approach can reduce both wasteful treatment and medical costs. It is important to note that the kit is used to complement conventional fungus testing methods and that direct microscopy must be used to confirm the final morphological diagnosis of the pathogenic fungal infection. Use of a combination of direct microscopy and this kit should improve the accuracy of diagnosis of tinea unguium.

Are Th17 Cells Playing a Role in Immunity to Dermatophytosis?

Despite their superficial localization in the skin, pathogenic dermatophytes can induce a complex but still misunderstood immune response in their hosts. The cell-mediated immunity (CMI) is correlated with both clinical recovery and protection against reinfection, and CD4+ T lymphocytes have been recognized as a crucial component of the immune defense against dermatophytes. Before the discovery of the Th17 pathway, CMI was considered to be only dependent of Th1 cells, and thus most studies on the immunology of dermatophytosis have focused on the Th1 pathway. Nevertheless, the fine comparative analysis of available scientific data on immunology of dermatophytosis in one hand and on the Th17 pathway mechanisms involved in opportunistic mucosal fungal infections in the other hand reveals that some key elements of the Th17 pathway can be activated by dermatophytes. Stimulation of the Th17 pathway could occur through the activation of some C-type lectin-like receptors and inflammasome in antigen-presenting cells. The Th17 cells could go back to the affected skin and by the production of signature cytokines could induce the effector mechanisms like the recruitment of polymorphonuclear neutrophils and the synthesis of antimicrobial peptides. In conclusion, besides the Th1 pathway, which is important to the immune response against dermatophytes, there are also growing evidences for the involvement of the Th17 pathway.

Relevant Animal Models in Dermatophyte Research.

Dermatophytoses are common superficial fungal infections affecting both humans and animals. They are provoked by filamentous fungi called dermatophytes specialized in the degradation of keratinized structures, which allows them to induce skin, hair and nail infections. Despite their high incidence, little investigation has been performed for the understanding of these infections compared to fungal opportunistic infections and most of the studies were based on in vitro experiments. The development of animal models for dermatophyte research is required to evaluate new treatments against dermatophytoses or to increase knowledge about fungal pathogenicity factors or host immune response mechanisms. The guinea pig has been the most often used animal model to evaluate efficacy of antifungal compounds against dermatophytes, while mouse models were preferred to study the immune response generated during the disease. Here, we review the relevant animal models that were developed for dermatophyte research and we discuss the advantages and disadvantages of the selected species, especially guinea pig and mouse.

Clinical study of Dermatophyte Test Strip, an immunochromatographic method, to detect tinea unguium dermatophytes.

The Dermatophyte Test Strip visualizes mycotic antigens by immunochromatography. It allows easy and fast detection of dermatophytes. A multicenter, single-arm, comparative clinical study was designed to evaluate the capacity of Dermatophyte Test Strip to detect dermatophytes in suspected tinea unguium specimens in comparison with direct microscopy and polymerase chain reaction (PCR). Signed consent was obtained from 222 subjects and all subjects completed the study. With the Dermatophyte Test Strip, dermatophytes were detected in 201 of 222 (90.5%) specimens but not in 21 of 222 (9.5%) specimens. With direct microscopy, dermatophytes were detected in 170 of 222 (76.6%) specimens but not in 52 of 222 (23.4%). Of the 45 specimens that showed inconsistent results between the two methods, PCR gave further results for 40 specimens, of which 37 (92.5%) specimens were positive and three (7.5%) were negative for dermatophytes. The positive concordance rate, negative concordance rate and overall concordance rate between the Dermatophyte Test Strip and direct microscopy were 81.1%, 66.7% and 79.7%, respectively. When inconsistent results were corrected using the results of PCR, these rates were 97.5%, 71.4% and 95.0%, respectively. When five specimens that could not be tested by PCR because no piece for the PCR test was left were excluded from analysis, these rates were 99.0%, 78.9% and 97.2%, respectively. The present results indicate good detection capacity of the Dermatophyte Test Strip. The Dermatophyte Test Strip provides a reliable, convenient and quick method to test for tinea unguium.

Immunoresponses in dermatomycoses.

Contact with fungal pathogens initiates a series of host responses beginning with innate immunity, which leads to fungal recognition and microbial killing. The innate immune system also modulates the adaptive immune responses, leading to the establishment of immunological memory and protection against pathogens. In the case of dimorphic fungi such as Candida albicans and Malassezia, the immune system plays an important role in tolerance and resistance when managing the organisms either as commensal microbiota or invading pathogens, and disruption of this balance can result in pathological consequences for the host. In addition, Malassezia and dermatophytes have immunomodulatory capabilities that allow them to adapt to their environments and they may exert different effects in healthy and diseased skin. Here, we discuss the host immune responses to dermatomycoses caused by dimorphic fungi such as C. albicans and Malassezia as well as dermatophytes such as Trichophyton spp. and Arthroderma benhamiae to gain a better understanding of the mechanisms of the host-dermatomycosis interaction.

Dermatomycoses and inflammation: The adaptive balance between growth, damage, and survival.

Dermatomycosis is characterized by both superficial and subcutaneous infections of keratinous tissues and mucous membranes caused by a variety of fungal agents, the two most common classes being dermatophytes and yeasts. Overall, the stepwise process of host infection is similar among the main dermatomycotic species; however, the species-specific ability to elicit a host reaction upon infection is distinct. Yeasts such as Candida albicans elicit a relatively low level of host tissue damage and inflammation during pathogenic infection, while dermatophytes may induce a higher level of tissue damage and inflammatory reaction. Both pathogens can, however, manipulate the host's immune response, ensuring survival and prolonging chronic infection. One common element of most dermatomycotic infections is the disease burden caused by inflammation and associated signs and symptoms, such as erythema, burning and pruritus. There is a strong clinical rationale for the addition of a topical corticosteroid agent to an effective antimycotic therapy, especially in patients who present with inflammatory dermatomycoses (e.g., tinea inguinalis). In this review, we aim to compare the pathogenesis of common dermatomycotic species, including Candida yeasts (Candida albicans), dermatophytes (Trichophyton, Epidermophyton or Microsporum species), and other pathogenic yeasts (Malassezia), with a special focus on unique species-specific aspects of the respective infection processes, the interaction between essential aspects of pathogenic infection, the different roles of the host inflammatory response, and the clinical consequences of the infection-related tissue damage and inflammation. We hope that a broader understanding of the various mechanisms of dermatomycoses may contribute to more effective management of affected patients.

Dermatophytes activate skin keratinocytes via mitogen-activated protein kinase signaling and induce immune responses.

Dermatophytes cause superficial and cutaneous fungal infections in immunocompetent hosts and invasive disease in immunocompromised hosts. However, the host mechanisms that regulate innate immune responses against these fungi are largely unknown. Here, we utilized commercially available epidermal tissues and primary keratinocytes to assess (i) damage induction by anthropophilic, geophilic, and zoophilic dermatophyte strains and (ii) the keratinocyte signaling pathways, transcription factors, and proinflammatory responses induced by a representative dermatophyte, Trichophyton equinum. Initially, five dermatophyte species were tested for their ability to invade, cause tissue damage, and induce cytokines, with Microsporum gypseum inducing the greatest level of damage and cytokine release. Using T. equinum as a representative dermatophyte, we found that the mitogen-activated protein kinase (MAPK) pathways were predominantly affected, with increased levels of phospho-p38 and phospho-Jun N-terminal protein kinase (JNK) but decreased levels of phospho-extracellular signal-regulated kinases 1 and 2 (ERK1/2). Notably, the NF-κB and PI3K pathways were largely unaffected. T. equinum also significantly increased expression of the AP-1-associated transcription factor, c-Fos, and the MAPK regulatory phosphatase, MKP1. Importantly, the ability of T. equinum to invade, cause tissue damage, activate signaling and transcription factors, and induce proinflammatory responses correlated with germination, indicating that germination may be important for dermatophyte virulence and host immune activation.

[Immunoallergic skin manifestations associated with new pets: three cases]. / Manifestations cutanées immuno-allergiques liées aux nouveaux animaux de compagnie : trois observations.

BACKGROUND: The number of household pets increased greatly during the twentieth century, with numbers of new pets (NP, i.e. any pets other than cats and dogs) rising especially sharply over the last decade. PATIENTS AND METHODS: We first of all report the case of a female patient with eczema lesions on areas skin coming into contact with a ferret, with removal of the animal resulting in wound healing, followed by two patients presenting atypical polymorphous erythema reactions induced by dermatophytes present in their pet rat. DISCUSSION: While the most common allergies are respiratory, allergic skin reactions, both immediate and delayed, may also result from contact with these new allergens. The animal itself or its environment may be the cause.

Dermatomycoses: challenges and human immune responses.

The most prevalent skin infections are mainly caused by species of dermatophytes of the genera Trichophyton, Microsporum, and Epidermophyton that infect keratinized tissues and stratum corneum of skin and hair. Besides proteases with putative role of kinases and other enzymes, immune modulators are abundantly secreted during infection as well. The molecular mechanism used by the dermatophytes to infect and counteract the host immune response is not well understood. The defense against infections basically depends on the host's immune responses to metabolites of the fungi, virulence of the infecting strain or species and anatomical site of the infection. The two aspects of the immune system, the immediate hypersensitivity and delayed-type hypersensitivity against dermatophytes may be crucial to the progression and severity of skin infection. Management of the infection through species identification and molecular diagnostic techniques as well as use of novel targeted drugs in addition to conventional anti-fungal compounds is of great importance in dealing with disease onsets and outbreaks. Here we reviewed the fungal skin infections elucidating their biologic and immunologic characteristics. Reaction to fungal invasion by the infected epithelial tissue on the host side is also discussed. Moreover, determinants of protective immunity and treatment options are focused that could confer long-lasting resistance to infection.

Assessment of the cutaneous immune response during Arthroderma benhamiae and A. vanbreuseghemii infection using an experimental mouse model.

BACKGROUND: Dermatophytoses are common but poorly understood skin infections. Most in vivo studies have been performed using the guinea pig as the experimental animal model, which has several limitations. OBJECTIVES: To develop a mouse model of dermatophytosis suitable for multiple purposes, including the investigation of immunity against dermatophytes. MATERIALS AND METHODS: Two peculiar fungal species, Arthroderma benhamiae and A. vanbreuseghemii, isolated from tinea in humans having contact with rodents were used for epicutaneous inoculation. During the infection, clinical and histopathological follow-up were performed. The recruitment of immune cells was evaluated by immunofluorescence staining and the levels of cytokine mRNA were quantified by quantitative reverse transcriptase-polymerase chain reaction in the skin of infected mice. RESULTS: The skin symptoms and microscopic lesions, including the colonization of keratinized epidermal and follicular structures by both dermatophytes, were highly similar to those observed in guinea pig infection models and in natural infections, mimicking acute superficial tinea in humans. The dermal inflammatory cellular infiltrate consisted of macrophages, dendritic cells and especially polymorphonuclear neutrophils, which are one of the histological 'clues' to the diagnosis of dermatophytosis. The in situ cytokine profile was characterized by the overexpression of transforming growth factor-ß, interleukin (IL)-1ß and IL-6 mRNA during infection, suggesting a role of the T-helper 17 pathway in the establishment of immunity. CONCLUSIONS: Our new reproducible and validated mouse model of dermatophytosis is a modern in vivo tool that allows a more in-depth understanding of the pathogenesis of human dermatophyte infections.

The Arthroderma benhamiae hydrophobin HypA mediates hydrophobicity and influences recognition by human immune effector cells.

Dermatophytes are the most common cause of superficial mycoses in humans and animals. They can coexist with their hosts for many years without causing significant symptoms but also cause highly inflammatory diseases. To identify mechanisms involved in the modulation of the host response during infection caused by the zoophilic dermatophyte Arthroderma benhamiae, cell wall-associated surface proteins were studied. By two-dimensional gel electrophoresis, we found that a hydrophobin protein designated HypA was the dominant cell surface protein. HypA was also detected in the supernatant during the growth and conidiation of the fungus. The A. benhamiae genome harbors only a single hydrophobin gene, designated hypA. A hypA deletion mutant was generated, as was a complemented hypA mutant strain (hypA(C)). In contrast to the wild type and the complemented strain, the hypA deletion mutant exhibited "easily wettable" mycelia and conidia, indicating the loss of surface hydrophobicity of both morphotypes. Compared with the wild type, the hypA deletion mutant triggered an increased activation of human neutrophil granulocytes and dendritic cells, characterized by an increased release of the immune mediators interleukin-6 (IL-6), IL-8, IL-10, and tumor necrosis factor alpha (TNF-α). For the first time, we observed the formation of neutrophil extracellular traps against dermatophytes, whose level of formation was increased by the ΔhypA mutant compared with the wild type. Furthermore, conidia of the ΔhypA strain were killed more effectively by neutrophils. Our data suggest that the recognition of A. benhamiae by the cellular immune defense system is notably influenced by the presence of the surface rodlet layer formed by the hydrophobin HypA.

Análisis del polimorfismo genético de los loci HLA-B y HLA-DR en pacientes con onicomicosis dermatofítica y familiares en primer grado / Analysis of Genetic Polymorphism of the HLA-B and HLA-DR Loci in Patients with Dermatophytic Onychomycosis and in Their First-Degree Relatives

En la onicomicosis hay factores predisponentes conocidos y una alta prevalencia en familiares no explicada por transmisión intrafamiliar. Analizamos la frecuencia génica de alelos de los genes HLA-B y HLA-DR en 25 familias de pacientes mexicanos con onicomicosis para conocer el papel del complejo mayor de histocompatibilidad (MHC) clase II en la susceptibilidad genética a esta enfermedad. Se estudiaron 78 individuos, 47 de ellos con onicomicosis y 31 sanos. Se determinaron las frecuencias génicas de los alelos de los loci HLA-B y HLA-DR y se compararon con las presentes en familiares de primer grado sin onicomicosis y con un grupo de individuos sanos. Estas fueron semejantes a las de familiares sanos; sin embargo, al comparar pacientes con controles históricos se encontró un aumento de la frecuencia del alelo HLA-DR8 (p=0,03; OR=1,89; IC 95%: 0,98-36). Estos datos sugieren que dentro del MHC existen genes de susceptibilidad al desarrollo de onicomicosis; en particular con el alelo HLA-DR8 (AU)

Onychomycosis is known to have predisposing factors and a high prevalence within families that cannot be explained by within-family transmission. We determined the frequency of HLA-B and HLA-DR haplotypes in 25 families of Mexican patients with onychomycosis in order to define the role of the class II major histocompatibility complex (MHC) in genetic susceptibility to this infection. Seventy-eight subjects participated in the study, 47 with onychomycosis and 31 healthy individuals. The frequencies of the HLA-B and HLA-DR haplotypes were compared with those found in first-degree relatives without onychomycosis and in a historic control group of healthy individuals. The frequencies in the controls were similar to those of the healthy relatives of the patients. However, on comparison of the patients with historic controls, we detected a higher frequency of the HLA-DR8 haplotype (P=0.03; odds ratio, 1.89; 95% confidence interval, 0.98-36). These findings suggest that there are polymorphisms in genes of the MHC that increase susceptibility to onychomycosis, particularly haplotype HLA-DR8 (AU)

Safety of a non-adjuvanted therapeutic vaccine for the treatment of feline dermatophytosis.

The safety of a non-adjuvanted inactivated fungal vaccine for the treatment of dermatophytosis in cats was investigated in two studies: a controlled laboratory study, and a placebo-controlled double-blind field study with a cross-over design in Europe. In the laboratory study, two groups of 10 cats each were administered an intramuscular twofold overdose, followed by five single 1 ml doses, of either vaccine or control product at 14-day intervals. In the field study, cats were treated with three intramuscular injections of 1 ml vaccine administered at 14-day intervals, as recommended by the manufacturer. A total of 89 cats were enrolled in the field study and divided into two groups to receive either vaccine or placebo for the first three treatments, followed by the opposite product for the final three treatments. The cats enrolled in the two studies were 12 weeks of age or older, as recommended by the manufacturer. All the cats were monitored closely for possible injection site reactions, systemic reactions (including changes in rectal body temperature) and adverse events. The results from both studies showed no significant differences between the vaccinated cats and the control or placebo-treated cats with regard to local or systemic reactions. A few mild to moderate local reactions were noted, but these were evenly distributed between the vaccinated and placebo-treated cats and resolved within a few days. No severe or serious adverse events related to the vaccinations were observed.

CD4+ and CD8+ T cells mediated direct cytotoxic effect against Trichophyton rubrum and Trichophyton mentagrophytes.

BACKGROUND: The cellular immune system is the most dominant factor in curing acute dermatophytosis. However, the exact immune mechanisms involved in generating this defense are complex and still obscure. The aim of this study was to investigate the fungicidal mechanism of T cells in the normal population versus patients with chronic fungal infections. METHODS: Thirty patients were included in the study: 15 patients with chronic dermatophytosis and 15 normal healthy patients with a history of acute dermatophytosis. The procedures were performed as follows. 1) Proliferation and cytotoxic activity of lymphocytes cultured with various dermatophytes homogenate such as, Trichophyton rubrum, Trichophyton mentagrophytes and Microsporum gypseum. 2) CD4(+) and CD8(+) T cells were separated by magnetic beads before culture with fresh spores of either T. mentagrophytes or T. rubrum. 3) Routine histology and ultrastructural study were performed to illustrate the mode of activity of the T cells against the dermatophytes. RESULTS: The study showed that both CD4 and CD8 possess cytotoxic activity against dermatophytes. However, the results demonstrated a suppression of lymphocyte proliferation response and a significant lower cytotoxic effect in chronic patients. Ultra structure and histological evaluation of the culture of hyphae with CD4(+) or CD8(+) T cells showed more prominently destructive effects in the culture of cells that had been obtained from normal population than those of patients with long-lasting fungal infections. CONCLUSION: The study suggests a selective impairment of lymphocyte function against dermatophytes, in patients with chronic dermatophytoses.