Case and Research Letter
Malassezia Growth on Peritumoral Skin After Routine Methyl-5-Aminolevulinate Photodynamic Therapy for Actinic Keratosis and Nonmelanoma Skin Cancer
Crecimiento de Malassezia en Piel Peritumoral Tras Terapia Fotodinámica con Metil-5-aminolevulinato para Queratosis Actínica y Cáncer de Piel No Melanoma
a Unit of Dermatology, Hospital San Jorge, Huesca, Spain
b Health Science Institute of Aragón, Zaragoza, Spain
c Microbiology Section, Hospital Royo Villanova, Zaragoza, Spain
d Laboratory of Microbiology, Municipal Institute of Public Health, Zaragoza, Spain
e IIS Aragón, Department of Microbiology, University Hospital Miguel Servet, University of Zaragoza, Zaragoza, Spain
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Gilaberte, C. Aspiroz, C. Alejandre, A. Rezusta" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Y." "apellidos" => "Gilaberte" "email" => array:2 [ 0 => "ygilaberte@salud.aragon.es" 1 => "ygilaberte@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Aspiroz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "C." 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"apellidos" => "Rezusta" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unit of Dermatology, Hospital San Jorge, Huesca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Health Science Institute of Aragón, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Microbiology Section, Hospital Royo Villanova, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Laboratory of Microbiology, Municipal Institute of Public Health, Zaragoza, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "IIS Aragón, Department of Microbiology, University Hospital Miguel Servet, University of Zaragoza, Zaragoza, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Crecimiento de <span class="elsevierStyleItalic">Malassezia</span> en Piel Peritumoral Tras Terapia Fotodinámica con Metil-5-aminolevulinato para Queratosis Actínica y Cáncer de Piel No Melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1208 "Ancho" => 1667 "Tamanyo" => 124752 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Box plot shows the difference in the number of <span class="elsevierStyleItalic">Malassezia</span> colonies before and after exposure of the peritumoral area and the adjacent control area to MAL-PDT and red light illumination, respectively.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Malassezia</span> (<span class="elsevierStyleItalic">Pityrosporum</span>) species are lipophilic yeasts that are recognized as commensals of the skin of warm-blooded vertebrates.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Aryl-hydrocarbon receptor (AhR) ligands produced by <span class="elsevierStyleItalic">Malassezia</span> species have been implicated in carcinogenesis, suggesting that this yeast may contribute to the development of skin cancer, particularly basal cell carcinoma (BCC).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This hypothesis suggests that skin cancer treatments that combine antitumoral and antimicrobial effects may be particularly effective.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We investigated the effect of routine methylaminolevulinate photodynamic therapy (MAL-PDT) on <span class="elsevierStyleItalic">Malassezia</span> species present in the flora of peritumoral skin. The participants were patients with non-melanoma skin cancer who were treated with MAL-PDT (Metvix® in combination with Aktilite® red light illumination, 37<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) in the Dermatology Department of the Hospital General San Jorge (Huesca, Spain) between September and November 2012.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Swab samples were taken from a 2-cm<span class="elsevierStyleSup">2</span> area of skin within 1<span class="elsevierStyleHsp" style=""></span>cm of the lesion before and after MAL-PDT. Control swab samples were taken from an adjacent area of healthy skin before and after exposure to red light illumination only. The skin was not prepared before swabbing. Swabs were then used to immediately inoculate the entire surface of individual Dixon plates, which were incubated at 35<span class="elsevierStyleHsp" style=""></span>°C.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Malassezia</span> species were identified by micromorphology (morphological microscopy), cultural characteristics (effect of temperature, subculture on Sabouraud agar, growth and appearance on Leeming and Notman agar, Dixon modified media, CHROMagar, and Tween agar), biochemical characteristics (catalase production, bile esculin test), and the assimilation profile when grown on Tween agar.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">All data are presented as the mean and standard deviation (SD). Differences between groups were evaluated using the Mann–Whitney <span class="elsevierStyleItalic">U</span> test, Kruskal–Wallis test, and Wilcoxon matched-pairs signed ranked test, assuming a confidence level of 95% (i.e., <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05). Analyses were performed using IBM SPSS software (Version 19.0). The study was approved by the regional ethics committee for clinical research.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thirty patients (19 men and 11 women) participated in the study. Of these, 19 (63.3%) were treated for actinic keratosis, 10 (33.4%) for BCC, and 1 (3.3%) for Bowen disease. Lesions were most commonly located on the forehead (26.7%) and scalp (23.3%), followed by the nose (16.7%), back (10%), cheek (6.7%), neck (6.7%), chest (6.7%), and ear (3.3%).</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 13 patients <span class="elsevierStyleItalic">Malassezia</span> species were detected in both the peritumoral and control areas before treatment. The most commonly found species was <span class="elsevierStyleItalic">Malassezia globosa</span> (10 patients), either alone or in combination with other species, followed by <span class="elsevierStyleItalic">Malassezia sympodialis</span> (3 patients). Treatment resulted in a decrease in the number of colonies in the peritumoral and control areas in 10 and 8 patients, respectively. The mean number of colonies observed before treatment was 46.00 (50.67) in the peritumoral area and 63.38 (119.44) in the control area. MAL-PDT resulted in a significant decrease in the number of colonies in the peritumoral area (20.46[33.94], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.023); this effect was not observed in the control area after exposure to red light illumination (40.69[61.49], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.22) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The decrease in the mean number of colonies induced by MAL-PDT was significantly greater in patients that were positive for both <span class="elsevierStyleItalic">M</span>. <span class="elsevierStyleItalic">globosa</span> and <span class="elsevierStyleItalic">M</span>. <span class="elsevierStyleItalic">sympodialis</span> (76[15.06]) than in those with <span class="elsevierStyleItalic">M</span>. <span class="elsevierStyleItalic">globosa</span> alone (12.36[20.54]) or with other <span class="elsevierStyleItalic">Malassezia</span> species (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.007). We found no association between the mean number of <span class="elsevierStyleItalic">Malassezia</span> colonies and patient gender (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.70), tumor type (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.95), or tumor location (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.21).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our results demonstrate that routine MAL-PDT attenuates the growth of <span class="elsevierStyleItalic">Malassezia</span> species on peritumoral skin. This observation is in line with previous reports describing the effectiveness of MAL-PDT in pityriasis versicolor,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> recalcitrant <span class="elsevierStyleItalic">Malassezia</span> folliculitis,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and onychomycosis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The inhibitory effect of MAL-PDT on <span class="elsevierStyleItalic">M</span>. <span class="elsevierStyleItalic">globosa</span> was greater than that observed for <span class="elsevierStyleItalic">M. sympodialis</span>, suggesting that sensitivity to MAL-PDT varies among <span class="elsevierStyleItalic">Malassezia</span> species. In line with this view, differential sensitivity to PDT in vitro has been described for other yeast species, such as <span class="elsevierStyleItalic">Candida</span>.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In most patients, we observed a decrease in the number of <span class="elsevierStyleItalic">Malassezia</span> colonies in the control area after exposure to red light illumination, in agreement with previous reports describing the inhibitory effects of a red light-emitting diode on the growth of bacteria and yeast.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There are 2 main limitations to our study. First, statistical power was limited by the small sample size, although this effect was somewhat offset by using each patient as their own control. Second, the potential fungicidal effect of MAL in the absence of illumination was not evaluated. While neither aminolevulinic acid nor MAL exert cytotoxic effects when administered in vivo without illumination, high concentrations of aminolevulinic acid can be toxic to certain cell types in vitro.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Bryld and coworkers<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> reported no significant changes in bacterial flora after MAL-PDT. MAL-PDT may be a particularly attractive treatment option if it could effectively eliminate <span class="elsevierStyleItalic">Malassezia</span> species without damaging cutaneous bacterial flora, especially if the proposed role of <span class="elsevierStyleItalic">Malassezia</span> species in carcinogenesis is confirmed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In summary, our findings demonstrate that MAL-PDT exerts a significant antifungal effect in vivo against commensal <span class="elsevierStyleItalic">Malassezia</span> species in non-melanoma skin cancer.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1208 "Ancho" => 1667 "Tamanyo" => 124752 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Box plot shows the difference in the number of <span class="elsevierStyleItalic">Malassezia</span> colonies before and after exposure of the peritumoral area and the adjacent control area to MAL-PDT and red light illumination, respectively.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Malassezia</span> species in skin diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "V. 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Gaitanis for constructive comments and critical review of the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000010600000001/v2_201706012025/S0001731014002221/v2_201706012025/en/main.assets" "Apartado" => array:4 [ "identificador" => "6160" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científico-clínicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000010600000001/v2_201706012025/S0001731014002221/v2_201706012025/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731014002221?idApp=UINPBA000044" ]
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