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Framing the future of antifungals in atopic dermatitis
Arjen F Nikkels1, Gérald E Piérard
1Department of Dermatopathology, University Medical Center of Liège, Belgium.
Abstract:
Atopic dermatitis (AD) is a frequent chronic inflammatory skin disease. Some fungal colonization or infection of the skin may exacerbate AD severity, particularly the so-called head and neck variant. In addition, excessive intestinal colonization by Candida albicans may represent an additional triggering factor. Hence, there is a rationale to use antifungals in selected AD patients. Early trials with topical ketoconazole in head and neck AD showed a decrease in Malassezia colonization, but no significant improvement was observed in the clinical severity. In contrast, clinical improvement and decreased serum IgE were obtained in patients with positive Malassezia radioallergosorbent tests (RASTs) who were treated by oral ketoconazole. Some preliminary data suggested that oral itraconazole treatment in AD patients reduced the need for topical corticosteroids, provided clinical improvement particularly in head and neck AD, reduced the cutaneous and intestinal fungal colonization that may trigger AD, reduced the percentage of positive Malassezia cultures and demonstrated a decrease in C. albicans and Malassezia RAST values. Furthermore, beside its antifungal action, itraconazole in part relieves pruritus and inflammation. In conclusion, oral itraconazole treatment can alleviate AD severity in selected patients. Fluconazole is also effective. Further research is warranted to identify whether the load in skin surface fungal agents, the fungal RAST values and specific prick testing should be assessed in order to optimize the antifungal management in AD patients.
Insights
Antifungal treatments like oral itraconazole may improve atopic dermatitis (AD) in some patients by reducing fungal colonization. Further research is needed to optimize antifungal strategies for AD management.
Area of Science:
- Dermatology
- Mycology
- Immunology
Background:
- Atopic dermatitis (AD) is a chronic inflammatory skin condition.
- Fungal infections, particularly Malassezia and Candida albicans, can worsen AD, especially the head and neck variant.
- Intestinal fungal colonization may also trigger AD.
Purpose of the Study:
- To investigate the efficacy of antifungal agents in managing atopic dermatitis.
- To determine if antifungals can reduce fungal load and improve clinical outcomes in AD patients.
Main Methods:
- Review of early trials using topical ketoconazole.
- Analysis of studies involving oral ketoconazole and itraconazole treatment for AD.
- Assessment of fungal colonization (skin and intestinal) and specific IgE levels (RASTs).
Main Results:
- Topical ketoconazole reduced Malassezia but did not improve AD severity.
- Oral ketoconazole improved AD and decreased IgE in patients with positive Malassezia RASTs.
- Oral itraconazole showed clinical improvement, reduced corticosteroid need, and decreased fungal colonization and RAST values in AD patients.
- Itraconazole also provided relief from pruritus and inflammation.
Conclusions:
- Oral itraconazole can alleviate AD severity in selected patients.
- Fluconazole is also effective.
- Further research is needed to identify biomarkers like fungal load and RAST values for optimizing antifungal therapy in AD.