Azole-Driven Cross-Resistance and Transporter Gene Expression in Malassezia Yeasts

Malassezia are commensal lipid dependent yeasts which can cause opportunistic skin infection. Topical imidazole antifungals such as clotrimazole and ketoconazole are the frontline treatment. However, the tendency of fungal infections to recur, combined with the emergence of multi-azole-resistant Malassezia isolates means that many patients have used these antifungal treatments repeatedly or for extended durations with limited efficacy. While the impact of single azole treatments has been studied, the ability of specific azoles to induce cross-resistance is unclear. Understanding the effect of prior exposure of one treatment on susceptibility to other antifungals is important in the selection of the appropriate treatment to avoid driving the evolution of greater resistance. We previously identified drug transporters from the ATP-Binding Cassette (ABC) and Major Facilitator Superfamily (MFS) to be upregulated on extended exposure to clotrimazole. In this study, we investigated the effect of extended clotrimazole, ketoconazole and fluconazole exposure on antifungal cross-resistance profiles and examined the expression of the MFS transporters OPT1 and FLR1 in resistance emergence. We observed that treatment with clotrimazole was associated with increased cross-resistance to other antifungals. Ketoconazole treatment caused elevated MICs in all tested antifungals that did not decrease after drug removal. These findings advance our understanding of fungal adaptive resistance mechanisms and inform improved antifungal strategies to mitigate resistance development.