Инфекция является наиболее частым осложнением атопического дерматита (АтД). В частности, некоторые пациенты с АтД проявляют повышенную восприимчивость к инфекциям кожи бактериальной, вирусной и грибковой этиологий. В ряде случаев инфекции даже могут быть системными. Бактериальные инфекции кожи встречаются чаще, чем вирусные и грибковые. Особенно тяжело протекает инфекция, вызванная герпес-вирусом, – герпетическая экзема, которая может спровоцировать опасные для жизни осложнения. Инфекции грибковой этиологии представлены главным образом видом Malassezia, особенно у больных с дерматитом головы и шеи. В обзоре особое внимание уделяется выявленным в настоящее время патофизиологическим механизмам, которые предположительно приводят к инфекциям кожи. Основными из них являются нарушение барьерной функции кожи, сложные иммунологические изменения, а также такие малопонятные факторы, как воздействие окружающей среды и дисбиоз кожи. Обзор включает также клиническую характеристику пациентов с различными инфекциями кожи, соответствующую терапию осложнений АтД.
Infection is the most common complication of atopic dermatitis (AtD). In particular, some patients with AtD exhibit increased susceptibility to skin infections of bacterial, viral, and fungal etiologies. In some cases, infections can even be systemic. Bacterial skin infections are more common than viral and fungal ones. An especially severe infection caused by the herpes virus is herpetic eczema, which can cause life-threatening complications. Infections of fungal etiology are represented mainly by the Malassezia species, especially in patients with dermatitis of the head and neck. The review focuses on the pathophysiological mechanisms identified to date that are thought to predispose to skin infections. The main ones are impaired skin barrier function, complex immunological changes, as well as poorly understood factors such as environmental exposure and skin dysbiosis. The review also includes the clinical characteristics of patients with various skin infections, as well as appropriate treatment for complications of AtD.
1. Wang V, Boguniewicz J, Boguniewicz M, Ong P. The Infectious Complications of Atopic Dermatitis. Ann Allergy Asthma Immunol. 2021;126:3-12. DOI:10.1016/j.anai.2020.08.002
2. Traidl S, Heinrich L, Siegels D, et al. TREATgermany Study Group. High recurrence rate of eczema herpeticum in moderate/severe atopic dermatitis -TREATgermany registry analysis. J Dtsch Dermatol Ges. 2023;21(12):1490-8. DOI:10.1111/ddg.15205
3. Narla S, Silverberg J. Association between atopic dermatitis and serious cutaneous, multiorgan, and systemic infections in US adults. Ann Allergy Asthma Immunol.
2018;120(1):66-72. DOI:10.1016/j.anai.2017.10.019
4. Reigh EL. Itching and Burning Man. Ann Allergy Asthma Immunol. 2024;132(6):703-4. DOI:10.1016/j.anai.2024.01.007
5. Guttman-Yassky E, Waldman A, Ahluwalia J, et al. Atopic Dermatitis: Pathogenesis. Semin Cutan Med Surg. 2017;36:100-3. DOI:10.12788/j.sder.2017.036
6. Simpson EL, Villarreal M, Jepson B, et al. Patients with Atopic Dermatitis Colonized with Staphylococcus aureus Have a Distinct Phenotype and Endotype. J Invest Dermatol. 2018;138(10):2224-33. DOI:10.1016/j.jid.2018.03.1517
7. Geoghegan J, Irvine A, Foster T. Staphylococcus aureus and atopic dermatitis: a complex and evolving relationship. Trends Microbiol. 2018;26:484-97. DOI:10.1016/j.tim.2017.11.008
8. Nakatsuji T, Chen T, Two A, et al. Staphylococcus aureus exploits epidermal barrier defects in atopic dermatitis to trigger cytokine expression. J Invest Dermatol. 2016;136:2192-200. DOI:10.1016/j.jid.2016.05.127
9. Kubo A, Nagao K, Yokouchi M, et al. External antigen uptake by Langerhans cells with reorganization of epidermal tight junction barriers. J Exp Med. 2009;206:2937-46. DOI:10.1084/jem.20091527
10. Schwermann N, Winstel V. Functional diversity of staphylococcal surface proteins at the host-microbe interface. Front Microbiol. 2023;14:1196957. DOI:10.3389/fmicb.2023.1196957
11. Berdyshev E, Goleva E, Bronova I, et al. Lipid abnormalities in atopic skin are driven by type 2 cytokines. JCI Insight. 2018;3(4). DOI:10.1172/jci.insight.98006
12. Liu H, Archer N, Dillen C, et al. Staphylococcus aureus epicutaneous exposure drives skin inflammation via IL-36-Mediated T cell responses. Cell Host Microbe.
2017;22(653):e5-666.e5. DOI:10.1016/j.chom.2017.10.006
13. Damour A, Garcia M, Seneschal J, et al. Eczema Herpeticum: Clinical and Pathophysiological Aspects. Clin Rev Allergy Immunol. 2020;59(1):1-18. DOI:10.1007/s12016-019-08768-3
14. De Benedetto A, Slifka MK, Rafaels N, et al. Reductions in claudin-1 may enhance susceptibility to herpes simplex virus 1 infections in atopic dermatitis. J Allergy Clin Immunol. 2011;128(1):242-6.e5. DOI:10.1016/j.jaci.2011.02.014
15. Traidl S, Roesner L, Zeitvogel J, Werfel T. Eczema herpeticum in atopic dermatitis. Allergy. 2021;76(10):3017-27. DOI:10.1111/all.14853
16. Lee YJ, Yassa C, Park S, et al. Interactions between Malassezia and New Therapeutic Agents in Atopic Dermatitis Affecting Skin Barrier and Inflammation in Recombinant Human Epidermis Model. Int J Mol Sci. 2023;24(7):6171. DOI:10.3390/ijms24076171
17. Hobi S, Cafarchia C, Romano V, Barrs V. Malassezia: Zoonotic Implications, Parallels and Differences in Colonization and Disease in Humans and Animals. J Fungi. 2022;8:708. DOI:10.3390/jof8070708
18. Tao R, Li R, Wang R. Dysbiosis of skin mycobiome in atopic dermatitis. Mycoses. 2022;65(3):285-93. DOI:10.1111/myc.13402
19. Darabi K, Hostetler S, Bechtel M, Zirwas M. The role of Malassezia in atopic dermatitis affecting the head and neck of adults. J Am Acad Dermatol. 2009;60(1):125-36. DOI:10.1016/j.jaad.2008.07.058
20. Casagrande B, Flückiger S, Linder M, et al. Sensitization to the yeast Malassezia sympodialis is specific for extrinsic and intrinsic atopic eczema. J Invest Dermatol. 2006;126(11):2414-21. DOI:10.1038/sj.jid.5700431
21. Devos S, van der Valk P. The relevance of skin prick tests for Pityrosporum ovale in patients with head and neck dermatitis. Allergy. 2000;55(11):1056-8.
DOI:10.1034/j.1398-9995.2000.00782
22. McGeachy MJ, Cua DJ, Gaffen SL. The IL-17 Family of Cytokines in Health and Disease. Immunity. 2019;50(4):892-906. DOI:10.1016/j.immuni.2019.03.021
23. Sparber F, De Gregorio C, Steckholzer S, et al. The Skin Commensal Yeast Malassezia Triggers a Type 17 Response that Coordinates Anti-fungal Immunity and Exacerbates Skin Inflammation. Cell Host Microbe. 2019;25(3):389-403. DOI:10.1016/j.chom
24. Ruchti F, Tuor M, Mathew L, et al. γδ T cells respond directly and selectively to the skin commensal yeast Malassezia for IL-17-dependent fungal control. PLoS Pathog. 2024;20(1):e1011668. DOI:10.1371/journal.ppat.1011668
25. Lee A, de Lencastre H, Garau J, et al. Methicillin-resistant Staphylococcus aureus. Nat Rev Dis Primers. 2018;4:18033. DOI:10.1038/nrdp.2018.33
26. Patel D, Jahnke MN. Serious Complications from Staphylococcal aureus in Atopic Dermatitis. Pediatr Dermatol. 2015;32(6):792-6. DOI:10.1111/pde.12665
27. Wang V, Keefer M, Ong PY. Antibiotic choice and methicillin-resistant Staphylococcus aureus rate in children hospitalized for atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122(3):314-7. DOI:10.1016/j.anai.2018.12.001
28. Labrosse R, Haddad E. Immunodeficiency secondary to biologics. J Allergy Clin Immunol. 2023;151(3):686-90. DOI:10.1016/j.jaci.2023.01.012
29. Alexander H, Paller AS, Traidl-Hoffmann C, et al. The role of bacterial skin infections in atopic dermatitis: expert statement and review from the International Eczema Council Skin Infection Group. Br J Dermatol. 2020;182(6):1331-42. DOI:10.1111/bjd.18643
30. George S, Karanovic S, Harrison D, et al. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database Syst Rev. 2019;2019(10):CD003871.
31. Ong PY, Leung DY. Bacterial and Viral Infections in Atopic Dermatitis: a Comprehensive Review. Clin Rev Allergy Immunol. 2016;51(3):329-37. DOI:10.1007/s12016-016-8548-5
32. Beck LA, Boguniewicz M, Hata T. Phenotype of atopic dermatitis subjects with a history of eczema herpeticum. J Allergy Clin Immunol. 2009;124(2):260-9,269.e1-7. DOI:10.1016/j.jaci.2009.05.020
33. de Beer F, Bakker D, Haeck I, et al. Dupilumab facial redness: Positive effect of itraconazole. JAAD Case Rep. 2019;5(10):888-91. DOI:10.1016/j.jdcr.2019.07.020
34. Adam DN, Gooderham MJ, Beecker J, et al. Expert consensus on the systemic treatment of atopic dermatitis in special populations. J Eur Acad Dermatol Venereol.
2023;37(6):1135-48. DOI:10.1111/jdv.18922
35. Eichenfield LF, Bieber T, Beck LA et al Infections in dupilumab clinical trials in atopic dermatitis: a comprehensive pooled analysis. Am J Clin Dermatol. 2019;20:443-56. DOI:10.1007/s40257-019-00445-7
36. Simpson EL, Silverberg JI, Nosbaum A, et al. Integrated safety analysis of Abrocitinib for the treatment of moderate-to-severe atopic dermatitis from the phase II and phase III clinical trial program. Am J Clin Dermatol. 2021;22:693-707. DOI:10.1007/s40257-021-00618-3
37. Boesjes CM, Van der Gang LF, Zuithoff N, et al. Effectiveness of Upadacitinib in Patients with Atopic Dermatitis including those with Inadequate Response to Dupilumab and/or Baricitinib: Results from the BioDay Registry. Acta Derm Venereol. 2023;103:adv00872. DOI:10.2340/actadv.v103.5243
38. Seegräber M, Worm M, Werfel T, et al. Recurrent eczema herpeticum – a retrospective European multicenter study evaluating the clinical characteristics of eczema herpeticum cases in atopic dermatitis patients. J Eur Acad Dermatol Venereol. 2020;34(5):1074-9. DOI:10.1111/jdv.16090
39. AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel; Chu DK, Schneider L, Asiniwasis R, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274-312. DOI:10.1016/j.anai.2023.11.009
40. Chu D, Chu A, Rayner D, et al. Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol. 2023;152(6):1493-519. DOI:10.1016/j.jaci.2023.08.030
41. Tsakok T, Schulenburg H, Smith C, et al The role of yeast in atopic dermatitis revisited: a critical appraisal. Curr Dermatol Rep. 2015;4:228-40.
42. Балаболкин И.И, Садикова Т.Е. Клинико-иммунологические варианты атопического дерматита у детей и подростков и эффективность патогенетической терапии. Педиатрия им. Г.А. Сперанского. 2013;92(3):6-13 [Balabolkin II, Sadikova TE. Kliniko-immunologicheskiie varianty atopicheskogo dermatita u detei i podrostkov i effektivnost' patogeneticheskoi terapii. Pediatria n.a. GN Speransky. 2013;92(3):6-13 (in Russian)].
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1. Wang V, Boguniewicz J, Boguniewicz M, Ong P. The Infectious Complications of Atopic Dermatitis. Ann Allergy Asthma Immunol. 2021;126:3-12. DOI:10.1016/j.anai.2020.08.002
2. Traidl S, Heinrich L, Siegels D, et al. TREATgermany Study Group. High recurrence rate of eczema herpeticum in moderate/severe atopic dermatitis -TREATgermany registry analysis. J Dtsch Dermatol Ges. 2023;21(12):1490-8. DOI:10.1111/ddg.15205
3. Narla S, Silverberg J. Association between atopic dermatitis and serious cutaneous, multiorgan, and systemic infections in US adults. Ann Allergy Asthma Immunol.
2018;120(1):66-72. DOI:10.1016/j.anai.2017.10.019
4. Reigh EL. Itching and Burning Man. Ann Allergy Asthma Immunol. 2024;132(6):703-4. DOI:10.1016/j.anai.2024.01.007
5. Guttman-Yassky E, Waldman A, Ahluwalia J, et al. Atopic Dermatitis: Pathogenesis. Semin Cutan Med Surg. 2017;36:100-3. DOI:10.12788/j.sder.2017.036
6. Simpson EL, Villarreal M, Jepson B, et al. Patients with Atopic Dermatitis Colonized with Staphylococcus aureus Have a Distinct Phenotype and Endotype. J Invest Dermatol. 2018;138(10):2224-33. DOI:10.1016/j.jid.2018.03.1517
7. Geoghegan J, Irvine A, Foster T. Staphylococcus aureus and atopic dermatitis: a complex and evolving relationship. Trends Microbiol. 2018;26:484-97. DOI:10.1016/j.tim.2017.11.008
8. Nakatsuji T, Chen T, Two A, et al. Staphylococcus aureus exploits epidermal barrier defects in atopic dermatitis to trigger cytokine expression. J Invest Dermatol. 2016;136:2192-200. DOI:10.1016/j.jid.2016.05.127
9. Kubo A, Nagao K, Yokouchi M, et al. External antigen uptake by Langerhans cells with reorganization of epidermal tight junction barriers. J Exp Med. 2009;206:2937-46. DOI:10.1084/jem.20091527
10. Schwermann N, Winstel V. Functional diversity of staphylococcal surface proteins at the host-microbe interface. Front Microbiol. 2023;14:1196957. DOI:10.3389/fmicb.2023.1196957
11. Berdyshev E, Goleva E, Bronova I, et al. Lipid abnormalities in atopic skin are driven by type 2 cytokines. JCI Insight. 2018;3(4). DOI:10.1172/jci.insight.98006
12. Liu H, Archer N, Dillen C, et al. Staphylococcus aureus epicutaneous exposure drives skin inflammation via IL-36-Mediated T cell responses. Cell Host Microbe.
2017;22(653):e5-666.e5. DOI:10.1016/j.chom.2017.10.006
13. Damour A, Garcia M, Seneschal J, et al. Eczema Herpeticum: Clinical and Pathophysiological Aspects. Clin Rev Allergy Immunol. 2020;59(1):1-18. DOI:10.1007/s12016-019-08768-3
14. De Benedetto A, Slifka MK, Rafaels N, et al. Reductions in claudin-1 may enhance susceptibility to herpes simplex virus 1 infections in atopic dermatitis. J Allergy Clin Immunol. 2011;128(1):242-6.e5. DOI:10.1016/j.jaci.2011.02.014
15. Traidl S, Roesner L, Zeitvogel J, Werfel T. Eczema herpeticum in atopic dermatitis. Allergy. 2021;76(10):3017-27. DOI:10.1111/all.14853
16. Lee YJ, Yassa C, Park S, et al. Interactions between Malassezia and New Therapeutic Agents in Atopic Dermatitis Affecting Skin Barrier and Inflammation in Recombinant Human Epidermis Model. Int J Mol Sci. 2023;24(7):6171. DOI:10.3390/ijms24076171
17. Hobi S, Cafarchia C, Romano V, Barrs V. Malassezia: Zoonotic Implications, Parallels and Differences in Colonization and Disease in Humans and Animals. J Fungi. 2022;8:708. DOI:10.3390/jof8070708
18. Tao R, Li R, Wang R. Dysbiosis of skin mycobiome in atopic dermatitis. Mycoses. 2022;65(3):285-93. DOI:10.1111/myc.13402
19. Darabi K, Hostetler S, Bechtel M, Zirwas M. The role of Malassezia in atopic dermatitis affecting the head and neck of adults. J Am Acad Dermatol. 2009;60(1):125-36. DOI:10.1016/j.jaad.2008.07.058
20. Casagrande B, Flückiger S, Linder M, et al. Sensitization to the yeast Malassezia sympodialis is specific for extrinsic and intrinsic atopic eczema. J Invest Dermatol. 2006;126(11):2414-21. DOI:10.1038/sj.jid.5700431
21. Devos S, van der Valk P. The relevance of skin prick tests for Pityrosporum ovale in patients with head and neck dermatitis. Allergy. 2000;55(11):1056-8.
DOI:10.1034/j.1398-9995.2000.00782
22. McGeachy MJ, Cua DJ, Gaffen SL. The IL-17 Family of Cytokines in Health and Disease. Immunity. 2019;50(4):892-906. DOI:10.1016/j.immuni.2019.03.021
23. Sparber F, De Gregorio C, Steckholzer S, et al. The Skin Commensal Yeast Malassezia Triggers a Type 17 Response that Coordinates Anti-fungal Immunity and Exacerbates Skin Inflammation. Cell Host Microbe. 2019;25(3):389-403. DOI:10.1016/j.chom
24. Ruchti F, Tuor M, Mathew L, et al. γδ T cells respond directly and selectively to the skin commensal yeast Malassezia for IL-17-dependent fungal control. PLoS Pathog. 2024;20(1):e1011668. DOI:10.1371/journal.ppat.1011668
25. Lee A, de Lencastre H, Garau J, et al. Methicillin-resistant Staphylococcus aureus. Nat Rev Dis Primers. 2018;4:18033. DOI:10.1038/nrdp.2018.33
26. Patel D, Jahnke MN. Serious Complications from Staphylococcal aureus in Atopic Dermatitis. Pediatr Dermatol. 2015;32(6):792-6. DOI:10.1111/pde.12665
27. Wang V, Keefer M, Ong PY. Antibiotic choice and methicillin-resistant Staphylococcus aureus rate in children hospitalized for atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122(3):314-7. DOI:10.1016/j.anai.2018.12.001
28. Labrosse R, Haddad E. Immunodeficiency secondary to biologics. J Allergy Clin Immunol. 2023;151(3):686-90. DOI:10.1016/j.jaci.2023.01.012
29. Alexander H, Paller AS, Traidl-Hoffmann C, et al. The role of bacterial skin infections in atopic dermatitis: expert statement and review from the International Eczema Council Skin Infection Group. Br J Dermatol. 2020;182(6):1331-42. DOI:10.1111/bjd.18643
30. George S, Karanovic S, Harrison D, et al. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database Syst Rev. 2019;2019(10):CD003871.
31. Ong PY, Leung DY. Bacterial and Viral Infections in Atopic Dermatitis: a Comprehensive Review. Clin Rev Allergy Immunol. 2016;51(3):329-37. DOI:10.1007/s12016-016-8548-5
32. Beck LA, Boguniewicz M, Hata T. Phenotype of atopic dermatitis subjects with a history of eczema herpeticum. J Allergy Clin Immunol. 2009;124(2):260-9,269.e1-7. DOI:10.1016/j.jaci.2009.05.020
33. de Beer F, Bakker D, Haeck I, et al. Dupilumab facial redness: Positive effect of itraconazole. JAAD Case Rep. 2019;5(10):888-91. DOI:10.1016/j.jdcr.2019.07.020
34. Adam DN, Gooderham MJ, Beecker J, et al. Expert consensus on the systemic treatment of atopic dermatitis in special populations. J Eur Acad Dermatol Venereol.
2023;37(6):1135-48. DOI:10.1111/jdv.18922
35. Eichenfield LF, Bieber T, Beck LA et al Infections in dupilumab clinical trials in atopic dermatitis: a comprehensive pooled analysis. Am J Clin Dermatol. 2019;20:443-56. DOI:10.1007/s40257-019-00445-7
36. Simpson EL, Silverberg JI, Nosbaum A, et al. Integrated safety analysis of Abrocitinib for the treatment of moderate-to-severe atopic dermatitis from the phase II and phase III clinical trial program. Am J Clin Dermatol. 2021;22:693-707. DOI:10.1007/s40257-021-00618-3
37. Boesjes CM, Van der Gang LF, Zuithoff N, et al. Effectiveness of Upadacitinib in Patients with Atopic Dermatitis including those with Inadequate Response to Dupilumab and/or Baricitinib: Results from the BioDay Registry. Acta Derm Venereol. 2023;103:adv00872. DOI:10.2340/actadv.v103.5243
38. Seegräber M, Worm M, Werfel T, et al. Recurrent eczema herpeticum – a retrospective European multicenter study evaluating the clinical characteristics of eczema herpeticum cases in atopic dermatitis patients. J Eur Acad Dermatol Venereol. 2020;34(5):1074-9. DOI:10.1111/jdv.16090
39. AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel; Chu DK, Schneider L, Asiniwasis R, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274-312. DOI:10.1016/j.anai.2023.11.009
40. Chu D, Chu A, Rayner D, et al. Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol. 2023;152(6):1493-519. DOI:10.1016/j.jaci.2023.08.030
41. Tsakok T, Schulenburg H, Smith C, et al The role of yeast in atopic dermatitis revisited: a critical appraisal. Curr Dermatol Rep. 2015;4:228-40.
42. Balabolkin II, Sadikova TE. Kliniko-immunologicheskiie varianty atopicheskogo dermatita u detei i podrostkov i effektivnost' patogeneticheskoi terapii. Pediatria n.a. GN Speransky. 2013;92(3):6-13 (in Russian).
Авторы
Д.Ш. Мачарадзе*
ФБУН «Московский научно-исследовательский институт эпидемиологии и микробиологии им. Г.Н. Габричевского», Москва, Россия
*dalim_a@mail.ru
________________________________________________
Dali Sh. Macharadze*
Gabrichevsky Research Institute for Epidemiology and Microbiology, Moscow, Russia
*dalim_a@mail.ru