Malassezia

Where Do you Find Malassezia

Malassezia is most likely to be found in oily parts of the skin where they sustain themselves by ingesting the fatty acids present in normal sebum. They are found in the highest density in oily areas such as the face, scalp and upper trunk. They can cause skin disease by overgrowth, descending into hair follicles, or through inflammation. Although called a superficial organism that causes superficial mycosis, they are seen in central and deep segments of hair follicles (in folliculitis). Due to improved microbe detection techniques, many studies now report finding Malassezia within the body of both healthy adults and immunocompetent patients with various ailments.

They have also been found in internal organs but it appears they may be a normal inhabitant of some organs just as they are on the skin and it is hard to know if they are involved in diseases in the organ when found.

Documented cases of Malassezia have been reported following lipid-rich Intravenous nutrition. The Malassezia was mostly found within the walls of arteries which contained lipid deposits.

Malassezia Confusion

There is a lot of confusion and disagreement about this yeast being either a commensual or pathogenic organism. People are starting to agree it is both. Many researchers thought Malassezia was simply showing up with the skin disease as a natural inhabitant of the skin. However, it appears from a 2012 published review of the research literature that there are higher counts with these various skin diseases than normal skin, and there may be pathogenic forms of Malassezia as well as commensal forms. One important take home from reading the review was that this yeast and the skin diseases associated with it can be treated with systemic or topical antifungals. I think this is the most important fact of the whole review; you use antifungals and Malassezia disappears and the skin gets better. Pretty obvious connection. You can read this review in its entirety here.

Malassezia Overgrowth

Overgrowth of Malassezia is more common in warm and humid tropical and subtropical climates. M. Globosa has been shown to increase in high summer temperatures due to sweating. Malassezia infections are associated with hyperhydrosis (excessive sweating), corticosteroid treatment, antibiotic treatment, use of immunosuppressive drugs such as cyclosporine and azathioprine, increased plasma cortisol levels,   and malnutrition.

Feeding Malassezia

Human sebum is the lipid (oil) source Malassezia thrives on. Sebum is a complex mixture of lipids. It contains triglycerides, fatty acids, wax esters, sterol esters, cholesterol, cholesterol esters, and squalene. They break the sebum down into triglycerides and esters, diglycerides, monoglycerides, and free fatty acids. This all leads toward the development of dandruff. People may notice dry flaky skin on other parts of their body besides their scalp. I call it body dandruff. You may also notice hypo- or hyperpigmented macules with no inflammation when Malassezia proliferates (pityriasis versicolor).

Malassezia And Other Common Fungus In the Outer Skin Layer

The outer layer of skin called the epidermis is a dense layer, made of keratinized cells that are constantly being renewed. There are three groups of filament-forming fungi that are known to commonly infect the keratinized and cornified layers of skin, nails and hair. They are Candida albicans, Trichophyton, and our friend Malassezia. Both Candida spp. and Malassezia spp. are considered commensal flora and the epidermal yeast form is not thought to alert the immune system or cause symptoms for people. They have all formed similar lipases and proteases to live in human skin.

Fungi Alter Their Shape When They Become Invasive

Some of these lipases and proteases are specifically formed during their hyphal phase when they are found to cause skin symptoms. In lab research it is noted that the hypha formation in these opportunistic pathogens is used to invade the skin.  Additionally, hyphal forms give them the ability to move to a different host environment, acquire nutrition, and form colonies. It is the hyphal form that is thought of as being pathogenic and symptomatic.

Virulence

Although the hyphal form is thought to be the most virulent form in the human body, the yeast form can cause nasty and even fatal infections in some cases. Both C. albicans, Malasseszia spp. as well as Trichophyton have been shown to reversibly switch between yeast and hyphal forms in diseased tissue. When they loose this ability to reversibly switch back and fourth, they loose virulence. Malassezia has not been studied as much as Candida in this respect, as Malassezia has been thought to be more of a superficial skin condition and not usually a systemic problem. However, this does not decrease the frustration and stress it causes those who have skin afflictions due to Malassezia. It is thought that both Malassezia and Trichophyton are limited to specific body environments due to nutrient needs (such as lipids for Malassezia) while Candida can proliferate in more areas of the body due to its ability to withstand various temperatures, and ph values, varying oxygen as well as nutrients.

Malassezia Biofilms And Hide & Seek

It is known that fungus can form biofilms. Forming hypha is integral to forming bioflms. Although hypha are not necessary for them to make biofilms, research has shown biofilms formed by yeast forms are thin and easier to remove from surfaces mechanically. Certainly, we know that Candida can form a creamy-white plaque like biofilm on mucosal surfaces such as seen orally and vaginally. Both Candida alibicans and Malassezia are found in biofilms on various medical plastics. Biofilms protect the fungus from antifungals. Candida albicans has been shown in mucosal infections to be modulated by a three-way interaction between the fungus, resident bacteria living with the fungus and the ambient host environment.

The Immune System Becomes Aware Of Yeast When It Starts to Grow A Biofilm

Yeast forms of Malassezia do not usually induce an inflammatory response. The hyphal forms release "pathogen-associated molecular patterns" that seem to attract the attention of the immune system. So, when the yeast morphs into the hyphal form to grow biofilm or to find new nutrients the immune system becomes aware of them.

Malassezia are thought to exist as a faculatative intracellular parasite in the keratinocytes by suppressing the inflammatory response that would usually happen when parasitized by a foreign critter.

In normal skin the yeast form is seen and in diseased skin the yeast and hyphal form is seen. Some factors that lead to hyphal formation are thought to be, hypercortisolism, corticosteroid or antibiotic use, genetic or constitutional factors, environmental/climatic factors.

Full Body Malassezia

An opportunistic Infection

I think these partial or full body invasions are probably opportunistic and the skin conditions may instigate a change from a nonpathogenic organism to a pathogenic organism, which is then harder to deal with.

The host of any commensal needs to have an immune system and skin barrier that can cope with these activities of the commensal/potential pathogen. This creates a situation for the host and commensal where there is a balance between the organisms virulence or the activities that allow it to stay alive and hold its space on the host, and the hosts response to prevent invasion and disease. The host and commensal both create methods to protect themselves from each other.

Malassezia Associated With Various Non-Skin Disease Processes

As mentioned previously Malassezia is found in organs where they may or may not be invasive.

Malassezia is associated with Crohn's disease, and ulcerative colitis. Antibodies against Malassezia are associated wtih Crohn's disease and psoriasis.

Malassezia is associated with Spondyloarthritides and in a recent study Malassezia was found in 9 out of 10 multiple sclerosis patients and in only 1 out of 9 non-MS controls.

Two  recent studies report finding Malassezia in the central nervous system in association with MS and Alzheimer's disease.

Malassezia Takes Over When The Immune System Is Asleep Or Lacking Vitality

The over proliferation of the fungus Malassezia on the skin, appears to be partly driven by a weak T cell-mediated immune response, and partly driven by an abundance of lipids which are required for Malassezia's growth. Skin disease occurs when the hosts ability to protect itself is not working or the virulence of the commensal overcomes the host. Increased virulence is seen when a fungus changes from a yeast form to a hyphal form. In addition the immune system is less able to get rid of an organism when it hides in a biofilm. The ability of fungi, bacteria, ectoparasites, and viruses to associate with each other and help each other over-come the hosts defenses is another factor. Research has found that weak T cell-mediated control of Malassezia appears to be the main contributing factor to seborrheic dermatitis in older adults.

Skin Barrier Function Disruption

Skin barrier function can be disrupted  from a variety of causes. Allergies to environmental stimuli, or reactions to toxins on the skin can cause increased surface humidity on the skin as fluid leaks onto damaged skin. This can feed fungi and bacteria. Faulty hormonal regulation can effect the skin and the immunes systems ability to defend the body. Even pregnancy has been shown to stimulate some commensal activity. (In dogs and some farm animals Demodex mites have been shown to start breeding during pregnancy as they get ready to invade the skin of the hosts new babies.) Hypothyroidism and hypercotisolism are associated with  fungal infection. Any change in hormonal status may cause increased commensal activity.

Multi-system Dysfunction

Anything that decreases the immune system response may leave an opening for a commensal such as Malassezia to proliferate. For example,  adrenal disease,  cancer and mold toxicity are associated with immune system dysregulation and can lead to skin disease from various commensals.

There is a need to examine and possibly change the bodies internal environment/skin environment. In addition, there may be a need to change the outer environment the person is living in. They need to check for any chemicals/heavy metals/mold/virus/bacteria etc that may be in or outside of them that could cause a weakening in the skins protective mechanisms or weakening in the general whole health of the body. It is important to specifically examine the immune system and neuroendocrine system health of the person while doing a whole person check up.

Dealing With Skin Crawling Sensations and Itching

My suggestion for a simple to use, cheap topical control that also supports the acid mantle of the skin is to use dilute "live" vinegar on all skin areas. The live vinegar is mixed with water. You can make it as strong or weak as necessary but could start with 25% vinegar. A wash cloth is dipped into this dilute vinegar/water mix and is used to saturate the skin. The scalp, the face, ears (pinky finger can be soaked and used inside ears, neck, torso, legs, feet, buttocks, anus, perianal region, vulva, penis. Pretty much everywhere and anywhere necessary. If the person feels a tickly or itchy area, they can reapply the dilute vinegar to that area.

An example of a useful topical cream is Derma Zinc. The cream is expensive, however small amounts of the cream cover large areas of skin.

There should be an examination of the persons whole body/mind/emotional/spiritual health and their environment to see what kind of changes need to be made.

Laboratory Evaluation

Evaluation is based on microscopic examination of pustule contents for hyphae and spores (appearing like a spaghetti and meatballs pattern). Deep skin scrapings or biopsies may help if pustules are not present.

General Treatment

Traditional Treatment

This fungus is often treated with azole antifungals or selenium sulfide in lotions, forms or shampoos. More resistant cases are often treated with  up to 8 weeks of systemic antifungal drugs such as itraconazole, ketoconazole  or fluconazole. However, my readers would probably like to know about alternatives. Commonly used antifungal drugs do not completely eradicate Malassezia and their populations rebound once such treatments are discontinued, so using these toxic drugs is not a cure-all.

Alternative Treatment

Internal And External Treatment

I would suggest you consider caprylic or undecylenic acid internally, undecylenic creams and/or Tea Tree oil or lavender oil externally for your patients.  You can also use the caprylic or undecylenic acid topically, but it is very messy. Zinc pyrithione cream has fungistatic properties. I have listed some research abstracts below to help you in your considerations. I really have to stress how wonderful the use of simple vinegar is externally. Live vinegar is anti-fungal and quiets the skin down quickly. It lowers the skin pH and has bacteria that may be helpful to repopulate natural skin bacteria. I have listed more information about it above. When using applications to the skin, remember that this fungus needs oil to live and using an oily ointment may make the skin condition worse. Be careful about over-treating the skin with strong essential oils. If you kill off the natural bacteria that live on the skin, you will see an exacerbation of the symptoms. If this happens, use only diluted vinegar and zinc pyrithione cream.

Use Of Essential Oils

If you decide to use essential oils, remember they are like bringing in super bombs and can also kill off beneficial bacteria. Lemon grass is one of the more heavy hitters, while oregano, Geranium, Thyme, Rosemary and cinnamon are also helpful. However, they should always be diluted. I suggest starting with 5% essential oil in a carrier that could be shampoo, cream or lotion. I suggest cream or lotion as they have less oil in them and oil is a growth medium for Malassezia. Only use small amounts of them. Using more than 10% of any of these essential oils per 90% carrier will usually cause irritation. Some of these essential oils are extremely irritating as you increase the amount being used.  Some people may even be sensitive to the essential oil at 10%. I would also suggest stopping their use if the skin becomes burnt looking as you are probably using too much or using it too often. Decrease the amount being used in the carrier by 1/2 and try again when the skin heals. Also, a person can be allergic or sensitive to any of these essential oils. Don't assume you are seeing a die-off reaction. You might be, but you also may simply be burning the skin.

Dead Sea Salts And Mud

Both the mud and Dead Sea salts have been used for fungal skin issues.  The microbiome seems to stay pretty stable when using Dead Sea mud/salt therapy but the mycobiome (fungus) decreases. The ability to decrease Malassezia proliferation may have to do with the zinc or other minerals in the salts and mud. We know that external use of a couple types of zinc (oxide and pyrithione) are helpful at clearing Malassezia.

Dead Sea Salt Skin Wash

½ tsp of Dead Sea Salt Minerals
2 cups of warm water

Gut Flora

Treatment should include an antifungal diet,  and supporting beneficial flora inside the body, just at the live vinegar helps support beneficial bacteria on the outside of the body. This data is easily accessible. I would point out that a key feature is to support the normal gut flora, and replace it as needed with fermented foods or supplements. Just as anticandidal diets and bacterial support of the gut helps decrease vaginal candida, it also works to support the normal flora in other parts of your body such as your skin. Gut bacteria should always be kept happy and healthy as it is supporting the entire ecosystem of the body. If you are needing to treat your external skin for a fungal infection, you should also be treating your digestive tract.

Shampoos

If you are looking for shampoos that help kill Malassezia, look for shampoos with selenium sulfide (Selenium sulfide shampoos can be irritating.) or pyrithione zinc. There are many choices in animal shampoos while very few for humans. Some folks skip shampooing and simply use a water rinse and vinegar in an attempt to support the normal scalp flora and kill off the out of control Malassezia.

Oils

I would warn you that the use of oils on the skin may feed this lipophilic (lipid loving) yeast. The craze of using coconut oil liberally on the skin for a variety of skin afflictions may make the feeling of something crawling and itching skin worse for these people even though coconut oil also contains caprylic acid which is itself an antifungal constituent. Some people report the coconut being helpful, but others find the fungus gets worse when the cononut oil. Just be aware of this possibility it could go either way depending on the species of Malassezia predominantly on your body.  In research labs when they study Malassezia hyphae, they have to give them a lipid source to get the yeast to grow hyphae in the lab. It turns out that they like long chain fatty acids and some species will even grow on the medium chain fatty acid called lauric acid, which is found in coconut oil. Therefore, you may have the species of Malasezzia that will feed on coconut oil. So, if you used coconut oil and you got great results, keep on using it. However, if you used it and the Malassezia grew and your condition worsened, consider using a medium chain triglyceride oil that is rich in caprylic and capric fatty acids without the lauric acid or at least super low in lauric acid. So, far I have found these oils work well for individuals and some people just use them without trying the coconut oil. However, coconut oil is less expensive. What we are trying to do through the use of this MCT oil high in caprylic acid is to lower the pH of the skin as well as to make sure it will not feed the Malassezia.

Other things that will generate a proliferation of Malassezia are the use of corticosteroids and or antibiotics.

I have  listed some individual research articles below for your interest. I specifically listed any alternative treatments for Malassezia that have published research. If you know of additional published research abstracts I should add, please send them to me.

 

Research

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533528/
Indian J Dermatol. 2015 Jul-Aug;60(4):332-9. doi: 10.4103/0019-5154.160475.
Malassezia-Can it be Ignored?
Thayikkannu AB1, Kindo AJ1, Veeraraghavan M2.

Abstract
Genus Malassezia comprises of 14 species of "yeast like fungi," 13 of which are lipophilic and 1 is nonlipophilic. They are known commensals and in predisposed individuals they commonly cause a spectrum of chronic recurrent infections. They rarely also cause serious illnesses like catheter-related blood stream infections, CAPD associated peritonitis etc., Though these fungi have been known to man for over 150 years, their fastidious nature and cumbersome culture and speciation techniques have restricted research. Since the last taxonomic revision, seven new species have been added to this genus. Their ability to evade the host immune system and virulence has increased the spectrum of the diseases caused by them. These agents have been implicated as causal agents in common diseases like atopic dermatitis recently. Though culture-based research is difficult, the new molecular analysis techniques and facilities have increased research in this field such that we can devote more attention to this genus to study in detail, their characteristics and their growing implications implications in the clinical scenario.
KEYWORDS:
Malassezia; pityriasis versicolor; seborrhoeic dermatitis

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484996

J Clin Med. 2015 May 29;4(6):1217-28. doi: 10.3390/jcm4061217.
The Role of Malassezia spp. in Atopic Dermatitis.
Glatz M1, Bosshard PP2, Hoetzenecker W3, Schmid-Grendelmeier P4.

Abstract
Malassezia spp. is a genus of lipophilic yeasts and comprises the most common fungi on healthy human skin. Despite its role as a commensal on healthy human skin, Malassezia spp. is attributed a pathogenic role in atopic dermatitis. The mechanisms by which Malassezia spp. may contribute to the pathogenesis of atopic dermatitis are not fully understood. Here, we review the latest findings on the pathogenetic role of Malassezia spp. in atopic dermatitis (AD). For example, Malassezia spp. produces a variety of immunogenic proteins that elicit the production of specific IgE antibodies and may induce the release of pro-inflammatory cytokines. In addition, Malassezia spp. induces auto-reactive T cells that cross-react between fungal proteins and their human counterparts. These mechanisms contribute to skin inflammation in atopic dermatitis and therefore influence the course of this disorder. Finally, we discuss the possible benefit of an anti-Malassezia spp. treatment in patients with atopic dermatitis.
KEYWORDS:
IgE antibodies; Malassezia spp.; atopic dermatitis; auto-reactive T cells; cytokines
PMID: 26239555 [PubMed] PMCID: PMC4484996 Free PMC Article

 

http://www.ncbi.nlm.nih.gov/pubmed/25085959
Cold Spring Harb Perspect Med. 2014 Aug 1;4(8). pii: a019802. doi: 10.1101/cshperspect.a019802.
Fungi on the skin: dermatophytes and Malassezia.
White TC1, Findley K2, Dawson TL Jr3, Scheynius A4, Boekhout T5, Cuomo CA6, Xu J7, Saunders CW7.

Abstract
Several human skin diseases and disorders are associated with two groups of fungi, the dermatophytes and Malassezia. Although these skin-related problems are not generally life threatening, they are among the most common diseases and disorders of mankind. These fungi are phylogenetically divergent, with the dermatophytes within the Ascomycota and Malassezia within Basidiomycota. Genome analysis indicates that the adaptations to the skin environment are different in these two groups of fungi. Malassezia are dependent on host lipids and secrete lipases and phospholipases that likely release host fatty acids. The dermatophytes encode multiple enzymes with potential roles in modulating host interactions: polyketide synthases, nonribosomal peptide synthetases, LysM, proteases, kinases, and pseudokinases. These two fungal groups have maximized their interactions with the host using two very different mechanisms.
Copyright © 2014 Cold Spring Harbor Laboratory Press; all rights reserved.
PMID: 25085959 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/26354806
Mycologia. 2015 Sep 9. pii: 15-147. [Epub ahead of print]
The human gut mycobiome: pitfalls and potentials-a mycologist's perspective.
Suhr MJ1, Hallen-Adams HE2.

Abstract
We have entered the Age of the Microbiome, with new studies appearing constantly and whole journals devoted to the human microbiome. While bacteria outnumber other gut microbes by orders of magnitude, eukaryotes are consistently found in the human gut and are represented primarily by the fungi. Compiling 36 studies 1917-2015 we found at least 267 distinct fungal taxa have been reported from the human gut, and seemingly every new study includes one or more fungi not previously described from this niche. This diversity, while impressive, is illusory. If we examine gut fungi, we will quickly observe a division between a small number of commonly detected species (Candida yeasts, Saccharomyces and yeasts in the Dipodascaceae, and Malassezia species) and a long tail of taxa that have been reported only once. Furthermore, an investigation into the ecology of these rare species reveals that many of them are incapable of colonization or long-term persistence in the gut. This paper examines what we know and have yet to learn about the fungal component of the gut microbiome, or "mycobiome", and an overview of methods. We address the potential of the field while introducing some caveats and argue for the necessity of including mycologists in mycobiome studies.
Copyright © 2015, Mycologia.
KEYWORDS:
Candida; human health; microbiome; next-generation sequencing
PMID: 26354806 [PubMed - as supplied by publisher]

 

http://www.ncbi.nlm.nih.gov/pubmed/26160660
Protein Expr Purif. 2015 Oct;114:89-94. doi: 10.1016/j.pep.2015.07.002. Epub 2015 Jul 6.
Heterologous expression and characterization of CYP61A1 from dandruff-causing Malassezia globosa.
Ohk SO1, Park HG2, Lee H2, Kwon YJ1, Kim BJ3, Kim D4, Chun YJ5.

Abstract
Malassezia globosa is pathogenic fungus that causes skin disorders including dandruff in humans. Many yeast cytochrome CYP enzymes are involved in the biosynthesis of sterols and are considered major targets of azole antifungal agents. Here, we report on the expression and characterization of the MGL_0310 gene product (CYP61A1), a sterol C-22 desaturase in M. globosa. The open reading frame of the CYP61A1 gene was amplified by PCR from M. globosa CBS 7966 genomic DNA and cloned into a pCW vector. The CYP61A1 gene was heterologously expressed in Escherichia coli and purified using a Ni(2+)-NTA affinity column. The purified CYP61A1 protein exhibited a CO-difference spectrum typical of CYPs with a maximum absorption at 452nm. Binding spectral titration with β-sitosterol and campesterol demonstrated the type I binding mode with an increase at 411nm and a decrease at 432nm. The calculated Kd values are 5.4±0.6μM and 6.1±1.0μM for β-sitosterol and campesterol, respectively. No metabolic product, however, was observed in the CYP61A1-supported enzyme reaction with these sterols. The purified CYP61A1 protein exhibited tight binding to azole agents, suggesting that this enzyme may be a target for the pathogenic M. globosa fungus. Moreover, several fatty acids were found to bind to CYP61A1, indicating that the architecture of the enzyme includes a relatively large active site space. This study provides new insight into the biosynthesis of fungal sterols in M. globosa and a basis for the development of antifungal as potential therapeutic agents to treat dandruff.
Copyright © 2015 Elsevier Inc. All rights reserved.
KEYWORDS:
Azole; C22-desaturase; CYP; CYP61A1; Malassezia globosa; P450; Sterol
PMID: 26160660 [PubMed - in process]

 

http://www.ncbi.nlm.nih.gov/pubmed/25968082

Hautarzt. 2015 Jun;66(6):465-84; quiz 485-6. doi: 10.1007/s00105-015-3631-z.
[Cutaneous Malassezia infections and Malassezia associated dermatoses: An update].
[Article in German]
Nenoff P1, Krüger C, Mayser P.

Abstract
The lipophilic yeast fungus Malassezia (M.) spp. is the only fungal genus or species which is part of the physiological human microbiome. Today, at least 14 different Malassezia species are known; most of them can only be identified using molecular biological techniques. As a facultative pathogenic microorganism, Malassezia represents the causative agent both of superficial cutaneous infections and of blood stream infections. Pityriasis versicolor is the probably most frequent infection caused by Malassezia. Less common, Malassezia folliculitis occurs. There is only an episodic report on Malassezia-induced onychomycosis. Seborrhoeic dermatitis represents a Malassezia-associated inflammatory dermatosis. In addition, Malassezia allergenes should be considered as the trigger of "Head-Neck"-type atopic dermatitis. Ketoconazole possesses the strongest in vitro activity against Malassezia, and represents the treatment of choice for topical therapy of pityriasis versicolor. Alternatives include other azole antifungals but also the allylamine terbinafine and the hydroxypyridone antifungal agent ciclopirox olamine. "Antiseborrhoeic" agents, e.g. zinc pyrithione, selenium disulfide, and salicylic acid, are also effective in pityriasis versicolor. The drug of choice for oral treatment of pityriasis versicolor is itraconazole; an effective alternative represents fluconazole. Seborrhoeic dermatitis is best treated with topical medication, including topical corticosteroids and antifungal agents like ketoconazole or sertaconazole. Calcineurin inhibitors, e.g. pimecrolimus and tacrolimus, are reliable in seborrhoeic dermatitis, however are used off-label.
PMID: 25968082 [PubMed - in process]

J Dermatol. 2015 Dec 24. doi: 10.1111/1346-8138.13245. [Epub ahead of print]
Microorganisms inhabiting follicular contents of facial acne are not only Propionibacterium but also Malassezia spp.
Akaza N1,2, Akamatsu H3, Numata S2, Yamada S1, Yagami A2, Nakata S1, Matsunaga K2.
Author information
Abstract
To clarify the relationship between major cutaneous microorganisms (Propionibacterium, Staphylococcus and Malassezia spp.) and acne vulgaris (acne), we examined the microbiota quantitatively in the follicular contents of inflammatory acne and on the facial skin of patients with acne. Fifteen Japanese untreated acne outpatients were studied. The follicular contents from inflammatory acne lesions of the face were collected using a comedo extractor. The skin surface samples were obtained by the swab method from 10 cm2 of facial skin. The microbiota was analyzed using polymerase chain reaction. The microbiota in follicular contents was similar to that on the skin surface, namely, there were large populations of Propionibacterium spp., Staphylococcus spp. and Malassezia spp. Moreover, the number of Malassezia spp. on the skin surface was correlated with that of inflammatory acne and that in follicular contents. This study clarified that there are large populations of Propionibacterium spp., Staphylococcus spp. and Malassezia spp. in follicular contents. These results suggest the possibility that not only Propionibacterium acnes but also other cutaneous resident microorganisms are related to acne. Particularly, we considered that Malassezia spp. is closely related.
© 2015 Japanese Dermatological Association.
KEYWORDS:
Malassezia ; Propionibacterium ; acne vulgaris; follicular content; microbiota
PMID: 26705192 [PubMed - as supplied by publisher]

Treatment Research

This fungus is often treated with azole antifungals as are many fungal infections. However, my readers would probably like to know about alternatives. I have listed some research abstracts below to help you in your considerations.

http://www.ncbi.nlm.nih.gov/pubmed/26334025
Mycoses. 2015 Oct;58(10):620-31. doi: 10.1111/myc.12370. Epub 2015 Sep 3.
Glutathione as a promising anti-hydrophobicity agent against Malassezia spp.
Sivasankar C1, Ponmalar A1, Bhaskar JP2, Pandian SK1.

Abstract
The genus Malassezia has recently attracted wide attention in medical microbiology and dermatology as a pathogen. They are lipophilic yeasts possessing high level of cell surface hydrophobicity (CSH). l-glutathione (GSH) is a ubiquitous antioxidant which offers protection against microbial infections. This study is intended to investigate the role of GSH as a potential anti-hydrophobicity agent against Malazessia spp. Microbial adherence to hydrocarbon assay was performed to assess the anti-hydrophobicity activity (AHA) of GSH against four Malassezia spp. The assay revealed that GSH at 400 μg ml(-1) concentration inhibited CSH, ranging from 84% to 95% in M. furfur, M. globosa, M. restricta and M. sympodialis without killing the cells. The AHA of GSH was corroborated by auto-aggregation assay and zeta-potential measurement, through which delayed cell aggregation was observed due to reduction in CSH level and not by modification in cell surface charge. In addition, colony-forming unit assay was performed in which 62-93% of CSH reduction was observed in Malassezia spp. tested. Furthermore, GSH treatment enhanced the sensitivity of Malassezia spp. towards human blood at the rate of 64-72%. The AHA was further confirmed through Fourier transform infrared analysis. Thus, this study portrays GSH as a prospective therapeutic alternative for Malassezia-mediated infections.
© 2015 Blackwell Verlag GmbH.
KEYWORDS:
Fourier transform infrared spectrum analysis; Malassezia; cell surface hydrophobicity; l-glutathione
PMID: 26334025 [PubMed - in process]

http://www.ncbi.nlm.nih.gov/pubmed/12070905
Schweiz Arch Tierheilkd. 2002 May;144(5):215-21.
Antifungal effect of Australian tea tree oil on Malassezia pachydermatis isolated from canines suffering from cutaneous skin disease.
Weseler A1, Geiss HK, Saller R, Reichling J.

Abstract
The lipophilic yeast Malassezia pachydermatis is part of the normal skin flora of most warm-blooded organisms. In a number of surveys it could be demonstrated that this yeast species might be involved in different skin diseases like seborrhoeic dermatitis, especially in dogs and cats. In order to look for an alternative therapeutic agent to the commonly used antimycotic and antiseptic synthetic substances the in vitro activity of Australian tea tree oil, the essential oil of Melaleuca alternifolia, against several strains of Malassezia pachydermatis was examined. All tested strains showed remarkably high susceptibility to tea tree oil. With these results the excellent antibacterial activity of tea tree oil is extended to a new group of fungal pathogens colonizing mainly mammals' skin. During the last ten years there was an increasing popularity of tea tree oil containing human health care products. The presented data open up new horizons for this essential oil as a promising alternative agent for topical use in veterinary medicine as well.
PMID: 12070905 [PubMed - indexed for MEDLINE]

 

http://www.ncbi.nlm.nih.gov/pubmed/11146344

Dermatology. 2000;201(4):332-6.
New strategies in dandruff treatment: growth control of Malassezia ovalis.
Baroni A1, De Rosa R, De Rosa A, Donnarumma G, Catalanotti P.

Abstract
BACKGROUND:
Cutaneous infections induced by Malassezia ovalis (Pityrosporum ovale) represent a therapeutic problem due to the high rate of recurrence.
OBJECTIVE:
We studied feasible strategies to control the growth of M. ovalis, compatible with topical use in cosmetic formulations. Studies were performed on the effects of pH, ionic strength, cinnamic acid and related compounds on mycotic growth.
METHODS:
M. ovalis was cultivated in modified Sabouraud agar. The effects of pH, ionic strength and cinnamic acid and related compounds on mycotic growth were studied by the membrane filter method.
RESULTS:
In vitro growth of M. ovalis is strongly affected by pH and ionic strength. pH 4.5 induced a growth inhibition of about 95% and 1 M NaCl, at the optimal growth pH, reduced cell growth by over 90%. Cinnamic acid showed an inhibitory effect of 50% at 0.005 g/dl; 30 min incubation with cinnamic acid 0.5 g/dl had a mycocidic effect.
CONCLUSION:
These results suggest the use of cosmetic compositions containing cinnamic acid or buffered acidic lotions and shampoos in the treatment of M. ovalis infections of the scalp, eventually in addition or alternative to antimycotic drugs or in maintenance therapy. Cosmetic formulations with high ionic strength or skin irritant derivatives such as cinnamaldehyde cannot be proposed for practical use.
Copyright 2000 S. Karger AG, Basel
PMID: 11146344 [PubMed - indexed for MEDLINE]

 

Int J Cancer. 1995 Jul 28;62(3):345-50.
Cinnamic acid: a natural product with potential use in cancer intervention.
Liu L1, Hudgins WR, Shack S, Yin MQ, Samid D.

Abstract
Cinnamic acid, a naturally occurring aromatic fatty acid of low toxicity, has a long history of human exposure. We now show that cinnamic acid induces cytostasis and a reversal of malignant properties of human tumor cells in vitro. The concentration causing a 50% reduction of cell proliferation (IC50) ranged from 1 to 4.5 mM in glioblastoma, melanoma, prostate and lung carcinoma cells. Using melanoma cells as a model, we found that cinnamic acid induces cell differentiation as evidenced by morphological changes and increased melanin production. Moreover, treated cells had reduced invasive capacity associated with modulation of expression of genes implicated in tumor metastasis (collagenase type IV, and tissue inhibitor metalloproteinase 2) and immunogenicity (HLA-A3, class-I major histocompatibility antigen). Further molecular analysis indicated that the anti-tumor activity of cinnamic acid may be due in part to the inhibition of protein isoprenylation known to block mitogenic signal transduction. The results presented here identify cinnamic acid as a new member of the aromatic fatty acid class of differentiation-inducers with potential use in cancer intervention.
PMID: 7628877 [PubMed - indexed for MEDLINE]

(Cinnamic acid found in high amounts in chinese cinnamon - Cinnamomum cassia, and next in raw grees olives.)

 

http://www.ncbi.nlm.nih.gov/pubmed/26166743
Nat Prod Res. 2015 Jul 13:1-7. [Epub ahead of print]
In vitro antifungal activity of extracts obtained from Hypericum perforatum adventitious roots cultured in a mist bioreactor against planktonic cells and biofilm of Malassezia furfur.
Simonetti G1, Tocci N, Valletta A, Brasili E, D'Auria FD, Idoux A, Pasqua G.

Abstract
Extracts of Hypericum perforatum roots grown in a bioreactor showed activity against planktonic cells and biofilm of Malassezia furfur. Dried biomass, obtained from roots grown under controlled conditions in a ROOTec mist bioreactor, has been extracted with solvents of increasing polarity (i.e. chloroform, ethyl acetate and methanol). The methanolic fraction was the richest in xanthones (2.86 ± 0.43 mg g- 1 DW) as revealed by HPLC. The minimal inhibitory concentration of the methanol extract against M. furfur planktonic cells was 16 μg mL- 1. The inhibition percentage of biofilm formation, at a concentration of 16 μg mL- 1, ranged from 14% to 39%. The results show that H. perforatum root extracts could be used as new antifungal agents in the treatment of Malassezia infections.
KEYWORDS:
Hypericum perforatum; Malassezia furfur; antifungal activity; biofilm; bioreactor; root cultures; xanthones
PMID: 26166743 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/pubmed/25676074
Mycoses. 2015 Apr;58(4):215-9. doi: 10.1111/myc.12300. Epub 2015 Feb 10.
Medium chain fatty acid ethyl esters - activation of antimicrobial effects by Malassezia enzymes.
Mayser P1.

Abstract
Free medium and short chain fatty acids are known to have broad antimicrobial activity. However, their practical use in topical therapy is limited by their intensive smell and acidity. Surprisingly, a nearly identical antimicrobial effect was found with the ethyl ester derivatives of these fatty acids, but only against Malassezia (M.) yeast, not against Candida spp. Obviously, these esters are hydrolysed by M. enzymes, thus generating a selective activation of antimicrobial activity especially in areas well populated with these yeast ('targeting'). Octanoic acid ethyl ester (CAS 106-32-1) was found to be most suitable. In an agar dilution test, the minimal inhibitory concentrations against M. globosa, M. pachydermatis and M. sympodialis, respectively, ranged between ~5 and 10 mmol l(-1) after 10 days of incubation. The effect started immediately and was not delayed by other lipid sources applied simultaneously. Based on these data, fatty acid monoesters may represent a new therapeutic concept in M.-associated diseases.
© 2015 Blackwell Verlag GmbH.
KEYWORDS:
Malassezia spp.; antimicrobial effects; atopic dermatitis; ethyl esters; hydrolytic activity; targeting
PMID: 25676074 [PubMed - in process]

 

http://www.ncbi.nlm.nih.gov/pubmed/6352533
Int J Dermatol. 1983 Jul-Aug;22(6):388-9.
The treatment of dermatophytoses of the glabrous skin: a comparison of undecylenic acid and its salt versus tolnaftate.
Battistini F, Cordero C, Urcuyo FG, Rojas RF, Ollague W, Zaias N.

Abstract
In a double-blind study, the efficacy of 1% tolnaftate cream, 3% undecylenic acid and its zinc salt, and a placebo cream were tested in dermatophytosis of the glaborous skin and groin. Ninety-seven subjects completed the study: 33 received tolnaftate, 23 of these subjects were cured clinically and mycologically. Thirty-two subjects received 3% undecylenic acid and 20% zinc undecylenate as a cream. Of these, 21 were cured clinically and mycologically. Only three of the 32 subjects receiving placebo were cured clinically and mycologically. Both tolnaftate and undecylenic acid and its zinc salt are effective in this condition.
PMID: 6352533 [PubMed - indexed for MEDLINE]

Undecylenic acid is 6 times more effective than caplykic aicd and has been shown to be effective at maintaining a healthy balance of interestinal and vaginal flora. If you want to know more about undercylenic acid, check out this link.
http://altmedrev.com/publications/7/1/68.pdf

 

http://www.ncbi.nlm.nih.gov/pubmed/26235676

Expert Opin Ther Targets. 2015 Aug 1:1-16. [Epub ahead of print]
Bacterial, fungal and protozoan carbonic anhydrases as drug targets.
Capasso C1, Supuran CT.

Abstract
INTRODUCTION:
The carbonic anhydrases (CAs, EC 4.2.1.1), a group of ubiquitously expressed metalloenzymes, are involved in numerous physiological and pathological processes, as well as in the growth and virulence of pathogens belonging to bacteria, fungi and protozoa. Areas covered: CAs belonging to at least four genetic families, the α-, β-, γ- and η-CAs, were discovered and characterized in many pathogens: i) Bacteria encode enzymes from one or more such families, which were investigated as potential drug targets. Inhibition of bacterial CAs by sulfonamides/phenol derivatives lead to inhibition of growth of the pathogen for Helicobacter pylori, Mycobacterium tuberculosis, Brucella suis; ii) Fungi encode for α- and β-CAs, and inhibitors of the sulfonamide, thiol or dithiocarbamate type inhibited the growth of some of them (Malassezia globosa, Candida albicans, Crytpococcus neoformans, etc) in vivo; and iii) Protozoa encode α-, β- or η-CAs. Sulfonamide, thiols and hydroxamates effectively killed such parasites (Trypanosoma cruzi, Leishmania donovani chagasi, Plasmodium falciparum) in vivo. Expert opinion: None of the microorganism CAs is validated as drug targets as yet, but the inhibitors designed against many such enzymes showed interesting in vitro/in vivo results. By interfering with the activity of CAs from microorganisms, both pH homeostasis as well as crucial biosynthetic reactions are impaired, which lead to significant antiinfective effects, not yet exploited for obtaining pharmacological agents. As resistance to the clinically used antiinfectives is a serious healthcare problem worldwide, inhibition of parasite CAs may constitute an alternative approach for obtaining such agents with novel mechanisms of action.
KEYWORDS:
X-ray; antiinfective; bacteria; carbonic anhydrases; fungi; hydroxamate; inhibitors; pathogens; protozoa; sulfonamide; thiols
PMID: 26235676 [PubMed - as supplied by publisher]

 

http://www.ncbi.nlm.nih.gov/pubmed/19827026

Phytother Res. 2010 May;24(5):715-9. doi: 10.1002/ptr.3004.
Antifungal activity of the aqueous extract of Ilex paraguariensis against Malassezia furfur.
Filip R1, Davicino R, Anesini C.

Abstract
Malassezia furfur is a lipodependent, dimorphic and saprophyte fungus which causes pityriasis versicolor, dandruff and seborrheic dermatitis in humans. The drugs available to treat this fungal infection are few. These drugs are highly toxic and are costly when used in prolonged treatments. For these reasons, it is necessary to find new compounds to treat these infections. Ilex paraguariensis St Hilaire is a plant that grows in Argentina, Brazil and Paraguay. The aim of this study was to evaluate the effect of the aqueous extract of Ilex paraguariensis on the growth of M. furfur. High performance liquid chromatography (HPLC) was employed to identify and isolate compounds of I. paraguariensis and the agar-well diffusion method was used to assess the antifungal activity of the extract. The fungicidal/fungistatic effect was evaluated by the modified Thompson assay. The results demonstrated that the aqueous extract of Ilex paraguariensis (1000 mg/ml) possesses inhibitory activity against M. furfur. This antimalassezial activity was equivalent to 2.7 microg/ml of ketoconazole. Therefore, the topical use of Ilex paraguariensis extract as alternative antifungal agent can be suggested.
Copyright (c) 2009 John Wiley & Sons, Ltd.
PMID: 19827026 [PubMed - indexed for MEDLINE]

 

 

DOG DATA

http://www.ncbi.nlm.nih.gov/pubmed/26286855
Vet Dermatol. 2015 Aug 19. doi: 10.1111/vde.12245. [Epub ahead of print]
Determining canine skin concentrations of terbinafine to guide the treatment of Malassezia dermatitis.
Gimmler JR1, White AG1, Kennis RA1, Cruz-Espindola C2, Boothe DM2.

Abstract
BACKGROUND:
Terbinafine (TBF) is known to concentrate and persist in human skin. Its use is increasing in veterinary medicine, but there are limited data concerning its tissue concentration and efficacy in dogs.
HYPOTHESIS/OBJECTIVES:
(i) Describe TBF accumulation in canine skin; (ii) Integrate pharmacokinetic data with historical minimum inhibitory concentration (MIC) results for Malassezia pachydermatis to verify the currently used dosage of TBF for the treatment of Malassezia dermatitis.
ANIMALS:
Ten healthy, client-owned dogs.
METHODS:
Dogs were given TBF (generic preparation, 250 mg tablets) 30 mg/kg per os (p.o.) once daily for 21 days. Serum, sebum and stratum corneum (SC) samples were collected on days 1, 5, 7, 11, 14, 21, 28 and 35. High-pressure liquid chromatography was used to determine drug concentrations in samples.
RESULTS:
Relevant (mean ± standard deviation) parameters for TBF in serum, paw SC, thorax SC and sebum, respectively, were: maximum concentration (Cmax , μg/mL) 23.59 ± 10.41, 0.31 ± 0.26, 0.30 ± 0.32 and 0.48 ± 0.25; half-life (t1/2 , d) 4.49 ± 2.24, 6.34 ± 5.33, 4.64 ± 3.27 and 5.12 ± 3.33; time to maximum concentration (Tmax , d) 10.40 ± 6.98, 13.20 ± 5.16, 11.90 ± 8.62 and 10.60 ± 3.69.
CONCLUSIONS AND CLINICAL IMPORTANCE:
These results suggest that TBF does not achieve high concentrations in canine SC or sebum compared to serum. The mean Cmax of all skin tissues (paw SC, thorax SC and sebum) barely exceeded the reported Malassezia MIC90, of 0.25 μg/mL, which indicates that doses higher than 30 mg/kg p.o. once daily may be necessary.
© 2015 ESVD and ACVD.
PMID: 26286855 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/pubmed/24625672

Med Mycol. 2014 May;52(4):350-5. doi: 10.1093/mmy/myt016. Epub 2014 Feb 28.
In vitro and in vivo activity of a killer peptide against Malassezia pachydermatis causing otitis in dogs.
Cafarchia C1, Immediato D, Paola GD, Magliani W, Ciociola T, Conti S, Otranto D, Polonelli L.

Abstract
In order to overcome the limitations inherent in current pharmacological treatments for Malassezia pachydermatis, the cause of otitis externa in dogs, the efficacy of a killer decapeptide (KP) was evaluated in vitro and in vivo. Sixteen dogs with naturally occurring M. pachydermatis otitis externa were enrolled, and the in vitro fungicidal activity of KP was evaluated using yeasts recovered from these animals. The therapeutic activity was evaluated in four groups of four animals each. The dogs were topically treated with KP (150 μl, 2 mg/ml) three times per week (group A) or every day (group B), treated with a scramble peptide every day (group C), or left untreated (group D). Assessment of clinical signs (pruritus, erythema, and lichenification and/or hyperpigmentation), expressed as mean of the total clinical index score (mTCIS), the population size of M. pachydermatis at the cytological examination (mean number of yeast cells at 40× magnification [mYC]), and culture testing (mean number of log10 CFU/swab [mCFU]), were conducted daily from the first day of treatment (T0) until two consecutive negative cultures (mCFU ≤ 2). KP showed an in vitro fungicidal effect against M. pachydermatis isolates, with an MFC90 value of 1 μg/ml. The mTCIS, mYC and mCFU were negative only in animals in group B after T8. Daily administration of KP for 8 days was safe and effective in controlling both clinical signs and the population size of M. pachydermatis causing otitis externa, thus offering an alternative to the currently available therapeutic or prophylactic protocols for recurrent cases of Malassezia otitis in dogs.
KEYWORDS:
Malassezia pachydermatis; dogs; killer peptide; otitis; therapy
PMID: 24625672 [PubMed - indexed for MEDLINE]

NOTE: Malassezia pachydermatis has been isolated from the facial granuloma of a healthy woman and her dog's skin scrapings and cerumen. The skin lesions healed after oral fluconazole and cryotherapy.

 

http://www.ncbi.nlm.nih.gov/pubmed/26083147
Vet Dermatol. 2015 Aug;26(4):278-e61. doi: 10.1111/vde.12220. Epub 2015 Jun 16.
A pilot study of the efficacy of wipes containing chlorhexidine 0.3%, climbazole 0.5% and Tris-EDTA to reduce Malassezia pachydermatis populations on canine skin.
Cavana P1, Peano A2, Petit JY3, Tizzani P2, Perrot S3, Bensignor E4, Guillot J1.

Abstract
BACKGROUND:
Wipes containing chlorhexidine and azole derivates have been recommended for veterinary use. No study has been published about their activity against Malassezia pachydermatis.
HYPOTHESIS/OBJECTIVES:
To evaluate the in vivo and in vitro activity of wipes soaked in a chlorhexidine, climbazole and Tris-EDTA solution against Malassezia pachydermatis.
ANIMALS:
Five research colony shar-pei dogs.
METHODS:
Wipes were applied once daily onto the left axilla, left groin and perianal area (protocol A), and twice daily on the right axilla, right groin and umbilical region (protocol B) for 3 days. In vivo activity was evaluated by quantifying Malassezia colonies through contact plates on the selected body areas before and after wipe application. The activity of the solution in which the wipes were soaked was assessed in vitro by contact tests following the European Standard UNI EN 1275 guidelines.
RESULTS:
Samples collected after wipe application showed a significant and rapid reduction of Malassezia yeast CFU. No significant difference in the Malassezia reduction was found between protocols A and B. In vitro assay showed 100% activity against Malassezia yeasts after a 15 min contact time with the wipe solution.
CONCLUSIONS AND CLINICAL IMPORTANCE:
Wipes containing chlorhexidine, climbazole and Tris-EDTA substantially reduced the M. pachydermatis population on the skin of dogs. The results, although this was an uncontrolled study performed on a small number of dogs, suggest that these wipes may be useful for topical therapy of Malassezia dermatitis involving the lips, paws, perianal area and skin folds.
© 2015 ESVD and ACVD.
PMID: 26083147 [PubMed - in process]

 

http://mbio.asm.org/content/4/2/e00117-13.full.pdf

MBio. 2013 Mar 19;4(2):e00117-13. doi: 10.1128/mBio.00117-13.
Living and thriving on the skin: Malassezia genomes tell the story.
Coelho MA1, Sampaio JP, Gonçalves P.

Abstract
Our understanding of the interactions between normal skin microbiota and the human host has been greatly extended by recent investigations. In their recent study in mBio, A. Gioti et al. (mBio 4[1]:e00572-12, 2013) sequenced the genome of the atopic eczema-associated yeast, Malassezia sympodialis, and compared its gene content and organization with that of Malassezia globosa, a species implicated in dandruff. Their findings were also contrasted with those previously obtained for Ustilago maydis, which is a close relative but ecologically distinct plant parasite. Besides gaining additional insight into key host-specific adaptations and the particular function and molecular evolution of allergens related to atopic eczema, Gioti et al. also uncovered several lines of evidence that elegantly suggest the presence of an extant sexual cycle, with important implications in disease.
Comment on
Genomic insights into the atopic eczema-associated skin commensal yeast Malassezia sympodialis. [MBio. 2013]
PMID: 23512963 [PubMed - indexed for MEDLINE] PMCID: PMC3604764 Free PMC Article

 

 

https://www.ncbi.nlm.nih.gov/pubmed/24746728

J Mycol Med. 2014 Sep;24(3):234-40. doi: 10.1016/j.mycmed.2014.02.005. Epub 2014 Apr 17.

Clinical and mycological evaluation of an herbal antifungal formulation in canine Malassezia dermatitis.

Nardoni S1, Mugnaini L2, Pistelli L3, Leonardi M3, Sanna V2, Perrucci S2, Pisseri F4, Mancianti F2.

Malassezia pachydermatis is a common cause of more widespread dermatitis in dogs (CMD). Recurrences are common, and this disorder can be very troubling for both dogs and for the pet owner.

MATERIAL AND METHODS:

The treatment of 20 dogs affected by dermatitis due to M. pachydermatis, with Malacalm(®), a commercially available mixture consisting of essential oils (Citrus aurantium 1%, Lavandula officinalis 1%, Origanum vulgare 0.5%, Origanummajorana 0.5%, Mentha piperita 0.5% and Helichrysum italicum var. italicum 0.5%, in sweet almond oil and coconut oil) is reported. The effectiveness of the whole mixture, of component essential oils and of their more represented compounds against clinical isolates was evaluated by a microdilution test. Twenty animals were topically administered the mixture twice daily for 1 month. Ten animals were treated with a conventional therapy based on ketoconazole 10mg/kg/day and chlorhexidine 2% twice a week for 3 weeks. At the end of both treatments animals significantly improved their clinical status. Adverse effects were never noticed. Follow-up visit performed on day 180th allowed to observe a recurrence of clinical signs in all the subjects treated conventionally, while not significant clinical changes were referred in dogs treated with Malacalm(®). The overall MIC value of Malacalm(®) was 0.3%. O. vulgare showed the lowest minimum inhibitory concentrations (MIC), being active at 0.8%, followed by M. piperita (1%), O. majorana (1.3%), C. aurantium (2%) and L. officinalis (4%) while H. italicum did not yield any antimycotic effect up to 10%. Active major compounds were thymol, carvacrol, p-cymene, 1,8-cineol, limonene and menthol.

CONCLUSION:

The phytotherapic treatment achieved a good clinical outcome, and no recurrence of skin disorders on day 180th was recorded. This herbal remedium appeared to be a safe tool for limiting recurrences of CMD.

 

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