Microbiol. Immunol.

, 44( 11), 945-947,2000

Comparative
Study of Staphylococcus
Isolated
from Lesional
and Non-Lesional
Skin of Atopic Dermatitis
Patients

aureus

Katsuhiko Matsui*,1, Akemi Nishikawa1, Hajime Suto2, Ryoji Tsuboi2, and Hideoki Ogawa2
1Department of Immunobiology, Meiji Pharmaceutical
University, Kivose, Tokyo 204-8588,
Dermatology, Juntendo University School of Medicine, Bunkvo-ku, Tokyo 113-8421, Japan

Japan, and 'Department of

Received June 26,2000. Accepted August 2,2000

Abstract: The skin of patients with atopic dermatitis (AD) is often colonized by Staphylococcus aureus, and
superantigenic exotoxins produced by the organism are thought to be an important precipitating factor of
AD. However, there are few reports comparing the characteristics of S. aureus isolated from the lesional and
non-lesional skin of identical AD patients. In this study, therefore, we examined whether the presence of
superantigen-producing
S. aureus correlates with the formation of eczematous lesion of AD patients.
The detection rate of S. aureus on the lesional skin of AD patients was higher than on the non-lesional skin
of AD patients. Furthermore, the bacterial cell count of S. aureus on the lesional skin of AD patients was
also significantly higher than that of the non-lesional skin of AD patients. However, there was no significant
difference between the detection rate of superantigenic exotoxin-producing S. aureus on the lesional and nonlesional skin of AD patients. These results suggest that the number of S. aureus present is more important
in the formation of eczematous lesion of AD patients than the presence of superantigenic exotoxin-producing
S. aureus strains per se.
Key words: Staphylococcus

aureus,

Atopic

dermatitis,

Superantigen

AD severity. Jappe et al (6) found that 45% of the S.

aureus strains from AD patients were capable of producing superantigens, but that this number did not exceed
the number of S. aureus strains capable of superantigen
production in healthy carriers. Based on these findings,
the authors question the hypothesis that skin colonization
with superantigen-producing S. aureus is an essential prerequisite in the pathogenesis of AD. However, since
there are few reports comparing toxin-producing S.
aureus on the lesional and non-lesional skin of identical
AD patients, we examined whether the presence of
superantigen-producing S. aureus correlates with the
formation of eczematous lesion of AD patients.
Specimens were obtained from the lesional and nonlesional skin (face, neck or arm) of 26 AD outpatients
(aged 7-45; 15 males and 11 females) at the Department
of Dermatology, Juntendo University Hospital, and from
the normal skin of 49 healthy subjects (aged 14-57; 20
males and 29 females). The diagnosis of AD was made
according to the Japanese Dermatological Association

Atopic dermatitis (AD) is a chronic inflammatory

skin disease with immunological abnormality and skin
barrier dysfunction.
Patients with AD have increased
serum levels of IgE, enhanced synthesis of Th2-type
cytokines such as interleukin (IL)-4 and IL-5 in their skin
lesion, and show frequent infection by Staphylococcus
aureus (2, 9, 11). S. aureus can be isolated from over
95% of the skin lesions of AD patients and is thought to
be an important precipitating factor of the disease (9). S.
aureus can produce superantigenic
exotoxins such as
staphylococcal
enterotoxin (SE)A, SEB, SEC, SED,
SEE, and toxic shock syndrome toxin (TSST)-1. Several
studies suggest that S. aureus may amplify the skin
inflammation in AD by secreting exotoxins as superantigens (8, 10, 12). In particular, the toxin-stimulated
peripheral blood mononuclear cells (PBMC) of AD
patients induce marked levels of IL-4, IL-5 and IgE,
compared with those in healthy individuals (4, 5, 10). On
the other hand, Akiyama et al (1) have reported that the
existence of exotoxins from S. aureus is not reflective of
*Addresscorrespondence to Dr. Katsuhiko Matsui, Department
of Immunobiology, Meiji Pharmaceutical University, 2-522-1
Noshio, Kiyose, Tokyo 204-8588, Japan. Fax: 0424-95-8612. Email: kmatsui@my-pharm.ac.jp

Abbreviations:

atopic

dermatitis;

PBMC,

SE,

enterotoxin;

toxin.

945

AD,

unit; IL, interleukin;

staphylococcal

peripheral
TSST,

CFU,
blood
toxic

colony-forming

mononuclear
shock

cells;

syndrome

946

K. MATSUI

criteria

for

were
Stamp
10

the

diagnosis

obtained
Check

sec.
on

their

agar

and

expressed

slide

to

S.

aureus

from

the

was

the
The

S.D.,

and

are

at P

S. aureus
staphylococcal

chain

previously

of

were

for

by

significance.

to be
the

toxin

sysCFU

analyzed

of

for

of

STPH

significant.

production

(SEASEE)

reaction

carried

obtained

API

test

assayed

the

Latex

also

mean

considered

also

enterotoxins

polymerase

the
the

them

were

were

PS

profile

a two-tailed

0.05

strains

by

skin
of

identification

reaction

between

with

cm2

were

of

to
were

staining

final

as

for

according

(CFU)/10

The

tests

site
colonies

numbers

Gram

Tokyo)

the

"Film

the

test

expressed

differences
t-test

Differences

of

and

TSST-1

as

described

genes

in Table 2. Forty percent of the S. aureus strains found

on the lesional skin of AD patients produced one or
more identifiable exotoxins. Similarly, 37.5% of the S.
aureus strains from the non-lesional skin of AD patients
and 40.0% of the S. aureus strains from the skin of
healthy subjects produced one or more detectable exotoxins, the individual components being similar to those
identified on the lesional skin of AD patients.
In this study, we were able to determine that the
detection rate of S. aureus increased in the order of skin
from healthy donors, non-lesional skin of AD patients,
and lesional skin of AD patients. When the CFU values
of S. aureus on a 10 cm2 area of the lesional and nonlesional skin, respectively, of AD patients were cornpared, the bacterial count of S. aureus on the lesional skin
was significantly higher. However, the detection rates of
superantigenic exotoxins in S. aureus strains from the
Table

1. Predominant

colonization

with S. aureus

on the lesion-

al skin of AD patients

(7).

Twenty-six
ed

positive

1.

S. aureus

AD
for

samples

patients

S.

the

of

positive

results.

obtained

from

from

patients.

healthy

96.2%

skin

of

Furthermore,
the

healthy

from

the

values

of

subjects

as

shown

of the

However,

non-lesional

obtained

49

colonization,

isolated

AD

samples

and

aureus

was

of

those

Ltd.,

organisms.
on

C,

colony

of

biochemical
data

Student's

the

agglutination

based

20

tem.

affected

37

units

Co.

identify

the

characterized

and

isolates

applying

to

examination

Chemical

out

were

bacterial

by

at

colony-forming

and

(Eiken

Agar"
culturing

plates

Microscopic

colonies

by

Soy

diameter,

as

area.

The

subject

overnight

the

color

AD.

each

Tryptic

After

grown

of

from

ET AL

lesional

only

patients

the

positive
were

non-lesional

skin

skin

30.8%

AD

subjects

testin Table

of
showed
results

lower
of

the

AD

than
patients

(10.2%).
The
skin

CFU
from

shown

in Fig.

found
al

on

skin

skin

both

of

1.

the
of

AD

AD

AD

The

skin

S.

aureus

patients

of

average

patients

of

The

AD

patients

non-lesional
subjects
in

CFU

non-lesional
Next,

(n=25)

value
was

skin
the

of

(n=5),
and

detection

of

S.

area

of
are

S. aureus
the

the

109 }

aureus

significantly
of

0.01).
values

superantigenic

cm2
subjects

lesion-

non-lesional

(n=8) }

skin
(PC

the

duce

CFU

10

S.D.

subjects

4,
tively.

healthy

CFU }

healthy

patients

on

and

AD

higher

patients

or

However,
of
of

the
AD

there

skin

175,
on

of

the

4 }

the
than

skin

were

healthy

6, respec-

lesional

no

skin

that

on

of

healthy

the

differences

subjects

and

the

patients.

rate
exotoxins

of

Fig.
the

S.

aureus

was

strains

determined,

that
as

proshown

al
jects

1. Comparison
skins
skin

of
of AD

(n =

5)

of

healthy
patients
or

the

bacterial

subjects
(n =

non-lesional

and
25)

cell
AD

versus
skin

of

numbers

patients.
normal
AD

of S. aureus
*P0.01
skin

patients

Table 2. The number of S. aureus cultures from AD patients and healthy subjects producing superantigenic exotoxins

on

(lesion-

of

healthy

(n=

8)).

sub-

947

NOTES

lesional skin, non-lesional skin of AD patients and the

normal skin of healthy subjects showed no notable differences. Furthermore, the bacterial cell count of exotoxin-producing S. aureus and that of non-toxin-producing S. aureus on a 10 cm2 area of lesional skin
showed no significant difference (data not shown). These
results suggest that the CFU value of S. aureus on a
given area of skin is more important in precipitating
eczematous lesions than the presence of superantigenic
exotoxin-producing S. aureus strains. In fact, Higaki et
al (3) have recently reported that the number of S. aureus
isolated increased in correlation to the increase in severity of the AD lesion. Furthermore, Nomura et al (13)
have mentioned that there was no statistically significant
difference in disease activity scores of AD patients with
or without exotoxin-producing S. aureus. In regard to the
pathogenesis of S. aureus in AD, our results therefore
suggest that colonization and/or the presence in absolute
numbers of the bacterium is more important than the
presence of superantigenic exotoxins per se, and that
other unidentified pathogenic factors may exist in nonexotoxin-producing strains. However, this study does not
exclude a possible role of superantigens in the acceleration of clinical course of the lesional skin of AD patients
with superantigenic exotoxin-producing S. aureus. Further studies will be required to define the cytokine patterns in the lesional skin of AD patients with or without
superantigenic exotoxin-producing S. aureus and the
levels of anti-exotoxin IgE antibodies in their sera.

not
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