Serum levels of IL-18 and sIL-2R in patients withalopecia areata receiving combined therapy with oralcyclosporine and steroids

Deborah Lee1, Soon-Kwon Hong1, Sung-Wook Park2, Dae-Young Hur3, Ji-Hong Shon4, Jae-Gook Shin4,

Seon-Wook Hwang1 and Ho-Suk Sung1

1Department of Dermatology, Inje University School of Medicine, Pusan, Korea;2Park Sung-Wook Dermatologic Clinic, Pusan, Korea;3Department of Anatomy and Research Center for Tumor Immunology, Inje University College of Medicine, Pusan, Korea;4Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Pusan, Korea

Correspondence: Deborah Lee, Inje University School of Medicine, Pusan, Korea, e-mail: btyouth@naver.com

Abstract: This study was to determine which immunologic factors

contribute to the prognosis of patients with alopecia areata (AA)

who were receiving oral cyclosporine A and methylprednisolone.

Patients with >25% hair regrowth were defined as responders, and

patients exhibiting £25% regrowth were poor-responders. The

serum levels of IL-18 and soluble IL-2 receptor (sIL-2R) were

measured at baseline in 21 patients with AA and 22 control

subjects. The mean serum level of IL-18 in the patients with

extensive AA was significantly higher than that in the control

subjects. The mean serum concentration of sIL-2R in the AA

patients significantly decreased after 1 month of treatment. The

mean basal serum level of IL-18 was highest in the responder,

whereas the baseline level of sIL-2R was significantly higher in the

poor-responder group than other groups. In conclusion, increased

serum sIL-2R level and lower IL-18 level at baseline was associated

with a poor prognosis in patients with AA.

Key words: alopecia areata – IL-18 – prognostic marker – soluble

IL-2 receptor

Accepted for publication 5 June 2009. Please cite this paper as: Serum levels of IL-18 and sIL-2R in patients with alopecia areata receiving combined therapy

with oral cyclosporine and steroids. Experimental Dermatology 2010; 19: 145–147.

Background

Although the aetiopathogenesis of alopecia areata (AA) is

not clearly understood, evidence suggests that T cells and

Th1 cytokines play important roles (1). Several studies have

attempted to identify correlations among the levels of Th1

cytokines, associated extended cytokines, disease severity,

and prognosis of AA (1–6).

Cyclosporin A (CsA) and corticosteroids have been used

for the treatment of AA with varying success (7–10).

Whereas CsA specifically acts by inhibiting IL-2 gene tran-

scription, corticosteroids act as non-selective immuno-

suppressive agents. Thus, combined therapy with CsA and

corticosteroids may have a synergistic therapeutic effect (11).

Questions addressed

Interleukin-2 (IL-2) plays a central role in the initiation and

development of immune responses through binding of the

cytokine to IL-2 receptor (IL-2R) and serum soluble IL-2

receptor (sIL-2R) measurements have been applied to a

broad spectrum of human disorders involving aberrant

immune activation (12). In addition, the importance of

IL-18 as an immunoregulatory factor is revealed by its effect

on the induction of IFN-c (13,14). So we attempted to find

the meaning of serum level of IL-18 and sIL-2R as immuno-

logical factor in patients with AA who were receiving

combined therapy with oral CsA and methylprednisolones.

Experimental design

Extensive AA was defined as AA involving >50% of the

scalp hair; localized AA was defined as AA involving no

more than four alopecic patches (i.e. £50% of the scalp

hair). The healthy volunteers were over the age of 18 and

had no family or personal history of AA, other auto-

immune disease and active inflammatory skin disease.

CsA (Cipol-N�) was started at a dose of 2.5–5 mg ⁄kg ⁄ day and was maintained at 2.5–3 mg ⁄ kg ⁄ day. Methyl-

prednisolone (Someron�) was started at a dose of

16–24 mg ⁄ day, tapered down for 5–6 weeks, and then

maintained at a dose of 2–4 mg ⁄ day.

The treatment response was assessed from photographs

and clinical records. Responders were defined as those

patients with >25% hair regrowth, and poor-responders

were those exhibiting £25% regrowth.

DOI:10.1111/j.1600-0625.2009.00937.x

www.blackwellpublishing.com/EXDLetter to the Editor

ª 2009 John Wiley & Sons A/S, Experimental Dermatology, 19, 145–147 145

The serum levels of IL-18 and sIL-2R were measured

using commercially available ELISA kits (R&D Systems,

Minneapolis, MN, USA) at baseline and after 1 month of

treatment.

All analyses were performed using SPSS, version 14.0.

The Mann–Whitney U-test was used to compare the serum

concentrations of the immunological markers among the

patients and controls. Differences between the groups with

a P value <0.05 were considered to be significant.

Results

The serum levels of IL-18 and sIL-2R were measured in 21

patients (14 with extensive AA and seven with localized

AA) before starting drug therapy and in 22 control sub-

jects. The mean serum concentrations of sIL-2R were

613.59, 664.71, and 571.18 pg ⁄ ml in the patients with

extensive AA, the patients with localized AA and the

controls, respectively (see Table S1). The sIL-2R serum

concentration was not significantly different among the

three groups. The mean serum IL-18 concentrations were

139.49, 119.27, and 107.36 pg ⁄ ml in the patients with

extensive AA, the patients with localized AA and the

controls, respectively (see Table S1). The mean serum level

of IL-18 was significantly higher in the patients with exten-

sive AA than in the control subjects (P < 0.05, see Fig. S1).

However, no significant differences were detected between

the patients with extensive and localized AA.

The mean serum level of IL-18 decreased from 141.34 to

114.21 pg ⁄ ml after 1 month of treatment, and the mean

level of sIL-2R decreased from 624.81 to 420.81 pg ⁄ ml over

the same period. The decrease of the serum sIL-2R concen-

tration, not IL-18, after 1 month of treatment was statisti-

cally significant (P < 0.05, see Fig. S2).

After classifying the AA patients as responder and poor-

responder groups following therapy (Fig. 1), we compared

the basal serum levels of IL-18 and sIL-2R among the two

response groups and the controls. The mean serum IL-18

level in the responders was significantly higher than that in

the controls (Fig. 2a, P = 0.025, see Table S2). The mean

serum sIL-2R level in the poor-responders was significantly

higher than that in the responders (P = 0.036, see Table

S2) and that in the controls (Fig. 2b, P = 0.019).

Conclusions

In the present study, no significant difference in the mean

serum sIL-2R level was detected among the patients with

extensive AA, patients with localized AA, and control sub-

jects. On the other hand, the mean serum concentration of

sIL-2R in the patients with AA significantly decreased after

4 weeks of therapy with CsA and steroids. This is not sur-

prising because CsA inhibits T-cell activation by preventing

the transcription of IL-2 (15). Additionally, the baseline

level of sIL-2R in the poor-responders was significantly

higher than those in the responders and controls (Fig. 2b).

It is consistent with several reports suggesting positive cor-

relation between the serum sIL-2R level and disease severity

in patients with psoriasis, which shares a common immu-

nopathology with AA (16–22). Valsecchi et al. showed

serum sIL-2R level in patients with AA was significantly

higher during the active phase than the stable phase (23).

In the present study, patients with AA were all chronic, sta-

ble and refractory state. Poor-responders were thought to

be in more severe states than responders, as such the serum

level of sIL-2R was higher. The results indicate that a high

basal serum sIL-2R might be a poor prognostic marker in

patients with AA.

In the present study, the mean serum level of IL-18 in

patients with extensive AA was significantly higher than

that in the control subjects (P < 0.05). Our findings imply

that the serum level of IL-18 roughly reflects the severity of

disease in AA because extent of hair loss is a major indica-

tor of disease severity in AA. In contrast, the mean basal

serum level of IL-18 was significantly higher in the respon-

der group than in the controls (Fig. 2a). This result was

unexpected because we proposed the disease severity of

responder was less severe and would show lower IL-18 level

as in psoriasis (14). But, there are possible explanations for

these observations. First, the biologic actions of IL-18 in

AA may be different from those in psoriasis, as IL-18 does

not reflect only T cells and its precursor is expressed by

(a)

(b)

Baseline After 3 months After 7 months

Baseline After 3 months After 7 months

Figure 1. (a) Poor-responder; a 25-year-old man with alopecia

universalis, before and after combined therapy with cyclosporine and

methylprednisolone. (b) Responder; an 18-year-old man with alopecia

universalis, before and after combined therapy with cyclosporine and

methylprednisolone.

Letter to the Editor

146 ª 2009 John Wiley & Sons A/S, Experimental Dermatology, 19, 145–147

epithelial cells throughout the body (13). Second, there

may be a lag phase between disease severity and the circu-

lating IL-18 level as IL-18 increase IFN-c production, such

that the serum level may not reflect the current disease

state. There have been no studies on association between

IL-18 and AA; thus, additional studies are required to

determine its meaning.

In the present study, we demonstrated that higher levels

of sIL-2R and lower levels of IL-18 at baseline were associ-

ated with a poor prognosis in patients with AA. Additional

serial follow-up measurements of the serum concentrations

of sIL-2R and IL-18 could lead to the development of

rapid, reliable, and non-invasive prognostic markers.

References

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Supporting information

Additional Supporting Information may be found in the

online version of this article:

Table S1. Comparison of the serum cytokine levels in

patients with extensive alopecia areata, patients with loca-

lized alopecia areata, and control subjects.

Table S2. Comparison of the baseline serum levels of IL-

18 and soluble IL-2 receptor in the patients and controls.

Figure S1. Serum levels of IL-18 in the controls and the

patients with extensive alopecia areata.

Figure S2. Changes in the serum level of soluble IL-2

receptor after combined therapy with cyclosporine and

steroids Methods.

Please note: Wiley-Blackwell are not responsible for the

content or functionality of any supporting materials sup-

plied by the authors. Any queries (other than missing

material) should be directed to the corresponding author

for the article.

Ser

um

co

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ntr

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f IL

-18

(pg

/ml)

0

50

100

150

200

250

300S

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m c

on

cen

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of

sIL

-2R

(p

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0

200

400

600

800

1000

Control Responder Poor-responder

Control Responder Poor-responder

* P < 0.05

‡ P < 0.05

†P < 0.05

(a)

(b)

Figure 2. (a) Comparison of the baseline serum levels of IL-18 among

the patient groups with alopecia areata and the controls. (b)

Comparison of the baseline levels of soluble IL-2 receptor among the

patient groups with alopecia areata and the controls (mean ± SD

values). *Responders versus controls, P = 0.025. �Poor responders versus

Responders, P = 0.036. �Poor responders versus Controls, P = 0.019.

Statistical analysis was performed with the Mann–Whitney U-test,

P < 0.05.

Letter to the Editor

ª 2009 John Wiley & Sons A/S, Experimental Dermatology, 19, 145–147 147