|Year : 2020 | Volume
| Issue : 3 | Page : 1011-1015
Clinical significance of serum prolactin levels in patients with alopecia areata
Shawky M El-Farargy1, Naglaa M Ghanayem2, Hanem N AbdEl-Fattah Habib3
1 Department of Dermatology, Andrology and S.T. Ds, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Dermatology, Andrology and S.T. Ds, Menoufia General Hospital, Menoufia, Egypt
|Date of Submission||09-Jan-2019|
|Date of Decision||04-Feb-2019|
|Date of Acceptance||10-Feb-2019|
|Date of Web Publication||30-Sep-2020|
Hanem N AbdEl-Fattah Habib
Menoufia City, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
To assess the value of elevated serum prolactin levels as a diagnostic marker in alopecia areata (AA).
AA is characterized by areas of nonscarring hair loss that ranges from a single oval patch to multiple patches. Immunological, environmental, psychological, and genetic factors may play a role in the pathogenesis of AA. Prolactin is a polypeptide hormone secreted from the anterior pituitary gland that has a variety of physiological actions including growth promoting activity and exerts a proliferative effect on human keratinocytes. Prolactin may therefore play an important role in the pathogenesis of AA, through its immunomodulatory function. Several studies have shown that prolactin and AA are positively correlated.
Patients and methods
This case–control study was conducted on 50 patients: 25 AA patients and 25 age-matched and sex-matched healthy controls during the period from November 2017 to March 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum prolactin levels were measured by chemiluminescence through an immunoassay-automated access 2 Beckman coulter.
Serum prolactin levels were significantly elevated in AA patients (mean ± SD, 16.8 ± 2.3) compared with healthy controls (mean ± SD, 9.7 ± 3.00). There was significant positive correlation between serum prolactin level and size of the AA lesion (r = 0.661, P < 0.005).
Serum prolactin levels were higher in AA patients compared with healthy controls. The levels were correlated with clinical severity in patients with AA. Therefore, serum prolactin level can be used as a diagnostic biomarker for evaluating the clinical status of AA.
Keywords: alopecia areata, biomarker, chemiluminescence, prolactin, skin disease
|How to cite this article:|
El-Farargy SM, Ghanayem NM, AbdEl-Fattah Habib HN. Clinical significance of serum prolactin levels in patients with alopecia areata. Menoufia Med J 2020;33:1011-5
|How to cite this URL:|
El-Farargy SM, Ghanayem NM, AbdEl-Fattah Habib HN. Clinical significance of serum prolactin levels in patients with alopecia areata. Menoufia Med J [serial online] 2020 [cited 2020 Nov 26];33:1011-5. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/1011/296702
| Introduction|| |
Alopecia areata (AA) is characterized by areas of nonscarring hair loss that range from a single oval patch to multiple patches . AA affects both sexes equally, affects patients of all ages, and is found in ∼0.1–0.2% of the general population . The etiology of AA is unknown but the disease is believed to have an autoimmune basis and a strong genetic component . Environmental as well as psychological factors may play a role in the pathogenesis of AA . It is clinically manifested by areas of nonscarring hair loss that range from a single oval patch to multiple patches that become confluent . Clinical types include patchy AA, alopecia totalis, alopecia universalis, diffuse AA, and ophiasis . Patchy AA is the most common variety of AA . Severity of alopecia tool (SALT) score is the most widely used tool for assessment of the severity of AA. The SALT score is a global severity score that captures percentage hair loss. The scalp is divided into four areas, namely the vertex, 40% (0.4) of scalp surface area; right profile of scalp, 18% (0.18) of scalp surface area; left profile of scalp, 18% (0.18) of scalp surface area; and posterior aspect of scalp, 24% (0.24) of scalp surface area. The percentage of hair loss in any of these areas is the percentage of hair loss multiplied by the percent surface area of the scalp in that area. SALT score is the sum of percentage of hair loss in all the above-mentioned areas . Prolactin is a polypeptide hormone secreted from the anterior pituitary gland . Prolactin has a broad spectrum of activities which are classified as reproduction, metabolism, osmoregulation, immunoregulation, and behavior . prolactin (PRL) also has immunomodulatory function through its effect on T lymphocytes, B lymphocytes, dendritic cells, and natural killer cells . High serum PRL levels are observed in AA patients . Therefore, it is possible that in addition to the involvement of prolactin in metabolic syndrome, prolactin may also directly affect the pathogenesis of AA . The PRL level may be useful as a biomarker for the diagnosis of AA and to adjust the treatment regimen during fluctuating severity of the disease. The aim of this study was to assess the value of elevated serum PRL level as a diagnostic marker in AA.
| Patients and Methods|| |
Study population and selection of patients
This study was approved by the Ethics Committee of Dermatology, Andrology and STDs and Medical Biochemistry Department, Faculty of Medicine, Menoufia University during the period from November 2017 to March 2018; and informed consent was obtained from every patient and control. It included 50 patients, 25 patients with AA (group I) and 25 age-matched and sex-matched healthy controls (group II). Exclusion criteria included hepatic and renal patients as both may affect the level of the prolactin hormone, pregnant or lactating women, females with a history of menstrual irregularities, patients who were receiving any medications affecting prolactin level, male patients with sexual problems, and presence of other autoimmune diseases. The patients were subjected to the following: (a) full history including personal, family, and clinical history of AA (onset, course, duration of the lesion). (b) Clinical examination: general and dermatological examination which include distribution of lesion, site, size, presence of nail affection, and positive family history. (c) Laboratory investigations collection of blood samples: peripheral venous blood samples (5 ml) were withdrawn from every patient under complete aseptic condition into a plain tube. After clot formation, centrifugation of samples at 2000g for 10 min was done and serum were separated and stored at −20°C until analysis of PRL. Jufengyuan Road, Baoshan District, Shanghai 200444 Shanghai China China. The kit uses one-step immunoenzymatic (sandwich) assay. A sample is added to a reaction vessel along with polyclonal goat anti-PRL-alkaline phosphatase conjugate, and paramagnetic particles coated with mouse monoclonal anti-PRL. The serum or plasma (heparin) PRL binds to the monoclonal anti-PRL on the solid phase, while the goat anti-PRL-alkaline phosphatase conjugate reacts with a different antigenic site on the serum PRL. After incubation in a reaction vessel, materials bound to the solid phase are held in a magnetic field while unbound materials are washed away. Then, the chemiluminescent substrate Lumi-Phos 530 is added to the vessel and light generated by the reaction is measured with a luminometer. The light production is directly proportional to the concentration of prolactin in the sample. The amount of analyte in the sample is determined from a stored, multipoint calibration curve.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0. (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level. The tests used were χ2 test, Monte–Carlo correction, F test (analysis of variance), Kruskal–Wallis test, and receiver operating characteristic curve.
| Results|| |
The mean age was 27.4 ± 9.8 with group I (patients) and it was 29.4 ± 10.2 in group II (controls). There was no significant difference between the studied groups regarding age and sex [Table 1]. The most common type of AA is patchy AA of the scalp, beard, and scalp and beard followed by ophiasis, alopecia totalis, and alopecia universalis, respectively. Regarding duration, most cases had a duration of less than 10 months. Regarding treatment, the most common cases were treated by topical steroid followed by intralesional steroid and narrow band UVB (NBUVB) [Table 2]. There was statistically significant increase of serum PRL level in patients (group I) compared with controls (group II) [Table 3]. Also, there is no statistically significant difference in prolactin level regarding sex, onset, and course of the disease. There is significant positive correlation between serum prolactin level and size of the lesion, whereas nonsignificant positive correlation existed with each of age and duration of the disease [Table 4]. Regarding sensitivity and specificity for PRL to diagnosis patients versus control: at a cutoff value of serum PRL 14.06 ng/ml, the sensitivity was 88%, specificity 92%, positive predictive value 91%, and negative predictive value 88.4% [Table 5].
|Table 1: Statistical comparison between the studied groups regarding age and sex|
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|Table 2: Clinical characteristics of alopecia areata among the studied patients (n=25)|
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|Table 3: Statistical comparison between the studied groups regarding serum prolactin level|
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|Table 4: Correlation coefficient between serum prolactin and each of age, duration of disease, and size of lesion in alopecia areata patients (n=25)|
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|Table 5: Validity test of serum prolactin to differentiate alopecia areata patients from controls|
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| Discussion|| |
AA is characterized by areas of nonscarring hair loss that range from a single oval patch to multiple patches. AA affects about 0.1–0.2% of the general population. High serum PRL levels are observed in AA patients . Therefore, it is possible that in addition to the involvement of PRL in metabolic syndrome, PRL may also directly affect pathogenesis of AA . The aim of this study was to evaluate the value of elevated serum PRL levels as a diagnostic marker in AA. For this purpose, 50 patients were included in this study classified into two groups: group I included 25 patients with AA and group II included 25 age-matched and sex-matched healthy persons as controls. Among AA patients, the majority of them were men (60%) but in the control group (60%) were women. The duration of their disease ranged from 1 week to 36 months, with no significant difference between both groups regarding either age or sex. This agrees with the study ofBilgic et al. , in which the mean age did not differ significantly between patients and controls. In the Lyakhovitsky et al.  study, there were 51.4% women and 48.6% men, with a female to male ratio of 1.06: 1 participant, age ranged from 50 to 78 years, with a median age of 58 years. This study found that the most common site of the lesions was in the scalp (56%) followed by beard (24%), while alopecia totalis and alopecia universalis were present in 8 and 4%, respectively. This is in line with the study of Tan et al. , who concluded that AA affects anywhere on the hair bearing skin; the scalp is the most common site (90%). Kyriakis et al. , found that the main presenting complaint was AA of the beard (50.5%), scalp (39.3%), beard and scalp (9.2%), and AA of the eyebrow (1.0%).
Lyakhovitsky et al.  found that the most prevalent clinical pattern was patchy disease (22/29; 75.9%), of whom 18 (62.1%) had multifocal patchy disease and four (13.8%) had mild patchy disease. Other clinical AA patterns were less frequent.
Topical corticosteroid is supposed to be the first choice for the treatment of patchy hair loss of limited extent . Patients of the present study are treated by topical corticosteroid followed by intralesional steroid and NBUVB. Lyakhovitsky et al. , reported that all of the study participiants had been treated, and all received topical corticosteroids. Other treatments included intralesional corticosteroid, minoxidil, dithranol, topical psoralen, ultraviolet A phototherapy, and systemic corticosteroid. For six (20.7%) participants, topical corticosteroid was the sole treatment. The rest receive multiple treatments, mostly topical and only four patients receive systemic corticosteroid. Also, Ross and Shapiro  reported that for circumscribed AA involving less than 50% of the scalp, intralesional corticosteroids are the first-line approach. Response rates of 64 and 97% using triamcinolone acetonide and triamcinolone hexaacetonide, respectively, have been reported.
In the present study, the serum prolactin levels in our AA patients were significantly higher compared with controls (P < 0.05). Also, there is significant positive correlation between serum prolactin level and the size of the lesion whereas no significant positive correlation existed with the duration of the disease. This agrees with the results of Elsherief et al.  and Ganzetti et al. .
Elsherief et al. , found that the serum prolactin level was significantly higher in patients than controls and no significant difference was found in patient serum prolactin with their age, sex, and disease duration; however there was a significant correlation between the type of alopecia and serum prolactin. They concluded that prolactin may play a role in the pathogenesis of AA, psoriasis, and vitiligo. Prolactin may serve as a biological marker of disease activity in patients with psoriasis and AA.
Gilhar et al. , found that there was no significant difference between patients and control. Also, no significant correlation was found between prolactin level and each of age, sex, and activity of AA.
Foitzik et al. , reported that the human skin, particularly hair follicles are both direct extra-mammary targets and extra-pitutary sources of PRL. PRL has been suggested to act as an autocrine hair growth modulator with catagen-promoting functions and may serve as a hair growth-inhibitory hormone.
The present study showed that there was no significant statistical difference in serum prolactin levels between male and female patients. This agrees with the result of Burak et al. , who found that there were no statistically significant differences between a sex-based subgroup analysis.
In this study, there is no significant difference in the serum prolactin level regarding the onset or course of AA. At a cutoff value of serum prolactin level of 14.00 ng/ml to diagnose AA patients from controls, the sensitivity is 88%, specificity 92%, positive predictive value 0.91%, negative predictive value 88.4%, with an accuracy of 84.33%.
El Tahlawi et al. , performed receiver operating characteristic analysis to determine the cutoff limit for the prolactin receptor level that would differentiate between normal and AA skin. At a cutoff point of 25.6 pg/ml, the sensitivity was 83.3%, and specificity was 50%.
Also Burak et al. , did not find a significant difference in the serum prolactin level between AA patients and controls, but found that the mean tissue level of the prolactin receptor was significantly higher in the lesional skin of the patients compared with the normal skin of the controls.
| Conclusion|| |
From this study we can conclude that serum PRL levels were significantly elevated in AA patients compared with healthy controls. The levels were correlated with clinical severity in patients with AA. Therefore, the serum PRL level can be used as a diagnostic biomarker for evaluating the clinical status of AA patients. Another study on a larger population is necessary to confirm the relationship between serum PRL levels and AA.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]