Postpy Dermatologii i Alergologii 5, October / 2013 282

Address for correspondence: Katarzyna Siniewicz-Luzeczyk, Department of Pediatrics, Preventive Cardiology and Immunology,
Military Medical Department, Medical University, 281/289 Rzgowska St, 93-338 Lodz, Poland, phone: +48 42 271 20 15, fax: +48 42 271 20 15,
e-mail: [email protected], [email protected]
Received: 8.02.2013, accepted: 23.05.2013.
Correlation between serum interleukin-31 level and
the severity of disease in children with atopic dermatitis
Katarzyna Siniewicz-Luzeczyk, Anna Staczyk-Przyuska, Krzysztof Zeman
Department of Pediatrics, Preventive Cardiology and Immunology, Medical University of Lodz, Poland
Head of Department: Prof. Krzysztof Zeman MD, PhD
Postep Derm Alergol 2013; XXX, 5: 282285
DOI: 10.5114/pdia.2013.38356
Original paper
Abst r act
Introduction: Atopic dermatitis (AD) is a chronic inflammatory skin disease, characterized by intense itch, typical local-
ization and a specific image of skin lesions. Pathogenesis of pruritus in AD is not fully understood, but recent stud-
ies emphasize the role of interleukin-31 (IL-31). This relatively recently described cytokine is considered to be a poten-
tial mediator inducing pruritus in AD.
Aim: To assess the correlation of serum IL-31 level and the disease severity in children with AD.
Material and methods: Twenty-five children (16 girls and 9 boys) with AD aged from 4 months to 17 years (mean age:
4.2 years) were enrolled in the study. Disease severity in children with AD was assessed using the SCORAD (Severity
SCORing of Atopic Dermatitis) index. Serum IL-31 levels were measured using ELISA with standard kits from EIAab R&D
Systems.
Results: Serum IL-31 level was significantly higher in AD children than in healthy children. There was no statistic correla-
tion between serum IL-31 level and the disease severity or itch intensity.
Conclusions: The disease severity and itch intensity do not correlate with serum IL-31 level in children with atopic dermatitis.
Key words: atopic dermatitis, interleukin 31, SCORAD, pruritus, children.
Introduction
Atopic dermatitis (AD) is a chronic, relapsing and pru-
ritic inflammatory skin disease, characterized by typical
localization and a specific image of skin lesions, with coex-
istence of other atopic diseases. Diagnostic criteria for AD
elaborated by Hanifin and Rajka have been universally
accepted, due to a large variety of the clinical picture [1].
Pruritus is one of the most common symptoms in AD,
practically occurring in each patient. Therefore, it has been
included as one of the four major diagnostic criteria [1, 2].
Scoring the intensity of pruritus is an integral part of the
SCORAD (Severity SCORing of Atopic Dermatitis) index, which
is commonly used to determine the severity of the disease
[3]. The etiology of pruritus in AD is not fully explained, how-
ever the participation of some endogenous mediators, neu-
rotransmitters, arachidonic derivatives and cytokines has
been taken into consideration in itch pathophysiology [4].
Recently, in numerous studies, interleukin-31 (IL-31) has been
associated with the pathogenesis of pruritus in chronic
inflammatory skin diseases [5]. This relatively newly de scri -
bed cytokine is preferentially produced by activated T cells
skewed towards Th2 [6]. Interleukin-31 is related to the
IL-6 cytokine family [7]. It signals through a heterodimeric
receptor composed of IL-31 receptor (IL-31RA) also known
as gp130-like receptor (GPL) and oncostatin M receptor
(OSMR) [6, 8, 9]. Dillon et al. demonstrated the development
of severe pruritus and skin lesions similar to AD in transgenic
mice with overexpression of IL-31 [7]. Other studies revealed
that IL-31 serum levels are higher in patients with AD com-
paring to healthy controls [10]. Moreover, serum IL-31 lev-
els correlate with the disease activity in atopic patients [11].
Evidence of the importance of IL-31 in the pathogenesis of
pruritus is also present in studies on IL-31 inhibitors relevant
to the treatment of AD [12, 13].
Aim
The aim of the study was to assess the correlation
between serum IL-31 levels and the disease severity in
patients with AD.
Postpy Dermatologii i Alergologii 5, October / 2013 283
Material and methods
Twenty-five children (16 girls and 9 boys) with AD aged
from 4 months to 17 years (mean age: 4.2 years) were en -
rolled in the study. The control group (CG) consisted of
20 healthy children diagnosed due to recurrent diseases
of the respiratory tract with no immunodeficiencies,
atopic and dermatological diseases with accompanying pru-
ritus. Atopic dermatitis was diagnosed according to criteria
proposed by Hanifin and Rajka [1]. Disease severity was
determined using the SCORAD (Severity SCORing of
Atopic Dermatitis) index including subjective symptoms,
extent and intensity of the lesions. Subjective itch inten-
sity was measured using a patient/parent-reported 0-10
scale (0: no pruritus, 10: extremely severe pruritus). Six-
teen children had moderate AD (SCORAD index 25-50) and
9 children had severe AD (SCORAD index over 50). Children
included in the study were hospitalized in the Department
of Pediatrics, Immunology and Nephrology of the Polish
Mothers Research Memorial Institute in Lodz in 2011-2012.
Serum IL-31 levels were measured using ELISA with stan-
dard kits from EIAab R&D Systems. Serum was stored at
30C until assayed. All analyses were performed according
to the manufacturers protocol. The tests were performed in
the immunological laboratory APC Medical Analysis in Lodz.
Statistical analysis
The statistical analysis was performed with the use
of Statistica programme 10.0PL (StatSoft, Poland). The
data were presented as a median value and interquar-
tile range (IQR) or as a mean value and standard error
(SE) according to the normal distribution and the num-
ber of patients in the group. Normal distribution was
tested with Shapiro-Wilk test, accepting p < 0.05 as the
value different from normal distribution. In all cases, sta-
tistically significant probability of error (p) was con-
sidered as less than 0.05. Correlations between serum
IL-31 level in the study and control groups and the disease
severity in AD patients were assessed using UMann-Whit-
ney test. The Spearman rank test was used to evaluate
the relationship between serum levels of IL-31 and itch
intensity.
Results
Serum IL-31 levels in both groups
Table 1 shows the median and quartile values of serum
IL-31 level in both groups. We found significant differences
between the group of patients with AD and CG (Figure 1).
The statistical analysis showed that serum IL-31 level
was significantly higher in AD than in the control group
(AD vs. CG, p < 0.000001).
Correlation between serum IL-31 level and the disease
severity
Serum IL-31 level was inversely correlated with the
disease severity by SCORAD index (p = 0.1). The test
result close to 0.1, and Figure 2 showing the median and
quartile values in the group of patients with severe AD
(SCORAD > 50 points) and moderate AD (SCORAD 25
50 points) are suggestive of a small number of patients
in groups.
Table 1. The median and quartile values of serum IL-31 level in AD and healthy children (CG). Significant differences be-
tween research groups were found
Group Concentration of IL-31
Q25 Median Q75
Control 8.1300 17.3200 35.9100
Atopic dermatitis 309.0000 350.6000 412.5000
All 19.8800 252.2000 350.9000
Figure 1. Comparison of the median and quartil values of
serum IL-31 levels between the group of patients with AD
and the control group
C
o
n
c
e
n
t
r
a
t
i
o
n

o
f

I
L
-
3
1

[
p
g
/
m
l
]
600
500
400
300
200
100
0
Atopic dermatitis Control group
Correlation between serum interleukin-31 level and the severity of disease in children with atopic dermatitis
Postpy Dermatologii i Alergologii 5, October / 2013 284
Correlation between serum IL-31 level and itch
intensity
Serum cytokine level was not significantly correlated
with itch intensity in patients with AD (p = 0.372), as shown
in Table 2.
Discussion
In the present study, we have shown that serum IL-31
level was higher in children with AD than in healthy patients,
which is consistent with the results given by other
authors. There are numerous reports in the literature indi-
cating the involvement of IL-31 in the pathogenesis of AD.
Sonokoly et al. and Raap et al., as one of the first,
achieved significantly higher serum IL-31 levels in the group
of patients with AD [11]. Similar results were obtained by
Ezzat et al. and Kim et al., comparing serum IL-31 levels in
AD patients with healthy ones. Analysis of serum IL-31 lev-
els were performed in both cases using ELISA method,
obtaining significantly higher results in AD patients [14, 15].
Nobbe et al. demonstrated increased immunoreactivity of
IL-31 in infiltrating inflammatory cells in AD compared with
pruritic or Th2-mediated diseases [16]. Szegedi et al.
proved that T cells in chronic AD skin produce IL-31 and that
AD lesions contain increased levels of these IL-31-pro-
ducing T cells [17].
In this study there was no correlation between the sever-
ity of the disease and serum IL-31 levels, which may be part-
ly consistent with Neiss et al.s study, who found statisti-
cally increased mRNA levels of IL-31 in biopsy specimens
of patients with AD, irrespective of the disease severity [18].
Similar reports with presented results can also be found
in the literature.
Ezzat et al. show a positive correlation by classifying
patients into three groups: severe, moderate and mild AD
[14]. Kim et al. point out to a positive correlation and a strong
interrelation between serum levels of IL-31, the degree of
the disease severity and mRNA level for this cytokine in
skin biopsies of patients with AD [15].
In the present study we have also shown no correla-
tion between itch intensity and serum level of tested
cytokine in AD patients. Kim et al. obtained different results
and demonstrated a correlation between subjective itch
intensity and serum IL-31 levels, what was suggestive of
a possible involvement of IL-31 as a mediator inducing not
only inflammation, but also pruritus in AD.
Important factors in the analysis of the presented results
are subjectivity of pruritus severity assessment and the num-
ber of the research groups. Studies performed on a mouse
model of dermatitis using a monoclonal antibody neu-
tralizing the effects of IL-31 are promising, due to no con-
clusive results that indicate a role of IL-31 not only in the
process of itching, but also its intensity. Studies show a sig-
nificant reduction in itching and inflammatory symptoms
[19]. Venereau et al. generated in experimental studies and
gave a description of the potential antagonist for IL-31
formed by external portions of oncostatinM receptor (OSMR)
and gp130-like receptor (GPL) fused with a linker, which neu-
tralized activity of IL-31 in different bioassays [13].
Certainly, further research on the pathomechanism of
pruritus in atopic dermatitis is warranted for the complete
understanding of the relations described in the literature.
Conclusions
Serum IL-31 level was significantly higher in AD than
in healthy children. There was no correlation between the
disease severity, itch intensity and serum level of the test-
ed cytokine.
Acknowledgments
Work funded by the Medical University of Lodz with
research task No. 502-03/5-047-01/502-54-048.
Table 2. Correlation of itch intensity with serum IL-31 level
Pair of variables N Spearman R t (N 2) Value of p
Itch and IL-31 25 0.186388 0.909828 0.372349
C
o
n
c
e
n
t
r
a
t
i
o
n

o
f

I
L
-
3
1

[
p
g
/
m
l
]
600
500
400
300
200
100
0
Atopic dermatitis Control group
Figure 2. Comparison of IL-31 level in patients with severe
AD (SCORAD > 50) and moderate AD (SCORAD 2550)
Katarzyna Siniewicz-Luzeczyk, Anna Staczyk-Przyuska, Krzysztof Zeman
Postpy Dermatologii i Alergologii 5, October / 2013 285
References
1. Hanifin JM, Rajka G. Diagnostic features of atopic dermati-
tis. Acta Dermatol Venereol (Stockh) 1980; 92 Suppl.: 44-7.
2. Hanifin JM, Thurston M, Omoto M, et al. The eczema area and
severity index (EASI): assessment of reliability in atopic der-
matitis. EASI Evaluator Group. Exp Dermatol 1994; 10: 11-8.
3. European Task Force on Atopic Dermatitis. Severity scoring
of atopic dermatitis: the SCORAD index. Dermatology 1993;
186: 23-31.
4. Stnder S, Steinhoff M. Pathophysiology of pruritus in atopic
dermatitis: an overview. Exp Dermatol 2002; 11: 12-24.
5. Castellani ML, Salini V, Frydas S, et al. Interleukin-31: A new
cytokine involved in inflammation of the skin. Int J Im -
munopathol Pharmacol 2006; 19: 1-4.
6. Heinrich PC, Behrmann I, Haan S, et al. Principles of inter-
leukin (IL)-6-type cytokine signalling and its regulation.
Biochem J 2003; 374: 1-20.
7. Dillon SR, Sprecher C, Hammond A, et al. Intreleukin 31,
a cytokine produced by activated T cells, induces dermatitis
in mice. Nat Immunol 2004; 5: 752-60.
8. Ghilardi N, Li J, Hongo JA, et al. A novel type I cytokine recep-
tor is expressed on monocytes, signals proliferation, and
activates STAT-3 and STAT-5. J Biol Chem 2002; 277: 16831-6.
9. Yamaoka K, Okayama Y, Kaminuma O, et al. Proteomic ap -
proach to FcepsilonRI aggregation-initiated signal trans-
duction cascade in human mast cells. Int Arch Allergy Im -
munol 2009; 149: 73-6.
10. Nobbe S, Dziunycz P, Mhleisen B, et al. IL-31 expression by
inflammatory cells is preferentially elevated in atopic der-
matitis. Acta Derm Venereol 2012; 92: 24-8.
11. Raap U, Wichmann K, Bruder M, et al. Correlation of IL-31
serum levels with severity of atopic dermatitis. J Allergy Clin
Immunol 2008; 122: 421-3.
12. Metz S, Naeth G, Heinrich PC, et al. Novel inhibitors for
murine and human leukemia inhibitory factor based on
fused soluble receptors. J Biol Chem 2008; 283: 5985-95.
13. Venereau E, Diveu C, Grimaud L, et al. Definition and char-
acterization of an inhibitor for interleukin-31. J Biol Chem
2010; 285: 14955-63.
14. Ezzat MH, Hasan ZE, Shaheen KY. Serum measurement of
interleukin-31 (IL-31) in paediatric atopic dermatitis: elevat-
ed levels correlate with severity scoring. J Eur Acad Derma-
tol Venereol 2011; 25: 334-9.
15. Kim S, Kim HJ, Yang HS, et al. IL-31 serum protein and tissue
mRNA levels in patients with atopic dermatitis. Ann Der-
matol 2011; 23: 468-73.
16. Nobbe S, Dziunycz P, Mhleisen B, et al. IL-31 expression by
inflammatory cells is preferentially elevated in atopic der-
matitis. Acta Derm Venereol 2012; 92: 24-8.
17. Szegedi K, Kremer AE, Kezic S, et al. Increased frequencies
of IL-31-producing T cells are found in chronic atopic der-
matitis skin. Exp Dermatol 2012; 21: 431-6.
18. Neiss MM, Peters B, Dreuw A, et al. Enhanced expression lev-
els of IL-31 correlate with IL-4 and IL-13 in atopic and allergic
contact dermatitis. J Allergy Clin Immunol 2006; 118: 930-7.
19. Grimstad O, Sawanobori Y, Vestergaard C, et al. Anti-inter-
leukin-31-antibodies ameliorate scratching behaviour in
NC/Nga mice: a model of atopic dermatitis. Exp Dermatol
2009; 18: 35-43.
Correlation between serum interleukin-31 level and the severity of disease in children with atopic dermatitis