Research JAMA Dermatology | Original Investigation Clinical Significance of Serum Soluble CD Molecules to Assess Disease Activity in Vitiligo Reinhart Speeckaert, MD, PhD; Jo Lambert, MD, PhD; Nanja van Geel, MD, PhD Editorial page 1187 IMPORTANCE It is difficult to determine disease activity in vitiligo owing to the absence of inflammatory signs, such as erythema or scaling. A biomarker that could confirm active disease and indicate likely future disease progression would therefore be of considerable value. OBJECTIVE To investigate whether soluble CD27 (sCD27), sCD25, or sCD40L could be valuable biomarkers to determine disease activity in vitiligo and indicate likely future progression. DESIGN, SETTING, AND PARTICIPANTS A combined cross-sectional and prospective study was conducted at the department of dermatology at Ghent University Hospital between February 24, 2012, and December 12, 2015. Ninety-three patients with vitiligo were enrolled, including 83 individuals with nonsegmental vitiligo and 10 with segmental vitiligo. Blood sampling was performed, and sCD25, sCD27, and sCD40L were measured in serum. MAIN OUTCOMES AND MEASURES The associations between sCD levels, disease activity, and future progression were investigated. RESULTS Of the 93 patients included in the study, 51 were women (55%); median (interquartile range) age was 36.5 (26.0-49.8) years. Both sCD27 (21.5 ng/mL [16.1-30.0 ng/mL] vs 18.4 ng/mL [12.5-22.1 ng/mL]; P = .006) and sCD25 (2.6 ng/mL [2.1-3.4 ng/mL] vs 2.2 ng/mL [1.7-2.4 ng/mL]; P = .002) levels were associated with active disease. Moreover, a statistically significant link with disease progression after 3 to 6 months was found for sCD27 (21.7 [17.0-29.1] vs 16.6 [13.5-23.7]; P = .02) but not for sCD25 (2.8 ng/mL [2.2-3.4 ng/mL] vs 2.3 [1.9-2.8 ng/mL]; P = .053). Further in vitro experiments showed a correlation between sCD25 and interferon γ (r = 0.562, P = .005), interleukin 10 (r = 0.453, P = .03), and sCD27 secretion (r = 0.549, P = .007). No associations were found for sCD40L levels. CONCLUSIONS AND RELEVANCE This study demonstrates increased levels of sCD27 and sCD25 in patients with active vitiligo. Moreover, these results provide the first evidence that these markers have a capacity to indicate the probability of future disease progression, which supports their role as biomarkers in vitiligo. Author Affiliations: Department of Dermatology, Ghent University Hospital, Ghent, Belgium. Corresponding Author: Reinhart Speeckaert, MD, PhD, Department of Dermatology, Ghent University Hospital, De Pintelaan 185, 9000 JAMA Dermatol. 2016;152(11):1194-1200. doi:10.1001/jamadermatol.2016.2366 Ghent, Belgium (reinhart.speeckaert Published online August 24, 2016. @ugent.be). 1194 (Reprinted) jamadermatology.com Copyright 2016 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Serum Soluble CD Molecules Associated With Vitiligo Original Investigation Research imited evidence is available on circulating markers that are linked to progressive vitiligo. Nonetheless, because Key Points an increased extent of vitiligo is associated with im- L Question Are serum soluble CD (sCD) levels associated with paired quality of life, adequate identification of disease disease activity in vitiligo? activity is crucial for therapeutic management.1 Several asso- Findings In this cross-sectional study of 93 patients with vitiligo, ciations between immunologic markers and vitiligo activity serum sCD25 and sCD27 were significantly linked with disease have been reported2 investigating the protein, RNA, and mi- activity in vitiligo. Moreover, sCD27 was associated with a capacity croRNA levels. Most studies are hampered by limited patient to indicate probable future disease progression. size and lack prospective follow-up. The link between soluble Meaning This study supports the role of sCD25 and sCD27 as CD (sCD) molecules and several autoimmune disorders is well biomarkers to assess vitiligo activity and indicate likely future established.3 Soluble CD molecules are shed from activated and progression. proliferating lymphocytes, which makes them useful mark- ers to confirm immunologic activity. Signaling of CD25 (also termed IL-2 receptor) is a critical The mean affected body surface area was 4.47% (median, 1.5% factor in maintaining T-cell tolerance, especially regarding regu- [IQR, 0.5%-5.0%]). The participants’ clinical characteristics are latory T-cell development.4 In general, sCD25 is relatively stable summarized in Table 1. Patients receiving no therapy or ap- over time, which makes it an attractive target to study inflam- plying topical formulations (excluding UV-B treatment) were matory disorders. Conflicting evidence exists as to whether enrolled. Patients who had received no treatment during 3 sCD25 is a marker of disease activity in vitiligo.5-7 Therefore, months before blood analysis were considered as untreated. additional research is needed on this topic, especially con- The study was approved by the ethics committee of Ghent sidering the lack of prospective follow-up in all previously University Hospital. All patients signed written informed performed studies. consent; no financial compensation was provided. A transmembrane protein, CD27 is expressed on T, B, and natural killer cells and belongs to the tumor necrosis factor re- Assessment of Disease Activity ceptor family. With binding to its ligand (CD70), CD27 en- Patient-reported disease activity was evaluated by using a ques- sures lymphocyte survival, increased T-cell proliferation, and tionnaire assessing disease activity, stability, and repigmen- memory cell formation. Its expression supports helper T-cell tation during the past 3, 6, or 12 months. Disease activity was type 1 (TH1) development. Soluble CD27 is released from the assessed by the physician and classified into 4 categories: very cell surface of activated lymphocytes by shedding that is in- active, moderate or low active, stable disease, and repigmen- duced by metalloproteinases or by differential splicing of the tation. This categorization was accomplished using digital fol- receptor protein. Increased levels have been found8 in sys- low-up photographs taken with or without a Wood lamp and temic lupus erythematosus, celiac disease, viral infections, and clinical examination. Furthermore, subsequent disease evo- lymphoid cancers, although, to our knowledge, it has never lution was investigated during a follow-up consultation after been studied in vitiligo. 6 to 12 months. The CD40-CD40L pathway is involved in multiple auto- Blood sampling was performed, and sCD25, sCD27, and immune disorders, such as thyroiditis, psoriasis, rheumatoid sCD40L (R&D Systems) were measured in serum using a com- arthritis, Sjögren syndrome, and systemic lupus erythemato- mercial kit (Human Fluorokine MAP Base Kit; R&D Systems). Fur- sus. In addition, CD40L is expressed on a variety of immune ther in vitro experiments were performed to investigate the as- cells and, after CD40-CD40L ligation, induces activation of T sociation between soluble CD release and cytokine production. and B lymphocytes. Furthermore, CD40-CD40L interaction Briefly,peripheral blood mononuclear cells obtained from 10 pa- leads to maturation of dendritic cells toward an antigen- tients with vitiligo and 10 healthy individuals serving as controls presenting phenotype.9,10 The purpose of this study was to in- were stimulated with anti-CD3/CD28 beads; supernatant was har- vestigate whether sCD27, sCD25, and sCD40L could be useful vested after 3 days for measuring sCD25 and sCD27. biomarkers to determine disease activity in vitiligo and indi- cate probable future progression. Statistical Analysis For comparison between nonparametric variables, the Mann- Whitney test or Kruskal-Wallis test was used. P < .05 was con- Methods sidered to indicate statistical significance. Adjustment for pos- sible confounding factors (use of treatment) was performed Participants using multivariate linear regression models in case of a con- Ninety-three patients with vitiligo were enrolled in this com- tinuous dependent variable and logistic regression in case of bined, cross-sectional, prospective study at the Department a dichotomous dependent variable. The Wald statistic in lo- of Dermatology at Ghent University Hospital, Ghent, Bel- gistic regression was also calculated. For correlation analysis, gium, between February 24, 2012, and December 12, 2015. Pearson correlation was conducted. Receiver operating char- Eighty-three patients with nonsegmental vitiligo and 10 acteristic (ROC) analysis was performed to determine the individuals with segmental vitiligo were included; 51 women sensitivity and specificity of sCD25 and sCD27 and the area (55%) and 42 men (45%) with a median age of 39.5 years (in- under the ROC curve. All statistical analyses were performed terquartile range [IQR], 27.0-52.8) participated in this study. using SPSS, version 23.0 (SPSS Science). jamadermatology.com (Reprinted) JAMA Dermatology November 2016 Volume 152, Number 11 1195 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Research Original Investigation Serum Soluble CD Molecules Associated With Vitiligo [12.5-22.1 ng/mL]; P = .006) (Figure 1B). Accordingly, higher Table 1. Clinical Characteristics sCD27 values were found in patients with active vitiligo (20.6 Characteristic No./Total No. (%) ng/mL [15.8-30.2 ng/mL] vs 18.4 ng/mL [13.6-24.2 ng/mL]; Vitiligo