10.5826/dpc.1302a118
Introduction:  Alopecia areata (AA) is a non-cicatricial inflammatory and autoimmune hair loss disease. In recent studies, it has been reported that hematological parameters can be used as oxidative stress markers in the diagnosis of many inflammatory diseases due to their low cost and widespread use.
Objectives: In this study, it was aimed to reveal the significant cut-off points of hematological inflammatory markers in AA that can guide clinicians in clinical practice and determine how many times they increase the risk of disease.
Methods: The present study is retrospective case-control type. Seventy patients with AA and seventy healthy controls were included in the study. The hematological parameters in both groups were evaluated retrospectively.
Results: Hemoglobulin, monocyte, platelet, monocyte high-density lipoprotein cholesterol (HDL-C) ratio (MHR), monocyte lymphocyte ratio (MLR), platelet lymphocyte ratio (PLR) were high in patients with AA, while the number of lymphocytes was low.  In ROC analysis, the optimal cut-off values for the diagnosis of AA were as follows: MLR 0.216, MHR 0.010, and PLR 111.715. In regression analysis, being above the following values of MLR 0.216, MHR 0.010, and PLR 111.715 increased the risk of developing AA by 6.3, 3.8, and 2.7 times, respectively.
Conclusions: It was seen that MHR and PLR, especially MLR, can significantly increase the risk of developing the disease in AA and can also be used as diagnostic markers.
text/xml
2160-9381
2735
en
Didem Dincer Rota
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Marker
The Use of New Hematological Markers in the Diagnosis of Alopecia Areata
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-04-29
2022-08-01
2023-04-29
2023-06-05
e2023118
Dermatol Pract Concept
Introduction:  Alopecia areata (AA) is a non-cicatricial inflammatory and autoimmune hair loss disease. In recent studies, it has been reported that hematological parameters can be used as oxidative stress markers in the diagnosis of many inflammatory diseases due to their low cost and widespread use.
Objectives: In this study, it was aimed to reveal the significant cut-off points of hematological inflammatory markers in AA that can guide clinicians in clinical practice and determine how many times they increase the risk of disease.
Methods: The present study is retrospective case-control type. Seventy patients with AA and seventy healthy controls were included in the study. The hematological parameters in both groups were evaluated retrospectively.
Results: Hemoglobulin, monocyte, platelet, monocyte high-density lipoprotein cholesterol (HDL-C) ratio (MHR), monocyte lymphocyte ratio (MLR), platelet lymphocyte ratio (PLR) were high in patients with AA, while the number of lymphocytes was low.  In ROC analysis, the optimal cut-off values for the diagnosis of AA were as follows: MLR 0.216, MHR 0.010, and PLR 111.715. In regression analysis, being above the following values of MLR 0.216, MHR 0.010, and PLR 111.715 increased the risk of developing AA by 6.3, 3.8, and 2.7 times, respectively.
Conclusions: It was seen that MHR and PLR, especially MLR, can significantly increase the risk of developing the disease in AA and can also be used as diagnostic markers.
Didem Dincer Rota
2023/04/29
10.5826/dpc.1302a118
e2023118
Ufuk University Faculty of Medicine Department of Dermatology, Ankara, Turkey
2160-9381
Marker
en
e2023118
Cosansu NC, Dikicier BS, Yaldiz M, Solak B. Is There Any Association Between the Monocyte/Lymphocyte Ratio and the Presence and Severity of the Disease in Patients with Psoriasis? Sak Tıp Derg. 2020;10(3):430-436. DOI: 10.31832/smj.719980.
The Use of New Hematological Markers in the Diagnosis of Alopecia Areata
https://dpcj.org/index.php/dpc/article/download/2735/2061
       The Use of New Hematological Markers in the
               Diagnosis of Alopecia Areata
              Gulhan Aksoy Sarac1, Onur Acar 2, Tufan Nayır3, Pınar Hararcı Yıldırım1,
                                      Didem Dinçer Rota1


1 Ufuk University Faculty of Medicine Department of Dermatology, Ankara, Turkey
2 Ağrı Provincial Health Directorate, Republic of Turkey, Ministry of Health, Ağrı, Turkey
3 Turkish Ministry of Health, Ankara, Turkey



Key words: alopecia areata, monocyte lymphocyte ratio (MLR), ROC analysis, marker
Citation: Aksoy Sarac G, Acar O, Nayir T, Hararcı Yıldırım P, Dinçer Rota D. The Use of New Hematological Markers in the Diagnosis of
Alopecia Areata. Dermatol Pract Concept. 2023;13(2):e2023118. DOI: https://doi.org/10.5826/dpc.1302a118
Accepted: November 16, 2022; Published: April 2023
Copyright: ©2023 Aksoy Sarac et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Onur Acar, MD, Ağrı Provincial Health Directorate, Republic of Turkey, Ministry of Health, Ağrı, Turkey.
Tel: +90 5062341595 ORCID ID: https://orcid.org/0000-0003-3561-3192 E-mail: dronuracar@yandex.com




  ABSTRACT             Introduction: Alopecia areata (AA) is a non-cicatricial inflammatory and autoimmune hair loss disease.
                       In recent studies, it has been reported that hematological parameters can be used as oxidative stress
                       markers in the diagnosis of many inflammatory diseases due to their low cost and widespread use.
                       Objectives: In this study, it was aimed to reveal the significant cut-off points of hematological inflam-
                       matory markers in AA that can guide clinicians in clinical practice and determine how many times they
                       increase the risk of disease.
                       Methods: The present study is retrospective case-control type. Seventy patients with AA and seventy
                       healthy controls were included in the study. The hematological parameters in both groups were eval-
                       uated retrospectively.
                       Results: Hemoglobulin, monocyte, platelet, monocyte high-density lipoprotein cholesterol (HDL-C)
                       ratio (MHR), monocyte lymphocyte ratio (MLR), platelet lymphocyte ratio (PLR) were high in pa-
                       tients with AA, while the number of lymphocytes was low. In ROC analysis, the optimal cut-off values
                       for the diagnosis of AA were as follows: MLR 0.216, MHR 0.010, and PLR 111.715. In regression
                       analysis, being above the following values of MLR 0.216, MHR 0.010, and PLR 111.715 increased
                       the risk of developing AA by 6.3, 3.8, and 2.7 times, respectively.
                       Conclusions: It was seen that MHR and PLR, especially MLR, can significantly increase the risk of
                       developing the disease in AA and can also be used as diagnostic markers.




Original Article | Dermatol Pract Concept. 2023;13(2):e2023118                                                                        1
Introduction                                                        outpatient clinic between June 2020 and June 2021 and
                                                                    healthy controls with no previous history of AA. Ethics com-
Alopecia areata (AA) is an inflammatory and autoimmune dis-         mittee approval of the study was received from Local Ethics
ease clinically ranging from small, round, well-defined hair loss   Committee. Demographic characteristics and laboratory val-
patch to its complete disappearance on the body and scalp [1].      ues were obtained from the database of the health center for
The incidence of AA, which is a non-scarring disease in which       both the case and control groups. Demographic data include
the hair follicle is preserved, is 2% [2]. The mean age at di-      age, gender, duration of illness (months). Laboratory data
agnosis of AA, which can be seen in all age groups without          include the levels of white blood cell (WBC: K/µL), hemo-
any difference between genders, is 30-39 years [3]. The etio-       globin (Hb: g/dL), platelets (PLT: K/µL), RDW, MPV (K/µL),
pathogenesis of AA has not yet been fully elucidated. Although      neutrophils (NE: K/µL), lymphocytes (LY: K/µL), monocytes
genetics and immunity are seen as the factors that cause the        (MN: K/µL), high-density lipoprotein cholesterol (HDL-C:
most disease, many factors such as melanocyte anomalies, ke-        mg/dL), NLR, PLR, MHR, and MLR.
ratinocyte degeneration, neurological factors, and emotional           Disease severity in patients with AA was evaluated ac-
stress have also been blamed [4-6]. The disease develops as a       cording to the classification made by Kavak et al and clas-
result of T cell-mediated cytotoxic damage to the hair follicle.    sified as mild (3 or fewer patches with a diameter of 3 cm
Since IL-17A, IL17F, IL21, IL22, IL6, and TNF alpha levels          or less, or involvement limited to eyebrows and eyelashes),
are elevated in AA patients, these cytokines are thought to         moderate (more than 3 alopecic patches or involvement of
play a role in the pathogenesis [7]. In recent studies, it has      more than 3 cm without alopecia totalis or alopecia univer-
been discussed that the whole blood parameters can be used          salis), severe (alopecia totalis or alopecia universalis) [13].
as an oxidative stress and diagnostic marker in many diseases          Patients with AA who had an active infection, malnutri-
associated with inflammatory processes. In clinical practice,       tion, anemia, immunodeficiency, chronic inflammatory skin
these markers are important for objective and quantitative          disease, rheumatological disease, heart disease, and drug
evaluation of the disease process and response to treatment, as     use were excluded from the study. The laboratory values of
well as the diagnosis [8]. Red-cell distribution width (RDW),       the patients with AA at the application date were included.
monocyte high-density lipoprotein ratio (MHR), monocyte             Laboratory values of the patients with AA regarding the
lymphocyte ratio (MLR), platelet lymphocyte ratio (PLR),            follow-up and treatment couldn’t be included because they
neutrophil-lymphocyte ratio (NLR) and mean platelet volume          were absent in the hospital record. Healthy controls were
(MPV) are investigated in many dermatological diseases such         comprised of individuals without active infection, systemic
as psoriasis, rheumatological diseases of dermatology, cutane-      or dermatological disease, and drug use. Both of two groups
ous vasculitis, atopic eczema, pityriasis rosea, Behçet disease,    don’t include members who got Covid-19 infection in recent
recurrent aphthous stomatitis, and pemphigus vulgaris [9-12].       six months.
    Although there are many studies on these dermatolog-
ical diseases in the literature, studies investigating the rela-    Statistical Analysis
tionship between AA and these inflammatory markers are              The data of the study were analyzed using SPSS 20 (Statis-
limited. In addition, no studies have been found showing at         tical Package for Social Sciences). Descriptive statistics were
which cutoff point these significant inflammatory markers           given as numbers, percentages, mean and standard deviation.
start to be significant and how many times they increase the        The relationship between continuous variables was evalu-
risk of developing the disease.                                     ated with the Pearson correlation test. The t-test was used
                                                                    for continuous variables between two independent groups.
Objectives                                                          Significant cut-off points were determined using ROC
                                                                    ­
                                                                    (­Receiver operating characteristic) analysis for markers with
In this study, it was aimed to compare the levels of RDW,
                                                                    significant differences between the two groups in the t-test.
MPV, MHR, MLR, NLR, PLR between patients with AA
                                                                    The odds ratios of the cut points that were found to be caus-
and healthy controls, and to reveal the significant cut-off
                                                                    ing high activity AA were analyzed using the logistic regres-
points that can guide clinicians in clinical practice and deter-
                                                                    sion model. All findings were evaluated at a 95% confidence
mine how many times they increase the risk.
                                                                    interval (CI) and 5% significance level (P).


Methods                                                             Results
Study Design and Patient Selection                                  Seventy patients with AA and 70 healthy controls were in-
This study was conducted as a retrospective case-control            cluded in this study. The mean age was 31.57 ± 9.92 years in
study with patients with AA who applied to the dermatology          the patient group and 31.51 ± 7.37 years in the control group.



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(2):e2023118
There was no significant difference between the groups ac-            Table 1. Comparison of laboratory values of
cording to age (P = 0.969). The mean age of patients with                  patients and controls using t-test.
AA was 29.78 ± 8.58 years in men and 33.47 ± 10.98 years
                                                                          Group             N      Mean          SD        P value
in women, and the difference was not statistically significant.
                                                                    WBC
The gender distribution was the same in the patient and con-
                                                                    Patient                70       7.26        1.80        0.115
trol groups, with 36 (51.4%) men and 34 (48.6%) women.
While the mean duration of disease was 1.22 ± 2.21 months           Control                70       7.67        1.16
in men and 3.05 ± 5.43 months in women, it was 2.11 ±               Hb (g/dL)
4.17 months in the whole AA group, and there was no sig-            Patient                70      14.91        1.65        0.004
nificant difference between the genders. Of the patients with       Control                70      14.15        1.37
AA, 41 (58.6%) had mild, 12 (17.1%) had moderate, and 17            RDW (%)
(24.3%) had severe alopecia.
                                                                    Patient                70      11.95        1.67        0.026
    The laboratory findings of the patient and control groups
                                                                    Control                70      12.44        0.76
are shown in Table 1. The mean of Hb (P = 0.004), MN (P <
                                                                    MN(K/µL)
0.001), PLT (P = 0.042), MHR (P < 0.001), MLR (P < 0.001)
and PLR (P < 0.001) was higher in patients with AA com-             Patient                70       0.57        0.17       <0.001

pared to the control group, while the number of lymphocytes         Control                70       0.38        0.66
was lower (P = 0.005).                                              HDL-C (mg/dL)
    Table 2 shows the effect of laboratory parameters on            Patient                70      52.49        10.83       0.252
disease duration in patients with AA. While the increase in         Control                70      50.31        11.62
HDL-C (r = 0.324, P = 0.013), MPV (r = 0.239, P = 0.046)            NE (K/µL)
and PLR (r = 0.297, P = 0.013) in patients with AA increased
                                                                    Patient                70       4.27        1.26        0.062
the duration of the disease (positive correlation); the increase
                                                                    Control                70       4.63        0.95
in Hb (r = -0.301, P = 0.011), LY (r = -0.269, P = 0.024) and
                                                                    PLT (K/µL)
MHR (r = -0.289, P = 0.015) was a factor reducing disease
duration (negative correlation). When classified according to       Patient                70     248.81        57.91       0.042

disease severity, for those who have severe AA disease the          Control                70     229.87        50.94
increase in HDL-C (r = 0.620, p = 0.008) led to increasing          LY (K/µL)
the duration of the disease (positive correlation). Also the        Patient                70       2.21        0.80        0.005
increase in Hb (r = -0.505, P = 0.039) led to decreasing the        Control                70       2.56        0.62
duration of the disease (negative correlation). While there         MPV (K/µL)
was a positive correlation between disease severity and RDW
                                                                    Patient                70       8.06        1.22        0.252
(r = 0.242, P = 0.044) and PLR (r = 0.315, P = 0.008); a
                                                                    Control                70       8.26        0.76
negative correlation between WBC (r = -0.236, P = 0.049),
                                                                    MHR
Hb (r = -0.285, P = 0.017), MN (r = -0.270, P = 0.024) and
MHR (r = -0.356, P = 0.002) was present. There was a pos-           Patient                70      0.011        0.004      <0.001

itive, weak and very significant correlation between disease        Control                70      0.007        0.001
duration and disease severity in patients with AA (r = 0.494,       MLR
P < 0.001).                                                         Patient                70      0.281        0.111      <0.001
    Table 3 and Figure 1 show the optimal value of labo-            Control                70      0.158        0.050
ratory parameters to diagnose AA using ROC analysis. In             NLR
ROC analysis, it was found that MLR (P < 0.001), MHR
                                                                    Patient                70      2.140        0.986       0.127
(P < 0.001) and PLR (P = 0.001) values could be used as
                                                                    Control                70      1.921        0.674
a diagnostic test in AA. The cut-off values of MLR 0.216
                                                                    PLR
value (AUC = 0.873, good usefulness, 85.7% sensitivity
and 70% specificity), MHR 0.010 value (AUC = 0.759,                 Patient                70     121.461      34.492      <0.001
moderate useful, 82.9% sensitivity and 58.6% specificity),          Control                70     94.805       29.309
PLR 111.715 value (AUC = 0.727, moderate useful, 75.7%
                                                                   Hb = Hemoglobin; HDL-C = high-density lipoprotein cholesterol;
sensitivity and 58.6% specificity) were found to be useful         LY = lymphocytes; MN = monocytes; MHR = monocyte high-density
as diagnostic tests.                                               lipoprotein cholesterol ratio; MLR = monocyte lymphocyte ratio;
                                                                   MPV = mean platelet volume; NE = neutrophils;NLR = neutrophil
    Table 4 shows how many times the parameters found to           lymphocyte ratio; PLR = platelet lymphocyte ratio; PLT = platelets;
be significant in diagnosing AA in the ROC analysis increase       RDW = red-cell distribution width; WBC = white blood cell.



Original Article | Dermatol Pract Concept. 2023;13(2):e2023118                                                                       3
     Table 2. Correlation analysis between disease duration and Alopecia Areata group parameters.
                                                  Disease Duration (months)
                        Mild&Moderate Patients             Severe Patients
                              (N = 53)                        (N = 17)              All Patients (N = 70)          Disease Severity
      Variables              r                P              r            P              r            P              r          P
 WBC                       0.054            0.703         -0.223        0.390       -0.205          0.089         -0.236     0.049
 Hb                        -0.010           0.946         -0.505        0.039       -0.301          0.011         -0.285     0.017
 RDW (%)                   -0.128           0.361          0.201        0.440        0.113          0.351          0.242     0.044
 MN (K/µL)                 0.012            0.931         -0.179        0.492       -0.230          0.055         -0.270     0.024
 HDL-C (mg/dL)             0.117            0.405          0.620        0.008        0.324          0.013          0.227     0.059
 NE (K/µL)                 0.024            0.865          0.375        0.138        0.193          0.110          0.083     0.496
 PLT (K/µL)                0.304            0.027         -0.264        0.306       -0.065          0.593          0.044     0.715
 LY (K/µL)                 -0.013           0.926         -0.482        0.050       -0.269          0.024         -0.182     0.132
 MPV (K/µL)                -0.150           0.284          0.312        0.222        0.239          0.046          0.195     0.106
 MHR                       -0.079           0.574         -0.355        0.161       -0.289          0.015         -0.356     0.002
 MLR                       -0.002           0.989          0.219        0.399        0.048          0.691         -0.064     0.601
 NLR                       0.024            0.865          0.375        0.138        0.193          0.110          0.083     0.496
 PLR                       0.167            0.231          0.366        0.149        0.297          0.013          0.315     0.008

Hb = Hemoglobin; HDL-C = high-density lipoprotein cholesterol; LY = lymphocytes; MN = monocytes; MHR = monocyte high-density lipo-
protein cholesterol ratio; MLR = monocyte lymphocyte ratio; MPV = mean platelet volume; NE = neutrophils; NLR = neutrophil lymphocyte
ratio; PLR = platelet lymphocyte ratio; PLT = platelets; RDW = red-cell distribution width; WBC = white blood cell.


                                        Table 3. Findings of the ROC analysis.
    Variables     AUC (p value)          95% CI            CO           Sen (%)          Spe (%)            PLR             NLR
 MLR              0.873 (<0.001)      0.815- 0.931        0.216           85.7               70.0           2.85            0.20
 MHR              0.759 (<0.001)      0.679- 0.840        0.010           82.9               58.6            2              0.29
 PLR              0.727 (<0.001)      0.643- 0.810      111.715           75.7               58.6           1.82            0.41

AUC = Area under curve; CI = confidence interval; CO = cutoff value; MHR = monocyte high-density lipoprotein cholesterol ratio;
MLR = monocyte lymphocyte ratio; NLR = negative likelihood ratio; PLR = platelet lymphocyte ratio; PLR = positive likelihood ratio;
ROC = receiver operating characteristic; Sen = sensitivity; Spe = specifity.




the probability of catching AA at the determined cut-off val-       these diagnostic values. This study is a pioneering study in
ues in the established logistic regression model. According to      terms of answering these questions that are not yet available
the logistic regression analysis result, an MLR value of 0.216      in the literature.
and above increases the risk of developing AA by 6.30 times             AA is a non-cicatricial, autoimmune, inflammatory hair
(95% CI: 2.41-16.45 P < 0.001), an MHR value of 0.010               loss disease that has many factors in its etiology and has
and above by 3.87 times (95% CI: 1.54-9.73 P = 0.004)               various clinical manifestations [1]. There is no significant
and a PLR value of 111.715 and above by 2.76 times (95%             difference between genders in terms of incidence. However,
CI:1.06-7.17 P = 0.037).                                            it was emphasized that the most common age of onset of the
                                                                    disease was between 50-59 years of age in women and 30-39

Conclusions                                                         years in men and that the average age of diagnosis was older
                                                                    in women than in men (36.2 versus31.5 years) [14]. In this
In this study, the relationship between complete blood count        study, the mean age of patients with AA was 29.78 ± 8.58
and biochemical parameters, which can be easily used by cli-        years in men and 33.47 ± 10.98 years in women, which is
nicians in routine, and AA disease is shown in detail. There        consistent with the literature.
is a limited number of studies on the subject in the literature,        Whole blood parameters are a low-cost test and are
and it has not been investigated yet at what values hema-           widely used by clinicians. It provides important informa-
tological and inflammatory markers are diagnostic for the           tion about systemic inflammation. In this study, Hb, MN,
disease and how much they increase the risk of disease in           PLT, MHR, MLR, and PLR values were higher in patients



4                                                                        Original Article | Dermatol Pract Concept. 2023;13(2):e2023118
                                                                 ROC CURVE
              1,0
                                                                                                             SOURCE OF THE
                                                                                                                CURVE
                                                                                                               MLR
                                                                                                               MHR
              0,8                                                                                              PLR
                                                                                                               REFERENCE LINE




              0,6
SENSITIVITY




              0,4




              0,2




              0,0
                    0,0           0,2           0,4                   0,6            0,8              1,0

                                                  1 - SPECIFICITY

                                          DIAGONAL SEGMENTS ARE PRODUCED BY TIES.

 Figure 1. ROC Curve.
 MHR: Monocyte high-density lipoprotein cholesterol ratio
 MLR Monocyte lymphocyte ratio
 PLR: Platelet lymphocyte ratio


                                             Table 4. Logistic regression results.
                          Variables                              OR                    95% CI                    P value
   MLR
   0.216 and above                                          6.309                   2.419- 16.456                <0.001
   Below 0.216                                          1 (reference)
   MHR
   0.010 and above                                          3.879                   1.546- 9.732                  0.004
   Below 0.010                                          1 (reference)
   PLR
   111.715 and above                                        2.761                   1.062- 7.174                  0.037
   Below 111.715                                        1 (reference)

CI = confidence interval; MHR = monocyte high-density lipoprotein cholesterol ratio; MLR = monocyte lymphocyte ratio; PLR = platelet
lymphocyte ratio; OR = odds ratio.

with AA compared to the control group, while the num-                   and HDL-C, MPV, and PLR, and a negative correlation
ber of lymphocytes was found to be lower. In addition,                  between Hb, LY, and MHR. But, when correlation analy-
there was a positive correlation between AA durations                   sis included only severe AA patients, there was a positive



Original Article | Dermatol Pract Concept. 2023;13(2):e2023118                                                                    5
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                                                                      6. Simakou T, Butcher JP, Reid S, Henriquez FL. Alopecia areata:
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                                                                         A multifactorial autoimmune condition. J Autoimmun.
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                                                                         2019;98:74-85. DOI: 10.1016/j.jaut.2018.12.001. PMID:
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inflammatory processes in many diseases involving many                   basis of alopecia areata: a comprehensive review. Autoimmun
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                                                                         biomarkers in psoriasis. Clin Exp Dermatol. 2009;34(6):658-663.
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                                                                         psoriatic arthritis: Response to therapy with biologics. J Derma-
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sis by 3.49 times [24]. In the study by Cosansu et al, it was
                                                                           PMID: 28493493.
stated that the MLR value of 0.192 was a moderately useful           10.   Kridin K, Shihade W, Zelber-Sagi S. Mean Platelet Volume
test in the diagnosis of patients with psoriasis, and similarly,           in Pemphigus Vulgaris. Angiology. 2018;69(4):303-307.
MHR and MLR values were significant markers in the diag-                   DOI:10.1177/0003319717718329. KPMID: 28681645.
nosis of vitiligo [25,18].                                           11.   Pancar GS, Eyupoglu O. Red Cell Distribution Width and Mean
                                                                           Platelet Volume in Patients With Pityriasis Rosea. J Clin Med
    There are some limitations to this study. Firstly, since
                                                                           Res. 2016;8(6):445-448. DOI:10.14740/jocmr2535w. PMID:
it was in a retrospective style, the laboratory values of the
                                                                           27222672. PMCID: PMC4852777.
patients at the time of application were included and no             12.   Turkmen D, Altunisik N, Sener S. Investigation of monocyte
evaluation could be made regarding the follow-up data. Sec-                HDL ratio as an indicator of inflammation and complete blood
ondly, the fact that it is a single-center study, and third, the           count parameters in patients with acne vulgaris. Int J Clin
relatively small number of patients and controls may cause                 Pract. 2020;74(12):e13639. DOI:10.1111/ijcp.13639. PMID:
                                                                           32741037.
differences in findings. Fourth, it may assess as another lim-
                                                                     13.   Kavak A, Baykal C, Ozarmağan G, Akar U. HLA in alopecia
itation that The Severity of Alopecia Tool score wasn’t used
                                                                           areata. Int J Dermatol. 2000;39(8):589-592. DOI:10.1046/
when classifying the severity.                                             j.1365-4362.2000.00921.x. PMID: 10971726.
    In conclusion, in this study, MHR and PLR values, espe-          14.   Mirzoyev SA, Schrum AG, Davis MDP, Torgerson RR. Lifetime
cially MLR, were shown to be low-cost and fast-accessible                  incidence risk of alopecia areata estimated at 2.1% by Roch-
oxidative stress markers in the diagnosis of AA. It is believed            ester Epidemiology Project, 1990-2009. J Invest Dermatol.
                                                                           2014;134(4):1141-1142. DOI:10.1038/jid.2013.464. PMID:
that our results may provide important information for fur-
                                                                           2420223. PMCID: PMC3961558.
ther studies on the use of hematological markers in AA.
                                                                     15.   Ozlu E, Karadag AS, Toprak AE, et al. Evaluation of Cardiovas-
                                                                           cular Risk Factors, Haematological and Biochemical Parameters,

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Original Article | Dermatol Pract Concept. 2023;13(2):e2023118                                                                               7
