Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(2):4962 1 Systemic Inflammatory Biomarkers in Alopecia Areata: The Role of SII, SIRI, and CRP/Albumin Ratio Işıl Deniz Oğuz1, Sevgi Kulaklı 1, Burak Akşan1 1 Giresun University School of Medicine, Department of Dermatology, Giresun, Turkey Key words: Alopecia Areata, CRP/albumin ratio, Systemic Immune-Inflammation Index, Systemic Inflammation Response Index, Inflammatory Biomarkers Citation: Oğuz ID, Kulaklı S, Akşan B. Systemic Inflammatory Biomarkers in Alopecia Areata: The Role of SII, SIRI, and CRP/Albumin Ratio. Dermatol Pract Concept. 2025;15(2):4962. DOI: https://doi.org/10.5826/dpc.1502a4962 Accepted: December 11, 2024; Published: April 2025 Copyright: ©2025 Oğuz 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: Işıl Deniz Oğuz, M.D. Giresun University, Faculty of Medicine, 28000, Giresun, Turkey. ORCID ID: 0000-0001- 8628-6107. E-Mail: isildenizoguz@yahoo.com.tr, deniz.oguz@giresun.edu.tr Introduction: Alopecia areata (AA) is an autoimmune disorder, with potential roles of both genetic and environmental factors. Although AA is a specific autoimmune disease targeting hair follicles, its frequent association with other autoimmune diseases supports the notion that the autoinflammation is not confined to the hair follicles but is systemic. Systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and CRP (C-reactive protein) albumin ratio (CAR) are elevated in various diseases and correlate with disease severity. Objectives: The aim of this study was to determine SII, SIRI, and CAR levels in alopecia areata pa- tients and investigate their correlation with disease severity. Methods: The data of 118 AA patients and 122 healthy controls were analyzed. Complete blood count (CBC), CRP, and albumin values were noted during clinic visits. CAR, SII, and SIRI were calcu- lated in both groups. Results: Although median SIRI and CAR levels were higher in the AA group, the difference was not statistically significant (P>0.05). However, median SII was significantly higher in the AA group (P<0.001). AA patients were divided into two groups according to disease severity: mild disease group (MD) and moderate and severe disease (MSD) group. SII, SIRI, and CAR did not differ between the two groups. Conclusions: In AA patients, SIRI and CAR did not show significant differences compared to the normal population, while SII was significantly higher. SII was not found to be associated with disease severity, suggesting that systemic inflammation may occur even in the mildest cases of the disease. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(2):4962 Introduction Alopecia areata (AA) is an inflammatory disorder character- ized by non-scarring alopecia affecting the scalp and/or body hair. The lifetime risk of developing AA is estimated to be 1.7%. While the exact etiology of the disease remains unclear, it is hypothesized to be an organ-specific autoimmune disor- der influenced by both genetic and environmental factors [1]. The autoimmune response, triggered by the loss of immune privilege in hair follicles due to various stimuli, leads to hair loss during the anagen phase of the hair growth cycle [2]. Key contributors for the development of auto- inflammation include autoreactive cytotoxic CD8+ NKG2D+ T lympho- cytes and IFN-gamma (IFN-γ). Furthermore, studies have demonstrated an increase in Th1 and Th17 lymphocytes, plasmacytoid dendritic cells, and NK cells in the hair follicles of alopecia areata patients, all of which are involved in the pathogenesis of the disease [3]. Despite being a disease spe- cifically targeting hair follicles, the frequent co-occurrence of AA with other autoimmune conditions, such as autoimmune thyroid disease and celiac disease, suggests that the inflam- mation is systemic rather than localized to the hair follicles alone [4]. In various diseases, inflammatory markers derived from complete blood count (CBC) have been shown to be elevated and correlate with disease severity [5,6]. The sys- temic immune-inflammation index (SII) and systemic inflam- mation response index (SIRI) are indices calculated using platelet and leukocyte subtypes that have gained attention in recent years [6]. These indices have also been found to cor- relate with disease severity in various chronic inflammatory skin diseases and to decrease with treatment [7,8]. Therefore, they are considered simple and accessible biomarkers for monitoring treatment response [8]. A review of the litera- ture did not reveal any study assessing SII and SIRI levels in alopecia areata. CAR (C-reactive protein to albumin ratio) is another easily calculable inflammatory marker similar to CBC-derived inflammation parameters, and the number of studies investigating CAR has increased in recent years. However, only one study has specifically examined CAR lev- els in alopecia areata patients [9]. Objectives In this cross-sectional study, the aims were to determine SII, SIRI, and CAR levels in alopecia areata patients and to inves- tigate their correlation with disease severity. Methods Study Design and Participant Population The study was conducted in accordance with the Helsinki Declaration. Following approval from Institutional Ethics Committee (Approval number: KAEK-14/ 07.02.2023), cross-sectional data were collected between March 2023 and March 2024. A total of 118 patients with AA, includ- ing alopecia totalis (AT) and alopecia universalis (AU), as well as 122 healthy controls with no history of alopecia areata were enrolled. Informed consent was obtained from all participants. Age and sex were recorded for both groups. In the AA group, additional data regarding the age at onset, disease du- ration, family history of alopecia areata, smoking status, and prior history of infections and medication use were gathered. The type of alopecia areata, affected body areas, presence of nail involvement, and Fitzpatrick skin type were also noted. Disease severity was assessed using the scoring system defined by Kavak et al. [10]. Patients with three or fewer alopecic patches, each with a widest diameter of 3 cm or less, or disease limited to the eyelashes and eyebrows, were clas- sified as having mild disease. Patients with more than three patches, or a patch with a diameter greater than 3 cm, were classified as moderate disease. Patients with AT or AU were defined as having severe disease. The Severity of Alopecia Tool (SALT) scores were calculated for patients with scalp involvement. Exclusion criteria included individuals under the age of 18, those with a history of medication affecting CBC and biochemical parameters, individuals with other inflamma- tory skin diseases, active infections, or with hematologic, rheumatologic, renal, or cardiac conditions. The control group consisted of healthy volunteers with- out any medical complaint who had no personal or family history of alopecia areata and who were undergoing labora- tory examinations for screening purposes. Laboratory Analysis CBC, C-reactive protein (CRP), and albumin values of both the patient and control groups were recorded during their clinic visits. CRP albumin ratio (CAR), systemic immune- inflammatory index (SII), and systemic inflamma- tory response index (SIRI) were calculated for both groups (SII= neutrophils × platelets / lymphocytes, SIRI  =  neutro- phils × monocytes / lymphocytes) [11]. Statistical Analysis Data were analyzed using IBM® SPSS® Statistics 25 Soft- ware (IBM Corp., Armonk, NY, USA). The Kolmogorov- Smirnov test was applied to assess the normality of the data. For descriptive statistics, mean±standard deviation and median (minimum-maximum) values were used for nor- mally and non-normally distributed data, respectively. The Mann-Whitney U test was used for non-normally distributed variables, while the Student T test was applied for normally distributed variables to compare numeric data. Pearson’s Original Article | Dermatol Pract Concept. 2025;15(2):4962 3 chi-squared test or Fisher’s exact test was used to compare categorical data. Spearman correlation test was used to de- termine the correlation between SALT scores and SII, SIRI, and CAR, A p-value of less than 0.05 was considered statis- tically significant. Results A total of 118 patients with AA and 122 age- and sex- matched healthy controls were included in the study. The median age was 32 (range: 18-67) years for the AA group and 31 (range: 18–86) years for the control group (P=0.89). In the AA group, 48 patients (40.7%) were female and 70 (59.3%) were male, while in control group, 47 individuals (38.5%) were female and 75 (61.5%) were male. No sig- nificant difference was observed between the two groups in terms of sex (P=0.73). Mean body mass index (BMI) of the AA patients and control group were 24.15±3.59 kg/m2 and 24.95 ±3.5 kg/m2, respectively (P=0.663). There was no significant difference in smoking prevalence between the AA group (55.1%) and the control group (47.6%) (P=0.195). Of the AA patients, 113 had patchy AA, three had patchy alopecia and ophiasis, one had AT, and one had AU. Ninety-three patients (78.8%) had scalp involvement, and 10 (8.5%) patients had nail involvement. Of the AA patents, 50.5% (N=60) had mild disease, 47.5% (N=56) had moderate disease, and 1.7% (N=2) had severe dis- ease. The median duration of AA was two (range: 0.03- 246) months, and the median age at onset was 28.5 (range: 2.5–66) years. The median SALT score of the patients with scalp involvement was 4 (1-100). Demographic charac- teristics of the AA group are summarized in Table 1. SII, SIRI, and CAR levels were compared between the AA and control groups. Although the median SIRI and CAR levels were higher in the AA group, the differences were not sta- tistically significant (P>0.05). However, the median SII was significantly higher in the AA group (P<0.001) (Table 2). AA patients were divided into two groups based on dis- ease severity: mild disease group (MD) or moderate and severe disease (MSD) group, with 60 and 58 patients in MD and MSD groups, respectively. There was no difference between two groups in terms of age, sex, family history of alopecia areata, involved body part, smoking, emotional stress, or infection history (P>0.05). The disease duration was significantly longer in the MSD group compared to the MD group (1.25 years versus 3 years, respectively; P<0.001). No significant difference was found between the two groups in terms of SII, SIRI, or CAR. A comparison between the MD and MSD groups is presented in Table 3. No significant correlation was identified between the SALT scores of 93 patients with scalp involvement and SI, SII, or CAR (p>0.05) (Table 4). Conclusions Chronic inflammatory skin diseases negatively impact qual- ity of life and require long-term monitoring and treatment. In the follow-up of these diseases, disease severity indices specific to each condition are used. Additionally, various bio- markers have also begun to be utilized. Moreover, a grow- ing body of research has identified various biomarkers to determine prognosis and to monitor treatment responses in dermatological conditions [12]. SII, SIRI, and CAR are in- flammatory markers that have gained increasing attention in recent years [13,14]. These markers have shown utility in assessing disease severity and monitoring treatment out- comes in dermatological conditions such as psoriasis, acne, hidradenitis suppurativa, chronic urticaria, and Behçet’s dis- ease [8,15-19]. CRP, a positive acute-phase protein produced by the liver in response to inflammation or tissue damage, is often used as a general marker of inflammation [9]. In au- toimmune diseases, inflammation occurs when the immune system targets and attacks the body's own tissues. Increased CRP levels can serve as an indicator of an inflammatory re- sponse within the body and are commonly used as a general marker of inflammation. [20]. Several studies have reported higher CRP and high-sensitivity CRP levels in alopecia areata (AA) patients compared to healthy controls [20-24]. In a meta-analysis conducted to identify potential biomark- ers for alopecia areata, 91 studies and 52 biomarkers were analyzed. The results indicated that serum IL-6 and CRP levels were significantly higher and vitamin D levels were significantly lower in alopecia areata patients compared to controls [25]. CAR, a novel biomarker indicating systemic inflammation, has been shown to predict disease prognosis more effectively than CRP alone [26]. A study by Kemeriz et al. on psoriasis patients found that CAR was significantly elevated and was the most strongly associated marker with psoriasis severity among several other inflammatory markers [27]. In our PubMed search, we identified only one current study on CAR in AA. Kalaycı et al. (2022) analyzed CAR levels in 65 AA patients and 65 controls. They found signifi- cantly higher CAR in the AA group and a positive correla- tion between CAR and disease severity. The optimal CAR value for severe AA was calculated to be 0.38 [9]. However, in our study, while CAR was slightly higher in the patient group, this difference was not statistically significant. In re- cent years, CBC-derived biomarkers have been extensively studied in various diseases, including AA, with mixed results. Saraç et al. found significantly higher levels of hemoglobin, monocytes, platelets, monocyte/high-density lipoprotein cho- lesterol (HDL-C) ratio (MHR), monocyte/lymphocyte ratio (MLR), and platelet/lymphocyte ratio (PLR) in AA patients compared to controls [28]. In contrast, Dere et al. found no significant difference in PLR, neutrophil/lymphocyte ratio 4 Original Article | Dermatol Pract Concept. 2025;15(2):4962 Table 1. Demographic Characteristics of AA Patients Median age-year (minimum- maximum) 32 (18-67) Sex N (%) Female 48 (40.7%) Male 70 (59.3%) Alopecia type N (%) Patchy 113 (95.8%) Patchy + ophiasis 3 (2.5%) AU+ AT 2 (1.7%) Family history- n(%) 28 (23.7%) Disease severity- N (%) Mild 60 (50.8%) Moderate 56 (47.5%) Severe 2 (1.7%) Median disease duration –month (minimum – maximum) 2 (0.03-246) Mean age of onset - year ±standard deviation 29.2±11.4 Median number of disease episodes (minimum-maximum) 1 (1-14) Localization – N (%) Scalp 93 (78.8%) Beard 30 (25.4%) Mustache 5 (4.2%) Eyebrows 4 (3.4%) Eyelashes 3 (2.5%) Body hair 6 (5.1%) Median SALT scores of patients with scalp involvement (minimum-maximum) 4 (1-10) Degree of SALT score –N (%) S1 83 (89.2) S2 4 (3.2) S3 4 (4.3) S4a 2 (2.2) S4b 1 (1.1) Nail involvement- N (%) 10 (8.5%) Nail findings- N (%) Beau's lines+ Median canaliform nail dystrophy 1 (0.8%) Leukonychia 1 (0.8%) Pitting+ trachyonychia 1 (0.8%) Longitudinal ridging 2 (1.7%) Pitting 2 (1.7%) Trachyonychia 3 (2.5%) Fitzpatrick skin type- N (%) 2 23 (19.5%) 3 84 (71.5%) 4 11 (9.3%) Smoking- N (%) 65 (55.1%) Emotional stress –N (%) 93 (78.8%) Infection- N (%) 9 (%7,6) Co morbidity- N (%) Thyroid disease 8 (6.8%) Familial Mediterranean fever 1 (0.8%) Urticaria 1 (0.8%) Hypertension 4 (3.4%) Irritable bowel disease 1 (0.8%) Abbreviations: AA: Alopecia areata; AU: Alopecia universalis; AT: Alopecia totalis; SALT: Severity of Alopecia Tool Original Article | Dermatol Pract Concept. 2025;15(2):4962 5 inflammatory states, SII accounts for the interaction be- tween inflammation and thrombosis by incorporating plate- let changes, which may provide a more comprehensive view of systemic inflammation. SIRI refers to neutrophil count x monocyte count / lymphocyte count and reveals the balance between inflammatory and anti-inflammatory responses. Both SII and SIRI are thought to be closely associated with the development of autoimmune diseases and tumors [30]. SII has also been shown to be associated with subclinical inflammation [31]. In our study, SII was significantly higher (NLR), and mean platelet volume (MPV) levels between AA patients and the normal population [29]. Similarly, İslam- oğlu et al. observed comparable red blood cell distribution width (RDW), MPV, plateletcrit (PCT), NLR, and PLR levels between AA patients and controls [22]. Upon reviewing the literature, it was noted that the levels of SII and SIRI, which are also calculated using CBC parameters and which have gained popularity recently, have not previously been exam- ined in AA patients. SII is calculated as platelet count x neu- trophil count / lymphocyte count. While NLR also reflect Table 2. Comparison of The Inflammatory Indexes Between AA and Control Groups Median (minimum- maximum) AA group N=118 Control group N=122 p SII 804.49 (342.7-1881.64) 501.29 (149.44-1546.61) <0.001* SIRI 0.86 (0.26-2.60) 0.79 (0.25-4.57) 0.274 * CRP/albumin ratio 0.178 (0.002-7.674) 0.172 (0.034-1.235) 0.372 * Abbreviations: *Mann-Whitney U test. AA: Alopecia areata; CRP: C-reactive protein; SII: Systemic immune-inflammatory index; SIRI: Sys- temic inflammatory response index Table 3. Comparison of MD and MSD Groups MD group N=60 MSD group N=58 p Median age-year (minimum- maximum) 29.5 (18-67) 33.5 (18-53) 0.129* Sex Female 21 (35%) 27 (46.6%) 0.202** Male 39 (65%) 31 (53.4%) Median disease duration –month (minimum – maximum) 1.25 (0.03-40.0) 3.0 (0.1-246) <0.01* Median age of onset (minimum- maximum) 27 (3-66) 29 (2,5-52) 0.588* Family history of AA 16 (27.6%) 12 (20.7%) 0.445** Fitzpatrick skin type- N (%) 2 15 (25%) 8 (13.8%) 0.087* 3 41 (68.3%) 43 (74.1%) 4 4 (6.7%) 7(12.1%) Localization – N (%) Scalp 48 (80%) 45 (77.6%) 0.748 ** Beard 12 (20%) 18 (31%) 0.169 ** Mustache 1 (1.7%) 4 (6.9%) 0.203 *** Eyebrows 1 (1.7%) 3(5.2%) 0.360 *** Eyelashes 0 3 (5.2%) 0.116 *** Body hair 1 (1.7%) 5 (8.6%) 0.111 *** Nail 6 (10%) 4 (6.9%) 0.74 *** Smoking – N (%) 37 (61.7%) 28 (48.3%) 0.144 ** Emotional stress –N (%) 47 (78.3%) 46 (79.3%) 0.897 ** Infection- N (%) 4 (6.7%) 5 (8.6%) 0.741 *** Median SIRI (minimum- maximum) 0.847 (0.290-2.137) 0.892 (0.263-2.605) 0.929 * Median SII (minimum- maximum) 832.88 (342.27-1607.64) 748.68 (448.04-1881.64) 0.329 * Median CRP/ albumin ratio (minimum- maximum) 0.178 (0.002-3.18) 0.180 (0.019-7.67) 0.708 * Abbreviations: *Mann-Whitney U test; **Chi-squared test; *** Fisher’s exact test; CRP: C-reactive protein; MD group: Mild disease group; MSD group: Moderate-severe disease group; SII: Systemic immune-inflammatory index; SIRI: Systemic inflammatory response index 6 Original Article | Dermatol Pract Concept. 2025;15(2):4962 4. 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Additionally, we did not use the SALT score for severity assessment due to the presence of isolated mustache and beard involvement with- out scalp involvement among our study population. The in- sufficient number of patients with alopecia totalis (AT) and alopecia universalis (AU) is another limitation. In conclusion, while SIRI and CAR did not show any significant differences between AA patients and controls, SII was significantly higher in AA patients. SII was not associ- ated with disease severity, suggesting that systemic inflam- mation may occur even in mild cases of the disease. References 1. Gönül M, Gül Ü, Piskin E, et al. Alopesi Areatali Hastalarin Geriye Dönük Degerlendirilmesi/Retrospective Evaluation of Alopecia Areata Patients. Turk Dermatoloji Dergisi. 2011;5(2): 43-47. DOI: 10.5152/tdd.2011.10. 2. Fukuyama M, Ito T, Ohyama M. 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