C-Reactive Protein Level

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An Bras Dermatol. 2016 Sep-Oct; 91(5): 580–583.
doi:  10.1590/abd1806-4841.20164655
PMCID: PMC5087213

C-reactive protein serum level in patients with psoriasis before and after treatment with narrow-band ultraviolet B*

Mahmoud Farshchian,1 Akram Ansar,1 Mohammadreza Sobhan,1 and Valiollah Hoseinpoor1
1Psoriasis Research Center, Department of Dermatology, Farshchian Hospital, Hamadan University of Medical Sciences – Hamadan, Iran
Mailing address: Mohammadreza Sobhan, Psoriasis Research Center, Department of Dermatology, Farshchian Hospital, Hamadan University of Medical Sciences, Mirzade Eshghy Street, 65168408741 Hamadan, Iran. E-mail: moc.oohay@nahbos_azerm
Received 2015 Apr 22; Accepted 2015 Oct 10.



C-reactive protein is an inflammatory biomarker and its level increases in the serum of psoriatic patients. Its level is also associated with Psoriasis Area and Severity Index score.


The aim of this study was to assess the decrement of serum C-reactive protein level with narrow-band ultraviolet B (NB-UVB) therapy.


C-reactive protein serum levels in psoriasis patients were measured before and after treatment with NB-UVB and the data were analyzed in relation to the Psoriasis Area and Severity Index score improvement.


Baseline C-reactive protein levels among psoriatic patients were higher than normal. These levels decreased significantly after treatment (P<0.001). At the beginning of the study, patients with higher levels of C-reactive protein also had more extensive and severe skin involvement. The highest decrease in C-reactive protein was observed in patients who responded better to the treatment and achieved a higher Psoriasis Area and Severity Index 75%. There was an association between baseline Psoriasis Area and Severity Index scores and C-reactive protein levels.


Patients with moderate to severe plaque-type psoriasis had active systemic inflammation, which was demonstrated by increased levels of C-reactive protein. Furthermore, skin disease severity was correlated with C-reactive protein levels. Phototherapy healed the psoriatic skin lesions and reduced inflammation, while decreasing C-reactive protein levels.

Keywords: C-Reactive Protein, Psoriasis, Ultraviolet therapy


Chronic plaque psoriasis is the most common type of psoriasis. It is estimated that the prevalence of psoriasis is 2%-5% worldwide. However, in Asia alone, the prevalence is 0.4%-0.7%. Psoriasis is determined by excessive proliferation and impaired evolution of keratinocytes. Due to its recurrent nature, psoriasis has a major impact on the patient’s quality of life.1 Phototherapy represents a mainstay treatment for psoriasis vulgaris. Psoriasis lesions can be healed by the narrow band ultraviolet B lights (NB-UVB) at a length of 311 nanometers, which has more impact than broadband ultraviolet over a short period; with only a 10% incidence of burning, compared with 28% for conventionally treated patients.2

Psoriasis also has an inflammatory nature that is demonstrated by excessive secretion of dermal, systemic, pre-inflammatory cytokines such as IL-2, IL-6,IL-12, IL8, IL-17, IL-19, IL-20, IL-22, IL-23, IL-24, IFN-? and TNF-?.3Furthermore, liver stimulation and the production of acute phase reactants such as C-reactive protein (CRP), which is considered an inflammatory biomarker, are believed to stem from IL-6 secretion induced by TNF-?.4 CRP is an acute phase reaction protein biomarker that is identifiable within 24 to 48 hours after tissue damage or infection. CRP indicates 6 to 8 hours of half-life and has a wide dynamic range used as an important marker in clinical studies,reducing with a successful treatment. Moreover, assessing CRP serum values is a suitable, daily monitoring method, which can display a clear perspective of events occurring over the preceding 12 hours. The systemic inflammatory pathways may guide treatment of the disease. Thus, new studies must focus on the new mediators that can be found as new therapeutic targets.5,6 For all the aforementioned reasons, we chose to assess the patients’ CRP serum levels to evaluate therapeutic response.


This clinical trial was conducted in individuals suffering from plaque psoriasis who were referred to the Farshchian Hospital, Hamadan, Iran, between March 2009 and March 2010. All of them were included in the study. Participating in this study was voluntary for the patients because it was inconsequential to their treatment. Patients who did not wish to complete the project were allowed to leave the study and subsequently excluded. Because participation was voluntary, refusal to participate involved no penalty or loss of benefits to which the subjects were otherwise entitled, and the subjects were permitted to discontinue participation at any time without penalty or loss of benefits to which the subjects were otherwise entitled. In sum, 30 patients started the study but 5 patients were excluded. Thus, the study continued with 25 cases of plaque type psoriasis. This study was confirmed with the ethical guidelines of the 1975 Declaration of Helsinki. An institutional review board approved the research. The variables investigated in this study were: patients’ CRP serum levels, pre- and post-phototherapy serum levels, pre- and post- treatment PSAI scores, the mean of CRP serum value changes pre- and post-treatment, and the PASI 75% value.

All participants were interviewed by a dermatologist and underwent physical examinations. A questionnaire was completed, providing information such as: age, sex, percentage of body surface area involved, intensity level, arrhythmia, skin thickness and skin shedding (desquamation) within the areas affected, pre- and post-treatment CRP serum levels, pre- and post-treatment PASI scores, the number of required treatment sessions and the cumulative doses of radiation emitted to patients to remove 75% of lesions.

CRP serum levels were assessed pre-treatment, following 25 treatment sessions and whenever patients indicated an improvement in skin lesions. After centrifuging blood samples and separating the serum, they were stored at -18°C and all dual samples (taken before and after treatment) were analyzed. Pre- and post-treatment CRP serum levels and their variation were calculated and recorded in the questionnaire. To evaluate CRP serum levels, Minineph Human C-Reactive Protein Kit (Product Code: ZK044. L.R) was used, which took CRP serum values of under 3.8mg as normal.

In this study, we assessed psoriasis severity based on PASI scores and the pre- and post-treatment scores. Finally, the difference between the initial PASI score and the final score was determined and PASI 75% was calculated based on Formula 1.

(Formula 1: how to calculate the lesion recovery rates: PASI % = (PASI1 – PASI2) / PASI1 * 100).

Phototherapy was conducted three times a week, using a wavelength of 311nm to treat the psoriatic lesions of patients with the first dose of 4% J/cm2. According to the predicted protocol from the skin department, the dose increased gradually, as shown in table 1.

Table 1

Treatment protocol for phototherapy using NB-UVB in psoriasis patients

Statistical analyses were performed based on initial and final CRP serum values, their changes pre- and post-treatment, and clinical criteria for determining PASI scores pre- and post- treatment. At the end, the pair T test and Spearman correlation coefficient were used to compare the means, to express the relations between variables and frequency via the data description approach.


In total, out of 25 patients, there were 18 males (72%) and seven females (28%). They were treated by NB-UVB therapy. The ages of these patients ranged from 21 to 67 years, with a mean age of 41.08±14.60 years. All the results obtained are summarized in table 2. Our findings suggested that 16 patients achieved a 75% or more reduction in their PASI score from baseline. The maximum, minimum and mean pre-treatment CRP serum levels were 18.580 mg/l, 2.10 mg/l and 5.79±3.62 mg/l, respectively. Meanwhile, the maximum, minimum and mean pre-treatment PASI scores were 53.10, 9.10 and 22.20±11.51, respectively. However, the maximum, minimum and mean post-treatment CRP levels were 6.88mg/l, 1/80mg/l, and 3.30±1.06, respectively. Furthermore, the maximum, minimum and mean post-treatment PASI scores were 15.00, 00.00 and 5.27±3.92, respectively.

Table 2

CRP serum levels and the PASI scores in 25 patients pre- and post-treatment with NB-UBV

The variation values observed for pre- and post-treatment CRP serum levels are displayed in graph 1.

Graph 1

Comparison of CRP serum levels in 25 patients before and after treatment by NB-UVB

Pre- and post-treatment PASI scores, along with the relationship between post-treatment CRP serum levels and PASI 75%, are shown in graph 2 and graph 3, respectively.

Graph 2

Comparison of PASI scores in 25 patients before and after treatment using NB-UVB
Graph 3

The relationship between CRP serum levels in 25 patients, pre- and post-treatment using NBUVB and PASI 75%


CRP is an acute phase reactive protein, known as a systemic inflammatory biomarker. Serwin reported increased CRP concentrations in active psoriasis.7Uysal et al. identified CRP as a marker for psoriasis severity.5 Isha found that CRP levels increased by more than 20 times in psoriasis patients compared with the healthy individuals. After 12 weeks of treatment, it fell to nearly 50% of the initial value.8 Similarly, we observed a significant decrease in post-treatment CRP serum levels due to NB-UVB phototherapy (P<0.001).

In a study conducted in 70 psoriasis patients, Biljan et al. observed that inflammatory parameters such as CRP serum levels were significantly related to the clinical demonstrations of psoriasis (p<0.005). They also identified a relationship between disease severity and the increased levels of inflammatory reactions.9

In a cross-sectional study conducted on 73 psoriasis patients, Coimbra et al. noted that CRP serum levels were related to PASI scores and that they could be reduced by using NB-UVB as a treatment. Consequently, it is suggested that CRP serum levels can be considered a useful marker for diagnosing psoriasis severity and monitoring disease activity or the disease’s reaction to treatment.10

In another study of 175 male psoriasis patients performed by Chodorowska, the clinical activity of psoriasis was calculated based on the PASI score, which reflected the increase in CRP serum levels during the acute phase (P<0.001).11

Strober et al. investigated the etanercept effects on CRP serum levels and observed increased CRP serum levels in patients with moderate to severe plaque-type psoriasis who were suffering from systemic inflammation. The activity of the skin disease was accompanied closely by improvement in serum CRP levels.12

Kanelleas et al. analyzed the role of inflammatory markers among psoriasis patients to evaluate the severity of the disease and its response to treatment. Furthermore, they found that inflammatory markers such as CRP serum levels diminish post-treatment (P<0.001) and identified a relationship between PASI scores and CRP. Due to this relation, inflammatory markers, especially CRP, can be used to evaluate the severity of psoriasis and its response to treatment. In addition, the inflammatory markers, together with the PASI score, may represent an inflammatory situation for psoriasis.13


According to the data recorded in the literature and the current survey results, the augmented CRP serum levels were found in patients with moderate to severe plaque-type psoriasis, marking the systemic inflammatory feature of this disease. We gathered evidence that correlates psoriasis severity with CRP. The study suggested that CRP serum levels increase with psoriasis disease activity, which is measured by the PASI score. Moreover, it was shown that using NBUVB 311nm phototherapy not only improves psoriasis lesions, but also reduces CRP serum levels. The aforementioned findings were supported by statistical evaluations on the relationship between serum CRP levels, PASI scores and clinical observations. It is noticeable that CRP levels are generally likely to decrease with the reduction of disease severity, due to the different treatment modalities, including phototherapy. On this topic, we would recommend that future studies compare the effects of various treatment modalities on CRP levels in psoriatic patients.


Conflict of interest: None

Financial Support: None

*Work performed at the Psoriasis Research Center – Hamadan, Iran.


1. Serwin AB, Wasowicz W, Gromadzinska J, Chodynicka B. Selenium status in psoriasis and its relations to the duration and severity of the disease. Nutrition.2003;19:301–304. [PubMed]
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6. Reich K. The concept of psoriasis as systemic inflammation implications for disease management. J Eur Acad Dermatol Venereol. 2012;26:3–11. [PubMed]
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J Orthop Sports Phys Ther. 2010 Apr 12. [Epub ahead of print]

Effects of Low-Level Laser Therapy (LLLT) in the Development of Exercise-Induced Skeletal Muscle Fatigue and Changes in Biochemical Markers Related to Post-Exercise Recovery.


Leal Junior EC, Lopes-Martins RA, Frigo L, De Marchi T, Rossi RP, de Godoi V, Tomazoni SS, da Silva DP, Basso M, Filho PL, de Valls Corsetti F, Iversen VV, Bjordal JM.


STUDY DESIGN: Randomized crossover double-blinded placebo-controlled trial. OBJECTIVE: To investigate if low level laser therapy (LLLT) can affect biceps muscle performance, fatigue development, and biochemical markers of post-exercise recovery. BACKGROUND: Cell and animal studies have suggested that LLLT can reduce oxidative stress and inflammatory responses in muscle tissue. But it remains uncertain whether these findings can translate into humans in sport and exercise situations. METHODS: Nine healthy male volleyball players participated in the study. They received either active LLLT (cluster probe with 5 laser diodes, l=810 nm, 200 mW power output, 30 seconds of irradiation, applied in 2 locations over the biceps of the non-dominant arm, 60 J of total energy) or placebo LLLT using an identical cluster probe. The intervention or placebo were applied 3 minutes before the performance of exercise. All subjects performed voluntary elbow flexion repetitions with a workload of 75% of their maximal voluntary contraction force (MVC) until exhaustion. RESULTS: Active LLLT increased the number of repetitions by 14.5% (mean of 39.56, SD +/- 4.33 versus 34.56 +/- 5.64, p=0.037) and the elapsed time before exhaustion by 8.0% (p=0.034), when compared to the placebo treatment. The biochemical markers also indicated that recovery may be positively affected by LLLT as indicated by post-exercise blood lactate levels (p<0.01), Creatine Kinase (CK) activity (p=0.017), and C-Reactive Protein (CRP) levels (p=0.047) showing a faster recovery with LLLT application prior to the exercise. CONCLUSION: We conclude that pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance, and decreased post-exercise levels of blood lactate, CK, and CRP. LEVEL OF EVIDENCE: Therapy, Level 1a. J Orthop

Sports Phys Ther, Epub 12 April 2010. doi:10.2519/jospt.2010.3294.


Assessment of Anti-Inflammatory Effect of 830nm Laser Light Using C-Reactive Protein Levels.


André Carlos de FREITAS1
Antonio Luiz Barbosa PINHEIRO2
Fábio Albuquerque THIERS4
Alessandro Leonardo de Barros VIEIRA5

1Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, PUC-RS, Porto Alegre, RS, Brazil
2Laser Center, School of Dentistry, Federal University of Bahia, Salvador, BA, Brazil
3Laboratory of Immunopathology Keizo Asami (LIKA), Federal University of Pernambuco, Recife, PE, Brazil
4Harvard Medical School, Boston, MA, USA
5Private Dental Practice, Recife, PE, Brazil

Correspondence: Prof. Dr. Antonio Liuz Barbosa Pinheiro, Departamento de Diagnóstico e Terapêutica, Faculdade de Odontologia, Universidade Federal da Bahia, Av. Araújo Pinho, 62, Canela, 40110-150 Salvador, BA, Brasil. Tel/Fax: +55-71-336-9479. e-mail: albp@ufba.br

Braz Dent J (2001) 12(3): 187-190 ISSN 0103-6440


The anti-inflammatory effect of non-surgical lasers has been proposed previously, however it was not scientifically proven. One method to assess levels of inflammation is the measurement of C-reactive protein (CRP), which is increased with the course of inflammation. The aim of this study was to assess the effect of 830nm laser irradiation after the removal of impacted third molars using the CRP as the marker of inflammation. Twelve patients were irradiated with 4.8 J of laser light per session 24 and 48 h after surgery. A control group (N=12) was treated with a sham laser. Blood samples were taken prior to, and 48 and 72 h after surgery. CRP values were more symmetric and better distributed for the irradiated group (0.320 mg/dl) than for the control (0.862 mg/dl) 48 h after surgery, however there was no statistically significant difference. After 72 h, both groups had statistically similar CRP levels (0.272 and 0.608 mg/dl), because of the normal tendency of decreasing CRP levels.

Key Words: dental surgery, inflammation, non-surgical lasers.


Lasers have been used in several medical specialities and recently the dental profession has used laser both as a surgical tool and a biomodulating agent (1). Laser development began in 1917, when Albert Einstein proposed the principles of the stimulated emission of radiation. In 1958, Shawlow and Townes suggested the basic principles of light amplification (2).

Laser is a non-ionizing electromagnetic highly concentrated light, which, in contact with different tissues, results in several effects in tissue depending upon the wavelength and the optical properties of the irradiated tissue. Because it is a non-ionizing form of radiation, laser light can be used repeatedly within the parameters used currently because it does not induce mutagenic response. The use of laser light is not contraindicated for pregnant women, pacemaker users, and does not interfere with monitoring in the operating room (3).

Medical lasers can be classified into three main groups: Low Intensity Laser Therapy (LILT), High Intensity Laser Therapy (HILT) and Selective Laser Therapy (SLAT). LILT is also known as Low Level Laser therapy or LLLT and can modify cell metabolism, improve wound healing, reduce pain and edema, and speed inflammation and wound healing (4,5).

Inflammation occurs when immunocompetent cells are activated in response to foreign bodies or antigenic proteins. This response may have a beneficial effect (e.g. phagocytosis) or a deleterious effect (e.g. destruction of bone and cartilage in arthritis) (6).

Anti-inflammatory agents are drugs used for the treatment of non-specific inflammatory process to control signs and symptoms such as: heat, redness, pain and lack of function. There are two kinds of anti-inflammatory agents available on the market: steroids and non-steroids. The use of these drugs may result in undesirable side effects; thus, the constant search for alternative methods to control inflammation without deleterious effects to the patient.

LLLT has been used as an important tool for the control of the inflammatory process. Its anti-inflammatory effect has been studied and its ability to induce analgesia under different conditions has also been reported  (7).

The serial determination of the levels of some serum proteins may be useful for the differentiation of inflammatory and non-inflammatory conditions, as well as between clinical conditions which are known to show increased or decreased acute phase response. One of these proteins is the C-reactive protein (CRP). The magnitude of the CRP response varies directly with the severity of tissue damage, type of the inflammatory stimuli, organ or tissue involved in the process, as well as on the monitoring of the natural course of the disease and the disease response to treatment (8). CRP plasma concentration is usually low (9), increases quickly at the onset of an acute inflammatory process and quickly falls when effective control of the process occurs (10,11).


This study was approved by the Ethical Committee of the Hospital das Clínicas  of the Universidade Federal de Pernambuco, Brazil. Twenty-four patients gave signed informed consent as determined by Brazilian regulations. The patients were selected according to the following criteria: lower wisdom tooth, older than 16 years of age and younger than 30 years of age, symptom free at the time of surgery, lack of pericoronaritis for at least 30 days prior to surgery. One week before surgery, a blood sample was taken to determine the baseline of CRP prior to surgery and irradiation. Patients with elevated CRP levels were dismissed from the study. Under local anesthesia, a maximum of two wisdom teeth were surgically removed using rotary and manual instruments. All patients received 500 mg of paracetamol after surgery. This drug was chosen because its very low anti-inflammatory action at usual doses (12). The drug was used immediately after surgery and repeated  every six hours if necessary, not exceeding 2000 mg/day.

The patients were randomly divided into two groups (even numbered patients were placed in the test group and odd numbered patients in the control group). Twenty-four and forty-eight hours after surgery, the twelve test patients received the irradiation at the Laser Center with an 830nm diode laser (40 mW; Laser Beam, Rio de Janeiro, RJ, Brazil) for a total dose of 4.8 J/cm2. Control patients were treated with a sham laser. Forty-eight and seventy-two hours after surgery, blood samples were taken and the CRP level was determined by nephelometry (13-15).

Statistical analysis was based upon the comparison between groups using the Kolmogorov-Smirnov, Mann-Whitney and Shapiro-Wilks tests (16).


Comparison of groups at baseline is shown in Table 1. Both groups had very similar levels of CRP (Kolmogorov-Smirnov = 0.17; critical value, at 5% = 0.50). Forty-eight hours after treatment (Table 2), CRP levels of irradiated patients showed a very symmetric distribution around the mean with a very small variability when compared to the controls. The Shapiro-Wilks test indicated that there was a normal distribution for the test group (S-W = 0.95; p = 0.438). However, the control group had a positive asymmetric distribution (S-W = 0.83; p = 0.021). Although there was a numerical difference between the two groups, the Mann-Whitney test did not show a significant difference between the medians of the two groups (W = 133.3; p = 0.338).

The results of the Kolmogorov-Smirnov test for two samples indicated at significance level of 5%; after 72 h the CRP levels showed the same distribution for both groups (K-S = 0.333; critical value at 5% = 0.50). Table 3 show a symmetric positive distribution for both groups. The differences of the distribution on the graphs is a reflex of the random variation.


Surgical removal of a wisdom tooth may result in edema, pain and slight bleeding. However, if these conditions are exacerbated or if there is the presence of infection or trismus, these can be considered as complications.  The lack of previous studies comparing the use of LLLT and other types of drug treatment for inflammatory conditions of the oral cavity makes it difficult to compare the results of this study. There was modification of the CRP level immediately after the surgical removal of the wisdom teeth and increased levels of CRP were found in both groups in agreement with other reports (10,11). This inflammatory response has been reported previously (17).

The level of CRP and the clinical stage of the disease have a direct relationship to the evolution of the disease and the plasma level of CRP (18). Despite the fact that several authors consider an increase of CRP levels to be an unspecific response to infection, inflammation or tissue damage (19), in this study, CRP levels were used to assess the anti-inflammatory action of the 830nm diode laser, based on other studies that used CRP levels for monitoring inflammation (17). CRP response allows monitoring of the anti-inflammatory effect of drugs. The use of aspirin, steroids, penicillin and other non-hormonal drugs will often result in a reduction of the CRP level as these drugs will suppress the underlying inflammatory process (20). However, paracetamol was used as the analgesic drug in this study because of its very low anti-inflammatory effect in usual doses (12).

The aim of post-operative therapeutics is not the suppression of inflammation, because this process is extremely important for wound healing. Therapeutic methods and drugs used in the post-operative process aim to minimize symptoms and provide more comfort for the patient. Thus, the use of a non-invasive treatment such as LLLT is a major step in clinical therapeutics because of the lack of side effects of LLLT.

Statistical analysis of the results detected a very symmetric distribution of CRP levels at the post-operative period of patients who had wisdom teeth surgically removed and were irradiated with 830nm laser light when compared to the levels observed for the controls.

Although this study failed to statistically confirm an anti-inflammatory effect of LLLT after surgical removal of wisdom teeth, the results show a reduction in the level of CRP in irradiated patients which may indicate attenuation of the inflammation; however, a larger sample is necessary to confirm this aspect. It is also important to observe that the complete treatment consisted of four minutes of irradiation within two days and that there was no additional cost for the patient, no need to use other drugs or any interference with routine life (3).


de Freitas AC, Pinheiro ALB, Miranda P, Thiers FA, Vieira ALB. Avaliação do efeito anti-inflamatório do laser diodo infravermelho de 830 nm através da monitorização da proteína c-reativa. Braz Dent J 2001;12(3):187-190.

A atividade anti-inflamatória da radiação Laser ainda não está muito bem estabelecida. Dentre as diferentes formas de avaliação da resposta inflamatória aguda encontra-se, a dosagem da proteína C-reativa (PCR), que na inflamação encontra-se elevada. O objetivo deste trabalho foi avaliar a capacidade anti-inflamatória do Laser Diodo Infra-Vermelho de 830nm no pós-operatório de cirurgias para remoção de terceiros molares retidos, através da análise cinética da variação dos níveis da PCR. A irradiação foi realizada a uma distância focal de 0,5cm, por um tempo total de dois minutos em corrente contínua, nos pontos preestabelecidos. As cirurgias foram realizadas no Bloco Cirúrgico do Departamento de Prótese e Cirurgia Buco Facial da Universidade Federal de Pernambuco. A população alvo foi de 24 pacientes divididos aleatoriamente em dois grupos. O grupo teste foi submetido à Laserterapia nas 24 e 48 horas pós-operatório (PO). O grupo controle foi submetido a uma falsa irradiação, com os mesmos intervalos do grupo teste. As amostras de sangue, para a dosagem da PCR foram colhidas antes da cirurgia e após 48 e 72 horas. Os valores da PCR no grupo teste 48 horas PO apresentou uma distribuição bastante simétrica em torno de sua média e com a variabilidade bem menor comparada com o grupo controle, porém não encontramos diferenças estatisticamente significante. Nas 72 horas PO os valores da PCR foram bastante semelhantes o que pode ser explicado, por uma tendência natural da queda desta proteína nesta fase.

Unitermos: cirurgia odontológica, inflamação, laser não cirúrgico.


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