You are on page 1of 4


Available online at


Variance of melatonin and cortisol rhythm in patients with

allergic rhinitis☆,☆☆

Vural Fidan, MD a,⁎, Hamit Hakan Alp, PhD b , Mustafa Gozeler, MD a ,

Onder Karaaslan, MD c , Omer Binay, MD d , Cemal Cingi, MD e
Erzurum Education and Research Hospital, Otorhinolaryngology Dept Erzurum, Turkey
Ataturk University Faculty of Medicine, Biochemistry Dept Erzurum, Turkey
Ataturk Training and Research Hospital, Plastic and Reconstructive Surgery Dept Izmir, Turkey
Eskisehir Yunus Emre Goverment Hospital, Otorhinolaryngology Dept Eskisehir, Turkey
Osmangazi University Faculty of Medicine, Otorhinolaryngology Dept Eskisehir, Turkey


Article history: Objective: Allergic rhinitis is an IgE-mediated inflammatory disease which effects 10%–50%
Received 26 November 2012 of the normal population. The mechanism of its formation and the circadian rhythm of
cortisol and melatonin in allergic rhinitis have not been investigated.
Study design: Salivary levels of melatonin and cortisol were measured by
radioimmunoassay in 35 newly diagnosed allergic rhinitis patients and in 23 control
subjects matched for age and gender.
Results: In the study group; amplitude, baseline and peak levels of salivary melatonin were
significantly decreased compared with healty controls (p < 0.001). No differences were
found in the acrophase and the peak duration of salivary melatonin between the study and
control groups (p > 0.05).
In the study subjects, the circadian rhythm of cortisol was flattened when compared with
the control group. The amplitude and the 24 h mean levels of salivary cortisol in the study
group were significantly lower than in the control group and the acrophase was delayed in
patients compared with control subjects (p < 0.001).
Conclusion: The circadian rhythms of salivary melatonin and cortisol were found to be
disrupted in patients with allergic rhinitis. These results may also be contributive data to
explain the pathogenesis of allergic rhinitis and also they can be applicable as adjunctive
therapeutic tools in the future and melatonin drugs might be an alternative in the therapy of
resistant allergic rhinitis patients or allergic rhinitis patients who cannot use cortisol drugs.
© 2013 Elsevier Inc. All rights reserved.

1. Introduction circadian rhythm, being worst at night and in the early

morning [1]. Also sneezing and rhinorrhea secondary to AR are
Allergic rhinitis (AR) is an inflammation of the nose. The also greater in intensity during the morning in approximately
typical symptoms of AR are rhinorrhea, itching, sneezing and 70% of sufferers [2]. The mechanism involved in circadian
nasal blockage. The severity of nasal congestion follows a rhythm of AR is not clearly understood yet. Asthma, nasal

This study was accomplished at Erzurum Education and Research Hospital.
This is an original paper and it was not presented in any meeting. We did not have any financial support or grantor.
⁎ Corresponding author. Erzurum Education and Research Hospital, Otorhinolaryngology Dept Erzurum, Turkey. Tel.: +90 505 5606842.
E-mail address: (V. Fidan).

0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9 417

polyposis and AR frequently coexist in the same patient and 2.2. Saliva collection
are thought to share common predisposing genetic factors
which interact with the environmental influences [3]. The sampling process was started at 12:00 in all cases and
Clinical guidelines for AR have identified sleep impairment samples were taken at 4 hourly intervals. Saliva samples were
as a significiant problem [4]. Also AR leads to sleep impair- taken under indoor light conditions. The intensity of light was
ment [5]. In addition, sleep impairment is accompanied by a limited to 300 lux in full light, but at 00:00 and 04:00 only
damaged circadian rhythm, which affects cortisol and mela- flashlight (about 50 lux) was used to light up the mouth.
tonin secretion. Approximately 10–20 ml of saliva was taken from each
Melatonin is the main hormone product of pineal gland subject. Saliva was collected prior to meals using a sugarless
and it coordinates the circadian rhythm in humans. Also, it gum to stimulate saliva flow if necessary. The samples were
has an important role in the immunomodulation, anti- inserted into 50 ml tubes and placed in the refrigerator at ±
inflammatory cascade and the antioxidative defense sys- 4 °C for 24 h. The samples were then centrifuged for 10 min at
tem [6–9]. Cortisol is a hormone which shows a cyclic 2000 × g to remove mucins from the saliva and all samples
secretion. It has a typical circadian pattern with higher were kept at − 40 °C until chemical analysis.
levels in the early morning [10]. Cortisol excretion is
coordinated via the hippocampus and the hypothalamic– 2.3. Saliva assay
pituitary–adrenal axis [11]. There is a considerable affiliation
between the plasma/serum and salivary levels of melatonin Melatonin in the saliva was evaluated by a radioimmunoassay
and cortisol [12]. (RIA) using kits obtained from BÜHLMANN Laboratories AG
Disturbed circadian rhythm of body may have a role in the (Baselstr. 55 CH-4124, Schönenbuch, Switzerland) (RK-DSM2).
development of AR. To our knowledge, no studies to date have The standard range of melatonin in this kit was 0.5–50 pg/ml).
searched the circadian rhythm of cortisol and melatonin in Day time (baseline) level, night time (peak) level, acrophase
patients with AR without asthma. Therefore, this study was (clock time at which the melatonin reaches peak level),
conducted to appreciate the circadian rhythm of melatonin amplitude (difference between peak and baseline level) and
and cortisol in this patient group. peak duration (time interval during the periodic curve de-
viates from the baseline level) were used as parameters to
assess the melatonin rhythm.
Salivary cortisol was evaluated by ELISA. The kit is
2. Patients and methods manufactured by Eagle Biosciences, Inc. (82 Broad Street,
Suite 383, Boston, USA) (COR32-K01). The standard range of
2.1. Study population the cortisol kit was 0.1–30 ng/ml. The 24-h mean level,
amplitude (distance from mean to peak levels) and acrophase
Thirty-five newly diagnosed AR patients without asthma (age (clock time at which the cortisol levels reaches highest level)
range 18–37 years (mean ± SD age, 25.3 ± 6.6)) who presented were used as parameters to assess the cortisol rhythm.
at the Otolaryngology Clinic of Erzurum Education and
Research Hospital between January 2009 and March 2011 2.4. Statistics
were included in this study. Twenty-four age and gender
matched volunteer control subjects (age range 18–39 years Statistical analyses were performed by using the SPSS®
(mean ± SD age, 26.1 ± 7.2)) were chosen among healthy software package, version 17.0 (SPSS Inc., Chicago, IL, USA)
patients attending the same hospital during the same period. for Windows®. Categorical variables are presented as per-
We received approval by the Local Hospital Ethical Committee centages and continuous variables are presented as mean ±
and also obtained the informed consent from the patients SD. Data continuous variables were analyzed statistically
before study. using nonparametric tests, using the Friedman two-way
At study entry, all subjects were examined in detail. ANOVA to establish whether melatonin levels differed in the
And also; routine blood and urine analyses, electrocardio- samples taken at the various times to evaluate both the ENP
graphs, spirometry, chest and sinus X-rays were performed patient and control groups. After confirmation, the Wilcoxon
in all subjects. matched-pairs signed-rank test was used to determine the
Study patients and control subjects with any clinical or differences between sample times, and a repeated-measures
laboratory evidence of inflammation, infection or asthma, ANOVA with between subject factors was used to compare the
those who had received hormone therapy and/or steroid cases with the control group. Finally, we used the Mann–
therapy in the one month prior to the study, or those who Whitney test to compare peak values between the patient and
were taking any drugs that might affect melatonin and control groups. A value of P < 0.05 was considered to be
cortisol levels (including antidepressants, antipsychotic med- statistically significant.
ications, benzodiazepines, calcium channel blockers, beta-
blockers, anticoagulants, interleukin-2, non-steroidal anti-
inflammatory drugs) were also excluded from the study. 3. Results
All subjects had given written informed consent to
participate and the aim of the study and possible risks were Thirty-five patients with AR were included in the study
fully explained. This study was acknowledged by the Ethical (mean ± SD age 25.3 ± 6.6 years; 22 (62.9%) males, 13 (37.1%)
Committee of Erzurum Education and Research Hospital. females). The control group included 24 healthy volunteer
418 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9

Fig. 2 – Circadian rhythm of salivary cortisol in the AR and

Fig. 1 – Circadian rhythm of salivary melatonin in the AR and control groups.
control groups.

In our clinical trial, we observed overall decreased levels of

salivary melatonin in AR patients but rhythmicity was seen in
subjects who were age and gender matched with the AR all subjects similar to the previously published papers [13–15].
group (mean ± SD age 26.1 ± 7.2 years; 14 (58.3%) males, 10 The underlying mechanism causing the decline of melatonin
(41.7%) females). in AR patients is still unknown. Although, we may not
Both the study and control groups displayed periodic strongly hypothesize a cause and effect relationship between
patterns in the amounts of salivary melatonin detected. AR and levels of cortisol/melatonin, but this decrease may be
However, the circadian rhythm profiles were more flattened associated with sleep impairment, but it could also be
in the AR group as shown in Fig. 1. associated with inflammation such as other studies [13–15].
As illustrated in Table 1, the amplitude, and the day time Some investigators have claimed that the decline in the
(baseline) and night time (peak) levels of salivary melatonin in melatonin levels might be either due to the direct inhibitory
the AR group were significantly lower than in the control effect of cortisone on pinealocytes or because melatonin is more
group (p < 0.001). No differences were seen in the acrophase rapidly metabolized during the stress caused by disease [16].
and the peak duration of salivary melatonin between the In the present study, we found that salivary cortisol levels
study and control groups (p > 0.05). were lower in patients with AR compared to healthy subjects
As shown in Fig. 2, the salivary cortisol patterns were and we know that chronic inflammation is present in patients
circadian in both groups. The amplitude and the 24 h mean with AR. Some researchers have also detected lower cortisol
levels of salivary cortisol in the AR group were significantly levels among patients with inflammatory diseases [13–15,17].
lower than in the control group (p < 0.001) (Table 2). The Chronic inflammation is seen in atopic disease, and
acrophase was delayed by about 8 h in AR patients (p < 0.001). chronic inflammation may be associated with a lower
response of the hypothalamopituitary axis, as different pro-
inflammatory cytokines inhibit the ACTH-induced production
4. Discussion of cortisol [18,19]. In an expermental mouse model of asthma,
increased airway inflammation was associated with de-
Sleep impairment is a major problem for patients who have creased corticosterone levels [20]. Lower basal cortisol levels
inflammatory disorders of the upper airway tract, such as may contribute to a lack of suppression of airway inflamma-
allergic rhinitis, rhinosinusitis, and nasal polyposis [6]. tion and thus increased sinonasal inflammation, which leads
Several studies of melatonin and cortisol levels in inflam- to AR.
matory diseases have been published. To our knowledge, the We have also documented that the acrophase was
present study is one of the first to report disturbed salivary significantly delayed in the AR group. Similar to our result,
melatonin and cortisol levels in patients with AR. Sleep other researchers have found that acrophase occurs later in
disturbances due to AR may be the causitive factor for the inflammatory patients [14,15,21]. This delay can be explained
abnormal cortisol/melatonin levels. Papers describing lower by sleep disturbance.
melatonin levels in inflammatory patients can be found in the According to our results, cortisol levels were disturbed in
published literature [13–15]. both the quantitative evaluation and the cyclic pattern in

Table 1 – The circadian rhythm parameters of salivary melatonin (mean ± SD).

AR Group (n = 35) Control Group (n = 23) P (One-way ANOVA)

Day Time (Baseline) (pg/ml) 4.3 ± 1.9 8.5 ± 3.2 <.001

Night Time (Peak) (pg/ml) 25.1 ± 7.8 77.6 ± 19.8 <.001
Amplitude (pg/ml) 19.2 ± 3.0 70.1 ± 18.7 <.001
Acrophase (hour:min) 03:01 ± 1:09 03:12 ± 1:26 >.05
Peak Duration (hour:min) 9.6 ± 1.2 10.1 ± 1.3 >.05
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9 419

Table 2 – The circadian rhythm parameters of salivary cortisol (mean ± SD).

AR Group (n = 35) Control Group (n = 23) p (One-way ANOVA)

24-h Mean Level (ng/ml) 3.8 ± 0.9 8.2 ± 1.4 <0.001

Amplitude (ng/ml) 2.9 ± 0.6 5.1 ± 1.8 <0.001
Acrophase (hour:min) 14:22 ± 1:35 06:13 ± 1:19 <0.001

patients with AR. Since cortisol is anti-inflammatory, the [7] Pappolla MA, Sos M, Omar RA, et al. Melatonin prevents death
decrease in this parameter could worsen the inflammatory of neuroblastoma cells exposed to the Alzheimer amyloid
peptide. J Neurosci 1997;17:1683–90.
process in the nose as well as the whole body. Therefore,
[8] Reiter RJ. The pineal gland and melatonin in relation to aging:
steroid therapy is an effective alternative in the treatment of a summary of the theories and of the data. Exp Gerontol
AR. We have suggested that melatonin treatment can be 1995;30:199–212.
applied with or without therapies in AR patients. In addition, [9] Martins E, Ligeiro AP, Fialho AM, et al. Melatonin modulates
chronotherapy should be used to improve the effect of allergic lung inflammation. Pineal Res 2001;31:363–9.
medications in this patient group. [10] Van Cauter E. In: Becker KL, editor. Endocrine rhythms. In
The findings of the present study add to our knowledge of principles and practice of endocrinology and metabolism.
Philadelphia: J.B. Lippincott Company; 1995. p. 41–50.
the melatonin and cortisol rhythm in AR patients. Further-
[11] Beyer HS, Matta SG, Sharp BM. Regulation of the messenger
more, our results may be applicable as therapeutic or ribonucleic acid for corticotropin-releasing factor in the
diagnostic tools in the near future and melatonin drugs paraventricular nucleus and other brain sites of the rat.
might be useful in the therapy of AR. Endocrinology 1988;123:2117–23.
[12] Jensen MA, Hansen AM, Abrahamsson P, et al. Development
and evaluation of a liquid chromatography tandem mass
spectrometry method for simultaneous determination of
Acknowledgment salivary melatonin, cortisol and testosterone. Chromatogr B
Analyt Technol Biomed Life Sci 2011;879:2527–32.
[13] Kos-Kudla B, Ostrowska Z, Marek B, et al. Diurnal rhythm of
Statistical assessment can be found in Methods section.
serum melatonin, ACTH and cortisol in asthma patients with
There is no conflict of interests between authors. long term glucocorticoid treatment. Endocr Regul 1997;31:47–54.
[14] Fei GH, Liu RY, Zhang ZH, et al. Alterations in circadian
rhythms of melatonin and cortisol in patients with bronchial
REFERENCES asthma. Acta Pharmacol Sin 2004;25:651–6.
[15] Fidan V, Alp HH, Kalkandelen S, et al. Melatonin and cortisol
rhythm in patients with extensive nasal polyposis.Am J
[1] Storms WW. Pharmacologic approaches to daytime and Otolaryngol 2012 Oct 16. doi:pii: S0196-0709(12)00183-4.
nighttime symptoms of allergic rhinitis. J Allergy Clin 10.1016/j.amjoto.2012.09.001. [Epub ahead of print].
Immunol 2004;114(5):46–53. [16] Barriga C, Martin MI, Tabla R, et al. Circadian rhythm of
[2] Smolensky MH, Reinberg A, Labrecque G. Twenty-four hour melatonin, corticosterone and phagocytosis: effect of stress. J
pattern in symptom intensity of viral and allergic rhinitis: Pineal Res 2001;30:180–7.
treatment implications. J Allergy Clin Immunol 1995;95(5): [17] Bakkeheim E, Mowinckel P, Carlsen KH, et al. Reduced basal
1084–96. salivary cortisol in children with asthma and allergic rhinitis.
[3] Li J, Wang HY, Zhang CQ, et al. Links between allergic rhinitis Acta Paediatr 2010;99:1705–11.
and asthma. Chin Med J 2006;119(8):676–83. [18] Calcagni E, Elenkov I. Stress system activity, innate and T
[4] Koh YY, Kim CK. The development of asthma in patients with helper cytokines, and susceptibility to immune-related
allergic rhinitis. Curr Opin Allergy Clin Immunol 2003;3(3): diseases. Ann N Y Acad Sci 2006;1069:62–76.
159–64. [19] Tsigos C, Chrousos GP. Hypothalamic–pituitary–adrenal axis,
[5] Craig TJ, Teets S, Lehman EB, et al. Nasal congestion neuroendocrine factors and stress. J Psychosom Res 2002;53:
secondary to allergic rhinitis as a cause of sleep disturbance 865–71.
and daytime fatigue and the response to topical nasal [20] Silverman ES, Breault DT, Vallone J, et al. Corticotropin-
corticosteroids. J Allergy Clin Immunol 1998;101(5):633–7. releasing hormone deficiency increases allergen-induced
[6] Garcia-Mauriño S, Gonzalez-Haba MG, Calvo JR, et al. airway inflammation in a mouse model of asthma. J Allergy
Melatonin enhances IL-2, IL-6, and IFN-gamma production by Clin Immunol 2004;114:747–54.
human circulating CD4+ cells: a possible nuclear receptor- [21] Haen E, Hauck R, Emslander HP, et al. Nocturnal asthma. Beta 2-
mediated mechanism involving T helper type 1 lymphocytes adrenoceptors on peripheral mononuclear leukocytes, cAMP-
and monocytes. J Immunol 1997;159(2):574–81. and cortisol-plasma concentrations. Chest 1991;100:1239–45.