BACKGROUNDPrader-Willi syndrome (PWS), a neurodevelopmental disorder resulting from the loss of paternally derived but maternally imprinted genes in chromosomal region 15q11-13, is typically associated with marked hyperphagia leading to massive obesity if food intake is not controlled. The hyperphagia-related behavior is currently attributed mainly to dysregulation of hypothalamic signaling pathways, but recently there has been increasing evidence for involvement of the dopaminergic reward system in appetite regulation in PWS. Epigenetic alterations in appetite-regulatory genes outside the PWS locus have been demonstrated, but without establishing a link to hyperphagia-related behavior in PWS. In the present study, gene promoter methylation of the dopaminergic genes dopamine transporter (DAT) and dopamine receptor D2 (DRD2) was examined by DNA bisulfite sequencing in 32 individuals with PWS compared with a control group (n = 14) matched for sex, age, and body mass index (BMI). Methylation analysis results were further examined for their correlation with hyperphagia-related behaviors in PWS assessed by Hyperphagia-Questionnaire for Clinical Trials (HQ-CT), a caregiver-report test instrument developed and validated for PWS. RESULTSStatistical analysis revealed significant hypomethylation of both the DAT and DRD2 gene promoter in PWS compared with controls. DRD2 methylation inversely correlated with hyperphagia-related behavior based on HQ-CT scores in the PWS group, whereas the statistical mixed linear model showed a significant effect of the factor HQ-CT score on both DRD2 and DAT gene promoter methylation. In addition, a significant positive correlation was found between DRD2 and DAT gene promoter methylation in PWS, with DRD2 methylation also depending on the age of the subjects. CONCLUSIONSPWS appears to be accompanied by epigenetic alterations in relevant dopaminergic genes, which in case of DRD2 may influence PWS-typical hyperphagia-related behavior, providing further evidence for the dopamine system as a behavior-modulating factor in PWS. In this regard, hypomethylation of the DRD2 gene promoter may represent a counterregulatory mechanism in response to a hypodopaminergic state generally associated with hyperphagia and obesity. Knowledge of dopaminergic dysregulation in PWS may open doors for future treatment options that possibly apply to other eating disorders and obesity-related diseases.