The Interplay Between Sleep Disorders and Dermatology

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While it is not known whether sleep disturbance causes skin disease or skin diseases causes sleep impairment, it is suspected that a bidirectional influence is at play. A recent review aimed to consolidate all existing research into sleep disorders in dermatology, with the goal of identifying chronic dermatologic diseases known to be exacerbated by them.¹

Methods

The review identified 72 publications with relevant information: 11 clinical trials (8 randomized), 5 meta-analyses, 19 reviews, and the remainder associated data. Publications included those discussing overall sleep disorders in dermatology, sleep disorders associated with certain dermatology drugs, dermatological conditions associated with certain sleep disorder drugs, and sleep disturbances due to itch or other skin irritations.

Basic Pathophysiology

Sleep can be characterized into two stages: rapid eye movement (REM) and non-REM (NREM), each crucial for functions such as memory consolidation.The circadian rhythm, a process that takes place over 24 hours, leads to consistent and restorative sleep. However, an altered circadian rhythm can lead to insomnia and other sleep disorders.²

Studies have shown that sleep loss can affect different parts of the immune system, which can lead to the development of a wide variety of disorders. The review stated the release of inflammatory cytokines due to reduced sleep causes damage to the skin barrier function, which can lead to the assumption that infections, as well as dermatologic diseases, are aggravated under these conditions.³ Some inflammatory conditions, such as psoriasis, can make it difficult to fall asleep in the first place due to their impact on body heat regulation.⁴

Chronic insomnia, found in as many as 33% of the population, can be caused or worsened by several factors. These can include psychological stressors, such as depression or anxiety, which can also lead to flare ups of various dermatological conditions like psoriasis, urticaria, and eczema. The review stated that it must be discussed that insomnia may not only be a consequence of this exacerbation, but also a cause.^5-6

Skin Diseases and their Association with Sleep Disorders

Atopic dermatitis (AD) has been frequently associated with sleep disturbance, with the review noting it is uncertain whether sleep disturbance is a symptom or cause of flares rather than a comorbidity. These sleep disturbances can lead to a reduced quality of life in dermatologic patients, more missed workdays, and an increased economic burden. Researchers noted that several drugs, such as cyclosporine, dupilumab, and azathioprine, resulted in substantial reductions in AD lesions and associated symptoms such as itching and sleep disturbances.^7-8

Eczema and psoriasis can also impact sleep due to their physical symptoms and systemic effects. Both conditions are associated with fatigue, psychological issues such as depression and anxiety, and physical limitations. Sleep disorders like obstructive sleep apnea and restless leg syndrome are also common among psoriasis patients, further complicating their sleep quality.⁹

Chronic urticaria causes itching and burning, disrupting sleep in more than 50% of patients. Anxiety, depression, and other psychological disorders are prevalent in these patients, exacerbating their sleep disturbances. Pruritus, or itching, is a common symptom across various chronic skin conditions, affecting sleep quality, work productivity, and overall well-being.¹⁰

Nocturnal pruritus, common in conditions like scabies and psoriasis, is influenced by factors like body temperature changes, skin barrier function, and cytokine levels. Hormonal fluctuations, such as decreased melatonin levels in AD, also contribute to sleep deprivation and worsening pruritus. Pruritus can also be a symptom of serious diseases like leukemia and lymphoma, impacting sleep and serving as a diagnostic clue in some cases.¹¹

Sleep Management Suggestions for Patients

Overall, researchers stated the interplay between skin conditions and sleep disturbances underscores the need for comprehensive management strategies that address both dermatologic symptoms and associated sleep disorders to improve patient outcomes and quality of life. They wrote that managing the itching associated with chronic skin conditions can help patients get a good night’s sleep, suggesting solutions such as: clean linens, keeping cool at night, keeping nails clean and trimmed, applying moisturizer before bed, and keeping to a structured sleep-wake schedule.

References

1. Mann C, Gorai S, Staubach-Renz P, et al. Sleep disorders in dermatology - a comprehensive review. J Dtsch Dermatol Ges. 2023;21(6):577-584. doi:10.1111/ddg.14992
2. Toh KL. Basic science review on circadian rhythm biology and circadian sleep disorders. Ann Acad Med Singap. 2008;37(8):662-668.
3. Gamaldo CE, Shaikh AK, McArthur JC. The sleep-immunity relationship. Neurol Clin. 2012;30(4):1313-1343. doi:10.1016/j.ncl.2012.08.007
4. Krauchi K, Deboer T. The interrelationship between sleep regulation and thermoregulation. Front Biosci (Landmark Ed). 2010;15(2):604-625. Published 2010 Jan 1. doi:10.2741/3636
5. Bhaskar S, Hemavathy D, Prasad S. Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities. J Family Med Prim Care. 2016;5(4):780-784. doi:10.4103/2249-4863.201153
6. Orzeł-Gryglewska J. Consequences of sleep deprivation. Int J Occup Med Environ Health. 2010;23(1):95-114. doi:10.2478/v10001-010-0004-9
7. Bawany F, Northcott CA, Beck LA, et al. Sleep disturbances and atopic dermatitis: Relationships, methods for assessment, and therapies. J Allergy Clin Immunol Pract. 2021;9(4):1488-1500. doi:10.1016/j.jaip.2020.12.007
8. Werfel T, Heratizadeh A, Aberer W, et al. Update "Systemic treatment of atopic dermatitis" of the S2k-guideline on atopic dermatitis. J Dtsch Dermatol Ges. 2021;19(1):151-168. doi:10.1111/ddg.14371
9. Gupta MA, Simpson FC, Gupta AK. Psoriasis and sleep disorders: A systematic review. Sleep Med Rev. 2016;29:63-75. doi:10.1016/j.smrv.2015.09.003
10. He GY, Tsai TF, Lin CL, et al. Association between sleep disorders and subsequent chronic spontaneous urticaria development: A population-based cohort study. Medicine (Baltimore). 2018;97(34):e11992. doi:10.1097/MD.0000000000011992
11. Rubenstein M, Duvic M. Cutaneous manifestations of Hodgkin's disease. Int J Dermatol. 2006;45(3):251-256. doi:10.1111/j.1365-4632.2006.02675.x