Sleep disorders and atopic dermatitis: A 2-way street?
2018; Elsevier BV; Volume: 142; Issue: 4 Linguagem: Inglês
10.1016/j.jaci.2018.08.005
ISSN1097-6825
AutoresYung-Sen Chang, Bor‐Luen Chiang,
Tópico(s)Food Allergy and Anaphylaxis Research
ResumoSleep disturbance is very common in patients with atopic dermatitis (AD) and is a major factor leading to impaired quality of life. Sleep disturbance is often viewed as one of the symptoms of AD and one of the measures of disease severity. In this review we describe a variety of sleep disorders associated with AD and a wide range of effect that sleep disorders have on patients with AD. We also discuss our current understanding of the mechanism of sleep disturbance in patients with AD. The relationship between sleep disorders and AD might be bidirectional and could form a vicious cycle. Therefore we suggest viewing sleep disorders as a comorbidity of AD for which regular screening and bidirectional management strategies are indicated, with equal focus on maintaining disease control and implementing specific strategies to improve sleep. Sleep disturbance is very common in patients with atopic dermatitis (AD) and is a major factor leading to impaired quality of life. Sleep disturbance is often viewed as one of the symptoms of AD and one of the measures of disease severity. In this review we describe a variety of sleep disorders associated with AD and a wide range of effect that sleep disorders have on patients with AD. We also discuss our current understanding of the mechanism of sleep disturbance in patients with AD. The relationship between sleep disorders and AD might be bidirectional and could form a vicious cycle. Therefore we suggest viewing sleep disorders as a comorbidity of AD for which regular screening and bidirectional management strategies are indicated, with equal focus on maintaining disease control and implementing specific strategies to improve sleep. Atopic dermatitis (AD) is a common allergic disease affecting 15% to 30% of children and 2% to 10% of adults.1Bieber T. Atopic dermatitis.N Engl J Med. 2008; 358: 1483-1494Crossref PubMed Scopus (1557) Google Scholar It is a chronically relapsing pruritic inflammatory skin disease with complex pathophysiology that is still not fully understood.2Leung D.Y. Guttman-Yassky E. Deciphering the complexities of atopic dermatitis: shifting paradigms in treatment approaches.J Allergy Clin Immunol. 2014; 134: 769-779Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar It has long been known that sleep disturbance is very common in patients with AD and is a major factor leading to impaired quality of life.3Camfferman D. Kennedy J.D. Gold M. Martin A.J. Lushington K. Eczema and sleep and its relationship to daytime functioning in children.Sleep Med Rev. 2010; 14: 359-369Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 4Ricci G. Bendandi B. Bellini F. Patrizi A. Masi M. Atopic dermatitis: quality of life of young Italian children and their families and correlation with severity score.Pediatr Allergy Immunol. 2007; 18: 245-249Crossref PubMed Scopus (88) Google Scholar, 5Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema.Int J Clin Pract. 2006; 60: 984-992Crossref PubMed Scopus (342) Google Scholar Sleep disturbance is often viewed as one of the symptoms of AD. For instance, the SCORAD index, the most commonly used symptom score for AD, includes a visual analog scale for subjective sleep loss,6Nantes B. Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis.Dermatology. 1993; 186: 23-31Crossref PubMed Scopus (1857) Google Scholar and studies assessing the effect of treatments for AD commonly evaluate whether the treatment improves sleep.7Hon K.L. Lam M.C. Leung T.F. Chow C.M. Wong E. Leung A.K. Assessing itch in children with atopic dermatitis treated with tacrolimus: objective versus subjective assessment.Adv Ther. 2007; 24: 23-28Crossref PubMed Scopus (40) Google Scholar, 8Leo H.L. Bender B.G. Leung S.B. Tran Z.V. Leung D.Y. Effect of pimecrolimus cream 1% on skin condition and sleep disturbance in children with atopic dermatitis.J Allergy Clin Immunol. 2004; 114: 691-693Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 9Simpson E.L. Gadkari A. Worm M. Soong W. Blauvelt A. Eckert L. et al.Dupilumab therapy provides clinically meaningful improvement in patient-reported outcomes (PROs): a phase IIb, randomized, placebo-controlled, clinical trial in adult patients with moderate to severe atopic dermatitis (AD).J Am Acad Dermatol. 2016; 75: 506-515Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar However, more and more studies have found that sleep disturbances have complex interrelationships with AD and a wide range of effect on patients with AD. Therefore we suggest that sleep disorders in patients with AD should instead be viewed as a comorbidity of AD and as an individual category to be regularly assessed and managed. Sleep disturbance is reported in 47% to 80% of children with AD and in 33% to 87.1% of adults with AD (Table I).1Bieber T. Atopic dermatitis.N Engl J Med. 2008; 358: 1483-1494Crossref PubMed Scopus (1557) Google Scholar, 2Leung D.Y. Guttman-Yassky E. Deciphering the complexities of atopic dermatitis: shifting paradigms in treatment approaches.J Allergy Clin Immunol. 2014; 134: 769-779Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar, 3Camfferman D. Kennedy J.D. Gold M. Martin A.J. Lushington K. Eczema and sleep and its relationship to daytime functioning in children.Sleep Med Rev. 2010; 14: 359-369Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 4Ricci G. Bendandi B. Bellini F. Patrizi A. Masi M. Atopic dermatitis: quality of life of young Italian children and their families and correlation with severity score.Pediatr Allergy Immunol. 2007; 18: 245-249Crossref PubMed Scopus (88) Google Scholar, 5Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema.Int J Clin Pract. 2006; 60: 984-992Crossref PubMed Scopus (342) Google Scholar, 6Nantes B. Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis.Dermatology. 1993; 186: 23-31Crossref PubMed Scopus (1857) Google Scholar, 7Hon K.L. Lam M.C. Leung T.F. Chow C.M. Wong E. Leung A.K. Assessing itch in children with atopic dermatitis treated with tacrolimus: objective versus subjective assessment.Adv Ther. 2007; 24: 23-28Crossref PubMed Scopus (40) Google Scholar, 8Leo H.L. Bender B.G. Leung S.B. Tran Z.V. Leung D.Y. Effect of pimecrolimus cream 1% on skin condition and sleep disturbance in children with atopic dermatitis.J Allergy Clin Immunol. 2004; 114: 691-693Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 9Simpson E.L. Gadkari A. Worm M. Soong W. Blauvelt A. Eckert L. et al.Dupilumab therapy provides clinically meaningful improvement in patient-reported outcomes (PROs): a phase IIb, randomized, placebo-controlled, clinical trial in adult patients with moderate to severe atopic dermatitis (AD).J Am Acad Dermatol. 2016; 75: 506-515Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 10Bartlet L.B. Westbroek R. White J.E. Sleep patterns in children with atopic eczema.Acta Derm Venereol. 1997; 77: 446-448PubMed Google Scholar, 11Chamlin S.L. Mattson C.L. Frieden I.J. Williams M.L. Mancini A.J. Cella D. et al.The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis.Arch Pediatr Adolesc Med. 2005; 159: 745-750Crossref PubMed Scopus (144) Google Scholar, 12Hon K.L. Leung T.F. Wong K.Y. Chow C.M. Chuh A. Ng P.C. Does age or gender influence quality of life in children with atopic dermatitis?.Clin Exp Dermatol. 2008; 33: 705-709Crossref PubMed Scopus (78) Google Scholar, 13Reid P. Lewis-Jones M.S. Sleep difficulties and their management in preschoolers with atopic eczema.Clin Exp Dermatol. 1995; 20: 38-41Crossref PubMed Scopus (101) Google Scholar, 14Dogan D.G. Canaloglu S.K. Kivilcim M. Kum Y.E. Topal E. Catal F. Sleep patterns of young children with newly diagnosed atopic dermatitis.Postepy Dermatol Alergol. 2017; 34: 143-147Crossref PubMed Scopus (12) Google Scholar, 15Chang Y.S. Chou Y.T. Lee J.H. Lee P.L. Dai Y.S. Sun C. et al.Atopic dermatitis, melatonin, and sleep disturbance.Pediatrics. 2014; 134: e397-e405Crossref PubMed Scopus (98) Google Scholar, 16Jeon C. Yan D. Nakamura M. Sekhon S. Bhutani T. Berger T. et al.Frequency and management of sleep disturbance in adults with atopic dermatitis: a systematic review.Dermatol Ther (Heidelb). 2017; 7: 349-364Crossref PubMed Scopus (51) Google Scholar, 17Lewis-Jones M.S. Finlay A.Y. Dykes P.J. The Infants' Dermatitis Quality of Life Index.Br J Dermatol. 2001; 144: 104-110Crossref PubMed Scopus (266) Google Scholar, 18Urrutia-Pereira M. Sole D. Rosario N.A. Neto H.J.C. Acosta V. Almendarez C.F. et al.Sleep-related disorders in Latin-American children with atopic dermatitis: a case control study.Allergol Immunopathol (Madr). 2017; 45: 276-282Crossref PubMed Scopus (9) Google Scholar, 19Camfferman D. Kennedy J.D. Gold M. Martin A.J. Winwood P. Lushington K. Eczema, sleep, and behavior in children.J Clin Sleep Med. 2010; 6: 581-588Crossref PubMed Scopus (59) Google Scholar, 20Silverberg J.I. Garg N.K. Paller A.S. Fishbein A.B. Zee P.C. Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 21Dahl R.E. Bernhisel-Broadbent J. Scanlon-Holdford S. Sampson H.A. Lupo M. Sleep disturbances in children with atopic dermatitis.Arch Pediatr Adolesc Med. 1995; 149: 856-860Crossref PubMed Scopus (145) Google Scholar The majority of studies in the literature describing sleep disturbance in patients with AD are based on questionnaires of subjective sleep problems. The most commonly reported sleep problems in both children and adults with AD include difficulty falling asleep, frequent nighttime awakenings, and excessive daytime sleepiness.4Ricci G. Bendandi B. Bellini F. Patrizi A. Masi M. Atopic dermatitis: quality of life of young Italian children and their families and correlation with severity score.Pediatr Allergy Immunol. 2007; 18: 245-249Crossref PubMed Scopus (88) Google Scholar, 10Bartlet L.B. Westbroek R. White J.E. Sleep patterns in children with atopic eczema.Acta Derm Venereol. 1997; 77: 446-448PubMed Google Scholar, 13Reid P. Lewis-Jones M.S. Sleep difficulties and their management in preschoolers with atopic eczema.Clin Exp Dermatol. 1995; 20: 38-41Crossref PubMed Scopus (101) Google Scholar, 14Dogan D.G. Canaloglu S.K. Kivilcim M. Kum Y.E. Topal E. Catal F. Sleep patterns of young children with newly diagnosed atopic dermatitis.Postepy Dermatol Alergol. 2017; 34: 143-147Crossref PubMed Scopus (12) Google Scholar, 16Jeon C. Yan D. Nakamura M. Sekhon S. Bhutani T. Berger T. et al.Frequency and management of sleep disturbance in adults with atopic dermatitis: a systematic review.Dermatol Ther (Heidelb). 2017; 7: 349-364Crossref PubMed Scopus (51) Google Scholar, 17Lewis-Jones M.S. Finlay A.Y. Dykes P.J. The Infants' Dermatitis Quality of Life Index.Br J Dermatol. 2001; 144: 104-110Crossref PubMed Scopus (266) Google Scholar, 18Urrutia-Pereira M. Sole D. Rosario N.A. Neto H.J.C. Acosta V. Almendarez C.F. et al.Sleep-related disorders in Latin-American children with atopic dermatitis: a case control study.Allergol Immunopathol (Madr). 2017; 45: 276-282Crossref PubMed Scopus (9) Google Scholar, 19Camfferman D. Kennedy J.D. Gold M. Martin A.J. Winwood P. Lushington K. Eczema, sleep, and behavior in children.J Clin Sleep Med. 2010; 6: 581-588Crossref PubMed Scopus (59) Google Scholar, 20Silverberg J.I. Garg N.K. Paller A.S. Fishbein A.B. Zee P.C. Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar Children with AD also reported more wake time after sleep onset and difficulty waking up in the morning.4Ricci G. Bendandi B. Bellini F. Patrizi A. Masi M. Atopic dermatitis: quality of life of young Italian children and their families and correlation with severity score.Pediatr Allergy Immunol. 2007; 18: 245-249Crossref PubMed Scopus (88) Google Scholar, 14Dogan D.G. Canaloglu S.K. Kivilcim M. Kum Y.E. Topal E. Catal F. Sleep patterns of young children with newly diagnosed atopic dermatitis.Postepy Dermatol Alergol. 2017; 34: 143-147Crossref PubMed Scopus (12) Google Scholar, 15Chang Y.S. Chou Y.T. Lee J.H. Lee P.L. Dai Y.S. Sun C. et al.Atopic dermatitis, melatonin, and sleep disturbance.Pediatrics. 2014; 134: e397-e405Crossref PubMed Scopus (98) Google Scholar, 19Camfferman D. Kennedy J.D. Gold M. Martin A.J. Winwood P. Lushington K. Eczema, sleep, and behavior in children.J Clin Sleep Med. 2010; 6: 581-588Crossref PubMed Scopus (59) Google Scholar, 20Silverberg J.I. Garg N.K. Paller A.S. Fishbein A.B. Zee P.C. Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 21Dahl R.E. Bernhisel-Broadbent J. Scanlon-Holdford S. Sampson H.A. Lupo M. Sleep disturbances in children with atopic dermatitis.Arch Pediatr Adolesc Med. 1995; 149: 856-860Crossref PubMed Scopus (145) Google Scholar Chamlin et al11Chamlin S.L. Mattson C.L. Frieden I.J. Williams M.L. Mancini A.J. Cella D. et al.The price of pruritus: sleep disturbance and cosleeping in atopic dermatitis.Arch Pediatr Adolesc Med. 2005; 159: 745-750Crossref PubMed Scopus (144) Google Scholar found that 30% of children with AD reported parent cosleeping, and cosleeping bothered 66% of these parents.Table ISleep disorders in patients with ADSleep disorders in patients with ADPrevalence/characteristicsTool for assessmentReferencesSubjective sleep problems Eczema-affected sleepChildren: 47% to 80%; 86% during eczema flare-upAdults: 33% to 87.1%Questionnaire; interview1-7 Difficulty falling asleepChildren: 10.2% to 51.4%; average sleep onset latency, 39.8 minutesAdults: 76.2% with mild disease, 89% with moderate disease, and 100% with severe diseaseQuestionnaire6-9 Nighttime awakeningsChildren: 43% to 73%; average, 2.7-3.5 awakenings per night during eczema flare-upAdults: 4.8% with mild disease, 76.2% with moderate disease, and 92.6% with severe diseaseInterview1, 4, 5, 7, 9, 10 More wake time after sleep onsetChildren: 38% stayed awake for 0.25-1 hours per night, 20% between 1-2 hours, and 11% for >2 hours; average, 88.3 minutesQuestionnaire5, 10 Difficulty awakening in the morningChildren: 58% to 62.5%Questionnaire6, 8 Excessive daytime sleepinessChildren: 43.1% to 61.9%Adults: OR, 2.66 (95% CI, 2.34-3.01)Questionnaire6, 11, 12 Parent cosleepingChildren: 30%; 66% parents bothered by cosleepingQuestionnaire2Objective sleep problems Prolonged sleep onset latencyChildren: average, 45 minutesActigraphy6 More wake time after sleep onsetChildren: average, 73.2-103.4 minutesAdults: average, 57.3 minutesActigraphy6, 13, 14 Lower sleep efficiencyChildren: average, 72% to 76.8%Adults: average, 90.6%Actigraphy; PSG6, 13-15 OthersChildren: less NREM sleepChildren and adults: more sleep fragmentation, more arousals and awakenings, more scratching and movement in sleepActigraphy; PSG; infrared video6, 16, 17Specific sleep disorders Sleep-disordered breathingChildren with eczema had increased risk of snoring (OR, 1.80; 95% CI, 1.28-2.54); children with AD had higher risk of OSA (HR, 1.86; 95% CI, 1.43-2.42)Adults with OSA more likely to have AD (HR, 1.5; 95% CI, 1.15-1.95); hazard risk was greater in male and young OSA patients (0-18 and 19-34 years)Questionnaire; population-based cohort study18-20 InsomniaAdult patients with AD are more likely to have insomnia (OR, 2.36; 95% CI, 2.11-2.64)Questionnaire, population-based12 OthersChildren with AD had more bedtime resistance and parasomniasChildren Sleep Habits Questionnaire21NREM, Non-REM. Open table in a new tab NREM, Non-REM. Only a few studies have taken objective measurements of sleep in patients with AD (Table I). Laboratory-based polysomnography (PSG), the gold standard assessment for sleep, has seldom been used to evaluate sleep in children with AD,22Reuveni H. Chapnick G. Tal A. Tarasiuk A. Sleep fragmentation in children with atopic dermatitis.Arch Pediatr Adolesc Med. 1999; 153: 249-253Crossref PubMed Scopus (94) Google Scholar, 23Monti J.M. Vignale R. Monti D. Sleep and nighttime pruritus in children with atopic dermatitis.Sleep. 1989; 12: 309-314Crossref PubMed Scopus (47) Google Scholar, 24Hon K.L. Leung T.F. Ma K.C. Li A.M. Wong Y. Yin J.A. et al.Resting energy expenditure, oxygen consumption and carbon dioxide production during sleep in children with atopic dermatitis.J Dermatolog Treat. 2005; 16: 22-25Crossref PubMed Scopus (22) Google Scholar possibly because of the inconvenience of having to be performed at a sleep center overnight. The attachment of multiple leads and equipment during the PSG examination might also result in more skin irritation for the patient with AD. Of the few studies that assessed the sleep of patients with AD by using PSG, Hon et al24Hon K.L. Leung T.F. Ma K.C. Li A.M. Wong Y. Yin J.A. et al.Resting energy expenditure, oxygen consumption and carbon dioxide production during sleep in children with atopic dermatitis.J Dermatolog Treat. 2005; 16: 22-25Crossref PubMed Scopus (22) Google Scholar found that sleep efficiency (the proportion of time in bed spent asleep) was reduced in children with AD compared with control subjects (72% vs 88%, P = .04). Stores et al25Stores G. Burrows A. Crawford C. Physiological sleep disturbance in children with atopic dermatitis: a case control study.Pediatr Dermatol. 1998; 15: 264-268Crossref PubMed Scopus (76) Google Scholar reported that sleep in children with AD was at least 4 times more disrupted than that in control subjects on both brief ( 2 minutes) periods of waking. Our group found that patients with AD had lower sleep efficiency (71.2% vs 76.2%, P = .004) and less non–rapid eye movement (non-REM) sleep than control subjects.15Chang Y.S. Chou Y.T. Lee J.H. Lee P.L. Dai Y.S. Sun C. et al.Atopic dermatitis, melatonin, and sleep disturbance.Pediatrics. 2014; 134: e397-e405Crossref PubMed Scopus (98) Google Scholar Actigraphy involves a small wrist-worn device that uses activity-based monitoring to estimate sleep-wake patterns. Because of its ease of use, it is increasingly applied to provide objective sleep assessments in patients with AD.3Camfferman D. Kennedy J.D. Gold M. Martin A.J. Lushington K. Eczema and sleep and its relationship to daytime functioning in children.Sleep Med Rev. 2010; 14: 359-369Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Our group has validated that actigraphic measures had high correlation with the gold standard PSG measures in patients with AD and suggest that actigraphy is a good and convenient method to assess the sleep of patients with AD in future studies.15Chang Y.S. Chou Y.T. Lee J.H. Lee P.L. Dai Y.S. Sun C. et al.Atopic dermatitis, melatonin, and sleep disturbance.Pediatrics. 2014; 134: e397-e405Crossref PubMed Scopus (98) Google Scholar Benjamin et al26Benjamin K. Waterston K. Russell M. Schofield O. Diffey B. Rees J.L. The development of an objective method for measuring scratch in children with atopic dermatitis suitable for clinical use.J Am Acad Dermatol. 2004; 50: 33-40Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar showed that children with AD spent a mean of 46 minutes less sleeping at night than control subjects (468 ± 3 vs 422 ± 37 minutes). Hon et al27Hon K.L. Lam M.C. Leung T.F. Kam W.Y. Lee K.C. Li M.C. et al.Nocturnal wrist movements are correlated with objective clinical scores and plasma chemokine levels in children with atopic dermatitis.Br J Dermatol. 2006; 154: 629-635Crossref PubMed Scopus (66) Google Scholar reported that actigraphic measures of activity were correlated with disease severity (r = 0.52, P < .01) and occurred most in the first 3 hours of sleeping in children with AD. Our group assessed the sleep of 72 children with AD and 32 control subjects with actigraphy and showed that children with AD had lower sleep efficiency (74.5% ± 9.2% vs 81.2% ± 7.6%, P = .001), more wake time after sleep onset (73.2 ± 45.7 vs 50.7 ± 29.9 minutes, P = .004), longer sleep onset latency (45 ± 29.3 vs 27 ± 16.2 minutes, P < .001), and a higher sleep fragmentation index score.15Chang Y.S. Chou Y.T. Lee J.H. Lee P.L. Dai Y.S. Sun C. et al.Atopic dermatitis, melatonin, and sleep disturbance.Pediatrics. 2014; 134: e397-e405Crossref PubMed Scopus (98) Google Scholar Some specific sleep disorders have been reported to be associated with AD. Sleep-disordered breathing has been found to be associated with AD in several studies: Chng et al28Chng S.Y. Goh D.Y. Wang X.S. Tan T.N. Ong N.B. Snoring and atopic disease: a strong association.Pediatr Pulmonol. 2004; 38: 210-216Crossref PubMed Scopus (109) Google Scholar reported that in preschool and primary school children in Singapore, habitual snoring was associated with AD (odds ratio [OR], 1.80; 95% CI, 1.28-2.54).28Chng S.Y. Goh D.Y. Wang X.S. Tan T.N. Ong N.B. Snoring and atopic disease: a strong association.Pediatr Pulmonol. 2004; 38: 210-216Crossref PubMed Scopus (109) Google Scholar Population-based studies from Taiwan have shown that patients with obstructive sleep apnea (OSA) had a higher risk of AD (hazard ratio [HR], 1.5; 95% CI, 1.15-1.95), especially in male patients with OSA (HR, 1.53; 95% CI, 1.14-2.06), children less than 18 years old with OSA (HR, 4.01; 95% CI, 1.57-10.26), and young patients with OSA aged 19 to 34 years (HR, 1.75; 95% CI, 1.00-3.04; adjusted for allergic rhinitis and asthma).29Tien K.J. Chou C.W. Lee S.Y. Yeh N.C. Yang C.Y. Yen F.C. et al.Obstructive sleep apnea and the risk of atopic dermatitis: a population-based case control study.PLoS One. 2014; 9: e89656Crossref PubMed Scopus (26) Google Scholar In children less than 18 years old, patients with AD had a higher risk of OSA than those without AD (HR, 1.86; 95% CI, 1.43-2.42; adjusted for comorbidities of AD, such as rhinitis).30Hu J.M. Lin C.S. Chen S.J. Chen C.Y. Lin C.L. Kao C.H. Association between obstructive sleep apnea and atopic dermatitis in children: a nationwide, population-based cohort study.Pediatr Allergy Immunol. 2018; 29: 260-266Crossref PubMed Scopus (10) Google Scholar It is hypothesized that the association between AD and OSA could be due to common underlying pathways of oxidative stress and systemic inflammation.29Tien K.J. Chou C.W. Lee S.Y. Yeh N.C. Yang C.Y. Yen F.C. et al.Obstructive sleep apnea and the risk of atopic dermatitis: a population-based case control study.PLoS One. 2014; 9: e89656Crossref PubMed Scopus (26) Google Scholar, 30Hu J.M. Lin C.S. Chen S.J. Chen C.Y. Lin C.L. Kao C.H. Association between obstructive sleep apnea and atopic dermatitis in children: a nationwide, population-based cohort study.Pediatr Allergy Immunol. 2018; 29: 260-266Crossref PubMed Scopus (10) Google Scholar A high sympathetic tone in patients with AD and resultant sleep fragmentation could also contribute to upper airway instability during sleep.31Gupta M.A. Simpson F.C. Vujcic B. Gupta A.K. Obstructive sleep apnea and dermatologic disorders.Clin Dermatol. 2017; 35: 319-327Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar A US population-based study showed that in adults eczema was associated with regular insomnia (OR, 2.36; 95% CI, 2.11-2.64).20Silverberg J.I. Garg N.K. Paller A.S. Fishbein A.B. Zee P.C. Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study.J Invest Dermatol. 2015; 135: 56-66Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar Urrutia-Pereira et al18Urrutia-Pereira M. Sole D. Rosario N.A. Neto H.J.C. Acosta V. Almendarez C.F. et al.Sleep-related disorders in Latin-American children with atopic dermatitis: a case control study.Allergol Immunopathol (Madr). 2017; 45: 276-282Crossref PubMed Scopus (9) Google Scholar reported that in Latin American children, patients with AD had more bedtime resistance, sleep-disordered breathing, and parasomnias compared with control subjects. Cicek et al32Cicek D. Halisdemir N. Dertioglu S.B. Berilgen M.S. Ozel S. Colak C. Increased frequency of restless legs syndrome in atopic dermatitis.Clin Exp Dermatol. 2012; 37: 469-476Crossref PubMed Scopus (17) Google Scholar reported that restless leg syndrome was more common in patients with AD than control subjects, although the underlying mechanism of this association is unclear. We suggest that patients with AD who complain of sleep problems should be carefully assessed for these associated sleep disorders to provide adequate treatment. After itch, sleep disturbance has been ranked as the second highest factor leading to impaired quality of life in children with AD.12Hon K.L. Leung T.F. Wong K.Y. Chow C.M. Chuh A. Ng P.C. Does age or gender influence quality of life in children with atopic dermatitis?.Clin Exp Dermatol. 2008; 33: 705-709Crossref PubMed Scopus (78) Google Scholar Children with AD have been reported to have lower quality of life than children with other chronic skin diseases, such as psoriasis, urticaria, and acne, and also other chronic diseases, such as renal disease, asthma, cystic fibrosis, epilepsy, and diabetes.33Beattie P.E. Lewis-Jones M.S. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases.Br J Dermatol. 2006; 155: 145-151Crossref PubMed Scopus (388) Google Scholar The quality of life and sleep of family members are also affected by childhood AD. In parents of children with chronic illnesses, sleep disruption is most highly reported in parents of children with AD, affecting 54% to 86% of parents.34Meltzer L.J. Moore M. Sleep disruptions in parents of children and adolescents with chronic illnesses: prevalence, causes, and consequences.J Pediatr Psychol. 2008; 33: 279-291Crossref PubMed Scopus (102) Google Scholar Mean reduction in parental sleep time during flare-ups in children with AD ranged from 0.66 to 2.6 hours per night.13Reid P. Lewis-Jones M.S. Sleep difficulties and their management in preschoolers with atopic eczema.Clin Exp Dermatol. 1995; 20: 38-41Crossref PubMed Scopus (101) Google Scholar, 35Moore K. David T.J. Murray C.S. Child F. Arkwright P.D. Effect of childhood eczema and asthma on parental sleep and well-being: a prospective comparative study.Br J Dermatol. 2006; 154: 514-518Crossref PubMed Scopus (106) Google Scholar Lawson et al36Lawson V. Lewis-Jones M.S. Finlay A.Y. Reid P. Owens R.G. The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire.Br J Dermatol. 1998; 138: 107-113Crossref PubMed Scopus (319) Google Scholar reported that 64% of parents of children with AD reported frustration and exhaustion caused by sleep problems, and 63% of siblings of children with AD were also losing sleep. Another study showed that the severity of sleep disturbance in the parents of children with AD was associated with the level of parental anxiety (maternal anxiety: r = 0.58, P = .002; paternal anxiety: r = 0.59, P = .01) and maternal depression (r = 0.73, P < .001).35Moore K. David T.J. Murray C.S. Child F. Arkwright P.D. Effect of childhood eczema and asthma on parental sleep and well-being: a prospective comparative study.Br J Dermatol. 2006; 154: 514-518Crossref PubMed Scopus (106) Google Scholar Sleep disturbance itself can have many negative consequences for children, including higher rates of behavioral problems, impaired neurocognitive function, and changes in mood.37Sadeh A. Gruber R. Raviv A. Sleep, neurobehavioral functioning, and behavior problems in school-age children.Child Dev. 2002; 73: 405-417Crossref PubMed Scopus (564) Google Scholar, 38Touchette E. Petit D. Seguin J.R. Boivin M. Tremblay R.E. Montplaisir J.Y. Associations between sleep duration patterns and behavioral/cognitive functioning at school entry.Sleep. 2007; 30: 1213-1219Crossref PubMed Scopus (356) Google Scholar A study found that 54% of parents of children with AD reported behavioral disturbances, such as irritability, bad temper, and being hurtful to other family members during flare-ups of AD.36Lawson V. Lewis-Jones M.S. Finlay A.Y. Reid P. Owens R.G. The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire.Br J Dermatol. 1998; 138: 107-113Crossref PubMed Scopus (319) Google Scholar A large cohort study including 1658 children showed that infant eczema with concurrent sleeping problems predicted emotional (OR, 2.63; 95% CI, 1.20-5.76) and conduct (OR, 3.03; 95% CI, 1.01-9.12) problems at 10 years of age.39Schmitt J. Chen C.M. Apfelbacher C. Romanos M. Lehmann I. Herbarth O. et al.Infant eczema, infant sleeping problems, and mental health at 10 years of age: the prospective birth cohort study LISAplus.Allergy. 2011; 66: 404-411Crossref PubMed Scopus (93) Google Scholar It has also been found that AD is associated with attention deficit hyperactivity disorder and short stature only when accompanied by sleep problems.40Silverberg J.I. Paller A.S. Association between eczema and stature in 9 US population-based studies.JAMA Dermatol. 2015; 151: 401-409Crossref PubMed Scopus (38) Google Scholar, 41Romanos M. Gerlach M. Warnke A. Schmitt J. Association of attention-deficit/hyperactivity disorder and atopic eczema modified by sleep disturbance in a large population-based sample.J Epidemiol Community Health. 2010; 64: 269-273Crossref PubMed Scopus (120) Google Scholar Because
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