Pearls for improving sleep in atopic dermatitis patients

March 23, 2020

Researchers of a recent paper highlight advice physicians can give atopic dermatitis patients to improve their sleep and quality of life.

Around eight in 10 patients with atopic dermatitis experience disturbed sleep due to their condition. In adults this can impact on their performance at work, reducing their productivity; and in children it can impact on their education and cognitive development, leading to behavioural problems and learning disabilities, and impact on the quality-of-life of the rest of the family.

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Researchers at the University of Arizona reviewed the literature to look at what advice physicians can give patient with atopic dermatitis to improve their sleep and quality-of-life and highlighted ‘clinical pearls’ in paper published in Dermatitis.1

Pruritus and scratching directly related to atopic dermatitis can disturbing sleep, so effective control of the condition is central to improving sleep.  Consistent moisturizing and use of topical anti-inflammatory agents leads to better disease control and improved sleep quality, and overnight wet wrap therapy can provide significant relief of night-time pruritus while preventing excoriation, writes Vivian Shi, M.D., Dermatology Division, University of Arizona, Tucson, Ariz.
Systemic treatments such as dupilumab have also been shown to reduce sleep disturbance.2

“Additional investigation of the impact of atopic dermatitis treatment modalities on sleep quality will help bring attention to this often-overlooked component of disease management and patient care,” writes Dr. Shi.

When assessing sleep disturbance and deciding how to address it, it is important to assess the impact of any existing comorbidities, such as obesity, mental disorders, environmental factors and other conditions such as asthma–which affects 40% to 60% of patients with atopic dermatitis, she says. Understanding the patient's sleep habits and routines; whether they experience difficulty falling asleep, staying asleep, or both; and any associations with insomnia such as scratching or asthma exacerbations will inform the management approach, she recommends patients and families keep a sleep diary for two weeks to help evaluate the problem and monitor responses to interventions.

Several non-pharmaceutical approaches can be taken to help the patient more comfortable when sleeping, such as avoiding friction from rough clothing.

“Cotton clothing is commonly recommended for atopic dermatitis patients but can be irritating when dyed or wet and is also prone to bacterial growth. Specially treated silk, such as Dermasilk, is loosely knitted and coated with silver or other antimicrobial agents, such as triclosan, and has been found to have a positive therapeutic effect in atopic dermatitis patients,” Dr. Shi writes.

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Following good sleep hygiene, Dr. Shi also suggests keeping a constant sleep schedule, avoiding daytime naps and caffeine in the afternoon, and ensuring the bedroom is a cool, calm place. Keeping skin temperature down may play an important role as decreased skin temperature leads to vasoconstriction, which can decrease inflammation and pruritus. In addition to keeping the bedroom cool, patients can also use cooling pillows and mattress covers, and sleep with fewer blankets.

Keeping computers and mobile phones switched off or out of the bedroom is also recommended as exposure to higher wavelength blue light emitted from these devices has been shown to decrease non-REM sleep.3

Massage therapy has been shown to relieve insomnia by relaxing muscles and reducing anxiety, according to the paper.4,5 It is believed that massage therapy increases peripheral blood circulation which counteracts the discomfort caused by vasoconstriction. Adding certain natural oils, relaxing music and ambient lighting can intensify the benefits of massage therapy.6 Virgin (cold-pressed) sunflower oils and coconut oils which have anti-inflammatory and antimicrobial properties respectively are particularly beneficial in atopic dermatitis, but olive oil can disrupt the skin barrier function and essential oils promote allergic contact dermatitis.7,8,9

“Insomnia is a significant and often underrecognized consequence of atopic dermatitis,” Dr. Shi concludes.

“Nonpharmaceutical techniques, including behavioral therapy, are especially important for children with atopic dermatitis to encourage development of long-term healthy sleep habits.”

She adds, “Pharmacologic interventions can be pursued when nonpharmaceutical techniques are inadequate to relieve insomnia.”

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The pharmacological options include:

Melatonin regulates the circadian rhythm, lowers core body temperature and reduces inflammatory markers associated with atopic dermatitis, such as IL-4 and immunoglobulin E.

Sedating antihistamines, such as diphenhydramine and hydroxyzine, are often used as first-line therapy in atopic dermatitis for their sedative effects, despite the American Academy of Dermatology guidelines highlighting that there is insufficient evidence to support antihistamine use in atopic dermatitis patients except for insomnia secondary to itch.10
Tricyclic antidepressants, such as doxepin and trimipramine, are used in low doses, but these should be avoided in the elderly because of their anticholinergic effects.

Mirtazapine is an adrenergic, histaminergic and serotonergic antagonist which may be useful in atopic dermatitis due to its antipruritic, anxiolytic, and sedative effects.11

Benzodiazepinesincrease the frequency of the γ-aminobutyric acid (GABA) receptor opening to cause sedation. However, benzodiazepines and nonbenzodiazepine hypnotics may cause respiratory depression, especially in patients with asthma, which is a common comorbidity of atopic dermatitis, and should be avoided in children and older patients because of their addictive potential.12

 

References:

1. Hendricks AJ, Manivannan M, Shi VY. Clinical Pearls on Sleep Management in Atopic Dermatitis. Dermatitis. 2019;30(5):287-293.

2. Cork MJ, Eckert L, Simpson EL, et al. Dupilumab improves patient-reported symptoms of atopic dermatitis, symptoms of anxiety and depression, and health-related quality of life in moderate-to-severe atopic dermatitis: analysis of pooled data from the randomized trials SOLO 1 and SOLO 2. J Dermatolog Treat. 2019;:1-9.

3. Chellappa SL, Steiner R, Oelhafen P, et al. Acute exposure to evening blue-enriched light impacts on human sleep. J Sleep Res. 2013;22(5):573-80.

4. Kaye AD, Kaye AJ, Swinford J, et al. The effect of deep-tissue massage therapy on blood pressure and heart rate. J Altern Complement Med. 2008;14(2):125-8.

5. Schachner L, Field T, Hernandez-reif M, Duarte AM, Krasnegor J. Atopic dermatitis symptoms decreased in children following massage therapy. Pediatr Dermatol. 1998;15(5):390-5.

6. Vaughn AR, Clark AK, Sivamani RK, Shi VY. Natural Oils for Skin-Barrier Repair: Ancient Compounds Now Backed by Modern Science. Am J Clin Dermatol. 2018;19(1):103-117.

7. Karagounis TK, Gittler JK, Rotemberg V, Morel KD. Use of "natural" oils for moisturization: Review of olive, coconut, and sunflower seed oil. Pediatr Dermatol. 2019;36(1):9-15.

8. Danby SG, Alenezi T, Sultan A, et al. Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care. Pediatr Dermatol. 2013;30(1):42-50.

9. Anderson C, Lis-balchin M, Kirk-smith M. Evaluation of massage with essential oils on childhood atopic eczema. Phytother Res. 2000;14(6):452-6.

10. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327-49.

11. Hundley JL, Yosipovitch G. Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol. 2004;50(6):889-91.

12. Kelsay K. Management of sleep disturbance associated with atopic dermatitis. J Allergy Clin Immunol. 2006;118(1):198-201.