Sleep disordered breathing and the risk of psoriasis among US women

Assessing sleep-related breathing disorders among newly diagnosed rheumatoid and psoriatic arthritis patients: a cross-sectional study

OBJECTIVES

This cross-sectional study aimed to determine the prevalence and risk factors for sleep-related breathing disorders (SRBD) in newly diagnosed, untreated rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients, and to develop a screening algorithm for early detection.

METHODS

We evaluated newly diagnosed RA or PsA patients using the Epworth Sleepiness Scale (ESS) questionnaire, cardiorespiratory polygraphy (RPG), and clinical and laboratory assessments. Sleep apnea syndrome (SAS) was diagnosed based on pathological RPG findings excessive daytime sleepiness, defined as ESS score above 10.

RESULTS

The study included 39 patients (22 RA, 17 PsA) and 23 controls. In RPG, SRBD was identified in 38.5% of arthritis patients compared to 39.1% of controls (p = 1.00), with male gender (p = .004) and age (p < .001) identified as risk factors. Excessive daytime sleepiness was noted in 36.4% of RA patients, 17.6% of PsA patients, and 21.7% of controls. Of the 24 patients diagnosed with SRBD, 41.6% met the criteria for SAS. SAS prevalence was 31.8% among RA patients, 0% in PsA patients, and 13% in controls. A significant association was observed between excessive daytime sleepiness and SRBD (p = .036).

CONCLUSION

Our findings reveal a high prevalence of SRBD in newly diagnosed, untreated RA and PsA patients in ESS and RPG, with excessive daytime sleepiness being a reliable predictor of SRBD. Patients with RA exhibited a higher predisposition to SAS. We therefore suggest incorporating ESS and RPG as screening tools in RA or PsA for early detection and management of SRBD.

Investigating Chronotype and Sleep Quality in Psoriatic Patients: Results from an Observational, Web-Based Survey

BACKGROUND

Psoriasis is an inflammatory disease for which the implications and repercussions go far beyond the skin. Psoriasis patients suffer not only due to its skin manifestations and related symptoms but also because of comorbidities and a huge emotional impact.

OBJECTIVE

The objective of this study was to investigate chronotype and sleep quality in a group of Italian psoriatic patients.

MATERIALS AND METHODS

An observational, cross-sectional, web-based study was set up by the Dermatology and Clinical Medicine Sections of the Department of Medical Sciences, University of Ferrara, Italy. The web questionnaire was sent to an email list of an Italian association of psoriatic patients with the aim of recording their main demographic, social, historical, and clinical data. The survey included two questionnaires: the Morningness-Eveningness Questionnaire (MEQ) and the Pittsburg Sleep Quality Index (PSQI).

RESULTS

Two hundred and forty-three psoriatic patients (mean age 52.9 ± 12.8 yrs., 32.5% males and 67.5% females) filled out the questionnaire. A good 63.8% of them were affected with psoriasis for more than 10 years, 25.9% reported having a diffuse psoriasis, and 66.7% were on treatment at the time they completed the questionnaire. With reference to chronotype, the mean MEQ score was 55.2 ± 10.7; furthermore, 44% of the patients were "morning-oriented types", M-types, or "larks", 44.5% were "intermediate-types" or I-types, and 11.5% were "evening-oriented types", E-types, or "owls". No correlations were found between chronotype and psoriasis extension. Based on the PSQI results, 72.8% of the study population was judged to have a low sleep quality. Sleep disturbance was significantly related to female sex, living alone, and the presence of comorbidities.

CONCLUSIONS

Sleep disturbance is very common in psoriatic patients, especially in those with comorbidities, in females, and in patients who live alone. The chronotype in psoriatic patients does not appear different when compared to the general population, nor does it seem to have any link with psoriasis severity.

Circadian Oscillations of Minimal Erythema Dose (MED) are Also Influenced by Diet in Patients with Psoriasis: A Chronomedical Study

INTRODUCTION

Minimal erythema dose (MED) remains a parameter of paramount importance to orient narrow-band (NB)-UVB phototherapy in psoriatic (PsO) patients. Recently, circadian rhythm and diet were recognized as potential MED modulators, but their mutual interaction remains understudied. Thus, we aimed to evaluate the potential diet modulation of MED circadian oscillations.

METHODS

In the first phase, a cohort study was performed comparing potential MED oscillations (morning, afternoon, and evening) among omnivorous psoriatic patients before and after a phototherapy cycle and omnivorous healthy controls. The two groups were age-, gender-, skin-type-, MED-, and diet-matched. Then, in the second phase, another cohort study was carried out comparing MED oscillations 24 h after the last phototherapeutic session only in psoriatic patients cleared with NB-UVB and undergoing different diets (vegan, vegetarian, paleo , ketogenic, intermittent circadian fasting, and omnivore). Patients with different diets were age-, gender-, and skin-type matched.

RESULTS

In the first phase, we enrolled only omnivores, specifically 54 PsO patients and 54 healthy individuals. Their MED before and after NB-UVB therapy changed significantly among the three different time-points (morning, afternoon, and evening) (p < 0.001). The time effect was statistically significant in both groups before and after phototherapy. In the second phase, we enrolled 144 PsO patients (vegan, vegetarian, paleo, ketogenic, intermittent circadian fasting, and omnivore). MED circadian oscillations preserved a significant difference also after clearance and were influenced by diet type and time of day (p < 0.001). In particular, vegans displayed the lowest MED values, whilst Ramadan fasting showed the highest values in morning, afternoon, and evening.

CONCLUSIONS

Diet, like other ongoing therapies, should be reported in the medical records of patients with psoriasis undergoing NB-UVB and patients with lower MEDs should be preferentially treated in the morning when the MED is higher.

Do Sleep Disorders and Western Diet Influence Psoriasis? A Scoping Review

Western diet may trigger sleep disorders and vice versa, but their single and mutual effects on systemic inflammatory diseases (i.e., psoriasis) are far from being fully elucidated. At the same time, psoriatic patients display a great burden of sleep disorders and dysmetabolisms related to an unhealthy lifestyle (i.e., diet). These patients are also affected by a chronic disorder deeply modulated by environmental factors (i.e., sleep and diet) capable to influence drug-response and disease progression. Thus, we aimed to summarize the evidence in the literature that may highlight a potential link among psoriasis–diet–sleep in order to further promote a multidisciplinary approach to psoriatic patients in the scientific community.

Airways therapy of obstructive sleep apnea dramatically improves aberrant levels of soluble cytokines involved in autoimmune disease

Obstructive Sleep Apnea (OSA) damages the health of 35% of adult Americans. Disordered sleep results in increased risk of several autoimmune disorders, but the molecular links to autoimmunity are poorly understood. Herein, we identified four cytokines associated with autoimmune disease, whose median serum levels were significantly different for OSA patients receiving airways therapy, from the levels in untreated OSA patients, APRIL (5.2-fold lower, p = 3.5 × 10^-11), CD30 (1.6-fold higher, p = 7.7 × 10^-5), IFN-Alpha-2 (2.9-fold higher, p = 9.6 × 10^-14) and IL-2 (1.9-fold higher, p = 0.0003). Cytokine levels in airways treated patients were similar to the levels in control subjects. t-SNE and UMAP analysis of these high dimensional patient cytokine data identified only two groups, suggesting a similar global response for all four cytokines to airways therapy. Our findings suggest the levels of these four cytokines may be altered by disordered sleep and perhaps by chronic hypoxia. Therapeutic options are discussed.

Bidirectional Association Between Psoriasis and Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

The link between psoriasis and obstructive sleep apnea (OSA) has not been confirmed. We aimed to investigate the relationship between psoriasis and OSA. We conducted a systematic review and meta-analysis of case-control, cross-sectional, and cohort studies on the association between psoriasis and OSA. We searched MEDLINE and Embase for relevant studies on May 11, 2019. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included studies. We performed random-effects model meta-analysis to calculate pooled odds ratio (ORs) with 95% confidence intervals (CIs) for case-control and cross-sectional studies as well as pooled incidence rate ratio (IRR) with 95% CIs for cohort studies in association between psoriasis and OSA. A total of 4 case-control or cross-sectional studies and 3 cohort studies with a total of 5,840,495 subjects were included. We identified a significantly increased odds for OSA in psoriasis patients (pooled OR 2.60; 95% CI 1.07-6.32), and significantly increased risk for psoriasis in OSA patients (pooled IRR 2.52; 95% CI 1.89-3.36). In conclusion, our study identified a bidirectional association between psoriasis and OSA. Sleep quality should be inquired in patients with psoriasis. Respirologist consultation or polysomnography may be indicated for those presenting with night snoring, recurrent awaking, and excessive daytime sleepiness.

Gut microbiota and nutrient interactions with skin in psoriasis: A comprehensive review of animal and human studies

The intestinal tract (i.e., the gut), is where the body’s nutrients are absorbed, and is simultaneously inhabited by numerous microbes. An increasing body of literature suggests a crucial role for the gut microbiome in modulating systemic inflammatory disease. Psoriasis is a chronic systemic inflammatory disease and its pathogenesis is related to the interaction between genetic susceptibility, immune response and environmental triggers. The omics era has allowed physicians to assess different aspects of psoriasis pathogenesis such as the microbiome, infectome, and autoinfectome. Furthermore, diet appears to play an important role in modulating disease activity, perhaps by influencing gut microbes. Given these observations, we aimed to summarize the current knowledge regarding skin-microbiome-gut-nutrients and psoriasis.

Sleep disorders in patients with psoriasis: a cross-sectional study using non-polysomnographical methods

BACKGROUND

Psoriasis is a chronic inflammatory skin disease which can cause sleep disturbances due to the disease itself or due to its complications. In this study, we aimed to analyze the array of sleep disturbances caused by psoriasis and to evaluate the interaction between the quality of sleep and the duration and severity of psoriasis.

METHODS

Study subjects included 60 patients with plaque psoriasis and 60 sex- and age-matched controls. The Psoriasis Area and Severity Index (PASI) was used to evaluate severity of disease. Body mass index (BMI), medication usage, and duration of disease were recorded. All subjects completed the Epworth Sleepiness Scale (EES), Pittsburgh Sleep Quality Index (PSQI), insomnia severity index (ISI), Berlin-sleep apnea questionnaire, and questions based on criteria of the International Restless Legs Syndrome Study Group indicating the presence of restless legs syndrome (RLS).

RESULTS

There were statistically significant and clinically relevant differences between the patients and controls regarding day-time sleepiness (ESS 5.3 vs 4.1, p = 0.037), sleep quality (PSQI 14.4 vs 4.9, p < 0.001), insomnia (ISI 19.7 vs 14.4, p < 0.001), sleep apnea (high risk 30% vs 7%, p = 0.01), and RLS (high risk 32% vs 0%, p < 0.001).

CONCLUSIONS

Patients with psoriasis experience poor sleep quality and are at markedly increased risk for insomnia, obstructive sleep apnea, and restless legs syndrome. These findings suggest the importance of evaluating patients with psoriasis for conditions that affect sleep. The study results further suggest that simple screening tools may be useful for this task.

Psoriasis and obstructive sleep apnea

BACKGROUND

Psoriasis is a chronic inflammatory skin disorder that is associated with the metabolic syndrome and its components. An association between obstructive sleep apnea (OSA) and the metabolic syndrome was previously observed.

OBJECTIVES

To investigate the association between psoriasis and OSA in a comprehensive community-based database.

MATERIALS AND METHODS

The study was performed utilizing the medical database of Clalit Health Services. Patients with psoriasis were compared to controls regarding the prevalence of OSA in a case-control study. A logistic multivariate model was used to control for independent covariates.

RESULTS

The study included 12,336 patients with psoriasis ≥21 years and 24,008 age- and sex-matched controls. The prevalence of OSA in patients with psoriasis was increased compared to the control group (2.7%, 1.5%, respectively, P < 0.001). Multivariate analysis adjusting for age, sex, ethnicity, body mass index, chronic obstructive pulmonary disease, hypothyroidism, hyperlipidemia, and peptic disease demonstrated a significant association between psoriasis and OSA (odds ratio = 1.27, 95% confidence interval 1.08-1.49, P < 0.001).

CONCLUSION

We found an association between psoriasis and OSA among a large cohort of patients with psoriasis. Clinicians should take into account that patients with psoriasis may have undiagnosed OSA.

Psoriasis is associated with risk of obstructive sleep apnea independently from metabolic parameters and other comorbidities: a large hospital-based case-control study

PURPOSE

Obstructive sleep apnea (OSA) represents a breathing disorder during sleep with significant health consequences. Few studies have examined the prevalence of OSA in psoriatic patients and whether OSA may be associated with psoriasis risk. We aimed to explore: (1) the inverse relationship, that is whether psoriasis might represent an independent predictor of OSA and its severity considering important predisposing factors and (2) the psoriatic phenotype related to severe OSA.

METHODS

In a large hospital-based case-control study, we examined a total of 253 patients with OSA and a control group of 104 subjects without OSA, who underwent full nocturnal polysomnography and dermatologic examination.

RESULTS

The prevalence of psoriasis was significantly greater in OSA patients than in controls (p = 0.03). Psoriasis was associated with OSA risk (p = 0.04) but not severity of OSA, sleepiness severity or sleep efficiency, independently from age, gender, anthropometric features, and significant comorbidities. The phenotype of a psoriatic patient suffering from severe OSA is not different from that of a patient with severe OSA and is not associated with psoriasis severity indexes. OSA psoriatic patients were not compliant with CPAP treatment in comparison with OSA patients without psoriasis.

CONCLUSION

Psoriasis may represent an independent risk factor for OSA above and beyond significant comorbidities, anthropometric and metabolic parameters. Physicians should be aware of the bi-directional association of psoriasis and OSA. Managing psoriasis may be a potential target for preventing OSA as well as the potential cardiovascular mortality related to OSA and psoriasis.

Psoriasis and comorbid diseases: Epidemiology

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. Psoriatic arthritis is a well-known comorbidity of psoriasis. A rapidly expanding body of literature in various populations and settings supports additional associations between psoriasis and cardiometabolic diseases, gastrointestinal diseases, kidney disease, malignancy, infection, and mood disorders. The pathogenesis of comorbid disease in patients with psoriasis remains unknown; however, shared inflammatory pathways, cellular mediators, genetic susceptibility, and common risk factors are hypothesized to be contributing elements. As additional psoriasis comorbidities continue to emerge, education of health care providers is essential to ensuring comprehensive medical care for patients with psoriasis.

Obstructive sleep apnea and dermatologic disorders

Obstructive sleep apnea (OSA) is present in at least 2% of women and 4% of men, and its prevalence is increasing, because a major predisposing factor for OSA is a high body mass index. Psoriasis has the most strongly substantiated link with OSA, where the relationship may be bidirectional. Dermatologic disorders may be comorbid with OSA due to several factors: (i) the heightened proinflammatory state in OSA, which can occur independent of body mass index, and may exacerbate inflammatory dermatoses; (ii) intermittent hypoxemia may promote neovascularization and tumor growth in certain cancers, such as melanoma; (iii) obesity, present in majority of OSA patients, can be associated with a heightened proinflammatory state; (iv) upper airway obstruction due to local tumors or soft tissue swelling due to physical urticaria or angioedema; (v) acute nasal congestion in the atopic patient with allergic rhinitis; (vi) dermatologic disorders associated with other OSA risk factors (eg, acanthosis nigricans and metabolic syndrome); and (vii) a high sympathetic tone (eg, in atopic dermatitis) and resultant sleep fragmentation contributing to upper airway instability during sleep. In many instances, the dermatology patient with OSA may have other medical and psychiatric comorbidities that are also associated with increased OSA risk.

Psoriasis and Sleep Apnea: A Danish Nationwide Cohort Study

STUDY OBJECTIVES

Psoriasis and sleep apnea are associated with significant morbidity and mortality. Although both diseases have been linked with systemic inflammation, studies on their potential bidirectional association are lacking. We investigate the potential association between psoriasis and sleep apnea.

METHODS

All Danish citizens age 18 y or older between January 1, 1997 and December 31, 2011 (n = 5,522,190) were linked at individual level in nationwide registries. Incidence rates (IRs) per 10,000 person-years were calculated and incidence rate ratios (IRRs) adjusted for age, sex, socioeconomic status, smoking history, alcohol abuse, medication, and comorbidity were estimated by Poisson regression.

RESULTS

There were 53,290, 6,885, 6,348, and 39,908 incident cases of mild psoriasis, severe psoriasis, psoriatic arthritis, and sleep apnea, respectively. IRRs (95% confidence interval) for sleep apnea were 1.30 (1.17-1.44), 1.65 (1.23-2.22), and 1.75 (1.35-2.26) in subjects with mild and severe psoriasis, and psoriatic arthritis, and IRRs for mild and severe psoriasis, and psoriatic arthritis in sleep apnea without continuous positive airway pressure (CPAP) therapy were 1.62 (1.41-1.86), 2.04 (1.47-2.82), and 1.94 (1.34-2.79), respectively. In patients with sleep apnea and CPAP therapy (i.e., severe sleep apnea) the IRRs were 1.82 (1.43-2.33), 3.27 (2.03-5.27), and 5.59 (3.74-8.37), respectively.

CONCLUSIONS

Psoriasis was associated with increased risk of sleep apnea, and sleep apnea was associated with increased risk of psoriasis. The clinical significance of this bidirectional relationship warrants further study.