The bidirectional interactions between psoriasis and obstructive sleep apnea

Risk of respiratory diseases among hospitalized patients with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a systemic disorder associated with various metabolic and inflammatory comorbidities. Although HS shares risk factors and pathogenic pathways with various respiratory conditions, few studies have explored the relationship between HS and respiratory disease.

METHODS

This is a cross-sectional, case-control, population-based study that examined the United States National Inpatient Sample database from January 1, 2002, to December 31, 2012. HS was identified using ICD-9-CM codes during hospital admissions. Multivariable logistic regression was used to evaluate for adjusted associations between HS and respiratory diagnoses as compared to matched controls.

RESULTS

Twenty-three thousand seven hundred and sixty-seven hospital admissions for HS were compared with 95,068 age- and sex-matched controls. HS patients had significantly higher adjusted odds of asthma (OR: 1.233; 95% CI: [1.170-1.299]; P < 0.001), chronic airway obstruction (OR: 1.532; 95% CI: [1.419-1.651]; P < 0.001), sarcoidosis (OR: 1.601; 95% CI: [1.157-2.214]; P < 0.001), and sleep apnea (OR: 1.274; 95% CI: [1.182-1.374]; P < 0.001).

CONCLUSION

HS is associated with several common forms of respiratory disease. Knowledge of these associations may allow for better recognition of respiratory disease in HS patients.

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.

Sleep Disorders and Psoriasis: An Update

Psoriasis alters patients’ quality of life. Among the disorders associated with psoriasis, sleep disorders are common, although they are not directly assessed by most quality-of-life scores. Thus, the specific evaluation of sleep disorders using dedicated scores is necessary, especially because such disorders alter patients;’ physical and psychological health. The relationship between psoriasis and sleep disorders has been shown in numerous studies, but has not yet been fully elucidated. The aim of this study was to update knowledge of sleep disorders in patients with psoriasis, through a review of the scientific literature since 1980. This work covers several topics of interest, such as sleep assessment methods, the prevalence of sleep disorders in patients with psoriasis, factors predictive of sleep disorders in patients with psoriasis, the impact of sleep disorders on comorbidities and quality of life, pathogenic mechanisms, obstructive sleep apnoea and restless leg syndromes, and the impact of biotherapy treatments on sleep disorders in patients with psoriasis.

Clinical and biological impact of the exposome on the skin

The skin exposome is defined as the totality of environmental exposures over the life course that can induce or modify various skin conditions. Here, we review the impact on the skin of solar exposure, air pollution, hormones, nutrition and psychological factors. Photoageing, photocarcinogenesis and pigmentary changes are well-established consequences of chronic exposure of the skin to solar radiation. Exposure to traffic-related air pollution contributes to skin ageing. Particulate matter and nitrogen dioxide cause skin pigmentation/lentigines, while ozone causes wrinkles and has an impact on atopic eczema. Human skin is a major target of hormones, and they exhibit a wide range of biological activities on the skin. Hormones decline with advancing age influencing skin ageing. Nutrition has an impact on numerous biochemical processes, including oxidation, inflammation and glycation, which may result in clinical effects, including modification of the course of skin ageing and photoageing. Stress and lack of sleep are known to contribute to a pro-inflammatory state, which, in turn, affects the integrity of extracellular matrix proteins, in particular collagen. Hormone dysregulation, malnutrition and stress may contribute to inflammatory skin disorders, such as atopic dermatitis, psoriasis, acne and rosacea.

Alcohol in Psoriasis-From Bench to Bedside

Alcohol affects the symptoms, compliance and comorbidities as well as the safety and efficacy of treatments in psoriatic patients. In this review, we aim to summarize and link clinical observations with a molecular background, such as signaling pathways at the cellular level and genetic variations, and to provide an overview of how this knowledge could influence our treatment selection and patient management.

Insights into interplay of immunopathophysiological events and molecular mechanistic cascades in psoriasis and its associated comorbidities

Psoriasis is an inflammatory skin disease with complex pathogenesis and multiple etiological factors. Besides the essential role of autoreactive T cells and constellation of cytokines, the discovery of IL-23/Th17 axis as a central signaling pathway has unraveled the mechanism of accelerated inflammation in psoriasis. This has provided insights into psoriasis pathogenesis and revolutionized the development of effective biological therapies. Moreover, genome-wide association studies have identified several candidate genes and susceptibility loci associated with this disease. Although involvement of cellular innate and adaptive immune responses and dysregulation of immune cells have been implicated in psoriasis initiation and maintenance, there is still a lack of unifying mechanism for understanding the pathogenesis of this disease. Emerging evidence suggests that psoriasis is a high-mortality disease with additional burden of comorbidities, which adversely affects the treatment response and overall quality of life of patients. Furthermore, changing trends of psoriasis-associated comorbidities and shared patterns of genetic susceptibility, risk factors and pathophysiological mechanisms manifest psoriasis as a multifactorial systemic disease. This review highlights the recent progress in understanding the crucial role of different immune cells, proinflammatory cytokines and microRNAs in psoriasis pathogenesis. In addition, we comprehensively discuss the involvement of various complex signaling pathways and their interplay with immune cell markers to comprehend the underlying pathophysiological mechanism, which may lead to exploration of new therapeutic targets and development of novel treatment strategies to reduce the disastrous nature of psoriasis and associated comorbidities.

The Assessment of Risk and Predictors of Sleep Disorders in Patients with Psoriasis-A Questionnaire-Based Cross-Sectional Analysis

Psoriasis is a chronic, inflammatory skin disease affecting 2-4% of the general population. Accompanying subjective symptoms (pruritus or pain) may cause decreased life quality including sleep disorders (SD). Sixty psoriatic patients fulfilled the following questionnaires: Pittsburgh Sleep Quality Index (PSQI), STOP BANG for the obstructive sleep apnea syndrome (OSAS) assessment, and Restless Legs Syndrome (RLS) Severity Scale. Patients' laboratory and clinical data were also investigated. All data obtained were compared to 40 participants without dermatoses. Mean PSQI, risk of OSAS, and RLS severity of psoriatics were significantly higher than in controls (p < 0.0001, p < 0.05, p < 0.05 respectively). There was a positive correlation between the time of suffering from psoriasis and the risk of OSAS (R = 0.286, p < 0.05). We did not observe any significant relationship between PSQI, risk of OSAS, or RLS and psoriasis severity assessed with PASI (Psoriasis Area and Severity Index). We identified four possible predictors of RLS: glucose, CRP and total cholesterol concentrations, and PSQI. SD are significantly more frequent in psoriatics than in people without chronic dermatological diseases but surprisingly they are not correlated with psoriasis severity. SD decrease patients' life quality and may result in serious consequences. Therefore, establishing recommendations concerning screening for SD and their predictors should be considered.

Sleep Apnea and Skin

Purpose of the Review

Skin disease is associated with obstructive sleep apnea (OSA) both epidemiologically and mechanistically. In this review we highlight conditions which have a well-established link to obstructive sleep apnea, such as psoriasis and atopic dermatitis.

Recent findings

We describe putative mechanistic links between OSA and skin disease involving inflammatory pathways, obesity, mechanical upper airways obstruction, and hypoxia. In the context of these mechanisms we describe specific skin conditions, and other conditions which are associated with both skin manifestations (including hair/nail findings) and OSA. The risks/ benefits of CPAP in the context of skin disease are also reviewed.

Summary

We conclude that further research is needed to understand the mechanisms behind the associations between OSA and skin disease. Given the frequent co-occurrence of OSA and skin conditions, there would be great benefit for OSA clinical trials to consider improvement in skin disease as an outcome measure.

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.

Factors Influencing Sleep Difficulty and Sleep Quantity in the Citizen Pscientist Psoriatic Cohort

INTRODUCTION

Sleep is essential for overall health and well-being, yet more than one-third of adults report inadequate sleep. The prevalence is higher among people with psoriasis, with up to 85.4% of the psoriatic population reporting sleep disruption. Poor sleep among psoriasis patients is particularly concerning because psoriasis is independently associated with many of the same comorbidities as sleep dysfunction, including cardiovascular disease, obesity, and depression. Given the high prevalence and serious consequences of disordered sleep in psoriasis, it is vital to understand the nature of sleep disturbance in this population. This study was designed to help meet this need by using survey data from Citizen Pscientist, an online patient portal developed by the National Psoriasis Foundation.

METHODS

Our analysis included 3118 participants who identified as having a diagnosis by a physician of psoriasis alone or psoriasis with psoriatic arthritis. Demographic information, psoriasis severity and duration, sleep apnea status, smoking and alcohol consumption, itch timing, and sleep characteristics were included. Two separate multivariate logistic regression models in STATA were used to determine whether the presence of psoriatic arthritis, age, gender, body mass index, comorbid sleep apnea, psoriasis severity, timing of worst itch, smoking status, or high-risk alcohol consumption were associated with sleep difficulty or low sleep quantity, defined by the American Academy of Sleep Medicine as less than 7 h of sleep per night on average.

RESULTS

Results from the multivariate logistic regressions found that sleep difficulty was associated with psoriatic arthritis (OR 2.15, 95% CI [1.79-2.58]), female gender (2.03 [1.67-2.46]), obese body mass index (BMI ≥ 30) (1.25 [1.00-1.56]), sleep apnea (1.41 [1.07-1.86]), psoriasis severity of moderate (1.59 [1.30-1.94]) or severe (2.40 [1.87-3.08]), and smoking (1.60 [1.26-2.02]). Low sleep quantity was associated with obese BMI (1.62 [1.29-2.03]), sleep apnea (1.30 [1.01-1.68]), psoriasis severity of moderate (1.41 [1.16-1.72]) or severe (1.40 [1.11-1.76]), and smoking (1.62 [1.31-2.00]). Sleep difficulty and low sleep quantity were not associated with age, alcohol consumption, or timing of worst itch.

CONCLUSION

These results are potentially meaningful in several aspects. We identify an important distinction between sleep difficulty and sleep quantity in psoriatic disease, whereby having psoriatic arthritis and being female are each associated with sleep difficulty despite no association with low sleep quantity. Furthermore, there is conflicting evidence from prior studies as to whether psoriasis severity is associated with sleep difficulty, but this well-powered, large study revealed a strong, graded relationship between psoriasis severity and both sleep difficulty and low sleep quantity. Overall, our results show that both sleep difficulty and low sleep quantity were associated with multiple factors in this analysis of a large psoriatic cohort. These findings suggest that dermatologists may gather clinically useful information by screening psoriatic patients for trouble sleeping and low sleep quantity to identify potential comorbidities and to more effectively guide disease management.

A cross-sectional survey of the nature and correlates of sleep disturbance in people with psoriasis

BACKGROUND

Research suggests that sleep disturbance is common in psoriasis. While several sleep investigations have been conducted in psoriasis populations, many have methodological shortcomings, and no study has examined multiple dimensions of sleep-wake functioning. Moreover, research has yet to be performed comprehensively examining the range of physical and psychological factors that may affect sleep in people with psoriasis.

OBJECTIVES

To characterize sleep disturbance using validated measures and to identify physical and psychological predictors of sleep quality in people with psoriasis.

METHODS

An online survey was conducted (186 respondents; mean age 39·2 years) comprising validated measures assessing sleep [Pittsburgh Sleep; Quality Index (PSQI), Berlin Questionnaire, Pre-Sleep Arousal Scale]; chronotype (Morningness-Eveningness Questionnaire); mood (Hospital Anxiety and Depression Scale); itch (5-D Itch Scale); and psoriasis severity (Simplified Psoriasis Index). Group comparisons and regression analyses were used to examine predictors of poor sleep.

RESULTS

The mean PSQI score was 9·2 ± 4·3, with 76·3% scoring above the threshold for poor sleep (≥ 6 on the PSQI) and 32·5% scoring 'positive' for probable obstructive sleep apnoea (OSA). Poor sleep and high likelihood of OSA were associated with more severe psoriasis (P < 0·05; η = 0·07; η² = 0·005). Cognitive arousal (β = 0·26, P = 0·001), itch (β = 0·26, P < 0·001) and depression (β = 0·24, P = 0·001) were the most robust predictors of poor sleep quality, which, together with somatic arousal (β = 0·17, P = 0·022), accounted for 43% of variance in PSQI scores.

CONCLUSIONS

Poor sleep is common in psoriasis and associated with psychological and physical factors. Rates of probable OSA are also high. Given the importance of restorative sleep for health, sleep complaints should receive greater clinical attention in the management of psoriasis.

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.

Measurement, Classification and Evaluation of Sleep Disturbance in Psoriasis: A Systematic Review

BACKGROUND

Psoriasis is a long-term immune-mediated inflammatory disorder mainly, but not only, affecting skin, and is associated with significant medical and psychological morbidity. Evidence suggests that sleep is disrupted in psoriasis, however high quality empirical evidence is lacking. Given the importance of sleep for health, characterisation of sleep disruption in psoriasis is an important goal. We therefore conducted a systematic review of the sleep-psoriasis literature.

METHODS

Searches were conducted in Pubmed, SCOPUS and Web of Science from inception to May 2016. Studies were compared against inclusion/exclusion criteria and underwent a quality evaluation. Given the heterogeneity of studies, we conducted a narrative synthesis of the findings.

RESULTS

Searches revealed 32 studies which met our predetermined inclusion/exclusion criteria. Whilst 93.7% of studies reported sleep disruption in this population, ranging from 0.05% to 85.4%, many had important methodological shortcomings. Over half of all quantitative studies (54.8%; 17/31) relied on non-validated measures, contributing to heterogeneity in study findings. In those that employed valid measures, assessing sleep was often not the primary objective. We frequently found the absence of adequate sample size calculations and poor statistical reporting.

CONCLUSION

This review showed that in psoriasis, reported sleep rates of sleep disturbance varied substantially. Most studies lacked a hypothesis driven research question and/or failed to use validated measures of sleep. We were unable to draw firm conclusions about the precise prevalence and nature of sleep disturbance within the psoriasis population. We offer suggestions to help advance understanding of sleep disturbance in psoriasis.