Sleep Disturbance in Psoriatic Disease: Prevalence and Associated Factors

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.

Intense symptoms of pain are associated with poor sleep, fibromyalgia, depression and sleep apnea in patients with rheumatoid arthritis and psoriatic arthritis. A register-based study

OBJECTIVES

To study whether poor sleep and comorbidities are associated with high symptom levels of patient-reported outcomes (PROs) pain, patient global assessment and fatigue in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), in a nation-wide cross-sectional setting.

METHODS

Clinical data were extracted from The Finnish Rheumatology Quality Register between 1.2021 and 9.2022. Self-reported sleep was categorized as "good" (little/no difficulties) or "poor" (great difficulties/can't) sleep. Data concerning comorbidities were collected from national registers. Descriptive statistics were used. Regression analyses were applied to analyze independent associations of sleep status, comorbidities and disease activity with pain in RA and PsA, adjusting for age and sex.

RESULTS

Among 13,512 patients with RA, 6052 [mean (SD) age 62 (13), 71% female] had sleep status reported; in PsA 1861/3636 [age 55 (13), 48% female]. In RA, 5072 (84%) reported good and 980 (16%) poor sleep; the corresponding numbers in PsA were 1460 (78%) and 401 (22%). Median values for objective disease activity were low and similar in patients with poor sleep and good sleep in both diseases. Among patients with no swollen joints, the median values for PROs were approximately three times higher for patients with poor sleep vs. good sleep in both diagnoses (P<0.001). In regression analyses, "poor" sleep was independently associated with higher symptoms in pain [B (95%CI) 20 (18,22) in RA and 23 (19, 26) in PsA], followed by comorbid fibromyalgia, as well as depression in RA and sleep apnea in PsA.

CONCLUSION

"Poor" sleep quality and comorbidities are independently associated with pain. Patient's sleep status is important to know especially in patients with severe symptoms without objective disease activity.

Sleep in psoriasis: A meta-analysis

OBJECTIVE

Currently, there are discrepant results regarding the quantitative effect of psoriasis on sleep, which may, in part, be attributed to the use of non-standardised questionnaires.

METHODS

The PubMed/Medline, Embase, and Cochrane databases were searched for cross-sectional, case-control or cohort studies that recruited patients with psoriasis and healthy controls and reported data regarding Pittsburgh Sleep Quality Index (PSQI) and the prevalence of sleep disturbance (SD) based on the PSQI, published from inception up to January 2023. Secondary outcomes included scores for the Insomnia Severity Index (ISI), Beck Depression Inventory (BDI), and Epworth Sleepiness Scale (ESS), and risk for restless legs syndrome (RLS). Meta-analyses using random-effects models were used for statistical analyses.

RESULTS

Fifteen studies including 1274 patients with psoriasis and 775 controls were analysed. A higher PSQI (weighted mean difference [WMD] = 3.397, P < 0.001, I2 = 84.2%) and a higher risk for SD (odds ratio [OR] = 6.640, P < 0.001, I2 = 67.5%) were observed in patients with psoriasis compared with controls. Subgroup analyses revealed a greater difference in PSQI score and/or risk for SD between patients with psoriasis and controls in subgroups of psoriatic arthritis, moderate-to-severe psoriasis, shorter psoriasis duration, and younger age. Moreover, patients with psoriasis exhibited higher ISI (WMD = 2.709, P < 0.001) and BDI scores (WMD = 4.565, P = 0.001), and risk for RLS (OR = 4.689, P = 0.01). However, there was no significant difference in ESS scores (WMD = -0.229, P = 0.77) compared with controls.

CONCLUSION

Psoriasis was associated with poor sleep quality and higher risk for SD, especially among patients with psoriatic arthritis, severe psoriasis, shorter duration of psoriasis, and younger age. Patients with psoriasis were also more likely to experience insomnia, RLS, and depression.

SLEEP quality in patients with psoriatic arthritis and its relationship with disease activity and comorbidities: a cross-sectional study

The assessment of psoriatic arthritis is complex and multidimensional. It is increasingly common to include the patient perspective using patient-reported outcomes. Although some research has explored sleep quality in patients with psoriatic arthritis, most studies have had small sample sizes, failed to assess sleep quality considering the inflammatory process together with the psychological well-being of patients, and have not described any use of sleep medication. Further, research to date has not provided data on the relationship of sleep quality with axial forms. In this context, the objective of this study was to assess sleep quality in patients with psoriatic arthritis and its relationship with clinical characteristics, disease activity, functioning, disease impact, fatigue and psychological status. A cross-sectional study was conducted including 247 consecutive patients with PsA recruited during 2021. Sleep quality was measured using the Pittsburgh Sleep Quality Index. We assessed correlations of Pittsburgh Sleep Quality Index score with peripheral disease activity (Disease Activity Index for PSoriatic Arthritis), axial disease activity (Ankylosing Spondylitis Disease Activity Score-C-reactive protein and Bath Ankylosing Spondylitis Disease Activity Index), functioning (Bath Ankylosing Spondylitis Functional Index and Health Assessment Questionnaire), impact (Psoriatic Arthritis Impact of Disease questionnaire), anxiety, depression (Hospital Anxiety and Depression Scale) and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue) scores. A multiple linear regression model was constructed with PSQI as the dependent variable and as independent variables those that could influence sleep quality. Nearly two-thirds (63.15%) of patients had poor sleep quality. Poorer sleep quality was associated with being female, higher joint counts, greater peripheral and axial disease activity, fatigue, anxiety and depression, functioning and disease impact (p < 0.001). Multiple linear regression analysis found that pain (β: 0.3; p < 0.007) and fatigue β: - 0.1; p < 0.001 contributed 40% to the sleep quality model. Poor sleep quality was common among patients with psoriatic arthritis. Emotional factors (fatigue, anxiety) seemed more important than inflammatory factors in sleep quality.

Evaluation of sleep quality and pruritus severity in psoriatic patients and their impact on quality of life: a cross section correlational study

Psoriasis is a chronic inflammatory condition associated with genetic and immunological susceptibility. The objective of the study was to evaluate pruritus and sleep quality in correlation (r) to psoriasis severity and to detect their impact on quality of life. Two hundred (200) patients with psoriasis were included. Psoriasis severity was determined using the psoriasis area severity index (PASI), the quality of life (QoL) was assessed by the psoriasis disability index (PDI) questionnaire, and the sleep quality was evaluated by the Pittsburgh sleep quality index (PSQI). Finally, the severity of itching was evaluated using a 12-item pruritus severity scale (PSS). Poor sleep quality was found in 16.0% of patients in this study. Poor sleep was detected among 50.0% of cases with severe psoriasis. PASI scores correlated significantly with sleep quality, duration and sleep disturbances (p < 0.001). The global PSQI and PASI were also significantly correlated (p = 0.004). In conclusion patients complaining of psoriasis exacerbated by pruritus and sleep problems demonstrated lower quality of life in all domains. Sleep disturbances and depressive symptoms impairing quality of life should be taken into consideration when screening patients suffering from psoriasis.

Triple jump for the optimal management of psoriatic arthritis: diet, sleep and exercise - a review

Psoriatic arthritis (PsA) is a complex, multiform and chronic inflammatory disease characterised by the association of arthritis and psoriasis combined with other related conditions and comorbidities. Treatment of PsA has rapidly evolved by the introduction of new biological drugs and small molecules which allow to achieve disease remission or low disease activity in most of the patients. However, unmet treatment needs still persist for those patients with persistent disease activity or symptoms, impaired function, reduced quality of life or comorbidities. In this context, non-pharmacological approaches, including diet modifications, an adequate sleep quality and physical activity could provide additional benefits. In recent years, diet modifications, improvement of sleep quality and physical activity became an area of interest for researchers and some studies showed how a holistic non-pharmacological approach may ameliorate the quality of life of patients with PsA.The aim of this manuscript was to review the current evidence on the intriguing link and potential effects of diet, sleep and exercise in PsA patients. In particular, we reviewed the literature focusing on the possible benefits of a holistic approach to PsA patients considering lifestyle modifications.

Actigraphy-derived physical activity levels and circadian rhythm parameters in patients with psoriatic arthritis: relationship with disease activity, mood, age and BMI

Background

Psoriatic arthritis (PsA) is associated with sleep disturbance, depression and a lifetime risk of obesity and cardiovascular disease. To date, there have been no studies investigating the relationship between objectively-measured physical activity (PA) levels and circadian rhythm disturbance with disease activity, daily symptoms and mood in patients with PsA.

Objective

This pilot study aimed to investigate the relationship between disease activity, daily symptoms and mood on PA and circadian rhythm in PsA.

Design

A prospective cohort study recruiting adults with PsA from rheumatology clinics at a single centre in the UK.

Methods

Participants wore an actigraph and recorded their symptoms and mood on a daily basis via a smartphone app for 28 days. Time spent in sedentary, light and moderate-to-vigorous physical activity (MVPA) and parameters reflecting the circadian rhythm of the rest-activity pattern were derived. This included the onset time of the least active 5-h (L5) and most active 10-h (M10) daily consecutive periods and the relative amplitude (RA). The relationship factors between baseline clinical status, daily symptoms, PA and circadian measures were examined using linear mixed effect regression models.

Results

Nineteen participants (8/19 female) were included. Participants with active PsA spent 63.87 min (95% CI: 18.5-109.3, p = 0.008) more in inactivity and 30.78 min (95% CI: 0.4-61.1, p = 0.047) less in MVPA per day compared to those in minimal disease activity (MDA). Age, body mass index and disease duration were also associated with PA duration. Participants with worse functional impairment had an M10 onset time 1.94 h (95% CI: 0.05-3.39, p = 0.011) later than those with no reported functional impairment. No differences were detected for L5 onset time or RA. Higher scores for positive mood components such as feeling energetic, cheerful and elated were associated with less time in inactivity and greater time spent in MVPA overall.

Conclusion

Our study highlights differences in PA and circadian rest-activity pattern timing based on disease activity, disability and daily mood in PsA. Reduced PA levels in patients with active disease may contribute to the observed increased risk of cardiovascular and metabolic sequelae, with further studies exploring this need.

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.

Increased prevalence of sleep disturbance in psoriatic arthritis is associated with inflammatory and non-inflammatory measures

OBJECTIVES

To examine the prevalence of sleep disturbances, quantified by the Pittsburgh Sleep Quality Index (PSQI), in patients with psoriatic arthritis (PsA), psoriasis (PsO) and healthy controls (HCs), explore associations between PSQI and clinical and patient-reported outcomes, and evaluate the effect of treatment on PSQI.

METHOD

Patients were included from the Parker Institute's PsA patient cohort to evaluate the prevalence of sleep disturbances. Univariate and multivariate regression analyses were used to explore associations between sleep disturbance and outcome measures. Treatment effect in PsA patients was assessed with a mixed-effect model for repeated measures.

RESULTS

In total, 109 PsA patients, 20 PsO patients, and 20 HCs were included. Sleep disturbances were reported by 66.1% of PsA patients, 45.0% of PsO patients, and 15.0% of HCs. Univariate regression analyses revealed statistically significant associations (p < 0.001) between PSQI and Disease Activity Score (DAS28CRP), tender points, visual analogue scale (VAS) patient global and pain, Psoriatic Arthritis Impact of Disease fatigue, Health Assessment Questionnaire (HAQ), and painDETECT score. Multivariate regression analysis demonstrated VAS patient global, VAS pain, and tender points as being independently associated with PSQI. The mixed-effect model revealed no effect of treatment.

CONCLUSION

More PsA patients than PsO patients and HCs reported sleep disturbances. Sleep disturbances were associated with inflammatory and non-inflammatory measures possibly explaining the limited effect of treatment. This demonstrates the need for interdisciplinary approaches to improve the management of sleep disturbance in PsA.Trial registration: ClinicalTrials.gov (NCT02572700).

Prevalence and factors associated with sleep disturbance in adult patients with psoriasis

BACKGROUND

Sleep, which is crucial for restoring of physiological functions and health, is reportedly impaired in psoriasis. The role of different potential sleep confounding factors, including detailed pruritus characteristics, and the complex interplay between psychological variables (anxiety and depression), pruritus and sleep disturbance in psoriasis remain insufficiently investigated.

OBJECTIVES

To investigate sleep characteristics and to identify clinical, demographic, and psychological factors associated with sleep disturbance in psoriasis.

METHODS

This cross-sectional study included 334 psoriasis patients (response rate 86%) and 126 control subjects (response rate 82%). Measures included sleep quality [Pittsburgh Sleep Quality Index (PSQI)], psoriasis severity, pruritus characteristics, including average pruritus intensity [Visual Analogue Scale (VAS)], severity of comorbidities, anxiety and depression (Hospital Anxiety and Depression Scale - HADS), and quality of life (Dermatology Life Quality Index - DLQI, and Short Form 12 - SF12).

RESULTS

Fifty-nine percent of patients, and 34% of control subjects (P<0.001) suffered from sleep disturbance (PSQI>5). Patients slept 1 hour less than control subjects (median 6 vs. 7 hours, P<0.001). Patients without pruritus had less impaired sleep (global PSQI) than patients with strong (P<0.001) and very strong pruritus (P<0.001). Anxiety (HADS-A) and depression (HADS-D) levels were the strongest predictors of sleep impairment, followed by pruritus exacerbation at night, age, female sex, pruritus exacerbation in the morning, average pruritus intensity (VAS), diagnosed depression and gastroesophageal reflux disease, altogether explaining 32% - 37% of the variance in global sleep quality. Both, anxiety (HADS-A) and depression (HADS-D) were significant mediators explaining the association between pruritus intensity (VAS) and sleep impairment in 42% and 37%, respectively.

CONCLUSIONS

Sleep disturbance in patients with psoriasis is highly prevalent. Patients with psoriasis should be assessed for sleep impairment, pruritus, anxiety, and depression. Reduction of pruritus should be considered as an important therapeutic goal, along with therapies aimed at reducing anxiety and depression.

Potential effects of shift work on skin autoimmune diseases

Shift work is associated with systemic chronic inflammation, impaired host and tumor defense and dysregulated immune responses to harmless antigens such as allergens or auto-antigens. Thus, shift workers are at higher risk to develop a systemic autoimmune disease and circadian disruption with sleep impairment seem to be the key underlying mechanisms. Presumably, disturbances of the sleep-wake cycle also drive skin-specific autoimmune diseases, but epidemiological and experimental evidence so far is scarce. This review summarizes the effects of shift work, circadian misalignment, poor sleep, and the effect of potential hormonal mediators such as stress mediators or melatonin on skin barrier functions and on innate and adaptive skin immunity. Human studies as well as animal models were considered. We will also address advantages and potential pitfalls in animal models of shift work, and possible confounders that could drive skin autoimmune diseases in shift workers such as adverse lifestyle habits and psychosocial influences. Finally, we will outline feasible countermeasures that may reduce the risk of systemic and skin autoimmunity in shift workers, as well as treatment options and highlight outstanding questions that should be addressed in future studies.

Sleep Disturbance and Self-management in Adults With Subarachnoid Hemorrhage: A Qualitative Study

Subarachnoid hemorrhage (SAH) survivors often experience sleep disturbances. Little is known about sleep-management practices used to improve their sleep. The purpose of this qualitative study was to explore interest in and engagement with self-management practices to promote sleep health in SAH survivors. We conducted a cross-sectional qualitative study using semi-structured interviews with a convenience sample of 30 SAH survivors recruited from a university hospital. We conducted content analysis of interview transcripts. Three themes and 15 subcategories were identified: (1) sleep disturbances (difficulties falling asleep, wake after sleep onset, daytime sleepiness, too much or insufficient sleep, and poor sleep quality); (2) sleep-management practices (exercise, regular sleep schedule, relaxation, keeping busy and staying active, changing beverage intake, taking supplements, taking medications, recharging energy, and barriers to sleep management); and (3) consulting with healthcare providers (discussing sleep problems with healthcare providers). Self-management strategies focusing on health-promoting behaviors may improve SAH survivors' sleep health.

Insomnia and other sleep disorders in dermatology patients: A questionnaire-based study with 634 patients

Insufficient sleep duration and quality are associated with various adverse health outcomes. Whereas sleep disorders have been studied in a few skin conditions, data in a more comprehensive dermatology population are lacking. We sought to describe the prevalence, causes, and consequences of sleep disorders in dermatology patients. In this cross-sectional, single-center study, dermatology patients completed a questionnaire addressing skin-related and non-skin-related health, sleep behavior, causes, and consequences of sleep disorders. According to the Regensburg Insomnia Scale, 27.92% of the 634 participants had insomnia (177 of 634 patients). Of these 177 patients, 115 (64.97%) were subjectively sleep disturbed, with skin-related causes accounting for 55.65% (64 of 115 patients), non-skin-related accounting for 33.04% (38 of 115 patients), and combined accounting for 11.30% (13 of 115 patients). Itch was the leading cause of skin-related sleep disorders (64.49%, 50 of 77 patients), followed by skin-related pain (55.84%, 43 of 77 patients) and skin-related fearful thoughts (54.55%, 42 of 77 patients). Sleep disorders reduced daytime performance in 68.70% (79 of 115 patients) and sleep quality of relatives in 20.87% (24 of 115 patients). The prevalence of insomnia among different diagnostic categories ranged from 20.31% to 50.00%. The most common strategy to improve sleep was taking sleep medication (57.39%, 66 of 115 patients). We conclude that sleep disorders are highly prevalent in dermatology patients, often leading to reduced daytime performance, impaired sleep among the patients' relatives, and increased use of substances.

Fatigue numeric rating scale validity, discrimination and responder definition in patients with psoriatic arthritis

Objectives

This study assessed the psychometric properties of the fatigue numeric rating scale (NRS) and sought to establish values for clinically meaningful change (responder definition).

Methods

Using disease-specific clinician-reported and patient-reported data from two randomised clinical trials of patients with psoriatic arthritis (PsA), the fatigue NRS was evaluated for test–retest reliability, construct validity and responsiveness. A responder definition was also explored using anchor-based and distribution-based methods.

Results

Test–retest reliability analyses supported the reproducibility of the fatigue NRS in patients with PsA (intraclass correlation coefficient=0.829). Mean (SD) values at baseline and week 2 were 5.7 (2.2) and 5.7 (2.4), respectively. Supporting construct validity of the fatigue NRS, moderate-to-large correlations with other assessments measuring similar concepts as measured by Sackett’s conventions were demonstrated. Fatigue severity was reduced when the underlying disease activity was improved and reductions remained consistent at week 12 and 24. A 3-point improvement was identified as being optimal for demonstrating a level of clinically meaningful improvement in fatigue NRS after 12–24 weeks of treatment.

Conclusions

Fatigue NRS is a valid and responsive patient-reported outcome instrument for use in patients with PsA. The established psychometric properties from this study support the use of fatigue NRS in clinical trials and in routine clinical practice. Robust validation of reliability for use in routine clinical practice in treating patients with active PsA in less active disease states and other more diverse ethnic groups is needed.

Sleep disturbance in adult dermatologic patients: A cross-sectional study on prevalence, burden, and associated factors

BACKGROUND

Sleep disturbance remains insufficiently characterized in many dermatoses.

OBJECTIVE

To investigate the prevalence, burden, and factors associated with sleep disturbance in dermatologic patients.

METHODS

We recruited 800 patients and recorded pruritus characteristics and sociodemographic and clinical parameters. Validated questionnaires were used to assess sleep disturbance, psychological distress, health-related quality of life, and work productivity.

RESULTS

Two thirds of patients met criteria of poor sleep, which was associated with psychological distress, diminished health-related quality of life, and lost work productivity. Patients with average and maximum pruritus on the visual analog scale exceeding 5 and 6.5 points, respectively, were at high risk of suffering pruritus-related sleep disturbance. Overall pruritus intensity and its nocturnal exacerbation contributed independently to sleep disturbance. Psychological distress was of even higher impact on sleep than pruritus and almost a third of the relationship between pruritus intensity and sleep was mediated by psychological distress.

CONCLUSION

Sleep disturbance is prevalent in dermatologic patients and constitutes a considerable burden.

CLINICAL IMPLICATION

Dermatologic patients with intense pruritus and psychological distress should be examined for sleep disorders. Adequate antipruritic therapy and complementary psychotherapy in affected patients may help them regain restorative sleep.

Nonpharmacologic Pain Management in Inflammatory Arthritis

This article provides an overview of nonpharmacologic options for the treatment of pain in patients with inflammatory arthritis, such as peripheral spondyloarthritis, psoriatic arthritis, ankylosing spondylitis, and rheumatoid arthritis. The experience of pain in chronic disease is a complex process influenced by multiple domains of health. The discussion focuses on the establishment of a framework for pain control that engages with factors that influence the experience of pain and explores the evidence base that supports specific modalities of nonpharmacologic pain control, such as mindfulness, cognitive behavioral therapy, exercise, massage, splinting, and heat therapy. Rheumatoid and spondyloarthritides are considered separately.

Physical and Psychosocial Burden of Psoriatic Arthritis: Longitudinal Data From a Population-Based Study in Norway

OBJECTIVE

Psoriatic arthritis (PsA) can have a significant impact on health-related quality of life (HRQoL). Data on the timing of changes in the HRQoL of patients with PsA are limited. The present study was undertaken to explore associations between sleep disturbance, fatigue, pain, anxiety, depression, general health status, and satisfaction with life before and after a diagnosis of PsA compared to the general population.

METHODS

Patients diagnosed with PsA between the Nord-Trøndelag Health Study (HUNT2 [1995-1997] and HUNT3 [2006-2008]) surveys were compared to the general population. The adjusted odds ratio (OR_adj ) with 95% confidence interval (95% CI) was estimated at both time points.

RESULTS

Among 36,507 individuals participating in both the HUNT2 and HUNT3 surveys, 160 were diagnosed with PsA between the surveys. The prevalence of sleep disturbances and fatigue was higher in PsA patients after diagnosis compared to the general population (OR_adj 2.24 [95% CI 1.55-3.25] and OR_adj 1.94 [95% CI 1.27-2.98], respectively). The prevalence of pain and poor health status were higher in patients with PsA compared with the general population even before PsA was diagnosed (OR_adj 2.81 [95% CI 1.96-4.02] and OR_adj 3.08 [95% CI 2.19-4.35], respectively) and increased after diagnosis of PsA (OR_adj 12.87 [95% CI 6.27-26.40] and OR_adj 5.63 [95% CI 3.99-7.95], respectively). For anxiety, depression, and life satisfaction, patients who developed PsA were comparable to the general population both before and after the diagnosis of PsA.

CONCLUSION

Compared to the general population, PsA patients reported a higher prevalence of pain and poorer health status before diagnosis. Increased prevalence of sleep disturbances and fatigue in PsA patients was only found after the PsA diagnosis, and no differences between patients with PsA and the control group were found for anxiety and depression.

Real-world evidence of the impact of adalimumab on work productivity and sleep measures in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis

Objective:

Our aim was to evaluate the effect of adalimumab on work productivity measures, overall activity impairment, and sleep quality in patients with active moderate to severe rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS) treated in routine care settings in Greece and determine factors associated with work impairment and sleep disturbance.

Methods:

Patients with active moderate to severe RA (n = 184), PsA (n = 166), and AS (n = 150) were enrolled in this 24-month, prospective, observational study at 80 hospital outpatient clinics and private practices throughout Greece. Patients received adalimumab alone or in combination with standard antirheumatic therapies according to routine care. Work productivity and sleep were assessed through two patient-reported outcome measures: the Work Productivity and Activity Impairment–General Health questionnaire and the Medical Outcomes Study Sleep Scale (MOS-SS). Pearson correlation coefficients were estimated to assess the association of work impairment and sleep disturbances with disease activity scores.

Results:

In the overall population, adalimumab significantly lowered absenteeism [mean (95% confidence interval) reduction, 18.9% (13.3–24.5%); n = 100]; presenteeism [40.0% (33.8–46.3%); n = 98], overall work productivity impairment [46.8% (40.4–53.2%); n = 94], activity impairment [47.0% (44.3–49.6); n = 421], and the MOS-SS sleep problems index [31.6 (29.5–34.1); n = 421] after 24-month treatment (p < 0.001). Significant improvements were also noted across the RA, PsA, and AS subpopulations (p < 0.05). Improvements in overall work impairment and sleep disturbance positively correlated with improvements in disease activity measures.

Conclusion:

Adalimumab improves work productivity and sleep problems while lowering disease activity in patients with moderate to severe RA, PsA, and AS managed in real-world settings.

Psoriatic arthritis: exploring the occurrence of sleep disturbances, fatigue, and depression and their correlates

Introduction

Sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) may be influenced by skin and musculoskeletal manifestations. All of these in turn affect the psychosocial impact of disease. The objective was to explore the occurrence of sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) patients, and their correlates.

Methods

A broad data collection was performed in 137 Norwegian PsA outpatient clinic patients including demographics, disease activity measures for both skin and musculoskeletal involvement, and patient-reported outcome measures. Sleep disturbances and fatigue were defined present if the numeric rating scale (0–10) score was ≥ 5. Anxiety/depression was assessed using a questionnaire (1–3; 1 defined as no anxiety/depression). Descriptive statistics was applied, and associations were explored using univariate and adjusted linear regression analysis.

Results

The mean age was 52.3 years, PsA disease duration 8.8 years; 49.6% were men and 54.8% were currently employed/working. The prevalence of sleep disturbances was 38.0%, fatigue 44.5%, and anxiety/depression 38.0%. In adjusted analysis, pain, fatigue, and higher mHAQ were associated with sleep disturbances. Sleep disturbances, pain, and anxiety/depression were associated with fatigue, whereas only fatigue was associated with anxiety/depression.

Conclusions

The prevalence of sleep disturbances, fatigue, and anxiety/depression was frequently reported by PsA patients. No measures reflecting skin involvement or objective measures of musculoskeletal involvement were independently associated with sleep disturbances, fatigue, or anxiety/depression. Our data suggest that patients’ perceptions of musculoskeletal involvement (pain or mHAQ) play an important role causing sleep disturbances and fatigue, whereas fatigue in PsA patients is strongly associated with anxiety/depression.

Prevalence and variables associated with fatigue in psoriatic arthritis: a cross-sectional study

OBJECTIVE

To describe the prevalence of and evaluate the factors associated with fatigue patients with psoriatic arthritis (PsA) in an Asian population.

METHODS

We used baseline data from a registry of patients with PsA attending an outpatient clinic of a tertiary hospital in Singapore. Demographic data and disease characteristics were evaluated. Fatigue was assessed by question one of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI-F) and the vitality domain of the Medical Outcome Survey, Short-Form 36 (SF-36 VT). We evaluated clusters of variables, and individual variables in association with fatigue.

RESULTS

We included 131 patients (50.4% men, 63.4% Chinese, median PsA duration 21.0 months) with completed data for fatigue. Forty-five patients (34%) experienced severe fatigue (defined by BASDAI-F > 5/10). We used principal component analysis and identified five clusters of variables that explained 62.9% of the variance of all factors. Of these, disease activity and impact, and disease chronicity were significantly associated with BASDAI-F and SF-36 VT. In multivariable analyses, back pain, peripheral joint pain and patient global assessment were associated with BASDAI-F, whereas peripheral joint pain and mental health were associated with SF-36 VT.

CONCLUSION

PsA-associated fatigue is prevalent in this Asian PsA cohort and is associated with disease activity, impact and chronicity.

The relationship between sleep disturbance, symptoms and daytime functioning in psoriasis: a prospective study integrating actigraphy and experience sampling methodology

OBJECTIVE/BACKGROUND

Sleep disturbance is common in individuals with psoriasis and appears to be related to both physical and psychological factors. We sought to examine whether psoriasis symptoms, night-time arousal and low mood predicted subsequent objective and self-reported sleep; and whether objective and self-reported sleep predicted next-day psoriasis symptoms and day-time functioning.

PARTICIPANTS/METHODS

A total of 19 individuals (Female: 11 [57.9%], median age: 39 years) with chronic plaque psoriasis and poor sleep quality (mean Pittsburgh Sleep Quality Index, PSQI = 9.11) participated. Momentary assessments of psoriasis symptoms, mood and daytime functioning were completed at five pseudo-random intervals each day for 15 days using time-stamped digital diary entry. Objective sleep was estimated using wrist-worn actigraphy. Self-reported sleep and night-time arousal were assessed each morning using validated measures.

RESULTS AND CONCLUSIONS

Two-level random intercept models showed that increased night-time arousal was associated with poorer diary-reported sleep. Neither self-reported nor objective sleep parameters were associated with daytime psoriasis symptoms in bi-directional analyses. Diary-reported sleep predicted next-day functioning, specifically sleepiness, concentration, and fatigue. Actigraphy-defined total sleep time predicted next-day fatigue. Night-time arousal is associated with poorer self-reported sleep in people with psoriasis, and sleep predicts next-day functioning. Contrary to our hypothesis, sleep disturbance does not appear to be associated with momentary assessments of psoriasis symptoms.

Sleep Quality in Psoriasis Patients and its Relations with Possible Affecting Factors

OBJECTIVES

Psoriasis (PS) is a chronic, immune-mediated inflammatory skin disease. PS may lead to significant effects on health-related quality of life (HRQoL) and other outcomes. In the present study, an investigation into sleep quality (SQ), and its possible relations with factors which may affect SQ were aimed.

METHODS

A total of 74 subjects from both sexes were enrolled in this study, between January and July 2017. Patients were evaluated with their demographics, body mass index (BMI), Psoriasis Area Severity Index (PASI), Pittsburgh Sleep Quality Index (PSQI), Psoriasis Quality of Life Index (PQLI), Self Perception Scale (SPS). Additionally, accompanying chronic diseases, disease duration and severity of pruritus were recorded. Obtained PSQI values were compared with the mentioned parameters concerning the significance of their relations with it. SPSS version 24, 2016 was used to analyse the data, and significance was evaluated with p-values of <0.05, 0.01, and 0.001, and rho (r) values of <0.2, =0.2-0.4, =0.4-0.6, =0.6-0.8 and >0.8.

RESULTS

Thirty-seven female and 37 male were studied. The mean age of total of the study population was 47.21±13.91. Mean BMI and mean duration were 30.09± 4.68 kg/m2, and 10.58±9.1 months. Mean values of PASI, PSQI, SPS, and PQLI of the study group were 19.79±16.99, 9.14±5.09, 142.12±23.83, and 21.94±16.31, respectively. Approximately thirty-one percent of them had at least one chronic disease. Alcohol and smoking rates were 17.56%, 50%. PASI was positive/strongly correlated with PQLI and negative/weakly correlated with SPS. No correlation was detected between PSQI values and age, gender, BMI, and SPS values. PSQI was moderately correlated with PQLI, diabetes mellitus (DM), and pruritus severity, whereas it was weak correlated with PASI, hypertension (HT), thyroid diseases and disease duration. PASI and DM showed a predictive effect on SQ.

CONCLUSION

SQ is affected by certain factors, such as QoL, disease severity, disease duration, pruritus severity, accompanying disorders, such as HT, DM and thyroid diseases, in which disease severity and DM have predictive effects on SQ in PS patients. Controls of disease activation and prevention of progression in DM may provide to keep SQ in PS.

Relationship between rosacea and sleep

Rosacea is a chronic facial skin disease involved in neurovascular dysregulation and neurogenic inflammation. Behavioral factors such as stress, anxiety, depression and sleep were identified to be associated with other inflammatory skin diseases. Few studies have reported sleep status in rosacea. Aiming to investigate the relationship between rosacea and sleep, a case-control survey was conducted, enrolling 608 rosacea patients and 608 sex- and age-matched healthy controls. Sleep quality was assessed through the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Diagnosis and severity grading of rosacea were evaluated under the standard guidelines of the National Rosacea Society. More rosacea patients (52.3%, n = 318) suffered poor sleep quality (PSQI, >5) than the healthy controls (24.0%, n = 146), displaying a much higher PSQI score (rosacea vs control, 6.20 vs 3.95). There was a strong association between sleep quality and rosacea (odds ratio [OR], 3.525; 95% confidence interval [CI], 2.759-4.519). Moreover, the severity of rosacea was also associated with sleep quality (OR, 1.847; 95% CI, 1.332-2.570). Single nucleotide polymorphisms in hydroxytryptamine receptor 2A and adrenoceptor-β1 genes, which are associated with sleep behaviour, were detected and revealed to be associated with rosacea. Furthermore, the LL-37-induced rosacea-like phenotype and sleep-deprivation mice models were applied, revealing that sleep deprivation aggravated the rosacea-like phenotype in mice, with higher expression of matrix metallopeptidase 9, Toll-like receptor 2, cathelicidin antimicrobial peptide and vascular endothelial growth factor. In conclusion, rosacea patients presented poorer sleep quality, as well as a higher propability of genetic background with sleep disturbance. In addition, poor sleep might aggravate rosacea through regulating inflammatory factors, contributing to a vicious cycle in the progression of disease.

Fatigue and contributing factors in Chinese patients with ankylosing spondylitis

OBJECTIVES

Fatigue is a common symptom in patients with ankylosing spondylitis (AS). However, fatigue of AS patients has not been well elucidated in China. This study aimed to evaluate the predictors of fatigue and the effects of fatigue on health-related quality of life among patients with AS.

METHOD

A total of 150 AS patients were involved in the study. A series of questionnaires included the following: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), the 10-cm Visual Analog Scale (VAS), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS), the Pittsburgh Sleep Quality Index (PSQI), the Health Assessment Questionnaire-Disability Index (HAQ-DI), the Short Form 36 Health Survey (SF-36), and the Fatigue Severity Scale (FSS). Independent samples t test, Mann-Whitney U test, chi-square analysis, Pearson/Spearman correlation, and binary logistic regression were used to analyze the data.

RESULTS

The results demonstrated that 48.7% individuals with AS suffered from fatigue. Binary logistic regression indicated that waist-to-hip ratio, BASDAI, and sleep disturbance were independent predictors of fatigue in AS patients. Meanwhile, severe fatigue led to lower quality of life.

CONCLUSION

These findings suggested that medical personnel should pay more attention to AS patients with fatigue and take effective measures to relieve fatigue. Key Points • Incidence of fatigue in AS patients is 48.7% according to this cross-sectional study. • The occurrence of fatigue was associated with higher WHR, higher BASDAI, and sleep disturbance. • We also found that the occurrence of fatigue significantly reduced the quality of life in AS patients both physically and psychologically.

Use of antidepressants and benzodiazepine-related hypnotics before and after initiation of TNF-α inhibitors or non-biological systemic treatment in patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis

Background

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are autoimmune disorders associated with an increased risk for depression, anxiety and sleeping problems. The objective of this study was to analyze use of antidepressants and benzodiazepine-related hypnotics (BRH) in Sweden before and after first time treatment with anti-TNF and non-biological systemic (NBS) treatments among patients with the above diagnoses, and to correlate such use with that of randomly selected population controls.

Methods

Patients and dispensed drugs were identified in nationwide Swedish healthcare registers. Proportions of subjects filling prescriptions of antidepressants and BRH from 2 years before start of treatment (index-date), and 2 years after index date were assessed. Using the period -6 months to index-date as reference, prevalence rate ratios were computed for 6 months' intervals before and after index. For up to ten randomly selected population controls per patient, the same measures were calculated.

Results

A total of 6256 patients started anti-TNF treatment, and 13,241 NBS treatment. The mean age at index was 52.0 for the anti-TNF group and 56.1 for NBS. Use of antidepressants and BRH was similar in both treatment groups (10.4-12.8%), significantly more common than in the controls (6.6 to 7.6%). For all patients, proportions filling prescriptions for antidepressants and BRH decreased directly or soon after the index; no such changes were seen in the controls, who all showed a slow but steady increase in use over time. Starters of anti-TNF treatment did not show clearer decreases in use of psychotropics than those initiating NBS.

Conclusions

Decreased rates of dispensed psychotropic drugs after the time of anti-TNF and NBS treatment initiation were seen among patients with autoimmune disorders but not population controls. This may correspond to treatment effects of anti-TNF and NBS also on psychiatric symptoms among these patients.

Systematic review of mental health comorbidities in psoriatic arthritis

OBJECTIVE

In this systematic review and meta-analysis of psoriatic arthritis (PsA) studies, we pooled data from existing literature to (1) estimate the prevalence of mental health disorders in PsA patients and (2) compare disease activity in PsA patients with and without these comorbidities.

METHOD

We searched PubMED, Web of Science, Scopus, PsycINFO and the Cochrane Library using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Where possible, meta-analysis was performed using random effects model. Prevalence estimates were pooled according to the severity of mental health disorders.

RESULTS

A total of 24 studies, amounting to 31,227 PsA patients, were included for review. Anxiety and depression were the only consistently reported mental health disorders, defined using a range of screening criteria/thresholds. Anxiety prevalence ranged from 4 to 61% with a pooled estimate of 33% (95%CI 17 to 53%) having at least mild anxiety and 21% (95%CI 14 to 29%) at least moderate. Depression prevalence ranged from 5 to 51%, with 20% (95%CI 8 to 35%) having at least mild and 14% (95%CI 8 to 21%) at least moderate. Only two studies compared disease activity according to the presence of mental health comorbidities; both reported higher disease activity and pain among those with comorbid anxiety and depression.

CONCLUSIONS

Anxiety and depression are highly prevalent among PsA patients. Studies of other mental health disorders were scarce. More studies are needed on the impact of these comorbidities on disease activity and long-term outcomes.Key Points• One in three patients with psoriatic arthritis has at least mild anxiety, while 1 in 5 reported at least mild depression.• PsA patients with anxiety and/or depression reported greater disease activity.• More research is needed on other mental health comorbidities, particularly sleep, suicide/self-harm and substance misuse.

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.