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In patients with atopic dermatitis (AD), the prevalence of sleep disturbance is twice that of the general population, affecting 47% to 80% of children and 33% to 90% of adults. In 2019, a identified sleep disturbance as one of the three most problematic symptoms for patients with AD and their families.

"Unfortunately, the literature on this topic remains sparse ...," wrote Wilfred Pigeon, PhD, of the University of Rochester Medical Center in New York, and co-authors in the . "Despite the fact that eczema has the of any skin condition worldwide, and more than 50% of children with AD report sleep disturbance as one of the most bothersome symptoms, we still know very little about this AD comorbidity," they continued. "[O]bjectively and efficiently quantifying AD sleep disturbance, understanding its pathophysiology, and identifying effective management strategies remain challenging."

The term "sleep disturbance" covers a broad range of sleep impairments that includes poor or disrupted sleep; sleep loss; and specific sleep disorders, such as insomnia and sleep apnea. In patients with AD, intense nighttime itching is often the primary sleep-destroyer, making it difficult for children and adults alike to fall asleep and stay asleep. This can lead to excessive daytime sleepiness, disturbed mood, compromised performance at work or school, strained interpersonal relationships, and social isolation.

In children with AD, sleep disturbances have also been associated with and . When a sleep disturbance becomes chronic, altered sleep-wake cycles can increase the risk of , and , the authors of the report noted.

In a U.S. population-based study of sleep disturbance in adults with AD published in the , researchers led by Jonathan Silverberg, MD, PhD, MPH, of George Washington University School of Medicine and Health Sciences in Washington, D.C., found that treatments targeting sleep loss were likely to improve patients' overall health.

An from a U.K. population-based birth cohort of 4,938 children followed for a median of 11 years showed that AD was associated with impaired sleep quality throughout childhood, even in those with mild or inactive disease. Children with active AD were more likely to report worse sleep quality at all time points, and had nearly 50% higher odds of sleep-quality disturbances compared with those without AD (adjusted OR 1.48, 95% CI 1.33-1.66). Children with the most severe active disease, as well as comorbid asthma or allergic rhinitis, had the worst sleep quality overall (adjusted OR 1.79, 95% CI 1.54-2.09).

Sleep disturbance is a key driver of the poor quality-of-life scores seen in patients with AD, and may even exacerbate AD symptoms, said Pigeon. This is why sleep assessment in patients with AD is so important, he told MedPage Today. With the exception of sleep apnea, which is diagnosed with an objective measurement of sleep, the effects of AD on sleep can be subjectively measured using validated self-report measures of sleep or key clinical interview questions, he noted.

"It is important that clinicians evaluate the severity of AD and ask general questions about itching, sleep, impact on daily activities, and persistence of disease during each patient visit and follow-up with the complaint of sleep disturbance," wrote authors of a systematic review in . "Management of sleep disturbance in AD should focus on adequate disease control of AD as well as possible medical interventions to help improve sleep."

"The highest-yield interventions for sleep disturbance are those that achieve better control of the underlying signs and symptoms of AD," Silverberg told MedPage Today. In some patients, additional therapies are required to address concomitant sleep disturbances, he said.

Sleep disorders and AD are likely a two-way street that forms a vicious cycle, noted authors of an article published in the . "We suggest viewing sleep disorders as a comorbidity of AD for which regular screening and bidirectional management strategies are indicated, with equal focus on maintaining disease control and implementing specific strategies to improve sleep," they wrote.

The sleep-AD and the sleep-itch relationships do appear to be bidirectional, so it is likely that improvement in one domain would lead to improvements in the other, confirmed Pigeon. The exception may be insomnia, he added, noting that "once insomnia becomes chronic, it tends to need direct intervention in order to resolve."

have shown that patients with AD may scratch for up to 14.3% of their sleep time during the night. This can cause tissue damage and exacerbate sleep disturbances by releasing inflammatory mediators and pruritogens, said researchers who suggested that sleep and inflammation are

Notably, sleep disturbance in a child with AD can have a domino-like effect on parents and other family members, setting them up for sleep disturbances of their own. In their literature review, Pigeon and colleagues found that 60% to 65% of parents and 63% of siblings of children with AD reported disturbed sleep. Sleeping with the child, as 30% of parents did in a misguided attempt to better manage the AD symptoms, only made sleep disturbances worse in both parent and child.

During disease flares, the rates of disturbed sleep skyrocketed in the parents of preschoolers with AD, with 86% of parents losing . What's more, parental sleep disturbances were maintained throughout childhood, particularly in mothers. "I'm tired, overwhelmed, and feel like I'm failing as a mother," said one woman who participated in an anonymous .

Asking about sleep in a child with AD "is the one question that truly changes my management beyond topical steroids," said Karan Lal, DO, of UMass Memorial Medical Center in Worcester, Massachusetts. "If kids aren't sleeping, then no one at home is sleeping and that means less effective work, days off from school, days off of work."

"Physicians often prescribe oral antihistamines to quell the child's itching but antihistamines don't address the underlying inflammation," said Lal, who is a spokesperson for the Society for Pediatric Dermatology.

"Rather than sedating patients, there has to be a shift in focus on treating the dermatitis," he told MedPage Today. "Based on my experience, treating the inflammation with medications like dupilumab (Dupixent), methotrexate, cyclosporine, and the JAK inhibitors affords patients better sleep without the need for antihistamines. My go-to is making sure the parents [of patients] are using the topical steroids, moisturizing and bathing [the child], and ensuring their child takes the anti-inflammatory, if prescribed, to promote better sleep hygiene."

Data on the treatment of sleep disorders in AD patients are very limited, particularly in children, said Pigeon. However, the more targeted, systemic anti-inflammatory treatments developed for AD may improve sleep, he noted, adding that dupilumab has been approved for use in children 6 years of age and up.

Clinical practice guidelines can be followed for the treatment of insomnia and sleep apnea in most patients with AD. When more conservative measures such as weight loss are not indicated or successful, first-line treatment for sleep apnea in both adults and children is positive airway pressure. In adults with insomnia, first-line treatment consists of cognitive-behavioral therapy. This may also prove helpful in some adolescent patients, although teens with AD and insomnia should first be assessed for circadian rhythm disorder, said Pigeon.

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