Introduction
Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting the pediatric and adult population with a lifetime prevalence of up to 20%1. It is characterized by recurrent itchy eczematous lesions, papulation, and lichenification, with high heterogeneity of clinical manifestations and diffuse dry skin as an expression of skin barrier dysfunction1.
Aside from the cutaneous signs and symptoms of AD, several atopic and non-atopic comorbidities can occur in AD patients1–3. Not surprisingly, the severe, persistent, and debilitating itch, typical of AD, causes sleep deprivation, anxiety and depression, and reduced quality of life and productivity2,3.
Sleep disturbances are one of the most relevant non-atopic comorbidities, reported by 33 to 87.1% of adults with AD4,5, a much higher percentage than the prevalence in the general population (7–48%)6. AD patients report lower sleep quality and more insomnia symptoms, experiencing difficulty in falling asleep, increased frequency and duration of nocturnal awakenings, and shorter sleep duration, which can lead to excessive daytime sleepiness, fatigue, and dysfunction3–9. Overall, sleep disorders significantly impact the general health and quality of life of AD patients10, impairing work and home functioning and interpersonal relationships6 and playing a critical role in the development of cardiovascular11, metabolic12, and psychiatric diseases13.
Psychological disorders represent another common comorbidity in the AD population. Patients with AD often develop psychosocial distress with high rates of mental disorders, such as depression and anxiety14–18. However, relatively little is known about AD and self-perceived stress in adults19–21. Stress could aggravate and trigger skin diseases22. Likewise, some dermatoses are a source of stress and impair quality of life19.
Despite their importance, sleep and psychological stress in AD were investigated by a few studies. Moreover, the literature in this field is limited to using simple dichotomous or Likert-type questions when comparing AD and healthy subjects5,20,21,23. Other studies on sleep in AD have even referred to single items taken from mood or quality of life questionnaires, neglecting the multidimensionality of sleep5,6,23. Therefore, the first aim of our study was to use a set of validated questionnaires to investigate sleep quality, insomnia, depression, anxiety, and perceived stress in AD patients through a case-control study. We hypothesize that more severe sleep disturbances, insomnia, depression, anxiety, and perceived stress may be observed in adults with AD than in the healthy population.
Although the relationship between AD, sleep, and psychological disorders is widely recognized, it is unclear how AD is associated with sleep and mental health problems. Investigations on the association between AD severity and sleep disorders showed conflicting results5. In most studies, sleep disturbances and quality appeared to worsen with AD severity; in others, only weak correlations or no significant correlation have been observed3–5,9. Similarly, some studies reported that increasing AD severity is associated with higher rates of depression, alexithymia, suicidal ideation, and anxiety15,16,18,24, but others showed that AD adults were more likely to develop depression and anxiety regardless of atopic eczema severity14. In contrast, most studies did not correlate psychological symptoms with AD severity18. To our knowledge, few studies have investigated the relationship between AD severity and self-perceived stress19,20.
Over time, the chronic nature of AD leads patients to face several difficulties that depend not only on the condition severity but especially on the personal perception of the disorder25. The perception of the disease is strongly influenced by the individual’s experience and interpretation of the disorder26.
To date, the severity-dependent relationship between AD symptoms and sleep and psychological disturbances has been studied mainly through objective tools widely used in clinical trials. However, the importance of patients’ disease perception versus objective measures should be considered in clinical and research settings25,26.
In this regard, the second objective of our study was to investigate the severity-dependent relationship between AD symptoms and sleep quality, insomnia, depression, anxiety, and perceived stress by differentiating clinical-oriented measures from patient-oriented subjective measures of the disease.