Effects of Disease Severity on Sleep and Quality of Life in Taiwanese Patients with Atopic Dermatitis

To the Editor: Atopic dermatitis (AD) has been known to be associated with reduced sleep quality and impaired quality of life (QoL).1Chang Y.S. Chiang B.L. Sleep disorders and atopic dermatitis: a 2-way street?.J Allergy Clin Immunol. 2018; 142: 1033-1040Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar,2Balieva F. Kupfer J. Lien L. et al.The burden of common skin diseases assessed with the EQ5D™: a European multicentre study in 13 countries.Br J Dermatol. 2017; 176: 1170-1178Crossref PubMed Scopus (85) Google Scholar A previous study demonstrated that increased AD severity was significantly correlated with both QoL and sleep quality.3Kong T.S. Han T.Y. Lee J.H. Son S.J. Correlation between severity of atopic dermatitis and sleep quality in children and adults.Ann Dermatol. 2016; 28: 321-326Crossref PubMed Scopus (37) Google Scholar Sleep disturbance was also more strongly associated with QoL than with AD severity.4Yano C. Saeki H. Ishiji T. et al.Impact of disease severity on sleep quality in Japanese patients with atopic dermatitis.J Dermatol Sci. 2013; 72: 195-197Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Previous studies used the SCORing Atopic Dermatitis index to evaluate disease severity, which may repeatedly measure the effects of sleep disturbance because it includes subjective loss of sleep. We conducted a noninterventional, cross-sectional study to investigate the associations among disease severity, QoL, and sleep quality. We recruited 200 patients diagnosed with AD from 3 hospitals in Taiwan from April 2018 to April 2019. We used the Objective Scoring Atopic Dermatitis (oSCORAD) scale,5Oranje A.P. Glazenburg E.J. Wolkerstorfer A. De Waard-van der Spek F.B. Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score.Br J Dermatol. 2007; 157: 645-648Crossref PubMed Scopus (345) Google Scholar Dermatology Life Quality Index (DLQI), and Pittsburgh Sleep Quality Index (PSQI) to evaluate disease severity, QoL, and sleep quality, respectively. We conducted a PSQI component analysis to identify which aspects of sleep are most affected by disease severity and QoL. A statistical analysis was performed using GraphPad Prism, version 8.4.0. We used Pearson correlation coefficient analyses to evaluate correlations with significance defined as P <.05. We used Bonferroni corrections to account for multiple comparisons in individual components of PSQI and conducted univariate and multivariate linear regression models to correct for the effects of age, sex, and body mass index. The study group had a mean age of 34.4 ± 12.4 years (range, 20-78 years), and the mean duration of the disease was 18.0 ± 11.3 years (range, 0.3-55 years). The mean oSCORAD index score was 27.56 ± 15.89, the mean DLQI score was 12.15 ± 6.11, and the mean global PSQI score was 8.65 ± 3.9. Significant correlations were observed between the oSCORAD and DLQI scores (P < .0001), between the oSCORAD and PSQI scores (P < .0001), and between the DLQI and PSQI scores (P < .0001). In the PSQI component analysis, all components showed significant correlations with the DLQI score. Four components showed significant correlations with the oSCORAD score, including subjective sleep quality (P < .0001), sleep latency (P = .0059), sleep disturbance (P = .0037), and daytime dysfunction (P < .0001) (Table I), whereas demographic characteristics, such as age, sex, and body mass index, did not significantly affect the PSQI component scores, as determined using the multivariate analysis (Table II).Table IAssociation between Pittsburgh Sleep Quality Index component scores and Objective Scoring Atopic Dermatitis scoresPSQI and oSCORADrCorrected significant P value∗Corrected significant P value: P < .05/7 = .00714.Global score0.3021<.0001∗Corrected significant P value: P < .05/7 = .00714.Subjective sleep quality0.3199<.0001∗Corrected significant P value: P < .05/7 = .00714.Sleep latency0.1939.0059∗Corrected significant P value: P < .05/7 = .00714.Sleep duration0.07524.2896Habitual sleep efficiency0.06828.3367Sleep disturbance0.2044.0037∗Corrected significant P value: P < .05/7 = .00714.Use of sleeping medication0.1817.01Daytime dysfunction0.3331<.0001∗Corrected significant P value: P < .05/7 = .00714.oSCORAD, Objective Scoring Atopic Dermatitis; PSQI, Pittsburgh Sleep Quality Index.∗ Corrected significant P value: P < .05/7 = .00714. Open table in a new tab Table IIUnivariate and multivariate relationships between Pittsburgh Sleep Quality Index score and possible affecting factorUnivariateMultivariateSlope (95% CI)P valueEstimate (95% CI)P valuePSQI global score Age0.007298 (−0.03683 to 0.05142).74460.01938 (−0.02275 to 0.06151).3654 Sex−0.7894 (−1.874 to 0.2953).1528−0.9125 (−1.964 to 0.1389).0885 BMI−0.05432 (−0.1938 to 0.08512).4433−0.06646 (−0.2013 to 0.06838).3322 oSCORAD0.07427 (0.04150-0.1070)<.00010.08008 (0.04702-0.1131)<.0001Subjective sleep qualitySleep latencySleep durationHabitual sleep efficiencySleep disturbanceUse of sleeping medicationDaytime dysfunctionP value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.P value∗P value was computed using simple linear regression.P value†P value was derived from multiple linear regression models, with all the variables listed above as independent variables.Age.4232.9481.5486.57.2675.2596.0907Sex.9858.1991.5564.0086.006.1315.3513.7711BMI.7047.0325.0248.5242.9167.8575.2815.9099oSCORAD<.0001<.0001.006.0019.2861.3419.0037.0013.0094.0033<.0001<.0001BMI, Body mass index; oSCORAD, Objective Scoring Atopic Dermatitis; PSQI, Pittsburgh Sleep Quality Index.∗ P value was computed using simple linear regression.† P value was derived from multiple linear regression models, with all the variables listed above as independent variables. Open table in a new tab oSCORAD, Objective Scoring Atopic Dermatitis; PSQI, Pittsburgh Sleep Quality Index. BMI, Body mass index; oSCORAD, Objective Scoring Atopic Dermatitis; PSQI, Pittsburgh Sleep Quality Index. Previous studies have revealed that subjective sleep quality and sleep latency are significantly correlated with the SCORing Atopic Dermatitis index score.3Kong T.S. Han T.Y. Lee J.H. Son S.J. Correlation between severity of atopic dermatitis and sleep quality in children and adults.Ann Dermatol. 2016; 28: 321-326Crossref PubMed Scopus (37) Google Scholar,4Yano C. Saeki H. Ishiji T. et al.Impact of disease severity on sleep quality in Japanese patients with atopic dermatitis.J Dermatol Sci. 2013; 72: 195-197Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar We found out that more parameters defining sleep quality were involved in our patients with AD, including subjective sleep quality, sleep latency, sleep disturbance, and daytime dysfunction. It might reflect that the severity of AD in the current study is higher than that in the previous ones, as noticed based on the higher SCORing Atopic Dermatitis index and DLQI scores,3Kong T.S. Han T.Y. Lee J.H. Son S.J. Correlation between severity of atopic dermatitis and sleep quality in children and adults.Ann Dermatol. 2016; 28: 321-326Crossref PubMed Scopus (37) Google Scholar,4Yano C. Saeki H. Ishiji T. et al.Impact of disease severity on sleep quality in Japanese patients with atopic dermatitis.J Dermatol Sci. 2013; 72: 195-197Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar although different cultural or environmental factors might also have played some roles. Our study further confirms the impact of the objective severity of AD on sleep quality. None disclosed.