Sleep on it

| Beth Orenstein

Like many people living with psoriatic arthritis, Julie Cerrone often woke up at night and was unable to get back to sleep because her joints ached so much. “When I was first diagnosed with psoriatic arthritis three years ago, my sleep patterns were so off,” Cerrone said.

Since then, the 30-year-old from Bethel Park, Pennsylvania, has controlled her psoriatic arthritis pain with medications, dietary changes, exercise and meditation, and is sleeping much better.

“Now I make sure I get eight to nine hours of sleep a night,” she said. “If I don’t, I can really feel it in my body.”

Cerrone is not alone. If you have psoriasis and/or psoriatic arthritis, chances are good that you also have trouble sleeping. According to a study in Dermatology Online Journal in 2013, adjusting for age, Body Mass Index and gender, patients with psoriasis were 4.3 times more likely to score in a higher insomnia category and a trend toward struggling with sleep.

In fact, sleep disorders are so common in psoriasis and psoriatic arthritis patients that they’re now considered comorbidities, or co-existing conditions, of psoriatic disease, said Dr. Kristina Callis-Duffin, NPF Medical Board member and associate professor of dermatology at the University of Utah in Salt Lake City.

An NPF survey of more than 400 psoriatic disease patients found that, among that group, those with psoriatic arthritis were most likely to report sleep disturbances, said Callis-Duffin, lead author of the survey, published in the Journal of the American Academy of Dermatology in April 2009.

So which comes first, psoriasis/psoriatic arthritis or sleep disorders?

“It’s complicated,” Callis-Duffin said. “It’s not a straightforward relationship, primarily because we don’t know if the psoriasis is causing the sleep disorder or the sleep disorder is driving the psoriasis.”

The psoriasis/sleep apnea connection

Sleep apnea — in which people repeatedly stop breathing during sleep — has been reported in 36 to 56.3 percent of patients with psoriasis, said Dr. Alexander Egeberg, a researcher from Herlev and Gentofte Hospital at the University of Copenhagen in Denmark.

And Israeli researchers, in a study of more than 12,000 patients with psoriasis and 24,000 controls published in the International Journal of Dermatology in November 2016, found such a large association between psoriasis and obstructive sleep apnea (OSA) that they concluded doctors who treat psoriasis should actively look for OSA in their patients, as it often goes undiagnosed.

One of the most common symptoms of obstructive sleep apnea is loud and chronic snoring, according to the National Heart, Lung and Blood Institute. Snoring may pause, followed by choking or gasping symptoms that a family member or bed partner likely will notice first. (Snoring alone is not necessarily a sign of sleep apnea.)

Other symptoms may include morning headaches, an inability to concentrate, feeling irritable or having mood swings, getting up frequently to go to the bathroom and a dry mouth or sore throat in the morning.

Egeberg was the lead author of a study, published in the Journal of Clinical Sleep Medicine in May 2016, that found psoriasis was associated with increased risk of sleep apnea, and sleep apnea was associated with increased risk of psoriasis.

Other sleep disrupters

The inflammation that accompanies psoriatic disease may be a culprit, Egeberg said. “Data suggest that inflammation may affect sleep patterns and sleep quality,” he noted.

Researchers at the University of California Los Angeles Cousins Center found that loss of sleep, even for a few hours a night, can cause your immune system to turn against you. In a study published in Biological Psychiatry in September 2008, the researchers wrote that loss of sleep triggers the key cellular pathway that produces tissue-damaging inflammation that can lead to immune-mediated disorders such as psoriasis and psoriatic arthritis.

Another study, published in the Archives of Dermatological Research in July 2015, also found that inflammation may be the common denominator connecting psoriasis and sleep apnea.

Medications used to treat psoriatic disease can have a positive impact on sleep patterns, Egeberg said. “Interestingly, studies on biologic therapies, such as TNF inhibitors (which target Tumor Necrosis Factor, a cause of inflammation) used for psoriasis, have shown marked improvement in quality of sleep and symptoms of sleep disorders.”

Another study, published in the Journal of Clinical Sleep Medicine in December 2012, found that obstructive sleep apnea was less common in patients with another inflammatory arthritis, spondyloarthritis, when they were on TNF-inhibitor therapy.

In addition to inflammation, obesity is also believed to play a role in both sleep disturbance and psoriasis.

Research has shown a link between obesity — clinically defined as being 30 or more pounds overweight — and having psoriasis and psoriatic arthritis, Callis-Duffin said. “If you draw an arrow from obesity to psoriasis and an arrow from psoriasis to obesity, that’s the model,” she said. “You can do that with sleep disturbances as well.”

Finally, stress can be a factor in poor sleep, said Callis-Duffin. “If you feel stressed, you won’t sleep well, and that could be the problem — the combination of stress and poor sleep makes psoriasis worse. You can’t separate them.”

Finding solutions

If you can’t sleep, talk to your doctor. Doing so is important for a number of reasons, said Dr. Abrar Qureshi, chief of the Department of Dermatology at Rhode Island Hospital, chair of the Department of Dermatology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, and NPF Medical Board member.

First, those with psoriasis are more likely to suffer from depression — at twice the rate of the general population. Depression may cause sleep disturbances, and/or your inability to get restful sleep can leave you depressed, Qureshi said.

Second, sleep disturbances can disrupt your sympathetic nervous system, which serves to accelerate heart rate, constrict blood vessels and raise blood pressure, Egeberg said. Thus, poor sleep and sleep apnea can increase the risk of developing cardiovascular disease. 

The American Heart Association warns that waking and gasping for air prevents restful sleep, and lack of sleep is associated with high blood pressure, irregular heart rhythms, stroke and heart failure. And because cardiovascular disease can be a comorbidity of psoriatic disease, this is of special concern to those with psoriasis and psoriatic arthritis.

To address these comorbidities, in the 15 years since he was a resident, Qureshi has changed the way he treats patients with psoriasis. 

“Years ago, we looked at our dermatology patients and treated them based on the extent of their psoriasis,” he said. “Now we ask about diet, exercise, smoking, morning stiffness and pain, and sleep habits. We ask about sleep apnea in particular and suggest they undergo a sleep study if they have any of its symptoms.”

Denny Long, 67, of Milford, Ohio, took advantage of that recommendation from his doctor. Long, who has had psoriasis for as long as he can remember, was having trouble sleeping and complained to his doctors about his snoring, waking at night and being tired all the time. An overnight sleep study resulted in a diagnosis of mild sleep apnea and restless leg syndrome.

“They found I would wake up 10 to 12 times a night,” he said. “That’s very, very mild. I was also moving my legs 700 times a night.”

If you or your doctors suspect you have OSA, “there’s no way around it but to get tested,” Qureshi said. “Sleep studies are much easier to do now.”

Testing can be done in your home in your own bed, he said. “A sleep specialist can look at the data and tell you that when you wore the machine, you had so many hours of restful sleep and woke so many times.”

If the results are severe, your doctor may refer you for a sleep study known as a polysomnogram, done overnight at sleep centers or sleep labs. The study measures brain activity, eye movements, heart rate and blood pressure while you sleep.

If you have moderate or severe sleep apnea, you may need to use a continuous positive airway pressure (CPAP) machine that blows air into your throat to keep your airway open while you sleep.

“If you do an overnight sleep center study and they find OSA, they can fit you for the CPAP during the same test,” Callis-Duffin said.

Following his sleep study, Long tried a CPAP machine but couldn’t find a mask he was comfortable with. He and his doctor decided his sleep apnea was mild enough that he could go without it.

Winding down

Simon Jury, 44, of Chelmsford, England, has had psoriasis for about 14 years and psoriatic arthritis for six. Like many people with psoriatic disease, when his skin is particularly itchy and his joints ache, Jury finds it difficult to sleep.

His biggest issue, he said, is waking up in discomfort “and feeling the need to move.” He often has to take painkillers to get back to sleep, leaving him too tired to drive to work in the morning.

His advice to those in the same situation is to find a way to de-stress.

“Find a way to wind down in the evening,” Jury said. “I try not to get stressed during the evening before bedtime. For me, cooking is my life, and a nice cooked meal in the evening relaxes me.”

He also soaks in a cool bath to ease his skin itch and moisturizes afterward, giving the moisturizer time to soak in before bed.

Tips for a better night’s sleep

Here are some tips from dermatologists and the National Sleep Foundation to help you sleep better, despite your psoriasis or psoriatic arthritis.

STICK TO A SLEEP SCHEDULE, even on weekends. Going to bed and waking up at the same time every day, including Saturdays and Sundays, helps regulate your internal body clock, according to the National Sleep Foundation.

AVOID TAKING NAPS, especially in the afternoon. If you need a nap to get you through the day, keep it short and avoid sleeping close to bedtime.

MAKE YOUR BEDROOM A SLEEPING CHAMBER. Don’t use your bed for anything other than sleeping or intimacy. Keep your bedroom between 60 and 67 degrees, dark and quiet. Make sure your mattress and pillows are comfortable and supportive.

TURN OFF YOUR PHONE AND OTHER ELECTRONIC DEVICES. Studies have shown that even small electronic devices emit enough light to confuse your brain and promote wakefulness.

WEAR COTTON GLOVES to bed to prevent you from scratching during the night.

AVOID STIMULANTS. Stop consuming caffeine by late afternoon, as it is a stimulant, and limit alcohol consumption. While alcohol is classified as a depressant, in small amounts it can act as a stimulant, according to research in the 2011 volume of Current Topics in Behavioral Neurosciences, and in larger amounts, it acts as a depressant and can be disruptive to restful sleep.


Driving Discovery, Creating Community

This year, we’re celebrating 50 years of driving efforts to cure psoriatic disease and improve the lives of those affected. See how far we’ve come with this timeline of NPF’s history. But there’s still plenty to do, and we can’t do it without you! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funding to promote research into better treatments and a cure by joining Team NPF, where you can walk, run, cycle, play bingo or even create your own DIY event. Contact our Patient Navigation Center for free, personalized support for living a healthier life with psoriatic disease. And keep the National Psoriasis Foundation going strong by making a donation today! Together, we will find a cure.

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