Letters
Volume 49, Issue 10, October 2020

October correspondence


Download article
Cite this article    BIBTEX    REFER    RIS

The opinions expressed by correspondents in this column are not endorsed by the editors or The Royal Australian College of General Practitioners.

Psoriatic patients: Sleep quality and physical activity should be inquired about

We congratulate Dr Benjamin S Daniel for the comprehensive review on the multiple comorbidities of psoriasis (AJGP July 2020).1 The author is right with his conclusion: ‘Treating a patient with psoriasis should encompass education about lifestyle changes and evaluating their risk of other comorbidities’.1 But there are two aspects worth mentioning.

First, more than 50% of patients with psoriasis report sleep disruption. Multivariate regression analysis has shown a significant association between sleep difficulty or low sleep quantity and psoriasis severity (moderate: odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.30, 1.94, P = 0.001; severe: OR: 2.40, 95% CI: 1.87, 3.08, P = 0.004).2 There is also a bidirectional association between sleep-related conditions such as obstructive sleep apnoea (OSA) and psoriasis. Intermittent hypoxemia during sleep leads to increased oxidative stress, with elevated levels of nuclear factor-kB, hypoxia-inducible factor-1a, endothelial nitric oxide synthase, vascular cell adhesion molecule 1 and vascular endothelial growth factor; and increased systemic inflammation indicated by elevated levels of interleukin-17 (IL-17), tumour necrosis factor alpha, IL-6, IL-7 and C-reactive protein.3 A recent meta-analysis by Ger and colleagues found that patients with psoriasis had 2.6-fold greater odds of having OSA (95% CI: 1.07, 6.32), and the incidence rate ratio for psoriasis was 2.52 in patients with OSA (95% CI: 1.89, 3.36).3 In addition, pruritus in patients with psoriasis is often so severe at night that sleep disturbances occur.4 Sleep impairment in psoriasis contributes significantly to disease burden and is associated with reduced quality of life; therefore, clinicians should screen the sleep quality in patients with psoriasis – these patients may have undiagnosed OSA.3–5 General practitioners (GPs) should know that sleep apnoea is also integrated into current guidelines of care for the management and treatment of psoriasis as an important comorbidity, for example the joint guideline of the American Academy of Dermatology and National Psoriasis Foundation.5 In a holistic approach, it is essential for GPs not only to integrate classic comorbidities such as psoriatic arthritis, cardiovascular disease, metabolic syndrome or mental health disorders, but also ‘new’ emerging comorbidities.

Second, there is increasing evidence showing that patients with psoriasis have significantly reduced levels of physical activity when compared with those without psoriasis.6,7 Regular moderate-to-vigorous physical activity can positively influence psoriasis prevalence as well as the incidence of the associated comorbidities through simultaneous epigenomic, antidiabetic, antihyperlipidemic, antihypertensive, anti-obesity, anti-inflammatory, antioxidative, anti-atherogenic, anticancerogenic, social and psychological effects.5–7 The fear that exercise may worsen psoriasis symptoms may be widespread among those affected.8 GPs should encourage all patients with psoriasis to be more physically active and help identify psoriasis-specific barriers to physical activity such as severity, skin sensitivity, clothing choice or participation in social and leisure activities (eg for sportswear, choose skin-friendly, soft and breathable fabrics such as high-tech sports textiles made of polyester with silver fibres that inhibit bacterial growth).6,7

 

Martin Hofmeister PhD
Nutrition Scientist
Department Food and Nutrition,
Consumer Centre of the German Federal State of Bavaria,
Munich, Germany

Amirhosein Ziyaiyan MSc
Department of Sports Physiology,
Faculty of Physical Education and Sports Science,

University of Tehran,
Tehran, Iran

References
  1. Daniel BS. The multiple comorbidities of psoriasis: The importance of a holistic approach. Aust J Gen Pract 2020;49(7):433–37. doi: 10.31128/AJGP-08-19-5035.
  2. Smith MP, Ly K, Thibodeaux Q, et al. Factors influencing sleep difficulty and sleep quantity in the Citizen Pscientist psoriatic cohort. Dermatol Ther (Heidelb) 2019;9(3):511–23. doi: 10.1007/s13555-019-0306-1.
  3. Ger TY, Fu Y, Chi CC. Bidirectional association between psoriasis and obstructive sleep apnea: A systematic review and meta-analysis. Sci Rep 2020;10:5931. doi: 10.1038/s41598-020-62834-x.
  4. Hawro T, Hawro M, Zalewska-Janowska A, Weller K, Metz M, Maurer M. Pruritus and sleep disturbances in patients with psoriasis. Arch Dermatol Res 2020;312(2):103–11. doi: 10.1007/s00403-019-01998-7.
  5. Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol 2019;80(4):1073–113. doi: 10.1016/j.jaad.2018.11.058.
  6. Zheng Q, Sun XY, Miao X, et al. Association between physical activity and risk of prevalent psoriasis: A MOOSE-compliant meta-analysis. Medicine (Baltimore) 2018;97(27):e11394. doi: 10.1097/MD.0000000000011394.
  7. Auker L, Cordingley L, Pye SR, Griffiths CEM, Young HS. What are the barriers to physical activity in patients with chronic plaque psoriasis? Br J Dermatol 2020. doi: 10.1111/bjd.18979. [ePub ahead of print]
  8. Schwarz PEH, Pinter A, Melzer N, Barteczek P, Reinhardt M. ERAPSO: Revealing the high burden of obesity in German psoriasis patients. Dermatol Ther (Heidelb) 2019;9(3):579–87. doi: 10.1007/s13555-019-0314-1.

Reply

Psoriasis should be considered a systemic disease; in time, emerging associations and other comorbidities will be discovered. Risk factors for obstructive sleep apnoea include smoking and obesity,1 both of which are more common in patients with psoriasis. The article by Ger et al is a review of observational studies that accounted for obesity as a confounder.2 The complex interaction between proinflammatory cytokines in psoriasis and its comorbidities is still not fully elucidated, but future research may reveal the interplay and pathways.

Psoriasis Area and Severity Index (PASI) scores are inversely correlated with the degree of physical activity.3 A high Dermatology Life Quality Index (DLQI) score is associated with less activity, with barriers including embarrassment/self-consciousness, clothing choice and skin disease that made playing sport difficult. Female sex and older age are associated with less activity, though the reasons for this are complex. General practitioners are in a privileged position to address and facilitate behavioural changes to reduce the risk of cardiovascular disease in patients with psoriasis.

Benjamin S Daniel
MBBS, MMed (Clin Epi),
BA, BCom, FACD,
Consultant Dermatologist,
Department of Dermatology,
St George Hospital NSW and
St Vincent’s Hospital, Vic

 

References
  1. Urbanik D, Martynowicz H, Mazur G, Poręba R, Gać P. Environmental factors as modulators of the relationship between obstructive sleep apnea and lesions in the circulatory system. J Clin Med 2020;9(3):836. doi: 10.3390/jcm9030836.
  2. Ger TY, Fu Y, Chi CC. Bidirectional association between psoriasis and obstructive sleep apnea: A systematic review and meta-analysis. Sci Rep 2020;10(1):5931. doi: 10.1038/s41598-020-62834-x.
  3. Auker L, Cordingley L, Pye SR, Griffiths CEM, Young HS. What are the barriers to physical activity in patients with chronic plaque psoriasis? Br J Dermatol 2020. doi: 10.1111/bjd.18979. [ePub ahead of print]

Download article