The role of sleep in optimizing health and well-being is a widely discussed topic in popular culture and research communities. However, one area where discussion is lacking is the interplay between sleep and dermatology.
In this article, we discuss the complex interplay between sleep and skin health, as well as review how poor sleep may contribute to worsening of skin disease in patients living with chronic dermatologic conditions like psoriasis and eczema.
Don’t Sleep on the Skin
The skin is the body’s largest and primary protective organ, serving as a first-order physical barrier against the environment.1 Surrounded by a complex lipid matrix, the primary skin cells (keratinocytes) form a tight skin barrier that serves many functions including temperature regulation, maintaining the body’s water balance, and protection against ultraviolet (UV) light.
Recent research also reveals that the skin is an active and critical immune organ containing both a variety of immune-competent cells and cytokines, making it the frontline of immune protection against environmental toxins and microbes.2 If the skin barrier becomes compromised, skin health is impacted, which may contribute to the development, or exacerbation, of various skin conditions and sensitivities.3
…And Get your Beauty Sleep
We are now learning that sleep plays an important role in the maintenance of the skin barrier. A 2015 study concluded that chronic poor sleep quality was associated with skin aging and suboptimal responses to environmental stressors on the skin.4
During this study, subjects were first divided into “good sleepers” (n=30) and “poor sleepers” (n=30) based on their Pittsburgh Sleep Quality Index (PSQI) score and sleep duration. Then, they were exposed to a standardized dose of UV light, and the resultant erythema (redness) response was evaluated.
At 24 hours, good sleepers had significantly better recovery from erythema compared to poor sleepers. Subjects’ skin was then tape-stripped, a method used to deliberately damage the skin barrier and measure the effect on water loss through the epidermis. Interestingly, poor sleepers had a higher level of water loss, even at baseline, and good sleepers had 30% greater barrier recovery compared with poor sleepers 72 hours following injury.
The authors hypothesize that this may be due to optimized DNA damage repair mechanisms in good sleepers compared to poor sleepers. Importantly, this may suggest that poor sleepers could suffer from more UV damage and slower recovery after physical injury, which not only has aesthetic implications for skin aging but also for the development of cutaneous malignancies (skin cancer).
Finally, a validated clinical tool, SCINEXATM, was used to assess intrinsic and extrinsic skin aging in all participants. Good sleepers consistently scored lower, meaning they had fewer objective signs of skin aging than poor sleepers. Therefore, sleep can impact skin function and, in the long term, lead to deficits in skin appearance.
Sleep and Skin Disease
We can now clearly see that adequate, good-quality sleep is necessary for skin functioning and the appearance of normal skin. However, what happens when the skin is not normal?
Many people in the United States are living with skin diseases. Two of the more common chronic conditions include eczema and psoriasis. Estimates suggest that 32 million people are living with eczema, while psoriasis impacts over 7.2 million people in the US.5
Unfortunately, not only are these diseases visible on the skin, causing high psychosocial burdens—including depression, anxiety, and low self-esteem, but they are also itchy. Those patients who report having more severe itching also report more sleep impairment on health-related quality of life questionnaires.6 This data provides meaningful insight into the perceived sleep quality and satisfaction of patients suffering from various dermatologic conditions.
Understanding that both psoriasis and eczema—in addition to various other chronic skin conditions—are mediated by dysregulated immune responses in the skin, we can appreciate the connection between sleep and skin conditions. Studies in healthy individuals show that skipping even one night of sleep leads to increases in immune cell populations and upregulated pro-inflammatory mediators in the skin. Patients with baseline inflammatory disease may be at greater risk for such changes.7
In one study, mice with psoriasis had significantly higher increases in pro-inflammatory cytokines and decreases in anti-inflammatory cytokines after sleep deprivation compared to control mice without psoriasis.8 This suggests that there is a greater vulnerability for sleep-induced inflammation in patients with skin disease and that sleep deprivation could make these diseases harder to control.
More recent literature also looks at the impacts of the skin microbiome on skin health and skin disease. The skin surface is covered with numerous microorganisms, and together with the physical barrier, they protect us from the invasion of pathogens. When the delicate balance within this symbiotic system is disturbed, changes in skin health and the incidence of skin disease can be seen. One study revealed that a regular late bedtime with inadequate sleep quantity not only damages the skin barrier and skin structure but also reduces the diversity and composition of the skin bacterial microbiome, which could have negative effects on skin health.9
Future Directions
As healthcare providers, it is crucial that we focus not only on treating the skin disease at hand but also on improving lifestyle factors such as sleep to help achieve the best outcomes for our patients.
Several epidemiologic studies have suggested that the risk of sleep loss-related health complications could be reduced significantly by more effective diagnosis and management of sleep disturbances.10 Therefore, it is crucial that dysregulated sleep be identified early, particularly in patients suffering from chronic inflammatory skin conditions. Effective treatments are available for sleep disturbances yet are likely underutilized in dermatology due to inadequate knowledge of the prevalence, phenotypes, and potential causes and outcomes of sleep disturbance.
The impact of suboptimal sleep and sleep deprivation has been shown to be correlated with numerous serious, chronic medical conditions, as well as the risk of developing particular inflammatory skin conditions. With such work, there is potential to make significant advances in improving the skin, sleep, and overall health of individuals. After all, our sleep and our skin are at stake!
Tina Bhutani, MD, is a dermatologist and associate professor in the University of California, San Francisco (UCSF) Department of Dermatology. She is co-director of the UCSF Psoriasis and Skin Treatment Center and UCSF Dermatology Clinical Research Unit and focuses on treating chronic inflammatory skin diseases, especially psoriasis and eczema.
Additional authors: Chandler Johnson, BA, BS; Kathryn Haran, BS; Payton Smith, BS; Allison Kranyak, MD; and Wilson Liao, MD
Source: SleepWorld Magazine May/June 2024
References
- Lopez-Ojeda W, Pandey A, Alhajj M, Oakley AM. Anatomy, Skin (Integument). [Updated 2022 Oct 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441980/.
- Salmon JK, Armstrong CA, Ansel JC. The skin as an immune organ. West J Med. 1994;160(2):146-52.
- Kahan V, Andersen ML, Tomimori J, Tufik S. Can poor sleep affect skin integrity? Med Hypotheses. 2010 Dec;75(6):535-7.
- Oyetakin-White P, Suggs A, Koo B, et al. Does poor sleep quality affect skin ageing? Clin Exp Dermatol. 2015;40(1):17-22.
- Penn Medicine. Eczema vs. psoriasis: Similarities, contrasts and treatment. Published March 24, 2022. https://www.pennmedicine.org/updates/blogs/health-and-wellness/2022/march/psoriasis.
- Hawro T, Przybyłowicz K, Spindler M, et al. The characteristics and impact of pruritus in adult dermatology patients: A prospective, cross-sectional study. J Am Acad Dermatol. 2021 Mar;84(3):691-700.
- Prather AA, Marsland AL, Hall M, Neumann SA, Muldoon MF, Manuck SB. Normative variation in self-reported sleep quality and sleep debt is associated with stimulated pro-inflammatory cytokine production. Biol Psychol. 2009 Sep;82(1):12-17.
- Hirotsu C, Rydlewski M, Araújo MS, Tufik S, Andersen ML. Sleep loss and cytokines levels in an experimental model of psoriasis. PLoS One. 2012;7(11):e51183.
- Shao L, Jiang S, Li Y, et al. Regular late bedtime significantly affects the skin physiological characteristics and skin bacterial microbiome. Clin Cosmet Investig Dermatol. 2022;15:1051-63.
- Perry GS, Patil SP, Presley-Cantrell LR. Raising awareness of sleep as a healthy behavior. Prev Chronic Dis. 2013;10:E133.
