The Psoriasis and Comorbidity Series: ‘Neglected’ Comorbidities, Part 1—Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a chronic, systemic disease characterized by repeated episodes of complete or partial collapse of the upper airways during rapid eye movement sleep, which cause interruptions or decreases in respiratory flow. Clinical signs and symptoms include daytime sleepiness; loud snoring, gasping, choking, snorting, or interruptions in breathing while sleeping (often reported by the patient’s partner); insomnia; and morning headaches.

The patient may exhibit an obese body habitus, crowded oropharyngeal airway, large neck and/or waist circumference, and signs of other associated conditions such as hypertension or diabetes.¹ It should come as no surprise that OSA is also associated with psoriasis because we know that obesity, hypertension, and diabetes are risk factors for psoriasis.

Significance and Prevalence of OSA in Psoriasis

Psoriasis significantly alters patients’ quality of life. But most psoriatic quality of life surveys do not address sleep disturbances, despite 90% of patients with psoriasis reporting trouble sleeping.² Sleep dysfunction among patients with psoriasis is particularly concerning because psoriasis is independently associated with many of the same comorbid conditions as sleep dysfunction, compounding their impact. This is more distressing because the global incidence of psoriasis has been increasing in the past 3 decades.³

A 2020 meta-analysis identified a strongly bidirectional relationship between psoriasis and OSA. Data suggest that the reported prevalence of OSA among patients with psoriasis varies across studies from 36% to 81.8%, compared with 3% to 7% in the general population.⁴ The meta-analysis also found that the rate of OSA increases with the duration of psoriasis and is higher in patients with severe psoriasis and psoriatic arthritis. A 2017 study found that the prevalence of OSA was significantly greater in patients with psoriasis; this association was independent from age, gender, metabolic parameters, and other comorbidities.⁵

Shared Pathogenesis

Although the pathogenesis is still being elucidated, many interrelated mechanisms have been suggested, namely a common systemic inflammatory pathogenic pathway. Increased levels of proinflammatory cytokines, such as IL-6, IL-17, and tumor necrosis factor alpha (TNF-α), are seen in both psoriasis and OSA.⁶ Additionally, research has shown that sleep deprivation can lead to increased levels of inflammatory cytokines, such as IL-1, IL-6, TNF-α, and C-reactive protein.

Autonomic activation secondary to psoriasis-related pruritis and pain is another proposed mechanism connected to the development of OSA. Autonomic activation and inflammation associated with OSA may also be a risk factor for psoriasis, highlighting again the bidirectional relationship between these 2 pathologies.

Finally, oxidative stress secondary to intermittent hypoxia during sleep leads to increased circulating hypoxia-inducible factor 1-α (HIF-1α) and vascular endothelial growth factor (VEGF). Increased levels of both HIF-1α  and VEGF have been found in psoriatic skin lesions as compared with normal skin.⁵

Interventions and Recommendations

In summation, the evidence to date supports a reciprocal association between psoriasis and OSA. All patients with psoriasis should be educated about the risk of OSA, and vice versa. Sleep disorders should be considered a crucial comorbidity of psoriasis, acting as both a mediator and an effect. The early detection and management of sleep disorders could significantly improve patients’ quality of life, making it important to assess sleep quality and the existence of sleep disturbances.

Patients with psoriasis should be questioned about a history or previous diagnosis of OSA, current OSA symptoms, and treatment adherence. Patients with suspected OSA should be referred to a sleep specialist for evaluation. Additionally, patients with a history of OSA should be questioned and counseled about the  negative dermatologic side effects of continuous positive airway pressure (CPAP) use. Possible adverse reactions include acne, allergic contact dermatitis, sebopsoriasis, perioral dermatitis, and pressure sores.⁷ Data suggest that patients with psoriasis and OSA are not as adherent to CPAP treatment as patients who have OSA without psoriasis.⁵ Considering that treatment of OSA with CPAP can improve psoriatic lesions and result in a decrease in TNF-α and IL-6,⁴ physicians should counsel patients on the importance of adherence while also helping manage any barriers.

References
1. Kline LR. Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate. Accessed August 15, 2022. https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-obstructive-sleep-apnea-in-adults

2. Ozeri D. Sleep problems common in psoriasis. Dermatology Times. August 21, 2019. Accessed August 10, 2022. https://www.dermatologytimes.com/view/sleepproblems-common-psoriasis

3. AlQassimi S, AlBrashdi S, Galadari H, Hashim MJ. Global burden of psoriasis—comparison of regional and global epidemiology, 1990 to 2017. Int J Dermatol. 2020;59(5):566-571. doi:10.1111/ijd.14864

4. Halioua B, Chelli C, Misery L, Taieb J, Taieb C. Sleep disorders and psoriasis: an update. Acta Derm Venereol. 2022;102:adv00699. doi:10.2340/actadv.v102.1991

5. Papadavid E, Dalamaga M, Vlami K, et al. Psoriasis is associated with risk of obstructive sleep apnea independently from metabolic parameters and other comorbidities: a large hospital-based case-control study. Sleep Breath. 2017;21(4):949-958. doi:10.1007/s11325-017-1507-4

6. 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

7. Summer J. Common CPAP side effects. American Sleep Association. Updated July 19, 2022. Accessed August 15, 2022. https://www.sleepfoundation.org/cpap/cpap-side-eff ects