Sleep quality of chronic urticaria patients

Introduction: Urticaria is a skin disease commonly seen in the general population characterized by itchy and edematous plaques that can emerge suddenly and may disappear within the same day. Urticaria may manifest with different etiologies and mechanisms and often presents heterogeneously. There are two main forms of urticaria: (I) acute urticaria which lasts for approximately less than 6 weeks and (II) chronic urticaria which may last for years. Additionally, there are other types of urticaria including urticaria accompanied by angioedema and the less rarely seen types including chronic inducible urticaria and the urticaria that occurs secondary to a syndrome. Urticaria is accompanied by angioedema in almost half of the patients. Urticaria leads to a negative impact on the quality of life of the patients, also leading to socioeconomic problems, particularly in chronic forms. In patients with chronic urticaria, pruritus is the hallmark symptom affecting sleep and quality of life. Histamine, in addition to its role in chronic urticaria, is known as an arousal-promoting agent. Moreover, it has a key role in the regulation of non-rapid eye movement (NREM) sleep by the proinflammatory cytokines such as IL-1 and TNF-α that are released together with histamine upon the stimulation of mast cells. Considering the effects of all these factors on sleep, the present study aimed to evaluate sleep quality in patients with chronic urticaria. Materials and Methods: The study included 70 patients aged 18-65 years that presented to Dicle University Medical School Dermatology Department and were diagnosed with chronic urticaria between October 2017 and February 2018 and a control group of 67 healthy persons. The diagnosis of chronic urticaria was established based on patient history, physical examination findings and the evaluation of previous images showing previous lesions (in patients with no active lesions). A written informed consent was obtained from each participant. The Pittsburgh sleep quality index (PSQI) was administered in both groups and the Urticaria Activity Score summed over 7 days (UAS7) and the Dermatology Life Quality Index (DLQI) were administered in the patient group only. The PSQI results were compared between the two groups and the relationship between UAS7 and DLQI was analyzed in the patient group. Results: The study included 70 patients with chronic urticaria and 67 healthy controls. The patient group comprised 67.1% women and 32.9% men with a mean age of 34.23 years and the control group comprised 62.6% women and 37.4% men with a mean age of 30.21 years. An underlying chronic disease was detected in 11.5% of the patients and 3% of the control group. Urticaria was accompanied by angioedema in 60% of the patients. Mean duration of disease was 37.1 (range, 3-144) months. Of all the patients, 85.7% of them were present with chronic spontaneous urticaria and 14.3% of them with chronic inducible urticaria. The most common subtype of chronic inducible urticaria was dermographism (50%), followed by pressure urticaria (20%), cholinergic urticaria (10%), aquagenic urticaria (10%) and aquagenic + cold urticaria (10%). Sleep quality was worse in the patient group compared to the control group. Mean PSQI score was 7.64 in the patient group compared to 4.21 in the control group (p=0.000). Poor sleep quality was found in 51 (72.9%) patients and in 12 (17.9%) control group. In terms of PSQI components, the scores for subjective sleep quality, sleep latency, sleep disturbances, use of sleeping medication and daytime dysfunction were significantly higher in the patient group compared to the control group. However, no significant difference was found with regards to sleep duration and habitual sleep efficiency. Mean UAS7 and DLQI scores were 12.10 and 8.14 in the patients with poor sleep quality (PSQI≥6) and 6.53 and 3.68 in the patients with good sleep quality (PSQI<6), respectively. Both UAS7 and DLQI scores established a significant correlation .with the PSQI scores. In conclusion, our study indicated that the sleep quality in patients with chronic urticaria was affected more than that of healthy controls and both the severity of the disease and the DLQI scores increased as the PSQI scores increased. Key words: Chronic urticaria, sleep quality, Pittsburgh Sleep Quality Index, Urticaria Activity Score, Dermatology Life Quality Index