The One Crucial Question to Ask Your Eczema Patient

One of the most harmful eczema symptoms isn’t visible in the clinic — it’s the sleep patients lose from itching, pain, and bleeding at night.

About 43% of people with eczema have sleep problems, according to a recent study review in Archives of Dermatological Research.

“If I had only one question to ask, that’s the one I would choose — how’s the sleep?” said Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Feinberg School of Medicine, Northwestern Medicine, Chicago.

Here’s why assessing sleep is crucial in eczema — and how to help patients rest better at night.

Why Sleep Should Be a Standard Part of Eczema Care

“People feel very alone in this, but almost everybody reports their itch is worse at night,” said Lio.

Preliminary research suggests that circadian rhythms in skin barrier function could partially explain this phenomenon. Another factor: When patients lie down to sleep, the day’s responsibilities done, they may finally notice their underlying itchiness.

“People describe it like the flood gates opening,” said Zelma Chiesa Fuxench, MD, MSCE, associate professor in dermatology at Perelman School of Medicine at the University of Pennsylvania, Philadelphia. “All of a sudden, they’re not thinking about anything else that they need to do to get through the day, and the itching is there.”

Some patients have insomnia — tossing, turning, and scratching for hours before falling asleep. Others “fall asleep great but then wake up multiple times or wake up early, kind of miserable and itchy,” said Lio. Then it’s hard to fall back asleep.

Some people scratch while sleeping, reducing sleep quality. They don’t feel rested despite going to bed and rising at normal times. “Oftentimes their skin looks terrible in the morning, and sometimes there’s even blood on the sheets,” said Lio.

People with severe eczema tend to have more sleep trouble. Research suggests that tissue damage and inflammation might cause sleep disturbances, and skin barrier disruption might alter circadian rhythms and increase sensitivity to environmental triggers.

What’s more, insufficient sleep can directly harm skin. “There are studies that show just keeping people up for one night, screwing up one night of sleep, has a measurable damaging effect on the skin barrier in healthy patients,” said Lio. “So imagine if you already have a damaged barrier and are staying up night after night. You’re really in a vicious loop.”

In eczema sufferers, sleep problems can reduce quality of life and can be linked with depression, anxiety symptoms, and neurocognitive deficits. “Understanding the impact of sleep loss is very important because of the association between lack of sleep and disease morbidity,” said Chiesa Fuxench.

Of course, poor sleep can harm patients’ overall health too. Bad sleep can also become a household problem that affects parents, caregivers, and partners of people with eczema, said Chiesa Fuxench.

What to Ask Eczema Patients About Sleep

Questions about sleep can give you a glimpse into a patient’s day-to-day eczema control, beyond what you can see during an appointment.

“With a very dynamic disease on the skin, we have what I’ll call the ‘mechanic’s problem,’” said Lio. That’s the phenomenon of your car’s funny noise disappearing when you take it to the shop.

“People will come in looking pretty good that day, so your clinical exam might not be that impressive,” he said. You might not think the patient needs treatment adjustment until you learn about their sleep habits.

And patients might not volunteer this information — you have to ask, said Chiesa Fuxench.

Here’s how:

• Use a validated screening tool. Ask patients to complete a quick questionnaire with a sleep-related question before their exam. The six-question Atopic Dermatitis Control Tool asks: Over the last week, how many nights did you have trouble falling or staying asleep because of your eczema? The seven-question Patient Oriented Eczema Measure asks: Over the last week, on how many nights has your sleep been disturbed because of the eczema?

  When patients circle their answer, they receive a numerical score you can track over time, from zero (no problem sleeping) to four (problems every night).

  It’s helpful to capture seven nights. If you ask patients about sleep without specifying a time frame, they might only recall the night before. Their answer might not reflect their overall sleep patterns.

  “If a patient says, ‘You know what, my eczema has been keeping me awake every day for the last week,’ then that, to me, it’s a huge exclamation point,” said Chiesa Fuxench.

• Ask a broad question. If you can’t use a screening tool, kickstart the conversation with a question that widely connects eczema and sleep. Chiesa Fuxench often asks: Are you having trouble sleeping, or is eczema affecting your sleep in any way?

  “What I did for many years was simply ask: How are you sleeping? Is it affecting your sleep? Do you find that you’re sleeping OK?” said Lio. “That’s probably sufficient for getting a good sense of what’s going on.”

How to Help People With Eczema Sleep Better

When eczema disturbs a patient’s sleep, Lio doesn’t recommend sleep medications or sedating first-generation antihistamines as first-line treatments. They don’t fix the underlying problem and can cause dependency.

Focus instead on the person’s skin. “My goal is to get their skin better, to get the itch under control so that they can sleep,” he said. “I want sleep to actually be a good measure of how we’re doing.”

If the patient is new or treatment-naive, consider starting treatment. Otherwise, consider advancing them to the next step of the therapeutic ladder.

“If it’s a patient who was already on therapy and they’re still having trouble sleeping, then it’s an opportunity for us to go back and reassess: What is happening here that you are having trouble sleeping? Is it that the medication tackles some things but not others? Do we need to reassess therapy? Do we need to be more aggressive with treatment?” said Chiesa Fuxench.

For example, if gentle cleansing and moisturizing aren’t enough, consider topical therapy. If topicals aren’t doing the trick, now might be the time to try systemic therapy or phototherapy, said Lio.

“This doesn’t necessarily mean they need a certain kind of drug,” said Lio. “It just means we need to do something different. We need to escalate therapy.”

Complementary therapies such as acupuncture and hypnotherapy also help some eczema patients reduce stress and sleep better, he said.

Standard sleep hygiene also applies, and a few eczema-specific bedtime habits may help:

• Keep pets out of bed to reduce skin irritation from dander.
• Ask your partner to give you a calming massage at night to relax before sleep.
• Use silk sheets to reduce friction.
• Wash your bedding every 1-2 days to remove dust mites. Use fragrance-free detergent and run the rinse cycle twice to remove soap residue.
• Forgot to wash your sheets? Keep an ultraviolet C sanitizing wand nearby and run it over your bedding to kill dust mites.
• Use an air purifier in your bedroom to remove dander and other irritants.

As you follow up with the patient, watch for other signs of sleep-sabotaging health problems. Ask: Are you having trouble functioning? The patient might need a referral to a mental health care provider or another specialist.

“Patients with atopic dermatitis may also have other reasons why they’re having trouble sleeping,” said Chiesa Fuxench. “We are physicians at the end of the day, and we have to look at the patient as this entire being, not just someone who has atopic dermatitis.”

Lio has consulted or advised for AbbVie Inc., Apogee Therapeutics Inc., Arcutis Biotherapeutics, Eli Lilly and Company, Galderma, Incyte Corporation, L’Oreal, Pfizer Inc., Regeneron Pharmaceuticals Inc., and Sanofi-Aventis US LLC, Skinfix Inc.; and Verrica Pharmaceuticals Inc. He has ownership or investment interest in Alphyn Biologics Inc., Boston Skin Science LLC, Codex Labs, Concerto Biosciences, LearnHealth Inc., Medable Inc., Modernizing Medicine Inc., Soteri Skin, Stratum Biosciences, Thimble Health LLC, Verdant Scientific Inc., Yobee Care Inc. He has the right to receive payments or may receive future financial benefits for inventions or discoveries related to Theraplex.

Chiesa Fuxench is a consultant for the Asthma and Allergy Foundation of America, National Eczema Association, Pfizer, AbbVie, and Incyte for which she has received honoraria for work related to eczema. She also has been a recipient of research grants from Regeneron, Sanofi, Tioga, Vanda, Menlo Therapeutics, Leo Pharma, and Eli Lilly for work related to eczema as well as honoraria for continuing medical education work related to eczema sponsored through educational grants from Regeneron/Sanofi and Pfizer.