Introduction 

You have probably wondered why people experience difficulty sleeping and staying asleep, especially at night. This can be due to a condition called neurodermatitis (skin irritation caused by allergy or eczema caused by allergy), medically known as Lichen Simplex chronicus.¹ It is characterised by sudden itching, excessive rubbing, scratching, and hyperpigmentation of the affected area. The affected skin resembles the bark of a tree and it often relapses after treatment. Neurodermatitis-related skin concerns rank among the highest part of nonfatal disease burden globally in children and adults, although it is not deadly, 10 to 20% of children are affected in advanced countries.^2,3 The occurrence of this condition is higher among women than men (ratio 2:1), and populations between the ages of 35 and 50 are at higher risk of developing Neurodermatitis due to the stressful life events this age group encounters.³

Known causes of neurodermatitis

• Underlying health conditions such as long-term blocked bile duct, lymph node cancer, eczema, gluten sensitivity, insect bite, and kidney failure
• Mechanical irritation such as wear and tear from clothes
• Environmental factors ( hot weather, sweat, irritating skin products such as aloe vera, tea tree oil, antiseptics, antifungal, feminine washer, perfume, preservatives, lubricants)
• Recently, a study highlighted that emotional triggers such as anxiety also contribute to continuous itching.³ According to research, chemicals in the brain such as dopamine and serotonin influence how itchiness is experienced by affected individuals. An imbalance in these chemicals can result in emotional distress (depression, anxiety) which in turn intensifies itching⁴

The elbow, outer part of the female genital area, neck, eyelid, face, scalp, forearm, scrotum, and ankle are commonly affected areas.⁵

There is a growing body of evidence from conducted research that indicates that there is an association between neurodermatitis and sleep disturbance, which has an overall impact on the quality of life of persons affected.^6,7

The impact of this condition on sleep results in psychological effects ranging from depression, anxiety, social isolation, and lack of flexibility. Sleep disturbance is a broad term used to describe lack of sleep, sleep disruption, or sleep disorders such as insomnia and sleep-related breathing problems.⁵

How does neurodermatitis disturb sleep?

Biologically neurodermatitis affects sleep when the body releases inflammatory chemicals. These inflammatory chemicals increase skin itching and sensitivity. At night the hormones that normally help reduce inflammation (anti-inflammatory hormones) and keep the skin calm are produced in lower quantities therefore itching tends to be more intense. As a result, affected persons wake up more often and have trouble staying asleep.⁸

Neurodermatitis disturbs sleep through severe itching (pruritis) in the affected area, especially at night.⁹ Sleep is facilitated by some essential regulatory functions in humans, and it occurs in four stages. The four stages are the lightest stage, the deeper light stage, the deepest stage, and the rapid eye movement stage ( most dreams occur in this stage).¹⁰ Sleep disturbance due to neurodermatitis has been noted to occur during all the stages of sleep, especially during the lightest stage, making it difficult for the affected individual to fall asleep.⁸ There is less scratching in the deepest stage, which can be linked to lower sensory perception during this sleep stage.¹¹ Children with this allergy-related skin irritation are more restless while sleeping, often awake, and spend more time awake after falling asleep.¹² Furthermore in children neurodermatitis-associated sleep disturbance is characterised by: excessive sweating at night, increased movement while asleep, and decreased sleep time.² In adults, especially women, the effect of this condition is not limited to sleep disturbance as it also significantly disrupts the sexual function of this gender.⁵

The following are factors that contribute to increased itching at night:

• Increased skin temperature due to thermoregulatory functions at night¹³
• Skin barrier intensity tends to increase at night⁸
• The hormone corticosteroid, which controls swelling and irritation, is produced in low quantities in the evening and night. This makes it difficult for the body to fight irritation, therefore contributing to nighttime itching, which in turn affects sleep¹³

Impact of neurodermatitis-associated sleep disturbance on health and daily life

1. It causes restlessness, lack of focus, behavioural and emotional disturbance, and less school productivity in children^14,15
2. In adults, it contributes to daytime tiredness and lack of concentration, resulting in unproductive behaviour¹⁶
3. A feeling of dissociation, social isolation, anxiety and depression, and also low self-esteem¹⁷

Diagnosis and assessment of neurodermatitis

This condition is diagnosed in the following ways:

• Physical examination of the affected area 
• Assessment of medical record
• Non-invasive skin examination with an instrument called a dermoscopy
• Through symptoms (itching, scratching) reported by affected individuals³
• Assessment of any other underlying health conditions such as asthma
• Potassium hydroxide and fungal cultures are used to assess genital occurrence of the condition

Assessment of sleep disturbance

Although subjective, sleep disturbance can be assessed using: 

• Questionnaires such as the Pittsburgh Sleep Quality Index (PSQI), and insomnia severity index
• Parental-reported sleep problems for children 
• Use of home-installed portable monitors 
• Use of a digital wearable (on the wrist) known as actigraphy to measure sleep and wake time
• Nonwearable can also be used such that they are placed under the mattress like a sensor¹⁴

Management and treatment strategies

Neurodermatitis rarely clears without treatment, management of neurodermatitis is complex and requires a well-established integrated approach to break the itching and scratching cycle.¹⁸ The choice of treatment is determined by the severity of the condition and the age of the patient.¹⁸ Some of the treatments include:

• Topical treatment with corticosteroids, topical emollients, and antihistamines is recommended to prevent allergy
• In severe cases, phototherapy with only ultraviolet B alone or in combination with ultraviolet A
• Oral administration of sleep hormones (melatonin)
• Treatment with drug and light (photochemotherapy),
• Surgical treatment such as cold surgery (cryosurgery)³
• Behavioural and psychological interventions such as anti-anxiety medications, muscle relaxation techniques, and mindfulness to prevent scratching
• Hygiene and environmental factors: reduction of the use of hard water for baths/ showers¹⁹ 

Summary 

Neurodermatitis is a skin condition characterised by prolonged itching and scratching especially at night. The severity of the itch-scratch cycle at night makes it difficult for affected persons to fall asleep and stay asleep for long. This condition causes emotional and psychological effects on affected individuals. It reduces productivity during the day and causes tiredness, restlessness, and lack of concentration especially in children. The effect of neurodermatitis on sleep has an overall negative impact on the quality of life of affected persons and their well-being. It is often caused by allergic reactions produced by medical, environmental, and mechanical factors.

Although neurodermatitis is not deadly, the impact it has on quality of life indicates the need for more advanced research to foster a better understanding of the intricate connection between neurodermatitis and the impact it has on sleep and emotional well-being. Effective treatment and management interventions that address both neurodermatitis and its impact on sleep will significantly improve health outcomes.

There is an association between neurodermatitis and sleep disturbance as evidenced in the various psychological and social impacts it has on affected persons as earlier discussed. The effect of this condition has an overall impact on the intellectual development of children and the productivity of adults.

FAQs

Is neurodermatitis infectious/contagious? 

No

How can I treat neurodermatitis? 

Use of anti-allergic drugs but be sure to consult the dermatologist first.

Are there home remedies for neurodermatitis? 

Yes ( Cool compress, cool baths, mindfulness)