Food allergy, dermatologic diseases, and anaphylaxis
Management of sleep disturbance associated with atopic dermatitis

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Atopic dermatitis (AD) is a common childhood skin disease that also affects adults. Sleep problems are frequently associated with AD and negatively affect both patients and their families. Although this problem is well recognized, there are currently limited studies of patients with AD to guide clinical management of sleep disturbances. This targeted review will inform clinicians of the potential therapeutic agents available to manage sleep disturbances and will review literature relevant to improving the sleep of children and adults with AD. On the basis of our clinical experience and the limited data available, we provide a suggested algorithm for clinicians treating sleep problems associated with AD, but clearly more studies are needed to both further characterize the sleep of patients with AD and to test the efficacy and effectiveness of candidate agents in clinical trials.

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Histamine and antihistamines

Clinicians consider the first-generation H1 receptor antagonists, or antihistamines, for treatment of sleep problems associated with AD for several reasons. In addition to antagonizing the inflammatory effects of histamine released from mast cells and basophils, the first-generation H1 receptor antagonists can cross the blood-brain barrier and affect histamine's role in maintaining central nervous system arousal.11 Diphenhydramine (Benadryl; Pfizer, New York, NY) and hydroxyzine (Atarax and

Benzodiazepines and nonbenzodiazapine hypnotics

Benzodiazepines act through the gamma-aminobutyric acid–A-benzodiazepine receptor and have been shown to reduce sleep latency and increase total sleep time, but negative effects can include changes in sleep architecture.15 Clinicians might choose benzodiazepines for patients with AD for their anxiolytic properties in addition to their sedating effects. Negative side effects can include muscle relaxation and memory problems. For patients with asthma, muscle relaxation might place them at

Chloral hydrate

Chloral hydrate also acts through the gamma-aminobutyric acid receptor. High doses can directly open the membrane chloride channel, leading to respiratory suppression and cardiovascular instability. Chloral hydrate therefore has a low therapeutic window, and we suggest 1 night of in-hospital observation with children before using this medication on a brief outpatient basis. Again, tolerance to the sedating effects can develop. Chloral hydrate is approved for use in children.

Melatonin

Melatonin is secreted by the pineal gland in a circadian rhythm that might be important in regulating sleep phase. There is controversy about the sleep-promoting effects of melatonin (see Scheer and Czeisler18 for a review of this literature). Two rigorous meta-analyses were recently performed. One combined all studies and found melatonin to have a small but statistically significant effect on sleep onset, duration, and efficiency.19 In the other study the categorization of study populations

Clonidine

Clonidine (Catapres; Boehringer Ingelheim Pharmaceutical Inc, Ridgefield, Conn) is labeled for children and adults as an antihypertensive agent and acts through stimulation of the α2-adrenoreceptors in the brain stem. Clonidine also decreases sleep latency, and there is conflicting evidence regarding its effect on sleep architecture, which might be related to differing effects with different doses.23, 24 Blood pressure should be monitored, and patients should be cautioned that abrupt

Clinical algorithm

On the basis of the above and our clinical experience, we have developed a suggested algorithm (Fig 1) to help make clinical decisions regarding the use of sleep medication. This algorithm is applicable to patients who are experiencing disturbed sleep and scratching during the night in the context of an exacerbation of AD. This algorithm assumes that the above patients are receiving appropriate care for their AD, including skin hydration, control of inflammation, and treatment of

Conclusion

The current literature demonstrates a need for effective treatment of sleep problems associated with AD. Sleep problems are common in patients with AD and are associated with scratching. In addition to the damage done to the skin by scratching, poor-quality sleep can have many other negative effects, including diminished quality of life for patients and their families, as well as a negative effect on motor and cognitive function. Despite our knowledge regarding poor sleep, little is known about

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  • Cited by (0)

    Disclosure of potential conflict of interest: The author has declared that she has no conflict of interest.

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