Abstract
Objective
To investigate the life, sleep quality and anxiety of rosacea patients in Yunnan and the improvement of these aspects after treatment.
Methods
A total of 141 patients with rosacea and 123 healthy controls were included in our study. The quality of life, sleep quality and anxiety of patients with rosacea and healthy controls were investigated by the Rosacea Severity Scores (RSSs), the Medical Outcomes Study 36‐item short‐form health survey (SF‐36), the Pittsburgh Sleep Quality Index (PSQI) and Self‐rating Anxiety Scale (SAS). The quality of life, sleep quality and anxiety of patients with rosacea were assessed again after treatment.
Results
Compared with healthy controls, patients with rosacea had significantly lower physical component scores (PCS) and mental component scores (MCS) but higher PSQI and SAS scores. After treatment, rosacea patients showed significantly higher MCS but lower PSQI and SAS scores. Correlation analysis showed a significant correlation between PCS, MCS, PSQI, SAS and RSSs.
Conclusions
Patients with rosacea have a lower quality of life and sleep quality and tend to be more anxious than healthy controls. In addition, the mental quality of life, sleep quality and anxiety of rosacea patients can be significantly improved after treatment. Therefore, it is important to pay attention to the psychological status of rosacea patients. Psychological counseling and intervention are necessary to better prevent and treat rosacea.
Keywords: anxiety, quality of life, rosacea, sleep quality
1. INTRODUCTION
Rosacea is a common, chronic, recurrent, inflammatory disease that mainly involves the facial area. The etiology and pathogenesis of rosacea are not clear. At present, it is believed that rosacea is a facial inflammatory disease induced by multiple factors, including skin barrier dysfunction, microecological disorders, inherent immune imbalance of the skin, abnormal regulation of neurovascular function, etc., triggered by endogenous or external causes. 1 , 2 Genes, stress, obesity and so on are common endogenous causes. 2 , 3 , 4 Sun exposure, microbial infection, smoking, alcohol and so on are common external causes. Stress is the most common endogenous cause of rosacea. A study found that 74.02% of rosacea cases were triggered or aggravated by stress. 5 Excessive mental stress exacerbates facial flushing in patients with rosacea. 6 Additionally, compared with healthy controls, patients with rosacea showed a higher probability of having psychological health disorders such as anxiety and depression. 7 , 8 Paroxetine, as an antidepressant, is an effective treatment for refractory erythema of rosacea, indicating that depression induces and aggravates the pathogenetic condition of rosacea. 9 Rosacea patients presented poorer sleep quality. Sleep deprivation aggravated the rosacea‐like phenotype in mice, with higher expression of matrix metallopeptidase 9, Toll‐like receptor 2, cathelicidin antimicrobial peptide and vascular endothelial growth factor. 10 The analysis of rosacea patients' brain activity using Positron Emission Tomography‐Computed Tomography (PET‐CT) unveiled reduced metabolism in regions such as the parietal lobe, temporal lobe, and postcentral gyrus. Simultaneously, there was an increase in metabolic activity observed in the frontal lobe, anterior central gyrus, and certain cerebellar regions. 11 Meanwhile, alterations in functional neuroimaging among individuals with anxiety disorders indicate heightened activity in limbic and paralimbic system structures as well as the frontal lobes. 12 Notably, there exists some resemblance in neurological changes between individuals with rosacea and those experiencing anxiety disorders.
Quality of life, sleep and anxiety are often used as tangible manifestations of psychosomatic factors in the target population. Previous studies have found that patients with rosacea suffer from decreased quality of life, sleep and anxiety, but these studies often focused only on individual aspects of their condition, lacking a comprehensive and integrated assessment and feedback of their condition after treatment. Therefore, we conducted a study of 141 patients with rosacea and 123 healthy controls in Yunnan Province to assess and compare their quality of life, sleep quality, and anxiety and to comparatively analyze relevant aspects of patients with rosacea before and after treatment.1 Materials and methods.
1.1. Patients
The study subjects were 141 patients with rosacea who came to our department from September 2020 to January 2023, and the diagnostic criteria of rosacea were in accordance with the criteria of the American Rosacea Expert Committee. Inclusion criteria: (1) age ≥ 18 years; (2) no other skin diseases or systemic diseases that may cause facial flushing or erythema, female exclusion pregnancy or breastfeeding status; and (3) able to understand the questionnaire content, willing to participate in the study and truthfully fill out the questionnaire. At the same time, 123 age‐ and sex‐matched outpatients or family members were also selected as a healthy control group. The study was approved by the Ethics Committee of our hospital, and all subjects signed an informed consent form.
1.2. Method and survey
Questionnaires were administered to the subjects after diagnosis in the outpatient clinic: (1) clinicians assisted subjects in completing basic demographic information and completed disease staging and severity assessment in patients with rosacea; (2) subjects completed the SF‐36, PSQI, and SAS. Then, patients with rosacea underwent a follow‐up visit after 2 months of regular treatment to complete the questionnaires once again. Of the 141 patients with rosacea, posttreatment questionnaires were collected from 56 patients.
1.2.1. Rosacea severity score (RSS)
Rosacea disease staging was accomplished using a grading system developed by the American Acne and Rosacea Society. 13 Scoring was based on four subtypes, each of which was scored as 0–3 according to none, mild, moderate, or severe. If a patient combines multiple subtypes, the scores are cumulatively summed, with the most severe being a perfect score of 12, and the lower the score, the less severe the condition.
1.2.2. The medical outcomes study 36‐item short‐form health survey (SF‐36)
The SF‐36 scale 13 , 14 was used to assess the subjects' quality of life in 8 dimensions, including physical functioning, role limitations: physical, bodily pain, general health, vitality, social functioning, role limitations: emotional and mental health. The mean scores of the first four dimensions represent PCS, which reflects the level of physical health‐related quality of life; the mean scores of the last 4 dimensions represent MCS, which reflects the level of mental health‐related quality of life. The SF‐36 scale is calculated on a scale of 0–100, with higher scores indicating a better quality of life.
1.2.3. The Pittsburgh Sleep Quality Index (PSQI)
Subjects' sleep quality was assessed using the PSQI scale, 15 which reflects seven aspects of sleep quality: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction, with scores ranging from 0 to 3 for each aspect and a total PSQI score ranging from 0 to 21 when summed over the seven aspects. Higher scores indicate poorer sleep quality, with PSQI > 5 indicating poor sleep quality and PSQI ≤5 indicating good sleep quality. 16
1.2.4. Self‐rating anxiety scale (SAS)
Subjects were assessed for anxiety using the SAS scale. 17 Anxiety was diagnosed by a standardized SAS score of ≥50 and was classified as mild anxiety in the range of 50–59, moderate anxiety in the range of 60–69, and severe anxiety in the range of ≥70.
1.3. Statistics
The data were statistically analyzed using SPSS27.0 statistical software. Count data were expressed as the number of cases and percentage n (%), and differences between groups were compared using the 2 test. Measurement data did not obey a normal distribution and were expressed as the median and quartile M [P25, P75], and differences between groups were compared using the Mann‒Whitney U test. Differences between patients with rosacea before and after treatment were compared using the Wilcoxon test. Differences between patients with rosacea before and after treatment were analyzed using Spearman's correlation analysis. p < 0.05 indicated statistical significance.
2. RESULTS
2.1. Total subject population
In this clinical trial, 121 females and 20 males were included in the rosacea group, with a median age of 36 years, of which 92 (65.25%) were under the age of 45 years and 49 (34.75%) were over the age of 45 years. A total of 103 females and 20 males were included in the healthy control group, with a median age of 36 years, of which 90 (73.2%) were under the age of 45 years and 33 (26.8%) were over the age of 45 years.
2.2. Life quality is reduced in patients with rosacea compared to the healthy population and improved after treatment
The rosacea group scored significantly lower than the healthy control group in the five dimensions of the SF‐36 scale: general health (GH), role‐emotional (RE), social functioning (SF), vitality (VT), and mental health (MH). The rosacea group scored significantly lower than the healthy control group in the PCS and MCS, with the differences being statistically significant (p < 0.05) (Table 1). The RE and MCS of rosacea patients were significantly elevated after treatment, and the difference was statistically significant (p < 0.05) (Table 2).
TABLE 1.
Comparison of SF‐36 scores between the rosacea group and the healthy control group [M (P25, P75)].
| Rosacea group | Healthy control group | Z | p | |
|---|---|---|---|---|
| Physical functioning (PF) | 100.00(95.00,100.00) | 95.00(85.00,100.00) | −4.174 | <0.001 * |
| Role‐physical (RP) | 100.00(75.00,100.00) | 100.00(100.00,100.00) | −1.242 | 0.214 |
| Bodily pain (BP) | 90.00 (74.00,100.00) | 84.00 (72.00,100.00) | −0.918 | 0.359 |
| General health (GH) | 60.00 (50.00,72.00) | 75.00 (57.00,87.00) | −5.181 | <0.001 * |
| Role‐emotional (RE) | 100.00 (33.30,100.00) | 100.00 (66.70,100.00) | −2.905 | 0.004 * |
| Social functioning (SF) | 87.50(75.00,100.00) | 87.50(87.50,100.00) | −2.972 | 0.003 * |
| Vitality (VT) | 65.00 (50.00,80.00) | 75.00 (60.00,80.00) | −3.601 | <0.001 * |
| Mental health (MH) | 68.00 (56.00,80.00) | 76.00 (64.00,88.00) | −3.467 | 0.001 * |
| Physical component score (PCS) | 84.75(76.13,89.25 | 88.50(78.50,93.00) | −2.525 | 0.012 * |
| Mental component score (MCS) | 72.38(55.91,85.81) | 81.50(69.38,90.25) | −4.121 | <0.001 * |
p < 0.05, significant.
TABLE 2.
Comparison of SF‐36 scores in patients with rosacea before and after treatment [M (P25, P75)].
| Before treatment | After treatment | Z | p | |
|---|---|---|---|---|
| Physical functioning (PF) | 100.00(95.00,100.00) | 97.50(90.00,100.00) | −1.806 | 0.071 |
| Role‐physical (RP) | 100.00 (81.25,100.00) | 100.00 (75.00,100.00) | −0.016 | 0.987 |
| Bodily pain (BP) | 90.00 (74.00,100.00) | 90.00 (75.50,100.00) | −0.217 | 0.829 |
| General health (GH) | 59.75(50.00,67.00) | 60.00 (52.00,74.25) | −1.784 | 0.074 |
| Role‐emotional (RE) | 66.70(8.33,100.00) | 100.00 (66.68,100.00) | −2.949 | 0.003 * |
| Social functioning (SF) | 87.50(75.00,100.00) | 87.50(75.00,100.00) | −1.424 | 0.154 |
| Vitality (VT) | 65.00 (50.00,80.00) | 72.50(56.25,80.00) | −1.91 | 0.056 |
| Mental health (MH) | 68.00 (60.00,80.00) | 72.00 (60.00,84.00) | −1.823 | 0.068 |
| Physical component score (PCS) | 83.63(78.00,87.75) | 83.88(76.25,88.00) | −0.039 | 0.969 |
| Mental component score (MCS) | 73.55(55.24,86.41) | 80.07(70.14,90.41) | −3.3 | 0.001 * |
p < 0.05, significant.
2.3. Reduced sleep quality in patients with rosacea compared to the healthy population improved after treatment
The five scores of subjective sleep quality, sleep latency, sleep duration, sleep disturbances, and daytime dysfunction were significantly higher in the rosacea group than in the healthy control group. Meanwhile, the total PSQI scale score was significantly higher in the rosacea group than in the healthy control group, and the difference was statistically significant (p < 0.05). In addition, the incidence of poor sleep quality in rosacea patients (58.16%) was also significantly higher than that in the healthy control group (33.33%) (Tables 3, 4, and Figure 1).
TABLE 3.
Comparison of PSQI scores between the rosacea group and the healthy control group.
| Rosacea group | Healthy control group | Z | p | |
|---|---|---|---|---|
| Subjective sleep quality | 1(1,2) | 1(0,1) | −5.922 | <0.001 * |
| Sleep latency | 1(1,2) | 1(0,2) | −3.89 | <0.001 * |
| Sleep duration | 1(0,1) | 0(0,1) | −2.503 | 0.012 * |
| Habitual sleep efficiency | 0(0,1) | 0(0,1) | −2.246 | 0.025 * |
| Sleep disturbances | 1(1,2) | 1(1,1) | −3.028 | 0.002 * |
| Use of sleeping medication | 0(0,0) | 0(0,0) | −1.227 | 0.22 |
| Daytime dysfunction | 1(1,2) | 1(0,2) | −4.767 | <0.001 * |
| PSQI | 7(5,9) | 4(3,6) | −5.601 | <0.001 * |
p < 0.05, significant.
TABLE 4.
Comparison of sleep quality between the rosacea group and the healthy control group.
| Rosacea group | Healthy control group | χ2 | p | |
|---|---|---|---|---|
| Good sleep quality | 59(41.84%) | 82(66.67%) | ||
| Poor sleep quality | 82(58.16%) | 41(33.33%) | 16.267 | <0.001 * |
PSQI > 5 indicates poor sleep quality, PSQI ≤5 indicates good sleep quality.
p < 0.05, significant.
FIGURE 1.
Incidence of poor sleep quality and anxiety in the rosacea group and healthy control group before and after treatment.
The sleep disturbances and daytime dysfunction scores of patients with rosacea decreased after treatment, but the difference was not statistically significant. The total PSQI score also decreased significantly, and the difference was statistically significant (p < 0.05). The incidence of poor sleep quality (53.57%) was lower than that before treatment (57.14%) (Table 5 and Figure 1).
TABLE 5.
Comparison of PSQI before and after treatment in patients with rosacea.
| Before treatment | After treatment | Z | p | |
|---|---|---|---|---|
| Subjective sleep quality | 1(1,2) | 1(1,2) | −2.923 | 0.003 * |
| Sleep latency | 1(1,2) | 1(0.25,2) | −1.271 | 0.204 |
| Sleep duration | 1(0,1) | 1(0,1) | −1.919 | 0.055 |
| Habitual sleep efficiency | 0(0,1) | 0(0,1) | −0.174 | 0.862 |
| Sleep disturbances | 1(1,2) | 1(1,1) | −0.728 | 0.467 |
| Use of sleeping medication | 0(0,0) | 0(0,0) | −1.633 | 0.102 |
| Daytime dysfunction | 2(1,2) | 1(1,2) | −1.637 | 0.102 |
| PSQI | 6(5,9.75) | 6(4,8) | −2.813 | 0.005 * |
| Good sleep quality | 24(42.86%) | 26(46.43%) | 0.1445 | 0.7038 |
| Poor sleep quality | 32(57.14%) | 30(53.57%) |
PSQI > 5 indicates poor sleep quality, PSQI ≤5 indicates good sleep quality;.
p < 0.05, significant.
2.4. Anxiety is more likely to occur in the rosacea group than in the healthy control group and improves after treatment
The SAS scores of the rosacea group were significantly higher than those of the healthy control group, and the difference was statistically significant (p < 0.05). The incidence of anxiety in the rosacea group (28.37%) was significantly higher than that in the healthy control group (10.57%) (Tables 6 and 7, Figure 1). Anxiety scores decreased after treatment in patients with rosacea, and the difference was statistically significant, with the incidence of anxiety decreasing from 30.36% to 16.07% (Table 8, Figure 1).
TABLE 6.
Comparison of SAS scores between the rosacea group and the healthy control group.
| Rosacea group | Healthy control group | Z | p | |
|---|---|---|---|---|
| Anxiety scores | 43.75(37.50,51.25) | 35.00(31.25,40.00) | −6.868 | <0.001 * |
p < 0.05, significant.
TABLE 7.
Comparison of the incidence of anxiety in the rosacea group and healthy control group.
| Rosacea group | Healthy control group | χ2 | p | |
|---|---|---|---|---|
| No anxiety(<50) | 101(71.63%) | 110(89.43%) | ||
| Anxiety(≥50) | 40(28.37%) | 13(10.57%) | 12.972 | <0.001 * |
p < 0.05, significant.
TABLE 8.
Comparison of SAS scores before and after treatment in patients with rosacea.
| Before treatment | After treatment | Z | p | |
|---|---|---|---|---|
| Anxiety scores | 43.13(36.56,52.50) | 43.12(36.56,47.19) | −1.997 | 0.046 * |
| No anxiety(<50) | 39(69.64%) | 47(83.93%) | 3.206 | 0.0734 |
| Anxiety(≥50) | 17(30.36%) | 9(16.07%) |
p < 0.05, significant.
2.5. There is a correlation among RSSs, PCS, MCS, PSQI, SAS
RSSs represent the RSSs, with larger values suggesting higher severity of disease. The PSQI reflects subjects' sleep, with larger values suggesting worse sleep. The SAS reflects subjects' anxiety, with larger values suggesting worse anxiety. PCS and MCS represent the physical component score and mental component score, respectively, with larger values suggesting a better quality of life in the relevant dimensions. The RSSs of rosacea patients were positively correlated with PSQI and SAS scores and negatively correlated with PCS and MCS scores, suggesting that higher rosacea severity was associated with decreased sleep quality, increased anxiety, and decreased physical and mental health. In addition, PCS and MCS were positively correlated with each other and negatively correlated with PSQI and SAS, and PSQI was positively correlated with SAS, suggesting a correlation between physiology and psychology in patients with rosacea, including quality of life, sleep, and anxiety (Figure 2).
FIGURE 2.
Relevance analysis among RSSs, life and sleep quality and anxiety scores in patients with rosacea. *p < 0.05, significant. 0.3 < r < 0.5 for weak correlation, 0.5 < r < 0.8 for strong correlation.
3. DISCUSSION
Rosacea is a chronic inflammatory skin disease characterized by alternating recurrent episodes and remissions. Its etiology and pathogenesis are not fully understood, and its clinical manifestations are varied, difficult to cure completely, and prone to recurring episodes. Therefore, patients with rosacea often suffer from varying degrees of reduced quality of life and sleep and even accompanying anxiety.
In this study, we investigated and analyzed the life, sleep quality, and anxiety of 141 patients with rosacea in Yunnan and compared them with 123 healthy people. We found that the five dimensions of general health, role‐emotional, social functioning, vitality, and mental health, as well as the physical component score and mental component score of patients with rosacea, were significantly lower than those of the healthy population. SALAMON M et al. found that patients with rosacea had lower scores on physical functioning, general health, vitality, role‐physical, bodily pain, and mental components than the healthy population, 18 and the results were overwhelmingly in agreement with the present study. The bodily pain of patients with rosacea was higher than that of the healthy population in the present study, but the difference was not statistically significant, and the reason for this may be related to the small sample size. In addition, this study found that the role‐emotional and mental component scores of patients with rosacea were significantly higher after treatment than before treatment. Previous studies that observed the quality of life of patients with rosacea before and after treatment found that the Dermatology Life Quality Index (DLQI) and Quality Of Life Score (QoL) were lower in treated rosacea patients than in pretreatment patients, that is, the level of quality of life improved, 19 , 20 , 21 which is consistent with the findings of this study. This shows that quality of life can be used as an important indicator to assess the efficacy of rosacea treatment to choose the appropriate treatment for patients.
Wang Z et al. found that subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, daytime dysfunction and total PSQI scale score were significantly higher in patients with rosacea than in healthy controls. The prevalence of poor sleep quality was also significantly higher in patients with rosacea than in healthy populations, and the severity of rosacea was negatively correlated with sleep quality, 10 which is consistent with the results of this study. In addition, this study found that the total PSQI scale score of patients with rosacea decreased and the percentage of good sleep quality increased after treatment, indicating that active treatment of rosacea has a certain degree of improvement in the accompanying sleep disorders, but there is no previous study that reported the improvement of sleep quality after the treatment of rosacea, so further research is needed.
A cross‐sectional study in Lithuania found that the severity score of anxiety in patients with rosacea was significantly higher than that of the healthy population, with 36.7% of patients experiencing anxiety symptoms, 22 and a survey study focusing on patients with rosacea in the Changsha area found that 53.9% of patients had anxiety problems. 23 In the present study, anxiety occurred in 28.37% of patients with rosacea, and the SAS scores of rosacea patients were significantly higher than those of the healthy population. The reason for the large difference in the incidence of anxiety may be related to the different methods of assessing anxiety in different regions. In addition, this study found that the SAS scores and the incidence of anxiety in patients with rosacea decreased significantly after treatment compared with the pretreatment period, suggesting that the patients' clinical symptoms improved while their anxiety state was alleviated during the treatment of rosacea. A study found that patients with rosacea treated with duloxetine hydrochloride in combination with doxycycline alone significantly improved their depression and anxiety conditions and life quality along with significant improvement in skin lesions in the former. 24 A randomized, double‐blind clinical trial found that patients with moderately severe rosacea presented with a predominantly erythematous phenotype who were treated with paroxetine alone and showed significant improvement in skin lesions when compared to a placebo group. 9 This shows that psychiatric factors play an important role in the development of rosacea, and the improvement of adverse psychosomatic factors such as anxiety and depression can significantly improve the treatment efficacy of rosacea and the quality of life of patients. The reason for this may be that rosacea shares a common inflammatory pathway with anxiety, depression and other psychosomatic disorders, and further studies are needed to elucidate the specific mechanisms.
In addition, this study found a correlation between the severity of patients with rosacea and their quality of life, sleep quality, and anxiety. The higher the severity of rosacea is, the worse the quality of life and sleep quality, and the more severe the anxiety. Apart from this, there were correlations between quality of life, sleep, and anxiety in rosacea patients, and all three had an effect on each other. Some studies have shown that the DLQI scores of rosacea patients are positively correlated with the Hospital Anxiety and Depression (HADS) scores, 25 which is consistent with the findings of this study. Therefore, the treatment of patients with rosacea should be comprehensive, focusing not only on the alleviation of clinical symptoms and signs but also on the improvement of life, sleep quality and psychological status.
In summary, this study shows that patients with rosacea not only have worse life and sleep quality but are also more likely to have comorbid anxiety or states. Moreover, after treatment, patients with rosacea can have their mental health‐related quality of life, sleep quality and anxiety improved to some extent. Therefore, during the treatment and management of rosacea, attention should be given to patients' life, sleep quality and psychosocial status, patients with significant anxiety or depression should be examined and evaluated in more depth, and appropriate interventions should be sought if necessary to achieve better treatment results and improve the overall quality of life of patients.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Yang Z, Zhao W, Hu M, et al. Quality of life, sleep and anxiety status among patients with rosacea in the Yunnan plateau region: A 2‐year retrospective study. Skin Res Technol. 2024;30:e13616. 10.1111/srt.13616
A survey on quality of life, sleep quality and anxiety in patients with rosacea in the Yunnan area
DATA AVAILABILITY STATEMENT
The data supporting the findings of this study are available upon reasonable request from the corresponding author, Hua Gu, at Guhua1978@sina.com. Due to ethical considerations and privacy concerns, the raw data cannot be publicly shared. However, summarized and anonymized data that underlie the findings of this study will be made available upon request. The authors confirm that the data supporting the findings of this study are available within the article or upon request.
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Associated Data
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Data Availability Statement
The data supporting the findings of this study are available upon reasonable request from the corresponding author, Hua Gu, at Guhua1978@sina.com. Due to ethical considerations and privacy concerns, the raw data cannot be publicly shared. However, summarized and anonymized data that underlie the findings of this study will be made available upon request. The authors confirm that the data supporting the findings of this study are available within the article or upon request.