Abstract
Introduction
Psoriasis is a chronic immune-mediated skin disease with known physical and mental health comorbidities, such as cardiovascular disease, depression, and anxiety. Psoriasis also has a significant impact on quality of life and sleep due to factors like itch and pain. This study aims to assess the relationship between sleep quality, mental health, and psoriasis, and specifically investigate the impact of poor sleep quality on mental health outcomes within participants with psoriasis.
Methods
In this cross-sectional study, we enrolled 556 participants into two cohorts: 487 participants were enrolled into the psoriasis cohort, and 69 were enrolled into the healthy control cohort. The demographics, disease severity, family history, sleep quality (PROMIS 8a, PROMIS 8b, and Insomnia Severity Index), and mental health (Patient Health Questionnaire-8 and Generalized Anxiety Disorder-7) of participants were assessed. Descriptive analysis and logistic regression models were employed to examine sleep and mental health, adjusting for potential confounders like demographics and comorbidities.
Results
A comparison of patients with psoriasis and healthy controls revealed worsened sleep and mental health outcomes in patients with psoriasis. Among participants with psoriasis, greater sleep impairment (Patient-Reported Outcomes Measurement Information System (PROMIS) 8a), sleep disturbance (PROMIS 8b), and insomnia were significantly associated with anxiety (ORa 1.22; 95% confidence interval (CI) 1.16, 1.30; ORa 1.26; 95% CI 1.16, 1.80; ORa 5.13; 95% CI 2.91, 9.33; respectively) and depression (ORa 1.42; 95% CI 1.32, 1.56; ORa 1.16; 95% CI 1.08, 1.26; ORa 7.04; 95% CI 4.01, 12.77; respectively).
Conclusion
These findings underscore the importance of recognizing how psoriasis can impact mental health and sleep. Building a collaborative relationship between patients with psoriasis and their providers is essential to improve overall sleep and life quality.
Supplementary Information
The online version contains supplementary material available at 10.1007/s13555-025-01449-4.
Keywords: Psoriasis, Sleep dysfunction, Mental health
Key Summary Points
| Why carry out this study? |
| Psoriasis is a chronic immune-mediated skin disease that has a significant impact on physical and mental health. Poor sleep and mental health are two underrecognized and undertreated comorbidities of psoriasis that contribute to poor overall health and decreased quality of life. |
| In this study, we aimed to assess the relationship between sleep quality, anxiety, and depression in those with psoriasis and healthy controls, utilizing validated traditional and novel questionnaires. Additionally, we sought to investigate the relationship between poor sleep and mental health within patients with psoriasis. |
| What was learned from this study? |
| Findings confirmed that psoriasis is strongly associated with poor sleep and worse anxiety and mental health compared to healthy controls. An assessment of the psoriasis cohort alone revealed worse sleep impairment, sleep disturbance, and insomnia were associated with greater anxiety and depression (p < 0.05). |
| These findings underscore the importance of recognizing the impacts of psoriasis on sleep and mental health and encourage the prioritization of the comorbidities in clinical management. |
Introduction
Psoriasis is an immune-mediated skin disease characterized by scaly plaques and is known to affect 125 million people worldwide [1]. It is associated with comorbidities such as psoriatic arthritis, obesity, and cardiovascular disease [1]. It is also associated with depression and anxiety and can significantly impact patient quality of life [1, 2]. Studies have shown that more than 10% of patients with psoriasis have clinical depression, over 20% have depressive symptoms, and they are 2.5 times as likely to have a diagnosis of anxiety [2, 3]. Furthermore, patients with psoriatic arthritis have higher rates of anxiety and depression compared to those with only skin disease [4]. It has been proposed that the pathophysiological mechanism behind negative mood symptoms, such as depression, and psoriasis is influenced by both the shame and stigma associated with the skin lesions, as well as a suggested pro-inflammatory state that leads to neurotransmitter dysfunction [5].
It has also been demonstrated that patients with psoriasis have an increased rate of sleep disturbance [6, 7]. Similarly to depression and anxiety, the proposed pathophysiologic link between psoriasis and sleep is multifactorial. One significant contributor is the discomfort and itching associated with psoriasis [8]. Other factors may include circadian rhythm disruptions, skin barrier dysfunction that hinders proper heat dissipation, which can make it difficult to fall asleep and stay asleep, and chronic inflammation that leads to nutrient deficiencies such as iron, increasing the risk of restless leg syndrome [6, 8]. Moreover, there is a shared increase in proinflammatory neurotransmitters and cytokines in sleep disorders and psoriasis [9].
In previous studies, the Pittsburgh Sleep Quality Index (PSQI) was the primary questionnaire used to measured sleep quality in patients with psoriasis [10]. In contrast, the Patient Reported Outcomes Measurement Information System (PROMIS) tools 8a and 8b are questionnaires that assess sleep impairment (8a) and sleep disturbance (8b) [11–13]. Specifically, the 8a and 8b questionnaires serve as two examples of PROMIS questionnaires developed as part of an initiative by the National Institutes of Health aimed at enhancing research on clinical patient-reported outcomes [14]. These tools have proven to be more precise compared to the PSQI [12]. Sleep impairment questions focus on the inability to get things done, concentrate, tiredness, and irritability due to poor sleep. In contrast, sleep disturbance questions focus on trouble sleeping, sleep quality, sleep satisfaction, staying asleep, and amount of sleep [12]. A study by Lei et al. in 2020 employed PROMIS to assess sleep disturbances in patients with atopic dermatitis [15]. However, to our knowledge, PROMIS has not been used to evaluate sleep in patients with psoriasis, even though it is considered more precise than PSQI [9, 12]. This study aims to be the first to utilize the more precise PROMIS to further explore the relationship between sleep and mental health disturbance in patients with patients.
In this study, we used validated questionnaires to assess the sleep quality and levels of anxiety and depression in patients with and without psoriasis. The main objectives of this study were (a) to examine the impact of psoriasis on these variables in comparison to healthy controls (HCs) and (b) to assess the impact of poor sleep quality on mental health outcomes in patients with psoriasis.
Methods
Survey Creation
This study included participants diagnosed with psoriasis or psoriatic arthritis (PsO/PsA) and HCs. Exclusion criteria for HCs included individuals with a diagnosis of psoriasis, psoriatic arthritis, eczema, lupus, other inflammatory skin disease (e.g., vitiligo, hidradenitis suppurativa) and age < 18 years. Exclusion criteria for patients with PsO/PsA included diagnosis of eczema, lupus, inflammatory skin disease other than psoriasis/psoriatic arthritis (e.g., vitiligo, hidradenitis suppurativa) and age < 18 years. All patients with PsO/PsA were included irrespective of their treatment status.
The sleep quality of both study groups was assessed using the validated sleep measures, PROMIS 8a, PROMIS 8b, and Insomnia Severity Index (ISI). Mental health was assessed in both groups using the validated Patient Health Questionnaire-8 (PHQ-8) and Generalized Anxiety Disorder-7 (GAD-7). A series of demographic questions was asked to investigate patient-reported gender, race, ethnicity, education level, income level, comorbidities, marital status, and substance use history. Finally, participants with psoriasis also answered questions related to their disease, such as body surface area (BSA) affected measured by the validated Patient Report of Extent of Psoriasis Involvement (PREPI), family history of psoriasis, diagnosis of psoriatic arthritis, and psoriasis treatment history.
Survey Distribution
A total of 487 patients with psoriasis and 69 HCs consented to participate in this cross-sectional questionnaire-based study. The survey was distributed to patients with psoriasis in two settings: (1) in the dermatology outpatient clinic and (2) via email. In the clinic, all patients of the University of California, San Francisco Psoriasis Center with a dermatologist-confirmed diagnosis of psoriasis, who consented to the study and met eligibility criteria, were enrolled. For email distribution, invitation emails were sent to patients with psoriasis registered on the National Psoriasis Foundation listserv. Of these individuals, 593 used the link to access the survey. All duplicate responses were removed. The survey was sent to eligible HCs recruited from university and hospital campus flyers.
Statistical Analysis
In descriptive analyses, we assessed the distribution of the study variables by cohort. Univariate analyses between cohort and demographic characteristics, comorbid medical conditions, and treatment history were analyzed using t tests and chi-square tests. Unadjusted and adjusted logistic regression models were calculated to assess the relationship between psoriasis and mental health (GAD-7 and PHQ-8) and psoriasis and sleep measures (PROMIS 8a, PROMIS 8b, and ISI). Within psoriasis subjects, the relationships between the three sleep measures and two mental health measures were assessed. Adjusted models included covariates determined a priori and by univariate analysis. Covariates included demographics (age, gender, race, income, education, employment, and marital status), comorbid conditions (BMI, hypertension, diabetes, non-alcoholic fatty liver disease, and osteoarthritis), substance use (cigarette use and alcohol use), psoriasis severity and history of treatment, and diagnosis of psoriatic arthritis. Statistical analyses were performed using R software, Version 4.1.3.
Ethical Approval
This study was approved by the institutional review board at the University of California, San Francisco (IRB# 22-36241). This study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. All subjects provided informed consent to participate in this study. No identifiable information is included in this manuscript.
Results
Cohort Characteristics
Table S1 reports the characteristics of the study population (n = 556) by cohort (HC and PsO). In the HC and PsO cohorts, most patients were white (72.5% and 88.7%, respectively) or Asian (17.4% and 6.2%). The most common comorbid medical conditions in both cohorts were obesity, hypertension, hyperlipidemia, depression, and anxiety.
The clinical characteristics of the psoriasis cohort are reported in Table S2. The mean (SD) age of symptom onset was 32.7 (15.9) years, and the mean (SD) age of diagnosis was 35.8 (15.7) years. The most common types of psoriasis reported were plaque psoriasis (66.7%), guttate psoriasis (35.1%), inverse psoriasis (23.6%), and nail psoriasis (23.4%); 86.2% of the cohort estimated that they currently had 0–10% BSA involvement, followed by 8.2% with 11–20% BSA, and 5.6% with a BSA of 21% or more. Furthermore, 39% reported having a diagnosis of psoriatic arthritis.
Sleep and Mental Health
The PsO cohort scored consistently worse on all three sleep measures (Table 1), including the PROMIS 8a (mean 19.7 HC, 23 PsO; p < 0.05), PROMIS 8b (20.1 HC, 22.6 PsO; p < 0.05), and ISI (7.1 HC, 13.3 PsO; p < 0.05). The PsO cohort also scored worse on the GAD-7 and PHQ-8, indicating a statistically significant difference in anxiety (5.1 HC, 7.8 PsO; p < 0.05) and depression (4.7 HC, 9.5 PsO; p < 0.05). Logistic regression evaluating the association between cohort (HC vs PsO) and sleep questionnaires revealed that greater sleep impairment (PROMIS 8a) and sleep disturbance (PROMIS 8b) were associated with psoriasis, before and after adjustment for demographics, substance use, and comorbidities (ORa 1.12; 95% CI 1.05, 1.20; ORa 1.22; 95% CI 1.08, 1.39) (p < 0.05, Table 1). Worse anxiety (GAD-7) and depression (PHQ-8) were also associated with psoriasis, even after adjustment (ORa 1.13; 95% CI 1.02, 1.25, ORa 6.05; 95% CI 2.01, 20.84) (p < 0.05, Table 1). Worse insomnia (ISI) was associated with a higher odds of psoriasis, though this was not statistically significant before or after adjustment.
Table 1.
Mean scores of sleep and mental health questionnaires by cohort, with results of t tests
| Healthy control cohort (mean (SD)) | Psoriasis cohort (mean (SD)) | Unadjusted OR (95% CI) | Adjusted OR (95% CI) | |
|---|---|---|---|---|
| PROMIS 8a (Sleep impairment) | 19.72 (8.35)* | 22.97 (6.64)* | 1.07 (1.03, 1.12)*** | 1.12 (1.05, 1.20)*** |
| PROMIS 8b (Sleep disturbance) | 20.14 (3.35)*** | 22.64 (3.13)*** | 1.27 (1.17, 1.38)*** | 1.22 (1.08, 1.39)* |
| Insomnia Severity Index | 7.12 (5.41)*** | 13.31 (5.66)*** | 1.63 (0.68, 4.81) | 3.93 (0.82, 25.8) |
| Generalized Anxiety Disorder-7 | 24.28 (4.37)*** | 28.29 (6.40)*** | 4.62 (2.50, 9.22)*** | 1.13 (1.02, 1.25)* |
| Patient Health Questionnaire-8 | 4.71 (4.79)*** | 9.50 (5.21)*** | 8.61 (4.49, 28.26)*** | 6.05 (2.01, 20.84)* |
Logistic regression results comparing cohort (healthy control and psoriasis cohort) with sleep questionnaires (PROMIS 8a, PROMIS8b, Insomnia Severity Index), and mental health questionnaires (Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8). Adjusted models were adjusted for age, gender, race, income, education, employment, marital status, smoking, alcohol use, BMI, and comorbidities including diabetes, and non-alcoholic fatty liver disease. PROMIS indicates the Patient-Reported Outcomes Measurement Information System
*p < 0.05; **p < 0.001; ***p < 0.0001
Additional analysis of sleep and mental health was conducted within the psoriasis cohort. After adjusting for age, race, gender, education, employment, marital status, BMI, and additional comorbidities, logistic regression revealed an association between worsened sleep outcomes and worsened mental health outcomes among patients with psoriasis (Table 2). Specifically, greater sleep impairment (PROMIS 8a), sleep disturbance (PROMIS 8b), and insomnia (ISI) were significantly associated with greater anxiety (ORa 1.22; 95% CI 1.16, 1.30; ORa 1.26; 95% CI 1.16, 1.80; ORa 5.13; 95% CI 2.91, 9.33; respectively) and depression (ORa 1.42; 95% CI 1.32, 1.56; ORa 1.16; 95% CI 1.08, 1.26; ORa 7.04; 95% CI 4.01, 12.77; respectively).
Table 2.
Logistic regression evaluating the impact of sleep (PROMIS 8a, PROMIS 8b, Insomnia Severity Index) on mental health measures (GAD-7, PHQ-8) in the psoriasis cohort
| Model 1: Generalized anxiety disorder (GAD-7) | Model 2: Depression (PHQ-8) | |||
|---|---|---|---|---|
| Unadjusted OR (95% CI) | Adjusteda OR (95% CI) | Unadjusted OR (95% CI) | Adjusteda OR (95% CI) | |
| PROMIS 8a (Sleep impairment) | 1.11 (1.08, 1.15)*** | 1.22 (1.16, 1.30)*** | 1.27 (1.21, 1.34)*** | 1.42 (1.32, 1.56)*** |
| PROMIS 8b (Sleep disturbance) | 1.14 (1.08, 1.22)*** | 1.26 (1.16, 1.80)*** | 1.16 (1.09, 1.24)*** | 1.16 (1.08, 1.26)*** |
| Insomnia Severity Index | 4.59 (3.15, 6.77)*** | 5.13 (2.91, 9.33)*** | 7.13 (4.72, 10.95)*** | 7.04 (4.01, 12.77)*** |
PROMIS indicates the Patient-Reported Outcomes Measurement Information System, GAD-7 indicates the Generalized Anxiety Disorder-7, and PHQ-8 indicates the Patient Health Questionnaire-8
aAdjusted for age, race, gender, education, income, employment, marital status, BMI, comorbidities (hypertension, diabetes, non-alcoholic fatty liver disease, and osteoarthritis) and cigarette use, alcohol use
***p < 0.001
Discussion
Psoriasis is a systemic condition that has several associated comorbidities. Mental health and poor sleep are two prominent comorbidities that are often underrecognized and underaddressed. In this study, we sought to investigate patient experiences with these conditions utilizing validated sleep and mental health questionnaires. The logistic regression results that showed significant associations between psoriasis and greater sleep impairment, sleep disturbance, anxiety, and depression add to previous research showing that patients with psoriasis are more likely to suffer from anxiety, depression, and reduced sleep quality compared to healthy controls. Our additional analysis of the psoriasis cohort, for the first time, revealed a direct correlation between the degree of sleep disturbance and the degree of depression and anxiety, utilizing the newer and more precise PROMIS questionnaire [12, 16]. Furthermore, these findings were independent of treatment status and a diagnosis of psoriatic arthritis, highlighting the impact of more significant sleep impairment and sleep disturbance on mental health outcomes in patients with psoriasis.
Additionally, findings of this study elucidate an interesting relationship between worse sleep and worse mental health in individuals with psoriasis. Poor sleep in relation to psoriasis is an important area of research, with proposed contributors including psoriasis-related pain and itch, in addition to the upregulation of inflammatory processes in psoriasis that can also contribute to sleep disturbance [17]. It is unclear, however, if it is the poor sleep quality that is leading to the increased rate of anxiety and depression or vice versa. Previous meta-analyses in the general population have shown that there is a causal relationship between sleep and mental health outcomes, with depression and anxiety improving with improved sleep, while other Mendelian randomization studies have shown a bidirectional causal relationship and shared genes between insomnia and psychiatric conditions such as depression [18, 19]. Given the multifactorial pathophysiological link between psoriasis and sleep, the exact cause may never be fully understood [6, 8]. It is evident, however, that improving either sleep or mental health may positively impact the broader community. Our findings indicate that specifically improving sleep quality in patients with psoriasis might contribute to lower levels of depression and anxiety.
There are a few limitations of this study. This study is an observational study that utilizes patient-reported surveys, which can introduce response and recall bias. Participants may under- or overreport information regarding their psoriasis and medical history, mental health, and sleep. Additionally, the observational, cross-sectional nature of this study limits the ability to draw causal inferences between the variables of interest.
Conclusion
These findings underscore the importance of recognizing the impact of psoriasis on mental health and sleep. Specifically, they demonstrate that greater sleep impairment, sleep disturbance, and insomnia were significantly associated with greater anxiety and depression. This was demonstrated using the newer and more precise PROMIS questionnaire to assess sleep quality. To our knowledge, this is the first study to use this questionnaire to evaluate sleep in patients with psoriasis. This underscores the need for a collaborative approach between patients with psoriasis and their healthcare providers to enhance overall sleep quality and life satisfaction.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors thank the participants of the study.
Author Contributions
Andrea Leung: Contributed to the conceptual development of the analysis, conducted the statistical analysis, drafted the manuscript, incorporated feedback from co-authors, and compiled references. Kathryn Haran: Contributed to the conceptual development of the study and survey, enrolled participants and collected data, drafted the manuscript, incorporated feedback from co-authors, and compiled references. Georgia Marquez-Grap: Reviewed and assisted with manuscript preparation and writing. Kristen Chang: Assisted with survey development and data collection. Chandler Johnson: Contributed to the conceptual development of the study and survey, and reviewed the manuscript. Allison Kranyak, Chandler Johnson: Contributed to the conceptual development of the study and survey, and reviewed the manuscript. Tina Bhutani: Contributed to the conceptual development of the study and survey and assisted with review and preparation of the manuscript. Wilson Liao: Oversaw and contributed to the conceptual development of the study and survey, the statistical analysis, manuscript preparation and writing, and revisions.
Funding
No funding or sponsorship was received for this study or the publication of this article.
Data Availability
The data from this study are available upon reasonable request.
Declarations
Conflict of Interest
Wilson Liao is an Editorial Board member of Dermatology and Therapy. Wilson Liao was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. The author(s) disclosed receipt of the following financial support: Tina Bhutani has received research funding from Amgen, Castle, CorEvitas, Novartis, Pfizer, and Regeneron. She has served as an advisor for Abbvie, Arcutis, Aslan, Boehringer-Ingelheim, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Janssen, Leo, Lilly, Pfizer, Novartis, Sanofi, Sun, Takeda, and UCB. She is a speaker for Janssen. Wilson Liao has received research grant funding from Amgen, Janssen, Leo, Novartis, Pfizer, Regeneron, and TRex Bio. All other authors (Andrea Leung, Kathryn Haran, Georgia Marquez-Grap, Kristen Chang, Chandler E Johnson, and Allison Kranyak) report no conflicts of interest.
Ethical Approval
This study was approved by the institutional review board at the University of California, San Francisco (IRB# 22-36241). This study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. All subjects provided informed consent to participate in this study. No identifiable information is included in this manuscript.
Footnotes
Andrea Leung and Kathryn Haran contributed equally.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data from this study are available upon reasonable request.