Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting approximately 10% of adults and 20% of children worldwide [1]. It is associated with reduced quality of life, including impaired sleep and cognition [2, 3]. Prior research suggests that sleep disturbance may predict memory problems in adults with AD. A recent study of 78 patients from Malaysia found poor sleep quality independently predicted memory problems among adults with AD (aOR, 95% CI: 4.4, 1.3–15.0) [4]. Another study of 5563 adults from the 2005–2006 National Health and Nutrition Examination Survey found those with AD were more likely to feel unrested (aOR, 95% CI: 2.44, 1.52–3.93) and have difficulty with concentrating (aOR, 95% CI: 1.67, 1.20–2.32) and remembering (aOR, 95% CI: 1.82, 1.29–2.55) due to fatigue [3]. The present study seeks to further investigate this topic using a nationally representative dataset.
We used data from participants in the 2024 National Health Interview Survey aged ≥ 18‐years without dementia or traumatic brain injury [5]. Participants were asked ‘The next question is about an allergic skin condition. Do you get an itchy rash due to eczema or atopic dermatitis?’ and ‘Have you ever been told by a doctor or other health professional that you had eczema or atopic dermatitis?’ AD was defined by affirmative responses to both questions. Participants were also asked how often over the past 30 days they felt well‐rested upon awakening and whether they had difficulties with memory or concentration. Weighted analyses accounted for primary sampling units and strata to produce results representative of the US population. Logistic regression evaluated the association of AD with sleep quality and self‐reported cognitive difficulties. Multivariable models adjusted for age, sex, race/ethnicity, education, family income‐to‐poverty‐threshold ratio, BMI and physical activity. These covariates were selected a priori based on a review of the literature for factors associated with AD and cognition. A mediation analysis was also conducted using structural equation modelling to examine the role of sleep quality in the AD‐cognition relationship. Additional details on analytic variables are provided in Table S1. Complete case analysis was performed as missingness was negligible (missing data percentages for each variable are provided in Table S2) [6]. Statistical significance was defined by two‐sided α = 0.05. Additional methodological details are provided in Supporting Information (Methods).
A total of 29 390 adults were included (Figure S1), of whom 2229 had AD (weighted prevalence: 7.7%). Participants with AD vs. those unaffected were more often female (63.7% vs. 50.0%), younger (46.5% aged 18–39 years vs. 37.4%), and more often endorsed memory (28.7% vs. 17.6%) and concentration difficulties (26.6% vs. 14.0%) (Table S3). Unadjusted survey‐weighted logistic regression indicated participants with AD had lower sleep quality (i.e., greater odds of being in a worse sleep quality category) (odds ratio [OR], 95% CI: 1.68, 1.52–1.84) and more self‐reported difficulties with memory (OR, 95% CI: 1.89, 1.67–2.13) and concentration (OR, 95% CI: 2.24, 1.96–2.55). Similarly, multivariable models supported associations of AD with lower sleep quality (adjusted odds ratio [aOR], 95% CI: 1.51, 1.37–1.66), memory difficulties (aOR, 95% CI: 1.98, 1.76–2.24) and difficulty concentrating (aOR, 95% CI: 2.13, 1.87–2.42). Among adults with AD, lower sleep quality was associated with memory (OR, 95% CI: 1.97, 1.68–2.31; aOR, 95% CI: 1.92, 1.62–2.27) and concentration difficulties (OR, 95% CI: 2.01, 1.69–2.39; aOR, 95% CI: 1.81, 1.50–2.17) (Table S4). Mediation analysis indicated sleep statistically mediates part of the cross‐sectional association between AD and self‐reported cognitive difficulties (memory: indirect association = 0.014, p < 0.001; concentration: indirect association = 0.013, p < 0.001), accounting for 11.8% of the total association for memory and 11.0% of the total association for concentration (Figure 1).
FIGURE 1.
Cross‐sectional mediation analysis of the role of sleep quality in the association between atopic dermatitis and cognitive difficulties. Coefficients are reported unstandardized and represent expected changes expressed in original variable units per unit change in the predictor. Sleep quality was measured on a 4‐point ordinal scale and treated as numeric in mediation models, while atopic dermatitis and cognitive difficulties were modelled on binary scales. All models adjusted for age, sex, race/ethnicity, education, family income‐to‐poverty‐threshold ratio, BMI and physical activity. Point estimates, confidence intervals and p‐values were adjusted for the sampling design by accounting for survey weights, primary sampling units and strata. The 95% confidence intervals for memory difficulties were: Direct association, 0.08–0.13; indirect association, 0.01–0.02; total association, 0.09–0.14. The 95% confidence intervals for concentration difficulties were: direct association, 0.08–0.11; indirect association, 0.01–0.02; total association, 0.09–0.13.
We found a cross‐sectional association between AD and self‐reported cognitive difficulties, with poor sleep quality statistically mediating approximately a ninth of this relationship. To our knowledge, this is the first study to quantify the potential role of sleep quality in the AD‐cognition relationship, generating hypotheses that may offer insights for intervention. Although sleep quality may play a measurable role, it likely represents just one component of this multifactorial relationship. Fully managing cognitive difficulties in AD may require addressing additional factors including systemic inflammation and exhaustion from chronic pruritus. Chronic inflammatory pruritus may affect cognition through neuroimmune interactions among keratinocytes, sensory neurons and immune cells [7]. However, interventional studies are needed to test intervention strategies. Limitations include the cross‐sectional design, precluding causal inference. Reverse or bidirectional relationships are possible. Psychological conditions and sleep‐related comorbidities were not adjusted for. These factors may represent either residual confounding or mediators of the AD‐cognition relationship. Prospective and mechanistic studies are needed to establish temporality and elucidate mechanisms.
Author Contributions
Moshe Schneiderman: conceptualization, formal analysis, methodology, visualization, writing – original draft, writing – review and editing. Ester Del Duca: validation, writing – review and editing. Alexandra Golant: validation, writing – review and editing. Emma Guttman‐Yassky: supervision, validation, writing – review and editing. Benjamin Ungar: project administration, supervision, validation, writing – review and editing. All authors gave final approval of the version to be published.
Funding
The authors have nothing to report.
Ethics Statement
Institutional review board approval was not needed as this project makes use of publicly available, deidentified data and does not qualify for human subjects research.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Analytic variable definitions, response categories, coding, and reference categories.
Table S2: Missing data counts and percentages.
Table S3: Stratified sample characteristics.
Table S4: Survey‐weighted logistic regression models of the associations of atopic dermatitis and sleep quality with cognitive difficulties.
Figure S1: Participant flow diagram.
Data Availability Statement
Data are publicly available online at the following URL: https://www.cdc.gov/nchs/nhis/documentation/2024‐nhis.html.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Analytic variable definitions, response categories, coding, and reference categories.
Table S2: Missing data counts and percentages.
Table S3: Stratified sample characteristics.
Table S4: Survey‐weighted logistic regression models of the associations of atopic dermatitis and sleep quality with cognitive difficulties.
Figure S1: Participant flow diagram.
Data Availability Statement
Data are publicly available online at the following URL: https://www.cdc.gov/nchs/nhis/documentation/2024‐nhis.html.