To the Editor,
During the current Covid-19 pandemic that the world is facing, a number of diseases and disorders have emerged with parallel increases. We are writing to call attention to a triad of conditions that may represent a vicious circle: hand eczema, sleep disorders, and a psychiatric condition – obsessive compulsive disorder. All three can be extremely debilitating in isolation and affect the quality of life of affected patients.
Hand eczema is a chronic inflammatory skin disease associated with multifactorial causes. It is predominantly an occupational disease, and is more common in adults. It can be the result of primary irritant exposure, contact allergy, and atopic dermatitis, and may lead to deleterious psychosocial damage [1,2] and mood disorders. In addition to the wide range of possible concerns related to the pandemic and about the eczema, the condition itself can directly affect sleep as a consequence of its debilitating symptoms that include pruritus, and pain from blisters, fissures, and wounds [1,2].
We should assume that people who already present chronic hand eczema are suffering even greater difficulties during this pandemic, as the condition is considered a significant dermatological challenge that is hard to manage even at the best of times, and in the current situation many people with the condition will be faced with a new set of problems.
Efforts to avoid virus transmission have increased concern about hand sanitization, as the virus can be deposited on the surface of objects and easily transferred to the hand [3]. Increased use of alcohol hand sanitizer and soap to wash the hands, and the more frequent cleaning of objects using chemical substances, such as sodium hypochlorite, detergents, and other antiseptics, has increased the contact of these agents with the hands. The effects of this can be made worse by the fact that not everyone has access to protective equipment, and even if they do there is possibility to forget to protect the hands during the disinfection process. In addition, it is important to consider front line workers, such as hospital staff who not only have to wash their hands more frequently but also are exposed to wearing gloves for extended periods, with some types of gloves promoting skin conditions, including eczema. All these factors can lead to the worsening of eczema in individuals who already have the condition or even to an increase in new cases.
Worries about the condition may add to the existing burden of concerns brought about by the pandemic and begin to impact a crucial element in the organism's homeostasis – sleep recovery. Poor sleep can bring additional consequences to mental health, and it is reasonable to assume that individuals with psychiatric conditions, such as mood disorders and anxiety, will be prone to suffer even more during the pandemic. We highlight one condition, obsessive-compulsive disorders (OCD), especially in respect of compulsive hand washers, who often induce severe skin damage and hand eczema through their condition [4]. This psychiatric disturbance is a complex condition, related with imbalanced neurochemical pathways, including the serotoninergic system, which plays a role in the sleep regulation [5]. It is characterized by repetitive and compulsive actions, and obsessive behavior that is usually out of control [5,6].
Regarding sleep, there is conflicting evidence on the association between sleep disturbance and symptoms of obsessive-compulsive disorder. Previous systematic reviews have shown that there may be a link between the conditions [[5], [6], [7]]. It has previously been reported that OCD can be related with significant sleep disturbance, especially when the psychiatric symptoms are more severe [5], which may signal sleep as an important biomarker in this condition that needs further investigation [6]. Insomnia, higher sleep latency, shorter sleep duration and delayed circadian rhythm have been reported to be sleep disorders associated with OCD, and being responsible for increasing the effects on mental health as a whole [6,8]. It seems that secondary causes, especially depression and anxiety, are important factors that could explain sleep disorders and circadian rhythm disturbs in individuals with OCD [6,7]. This interaction may reflect some similarities regarding the serotonin pathways affected in these conditions, and may explain the satisfactory response to the use of serotonin reuptake inhibitors in some cases of OCD [9].
The repetitive thoughts and stereotyped behaviors characteristic of OCD seem to be affected by sleep deprivation, as sleep disruption can reduce the ability to inhibit responses to perseverative compulsions [10]. This might be explained by the cortical affection related with shorter sleep, promoting the maintenance of OCD symptoms [10]. Although it has previously been shown that hand eczema may be worsened by the obsessive and compulsive cleaning symptoms of OCD, and that sleep disorders can be related with this psychiatric disorder, studies of this triple association are still lacking. A study associating OCD with hand eczema reported higher levels of anxiety in the presence of both conditions, and suggested that a bidirectional pathway might exist, as OCD symptoms could be consequence of or a reason for repetitive hand washing and even picking and hurting the skin [1]. People who already suffer from OCD and/or hand eczema need further assistance, that includes sleep regulation. Better sleep habits could be crucial to the management of hand eczema and OCD, as well as to possible parallel conditions that could be related with OCD outbreaks, such as anxiety and depression.
The current pandemic is likely to result in an exponential increase in the prevalence of mood disorders and anxiety, sleep disorders and OCD, thereby worsening hand eczema. Further investigation of this possible triple interaction is warranted. Clearer evidence and a better understanding of how this triad might interact to create a vicious circle could provide great benefits to psychiatric and dermatological treatments, and help to reduce the deleterious impact on patients’ well-being. Mental health could be directly related with sleep quality, and consequently to whole organism regulation, especially skin homeostasis. Sleep could, therefore, be key to promoting quality of life in this affected population, especially during the pandemic.
Funding and Acknowledgements
Our studies are supported by the Associação Fundo de Incentivo à Pesquisa (AFIP). S.T. and M.L.A. receive CNPq fellowships. E.M.S.X. receives a CAPES post-graduate grant. No sponsorship was received for the publication of this manuscript.
Footnotes
All the authors declare no conflicts of interest.
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: https://doi.org/10.1016/j.sleep.2020.12.043.
Conflict of interest
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