Pruritus or itchy skin is often time exacerbated at night resulting in sleep disturbance and deterioration in the quality of life. In patients with inflammatory skin conditions such as psoriasis and atopic dermatitis, up to 65% reported increased night-time itching, also known as nocturnal pruritis. It is also common in scabies and was reported in patients with systemic diseases such as liver disease and chronic kidney failure.
The disruption of sleep patterns due to nocturnal pruritus caused children with atopic dermatitis to spend an average of 46 min less time sleeping than other children. Adult patients with atopic dermatitis were reported to sleep less, awoke twice as often as other adults, resulting in lower overall sleep quality.
Sleep deprivation can consequently contribute to irritability, daytime somnolence, impaired functioning and psychological problems. Reduced sexual desire and sexual function are also reported amongst many patients with nocturnal pruritis. Pruritus also leads to increased skin inflammation, which causes further itching and scratching, known as the itch-scratch cycle.
Why does the itch exacerbate at night
The underlying mechanisms responsible for night-time itching or nocturnal pruritis are not well understood. One possible explanation may be related to the trans-epidermal water loss (TEWL), a measure of skin barrier integrity. TEWL is reported to be significantly increased during the night and is minimal during the morning. The higher TEWL in the evening suggests that the epidermal barrier function is not optimal at this time, possibly facilitating the entry of irritants and itch-causing agents.
Night time increase in skin temperature may provide another plausible explanation for the nocturnal exacerbation of pruritus. Our core temperature is maximal in the early evening and minimal in the early morning. Itch has been reported to be aggravated by ambient heat as itch sensation is believed to be increased by the effect of heat on nerve endings.
The circadian rhythm which is responsible for the fluctuant differences in many chemicals in the human body according to the day-night cycle may also play a role. For example, corticosteroids which are an anti-inflammatory hormone is low in the evening and night. This leads to a decreased anti-inflammatory response and may facilitate exacerbation of nocturnal pruritus.
How to manage nocturnal pruritis
Nocturnal pruritis and sleep deprivation have many deleterious health effects. Pruritis among patients undergoing hemodialysis caused a 17% increased in death risk, probably due to decreased quality of sleep. Sleep deprived individuals have been determined to have higher levels of grehlin, which drives appetite, and may lead to weight gain and obesity. This may, in turn, lead to further complications, such as diabetes mellitus, hypertension, cerebrovascular events and ischemic heart disease.
There are many over the counter and prescription drugs for nocturnal pruritis. Topical corticosteroids and sedating antihistamines are some medications used in the treatment of nocturnal pruritis. Antidepressants as Mirtazapine is also given due to its antihistamines action. Other medications used include benzodiazepines, k-opioid agonists and gabaergics.
As the chemical fluctuation induces by circadian rhythm is influenced by light and melatonin, bright light therapy and melatonin are also suggested as a treatment option of nocturnal pruritus. Bright light therapy directed towards the eyes has been successfully used to treat the severe itch of cholestasis while controlled-release melatonin has been shown to improve sleep quality in the elderly.
Besides medication, home treatment and preventive measures you can take include:
- Adequate moisturization. Transepidermal water loss is associated with an increase in night-time itchiness in patients with atopic dermatitis. Moisturizers and emollients will not only moisturize the skin but also produce an occlusive film that limits water evaporation. Moisturizers with a low pH may be especially useful in optimizing the skin barrier function through their maintenance of the normal acidic pH of the skin surface.1
- Take a bath or shower. Bath in cool or lukewarm water before bed, using fragrance-free soaps, baking soda, or colloidal oatmeal. Rinse throughout and apply moisturizer.
- Use a humidifier in the bedroom to moisten the air
- Apply cool and wet compress, such as using a cold, damp cloth, to the skin before bed
- Use a fan to create airflow and background noise as a source of mental distraction
- Avoid scratching as it can further irritate the skin. Trim your fingernails or wear gloves or mittens at bedtime.
- Wear comfortable sleepwear that is loose fitting to allow the skin to breathe
- Avoid any trigger factors. Check the bedroom for signs of bed bugs or other insect infestations. Avoid having a pet in your bedroom.
- Try to relax. Stress can further exacerbate pruritis. Use meditation or relaxation techniques, such as visualization, before bed. Caffeine-free tea, such as chamomile or peppermint, may soothe you before bedtime. 2 to 3 drops of relaxing essential oil, such as lavender, on the pillow, may help you get a good night sleep.
Hello Health Group does not provide medical advice, diagnosis or treatment.
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