Purpose of Review
Skin disease is associated with obstructive sleep apnea (OSA) both epidemiologically and mechanistically. In this review, we highlight conditions which have a well-established link to obstructive sleep apnea, such as psoriasis and atopic dermatitis.
We describe putative mechanistic links between OSA and skin disease involving inflammatory pathways, obesity, mechanical upper airways obstruction, and hypoxia. In the context of these mechanisms, we describe specific skin conditions, and other conditions which are associated with both skin manifestations (including hair/nail findings) and OSA. The risks/benefits of CPAP in the context of skin disease are also reviewed.
We conclude that further research is needed to understand the mechanisms behind the associations between OSA and skin disease. Given the frequent co-occurrence of OSA and skin conditions, there would be great benefit for OSA clinical trials to consider improvement in skin disease as an outcome measure.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Chervin RD, Ruzicka DL, Vahabzadeh A, Burns MC, Burns JW, Buchman SR. The face of sleepiness: improvement in appearance after treatment of sleep apnea. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013;9(9):845–52.
Jennum P, Ibsen R, Kjellberg J. Morbidity prior to a diagnosis of sleep-disordered breathing: a controlled national study. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013;9(2):103–8.
Jennum P, Ibsen R, Kjellberg J. Morbidity and mortality in children with obstructive sleep apnoea: a controlled national study. Thorax. 2013;68(10):949–54.
Hirotsu C, Nogueira H, Albuquerque RG, Tomimori J, Tufik S, Andersen ML. The bidirectional interactions between psoriasis and obstructive sleep apnea. Int J Dermatol. 2015;54(12):1352–8.
Gupta MA, Simpson FC, Vujcic B, Gupta AK. Obstructive sleep apnea and dermatologic disorders. Clin Dermatol. 2017;35(3):319–27.
• Gabryelska A, Sochal M, Wasik B, Białasiewicz P. Patients with obstructive sleep apnea are over four times more likely to suffer from psoriasis than the general population. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2018;14(1):153 Several epidemiologic studies have demonstrated the association between OSA and psoriasis. This is the most recent study to add to that literature; this letter to the editor found psoriasis in 8.7% of 245 OSA patients (AHI > 5) undergoing PSG.
Yang YW, Kang JH, Lin HC. Increased risk of psoriasis following obstructive sleep apnea: a longitudinal population-based study. Sleep Med. 2012;13(3):285–9.
Papadavid E, Dalamaga M, Vlami K, Koumaki D, Gyftopoulos S, Christodoulatos GS, et al. Psoriasis is associated with risk of obstructive sleep apnea independently from metabolic parameters and other comorbidities: a large hospital-based case-control study. Sleep Breath. 2017;21(4):949–58.
Karaca S, Fidan F, Erkan F, Nural S, Pinarcı T, Gunay E, et al. Might psoriasis be a risk factor for obstructive sleep apnea syndrome? Sleep Breath. 2013;17(1):275–80.
Kabeloglu Ilbay V, Tas B, Altuntas M, Atakli HD, Soysal A. Risk of obstructive sleep apnea syndrome in psoriasis patients. Arch Iran Med. 2019;22(3):137–43.
Papadavid E, Vlami K, Dalamaga M, Giatrakou S, Theodoropoulos K, Gyftopoulos S, et al. Sleep apnea as a comorbidity in obese psoriasis patients: a cross-sectional study. Do psoriasis characteristics and metabolic parameters play a role? J Eur Acad Dermatol Venereol. 2013;27(7):820–6.
Fishbein AB, Sheldon S, Grimaldi D. Author response. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2020;16(3):465.
Gupta MA, Simpson FC, Gupta AK. Psoriasis and sleep disorders: a systematic review. Sleep Med Rev. 2016;29:63–75.
Saçmacı H, Gürel G. Sleep disorders in patients with psoriasis: a cross-sectional study using non-polysomnographical methods. Sleep Breath. 2019;23(3):893–8.
Gabryelska A, Białasiewicz P. Is autonomic activation a middleman between obstructive sleep apnea syndrome and psoriasis? Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2018;14(6):1087–8.
Gowda S, Goldblum OM, McCall WV, Feldman SR. Factors affecting sleep quality in patients with psoriasis. J Am Acad Dermatol. 2010;63(1):114–23.
Maari C, Bolduc C, Nigen S, Marchessault P, Bissonnette R. Effect of adalimumab on sleep parameters in patients with psoriasis and obstructive sleep apnea: a randomized controlled trial. J Dermatol Treat. 2014;25(1):57–60.
Fishbein AB, Vitaterna O, Haugh IM, Bavishi AA, Zee PC, Turek FW, et al. Nocturnal eczema: review of sleep and circadian rhythms in children with atopic dermatitis and future research directions. J Allergy Clin Immunol. 2015;136(5):1170–7.
Fishbein AB, Mueller K, Kruse L, Boor P, Sheldon S, Zee P, et al. Sleep disturbance in children with moderate/severe atopic dermatitis: a case-control study. J Am Acad Dermatol. 2018;78(2):336–41.
Treister AD, Stefek H, Grimaldi D, Rupani N, Zee P, Yob J, et al. Sleep and limb movement characteristics of children with atopic dermatitis coincidentally undergoing clinical polysomnography. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2019;15(8):1107–13.
Tien KJ, Chou CW, Lee SY, Yeh NC, Yang CY, Yen FC, et al. Obstructive sleep apnea and the risk of atopic dermatitis: a population-based case control study. PLoS One. 2014;9(2):e89656.
• Hu JM, Lin CS, Chen SJ, Chen CY, Lin CL, Kao CH. Association between obstructive sleep apnea and atopic dermatitis in children: a nationwide, population-based cohort study. Pediatr Allergy Immunol. 2018;29(3):260–6 This is the most recent epidemiologic publication linking atopic dermatitis with OSA, and to our knowledge the largest pediatric cohort study including 120,736 AD patients and 120,736 age-/gender-matched controls. They found atopic dermatitis patients have a 1.86-fold risk of OSA.
Alexopoulos EI, Bizakis J, Gourgoulianis K, Kaditis AG. Atopy does not affect the frequency of adenotonsillar hypertrophy and sleep apnoea in children who snore. Acta Paediatr (Oslo, Norway : 1992). 2014;103(12):1239–43.
Huo Z, Shi J, Shu Y, Xiang M, Lu J, Wu H. The relationship between allergic status and adenotonsillar regrowth: a retrospective research on children after adenotonsillectomy. Sci Rep. 2017;7:46615.
Nagaya T, Kawata K, Kamekura R, Jitsukawa S, Kubo T, Kamei M, et al. Lipid mediators foster the differentiation of T follicular helper cells. Immunol Lett. 2017;181:51–7.
Paulucci BP, Pereira J, Picciarelli P, Levy D, Di Francesco RC. Expression of cysteinyl leukotriene receptor 1 and 2 (CysLTR1 and CysLTR2) in the lymphocytes of hyperplastic tonsils: comparison between allergic and nonallergic snoring children. Int Forum Allergy Rhinol. 2016;6(11):1151–8.
Kheirandish-Gozal L, Bandla HP, Gozal D. Montelukast for children with obstructive sleep apnea: results of a double-blind, randomized, Placebo-Controlled Trial. Ann Am Thorac Soc. 2016;13(10):1736–41.
Dayyat E, Serpero LD, Kheirandish-Gozal L, Goldman JL, Snow A, Bhattacharjee R, et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009;135(5):1142–9.
Silverberg JI, Becker L, Kwasny M, Menter A, Cordoro KM, Paller AS. Central obesity and high blood pressure in pediatric patients with atopic dermatitis. JAMA Dermatol. 2015;151(2):144–52.
Silverberg JI, Silverberg NB, Lee-Wong M. Association between atopic dermatitis and obesity in adulthood. Br J Dermatol. 2012;166(3):498–504.
•• Fishbein AB, Lor J, Penedo FJ, Forrest CB, Griffith JW, Paller AS. Patient-Reported Outcomes for Measuring Sleep Disturbance in Pediatric Atopic Dermatitis: cross sectional study of PROMIS Pediatric Sleep Measures and Actigraphy. Journal of the American Academy of Dermatology. 2020; This is the first study to present an evidence-based algorithm for assessing sleep in children with atopic dermatitis, first by screening with patient/parent-reported measures and then objective sleep assessment as needed.
Tahrani AA, Ali A, Raymond NT, Begum S, Dubb K, Mughal S, et al. Obstructive sleep apnea and diabetic neuropathy: a novel association in patients with type 2 diabetes. Am J Respir Crit Care Med. 2012;186(5):434–41.
Altaf QA, Ali A, Piya MK, Raymond NT, Tahrani AA. The relationship between obstructive sleep apnea and intra-epidermal nerve fiber density, PARP activation and foot ulceration in patients with type 2 diabetes. J Diabetes Complicat. 2016;30(7):1315–20.
Vas PR, Ahluwalia R, Manas AB, Manu CA, Kavarthapu V, Edmonds ME. Undiagnosed severe sleep apnoea and diabetic foot ulceration - a case series based hypothesis: a hitherto under emphasized factor in failure to heal. Diabetic medicine : a journal of the British Diabetic Association. 2016;33(2):e1–4.
Wertenteil S, Strunk A, Garg A. Incidence of obstructive sleep apnoea in patients with hidradenitis suppurativa: a retrospective population-based cohort analysis. Br J Dermatol. 2018;179(6):1398–9.
Setji TL, Brown AJ. Polycystic ovary syndrome: diagnosis and treatment. Am J Med. 2007;120(2):128–32.
Hoppin AG, Katz ES, Kaplan LM, Lauwers GY. Case records of the Massachusetts General Hospital. Case 31-2006. A 15-year-old girl with severe obesity. N Engl J Med. 2006;355(15):1593–602.
Buyuktas D, Arslan E, Celik O, Tasan E, Demirkesen C, Gundogdu S. Elephantiasis nostras verrucosa on the abdomen of a Turkish female patient caused by morbid obesity. Dermatol Online J. 2010;16(8):14.
Shanmugam VK, Tsagaris KC, Attinger CE. Leg ulcers associated with Klinefelter's syndrome: a case report and review of the literature. Int Wound J. 2012;9(1):104–7.
Hegele RA, Al-Attar SA, Rutt BK. Obstructive sleep apnea in 2 women with familial partial lipodystrophy due to a heterozygous LMNA R482Q mutation. Cmaj. 2007;177(7):743–5.
Carr A, Cooper DA. Adverse effects of antiretroviral therapy. Lancet. 2000;356(9239):1423–30.
Epstein LJ, Strollo PJ Jr, Donegan RB, Delmar J, Hendrix C, Westbrook PR. Obstructive sleep apnea in patients with human immunodeficiency virus (HIV) disease. Sleep. 1995;18(5):368–76.
Harsch IA, Bergmann T, Koebnick C, Wiedmann R, Ruderich F, Hahn EG, et al. Adiponectin, resistin and subclinical inflammation--the metabolic burden in Launois Bensaude syndrome, a rare form of obesity. Journal of physiology and pharmacology : an official journal of the Polish Physiological Society. 2007;58(Suppl 1):65–76.
Hanson RD, Olsen KD, Rogers RS 3rd. Upper aerodigestive tract manifestations of cicatricial pemphigoid. Ann Otol Rhinol Laryngol. 1988;97(5 Pt 1):493–9.
Gozal D, Ham SA, Mokhlesi B. Sleep apnea and cancer: analysis of a nationwide population sample. Sleep. 2016;39(8):1493–500.
Santamaria-Martos F, Benítez I, Girón C, Barbé F, Martínez-García MA, Hernández L, et al. Biomarkers of carcinogenesis and tumour growth in patients with cutaneous melanoma and obstructive sleep apnoea. Eur Respir J. 2018;51(3).
Almendros I, Martínez-García M, Campos-Rodríguez F, Riveiro-Falkenbach E, Rodríguez-Peralto JL, Nagore E, et al. Intermittent hypoxia is associated with high hypoxia inducible factor-1α but not high vascular endothelial growth factor cell expression in tumors of cutaneous melanoma patients. Front Neurol. 2018;9:272.
•• Martinez-Garcia MA, Campos-Rodriguez F, Nagore E, Martorell A, Rodriguez-Peralto JL, Riveiro-Falkenbach E, et al. Sleep-disordered breathing is independently associated with increased aggressiveness of cutaneous melanoma: a multicenter OBSERVATIONAL STUDY in 443 patients. Chest. 2018;154(6):1348–58 First study to show SDB is associated with melanoma aggressiveness. This well-designed study of 443 melanoma patients evaluated objective sleep disordered breathing measures (such as AHI) and patient-reported measures to demonstrate the association of SDB and several markers of melanoma aggressiveness (i.e. ulceration, sentinel lymph noted spread, etc). There was a “severity dependent” effect of AHI on tumor staging.
Martinez-Garcia MA, Campos-Rodriguez F, Almendros I, Garcia-Rio F, Sanchez-de-la-Torre M, Farre R, et al. Cancer and sleep apnea: cutaneous melanoma as a case study. Am J Respir Crit Care Med. 2019;200(11):1345–53.
Baik I, Lee S, Thomas RJ, Shin C. Obstructive sleep apnea, low transferrin saturation levels, and male-pattern baldness. Int J Dermatol. 2019;58(1):67–74.
Pépin JL, Leger P, Veale D, Langevin B, Robert D, Lévy P. Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest. 1995;107(2):375–81.
Matin A, Bliwise DL, Wellman JJ, Ewing HA, Rasmuson P. Resolution of dyshidrotic dermatitis of the hand after treatment with continuous positive airway pressure for obstructive sleep apnea. South Med J. 2002;95(2):253–4.
Nino G, Singareddy R. Severe onychophagia and finger mutilation associated with obstructive sleep apnea. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013;9(4):379–81.
The authors would like to acknowledge Ms. Andrea Fawcett for her help in the literature review.
Conflict of Interest
Dr. Fishbein has grant support from Pfizer and served as consultant for Regeneron. Dr. Fishbein also has grant support from NIH.
Human and Animal Rights
This article does not contain any studies with human or animal subjects performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Sleep and Sleep Apnea at the Extremes
About this article
Cite this article
Soundararajan, V., Lor, J. & Fishbein, A.B. Sleep Apnea and Skin. Curr Sleep Medicine Rep 6, 94–100 (2020). https://doi.org/10.1007/s40675-020-00179-7