Sleep Disturbance and Atopic Dermatitis: A Bidirectional Relationship With Clinical and Therapeutic Implications

Sleep disturbance is one of the most frequent and clinically consequential problems in atopic dermatitis. Current evidence indicates that it is not merely a secondary symptom of pruritus but a complex disease domain associated with higher inflammatory activity, sleep fragmentation, impaired quality of life, daytime fatigue, and anxiety or depressive symptoms. The best established pathway runs from active dermatitis to impaired sleep: nocturnal itch, scratching, pain, xerosis, heat sensation, and epidermal barrier dysfunction promote repeated awakenings and difficulty maintaining sleep. However, growing mechanistic and epidemiological evidence supports a bidirectional model. Insufficient, fragmented, or circadian-misaligned sleep may impair barrier repair, increase transepidermal water loss, alter neuroimmune itch signaling, and perpetuate behavioral amplification through scratching, stress, and reduced treatment adherence. This narrative review synthesizes recent literature on the epidemiology, sleep phenotype, biological mechanisms, assessment tools, therapeutic evidence, and research gaps linking sleep disturbance with aggravation of atopic dermatitis. The clinical implication is practical: sleep should be assessed as a core treatment outcome in atopic dermatitis, and persistent sleep disruption should be interpreted as a marker of undercontrolled disease and a potential amplifier of cutaneous inflammation.