10.5826/dpc.1204a167
Introduction: Diseases affect sleep quality and the state of sleep quality may also affect the state of diseases by affecting the immune system. Depending on the immune status of the patients with cutaneous warts, the extent of the disease and the response to treatment may vary.
Objectives: We aim characterize the association between cutaneous warts and sleep quality.
Methods: A prospective controlled study was conducted. Patients over 18 years old with cutaneous wart were enrolled. Control subjects were age- and sex- matched healthy people. Demographic and clinical data of the participants were questioned. Sleep quality of participants was evaluated with Pitssburgh Sleep Quality Index (PSQI).
Results: A total of 138 patients with cutaneous warts (genital (n=59), nongenital (n=79)) and 83 controls were interviewed. Patients with cutaneous warts showed significantly higher global PSQI score than the control group (warts vs control, 7.68±3.53 vs 4.92±2.91). The rate of having poor sleep quality in the patient group was higher than the individuals in the control group (Odds ratio (OR): 3.835). Patients with genital warts showed significantly higher global PSQI score than the patients with nongenital warts (genital vs nongenital, 8.61±3.63 vs 6.98±3.32). Female patients with genital warts showed significantly higher global PSQI score than male patients with genital warts.
Conclusions: Evaluation of sleep quality in patients with warts, especially in patients with genital warts may be suggested. The management of sleep disturbances in cutaneous warts may help increase the quality of life of patients and may effect on disease control.
text/xml
2160-9381
2152
en
Vildan Manav
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
warts, sleep quality, Pitssburgh Sleep Quality Index (PSQI)
Evaluation of Sleep Quality in Patients with Genital and Nongenital Cutaneous Warts: A prospective controlled study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-11-02
2022-10-31
2022-11-29
e2022167
Dermatol Pract Concept
Introduction: Diseases affect sleep quality and the state of sleep quality may also affect the state of diseases by affecting the immune system. Depending on the immune status of the patients with cutaneous warts, the extent of the disease and the response to treatment may vary.
Objectives: We aim characterize the association between cutaneous warts and sleep quality.
Methods: A prospective controlled study was conducted. Patients over 18 years old with cutaneous wart were enrolled. Control subjects were age- and sex- matched healthy people. Demographic and clinical data of the participants were questioned. Sleep quality of participants was evaluated with Pitssburgh Sleep Quality Index (PSQI).
Results: A total of 138 patients with cutaneous warts (genital (n=59), nongenital (n=79)) and 83 controls were interviewed. Patients with cutaneous warts showed significantly higher global PSQI score than the control group (warts vs control, 7.68±3.53 vs 4.92±2.91). The rate of having poor sleep quality in the patient group was higher than the individuals in the control group (Odds ratio (OR): 3.835). Patients with genital warts showed significantly higher global PSQI score than the patients with nongenital warts (genital vs nongenital, 8.61±3.63 vs 6.98±3.32). Female patients with genital warts showed significantly higher global PSQI score than male patients with genital warts.
Conclusions: Evaluation of sleep quality in patients with warts, especially in patients with genital warts may be suggested. The management of sleep disturbances in cutaneous warts may help increase the quality of life of patients and may effect on disease control.
Vildan Manav
2022/10/31
10.5826/dpc.1204a167
e2022167
Department of Dermatology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey
2160-9381
warts, sleep quality, Pitssburgh Sleep Quality Index (PSQI)
en
e2022167
Evaluation of Sleep Quality in Patients with Genital and Nongenital Cutaneous Warts: A prospective controlled study
https://dpcj.org/index.php/dpc/article/download/2152/1802
Evaluation of Sleep Quality in Patients With Genital
 and Non-Genital Cutaneous Warts: a Prospective
                 Controlled Study
                                           Müge Göre Karaali1, Vildan Manav2


1 Department of Dermatology, Erzincan Binali Yildirim University, Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
2 Department of Dermatology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey



Key words: warts, sleep quality, Pittsburgh Sleep Quality Index, genital warts
Citation: Göre Karaali M, Manav V. Evaluation of Sleep Quality in Patients with Genital and Nongenital Cutaneous Warts: A prospective
controlled study. Dermatol Pract Concept. 2022;12(4):e2022167. DOI: https://doi.org/10.5826/dpc.1204a167
Accepted: March 23, 2022; Published: October 2022
Copyright: ©2022 Göre Karaali et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Muge Gore Karaali, MD, Erzincan Binali Yıldırım University, Mengücek Gazi Training and Research Hospital,
Department of Dermatology, Erzincan, Turkey. Phone number: +9005303093328, E-mail: mugegore@hotmail.com




  ABSTRACT             Introduction: Diseases affect sleep quality, and sleep quality may also affect diseases by affecting the
                       immune system. Depending on the immune status of patients with cutaneous warts, the extent of the
                       disease and the response to treatment may vary.
                       Objectives: This study aimed to characterize the association between cutaneous warts and sleep
                       ­quality.
                       Methods: A prospective controlled study was conducted. Patients over 18 years with cutaneous warts
                       were enrolled. The control subjects were healthy, age- and sex- matched people. Demographic and
                       clinical data on the participants were gathered. The sleep quality of participants was evaluated with
                       the Pittsburgh Sleep Quality Index (PSQI).
                       Results: A total of 138 patients with genital or non-genital cutaneous warts (N = 59, N = 79,
                       ­respectively) and 83 controls were interviewed. The average global PSQI score of the group with cu-
                        taneous warts was significantly higher than that of the control group (1.292 95% confidence interval
                        1.174-1.422). The rate of poor sleep quality in the patient group was higher than in the control group
                        (odds ratio 3.835). Patients with genital warts had a significantly higher average global PSQI score
                        than patients with non-genital warts (8.61 ± 3.63 versus. 6.98 ± 3.32). Female patients with genital
                        warts had a significantly higher average global PSQI score than male patients with genital warts.
                       Conclusions: Evaluation of sleep quality in patients with warts, especially in patients with genital
                       warts, may be suggested. The management of sleep disturbances associated with cutaneous warts may
                       help increase the quality of life of patients and may affect disease control.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022167                                                                          1
Introduction                                                     Exclusion Criteria for Patient Group
                                                                 Patients aged < 18 years, patients known to have sleep dis-
Sleep is an active, restorative, physiological, and neuro-       orders, patients with other chronic and/or any inflammatory
biological state that occupies approximately one third of        systemic and/or dermatologic disorders that may affect sleep
our lives. It is mainly regulated by the homeostatic sleep       quality, and pregnant and lactating women were excluded
drive and the circadian system, often called the “central        from the patient group.
clock,” controlled particularly by the cortisol and mela-
tonin hormones [1,2]. Sleep disruption associated with
                                                                 Exclusion Criteria for Control Group
skin diseases may impair quality of life. Poor sleep quality
                                                                 Patients aged < 18 years, patients with other chronic and/
also has a significant effect on the nervous and immune
                                                                 or any inflammatory systemic and/or dermatologic disorders
systems. Moreover, poor sleep quality may induce and/or
                                                                 that may affect sleep quality, and pregnant and lactating
aggravate skin disease by affecting the regional immune
                                                                 women were excluded from the control group.
function [3].
    Skin also plays a major role in convenient sleep activity
by regulating body temperature, peripheral circadian oscil-
                                                                 Ethical Considerations
lators, ultraviolet (UV)-induced fluctuations in melatonin       All participants signed the written consent form before the
levels, and cortisol [1]. It has been reported that only one     questionnaire, provided information, and gave permission to
night of sleep deprivation may hinder the recovery of the        use that information in the study regarding the survey. Ethics
skin barrier. Natural killer cells and some proinflammatory      committee approval was received from the University Scien-
cytokines (interleukin-1beta/tumor necrosis factor-alfa),        tific Research and Publication Ethics Board.
which play an important role in the regulation of non-rapid
eye movement (NREM) sleep, may increase after sleep dis-         Survey
ruption [4].                                                     In the first section, the demographic and clinical data of the
    Especially chronic inflammatory skin conditions (eg          participants were queried. The questions included age, sex,
atopic dermatitis, psoriasis vulgaris, and chronic ­urticaria)   and presence of systemic, autoimmune, and dermatological
may affect sleep quality [5–7]. Recently, rosacea, lichen        diseases. The type of warts (genital/non-genital), number
planus, hidradenitis suppurativa, acne vulgaris, and Be-         of warts (single, 1–5 warts, >5 warts), localization of warts
hçet disease have been shown to negatively affect sleep          (if non-genital), and duration of the disease were recorded.
­quality [8–12].                                                    The sleep quality of participants was evaluated with
    Cutaneous warts are a common infectious skin disease         the Pittsburgh Sleep Quality Index (PSQI). It is a self-rated
caused by human papillomavirus (HPV). Depending on               questionnaire evaluating sleep quality and sleep disturbances
a patient immune status, common warts may appear any-            over an interval of the previous month. The questionnaire
where on the skin; moreover, spontaneous remission and           included 11 questions about subjective sleep quality, sleep
treatment-resistant lesions may be seen, and it is thought       latency, sleep duration, habitual sleep efficiency, sleep distur-
that the immune system is effective in the response to treat-    bance, use of sleeping medication, and daytime dysfunction.
ment [13]. Although diseases themselves affect the quality of    Each domain was scored with 0–3 points. PSQI scores range
sleep, sleep quality can also affect diseases by affecting the   from 0–21 points. A global PSQI score of 5 or higher reflects
immune system.                                                   poor sleep quality.
    Objectives: The aim of this study was to better charac-
terize the association between cutaneous warts and sleep         Statistical Analysis
quality.                                                         SPSS 22.0 package program was used to evaluate the data.
                                                                 The descriptive statistics were the number and percentage for
Methods                                                          categorical variables and numerical variables as mean, stan-
                                                                 dard deviation, minimum, maximum, and median. The rates
Study Participants                                               in groups were compared using the Chi-squared test, Mann–
A prospective, controlled study was conducted between            Whitney U test, and Kruskal–Wallis test. The distribution of
January and July 2021. The study included patients over          variables was measured by the Kolmogorov–Smirnov test.
18 years old who were enrolled from tertiary referral der-       Since the numerical variable did not meet the normal distri-
matology outpatient clinics and diagnosed with cutaneous         bution condition, the Mann–Whitney U and Kruskal–Wallis
warts. The control subjects were healthy, age- and sex-          tests were used for comparison. Statistical alpha significance
matched people.                                                  level was accepted as P < 0.05.




2                                                                    Original Article | Dermatol Pract Concept. 2022;12(4):e2022167
Results                                                                 Comparison of Sleep Quality Between
                                                                        Patient and Control Groups
Demographic and Clinical Characteristics                                Patients with cutaneous warts had a significantly higher av-
A total of 138 patients with genital and non-genital cuta-              erage global PSQI score than the control group with an odds
neous warts (N = 59, N = 79, respectively) and 83 healthy,              ratio [OR] of 1.292, 95% confidence interval (CI) 1.174-
sex- and age-matched controls were interviewed. General                 1.422, with a significantly higher score in all components of
characteristics of the participants are shown in Table 1. The           the PSQI excluding use of sleeping medication.
majority of patients with genital warts were male (89.8%).                 Poor sleep quality was observed in 79.7% of the patient
The sex distribution in patients with non-­
                                          genital warts                 group and in 50.6% of the control group (P < 0.05). It was
was similar. The most frequent localizations of non-gen-                determined that the rate of poor sleep quality in the patient
ital warts were plantar and palmar (40.5% and 39.2%,                    group was higher than in the control group (OR: 3.835;
respectively).                                                          95% CI: 2.110-6.972) (Table 2).




          Table 1. General Characteristics of Participants and Association Between Sleep Quality
                                   and Demographic Characteristics.
                                                    Nongenital (N = 79)             Genital (N = 59)           Control (N = 83)
                                                       mean ± SD                      mean ± SD                  mean ± SD
 Age (years)                                             27.94±10.23                   31.54±10.01               30.20±9.57
 Disease duration (years)                                 1.08±1.55                     1.20±1.39
                                                            N (%)                         N (%)                     N (%)
 Sex
 Male                                                      39(49.4)                      53(89.8)                  47(56.6)
 Female                                                    40(50.6)                       6(10.2)                  36(43.4)
 Number of warts
 1                                                         36(45.6)                       1(1.7)
 1-5                                                       28(35.4)                      16(27.1)
 >5                                                        15(19.0)                      42(71.2)
 Localization
 – Hand                                                    31(39.2)
 – Plantar                                                 32(40.5)
 – Facial                                                   9(11.4)
 – Palmoplantar                                              4(5.1)
 – Others                                                    3(3.8)
                                                    Non-genital (N = 79)            Genital (N = 59)                  z/P
                                                    N            mean ± SD         N        mean ± SD
 Age
 ≤ 30 years                                         56           6.76±3.09        33        8.33±3.72            -1.898/0.058
 >30 years                                          23           7.52±3.83        26        8.96±3.56            -1.327/0.184
 z/P                                                     -0.786/0.432                  -0,797/0.425
 Sex
 Male                                               39           6.87±3.18        53        8.30±3.65            -1.737/0.082
 Female                                             40           7.10±3.48         6       11.33±2.06           -2.621/0.009*
 z/P                                                     -0.015/0.988                  -2.102/0.036*
 Disease duration
 ≤ 1 year                                           65           6.87±3.40        42        8.66±3.88           -2.278/0.023*
 >1 year                                            14           7,.0±2.95        17        8.47±3.04            -0.979/0.327
 z/P                                                     -0.574/0.566                  -0.109/0.913

SD = standard deviation; z = Mann Whitney U test.
* P < 0.05.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022167                                                                     3
                  Table 2. Comparison of Sleep Quality Between Patient and Control Group.
    Pittsburgh Sleep Quality
     Index (PSQI) and PSQI          Patients (N = 138)      Control (N = 83)                                   Odds Ratio a
            domains                    mean ± SD              mean ± SD                  z/P             (95% confidence interval)
 Global PSQI                             7.68±3.53             4.92±2.91           -5.549/0.000*             1.292 (1.174-1.422)
 Subjective sleep quality                1.42±0.64             1.18±0.68           -2.498/0.012*             1.764 (1.152-2.701)
 Sleep latency                           1.55±0.88             1.03±0.86           -4.127/0.000*             1.955 (1.405-2.720)
 Sleep duration                          1.18±1.06             0.77±0.83           -2.738/0.006*             1.541 (1.153-2.060)
 Habitual sleep efficiency               0.55±0.74             0.12±0.32           -4.813/0.000*             4.587 (2.299-9.154)
 Sleep disturbance                       1.23±0.63             0.74±0.55           -5.460/0.000*             3.936 (2.316-6.690)
 Use of sleeping medication              0.47±0.91             0.27±0.70            -1.648/0.099             1.363 (0.952-1.950)
 Daytime dysfunction                     1.25±1.01             0.79±0.77           -3.210/0.001*             1.704 (1.251-2.321)
                                                                                          2
 Sleep quality                             N (%)                 N (%)                   x /P
 Poor sleep quality                      110 (79.7)            42 (50.6)
                                                                                   20.449/0.000*             3.835 (2.110-6.972)
 Good sleep quality                      28 (20.3)             41 (49.4)

SD = standard deviation; z = Mann Whitney U test; x2 = Xi square test.
* P < 0.05; , a Logistic regression analysis.


      Table 3. Comparison of Sleep Quality Between Patients With Genital and Non-genital Warts.
 Pittsburgh Sleep Quality Index             Non-genital (a)        Genital (b) (N = 59)         Control (c) (N = 83)
    (PSQI) and PSQI domains               (N = 79) mean ± SD          mean ± SD                    mean ± SD                 KW/p
 Global PSQI                                    6.98±3.32                 8.61±3.63                 4.92±2.91           36.79/0.000*
                                                                                                                           b>a>c a
 Subjective sleep quality                       1.39±0.70                 1.47±0,56                 1.18±0.68           6.904/0.032*
                                                                                                                           b>a=c a
 Sleep latency                                  1.46±0.85                 1.66±0.90                 1.03±0.86           18.222/0.000*
                                                                                                                           a=b>c a
 Sleep duration                                 1.06±1.01                 1.33±1.10                 0.77±0.83           9.666/0.008*
                                                                                                                           b>a=c a
 Habitual sleep efficiency                      0.54±0.81                 0.55±0.65                 0.12±0.32           23.997/0.000*
                                                                                                                           a=b>c a
 Sleep disturbance                              1.13±0,61                 1.37±0.64                 0.74±0.55           33.497/0.000*
                                                                                                                           a=b>c a
 Use of sleeping medication                     0.36±0.78                 0.62±1.04                 0.27±0.70            4.411/0.110
 Daytime dysfunction                            1.01±0.98                 1.57±0.98                 0.79±0.77           21.785/0.000*
                                                                                                                           b>a>c a

KW = Kruskal Wallis test.
* P < 0.05; a Bonferroni’s correction: P < 0.0167.


Comparison of Sleep Quality Between Patients                             warts (11.33 ± 2.06 versus 8.30 ± 3.65). There was no sig-
With Genital and Non-genital warts                                       nificant difference in sleep quality regarding age, number of
Patients with genital warts had a significantly higher aver-             warts, or disease duration (Table 1).
age global PSQI score than patients with non-genital warts
(8.61 ± 3.63 versus 6.98 ± 3.32), with a significantly higher
score in 2 components of the PSQI, ie sleep disturbance and
                                                                         Conclusions
daytime dysfunction (Table 3; Figure 1).                                 Although the reason cannot be fully clarified, chronic inflam-
                                                                         matory skin diseases (eg atopic dermatitis, psoriasis vulgaris,
Association Between Sleep Quality                                        chronic urticaria) and rosacea, lichen planus, hidradenitis
and Demographic Characteristics                                          suppurativa, acne vulgaris and Behçet disease are shown to
Female patients with genital warts had a significantly higher            have a negative effect on sleep quality [5–12]. Apart from
average global PSQI score than male patients with genital                symptoms such as pain and itching caused by diseases, the



4                                                                            Original Article | Dermatol Pract Concept. 2022;12(4):e2022167
           Figure 1. Comparison of sleep quality among patients with genital and non-genital warts and controls.
           *P < 0.05.
           Non-genital: a. Genital: b. Control: c.
           Global PSQI b>a>c**
           subjective sleep quality b>a=c**
           sleep latency a=b>c**
           sleep duration b>a=c**
           habitual sleep efficiency a=b>c**
           sleep disturbance a=b>c**
           use of sleeping medication -
           daytime dysfunction b>a>c**
           **Bonferroni correction: P < 0.0167.


psychosocial effects of dermatological diseases cannot be             between cytokines, host immune function, and the sleep-
denied. Sleep quality is also one of the most important of            wake cycle, sleep disturbance may play a role in the inflam-
these psychosocial effects. For this reason, the effects of der-      matory cascade that can result in a chronic inflammatory
matological diseases on sleep quality have been frequently            state [1].
investigated in recent studies.                                           Cutaneous warts are a common disease, and depending
    In fact, although diseases themselves affect sleep quality,       on the immune status of the person, the extent of the dis-
sleep quality may also affect diseases by affecting the im-           ease and the response to treatment may vary [14]. In the
mune system. Sleep disorders may result in some changes in            literature, only one study has mentioned the effect of cuta-
immune system functions. In accordance with the association           neous warts on sleep quality [15]. In the study of Liu et al,



Original Article | Dermatol Pract Concept. 2022;12(4):e2022167                                                                   5
in which 215 patients with palmoplantar warts were eval-                   The shortcoming of the study is that concurrent quality
uated, 11.0% of the patients reported poor sleep quality;            of life was not evaluated. In addition, since the treatment op-
however, this study was conducted without questionnaires             tions were not standard in all patients, it was not evaluated
or a control group. Although the reason is not mentioned, it         whether the sleep quality of the patients had an effect on the
was observed that the treatment response was low in those            response to treatment.
with poor sleep quality [15]. Our study is significant in that             Our study reveals the association between poor sleep
it is the first controlled study in this respect and that patients   and cutaneous warts. Cutaneous warts seem to have an ef-
with genital warts (ie as opposed to only non-genital warts)         fect on sleep, but perhaps the reverse direction is also true.
were also evaluated.                                                 Evaluation of sleep quality in patients with warts, espe-
    In our study, patients with cutaneous warts had a sig-           cially in patients with genital warts, may be suggested. The
nificantly higher average global PSQI score than that of the         management of sleep disturbances in cutaneous warts may
control group. Here, the disease itself, treatment processes,        help increase the quality of life of patients and may affect
and response or non-response to treatment may affect sleep           disease control.
quality. However, the sleep quality of the patients may also
affect their immune status, thus affecting the elimination of
the virus or the extent of the virus and the response to treat-      References
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022167                                                                        7
