Why does eczema get worse at night?

Numerous factors can cause eczema to worsen at night including the loss of skin moisture, changes in body temperature, exposure to allergens and natural fluctuations in levels of inflammatory cytokines. Night-time scratching can drive inflammation, worsening the skin's irritation and, without daytime distractions, itching may feel more intense.

Eczema at night

I'm very lucky in that I suffer only from very mild contact dermatitis on my hands. It's a form of eczema that develops when I come into contact with a skin irritant like detergent. I can testify that when I have a flare-up, it is the night-time when symptoms are at their worst. They call itching that drives you crazy during the night 'nocturnal pruritus' - I would love this to be a Harry Potter-style spell or incantation that would vanquish the intense itchiness!

Sometimes, I wake up scratching, and this can make the skin quite sore and ironically makes the itch feel as if it is penetrating even deeper into my skin.

It is estimated that eczema affects up to 1 in 5 children and 1-3% of adults.(1) That's a lot of itchy and sleep-deprived people and it's difficult to know which conundrum is to blame. Does lack of sleep make the eczema worse? Or, is the eczema preventing a restful night?

Eczema is a complex condition and there is not a simple solution that works for everyone; but, identifying factors and triggers that can make it worse and eliminating them can help towards easing or reducing your troublesome symptoms.

5 reasons why eczema symptoms are worse during the night

So, let's take a closer look at 5 key reasons or factors which can cause your eczema to worsen at night, why this happens and what can help ease your eczema symptoms when you are trying to sleep:

1. Body temperature

Skin temperature increases when you are trying to get to sleep and this can drive inflammation and itch. It's interesting to look at why this happens. At night, the core temperature of our body and our brain temperature both drop, and this induces sleep. The faster this happens in the hours before you go to sleep determines how fast you fall into the early stages of sleep.(2) The body cools itself down by dilating outer blood vessels on the skin, increasing the surface area that blood flow reaches (or in plain speak - the hot blood rushes to the outside layers of the body). This makes the skin, hands and feet hotter in the process, and it is this that can make everything itchier.

If bedclothes are too heavy, this overheating of the skin can continue all night. Foods like coffee, alcohol, and hot spices are vasodilators, which means they increase the dilation of the blood vessels, further driving heat. You will be aware of this if any of the above gives you a big red face.

Avoid hot showers or baths before bed. Layer the bedclothes so that they are as light as possible and it may help regulate the body's temperature during sleep. My husband and I have very different core temperatures at night, and there is no duvet on the planet that we can agree on. The day we each brought a separate duvet is the day we stopped bickering about bedclothes – I recommend it, darling!

2. Inflammatory cytokines

The immune system and our body clock work together. Unfortunately, what helps us get to sleep may perversely worsen eczema symptoms by increasing skin inflammation. Cytokines are proteins that act as signals between immune cells and other cells of the body. Some cytokines, like interferon gamma (IFNγ), are thought to be sleep promotors, and 'switch on' inflammatory signals. Levels of these are naturally higher during the night when the immune system is actively working to rejuvenate and protect our cells. Other cytokines are anti-inflammatory and they may not be active during the night as they may inhibit sleep.(3)

This is also the case with cortisol, often touted as our stress hormone but it has an important role as an anti-inflammatory hormone in the body. Our sleep cycle depends on cortisol levels dropping during the night and rising towards morning to wake us up.(4) The mediators of our natural sleep cycle and the work of the immune system may therefore collaborate to create a situation that will worsen eczema.

3. The itch-scratch cycle

Eczema is often referred to as the 'itch that rashes' because it is the scratching that is more likely to cause the redness and rash that may occur. It's nigh on impossible to try to avoid scratching in your sleep and unfortunately, this makes the itching worse. Any skin lesion caused by the eczema or by scratching tends to trigger inflammatory cytokines, as the immune system reacts to what it perceives as potential damage or threat. Inflammation increases the itch and this causes more scratching: it's a vicious circle.

Those with eczema may also suffer from sensory hypersensitivity, which may make their brains mistake sensations of touch for something itchy.(5) It's also very difficult to ignore uncomfortable sensations like itching when the mind is not occupied with movement or distractions like TV.

Try to avoid scratching by pressing with the palm of the hand instead of digging the nails in. There's a bit more information on reasons why eczema may be getting worse here. Keep the nails short and keep clothing and bedclothes as soft as possible to avoid any chaffing or unnecessary abrasion. Soft cotton and silks are better materials to wear rather than synthetic fabrics that will retain heat.

4. Exposure to allergens

Many with eczema inherit a type of skin from their parents that lacks a protein called filaggrin. This is important for maintaining the skin's barrier function and its ability to protect the skin from damage and allergic reactions. This barrier is made up of many components that include layers of filaggrin, tough collagen and immune cells. The idea is to keep moisture in and to keep invaders and toxins out.

Eczema and atopic dermatitis are also strongly associated with dust mite allergy.(6) Dust mites are everywhere, including beds, and they feed on dead skin particles and microbes. The mites themselves and their faeces can be allergens. When eczema causes the skin to become very dry and more easily damaged, immune cells are exposed to dust mite particles. They can mistakenly identify this as a threat, become over-sensitised and produce an allergic response – usually inflammation, itching, redness.

Not so fun fact: Allergies and eczema can develop at any age.

It's very difficult to avoid dust but these are some of the measures that may help.

Wool blankets, feather pillows and duvets should be avoided and switched to allergy-friendly alternatives.
Bed linen should be washed weekly with a 60-degree wash cycle.
Rooms should be hoovered and dusted frequently with a damp cloth.

5. Skin moisture

The dryer that skin becomes, the itchier and more sensitive it will feel. Sweating during the night may cause a loss of moisture from the skin during the night and moisturiser applied earlier during the day may have worn off by bedtime. Sebum, the oil that is responsible for making the skin oily is at its lowest rate of production at 4 am in the morning, curiously while the skin is at its most absorbent.(7)

For all those reasons, it makes sense to slap on a nutrient-rich moisturiser before bed. I like to use Neem Cream made from a tree that grows in the Indian sub-continent. Neem's oil and leaves have a long tradition of use in the treatment of dry and irritated eczema-prone skin. Finally, keep the body as cool as possible during the night to avoid the loss of moisture through sweating, and here is a little more reading if you would like to know why sweat can make eczema worse.