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Depratoetal. BMC Medicine (2024) 22:67
https://doi.org/10.1186/s12916-024-03291-5
RESEARCH ARTICLE
Inuence oflight atnight onallergic
diseases: asystematic review andmeta-analysis
Andy Deprato1,2, Robert Maidstone3, Anna Palomar Cros4,5,6, Ana Adan7,8, Prasun Haldar9,
Barbara N. Harding4,5,6, Paige Lacy1, Lyle Melenka10, Saibal Moitra11, José Francisco Navarro12,
Manolis Kogevinas4,5,6,13, Hannah J Durrington3 and Subhabrata Moitra1,14*
Abstract
Background Allergic diseases impose a significant global disease burden, however, the influence of light at night
exposure on these diseases in humans has not been comprehensively assessed. We aimed to summarize available
evidence considering the association between light at night exposure and major allergic diseases through a system-
atic review and meta-analysis.
Methods We completed a search of six databases, two registries, and Google Scholar from inception until December
15, 2023, and included studies that investigated the influence of artificial light at night (ALAN, high vs. low exposure),
chronotype (evening vs. morning chronotype), or shift work (night vs. day shift work) on allergic disease outcomes
(asthma, allergic rhinitis, and skin allergies). We performed inverse-variance random-effects meta-analyses to exam-
ine the association between the exposures (ALAN exposure, chronotype, or shiftwork) and these allergic outcomes.
Stratification analyses were conducted by exposure type, disease type, participant age, and geographical location
along with sensitivity analyses to assess publication bias.
Results We included 12 publications in our review. We found that exposure to light at night was associated
with higher odds of allergic diseases, with the strongest association observed for ALAN exposure (OR: 1.88; 95% CI:
1.04 to 3.39), followed by evening chronotype (OR: 1.35; 95% CI: 0.98 to 1.87) and exposure to night shift work (OR:
1.33; 95% CI: 1.06 to 1.67). When analyses were stratified by disease types, light at night exposure was significantly
associated with asthma (OR: 1.62; 95% CI: 1.19 to 2.20), allergic rhinitis (OR: 1.89; 95% CI: 1.60 to 2.24), and skin allergies
(OR: 1.11; 95% CI: 1.09 to 1.91). We also found that the association between light at night exposure and allergic dis-
eases was more profound in youth (OR: 1.63; 95% CI: 1.07 to 2.48) than adults (OR: 1.30; 95% CI: 1.03 to 1.63). Addition-
ally, we observed significant geographical variations in the association between light at night exposure and allergic
diseases.
Conclusions Light at night exposure was associated with a higher prevalence of allergic diseases, both in youth
and adults. More long-term epidemiological and mechanistic research is required to understand the possible interac-
tions between light at night and allergic diseases.
Keywords Allergic rhinitis, Asthma, Chronotype, Shift work, Skin allergies
Open Access
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BMC Medicine
*Correspondence:
Subhabrata Moitra
moitra@ualberta.ca
Full list of author information is available at the end of the article
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Background
Almost all human biological functions are synchronized
with an endogenous circadian timing system which is
further influenced by several exogenous cues, known as
“zeitgebers.” Of all known zeitgebers with the potential
to regulate our biological rhythms, the light/dark cycle
has the strongest influence [1, 2]. Humans are diurnal
animals, i.e., we remain active primarily during the day-
time and transition to dormancy at night; however, the
discovery of electricity and the subsequent invention
of artificial light has significantly extended our activ-
ity period into the night. ese altered activity patterns
have facilitated the rise of the evening chronotype, or
“night owls,” where individuals are increasingly preferring
to remain active mostly at night. Additionally, industri-
alization movements capitalized on artificial light with
the conceptualization of night shift work, as the global
economy started to require 24-h production to meet
growing societal demands [3, 4]. Night shift work and
evening chronotype, the two major risk factors for circa-
dian misalignment, are known to be associated with sleep
disruption and increased risk of several chronic diseases
including metabolic and cardiovascular diseases, mental
disorders, and cancer [5–9]. Despite this, a significant
proportion of the population is active during the evening
and overnight because of more nighttime activities, and
nearly one-fifth of the working population in first-world
countries work permanent or rotating night shifts [10].
In addition to the evening chronotype and night shift
work, environmental light pollution, commonly known
as artificial light at night (ALAN), has played a major role
in disrupting the nocturnal environment and driving a
large proportion of the global population towards circa-
dian misalignment, particularly in cities and large urban
centers [11]. Given global urbanization trends and the
spread of technological infrastructure, more than 80% of
the world’s population is estimated to be directly affected
by outdoor ALAN. Nighttime skies are becoming
increasingly polluted by excessive, misdirected, or obtru-
sive artificial light from several (mostly outdoor) sources,
including residential or industrial areas, streetlights,
and the reflection of this very light from the atmosphere
(Fig.1) [11–14]. For several decades, sodium vapor, metal
halide, and fluorescent lamps were predominately used
for outdoor lighting. However, due to lower production
and maintenance costs, “white” light-emitting diode
(LED) lamp use has increased exponentially, particularly
in low-middle-income countries, consequently driving an
increase in the blue light spectrum emitted by such light
pollution [15]. Concurrently, indoor ALAN exposure at
any hour continues to increase through lighting and per-
sonal devices, such as televisions, computer screens, and
cell phones, all of which primarily emit blue-white light
[16]. is increased blue-white light exposure is espe-
cially problematic due to its substantially greater ability
to suppress melatonin secretion and circadian function
compared to other wavelengths [17]. ALAN exposure
has also been linked to chronic diseases and significantly
influences metabolism, sleep, cancer, obesity, and men-
tal health [18–23]. Further, these concerns also extend to
those with evening chronotypes and night shift workers
as they are also exposed to these light sources. In sum-
mary, ALAN imposes significant effects on circadian
rhythmicity, which may lead to adverse effects on human
health.
It is now well understood that ALAN can disrupt the
rhythmicity of circadian genes through a Ca2+-dependent
pathway [24]. Circadian genes play important roles in
regulating the cascade of inflammatory gene expres-
sion in allergic diseases and ALAN-induced disruption
of these genes may trigger proinflammatory responses,
such as allergic reactions. Apart from direct control,
several studies have shown that allergic diseases also
have circadian rhythmicity [25–29]; for example, asthma
and other allergic diseases such as allergic rhinitis and
atopic dermatitis are known to have marked variations
in symptoms at different times of the day due to under-
lying rhythmic inflammatory pathways [30–34]. Allergic
diseases, including asthma, are very common chronic
inflammatory diseases, affecting at least 8 to 10% of the
global population [35]. Although several recent reports
have suggested that an imbalance of light/dark homeosta-
sis may be linked to allergy and asthma outcomes, there
has not been a systematic analysis of the epidemiologi-
cal evidence on this topic which could potentially bring
attention to the hazards of light at night exposure. Given
the availability of such epidemiological evidence, we per-
formed a systematic review and meta-analysis to provide
a comprehensive assessment of the associations between
light at night exposure and allergic diseases, which could
potentially provide valuable information for further stud-
ies and prevention strategies in this area.
Methods
Search strategy andstudy selection
is study was designed and conducted according to the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines [36]. e proto-
col for this review, which includes further rationale and
methodological details, was previously published on July
12, 2022 [37]. Since our review considers only published
and publicly accessible information, it did not require
formal ethics approval.
Eligibility criteria for included studies were guided by
the population, exposure, comparison, outcome, and
study design (PECOS) framework [36]. Studies that
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Depratoetal. BMC Medicine (2024) 22:67
considered any human population with direct assessment
of ALAN (indoor or outdoor ALAN) or indirect assess-
ment of ALAN (evening chronotype or night shift work)
were eligible for inclusion. Included studies must have
compared the prevalence of allergic diseases (asthma,
allergic rhinitis, and skin allergies) in high versus low
(e.g., evening vs. morning chronotype) or yes versus no
(night vs. day shift work) exposure groups. In the case of
multiple levels of exposure in a study (ALAN), the high-
est versus lowest exposure approach was taken to com-
pare outcomes in only the highest and lowest exposure
groups. We included any primary studies (except case
studies) published in English (or able to be translated)
in peer-reviewed journals. We did not limit studies by
publication country or date. If multiple studies were
published for a given investigation, we only included the
most recent or complete study as the parent study.
One author with library search experience (AD)
developed and conducted a comprehensive search of
six electronic databases, two registries, and Google
Scholar from inception until December 2, 2022,
through the University of Alberta library services. No
filters or limiters were applied to any library searches
and complete search strategies are included in the
additional file (Additional file1: TableS1). An updated
search to identify studies published after the initial
search was completed on December 15, 2023, through
the McMaster University Health Sciences Library.
Additional hand searches, bibliographic searches, and
contact with study authors were also completed to iden-
tify any further studies. Search results were uploaded to
the systematic review management software Covidence
(Melbourne, VIC, Australia), where duplicate records
were removed. One reviewer (first author) completed
the initial title and abstract screening, and two review-
ers (first and last author) independently assessed all
remaining full texts for inclusion, with disagreements
resolved through consensus or a third reviewer (HD).
Content experts then reviewed and finalized the list of
included studies.
Fig. 1 Street-level haze at night from light pollution in Kolkata, India on October 22, 2022. (Picture courtesy of Professor Bhramar Mukherjee,
University of Michigan, USA)
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Depratoetal. BMC Medicine (2024) 22:67
Data analyses
Two reviewers (first and last author) independently col-
lected data from all included studies into Google Sheets
(Google, Mountain View, CA, USA). Extracted data items
included study and population characteristics, exposures
(indoor or outdoor ALAN exposure, chronotype, or shift
work), comparators, and outcomes. Content experts
independently verified all extracted data. We performed
meta-analyses to examine the association between light
at night exposure (outdoor ALAN exposure, chronotype,
or shift work) and all the allergic outcomes of interest in
our review (asthma, allergic rhinitis, and skin allergies).
Exposure-specific and outcome-specific meta-analyses
were the main outcomes considered in this review, which
were further explored through additional stratification
analyses. For studies reporting more than one allergic
outcome, we took the pooled estimate of those outcomes
for our analyses. We estimated the overall association
between light at night exposure and allergic outcomes
by calculating the natural logarithms of odds ratios (OR)
and corresponding standard errors (SE) for the pooled
estimate from each study and applied an inverse-variance
random-effects model to create the corresponding forest
plot [38]. As many studies did not report adjusted ORs
or reported other types of estimates such as prevalence
ratios (PRs) or relative risks (RRs), we could not assess
adjusted ORs. e ORs used for these analyses were
either extracted from included studies or calculated from
presented data; or if estimates were reported differently,
such as through PRs or RRs. Heterogeneity was assessed
by I2 statistics [39] and reported as low, moderate, and
high if the I2 values were quantified as < 50%, 50% to 75%,
and > 75%, respectively [40].
We stratified the meta-analyses by (i) each exposure
and each outcome (e.g., outdoor ALAN and asthma), (ii)
age group (youth and adults), and (iii) continent. Meta-
analyses were completed for each outcome through
Review Manager (RevMan) version 5.4 (Cochrane, Lon-
don, UK). Significance was defined as two-sided p < 0.05.
Quality assessment
Two reviewers (first and last author) independently
assessed the risk of bias of included studies at the individ-
ual study level using the Risk of Bias In Non-randomized
Studies – of Exposures (ROBINS-E) tool [41]. e Grad-
ing of Recommendations, Assessment, Development, and
Evaluation (GRADE) framework was independently com-
pleted by two reviewers to assess the quality of evidence
across included studies for each main outcome according
to defined GRADE criteria [42]. We constructed fun-
nel plots to assess the asymmetry of study results fol-
lowed by Egger’s test [43] and Begg’s test [44] to check
for publication bias in main outcomes. A p-value < 0.05
indicated significant publication bias.
Results
Search results andstudy characteristics
e details of the study selection are presented in Fig.2.
We identified 3368 publication records through ini-
tial database searching, where after removing dupli-
cates (n = 1199) and those that did not match our study
questions (n = 2076), we completed a full-text review of
93 studies. We excluded full texts that did not consider
the outcomes of interest of this review (n = 34), did not
have any eligible data of interest (n = 22), had an ineligi-
ble study design (n = 7), or did not have a published full
text available (n = 14). After a thorough screening, we
included 12 studies with a total population of 855,917
individuals (563,937 adults and 291,980 children and
adolescents) for subsequent qualitative and quantita-
tive analyses. e summary of the updated search is pre-
sented in Additional file1: TableS2.
e characteristics of each study included in the meta-
analysis are presented in Table1. All studies were cross-
sectional, of which, only one directly examined ALAN
exposure [45], whereas most studies considered chrono-
type (n = 6) [46–51] and shift work (n = 5) [52–56]. We
did not find any studies that included more than one
exposure at a time (e.g., ALAN and shift work and ALAN
and chronotype). Over half of the included studies were
reported from Asia (n = 7) [45, 47, 49, 50, 53–55], while
fewer reports came from Europe (n = 3) [46, 51, 56] and
the Americas (n = 2) [48, 52]. Allergic diseases in chil-
dren and adolescents were addressed in five studies, and
while almost all studies reported asthma as the primary
outcome, allergic rhinitis (n = 6) and skin allergies (n = 5)
were much less commonly considered.
Light atnight andallergic diseases
e associations between light at night exposure and any
allergic diseases are summarized in Fig.3. e only study
examining outdoor ALAN exposure in relation to allergic
diseases showed a significant association between out-
door ALAN exposure and allergic diseases (OR: 1.88; 95%
CI: 1.04 to 3.39). However, having an evening chrono-
type was found to be marginally associated with higher
odds of allergic diseases (OR: 1.35; 95% CI: 0.98 to 1.87)
while those exposed to night shift work had significantly
higher odds of having any allergic diseases (OR: 1.33; 95%
CI: 1.06 to 1.67). rough our outcome-specific strati-
fication analyses, we found that any means of exposure
to light at night was significantly associated with higher
odds of asthma (OR: 1.62; 95% CI: 1.19 to 2.20), allergic
rhinitis (OR: 1.89; 95% CI: 1.60 to 2.24), and skin allergies
(OR: 1.44; 95% CI: 1.09 to 1.91) (Fig.4). In the subgroup
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Depratoetal. BMC Medicine (2024) 22:67
analysis by each exposure and each outcome, we found
that outdoor ALAN was significantly associated with
asthma (OR: 3.51; 95% CI: 2.56 to 4.82) and allergic rhini-
tis (OR: 1.97; 95% CI: 1.77 to 2.20), but not skin allergies
(OR: 1.00; 95% CI: 0.85 to 1.18) (Fig.5a). However, due to
only one study on outdoor ALAN, we could not estimate
heterogeneity. Similarly, evening chronotype was signifi-
cantly associated with all three outcomes, asthma (OR:
1.49; 95% CI: 1.02 to 2.17), allergic rhinitis (OR: 1.86;
95% CI: 1.41 to 2.46), and skin allergies (OR: 1.84; 95%
CI: 1.20 to 2.83) (Fig.5b). Night shift work was signifi-
cantly associated with asthma (OR: 1.22; 95% CI: 1.02 to
1.44) and allergic rhinitis (OR: 2.79; 95% CI: 1.18 to 6.60),
but not with skin allergies (OR: 1.42; 95% CI: 0.96 to 2.09)
(Fig. 5c). We also found that the associations between
light at night exposure and any allergic diseases were
higher among youths (OR: 1.63; 95% CI: 1.07 to 2.48)
compared to adults (OR: 1.30; 95% CI: 1.03 to 1.63) in our
age-specific stratification analyses (Fig.6).
Studies published in the Americas showed a significant
positive association between light at night exposure and
allergic diseases (OR: 2.35; 95% CI: 1.40 to 3.96) with
low heterogeneity (I2: 33%), while Asian studies showed
relatively less strong associations between light at night
exposure and any allergic diseases, although these stud-
ies were significantly heterogeneous (OR: 1.35; 95% CI:
1.13 to 1.61; I2: 84%). However, the pooled estimate of
the European studies did not exhibit any significant asso-
ciations between light at night exposure and allergic dis-
eases (OR: 1.04; 95% CI: 0.66 to 1.65; I2: 89%) (Fig.7). A
summary of all analyses is presented in Additional file1:
TableS3.
Quality assessment
After visually inspecting the funnel plots and Egger’s and
Begg’s tests in the quality assessment for each exposure
and allergic outcome, we found very little publication
bias among studies assessing the association between
evening chronotype and any allergic conditions (Egger’s
and Begg’s test p-values were 0.31 and 0.85, respectively).
Similarly, very little bias was observed among studies
investigating night shift work and allergic outcomes (Egg-
er’s and Begg’s test p-values were 0.27 and 0.14, respec-
tively). However, we could not assess bias for outdoor
ALAN and allergic outcomes for limited studies (n = 1)
(Additional file1: Fig. S1). Similarly, in the analysis for
Fig. 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the selection process for eligible studies
considering the influence of light at night exposure on allergic diseases
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Depratoetal. BMC Medicine (2024) 22:67
any ALAN exposure and each of the allergic outcomes,
we observed little bias among studies (Additional file1:
Fig. S2).
Overall, a majority (7 out of 12) of the included stud-
ies had low risk, three studies had some concerns, and
only 2 studies were of high risk of bias according to the
ROBINS-E tool for bias assessment (Additional file 1:
Fig. S3). One-third of the studies had some bias due to
confounding, and only one study (8%) had bias arising
from the measurement of the outcome. However, there
were no major biases in terms of exposure assessment,
selection of participants, post-exposure interventions,
missing data, and selection of the reported results (items
D2-D5 and D7 of the ROBINS-E tool). As all studies were
observational, the quality of overall evidence was very
low to moderate as per the GRADE criteria, however,
there were no significant concerns identified in the cer-
tainty assessments (Additional file1: TableS4).
Discussion
Study ndings
is meta-analysis synthesized epidemiological evidence
of the association between exposure to light at night
and allergic diseases. Both outdoor ALAN and night
shift work were found to be significantly associated with
higher odds of allergic diseases while we found a bor-
derline significant association between evening chrono-
type and allergic diseases. Light at night exposure had
Table 1 Characteristics of included studies considering the influence of light at night exposure on allergic diseases
Studies were listed in alphabetical order
Study Study design Country Population Exposure(s)
considered Outcome(s)
considered Quality assessment
Basnet et al. (2018)
[46]Cross-sectional Finland 6424 adults (FINRISK
study 2012) Chronotype Asthma Low risk of bias
Chen et al. (2022) [47] Cross-sectional China 10,409 primary
school children
(Shanghai Children’s
Allergy Study)
Chronotype Asthma, allergic rhini-
tis, and skin allergies Some concerns
for bias
Ferreira et al. (2022)
[48]Cross-sectional Brazil 1457 adolescents Chronotype Asthma Some concerns
for bias
Fischer et al. (2001)
[52]Cross-sectional Brazil 124 adult male print-
ing company workers Shift work Asthma, allergic rhini-
tis, and skin allergies High risk of bias
Haldar et al. (2020)
[49]Cross-sectional India 1684 adolescents
(PERFORMANCE
study)
Chronotype Asthma, allergic rhini-
tis, and skin allergies Low risk of bias
Han and Chung
(2020) [50]Cross-sectional South Korea 278,430 adolescents
(Korea Youth Risk
Behaviour Web-Based
Survey)
Chronotype Asthma Low risk of bias
Huang et al. (2021)
[53]Cross-sectional China 7411 automobile
manufacture workers
(Dongfeng-Tongji
Cohort Study)
and non-ferrous
metal smelting work-
ers (Hunan Chronic
Disease Cohort
Study)
Shift work Skin allergies Low risk of bias
Kim et al. (2020) [54] Cross-sectional South Korea 20,613 female nurses
(Korea Nurses’ Health
Study)
Shift work Skin allergies Some concerns
for bias
Lu et al. (2019) [55] Cross-sectional The Philippines 630 call center
and business out-
sourcing employees
Shift work Skin allergies High risk of bias
Maidstone et al.
(2021) [56]Cross-sectional UK 502,540 adults (UK
Biobank) Shift work Asthma Low risk of bias
Merikanto et al.
(2014) [51]Cross-sectional Finland 6089 adults (FINRISK
study 2007) Chronotype Asthma and allergic
rhinitis Low risk of bias
Tang et al. (2022) [45] Cross-sectional China 20,106 college
students Outdoor artificial
light at night Asthma, allergic rhini-
tis, and skin allergies Low risk of bias
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Depratoetal. BMC Medicine (2024) 22:67
remarkable associations with all major allergic diseases
such as asthma, allergic rhinitis, and skin allergies, and
the associations were stronger among youth than adults.
While studies from the Americas and Asia strongly sup-
ported a positive association between light at night expo-
sure and allergic diseases, European studies provided
mixed evidence.
e associations identified in the meta-analysis
between circadian misalignment and allergic diseases
are broadly consistent with previous narrative reviews
Circadian misalignment could take place due to phase
delays as a result of shifting towards night, particu-
larly because of a disrupted melatonin cycle [57–60].
Although the concept of “nocturnal asthma” was pro-
posed more than 50 years ago [61], several recent
reports have come up with more supportive evidence
of the involvement of circadian clocks in nocturnal
symptoms in asthma, primarily from laboratory inves-
tigations [31, 51, 62]. Apart from the only study on out-
door ALAN, studies investigating associations between
evening chronotype, and allergic diseases found a bor-
derline significant association (p = 0.07). is could
partly be because of the mixed population, i.e., youths
and adults, whereas in occupational studies on shift
work, a stronger association between light at night
and allergic diseases was observed [52–56]. Addition-
ally, the stronger association between light at night and
allergic diseases in youths indicates that circadian mis-
alignment might have a stronger influence on biologi-
cal function in this population compared to adults. is
might be explained by younger children typically being
more morning-oriented than adults [63–65], where a
sudden change of greater magnitude in phase transi-
tion may lead to greater health consequences among
this younger population. Lastly, studies have found
that geographical location plays an important role in
determining the circadian preference of an individual,
mainly because of natural daylight and cultural rea-
sons [66, 67]. Moreover, the prevalence of allergic dis-
eases differs across continents [68], all of which might
explain the intercontinental variation of the relation-
ships between light at night exposure and allergic dis-
eases we observed. Nevertheless, the number of studies
from Asia was much higher than studies published
Fig. 3 Association between light at night exposure and the odds of allergic diseases stratified by exposure type. Analyses were conducted
with an inverse-variance random-effects model. Each square represents the reported odds ratios in each original study, and the size of the square
represents the pooled weight that the study was given according to the sample size. The line through the square indicates the corresponding
confidence interval (CI). Diamonds represent the overall effect in pooled studies
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Depratoetal. BMC Medicine (2024) 22:67
from other continents, which might also explain the
variability in the associations.
e studies analyzed in this meta-analysis were hetero-
geneous, partly because of the nature of data integration
for the analysis. First, we calculated unadjusted ORs for
some studies while for other studies, we had to consider
adjusted ORs (minimally adjusted models). erefore, the
possibility of confounding effects of major determinants
such as age and sex could not be reflected in unadjusted
ORs. Further, several included studies had very large
sample sizes which could inherently influence statistical
calculations towards greater heterogeneity. We found lit-
tle publication bias for light at night and allergic disease
studies, mostly because there were comparatively fewer
studies with negative or null associations, presumably,
because of the uneven sample size of studies included in
this analysis. However, a similar result from our sensitiv-
ity analysis supports the notion that our findings were
not driven by publication bias.
Clinical andpublic health implications
e prevalence of allergic diseases, mainly respiratory
allergies such as asthma and allergic rhinitis, is increas-
ing globally at a rapid rate and is a major health con-
cern for children and adolescents. e management of
these diseases is often behavioral, such as changes in
lifestyle and diet. Younger generations have become
mostly night-oriented due to lifestyle or work-related
Fig. 4 Association between light at night exposure and the odds of allergic diseases stratified by type of allergic disease. Analyses were conducted
with an inverse-variance random-effects model. Each square represents the reported odds ratios in each original study, and the size of the square
represents the pooled weight that study was given according to the sample size. The line through the square indicates the corresponding
confidence interval (CI). Diamonds represent the overall effect in pooled studies
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Depratoetal. BMC Medicine (2024) 22:67
conditions and such phase delays are often detrimen-
tal to health. While experimental studies have pre-
sented a link between light at night mediated circadian
disruption and immunological manifestations of aller-
gic diseases [27, 69–71], simple physical modifica-
tions, such as changing indoor lighting to amber and
Fig. 5 Association between light at night exposure and the odds of allergic diseases stratified by type of allergic disease for a artificial light at night
exposure, b chronotype, and c shift work. Analyses were conducted with an inverse-variance random-effects model. Each square represents
the reported odds ratios in each original study, and the size of the square represents the pooled weight that the study was given according
to the sample size. The line through the square indicates the corresponding confidence interval (CI). Diamonds represent the overall effect
in pooled studies
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Depratoetal. BMC Medicine (2024) 22:67
switching computer or mobile screens to night mode
could help attenuate this detrimental relationship.
Investigations on the circadian rhythmicity of allergic
diseases also vouch for chronotherapy in allergic dis-
eases, i.e., timing medication based on the timing of
symptoms [72, 73]. is might present a more favora-
ble way of managing allergic diseases to some, while
potentially also reducing the dosage and over-reliance
of particular medications by patients although we must
be aware that the causal relationships between circa-
dian dysregulation and allergic diseases are still to be
established. It must be remembered that childhood
allergies can have serious health consequences at a
later stage in life if they remain untreated. erefore,
parents must be vigilant in ensuring their younger chil-
dren do not develop overly evening-oriented lifestyles
to minimize the possibility of over-exposure to light at
night. From an occupational perspective, certain pro-
fessions require night shift work (e.g., healthcare, first
response, law enforcement) which could predispose
potentially susceptible individuals to allergy-aggravat-
ing light at night exposure. Considering appropriate
physical, policy, or ergonomic controls (e.g., blue-light
filtering glasses, decreased use of blue-white lighting,
or reducing night shift work for individuals with severe
allergies) is critical in ensuring the well-being of indi-
viduals in these occupations.
Potential mechanisms
e circadian clock is an important regulator of allergic
reactions (29). Reports also suggest that most allergic dis-
eases follow circadian rhythmicity as some of the major
cellular functions in allergies such as mast cell activation
or epithelial barrier function are dependent on circadian
timing [26–28]. Although the physiological circadian var-
iation in atopic conditions or change in airway caliber in
asthma are directly controlled by central and peripheral
biological clocks rather than external environmental cues
such as light/dark cycles [74], little has been explored so
far about the roles of external environmental influences
on allergies and asthma. Two recent reports showed that
the airway eosinophils, fractional exhaled nitric oxide,
and volatile organic compounds in the exhaled breath of
patients with asthma follow circadian rhythmicity [30,
75], although the underlying mechanism is still not well
understood. Although some animal studies demonstrated
that circadian rhythm disruption could lead to systemic
allergic reactions such as allergic rhinitis in mice possi-
bly by elevating 2-like immune responses [76], human
studies in this area have not evolved significantly. In one
Fig. 6 Association between light at night exposure and the odds of allergic diseases stratified by age group. Analyses were conducted
with an inverse-variance random-effects model. Each square represents the reported odds ratios in each original study, and the size of the square
represents the pooled weight that the study was given according to the sample size. The line through the square indicates the corresponding
confidence interval (CI). Diamonds represent the overall effect in pooled studies
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 15
Depratoetal. BMC Medicine (2024) 22:67
recent study among 51 male rotating shift workers from
a car industry in Barcelona, Spain, investigators found
that night shift was associated with disruption of multi-
ple immune response pathways, which could link to an
altered allergic response [77], As ALAN, night shift work,
and eveningness are known to cause circadian disrup-
tion, a probable link between light at night exposure and
allergic diseases could be mediated through circadian
misalignment, which further connects to disruption in
melatonin homeostasis. Although typically considered
the sleep hormone, recent studies have focused on mel-
atonin for its immunomodulatory role, particularly in
asthma and allergic diseases, especially when the biologi-
cal clock is dysregulated or disrupted [78]. However, the
role of melatonin in asthma has remained unclear and
evidence as to whether melatonin acts as a pro- or anti-
inflammatory substance has been contradictory. More
studies are required to understand the potential mecha-
nisms of circadian misalignment in asthma and allergic
rhinitis.
It has been demonstrated that the physiological and
immunological functions of the skin follow circadian
rhythmicity. For example, skin hydration and bar-
rier function reach zenith during the daytime [34, 79],
while circulating naïve T-cells and pro-inflammatory
cytokines, such as interleukin (IL)-12 reach their peak
at night in adults [80, 81]. Skin integrity such as hydra-
tion and defense mechanisms is further regulated by
circadian CLOCK (Circadian Locomotor Output Cycles
Kaput) and BMAL1 (Basic Helix-Loop-Helix ARNT
Like 1) genes [82]. us, a circadian phase disruption
caused by ALAN, shift work, or eveningness could lead
to irregular expression of these circadian genes, and as
a result, the downstream functions of these genes are
greatly affected, leading to clinical conditions such as
atopic dermatitis [82]. Allergic skin conditions such
as atopic dermatitis and eczema are also influenced by
melatonin. Previous studies suggested that melatonin
offers a protective role in eczema by reducing circulat-
ing immunoglobulin (Ig)-E antibodies [78]. In a dou-
ble-blind randomized controlled study, children with
atopic dermatitis who received melatonin supplemen-
tation had a significantly improved disease condition
than those receiving a placebo [83]. us, melatonin
Fig. 7 Association between light at night exposure and the odds of allergic diseases stratified by continent. Analyses were conducted
with an inverse-variance random-effects model. Each square represents the reported odds ratios in each original study, and the size of the square
represents the pooled weight that the study was given according to the sample size. The line through the square indicates the corresponding
confidence interval (CI). Diamonds represent the overall effect in pooled studies
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 12 of 15
Depratoetal. BMC Medicine (2024) 22:67
suppression caused by exposure to light at night further
facilitates skin allergies.
Strengths andlimitations
is is the first meta-analysis of population-based studies
summarizing the associations between exposure to light
at night and allergic diseases. We have included multiple
studies among populations residing at various geological
locations and with differently measured exposures to light
at night. One of the major strengths of this review is that
included studies used standard measures of light at night
exposure, i.e., either by direct measurement of ALAN, by
job category (day vs. night shift work), or by standardized
questionnaires of morningness-eveningness. Secondly,
studies were available on both youth and adult popula-
tions, which minimizes the possibility of specific age-
dependent responses. Lastly, most studies had reliable
moderate-to-large sample sizes and well-described statis-
tical methodologies. One of the common weaknesses of
these studies is that their study participants belonged to
specifically selected groups of people of whom the expo-
sure to light at night was examined, except for some large
nationwide cohorts. Second, all studies included in this
analysis were cross-sectional, thus a causal interpretation
of study findings could not be made. ird, no included
studies considered more than one exposure to light at
night, and thus, we could not identify any synergistic
role of multiple exposures on allergic diseases. Fourth,
we found only one study on outdoor ALAN eligible for
inclusion in this study [45], therefore, we could not com-
pare it with other studies of similar exposure. Moreo-
ver, the said study did not have a reference group (group
without potential exposure to outdoor ALAN); therefore,
we could only compare the dose–response (high vs. low)
relationship of outdoor ALAN and could not compare
the net influence of outdoor ALAN on the allergic dis-
ease outcomes. is study focuses on outdoor ALAN
and data was assessed from satellite image (750m resolu-
tion), which could have a possible potential for exposure
misclassification. We need more studies on an individual
level and on indoor exposure (if participants have light-
blocking mechanisms this outdoor ALAN may not enter
participants’ bedrooms). Fifth, evening chronotype and
night shift work were used as a proxy for ALAN exposure
and might not be properly classified as ALAN exposure
regarding exposure assessment. It should be remembered
that there could be additional job-related exposures in
shift work such as shift duration, shift rotation, work
environment, job stress, and excessive workload, which
might impart additional risks for allergic diseases; there-
fore, more direct evidence of outdoor ALAN and allergic
diseases is needed. Sixth, we observed high heterogene-
ity in the included studies in regard to the estimates of
the associations between the exposure and the disease
of interest, which might be considered as a limitation of
this study. is high heterogeneity could be due to mul-
tiple factors such as study participants (children, youths,
or adults, different sexes, etc.), exposure types, dura-
tion and assessment, analytical models, and last but not
least, geographical locations; however, despite grouping
similar exposures and outcomes, the heterogeneity per-
sisted, which indicates involvement of possible residual
confounding in those studies. Additionally, as human
studies linking circadian rhythms and allergic diseases
are relatively fewer and mostly observational, it was not
possible to perform more in-depth sensitivity analyses
or dose–response analyses. Seventh, as all studies except
one [45] did not have a quantitative assessment of expo-
sure, we were unable to perform any dose–response
meta-analysis. Lastly, allergic diseases are greatly influ-
enced by several other social, environmental, and genetic
determinants [84–92], which were not taken into account
in most of the studies considered, and thus the possible
involvement of any mediators or effect modifiers such
as socioeconomic condition, air pollution, or parental
allergy could not be confirmed in this analysis.
Conclusions
In conclusion, this meta-analysis shows overall positive
associations between light at night exposure and aller-
gic diseases, especially for asthma and allergic rhinitis.
e association was stronger among youth than adults.
Although the possible mechanisms of such associations
have not been established yet, it is assumed from experi-
mental studies that phase delays may disrupt melatonin
rhythms, which may influence downstream immunological
pathways. More studies, preferably interventional in design,
are warranted to extend this research to reduce or protect
against light at night exposure and assess whether these
findings can be translated into changes in clinical practice
to improve care and treatment for allergic diseases.
Abbreviations
ALAN Artificial light at night
BMAL1 Basic Helix-Loop-Helix ARNT Like 1
CI Confidence interval
CLOCK Circadian Locomotor Output Cycles Kaput
GRADE Grading of Recommendations, Assessment, Development, and
Evaluation
IgE Immunoglobulin E
LED Light-emitting diode
OR Odds ratio
PECOS Population, exposure, comparison, outcome, and study design
framework
PR Prevalence ratio
PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses
ROBINS-E Risk of Bias In Non-randomized Studies – of Exposures
RR Relative risk
SE Standard error
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 13 of 15
Depratoetal. BMC Medicine (2024) 22:67
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12916- 024- 03291-5.
Additional le1: TableS1. Comprehensive strategy of the initial search
to identify studies considering the influence of light at night exposure on
allergic diseases. TableS2. Comprehensive strategy of the updated search
to identify studies considering the influence of light at night exposure
on allergic diseases. TableS3. Summary of meta-analyses considering
the association between light at night exposure and the odds of allergic
diseases. Fig. S1. Funnel plot of the exposure-specific meta-analysis for
the association between light at night exposure and the odds of allergic
diseases. Fig. S2. Funnel plot of the outcome-specific meta-analysis for
the association between light at night exposure and the odds of allergic
diseases. Fig. S3. Risk of Bias In Non-randomized Studies – of Exposures
(ROBINS-E) quality assessment of included studies considering the influ-
ence of light at night exposure on allergic diseases. TableS4. Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE)
criteria evidence table of meta-analyses considering the influence of light
at night exposure on the odds of allergic diseases.
Acknowledgements
None.
Authors’ contributions
The authors’ contributions to this work were as follows. AD: methodology,
formal analysis, investigation, data curation, and writing—original draft.
RM: conceptualization and writing—reviewing and editing. APC: concep-
tualization and writing—reviewing and editing. AA: conceptualization and
writing—reviewing and editing. PH: writing—reviewing and editing. BNH:
conceptualization and writing—reviewing and editing. PL: writing—reviewing
and editing and funding acquisition. LM: writing—reviewing and editing. SM1:
writing—reviewing and editing. JFN: writing—reviewing and editing. MK:
conceptualization and writing—reviewing and editing. HD: conceptualization
and writing—reviewing and editing. SM2: conceptualization, methodology,
writing—original draft, writing—reviewing and editing, supervision, and
project administration. All authors read and approved the final manuscript.
Authors’ Twitter handles
@Subha_Moitra (Subhabrata Moitra).
@robertmaidstone (Robert Maidstone).
@annapalomarc (Anna Palomar Cros).
@UAProfessor (Paige Lacy).
@KogevinasM (Manolis Kogevinas).
@h_durrington (Hannah Durrington).
Funding
AD received a summer studentship award from the Northern Alberta Clinical
Trials and Research Centre, Alberta, Canada. This work was partially supported
by a grant from Synergy Respiratory and Cardiac Care, Alberta, Canada to PL.
However, the study sponsors were not involved in the design of the study; the
collection, analysis, and interpretation of data; writing the report; or the deci-
sion to submit the report for publication.
Availability of data and materials
We did not create any new data for this manuscript. All data associated with
the manuscript were previously published and can be accessed from the
respective journals.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
All authors provided consent for publication.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Alberta Respiratory Centre and Division of Pulmonary Medicine, University
of Alberta, Edmonton, AB, Canada. 2 Michael G. DeGroote School of Medi-
cine, McMaster University, Hamilton, ON, Canada. 3 Division of Immunology,
Immunity to Infection, and Respiratory Medicine, University of Manchester,
Manchester, UK. 4 Non-Communicable Diseases and Environment Programme,
Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain. 5 Department
of Experimental and Health Sciences, University of Pompeu Fabra (UPF), Barce-
lona, Spain. 6 Consortium for Biomedical Research in Epidemiology and Public
Health (CIBERESP), Carlos III Institute of Health, Madrid, Spain. 7 Department
of Clinical Psychology and Psychobiology, University of Barcelona, Barce-
lona, Spain. 8 Institute of Neurosciences, University of Barcelona, Barcelona,
Spain. 9 Department of Medical Laboratory Technology, Supreme Institute
of Management and Technology, Mankundu, India. 10 Synergy Respiratory
and Cardiac Care, Sherwood Park, Alberta, Canada. 11 Department of Allergy
and Immunology, Apollo Multispeciality Hospitals, Kolkata, India. 12 Depart-
ment of Psychobiology and Methodology of Behavioural Sciences, University
of Málaga, Málaga, Spain. 13 Hospital del Mar Medical Research Institute (IMIM),
Barcelona, Spain. 14 Canadian VIGOUR Centre, Department of Medicine, Univer-
sity of Alberta, Edmonton, AB, Canada.
Received: 30 October 2023 Accepted: 9 February 2024
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