Sensitive skin

What is sensitive skin?

Sensitive skin (also known as sensitive skin syndrome) describes a skin type that is easily irritated and has a reduced tolerance to topical products.

A definition of sensitive skin was created by a special interest group on sensitive skin at the International Forum for the Study of Itch (IFSI):

“A syndrome defined by the occurrence of unpleasant sensations (stinging, burning, pain, pruritus, and tingling sensations) in response to stimuli that normally should not provoke such sensations. These unpleasant sensations cannot be explained by lesions attributable to any skin disease. The skin can appear normal or be accompanied by erythema. Sensitive skin can affect all body locations, especially the face.”

Who gets sensitive skin?

Sensitive skin is highly prevalent globally and reported in roughly 60-70% of women and 50-60% of men.

Epidermal thickness is observed to be greater in males than in females, which may explain the higher prevalence of sensitivity among women. However, irritant testing finds essentially no differences in reactivity. Additionally, women tend to use more products, especially on the face, thereby increasing potential triggering exposures.

Factors associated with sensitive skin include:

• Fitzpatrick skin phototype I
• Underlying dermatoses that disrupt the skin barrier function (see differential diagnosis section below)
• Irritable bowel syndrome and eye sensitivity.

What causes sensitive skin?

Sensitive skin is strongly associated with a disrupted skin barrier and neurosensory dysfunction.

An altered skin barrier is vulnerable to penetration by external factors, inadequately protects nerve endings, and allows access to antigen-presenting cells of the immune system, increasing the risk of developing atopy. For more information, see: Skin barrier function

Neurosensory perturbations can result in hyperactivity of sensory neurons responsible for pain, itch, and temperature sensation, as well as an exaggerated inflammatory cascade in response to triggers.

Epidermal alterations in people with sensitive skin include:

• Altered trans-epidermal water loss
• Thin and/or dehydrated stratum corneum
• Reduced lipids and ceramides
• Increased sweat glands.

Changes to neurosensory function can include:

• Reduction in intraepidermal nerve fibre density (peptidergic C-fibres), which is seen with small-fibre neuropathy
• Increased activation of transient receptor potential vanilloid 1 (TRPV1), an ion channel on sensory nerve terminals that triggers the release of neuropeptides (eg, substance P) that drive inflammation.

Sensitive skin is exacerbated by various triggers, such as:

• Skin irritants, of which wet work is the most important
  • Skin irritation is usually the result of cumulative exposure to multiple mild irritants
  • Other common irritants include cosmetics, soaps and cleansers, fragrances, alpha hydroxy acids, preservatives (eg, formalin, paraben, quaternium-15)
• Irritating body fluids such as sweat, urine, and faeces
• Certain medications eg, increased photosensitivity with macrolide or retinoid use
• Environmental factors such as heat, cold, low humidity, air pollution, and ultraviolet light
• Mechanical factors such as friction (eg, excessive exfoliation or clothing), pressure, vibration, and occlusion
• Hormonal change, including menopause
• Diet and nutrition, including alcohol intake
• Psychological stress.

Various skin disorders also increase skin sensitivity — see the differential diagnosis section below.

What are the clinical features of sensitive skin?

Individuals with sensitive skin typically report unpleasant symptoms such as stinging, itching, and burning that appear out of proportion to physical findings. Symptoms can range from mild to severe.

Visible skin changes may include redness, dryness, scaling, peeling, papules, pustules, comedones, and hives.

The face and intertriginous areas (eg, axillae, groin, and genitals) are particularly prone to developing sensitivity as the skin there is thinner. Products that are tolerated on other body sites can cause irritation and rashes when applied to these areas.

What are the complications of sensitive skin?

• Secondary bacterial infection due to barrier disruption and scratching
• Reduced adherence to necessary topical therapy (eg, sunscreen, acne treatment, topical corticosteroids) where the vehicle or active ingredient triggers symptoms
• Negative psychosocial impact eg, anxiety around product selection, avoidance of social or occupational situations

How is sensitive skin diagnosed?

Sensitive skin is usually a self-reported problem and can be diagnosed clinically after excluding other underlying dermatoses. Methods to quantify sensitive skin include a lactic acid sting test (LAST), diagnostic questionnaires, and stratum corneum sampling to assess levels of natural moisturising factors and lipid profiles.

What is the differential diagnosis for sensitive skin?

The following disorders are both differentials and underlying drivers of skin sensitivity:

• Acne
• All types of dermatitis eg, irritant contact dermatitis (ICD), allergic contact dermatitis, atopic dermatitis
• Aquagenic pruritus
• Carcinoid syndrome
• Cutaneous dysaesthesia
• Cutaneous mastocytoses
• Dry skin
• Photodermatoses
• Rosacea
• Urticaria.

What is the treatment for sensitive skin?

Treatment of sensitive skin generally involves managing any underlying skin condition and avoiding known triggers.

Other skin care and general measures:

• Use soap-free cleansers
• Apply non-irritating emollients and moisturisers regularly
• Practice good sun protection with clothing, hats, and a broad-spectrum sunscreen.
• Avoid harsh cosmetic products such as chemical and mechanical exfoliants
• Avoid long hot showers, and apply emollient to damp skin after showering
• Avoid fragranced products eg, laundry detergent, personal care products, hand soaps; instead opt for fragrance-free formulations
• Wear soft, non-irritating clothing
• Limit wet work and wear cotton gloves under waterproof kitchen gloves
• Perform open application tests on new topical products on a small area before full-face or full-body use; introduce one new product at a time.