Historical Context of Skin Sensitivities 

Sensitive skin syndrome (SSS) is driven by a range of subjective sensations experienced by patients, which make it difficult to quantify.¹

• The conditions of “sensitive skin” were first described by dermatologists in the 1970s as a reaction to cosmetics and initially believed to be an unusual reaction in a small subset of individuals^2-4
• The conditions were fully described by Maibach in 1987 under the name cosmetic intolerance syndrome (CIS)^2,5
• Recent studies have shown that individuals with sensitive and reactive skin conditions may represent more than half the global population^3,6
• SSS is now defined by set of heterogeneous conditions and backed by a growing amount of scientific literature^5,7

References:

1. Misery L, et al. Int J Dermatol. 2011;50(8):961-967. 2. Maibach HI, et al. Clin Dermatol. 1988;6(3):102-107. 3. Misery L, et al. Acta Derm Venereol. 2017;97(1):4-6. 4. Farage MA. Front Med (Lausanne). 2019;6:98. 5. Duarte I, et al. An Bras Dermatol. 2017;92(4):521-525. 6. Misery L, et al. Front Med (Lausanne). 2020;7:159. 7. Talagas M, et al. Front Med (Lausanne). 2019;6:108.

Defining Sensitive Skin Conditions ​

Sensitive skin is a condition with a high global prevalence, but it remains difficult to define and diagnose^1-4

• Although many people describe themselves as having sensitive skin, there has been little global medical consensus about what it is and how it occurs^5,6
• “Sensitive skin” refers to skin that is more prone to inflammation, but diagnosing complex symptoms creates a clinical challenge for dermatologists and other skin care professionals^3,7
• “Unpleasant responses to stimuli that shouldn’t provoke such reactions” is the basis for the current understanding and definition of sensitive skin developed by a special interest group of the International Forum for the Study of Itch (IFSI) in 2017, and the definition is used to separate it from other skin disorders or diseases^3,7

“Sensitive skin is clinically defined by characteristic sensory perceptions including tightness, abnormal stinging, burning,

tingling, pain and pruritus. Although often transient, and in many cases unaccompanied by visual dermatological responses, sensitive skin affects the quality of life.” ⁵

      —Misery L, et al, 2016

Reference:

1. Guerra-Tapia A, et al. Actas Dermosifiliogr (Engl Ed). 2019;110(10):800-808. 2. Farage MA. Front Med (Lausanne). 2019;6:98. 3. Misery L, et al. Acta Derm Venereol. 2017;97(1):4-6. 4. Do LHD, et al. Am J Clin Dermatol. 2020;21(3):401-409. 5. Misery L, et al. J Eur Acad Dermatol Venereol. 2016;30(suppl 1):2-8. 6. Misery L, et al. J Eur Acad Dermatol Venereol. 2018;32(12):2217-2223. 7. Duarte I, et al. An Bras Dermatol. 2017;92(4):521-525

Pathogenesis of Skin Sensitivities 

Skin sensitivities mainly occur in response to exogenous stimuli (physical, thermal, and chemical) but can also be endogenous (psychological or hormonal)^1,2

• Many factors can lead to sensitive skin, with growing evidence indicating that it may be related to genetics³
• Weather, environment, and reactions to chemical stimuli, including cosmetics and fragrances, that contact the skin are the main drivers that trigger skin sensitivities^4,5
• Rashes or irritations from clothing or friction can also cause allergic reactions with skin sensitivities^5-7

Reference:

1. Talagas M, et al. Front Med (Lausanne). 2019;6:108. 2. Misery L, et al. Int J Dermatol. 2011;50(8):961-967. 3. Wu Y, et al. J Drugs Dermatol. 2021;20(4):s17-s22. 4. Misery L, et al. J Eur Acad Dermatol Venereol. 2016;30(suppl 1):2-8. 5. Farage MA. Front Med (Lausanne). 2019;6:98. 6. Berardesca E, et al. Int J Cosmet Sci. 2013;35(1):2-8. 7. Misery L, et al. J Eur Acad Dermatol Venereol. 2018;32(12):2217-2223.

Mechanism of Disease: Impaired Skin Barrier Function

Skin sensitivities mainly occur in response to exogenous stimuli (physical, thermal, and chemical) but can also be endogenous (psychological or hormonal)^1,2

• An impaired barrier function of the stratum corneum (the outermost layer of the epidermis) is one mechanism that drives skin sensitivities^1-3
• A disrupted epithelial barrier makes it easier for irritants or allergens to penetrate the skin and fails to adequately protect nerve endings just beneath the skin^1-4
• This reaction increases trans-epidermal water loss, which leads to pruritis, dryness, and irritation, which further damages the epithelial barrier and facilitates the penetration of more irritants^1-4

Mechanism of Disease: Nerve Responses

Recent research into the dysfunction of intra-epidermal nerve fibers (IENF) has explored the role of keratinocytes, nerve fibers, and sensory receptors in the pathophysiology of sensitive skin

The acceleration of nerve responses increases with the amount and pace of stimuli, and the lower sensitivity threshold means that more of those stimuli will provoke an inflammatory response that further exacerbates symptoms.^1,2

These mechanisms combine to create a cycle of dry, flaky skin and skin tightness that can have a significant impact on patient comfort and quality of life.^1-4

“Skin C-fibres are equipped with sensory neuroreceptors. Endothelin (ET) receptors and pain ⁄ cold ⁄ heat receptors of the transient receptor potential (TRP) family are candidates for inducing pain, burning, itch in sensitive skin. These sensory receptors are not only expressed on nerve endings, but also in keratinocytes, which may explain why sensitive skin responds to different environmental, physical and chemical factors limited to the skin and can be treated by appropriate cosmetics.” ² —Ständer S, et al, 2009

Reference: 

1. Talagas M, et al. Front Med (Lausanne). 2019;6:108. 2. Ständer S, et al. Exp Dermatol.2009;18(5):417-423. 3. Farage MA. Front Med (Lausanne). 2019;6:98. 4. Misery L, et al. J Eur Acad Dermatol Venereol. 2016;30(suppl 1):2-8.  

Clinical Challenges and Diagnostic Tools

Diagnosis of sensitive skin is a complex challenge for dermatologists^1,2

Clinical Challenges in Managing Sensitive Skin

1. Symptoms and severity measurements of sensitive skin are typically self-reported (subjective) and out of proportion to what is visible upon objective clinical observation.^2-4
2. Patients may complain of severe facial irritation, burning, or stinging after using a particular cosmetic product, but they do not have the physical signs of scaling, induration, or erythema that you might expect in skin diseases. In many cases, the skin appears normal^.1-3
3. Sensitive skin can affect all body locations but is especially common on the face. Researchers have also found hand, scalp, foot, neck, torso, and back sensitivity as well as sensitivity of the genital skin.^2-5

Diagnostic Tools

The Burden of Sensitive Skin (BoSS) questionnaire has become a reliable clinical tool to evaluate the burden of disease caused by sensitive skin and is used in combination with other tests developed to treat patients with reported skin sensitivities.1,4 

To read more:

Misery L, Jourdan E, Abadie S, et al. Development and validation of a new tool to assess the Burden of Sensitive Skin (BoSS). J Eur Acad Dermatol Venereol. 2018;32(12):2217-2223. doi:10.1111/jdv.15186

https://onlinelibrary.wiley.com/doi/epdf/10.1111/jdv.15186

Disease Burden

“Objectively measurable signs of irritation are not always present in individuals with sensitive skin; however, subjective sensory effects, such as itching, burning, stinging, tightness, and dryness, are consistently present.”¹ —Farage MA, 2019

GLOBAL REPORTS OF SKIN SENSITIVITIES BY SEX 

50%–60% Men¹ ~60%–70% Women¹

• Skin sensitivities are more frequent in women than in men^1,2
• More women report “very sensitive” skin, and more men report
• “slightly sensitive” skin. The high number of products for facial skin made for women, the thickness of the epidermis on the face, and higher density of nerves on the face may provide an explanation for greater sensitivity among women^1-4
• Sensitive skin can affect any person, of any age, in any location around the world^1-3
• The gap between men and women may be closing. As skin care and personal grooming products specifically for men become more common, male consumers will likely focus more on skin condition¹
• There is no clear consensus on whether ethnicity differences play a role in skin sensitivity. Skin types and ethnicity are known to include pronounced differences in skin structure; however, no racial differences in innervation on an architectural or biochemical level have been observed. There have been notable cultural findings^4-7
• China, for instance, shows a lower perception of skin sensitivity, owing largely to cultural differences. Mexico also has a relatively low prevalence of subjects from the general population claiming sensitive skin^1,3,6
• Fair skin phototypes are more commonly associated with self-reported sensitive skin compared with darker skin phototypes^1,3,7,8

Reference:

1. Farage MA. Front Med (Lausanne). 2019;6:98. 2. Misery L, et al J Eur Acad Dermatol Venereol. 2018;32(12):2217-2223.  3. Berardesca E, et al. Int J Cosmet Sci. 2013;35(1):2-8. 4. Farage MA, et al. Contact Dermatitis. 2006;55(1):1-14. 5. Duarte I, et al. An Bras Dermatol. 2017;92(4):521-525. 6. Do LHD,
et al. Am J Clin Dermatol. 2020;21(3):401-409. 7. Misery L, et al. Int J Dermatol. 2011;50(8):961-967.
8. Polena H, et al. Acta Derm Venereol. 2021;101(11):adv00606.

Caring for Skin Sensitivities 

“After [diagnosis], clinicians [should] start educating patients about the risk of occurrence and the behavioral changes that will help alleviate symptoms.”¹ —Do LHD, et al, 2020 

Tips for the management of sensitive skin^2-5

• Sensitive skin is not a sign of a serious skin condition.
• Apply the smallest possible number of cosmetic products. Choose those intended for “sensitive skin.”
• Choose fragrance-free formulations.
• Avoid soaps.
• Use nonrinsing cleansing lotions or thermal spring water spritzers.
• Do not forget to thoroughly dry the area by gently patting with a paper tissue (do not use cotton or wool).
• Choose moisturizing creams with a mild texture or even cold creams or cerates.
• In case of exposure to air conditioning or to overly heated environments, do not hesitate to reapply these creams several times per day.
• Choose hair products without irritating tensio-active surfactants.
• Avoid skin-cleansing and exfoliating masks.
• Avoid applying products containing AHA or retinaldehyde.
• If any cosmetic product application is responsible for burning and discomfort, discontinue use immediately.
• Protect skin from temperature changes, sunlight, wind, and exposure to heat.
• Consumption of alcohol must be limited as much as possible.
• Observe whether the skin is more irritable after intake of coffee or spices.
• If necessary, treat depression and neuropsychiatric signs.
• After 3 to 6 months’ avoidance of skin care products, progressively reintroduce cosmetic products one by one and at intervals of 1 or 2 weeks.

Remember that a recurrence is always possible.

AHA = alpha hydroxy acid

Reference:

1. Do LHD, et al. Am J Clin Dermatol. 2020;21(3):401-409. 2. Misery L, et al. J Eur Acad Dermatol Venereol. 2016;30(suppl 1):2-8. 3. Guerra-Tapia A, et al. Actas Dermosifiliogr (Engl Ed). 2019;110(10):800-808. 4. Pons-Guiraud A, et al. J Cosmet Dermatol. 2004;3(3):145-148. 5. Escalas-Taberner J, et al. Actas Dermosifiliogr. 2011;102(8):563-571.