compared to Caucasian women (P=0.0005). Innervation density was 3.5-fold higher in Japanese non-stingers than stingers (P=0.022), but this was not observed in Caucasians.The Japanese cheek site was more sensitive to hot pain (P=0.001) than Caucasians. Japanese stingers were more sensitive to von Frey hairs (P less than 0.05) and cold pain (P less than 0.05) than non-stingers. No sensory differences were observed in Caucasian sub-populations.No correlations between PGP9. 5 staining density and QST data were found in Caucasians or their sub-populations. Japanese subjects as a whole showed that an increasing amount of nerve fibers had a lower cold sensation threshold (felt cold at a lower temperature) (r=-0.56; P=0.006). Japanese stingers with an increasing amount of nerve fibers had a lower cold sensation threshold (felt cold at a lower temperature), which was not seen in non-stingers (r=-0.60; P=0.01). Japanese non-stingers with an increasing amount of nerve fibers had a higher hot pain threshold, which was not seen in stingers (r=0.86, P=0.03).This study demonstrated that nerve fiber type, distribution and expression of receptors may play an important role in determining sensory response. A separate study on Japanese subjects showed that the cheek site showed greater nerve innervation compared to a hairline site. 25 Baby Skin The infant skin barrier formation begins in utero. Recent research has shown that infants with elevated transepidermal water loss two days after birth are more likely to develop atopic dermatitis. 30-32 Further, during early skin maturation and barrier development, infant skin is more vulnerable to chemical damage, microbial infection, and skin diseases, which can develop into longer-term health issues of greater consequence. 33 There are several structural and functional differences between infant skin compared to adult skin. Stamatas et al. showed structural differences in infants compared to adults included smaller corneocytes, a thinner stratum corneum and epidermis, and denser microrelief lines, which could all be factors in faster transport of an external irritant through the skin and faster loss of hydration to maintain a healthy skin barrier. 34 There are also compositional and functional differences in the infant skin barrier compared to adult skin such as decreased NMFs, sebum, and lipid to protein ratio, as well as high transepidermal water loss and rate of water absorption. 32,34-36 Very young infants also show lower diversity in the skin microbiome compared to adult skin.37 The clinical consequence of this could leave young infants less able to resist environmental alterations and chemical or physical irritants.When matching the same body sites on arms and legs for adults compared to infants, transepidermal water loss is much higher in infants compared to adults (Figure 5).Although the severity may vary between infants and sensitive skin adults, there is a similar vulnerability between the two groups in terms of decreased NMFs, elevated TEWL, and increased permeability to exogenous factors, compared to healthy adult skin. ‘Prone’ Skin (Eczema, Acne, Rosacea, etc.) Although no agreed definitions exist for ‘prone’ skin (eczema-,
acne-, and/or rosacea-prone), common standards reference either a previous diagnosis of the condition by a physician and/ or a familial/genetic predisposition for the disease. A common symptom across all three conditions is inflammation and erythema, although the nature of this varies across subtypes, and dryness and itch with eczema- and rosacea-prone skin. 18 Acne-prone skin is common in adolescents and young adults, and to a lesser degree as late-onset or adult-onset in women in their 30s and 40s. Adjuvant products for acne-prone skin include products for the reduction of sebum production, pore cleansing/unclogging, bacteria removal, and reduction of inflammation and redness. 18 Mild cleansing and moisturization has been previously shown to improve skin barrier and overall skin condition. 38-40 Rosacea is a chronic condition that primarily affects the central face, and most commonly occurs in adults from 30s onward. Although the cause is as yet unknown, common facial signs linked to rosacea include flushing/blushing and persistent inflammation, erythema, telangiectasia, coarseness of skin, and an inflammatory papulopustular eruption resembling acne. 41 People with rosacea-prone skin typically see increased symptoms or flare-ups with common triggers such as changing environmental conditions, drinking hot or caffeinated beverages, exercise, consuming spicy foods or alcohol, stress, topical products that irritate the skin, etc. 41 Recent research includes identifying genomic regions potentially associated with rosacea symptom severity, 42 and genetic loci associated with rosacea. 43 Typical topical products for rosacea-prone skin include mild cleansers intended for sensitive skin use and skin barrier repair facial lotions.Eczema-prone individuals typically experience symptoms such as moderately to severely dry, red, itchy and inflamed skin. Eczema is more common in infants and young children but can also occur in adults with no prior history of childhood eczema. Most eczema-prone individuals have experienced moderate to severe symptoms of itch, which can lead to excessive scratching and further disruption of the skin barrier. Typical topical products for eczema-prone individuals include mild cleansers and barrier repair moisturizers. In addition, moisturizers that provide longer-lasting hydration throughout the day are more effective for alleviating symptoms and preventing triggers with changing environmental conditions throughout the day than those intended for instant moisturization benefits only.The symptoms of erythema, inflammation, and dry skin itch can have a dramatic effect on QoL, for example discomfort with associated symptoms, functional capabilities, and social interactions, 44,45 as well as mental well-being, 46 perceived stress, 47 and self-esteem. 48 There are important learnings from the compatibility of cosmetic products for daily use with diseased skin – for example, to minimize dryness and redness either in frequency or severity of symptoms. In recent studies, a mild non-foaming face cleanser with a low level of non-ionic surfactant and fatty acids was compatible for daily use in patients with rosacea using topical metronidazole.49 When the only change to daily regimens was the replacement of the patients’ normal cleansers with the mild non-foaming face cleanser, 96% of patients showed improvement or remained unchanged in dermatologist-assessed erythema and dryness, and subjective evaluation of tightness, irritation, and tingling was significantly reduced (P<0.05). Subjects also noticed significant improvement to skin smoothness following the switch to the non-foaming face cleanser.Similarly, a mild syndet bar intended for sensitive skin has been shown to be compatible for daily use in patients with acne and rosacea.36 In the acne group, 75% of subjects indicated they would prefer to use the mild syndet bar in place of their usual cleanser and the bar was well tolerated in both patient populations.These studies in diseased skin state highlight the importance of cleanser selection, to ensure the skin barrier is not further compromised. Aging/Xerotic Skin Dry, itchy, senile xerotic skin is associated with decreases in stratum corneum (SC) lipid levels with aging, especially ceramide levels, reduced desquamation, and epidermal turnover. 50,51 In addition, with aging/xerotic skin there is a decline in SC natural moisturizing factor (NMF) levels, which impacts SC water holding capacity.In the dermis, dermal proteins (predominantly elastin and collagen), proteoglycans [PGs] and glycose aminoglycans [GAGs]) decrease with age, impacting the water-holding properties of the dermis. As a results of a more fragile skin barrier with aging, xerotic skin, TEWL is also elevated.Clinical signs can vary widely, including intense itching and pruritis, erythema, scaling, flaking due to abnormal desquamation, and cracking. Xerosis can progress to asteatotic eczema, where fissures and excoriation allow environmental irritants to penetrate the skin and cause inflammation, compromising the stratum corneum. 50 Similar to other sensitive skin subtypes, changes in the environment (eg, loss of humidity), harsh cleansers, chemical irritants, etc. can further exacerbate the condition. With the rise in the aging population, and the high prevalence of skin disorders in the elderly population, a good skin care regimen to maintain the fragile skin barrier is particularly important for this group. 5018
Implications for Skin Cleansing and Care While sensitive skin is multifactorial, and hence the underlying external or physiological triggers vary, there is a commonality in skin care to return the condition of the sensitive skin individual to a ‘balanced’, healthy skin barrier similar to a non-sensitive individual. Another commonality across subtypes is susceptibility of the skin barrier to irritation resulting in increased dryness, redness, and/or sting.Previous research has shown mild cleansing with sun protection and moisturizers that improve condition of the skin barrier is beneficial to subjects with self-perceived sensitive skin and a history of reactions to cosmetic products, a history of rosacea with an atopic background, or previous history of retinoid sensitivity. 52 With the advent of more personalization in skin care, it is expected that there will be continued improvement in clinical outcomes for sensitive skin sufferers, both from relief from symptoms as well as improvement to the skin barrier, which in turn will minimize the frequency and severity of symptoms.
While sensitive skin is multifactorial, and hence the underlying external or physiological triggers vary, there is a commonality in skin care to return the condition of the sensitive skin individual to a ‘balanced’, healthy skin barrier similar to a non-sensitive individual. Another commonality across subtypes is susceptibility of the skin barrier to irritation resulting in increased dryness, redness, and/or sting.Previous research has shown mild cleansing with sun protection and moisturizers that improve condition of the skin barrier is beneficial to subjects with self-perceived sensitive skin and a history of reactions to cosmetic products, a history of rosacea with an atopic background, or previous history of retinoid sensitivity.
The authors are employees of Unilever.
- Besne I, Descombes C, Breton L. Effect of age and anatomical site on density of sensory innervation in human epidermis. Archives Dermatol. 2002;138(11):1445-50.
- Saint-Martory C, Roguedas-Contios AM, Sibaud V, et al. Sensitive skin is not limited to the face. Br J Dermatol. 2008;158: 130-133.
- Aramaki J, Kawana S, Effendy I et al. Differences of skin irritation between Japanese and European women. Br J Dermatol. 2002;146(6):1052-6.
- Marriott M, Whittle E, Basketter DA. Facial variations in sensory responses. Contact Dermatitis. 2003;49(5):227-31.
- Marrakchi S, Maibach HI. Sodium lauryl sulfate-induced irritation in the human face: Regional and age-related differences. Skin Pharmacol Physiol. 2006;19(3):177-80.
- Marrakchi S, Maibach HI. Functional map and age-related differences in the human face: nonimmunologic contact urticaria induced by hexyl nicotinate. Contact Dermatitis. 2006;55(1):15-9.
- Foy V, Weinkauf R, Whittle E et al. Ethnic variation in the skin irritation response. Contact Dermatitis. 2001;45(6):346-9.
- Misery L , Loser K, Stander S. J Eur Acad Derm Venereol 2016;Jan (Supplement):2-8.
- Berardesca E, Fluhr JW, Maibach HI. Sensitive Skin Syndrome. Taylor & Francis CRC Press. 2006.
- Maibach HI. The cosmetic intolerance syndrome. Ear Nose Throat J. 1988;66:29-33.
- Inamadar AC, Palit A. Sensitive skin: An overview. Indian J Dermatol Venereol Leprol. 2013;79:9-16.
- Kligman AM. Human models for characterizing “sensitive skin”. Cosmet Dermatol. 2001;14:15-19.
- Kligman AM, Sadiq I, Zhen Y, et al. Experimental studies on the nature of sensitive skin. Skin Res Tech. 2006;12(4):217-222.
- Pons-Guiraud A. Sensitive skin: A complex and multifactorial syndrome. J Cosmet Dermatol. 2004;3:145-148.
- Frosch PJ, Kligman AM. A method for appraising the stinging capacity of topically applied substances. J Soc Cosmet Chem. 1977;28(5):197-209.
- deGroot A. Cutaneous hazards associated with the use of cosmetics. The environmental threat to the skin. London: Dunitz, 1992;173-176.
- Querleux B, Dauchol K, Jorrdain R, et al. Neural basis of sensitive skin: an fMRI study. Skin Res Tech. 2008;14:454-461.
- Baumann L. Understanding and treating various skin types: The Baumann Skin Type Indicator. Dermatol Clin. 2008;26:359-373.
- Misery L, Sibaud V, Merial-Keny C. Sensitive skin in the American population: prevalence, clinical data and the role of dermatologist. Int J Dermatol. 2011;50:961-967.
- Misery L, JEAN-Decoster C, Mery S, et al. A new ten-item questionnaire for assessing sensitive skin: the sensitive scale-10. Acta Derm Venereol. 2014;94:635-639.
- Escalas-Taberner J, González-Guerra E, Guerra-Tapia A, Sensitive skin: a complex syndrome. Actas Dermosifiliogr. 2011;102(8):563-571.
- Misery L, Myon E, Martin N, et al. Sensitive skin: Psychological effects and seasonal changes. J Eur Acad Dermatol Venereol. 2007;21:620-628.
- Harding CR, Watkinson A, Rawlings AV. Dry skin, moisturization and corneodesmolysis. Int J Cosmet Sci. 2000;22:21-52.
- Rawlings AV, Harding CR. Moisturization and skin barrier function. Dermatol Ther. 2004;17(Suppl. 1):43-8.
- Maddison B, Foy V, Civil J, et al. Japanese cheek skin has greater innervation and heightened sensory thresholds compared to hairline skin. Poster Proceedings in Int Fed Soc Cos Chem (IFSCC) 2008, Barcelona, Spain.
- Farage MA, Maibach HI. Sensitive skin: closing in on a physiological cause. Contact Dermatitis. 2010;62:137-149.
- Shingleton WD, Foy V, Maddison B, et al. Characterisation of changes in the stratum corneum. Poster Proceedings in Int Fed Soc Cos Chem (IFSCC) 2008, Barcelona, Spain.
- Aramaki J, Kawana S, Effendy I, Happle R, Loffler H. Differences of skin irritation between Japanese and European women. Br J Dermatol. 2002;146(6):1052-6.
- Maddison B, Foy V, Stocks J, et al. Differences in sensory and nerve fiber distribution at the cheek between ethnic (sub) populations. Poster Proceedings in Int Fed Soc Cos Chem (IFSCC) 2008, Barcelona, Spain.
- Horimukai K, Morita K, Narita M, et al. Transepidermal water loss measurement during infancy can predict the subsequent development of atopic dermatitis regardless of filaggrin mutations. Allergol Int. 2016;65: 103-8.
- Berents TL, Lødrup KC, Carlsen P, et al. Transepidermal water loss in infancy associated with atopic eczema at 2 years of age: a population-based cohort study. Br J Dermatol. 2017;177(3):e35-37.
- Kelleher M, Dunn-Galvin A, Hourihane JO, et al. Skin barrier dysfunction measured by transepidermal water loss at 2 days and 2 months predates and predicts atopic dermatitis at 1 year. J Allergy Clin Immunol. 2015;135:930-935.
- Oranges T, Dini V, Romanelli M. Skin physiology of the neonate and infant: clinical implications. Adv Wound Care. 2015;4(10):587-595.
- Stamatas GN, Nikolovski J, Mack MC, et al. Infant skin physiology and development during the first years of life: a review of recent findings based on in vivo studies. Int J Cos Sci. 2011;33(1):17-24.
- Nikolovski J, Stamatas G, Kollias N, Wiegand B. Barrier function and water-holding transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life. J Invest Dermatol. 2008;128:1728-1736.
- Johnson AW, Ananthapadmanabhan KP, Hawkins SS, et al. Bar Cleansers. In: Draelos, ed. Cosmetic Dermatology: Products and Procedures, 2nd edition, Wiley-Blackwell, 83-95.
- Capone K, Dowd SE, Stamatas GN, et al. Diversity of the human skin microbiome early in life. J Invest Dermatol. 2011;131:2026-2032.
- Isoda, K, Seki T, Inoue Y. Efficacy of the combined use of a facial cleanser and moisturizers for the care of mild acne patients with sensitive skin. J Dermatol. 2015;42:181-188.
- Mills OH, Berger RS. Defining the susceptibility of acne-prone and sensitive skin populations to extrinsic factors. Dermatol Clin. 1991;1:93-98.
- Schoelermann AM, Weber TM, Arrowitz C et al. Skin compatibility and efficacy of a cosmetic skin care regimen with licochalcone A and 4-t-butylcyclohexanol in patients with rosacea subtype I. J Eur Acad Dermatol Venereol. 2016;30(S1):21-7.
- Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148-155.
- Aponte JL, Chiano MH, Yerges-Armstrong LM, et al. Assessment of rosacea symptom severity by genome-wide association study and expression analysis highlights immuno-inflammatory and skin pigmentation genes. Hum Mol Gen. 2018 May 16. Doi: 10.1093/hmg/ddy184. [Epub ahead of print]
- Chang AL, Chung PI, Chen YJ, et al. Assessment of the genetic basis of rosacea by genome-wide association study. J Invest Dermatol. 2015;135:1548-1555.
- Seema P, Kini MD, DeLong LK, et al. The impact of pruritus on quality of life: the skin equivalent of pain. Arch Dermatol. 2011;147(10):1153-6.
- Desai NS, Poindexter GB, Monthrope YM, et al. A pilot quality-of-life instrument for pruritus. J Am Acad Dermatol. 2008;59:234-44.
- Tennant R, Hiller L, Fishwick R et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5:63.
- Cohen S, Kamarck T, and Mermelstein, R. A global measure of perceived stress. J Health and Soc Behav. 1983;24:386-396.
- Heatherton TF, Polivy J. Development and validation of a scale for measuring state self-esteem. J Pers Soc Psychol. 1991;60:895-910.
- Krisiak J, Hawkins S, Hermanson K. Compatibility and tolerability of a new non-foaming facial cleanser for subjects with rosacea. In: Amer Acad Derm Annual Meeting 2018, San Diego, CA, USA.
- Barr J. Skin matters: impaired skin integrity in the elderly. Ostomy Wound Manage. 2006;52(5).
- Rawlings A. The stratum corneum and aging. In: Textbook of Aging Skin Farage et al, eds., 2006:67-90.
- Hawkins S., Subramanyan K, Liu D, Bryk M. Cleansing, moisturizing, and sunprotection regimens for normal skin, self-perceived sensitive skin, and dermatologist-assessed sensitive skin. Dermatol Ther. 2004;17:63-68.