Introduction
Sensitive skin (SS), a subjective syndrome of cutaneous hyperreactivity to otherwise innocuous stimuli, affects approximately 40-50% of the population. Increased stratum corneum permeability, hyperactivity of intraepidermal nerve fibers, and sensitization of transient receptor potential vanilloid 1 (TRPV1) channels contribute to the lower sensitivity threshold and neurosensory discomfort of SS, however, pathophysiology is incompletely understood.1,2 SS manifests as dry, easily irritated skin (commonly on the face) with reactive erythema, pruritis, burning, tightness, or stinging. There is limited data on SS management to guide clinical decision-making and no consensus on best approach. Despite these challenges, dermatologists should be equipped to encounter SS; individuals with SS are more likely seek dermatology care and more likely to rely on medical advice for skincare product purchases than those without SS.3 Herein, we present a practical approach to the patient with SS and briefly highlight novel treatments using current evidence in the literature.
SS should be considered a diagnosis of exclusion; other dermatoses that increase skin sensitivity (Table 1) must be identified and appropriately treated if present. Patients initially presenting with SS should discontinue all topical products for two weeks, then undergo dermatologic evaluation. If SS is still suspected, products can be gradually tested and reintroduced with emphasis on identifying triggers for reactivity. SS may be triggered by lifestyle-related (cosmetics, products, foods, alcohol), environmental (pollution, UV exposure, heat, weather), or endogenous (psychological factors, hormonal changes, stress) factors.1 Patients should develop a list of triggers and
minimize exposures.4,5 Sensitive Scale-10 (SS-10), a validated scale measuring severity of SS,6 can be used to establish a baseline and track symptoms longitudinally.
During acute periods of SS reactivity, severe neurosensory discomfort can be managed with topical calcineurin inhibitors (TCIs). TCIs' anti-inflammatory and anti-pruritic effects occur through inhibition of calcineurin-dependent T-cell activation, reducing pro-inflammatory cytokines. Calcineurin inhibition also paradoxically favors activation of TRPV1, a channel perpetuating neurogenic inflammation.7 This explains the initial irritating effect of TCI application, while eventual channel desensitization allows for soothing effects of prolonged use.8 SS, associated with TRPV1 sensitization, benefits from this long-term mechanism; application of pimecrolimus 1% cream significantly reduces pruritis and burning sensations in SS patients.9
Long-term management of SS necessitates daily skincare that improves skin hydration, increases stratum corneum integrity, and decreases susceptibility to irritants.10-12 Fundamental SS skincare routines include mild cleanser, moisturizer, and sun protection.13 Preferred cleansers have a pH near physiological skin and contain emollients. Patients should avoid facial washing with water or soap to limit excessive removal of lipids and natural moisturizing factors.14 Optimal moisturizers contain humectants (eg: glycerin, hyaluronic acid, aloe vera) and emollients (ceramides, plant oils).1 Lastly, daily sunscreen should be broadspectrum, SPF 30 or greater, and include inorganic UV filters (titanium dioxide, zinc oxide) due to lower allergenic potential.11 All formulations should be fragrance-free, hypoallergenic, and non-irritating. Active ingredients in skincare products can be tailored to target symptoms of SS. There is currently no federal or legal standard regulating ingredients in products marketed for SS,15 and many lack testing in SS specifically. Therefore, understanding of the specific active ingredients in sensitive skincare and their utility in related conditions can aid product counseling. We review the evidence for common active ingredients in SS products in Table 2. The best products will likely involve a synergistic effect of several ingredients.
Sensitive skin (SS), a subjective syndrome of cutaneous hyperreactivity to otherwise innocuous stimuli, affects approximately 40-50% of the population. Increased stratum corneum permeability, hyperactivity of intraepidermal nerve fibers, and sensitization of transient receptor potential vanilloid 1 (TRPV1) channels contribute to the lower sensitivity threshold and neurosensory discomfort of SS, however, pathophysiology is incompletely understood.1,2 SS manifests as dry, easily irritated skin (commonly on the face) with reactive erythema, pruritis, burning, tightness, or stinging. There is limited data on SS management to guide clinical decision-making and no consensus on best approach. Despite these challenges, dermatologists should be equipped to encounter SS; individuals with SS are more likely seek dermatology care and more likely to rely on medical advice for skincare product purchases than those without SS.3 Herein, we present a practical approach to the patient with SS and briefly highlight novel treatments using current evidence in the literature.
SS should be considered a diagnosis of exclusion; other dermatoses that increase skin sensitivity (Table 1) must be identified and appropriately treated if present. Patients initially presenting with SS should discontinue all topical products for two weeks, then undergo dermatologic evaluation. If SS is still suspected, products can be gradually tested and reintroduced with emphasis on identifying triggers for reactivity. SS may be triggered by lifestyle-related (cosmetics, products, foods, alcohol), environmental (pollution, UV exposure, heat, weather), or endogenous (psychological factors, hormonal changes, stress) factors.1 Patients should develop a list of triggers and
minimize exposures.4,5 Sensitive Scale-10 (SS-10), a validated scale measuring severity of SS,6 can be used to establish a baseline and track symptoms longitudinally.
During acute periods of SS reactivity, severe neurosensory discomfort can be managed with topical calcineurin inhibitors (TCIs). TCIs' anti-inflammatory and anti-pruritic effects occur through inhibition of calcineurin-dependent T-cell activation, reducing pro-inflammatory cytokines. Calcineurin inhibition also paradoxically favors activation of TRPV1, a channel perpetuating neurogenic inflammation.7 This explains the initial irritating effect of TCI application, while eventual channel desensitization allows for soothing effects of prolonged use.8 SS, associated with TRPV1 sensitization, benefits from this long-term mechanism; application of pimecrolimus 1% cream significantly reduces pruritis and burning sensations in SS patients.9
Long-term management of SS necessitates daily skincare that improves skin hydration, increases stratum corneum integrity, and decreases susceptibility to irritants.10-12 Fundamental SS skincare routines include mild cleanser, moisturizer, and sun protection.13 Preferred cleansers have a pH near physiological skin and contain emollients. Patients should avoid facial washing with water or soap to limit excessive removal of lipids and natural moisturizing factors.14 Optimal moisturizers contain humectants (eg: glycerin, hyaluronic acid, aloe vera) and emollients (ceramides, plant oils).1 Lastly, daily sunscreen should be broadspectrum, SPF 30 or greater, and include inorganic UV filters (titanium dioxide, zinc oxide) due to lower allergenic potential.11 All formulations should be fragrance-free, hypoallergenic, and non-irritating. Active ingredients in skincare products can be tailored to target symptoms of SS. There is currently no federal or legal standard regulating ingredients in products marketed for SS,15 and many lack testing in SS specifically. Therefore, understanding of the specific active ingredients in sensitive skincare and their utility in related conditions can aid product counseling. We review the evidence for common active ingredients in SS products in Table 2. The best products will likely involve a synergistic effect of several ingredients.
