The Spectrum of Sensitive Skin: Considerations for Skin Care in Vulnerable Populations

January 2019 | Volume 18 | Issue 1 | Supplement Individual Articles | 68 | Copyright © January 2019


Stacy S. Hawkins PhD and Vickie Foy BS

Unilever Research & Development, Trumbull, CT

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-,
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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. 50
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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.

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AUTHOR CORRESPONDENCE

Stacy S. Hawkins PhD stacy.hawkins@unilever.com