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Sensitive Skin, Skin Care Products, and Cosmetics
Skin care and cosmetics used in subjects affected by sensitive skin should be carefully selected in order to have a good compliance and possibly promote skin health. Indeed, sensitive skin has been classified primarily as a local reaction after the application of a cosmetic product (1).
Cleansers
Appropriate skin care includes cleansing, moisturizing, and application UV protection to maintain healthy skin. UV protection consists of sun avoidance, UV-protective clothing, and sunscreens (2). Therefore, effective cleansers for eczema and sensitive skin should provide effective cleansing without compromising the barrier integrity, and cosmetic or therapeutic moisturizers should be indicated as an important adjunct to alleviate dryness of the skin and restore skin barrier function (3).
Washing twice daily with a classic alkaline soap (pH 10.2) reduces the thickness of the SC cell layers, with associated attrition of intercellular lipids causing dryness, desquamation, and barrier damage (4). In diseased skin such as in sensitive or atopic skin, special cleansing agents are recommended consisting of non-soap-based surfactants, synthetic detergents (syndets) with an acidic or neutral pH, and lipid-free cleansing lotions. New formulations also include cleansers restoring intercellular lipids by delivering ceramides or similar lipids after washing (5). In a study of skin irritation of six cleansing agents designed for sensitive skin, 60 patients used a bar and a lipid-free liquid cleanser in a paired-comparison design. Among the users of the bar soaps, 41% of the patients discontinued because of facial erythema. However, there were no discontinuations among patients using the nonsoap cleansing lotion, which was also rated as causing the least irritation (6). Lipid-free cleansing lotions contain fatty alcohols and are designed for sensitive or dry skin; lotion formulations can be removed without water (7). Lipid-free cleansers also contain emollients and/or humectants to cleanse while protecting the skin from moisture loss. The pH of a cleanser is also important; neutral or acid pH cleansers (about 5.5), close to the normal pH of the epidermis, are recommended. It has been suggested that alkaline cleansing agents contribute to the dehydration of the SC and dry skin and should be avoided (8,9). Furthermore, the preventing loss of SC hydration can help in improving barrier performance.
Water alone is not recommended for cleansing. Barrier function is not improved by using water alone without soap because water is a uniphase element and is not immediately absorbed into the skin (3).
Moisturizers
Therapeutic moisturizers are important in the management of the treatment, as they improve skin hydration, reduce susceptibility to irritation, and restore integrity of the SC. There are three types of moisturizers: humectants (urea, propylenglicol, dexpanthenol, lactic acid), which have a water-binding capacity; emollients (petrolatum, lanolin, oils), which have an occlusive film that retains water; and physiological or structural lipids (ceramides or fatty acids), which fill the intercellular lipid layer. An effective moisturizer would include humectants, for hydration, and structural lipids, for replenishing the skin (10). However, most of the randomized controlled studies in this area refer to moisturizers designed to be used for atopic patients; nevertheless, due to the similarity in barrier function and the clinical overlap between AD and sensitive skin, most of the results of these studies are also applicable to sensitive skin. In a study of 580 consecutive patients affected by irritant dermatitis or AD, a combined lipid mixture containing ceramides was useful in relieving dry skin and improving barrier function with or without concurrent steroid treatment (11). Similarly, in an uncontrolled trial of 24 children with AD, the patients were treated with a barrier-repair emollient containing ceramides twice daily for 12 weeks while continuing prior topical treatment. Almost all (n = 22) patients showed significant improvement within 3 weeks (12).
The benefits of long-term use of moisturizers include changes in skin barrier function (13). A study on the effects of a urea-containing moisturizer on the barrier properties of atopic skin found that the moisturizer improved the water barrier function (as reflected by TEWL) and significantly reduced skin susceptibility to SLS (14).
Sunscreens
Since sensitive skin is occurring mainly on the face, UV exposure should be avoided. Besides skin damage induced by UV (photoaging), it is well established that photoexposure can trigger the onset of sensitive skin-related dermatoses such as rosacea (15). Therefore, the use of topical sunscreen is recommended. This could be included in a moisturizing day cream or lotion in winter, with SPF of up to 20; in summer; or when in outdoor activities; SPF 50 is needed with repeated application every 2–3 hours or after swimming or beach activities. Protective clothing may be extremely useful in order to avoid repeated application of chemicals on the skin.
Other general recommendations for use of cosmetics in sensitive skin are shown below
• Use cosmetics and makeup that are easy to remove with water or mild detergents.
• Prefer light makeup and not too much occlusive.
• Prefer makeup with sunscreen included.
• Prefer cosmetics tested for nickel and other heavy metals.
• Avoid cosmetics with preservatives and fragrances.
• Choose cosmetics with simple formulations, possibly with less than 10 ingredients.
• In case of very sensitive skin, test your cosmetic prior to regular use for a few days on the forearm.
REFERENCES
1. Kligman AM, Sadiq I, Zhen Y et al. Experimental studies on the nature of sensitive skin. Skin Res Technol 2006; 12(4): 217–22.
2. Burr S, Penzer R. Promoting skin health. Nurs Stand 2005 May 18–24;19(36):57–65.
3. Cheong WK. Gentle cleansing and moisturizing for patients with atopic dermatitis and sensitive skin. Am J Clin Dermatol 2009; 10 Suppl 1: 13–7.
4. White MI, Jenkinson DM, Lloyd DH. The effect of washing on the thickness of the stratum corneum in normal and atopic individuals. Br J Dermatol 1987; 116(4): 525–30.
5. Solodkin G, Chaudhari U, Subramanyan K et al. Benefits of mild cleansing: Synthetic surfactant based (syndet) bars for patients with atopic dermatitis. Cutis 2006; 77(5): 317–24.
6. Mills OH, Berger RS, Baker MD. A controlled comparison of skin cleansers in photoaged skin. J Geriatr Dermatol 1993; 1: 173–9.
7. Bikowski J. The use of cleansers as therapeutic concomitants in various dermatologic disorders. Cutis 2001 December; 68(5 Suppl): 12–9.
8. Ananthapadmanabhan KP, Lips A, Vincent C et al. pH-induced alterations in stratum corneum properties. Int J Cosmet Sci 2003 June; 25(3): 103–12.
9. Fluhr JW, Kao J, Jain M, Ahn SK, Feingold KR, Elias PM. Generation of free fatty acids from phospholipids regulates stratum corneum acidification and integrity. J Invest Dermatol 2001 July; 117(1): 44–51.
10. Loden M. The clinical benefit of moisturizers. J Eur Acad Dermatol Venereol 2005 November; 19(6): 672–88.
11. Berardesca E, Barbareschi M, Veraldi S, Pimpinelli N. Evaluation of efficacy of a skin lipid mixture in patients with irritant contact dermatitis, allergic contact dermatitis or atopic dermatitis: A multicenter study. Contact Dermat 2001; 45(5): 280–25.
12. Chamlin SL, Kao J, Frieden IJ et al. Ceramide-dominant barrier repair lipids alleviate childhood atopic dermatitis: Changes in barrier function provide a sensitive indicator of disease activity. J Am Acad Dermatol 2002 August; 47(2): 198–208.
13. Buraczewska I, Berne B, Lindberg M, Torma H, Loden M. Changes in skin barrier function following long-term treatment with moisturizers, a randomized controlled trial. Br J Dermatol 2007 March; 156(3): 492–8.
14. Loden M, Andersson AC, Lindberg M. Improvement in skin barrier function in patients with atopic dermatitis after treatment with a moisturizing cream (Canoderm). Br J Dermatol 1999 February; 140(2): 264–7.
15. Berardesca E, Iorizzo M, Abril E, Guglielmini G, Caserini M, Palmieri R, Pierard GE. Clinical and instrumental assessment of the effects of a new product based on hydroxypropyl chitosan and potassium azeloyl diglycinate in the management of rosacea. J Cosmetic Dermatol 2012; 11(1): 37–41.
