[Academic Presentation] Raising Awareness of Sensitive Skin

Article reprinted from: Chinese Medical Abstracts – Dermatology, Issue 1, 2017.

Author: He Li

Sensitive skin (SS) refers specifically to a state of heightened reactivity that occurs under physiological or pathological conditions, predominantly on the face. It has a high prevalence worldwide, though reported incidence rates vary considerably across different regions. Its etiology is complex, its pathogenic mechanisms remain incompletely understood, and it tends to recur, significantly impairing patients’ quality of life. Diagnosis of sensitive skin is characterized by reliance on subjective symptoms—such as burning, stinging, pruritus, and tightness—rather than objective clinical signs. In the past, the concept of sensitive skin was poorly defined, leading to frequent misdiagnosis or missed diagnosis and inappropriate management. Therefore, enhancing awareness and understanding of sensitive skin is essential.

1 Accurately defining sensitive skin

In the past, sensitive skin was poorly understood; some regarded it as a natural skin condition that did not warrant pharmacologic intervention or treatment, which sometimes led to its progression into more severe dermatoses such as allergic dermatitis. Others viewed it as a distinct skin disorder; however, skin diseases are abnormal physiological processes arising from disrupted homeostatic regulation under specific etiologic factors, and they can trigger a cascade of metabolic disturbances.

Changes in function and structure manifest as abnormalities in symptoms, signs, or behavior. Early‑stage sensitive skin may represent an adaptive stress response aimed at helping the body adjust to environmental conditions and can resolve spontaneously within a short period. Clearly, classifying it as a dermatological disorder is unscientific. The consensus statement provides a scientific definition of sensitive skin, emphasizing that its underlying characteristic is a state of heightened cutaneous reactivity.

2 In-depth Understanding of the Etiology and Mechanisms of Sensitive Skin

The etiology of sensitive skin is complex. Historically, it was regarded as an allergic dermatosis, and treatment often involved the topical application of glucocorticoid preparations. However, this approach not only failed to resolve the underlying issue but also exacerbated damage to the skin barrier, leading to new dermatoses such as corticosteroid‑dependent dermatitis. Consequently, the cure rate for sensitive skin remains low, and recurrence is frequent. The consensus document clarifies that sensitive skin arises on a genetic predisposition background and is triggered by a combination of individual factors—such as genetics, age, sex, hormonal status, and psychological factors—and external influences—including physical agents like sun exposure and air pollution, as well as chemical and iatrogenic factors. This framework provides a theoretical basis for avoiding precipitating factors and implementing evidence‑based prevention and management strategies.

Based on its pathogenic mechanisms and the interrelationships among them, skin barrier disruption is considered the underlying basis of sensitive skin, with bidirectional interactions involving telangiectasia, immune responses, and inflammatory processes. This further elucidates that sensitive skin represents a complex cascade involving the skin barrier–nervous system, vascular–immune, and inflammatory pathways.

2.1 Skin Barrier Damage and High Temperatures

Low temperature and histamine release interact with each other in a reciprocal causal relationship. Alterations in the skin’s structural integrity, reduced ceramide levels, and imbalances in intercellular lipids of the stratum corneum are key contributors to skin barrier dysfunction. Both high and low temperatures can delay skin barrier repair, while histamine can inhibit the terminal differentiation of keratinocytes, thereby compromising skin barrier function.

2.2 Skin barrier impairment leads to dysregulation of cutaneous sensory nerve function.

A compromised skin barrier reduces the epidermis’s ability to protect cutaneous nerve endings, directly triggering sensations of burning, stinging, itching, and tightness.

3. Enhancing awareness of the clinical characteristics and diagnostic criteria of sensitive skin

Clinically, some cases of sensitive skin are diagnosed solely on the basis of objective signs such as erythema, papules, and telangiectasia; however, a substantial proportion of individuals with sensitive skin do not exhibit these findings. The consensus explicitly states that subjective symptoms—including burning, stinging, pruritus, and tightness—are the fundamental clinical features of sensitive skin. Objective signs like flushing, erythema, telangiectasia, and scaling, as well as subjective, semi‑objective, and objective assessment methods, should be used only as supplementary references for diagnosis. Subjective assessment is typically conducted via questionnaires, semi‑objective evaluation commonly employs the lactic acid‑induced stinging test, and objective assessment relies on non‑invasive measurements of cutaneous physiological parameters, local blood flow velocity, and histograms of blood flow distribution.

Previously, there was no definitive diagnostic criterion for sensitive skin, which was often confused with allergic dermatitis. Some also regarded sensitive skin as an early manifestation of rosacea. Clinically, conditions such as rosacea, corticosteroid‑dependent dermatitis, contact dermatitis, and atopic dermatitis—particularly in their early stages—as well as patients with acne who have long‑term topical use of irritating agents or those who have undergone laser procedures, may all exhibit some or all of the signs and symptoms of sensitive skin, leading to widespread misdiagnosis and missed diagnoses. This consensus document has clearly defined the diagnostic criteria for primary sensitive skin; here, we further supplement these with diagnostic criteria for secondary sensitive skin: when burning, stinging, pruritus, and a sensation of tightness—subjective symptoms that cannot be accounted for by the underlying primary condition—occur during the course of another skin disorder or in response to external stimuli, such cases may be diagnosed as secondary sensitive skin.

During the diagnostic process, clinicians should focus on the core issues in line with established consensus; determining whether sensitive skin is primary or secondary is of critical importance for treatment.

4. Emphasize the treatment of sensitive skin.

Due to the unclear underlying mechanisms, previous treatments for sensitive skin have often been nonstandard, resulting in low cure rates and a high likelihood of recurrence. The incidence and severity of sensitive skin vary considerably; therefore, avoiding triggering factors and restoring the skin barrier are fundamental to management. Based on pathogenic mechanisms, the consensus document establishes general treatment principles for primary sensitive skin. However, an individualized management approach is essential: appropriate interventions should be selected according to the specific etiology, patient population, disease severity, and accompanying symptoms, while minimizing exposure to precipitating factors. Prior to initiating therapy, it is crucial to distinguish between primary and secondary forms: primary cases can be managed in accordance with the consensus guidelines, whereas secondary cases require treatment targeting the underlying condition, supplemented by adherence to the principles applicable to primary sensitive skin.

4.1 Restoring the Skin Barrier

Sun protection: The key to restoring the skin barrier is to choose medical skincare products that have been rigorously tested and clinically validated, are highly safe, and possess skin‑barrier‑repairing and soothing properties. Silica and bicarbonate found in natural spring water, as well as sea buckthorn oil and purslane, all offer natural soothing, anti‑irritant, and anti‑inflammatory effects. Hyaluronic acid, a component of the extracellular matrix, helps restore skin barrier function. Because an impaired skin barrier makes sensitive skin particularly intolerant to UV radiation, it’s essential to use medium‑ or high‑SPF sunscreens when going outdoors; however, during periods of severe acute inflammation, sunscreen application should be avoided.

4.2 Physical therapy is fundamental.

Physical therapies such as cryotherapy, red and yellow light therapy, and intense pulsed light can effectively alleviate patient discomfort and constrict dilated blood vessels. Combining yellow light with cryo‑ultrasound technology can yield favorable outcomes for individuals with sensitive skin. Intense pulsed light and radiofrequency treatments should be administered only after the skin barrier has fully recovered.

4.3 Select appropriate medications for treatment based on the patient’s severity.

For patients experiencing marked sensations of stinging, burning, tightness, and pruritus, oral administration of photosensitizing‑suppressing agents (such as hydroxychloroquine hydrochloride), antihistamines (such as loratadine tablets), and non‑specific anti‑inflammatory agents (such as compound glycyrrhizin) may be considered. Topical calcineurin inhibitors (such as tacrolimus ointment or pimecrolimus cream) may also be used as appropriate. In cases of anxiety or depressive symptoms, oral administration of flupentixol hydrochloride/melitracen hydrochloride may be considered.

5 Areas of Unresolved Concern in Sensitive Skin

Much remains to be done in both basic and clinical research on sensitive skin, including elucidating the epidemiology of sensitive skin in China—particularly its prevalence across different regions and ethnic groups, as well as the associated risk factors and triggers—and investigating its molecular mechanisms and susceptibility genes. It is also essential to identify key therapeutic targets in the pathogenic pathways and to develop novel treatments, such as agents that modulate TRP ion channel activity. Defining the severity of sensitive skin is critical for effective management; accordingly, how to systematically assess disease severity by integrating subjective perceptions with subjective, semi‑objective, and objective measures represents an urgent challenge that requires resolution.

In summary, sensitive skin is relatively common in China, and there is a pressing need to strengthen both basic and clinical research to comprehensively enhance the prevention and management of this condition. The previous issue published the “Chinese Expert Consensus on the Diagnosis and Treatment of Sensitive Skin.” Although the consensus is not yet fully comprehensive, it provides dermatologists nationwide with a preliminary understanding of the concept, pathogenesis, diagnosis, and treatment of sensitive skin, and will undoubtedly play an important role in elevating the clinical standards for managing this condition in China.

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