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A Sensitive Issue As our lifestyle is evolving so are the types of skin diseases. The frequency of inflammatory diseases as well as carcinomas, have significantly increased over the past few decades. The complaint by patients of having some sort of sensitivity in their skin has become very common and according to various studies, it can affect up to fifty percent of the adult population. Sensitive skin is also known as reactive or over reactive skin, intolerant skin or irritable skin. It is more commonly reported by women who become very frustrated and knock at many doors to seek help. ‘Sensitive skin’ is an umbrella term used to describe several unpleasant sensations of varying intensity that are transient in nature. The skin can look normal or uncommonly dry, scaling, inflamed. It is accompanied by several symptoms that clinically defines this condition, including, the occurrence of abnormal stinging, burning, pain, itch and tingling sensations. This may be in response to multiple factors, which may be physical (UV radiation, heat, cold and wind), chemical (cosmetics, soaps, water and pollutants), psychological (stress) and hormonal (menstrual cycle). The use of certain medications can also contribute to the sensations and should always be excluded when a person is examined. The exact reason for sensitive skin is not fully understood, but tends to involve neurogenic inflammation after the enhanced activation of sensory proteins in keratinocytes and nerve endings. In layman’s term, it seems to be nerves that get over stimulated in the skin cells. These in turn cause the unwanted sensations. Though, various tests have been developed to quantify the level of sensitivity, there is uniformity as the level of tolerance is subjective and varies from person to person. An easy and simple way to classify the patients is to put them into four categories: very sensitive skin, sensitive skin, slightly sensitive skin and non-sensitive skin. All skin areas can become sensitive and the four most commonly reported sites are the face, scalp, under arm and genital regions. The face is exposed to most external factors and the areas most commonly involved are the nasolabial folds, eyelids, chin, forehead and sometimes the cheeks.  The cold, wind, sun, severe heat, air conditioning, pollution, dry air and cosmetics can impact on the facial skin, more than on other parts of the body, which are usually protected and covered. Whilst environmental factors are not modifiable, the use of cosmetics are the most clear and avoidable triggers of skin reactivity. Chronic use could favour the acquisition of chronic sensitive skin and could explain the increase in prevalence with age. As for the scalp, the symptoms can be slightly different, with itching and prickling feelings being the most common complaint. Also, the main triggering factors are heat, stress and use of shampoos, which is slightly different from other areas. Scalp sensitivity is frequent in people with or without dandruff and is related to the complex neuroanatomy of the area. Treatment can also be challenging. The skin of the genitalia and axillae can become very sensitive, without an apparent disease. It is a very common condition, however, rarely reported. The presence of pruritus, irritation and abnormal sensations can severely impact on an individual’s sexual well-being. The genital skin tends to be thinner and very sensitive to hygiene products. The high humidity in the area due to occlusion, can also favour the growth of various organisms, which need to be excluded. The under-arm can become very painful and most deodorants cause irritation to the area. The use of baby powder to absorb the sweat, and applying roll-ons slightly away from the axillae can assist. There are many conditions that can lead to abnormal sensations on the skin. The presence of redness, inflammation and dryness can assist in making other diagnoses. Mild eczema rash can sometimes be less obvious when the patient has applied emollients thus they must comeback for a consultation, without applying any creams. At times, rosacea can give abnormal sensations on the face and needs to be excluded. Rosacea occurs commonly in the thirties and tends to affect fair individuals. Patients can feel heat sensation, itch and heaviness on their face. Sometimes there is presence of pustules and papules and most often the face and nose become red, giving the impression that the person is an alcoholic. There are several aggravating factors, including the use of alcohol, hot drinks like coffee, spicy food and sun exposure. Once the diagnosis is made, there are several medications that can be used to improve the condition. It is necessary to keep in mind that abnormal sensations without any objective symptom could also be related to neuropathies or somatoform skin disease. Neuropathies due to spinal cord compressions or diabetes are common. Diabetes can cause itch, burn or painful sensations mainly in the lower limb regions, leading to altered skin sensitivity. Identifying appropriate skin-care and cosmetic products tolerated by patients with skin that is reactive to irritants is often difficult. Sensitive-skin products should be free of ingredients like volatile solvents (e.g. ethanol, volatile propellants), aromatics (e.g. menthol, benzyl alcohol) and penetrants (e.g. low-molecular weight glycols, -hydroxy acids, and retinoids). Other features desirable in sensitive-skin products are simple products with fewer than 10 ingredients, use of chemical-free sunscreens ( e.g. titanium dioxide or zinc oxide), less irritating preservatives( e.g. parabens) and incorporation of anti-irritants( e.g. aloe  Vera, chamomile, bisabolol). The use of powder or stick makeup products are generally less irritating than liquid products. For mascara, black is usually the least irritating colour and washable products are advisable to prevent irritation when the mascara is removed. People with sensitive skin can be very frustrated and doctors treating them should display a lot of patience. The best strategy is to stop also cosmetics and identify other aggravating factors, so that they can be dealt with, if possible. Then the patient should introduce only the essential cosmetics one by one, using simple bland emollients  to wash the sensitive areas. They must be advised against facials, steaming, waxing and scrubbing. In severe cases, use of medications like mild steroid creams, as well as counselling can help. Dr Rakesh Newaj Specialist Dermatologist MBBCh (Wits) FC Derm (SA) Fax: 0865037142 www.dermatologistjohannesburg.com 266 Polaris ave, Waterkloof ridge Pretoria Tel: (+2712)-7514001  Arwyp medical centre, 3rd floor, Medical suites, Kempton park Johannesburg  Tel: (+2711) -9221565
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