Striking A Nerve: Sensitive Skin Syndrome

In this episode of Derm-it Trotter! Don't Swear About Skincare Dr. Shannon C. Trotter is joined by Dr. Adam Friedman to discuss Sensitive Skin Syndrom. Sensitive Skin Syndrome is a legitimate condition affecting many individuals, characterized by heightened sensitivity to various stimuli without visible skin disorders. Our conversation with Dr. Adam Friedman emphasizes the importance of validating these experiences, understanding underlying causes, and exploring effective treatments. 
• Definition and recognition of sensitive skin syndrome 
• Prevalence statistics highlighting affected populations 
• Major triggers, including environmental conditions and lifestyle factors 
• Importance of cautious product testing and selection 
• Recommendations for effective skincare management, including sunscreens and moisturizers 
• Be wary of unregulated marketing claims in sensitive skin products 

Please reach out to your board-certified dermatologist to get more information.

Transcript

Understanding Sensitive Skin Syndrome

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skin care experts to separate fact from fiction and simplify skin care. Let's get started.

Speaker 2 0:18

Welcome to the Dermot Trotter Don't Swear About Skin Care podcast, where we're talking everything skin to really share expert-led information so you can feel comfortable in the skin you're in. Today on the podcast I have a special guest, dr Adam Friedman. He's a professor and chair of dermatology and serves as the director of the residency program, translational research, hidronitis separativa and the support of oncodermatology programs at the Department of Dermatology at the George Washington University School of Medicine and Health Sciences in Washington DC. Welcome to the podcast, dr Friedman.

Speaker 3 0:52

Thanks so much for having me. With a name like that for a podcast, how could I possibly say no?

Speaker 2 0:58

Exactly, I don't want you swearing and that's our whole goal is to really help patients. You know, really just you get frustrated. You know, really just you get frustrated. You know, hear all this information as we talked about earlier. You know this noise on social media. How do you really sift through things and figure out fact from fiction and really know you're getting good information? So our goal is hopefully to give that to patients and the public so they're not wanting to swear about skincare.

Speaker 2 1:19

One of the topics I wanted to talk more about and I know you've done a lot of work in this area is sensitive skin and sensitive skin syndrome, because I think a lot of patients come in and say, oh, I've got sensitive skin. You know I can't use this, I can't use that. But I think we're learning a lot more about truly a different entity of sensitive skin syndrome and what this really means for patients, and I think these patients often think they're crazy. So I want to really give them some credibility, you know, to what they're experiencing and have you talk a little bit more about this. So do you mind kind of explaining a little bit about what sensitive skin syndrome is and how it presents?

Speaker 3 1:52

Yeah so. So, first and foremost, they're not crazy, and I wouldn't necessarily suggest that this is a self-reflection, but rather I think often to your point. Someone comes and says my skin's sensitive. But rather I think often to your point. Someone comes and says my skin's sensitive, I can't put anything on my skin. I would bet and I'm not a betting person that someone has dismissed them at some point, said, oh, stop it, you're just complaining. Yeah, you're quote unquote sensitive.

Speaker 3 2:16

But this is a very real thing and I think we are just starting to scratch the surface in terms of understanding what it is. What's driving it, though, to your point, there's a lot of research going into it. Actually, there's an international initiative called the Global Sensitive Skin Care Faculty that's pulling in experts from around the world to really get at this monumental problem. But, simply put, when we think about sensitive skin, we are really thinking about a subjective skin hyperreactivity to stimuli out there that really should not be setting us off, and this will be perceived as itching, tingling, burning, heat, tightness, pain, stinging, overall general discomfort. Now, often this is invisible, and I think that's probably an added piece. We have what we call invisible dermatoses, invisible skin problems that someone will feel, but you can't see it and therefore, if you can't see it, it can't exist right. Wrong vessels are widening, but depending on skin tone, that may not be so obvious. What may look pink or red on my skin may look more purple, brown or black or off-white in some of the darker skin. So it does add to that burden of can't. You see, I'm sensitive, my skin is turning a different color and, depending on skin tone, you may not be able to appreciate it.

Speaker 3 3:40

I think the most important piece of information to walk away with is this is a massive problem. There have been several studies the largest to date was a global study that has not even been published yet we're in process, but it's been presented at several meetings where we surveyed over 16,000 people across the globe to really understand and assess what is sensitive skin, how many people are affected, what is driving it, what are the pain points, ultimately, to define the problem so we can have solutions. And what we found was that 70% of the global population has some degree of sensitive skin. 70% that's a lot of people Now of those, 40% have truly sensitive or very sensitive skin. The most important thing, though, I think this is the most validating Of that massive number of people 40% have no other skin problem. So 40% of people who say I have sensitive skin have nothing else going on. This is not a secondary component of acne, rosacea, eczema the list can go on and on. This is an independent problem. So I do believe it is a diagnosis of exclusion. You got to rule out other things. By the end of the day, 40% of this 70% has just this as their one skin complaint, and I think it's important for us to recognize and that's validating that when people say I have sensitive skin and you can't see it and I don't have anything else, they're telling the truth. So I think that's a big check that really validates this as a unique problem.

Speaker 3 5:10

Now, where do we see it? How does it manifest? Predominantly, the focus has been on the face, and I will talk about this a little bit later in terms of a tool that we use to define sensitive or non-sensitive skin, which is designed to focus only on facial involvement. But I think sensitive skin can occur anywhere on the body and there are giant buckets of things that can really drive it. So we think of maybe environmental exposures, sunlight, wind, temperature changes, lifestyle factors, what we put on our skin. Diet, alcohol consumption, occupation, work and even physiologic things like hormonal changes, stress, I would say, sleep All these things can contribute. The question is which ones are most important.

Speaker 3 5:54

That was another piece of that big study to really get into what are the biggest drivers of activity. And actually from this study our perception has somewhat changed. So we used to think and I'm sure if you were a bedding person you would say well, it's cosmetics, it's things you put on your skin. Clearly you got sensitive skin, you throw something on and that's going to make it worse. That's actually not true. At least we thought that was the case. But now we know it's actually environmental change, like weather changes, know?

Speaker 3 6:24

it's actually environmental change, like weather changes. So extremes of temperature, especially heat, can set this off. People with sensitive skin have at least two kind of social factors, like stress or sleep, that will drive and worsen the condition, and I think that's an important point, that it's not always linear. You can have multiple things go on in your life that you define as the things that will set this off. No-transcript.

Speaker 2 7:02

Wow, that was a great introduction. So I think you know the take-home points I hear from. That is you know we're learning a lot, a lot of research going on and really the validation that you talked about, because you know, I do think patients think that this is in their head sometimes, especially when we have these rashes. You know that we can see things and diagnose them. But when patients have more of a complaint that's you know more of that type of, you know the sensory type issue they kind of feel like, oh, I feel like nobody believes me. So I think that's that's seen for, kind of you know, when somebody comes in and you're suspecting sensitive skin syndrome more than just you know your average, okay, certain product irritates them, like what signs and symptoms are you looking for and how do you go about kind of making that diagnosis?

Speaker 3 7:42

So we are fortunate that we actually have a validated, granted research tool, but often we use these research tools that are employed in clinical trials and for all those sensitive skin sufferers I want you guys to know there are clinical trials ongoing now looking at how products can be used in those with truly defined sensitive skin. So this is a tool that was developed by a professor in Europe named Laurent Misery that was validated, that looks at 10 different features, some of them we already mentioned stinging, burning, pain, itch, redness over a three-day period and for each of those you give a numerical score, so a number of 0 to 10. And if you hit a certain score, when you add them all up above 13, that is defined of sensitive skin and depending on what that number is, it could be mild, it could be truly sensitive or very sensitive. So we have a pretty easy tool and something I'm really pushing for is to make this tool readily available. I mean there should be an app for that where you can easily do a sensei score on the sensei scale and really define whether you have true sensitive skin or not. Now it doesn't mean that if, let's say, you have rosacea and you take this, you wouldn't be positive on this scale. I would expect that. But for those and it's a large number who have no visible signs of disease but yet feel all those different things tightness, they see, redness, they have pain and stinging but yet feel all those different things tightness, they see, redness, they have pain and stinging this is kind of a way to give a quantifiable score to that, to have a number associated with that experience.

Speaker 3 9:14

So I do use the call it the SS10 in my practice. But even with clinical studies we're using it as well. I think that, granted, even if you never even heard of the SS10, and in your practice I'm sure you're asking questions that help guide you. I think that, granted, even if you never even heard of the SS 10, and in your practice I'm sure you're asking questions that help guide you. I think what's nice about this, going back to validation, is we're we're actually asking questions, we're having, we're tallying up numbers.

Speaker 3 9:36

There's something about that, that that gives it more credibility, right? That like, oh, I'm, you know count, you know tallying up your score and oh, yep, you're tallying up your score and oh yep, you're a 25 on the Sensi scale. That's very different than saying, oh yeah, you have sensitive skin. I hear you, I'm listening. Once again it goes back to validating, because I think, especially with this large cohort of individuals who are suffering with all these symptoms, many have been burned, literally and figuratively, by product recommendations, by mismarketing to sensitive skin, and so there's already some hesitation, some trepidation, that you really don't get this and you're probably going to tell me to do something. I've been told before that's only going to make this worse, so why am I even bothering? So it is also a way to open that door to kind of revisit something they may have spoken to someone else about and say oh yeah you know, this is a real thing, we have a way to measure it and we're actually currently studying it.

Speaker 2 10:29

Yeah, and I think the measurement tool is helpful too for patients. When you talk about treatment which we'll touch on in a minute because you know you can be trying to get that score down for them. You know, or potentially you know, if we use, you know if it can relate in that way, but you know where you're like. You know it's sort of a subjective report. You know this is just how you are feeling, but putting a number to it, I think, makes it real for patients. So there's value in that. And then how you treat it, you know for patients who think they might be experiencing it, and what we've learned thus far. You know why do we think this is happening? You know we mentioned environmental factors, but do we really understand the pathophysiology, what's going on in the skin or the signals to the brain that really explain why somebody might suffer with sensitive skin syndrome?

Speaker 3 11:10

Yeah, that's like the kabillion dollar question.

Skin Sensitivity and Treatment Considerations

Speaker 3 11:12

So, we're still working on it. It is a work in progress. It's that little construction guy on the TV chipping away at something. But we have learned quite a lot in recent years. So I think the best way to think about this from an underpinnings of disease perspective, that it's probably an intersection between disrupted armor, a disrupted skin barrier which we know is there, and I'll explain that in a moment Neurosensory dysfunction. The nerves of the skin are sending inappropriate signals to things that should not be pissing them off. Sorry, did I swear? Oh no, we went against the name Perfect. And the third piece is immune system dysregulation. So we are getting bits and pieces of all three of those and actually, if I were to say those three at one of our conferences and not say what disease I'm talking about, people might think about diseases like eczema paragonodularis, and I think that there is some overlap in those cellular pieces, biological pieces, of this disease.

Speaker 3 12:21

Study performed by actually one of my, I'll say, gssf Global Sense of Skincare faculty members, dr Giovanni Pelicani, where he used some really fancy schmancy imaging technology, confocal microscopy, optical coherence, tomography that's a mouthful, but in essence he was able to visualize the different layers of the skin without cutting into it and what he saw in those with sensitive skin proven by the Sensi scale versus those who do not have sensitive skin that that top layer called the stratum corneum, our living barrier that reacts to the outside, that protects us from all the nasty crap out there and keeps good stuff in, was fragmented. It was thinner than a normal stratum corneum. The epidermis, which is the composite of that upper layer that includes the stratum corneum, the epidermis, which is the composite of that upper layer that includes the stradum corneum, was actually thicker than a normal epidermis. The collagen everyone knows collagen People talk about oh, I'm going to drink some collagen, put some collagen on. This is the backbone of our skin. This gives really the structural stability of our skin was also fragmented, chopped up. It was not looking so healthy and even the vasculature, the blood vessels that feed the skin, was somewhat reduced. Now what does that mean from a clinical or everyday life perspective? We're not sure, but we know that there are inherent defects, there are inherent dysfunction, just in the structure of the skin, compared to someone who doesn't have sensitive skin.

Speaker 3 13:45

Now, in thinking about, you know what was one of the number one drivers of sensitive skin from the recent survey I mentioned in terms of temperature. Actually sweating was up there too. I was curious to see if that maybe there was some overlap between other invisible diseases that we manage like hyperhidrosis, which literally means excessive sweating. I'm not talking about a little flop sweat, I'm talking about four times sweating that's needed to actually cool yourself or regulate your body temperature Another disease that we don't really understand why it's happening. And so we partnered with the International Hyperhidrosis Society and tapped into their massive patient membership and tapped into their massive patient membership and we identified over 500 people with what's called primary hyperhidrosis, meaning they have this four times extra sweating for no rhyme or reason, no underlying medical problem or medication, and we found that 90% of them had sensitive skin. Based on Sensi Scale, 10 scores.

Speaker 3 14:45

Now one could argue well, yes, sweat is an irritant, right, that makes sense.

Speaker 3 14:49

But we thought that out.

Speaker 3 14:52

We knew someone is going to be snarky and say oh, it's the sweat that's doing it.

Speaker 3 14:56

No, no, no, actually, people with hyperhidrosis, with sensitive skin, their sensitive skin was in areas where they didn't have that excessive sweating, so it wasn't. The irritating fact is that there is some overlap between these conditions and we know that that extra sweating comes from the signaling of particular nerves, what's called cholinergic stimulation, that probably those same nerves are playing a role in sensitive skin too, and that's where that neurosensory dysfunction comes in, that there's probably inappropriate nerve signaling. And then that last piece about immune dysfunction, the immune system acting awry. There is some evidence that certain signals that we in dermatology have become very familiar with, like the itchy cytokine in leucine 31, that this is also overly produced and expressed. So there's clearly something unique going on in this very large cohort of patients. The question is what's the biggest driver and how do we target it and how would he make a difference? But I think first things first we have to understand and characterize the condition and then we can actually come up with solutions that really get at the underpinnings of the condition itself.

Speaker 2 16:06

So, for what we know now and I know there's a lot of ongoing research what is your treatment approach for somebody that you come in presents with those signs and symptoms? You're like, yep, this is going on, they meet the criteria and you want to initiate treatment. What is your approach to that for that patient?

Speaker 3 16:21

Well, that's so easy, right? No, even with all this work, it's still very difficult. So, I think, some basic rules aside from what are the products I reach for. So, regardless of how we move forward in terms of recommendations, whether it be over the counter or prescription, I always tell anyone who I've identified with sensitive skin that we're going to do patch testing, not the patch testing you and I are familiar with, which is for allergic testing, but rather we are going to apply whatever product we're going to use to only a small area in the area that that individual says they have sensitive skin, the face being the most common, and we're going to do that for a couple of days and just a little bit just to make sure that it is tolerated. So, even with good data supporting the use of said product X in sensitive skin, I'm still going to tread lightly, but, given what we understand with respect to barrier dysfunction, the armor is dysfunctional, the nerves are a little too excitable and maybe heat makes it worse, so possibly something that cools might make it better. And, of course, inflammation. I'm going to focus on basics, and those basics are protecting against UV radiation using sunscreen and I find that mineral sunscreens are going to be less instigating when it comes to sensitive skin. They're more inert, meaning they're not very reactive versus the chemical sunscreens. That's still not always true, but I think it's safer to go that route. We're going to talk about using a moisturizer, and one that is going to have ingredients that are really designed to help fortify the skin and help the skin work for you, and there are a whole bunch of different ingredients that certainly fit into that, and there are a whole bunch of different ingredients that certainly fit into that various oils and even composites of Cloto oatmeal, for example.

Speaker 3 18:16

We're going to talk about mild cleansers and something of late that I've noticed and maybe you're seeing this and maybe those listening can relate there's a big focus on exfoliation. I don't know where this came from, but everyone their mother's like I got exfoliate. You have to like it'd be sacrilege not to. I'm like why I don't get it. You know, the funny thing is our skin will exfoliate itself right. If we lock a little bit of moisture in that top layer and we're doing everything right, our skin is constantly turning over. It's when you have those issues with the barrier, like we see just having sensitive skin that's when the skin kind of layer cakes and becomes rigid and lusterless, and so it may need a little extra help getting off. But exfoliation sensitive skin that is like the worst Tinder mix or mate or whatever match possible, because often a lot of those ingredients are going to be very irritating, and so that's where for any of the things I mentioned sunscreen, moisturizers, cleansers and exfoliants you're going to want to look for ones that have actually been studied in those who actually have sensitive skin.

Speaker 3 19:24

Now, taking a step back and thinking about products marketed as sensitive skin, this is not an FDA-regulated term, right? This is not a claim that then falls under a drug claim, and even over the counter, there are drug kind of silos or categories. So I could wake up tomorrow and just say, yes, friedman's famous formula for sensitive skin, and no one's going to say you can't say that. And what we've actually seen? We did a study here at GW where we identified individuals who said they have sensitive skin, validated with the Sensi Scale 10. Also, they said that they were going to use a product for sensitive skin. Compared to someone without sensitive skin, they were seven and a half times more likely to buy a product that said for sensitive skin. 70% of them also found that those products made them worse.

Speaker 3 20:18

So we have to be very careful that that's a marketing term, that it's not regulated, and so that's where the evidence comes in. And so when we look at the major kind of product lines and I would love to get your take on this I typically say to my patients you know, go with the products that come from companies that have the resources to actually back up their claims, versus the you know niche brand that is selling it out of their parents' basement where they don't have a clinical trial program, they don't have labs to actually evaluate that. I try not to play favorites or be biased, but I'm like it's just, I'm being realistic. Those smaller brands that only have a website and nothing else, they're not going to have the wherewithal to really match those claims with good science. How do you approach that with your patients?

Speaker 2 21:04

Totally agree and I think it's tempting because they will see a lot of these niche products or companies on social media. They'll be intrigued and they're trendy or somebody else has tried it and they'll trust you know the opinion of somebody they've just seen for a few seconds on a TikTok or an Instagram post and really not pay attention to what's behind all of that. So I agree with you totally Having products that have that clinical data to support that they're really going to make a good impact for that patient is important.

Speaker 3 21:32

Yeah, I, I completely agree. I mean, I, I'm like, I feel like I'm the Jerry Maguire of dermatology. You know, show me the science you know, show me your data. I'm not going to scream it at you, but yeah, I feel like you know show me the data.

Speaker 3 22:11

I just won't swear. That's that important thing. There you go, all right, conducted numerous studies employing the Sensi Scale 10 to really identify patients with true sensitive skin to then evaluate how does a cleanser, an exfoliant, a moisturizer, with ingredients that were really purposely thrown together not just like let's throw it in a stirring bowl and kind of mix it together that these should theoretically help someone sensitive skin? But then you have to put your money where your mouth is and actually prove that. And so they've published multiple studies. There are systematic reviews, which are research reviews in that you take a bunch of different studies and kind of analyze all the data together to prove that in this case, certain products will be safe in this kind of venue. So I definitely give them credit.

Speaker 3 22:49

But obviously I'm conflicted. I work with them on this stuff, but I am of the mindset that I will only work on things that I believe in, and I've been very impressed with the work to date. But I'm seeing others jumping into the, you know, into this foray. You know, kenview, for example, is another one, especially when we think about products under the Aveeno umbrella. But no question, this is taking my bias hat off and just personally as a scientist and a clinician, no question, cetaphil has really taken the charge, which is great because of that question well, what do I use? And if we're going to be scientific, we need the science to really back that up.

Speaker 2 23:28

Completely agree. Well, I can't believe our time's already up. This has been a great conversation on sensitive skin syndrome. I really hope, too, for your listeners out there you understand that this is a real entity. It's not in your head. As Dr Friedman said, we are learning more and more about it. So if you even suspect that you have it, please see your dermatologist, because there can be options for treatment. You just don't have to live with it. Dr Freeman, for our listeners, if they want to find you, where can they find you? At online or social media if they want to track you down.

Speaker 3 23:56

So if they want to find me on social media, they'll be a little disappointed, as they'll see pictures of my kids, like, posted once every six months. As I'm not I'm not the best at it I am on LinkedIn and I, you know, I work at George Washington School of Medicine and Health Sciences in Washington DC. So on the GW website, if you're in the area and we have a robust clinical program here with phenomenal physicians, all who would welcome you with open arms. But, yeah, maybe you've inspired me to up my social media game, because it's like it's not even a fingerprint, it's more of like a clipping of a toenail at this point.

Speaker 2 24:32

We can definitely band together. I do parodies too, so you want a little dance routine, little song, we can include you as well.

Speaker 3 24:37

You definitely don't want to see my dancing, but we'll workshop it for sure we can talk.

Speaker 2 24:43

All right. Well, thank you again, dr Friedman. It's been a pleasure. I hope again you've learned something about sensitive skin syndrome for those of you that even know it existed out there, and for those of you that are suffering with it again. Please reach out to your board-certified dermatologist to get more information. And thanks for listening again to the Dermot Trotter Don't Swear About Skin Care podcast.

Speaker 1 25:02

Thanks for listening to Dermot Trotter. For more about skin care, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skin care sanity. Until next time, stay skin smart.