During the initial consultation, a thorough evaluation and health history will help determine causes of the condition. Understanding the client’s predisposed factors, as well as health history, will help determine the causes to their sensitive skin condition, aiding in determining treatment protocol.

ETHNICITY
Defining ethnicity is one way to determine predisposed factors to certain sensitive skin conditions. Individuals with Irish, Scottish, Welsh, Scandinavian, or Eastern European descent were shown to have elevated rates of rosacea. A survey done by the National Rosacea Society found that 40 percent of patients with rosacea had a relative with similar symptoms, 33 percent of respondents claim to have one parent of Irish heritage, and 27 percent had a parent of English descent. With rosacea, skin is sensitive to environmental factors and can worsen without treatment. It has been found that rosacea is further associated with an impaired skin barrier, which can allow irritants to penetrate the epidermis, causing vasodilatation, flushing, and inflammation.
Other considerations for sensitive skin would be darker racial ethnicities. Individuals with Fitzpatrick skin phototypes III through VI are more sensitive to skin inflammatory responses. During the inflammatory skin response, darker skin phototypes have an increase of melanocyte activity and are more prone to post-inflammatory scarring. Tyrosine inhibitors, such as kojic acid or arbutin, can help reduce melanocyte activity during the inflammatory process.

IMPAIRED SKIN BARRIER
The skin is constantly going through a repair process so it is necessary to strengthen and protect the skin barrier and immune response in skin cells. The stratum corneum is the skin barrier and the top layer of the epidermis. The function of the stratum corneum is crucial to disease pathogenesis and in treating skin conditions. Genetic research has shown that there is an importance in epidermal function and skin diseases such as atopic dermatitis. Strengthening the function of the stratum corneum is crucial to skin barrier function. Exfoliating dead keratinized cells contained in the stratum corneum and retaining moisture in the skin is key to improving the function of the stratum corneum and improving the skin barrier. Ideally, polyhydroxy acids are a gentle but effective way of exfoliating sensitive skin by normalizing the natural keratinization process of skin cells. With a stronger skin barrier there is a decrease in transepidermal water loss, therefore, improving the integrity of the skin.
In the epidermis, ceramides are known to be an integral part of the extracellular stratum corneum lipid bilayers that constitute the permeability barrier of the skin. Studies have shown that a ceramide deficiency in the epidermis is seen with patients who have psoriasis and atopic dermatitis and an increase of Tumor Necrosis Factor (TNF) in response to cutaneous permeability barrier disruption and wound healing. This TNF signaling generates ceramide, an important regulator of proliferation, differentiation, and apoptosis in the skin. Research has shown that a decrease in ceramide levels in the epidermis impairs the water-holding capacity of the skin and decreases the skin barrier function. Topical ceramides, as well as hyaluronic acid and pantothenic acid (vitamin B5), will increase moisture retention in the skin and encourage a stronger skin barrier.
Ingredients such as niacinamide, also known vitamin B3 or niacin, has been shown in clinical studies to strengthen the skin barrier and integrity of the skin and repair cells that have been damaged by ultraviolet radiation. Clinical studies have shown that the use of topical niacinamide, for 12 weeks, improved skin barrier function and skin integrity. Niacinamide improved the skin barrier by creating stronger stratum corneum layers as well as a tighter cellular matrix. Studies confirmed that niacinamide was found to repair tissues and strengthen the epidermis, making it more intact.

INFLAMMATION AND DISEASE
The inflammatory process occurs as a response to the body’s innate immune system and is the body’s attempt at self-protection from an injury or infection. The inflammatory process consists of histological cytologic changes, cellular infiltration, and mediator releases in which the body removes harmful stimuli, including damaged cells, irritants, or pathogens, which begins the natural healing process. Keratinocytes are cells that are immunomodulators and responsible for stimulating inflammation and activating the skin immune cells, known as Langerhans cells, in response to injury.
Studies have shown that there is a connection between inflammation and disease. Internally, inflammation is not visible to the eye but takes place on a cellular level. Inflammation does its damage by stimulating free radicals that accelerate aging and disease by attaching to and damaging cells. Causes of inflammation include a high-glycemic diet, environmental stressors, and excessive exposure to ultraviolet light, hormonal changes, stress, and a weakened immune system. The causes of inflammation should be considered with inflamed and compromised skin conditions.

WEAKENED IMMUNE SYSTEM
Sensitized skin is skin that has a condition which makes the skin more sensitive. Commonly, sensitized skin is a result of an immune disorder or a weakened immune system. With proper treatment, conditions such as acne, psoriasis, and eczema can improve and become less sensitive. The most important factor to consider when treating sensitized skin is strengthening the immune system and skin barrier function.
Interleukins are cytokines that participate in the regulation of immune responses and inflammatory reactions. Clinical studies found that patients with psoriasis had elevated levels of pro-inflammatory Interleukin-6. With psoriasis, activated immune response T-cells produce inflammatory cytokines that induce hyperproliferation of keratinocytes.
This hyperproliferation-induced inflammation, caused by keratinocytes, results in a profusion of T-cells and other immune related cells that interfere with the epidermis, therefore, stimulating wound healing cytokines that further exacerbate the condition.

IMMUNE HEALTH AND VITAMIN DEFICIENCIES
Scientists have linked various aspects of immune health to a vitamin D3 deficiency. A vitamin D3 deficiency may have an influence on the development and progression of various autoimmune diseases. Vitamin D3 acts as an immune system modulator, preventing expression of inflammatory cytokines and increasing the efficacy of macrophages. Vitamin D3 stimulates antimicrobial peptides which exist in immune white blood cells such as neutrophils, monocytes, and natural killer cells. The importance of vitamin D3 should be considered when treating autoimmune skin conditions and disorders, as well as sensitive skin and inflammatory skin conditions.
In clinical studies, it was found that a deficiency of vitamin A in the body affects immune responses involving white blood cells such as neutrophils, macrophages, and natural killer cells. A vitamin A deficiency is commonly found as a contributing cause to various skin diseases. Retinyl acetate, a derivative of vitamin A, is known to inhibit the growth of tumors in some cancer cell types and has immunodulatory properties.
Zinc is an essential trace element and is necessary for bodily functions. Studies have shown that deficiencies in zinc can contribute to various disease states, including conditions such as acne as well as those that involve absorption abnormalities, insulin dependent diabetes, and sickle cell anemia. Symptoms of a mild zinc deficiency may include roughened skin and impaired wound healing, whereas symptoms of a severe zinc deficiency can include erythema, inflammation, redness, and scaling. When treating compromised skin conditions, vitamin and mineral deficiencies should be considered.

NUTRITIONAL SUPPLEMENTS
Research has shown that nutrients that possess antioxidant properties act as natural anti-inflammatories. Antioxidant nutrients are anti-aging, anti-inflammatory, fat metabolizing, and have peptide boosting benefits. Eating an anti-inflammatory diet will prevent and reverse oxidative damage caused by free radicals on a cellular level and help boost immunity.
A rapid rise in blood sugar can cause inflammation in the body. Vitamin B6 plays a role in metabolizing proteins, sugars, and fatty acids and can help control inflammation associated with increased blood sugar levels. In clinical studies, it was found that a deficiency of vitamin B6 can contribute to inflamed skin conditions by helping control inflammation, maintaining a healthy immune system, and producing antibodies to fight infection. Nutritional supplement therapy should be considered when treating inflamed skin conditions.

DIGESTIVE HEALTH
Studies have shown that digestive health can have an effect on certain types of disease. Hydrochloric acid is essential in the digestive process and provides antiseptic role-killing microorganisms that exist in ingested food. Hydrochloric acid is of critical importance to help prevent yeast, bacterial, viral, protozoal, and parasitic infections, all common causes of digestive distress. Several diseases are associated with hydrochloric acid depletion, including adult acne, skin disorders, and many other serious diseases. The amount of hydrochloric acid can be affected by antibiotics, caffeine, nutrient intake and absorption, high-glycemic diet and fats, hypothyroidism, and malfunctioning of adrenal glands. When treating clients with inflamed skin conditions or adrenal disorders, depletion of hydrochloric acid should be considered.
Strengthening immunity and improving gut microbiota will help improve skin conditions. Probiotics are live cultures of natural bacteria that are necessary for a healthy immune system and are important for digestive health. Improving digestive health will help improve sensitive skin conditions as well as immune disorders which contributes to sensitized skin conditions. For optimal benefit, probiotics should not be used in conjunction with antibiotic therapy. Antibiotics have broad spectrum effects and will diminish necessary healthy bacteria to balance immune health. When addressing digestive health, antibiotic drug therapy as well as food sources that are fed antibiotics should be considered.
Other factors that can contribute to sensitive skin are lifestyle and medications which affect digestive health and are an important consideration when treating the progression of skin conditions.

ROSACEA
Rosacea is the most common of sensitive skin conditions. Often referred to as adult acne, rosacea may begin as a tendency to flush or blush easily and can progress to persistent redness. The redness may appear in the center of the face and may gradually involve the cheeks, forehead, chin, neck, and nose. When rosacea first develops, it may come and go on its own, but as the disease progresses, the skin may not return to its normal color and small blood vessels and tiny pimples may begin to appear on and around the reddened area. However, unlike acne, there are no blackheads.
Rosacea can become worse over time without medical treatment and proper skin care. The condition rarely reverses itself and may last for years. Those most likely to develop rosacea are fair-skinned adults between the ages of 30 and 55. This condition is most commonly genetic and can even affect children. For some unknown reason, women get rosacea more often than men, and in some cases it may be associated with menopause. Rosacea usually develops over a long period of time and can cause a sensitivity to heat, a ruddy complexion, or an extreme sensitivity to cosmetics.
Causes of rosacea can include underlying medical conditions and temporary ailments which can stimulate flushing in the skin. Health conditions such as menopause, fevers, colds, coughs, and systemic diseases, such as high blood pressure, can be associated with and contribute to rosacea flare-ups.
Certain medications can contribute to rosacea and sensitive skin conditions. Drugs such as vasodilator medications, commonly used to treat cardiovascular disease, can also contribute to skin flushing because of their ability to dilate blood vessels. Other medications, such topical steroids used long term, have been found to induce rosacea symptoms. In clinical studies, symptoms improved for rosacea patients who discontinued topical steroids and used topical antibiotics. The use of topical antibiotics can reduce inflammation and treat the microbial component of this disease.
An immune response triggered by a type of anti-microbial peptide (germ killing peptide) has been associated with rosacea. Scientists have discovered that patients with rosacea had elevated levels of cathelicidin, an antimicrobial peptide, and elevated levels of stratum corneum tryptic enzymes. Cathelicidin is found in epithelial cells which are found in the body and skin. Cathelicidin is also found in white blood cells such as neutrophils and macrophages, which are activated by viruses, bacteria, and fungi. The evidence of elevated levels of cathelicidin found in white blood cells demonstrates that the body is fighting a microbial component to this skin disease.
The microbial component of rosacea skin conditions could be caused by the demodex mite. The demodex mite is an obligatory human ectoparasite and resides in or near the pilosebaceous units in the skin. A recent study found that a certain bacteria present on demodex mites could prompt an inflammatory response in rosacea patients. The bacteria bacillus oleronius was isolated from a demodex mite found on a patient with papulopustular rosacea and a potential role for this bacterium in the induction of rosacea was proposed. Staphylococcus epidermidis has been isolated predominantly from the pustules of rosacea patients, not from unaffected skin, and may be transported around the face by demodex mites. These findings raise the possibility that rosacea is fundamentally a bacterial disease resulting from the over-proliferation of demodex mites that live in damaged skin caused by a weakened immune system. The primary cause of immune suppression is probably based on hereditary defect of T-cells, subsequently reinforced by substances produced by mites and bacteria, with intact B-cell immunity.
Lactoferrin can have microbial affects when treating rosacea. Lactoferrin is an iron-binding protein (chelator) that is associated with functions in the body and participates in iron storage, as well as iron transport to cells. Iron is crucial for the normal function of both pathogens and the host cell; the ability to acquire iron during an infection is an important factor for the sustainability of the pathogen. Lactoferrin, by chelation and storage of plasma iron in the liver and spleen, temporarily restricts iron access to microorganisms and formation process of toxic reactive oxygen species, therefore, restricting their growth. Lactoferrin has bacteriostatic and fungistatic benefits that could effectively reduce the microorganism component associated with rosacea.
Supplements such as lactoferrin have the ability to restrict the access of iron to microorganisms and pathogens, therefore, improving inflammatory responses of white blood cells causing inflammation. In clinical studies, lactoferrin was shown to have anti-inflammatory activity and systemic effects on inflammatory diseases. Lactoferrin was also shown to decrease skin inflammation due to its broad antibacterial and anti-inflammatory activity. The anti-inflammatory benefits of lactoferrin may help reduce inflammation and improve rosacea skin conditions.

TREATING SENSITIVE SKIN CONDITIONS
When treating sensitive skin conditions, the practitioner should consider and address numerous factors such as predisposed ethnicity, an impaired skin barrier, a weakened immune system, digestive health, inflammation and diet, vitamin and mineral deficiencies, and underlying health conditions and medications which can contribute to the sensitive skin condition. Sensitive skin conditions commonly have internal factors that exasperate the condition and should be addressed along with strengthening the skin barrier and function of the stratum corneum by reducing transepidermal water loss.

Linda Gulla is founder of the International Institute for the Advancement of Aesthetic Medicine and offers advanced training to professionals as an educator and adjunct instructor in CME and CE. Gulla shares her knowledge in medical aesthetics, giving presentations to professionals at the International Dermal Institute. She has authored and published resource manuals in medical aesthetics and shared her expertise in advanced aesthetics as an editorial reviewer with Milady. Gulla provides professionals with opportunities for career advancement with the convenience of self-study, offering the first online certification in medical aesthetics, which includes content that has been accredited by the ACCME. This email address is being protected from spambots. You need JavaScript enabled to view it.