The methodology of how to approach the care of clients with sensitive skin has often been an evolving and dynamic challenge, particularly, taking into consideration many unknown variables regarding the underlying health of an individual or identifying the actual degree of skin sensitivity. Our focus should include the care and nurturing of sensitive skin, understanding the potential influences on hypersensitivity, and an increasing correlation with autoimmune diseases. UNDER IT ALL – UNDERSTANDING INFLAMMATION Inflammation is the physiological process of the immobilization of body defenses against foreign substances, irritants, or infectious agents. It is a complex series of events and interactions between fragments of dead cells, surrounding tissues, circulating blood cells, and specific antibodies. Inflammation occurs when tissues are injured by bacteria, trauma, allergens, toxins, or heat, and it is considered one of the first responses of the immune system to fight infection. Inflammation often perpetuates a disease state in the body and, in the case of autoimmune diseases, the immune cells are integral on behalf of the body’s defense mechanisms. During inflammation, inflammatory mediators, bradykinin and histamine, react to facilitate the expansion of blood vessels to permit more blood to reach the affected tissue, resulting in erythema. Defense cells then activate to assist in supplying blood to inflamed tissues to attempt to assist in the healing process. Lymphatic fluid then appears to add defense to the affected tissue; however, it frequently impacts swelling and edema. Hormone mediators activate and can irritate the nerves transmitting signals to the brain to communicate the message of itching, burning, stinging, or pain. In the case of chronic auto immune inflammatory diseases, the process is continually repeated with varying degrees of intensity and symptomology as a result of the initiation of periods of re-occurring inflammatory events. When the skin is exposed to a triggering stimulus, such as an allergen or ingredient with often an “unknown” sensitivity, the reaction may be delayed and not always be detectable or visible to the naked eye. Clinical presentations may be seen and identified, whereas subclinical inflammation cannot be determined by just looking at the skin. In the case of highly sensitive skin and compromised health, the term subjective or sensory irritation is used to describe specific or sensory mediated neural irritation. The irritation is stimulated by a sensory discomfort such as itching, stinging, tingling, or burning, but does not exhibit histological evidence of inflammation. In this case, it is the direct involvement of nerves and blood vessels which contribute to the development of the symptoms. Delayed sensitivity reactions can generally occur anywhere from two to six hours, or longer in some individuals. It is important to note that each individual may respond differently to products, ingredients, or treatments. And, in some cases, reactions may happen with no apparent trigger. All individuals are subject to allergic reactions at various times throughout their lives and careful consideration should be given to all clients with known health conditions, immune disorders, and, especially, those that may take multiple medications. Inflammation may present not so common reactions identified in the treatment room, such as fever and even the lowering of blood pressure. It should be noted that inflammation can develop without a known cause. MULTIPLE CHEMICAL SENSITIVITIES (MCS) Multiple chemical sensitivities (MCS) is an actual syndrome, also referred to as idiopathic environmental intolerances (IEI), that defines a branch of environmental medicine and specialty physicians that work specifically with environmental influences and illness. Multiple chemical sensitivity syndromes represent unusual and severe allergy-like reactions to any number of assorted and, often, common chemicals and pollutants – such as solvents, volatile organic compounds (VOCs), perfumes, cosmetics, smoke, air fresheners, candles, petrol, exhaust, building vapors, and cleaning products – and may constitute as many as 90,000 chemicals circulating in the world.1 These sensitivities are different from traditional allergies which can be ascertained by laboratory testing. Many of the individuals afflicted with MCS are sensitive to several antagonists and, often, the influx of pollen, dust mites, and pet dander or fur can create a severe distress syndrome in addition to the primary sensitivities that may have been identified. One of the perplexing problems is that, in some individuals, the mechanisms are not easily identifiable and are often referred to as idiopathic. In this instance, even traditional therapies, steroids, allergy medicines, and so forth may not be effective and the best possible outcome for treatment is for the individual to avoid any and all potential triggers and exposures. An individual with MCS may have sensitivity or reactions to either very high or low levels – where other individuals around them may not be able to detect any sensitivity at all. The problem may be continual and not an isolated event. The same symptoms are reproducible with repeated exposures to the same antagonist. The person is affected by many triggers and improves when the triggers are absent. WHAT IS THE RELATIONSHIP WITH MCS AND THE SKIN? There is a connection between neurogenic inflammation, allergic inflammation, and central nervous system involvement. Within an allergic reaction, histamine binds to sensory nerves and activates neurogenic inflammation. Many individuals with chemical sensitivities have rosacea with erythema and inflammation triggered by exposure to foods and chemicals. Neurogenic inflammation is known to play a role in rosacea. Airborne particles can also aggravate airborne contact dermatitis.2 Individuals who suffer from MCS may even have reactions to sensitive skin products, as their allergies may not be identified by simple allergy tests. Aestheticians working with sensitive skin, rosacea subtypes, immune disorders, or oncology clients should take precautions in the treatment room to avoid exposure to potential triggers by having suitable air filtration and avoid any fragrances in products or scented items in the common areas of their spa. Cleaning products should also be a consideration, as well as hand and laundry detergents. It is important to pay close attention to client communication and respect the signs of sensitivity. What may appear to be flushing may be underlying neurogenic inflammation, such as neurodermatitis. Also, what may be construed as a simple stinging sensation a few hours after the facial may transpire into something more serious. Always follow up with rosacea and hypersensitive skin clients post-treatment. DIABETES Type 1 diabetes affects the body as it is not able to break down carbohydrates into glucose to be able to use it for energy. The cells of the body depend on insulin as a hormone and, in type 1 diabetes, insulin therapy is required for a lifetime. Type II diabetes is the most common form of diabetes and results in insulin resistance. It is a chronic condition centered around the way the body uses glucose, nutritional intake, and exercise. Like type 1 diabetes, it requires continual monitoring and testing to prevent interrelated diseases, such as neuropathy, kidney, heart, and eye diseases. It is estimated that 29.1 million people in the United States have diabetes; however, it is estimated that 8.1 million may not be diagnosed or aware that they have diabetes.3 Latent autoimmune diabetes (LADA), or diabetes “1.5,” is a diabetic disorder in adults with progressive involvement of B cells, eventual B cell failure, and the immune system. It typically affects individuals over thirty years old and potentially individuals of slender body frame and normal weight. Similar to type 1 diabetes, the pancreas stops producing adequate insulin. However, latent autoimmune diabetes is immune related and, although insulin may not be required immediately upon diagnosis, as the body is unable to produce insulin itself, insulin may be necessary. Chronic inflammation may greatly contribute to its onset, as well as poor nutritional habits, toxins, stress, and sedentary lifestyle. WHAT IS THE RELATIONSHIP OF DIABETES AND THE SKIN? One of the potential early warning signs of diabetes is frequent urination and excessive thirst. This symptomology is linked to skin dehydration and heightened skin sensitivity. The body reabsorbs glucose as it passes through the kidneys; however, in diabetes, blood sugar rises and the kidneys have difficulty in re-absorbing glucose, resulting in more production of urine, prompting frequent urination and increased thirst. As the body is using more fluids to produce urine, the skin becomes dehydrated, increasing the potential for skin sensitivity, itching, scaling, and, in some individuals, petechiae or bleeding from scratching. This syndrome can also be problematic, as diabetics may be more prone to skin infections as a result of compromised barrier function. More serious diabetic skin conditions may include: ancanthrosis nigracans boils bullosis diabeticorum carbuncles diabetic dermopathy digital sclerosis disseminated granuloma annulare eruptive xanthomadtosis folliculitis necrobiosis lipoidica diabeticorum shingles staph infections styes vitiligo Endocrinologists pay particular attention to glycated proteins in diabetic tissue. Glucose in the blood and other body fluids can attach to many various protein molecules in the skin and other tissues. Glycated proteins (AGES) form stiffer tissues, glycated skin, and compromised blood vessel walls that can impact blood pressure. Glycated proteins can be measured and observed by physicians on the skin surface with an AGE reader, as they reflect fluorescence differently than non-glycated skin.4,5 Chemical peels and related skin peeling agents, microdermabrasion, dermaplaning, microblading, heat-based, and laser therapy warrant very careful consideration and, in most cases, direct contraindications, as the potential risks outweigh the benefits. This is particularly true of individuals with multiple disease states, such as diabetes, high blood pressure, heart disease, glaucoma, thyroid, or many autoimmune diseases. Another potential complication is the intake of multiple medications, including diabetic medications and blood thinners that may either cause unknown skin sensitivity or bleeding or may provoke other reactions. The recommended approach for all individuals with skin sensitivity is to avoid heat, steam (the Lucas Championniere is recommended), exfoliants, and peels and to ensure the products you are working with have been specifically formualted or approved for sensitive skin. The best approach is a safe approach and less is more for reducing the opportunity for skin sensitivities. References 1 “Chemical Sensitivity.” American Academy of Environmental Medicine. https://www.aaemonline.org/chemicalsensitivity.php. 2 Meggs, William J. “The Role of Neurogenic Inflammation in Chemical Sensitvity.” Ecopsychology 9, no. 2 (2017). https://www.liebertpub.com/doi/full/10.1089/eco.2016.0045. 3 “Type 2 Diabetes Statistics and Facts.” healthline. https://www.healthline.com/health/type- 2-diabetes/statistics#1. 4 Fokkens, Bernardina T. and Andries J. Smit. “Skin fluorescence as a clinical tool for non- invasive assessment of advanced glycation and long-term complications of diabetes.” Glycoconjugate Journal 33 (2016): 527-535. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975757. 5 “Non-invasive assessment of cardiovascular risk and risk of diabetes.” Diagnoptics. https://www.diagnoptics.com. 6 Inamadar, Arun C. and Aparna Palit. “Sensitive skin: An overview.” Indian Journal of Dermatology, Venerology, and Leprology 79, no. 1 (2013). https://pdfs.semanticscholar.org/f1d3/03e100c06036fb0c6115446ea23511430d25.pdf. Erin Madigan-Fleck is a licensed aesthetic instructor and aesthetician with more than 30 years of experience in the aesthetics and wellness industry. She is NCEA certified, holds a doctorate in naturopathic medicine, and is the owner of DermaEducation TV post-graduate aesthetic training. She has a private practice, Naturophoria, in Atlanta, Georgia and can be reached at dermaeducationtv.com. Want to read more? Subscribe to one of our monthly plans to continue reading this article.