7

Sensitive Skin and Moisturization

Paolo U. Giacomoni
Clinique Laboratories, Inc., Melville, New York

Neelam Muizzuddin,
Rose Marie Sparacio, Edward Pelle,
Thomas Mammone,
Kenneth Marenus, and Daniel Maes
Estee Lauder, Melville, New York

1 INTRODUCTION
Skin moisturization is a state of the surface of the skin, which is more often rec-
ognized by the individuals when moisturization is lacking, and when one has skin
conditions that can be called dry, very dry, rough, or even ichthyotic. The mois-
turization of the upper part of the skin is likely to be dictated by the presence of
lipids, water, urea, and other compounds. It can also be considered to be the con-
sequence of how well the outer envelope of the skin opposes the evaporation.
Several authors have undertaken to measure the water content of the outer surface
of the skin. Other authors have emphasized the importance of the so-called trans-
epidermal water loss (TEWL), expressed as grams of water per square meter per
hour. The capability of the skin to oppose water evaporation can be equated to its
capability to provide an overall barrier. The measure of TEWL provides informa-
tion on the changes in moisturization induced by a treatment, which does not af-

145
146 Giacomoni et al.

fect the barrier, and on changes of the barrier properties induced by a treatment,
which does not affect moisturization.
Skin sensitivity is a self-assessed diagnosis of a physiological state that
lacks rigorous clinical definition, complete etiological analysis, and accurate di-
agnostic tools. This undesirable state of the skin is characterized by a disagree-
able feeling on the surface of the skin or by the observation of hyper-reactivity of
the skin when it is exposed to mild environmental conditions such as water, wool
fabrics, or cosmetics. According to Draelos [1], approximately 40% of the popu-
lation believes it possesses the characteristics of sensitive skin, as determined by
consumer marketing surveys. The characteristics of sensitive skin are the ones
felt when, in response to topical application of cosmetics and toiletries, stinging,
burning, pruritus, erythema, and desquamation are observed. Yet, as late as in
1997, Draelos noted, “Given the current incomplete knowledge of the sensitive
skin condition, it is impossible to arrive at a consensus regarding the definition
and origins of sensitive skin” [1].
The definitions of sensitive skin and of skin moisturization are partially
subjective, and different people do react differently to the feeling of dry skin. It
has been therefore particularly difficult to design experimental protocols and to
interpret the results of experiments in the field of skin sensitivity and moisturiza-
tion. These experiments are generally aimed at pointing out physiological and
molecular properties able to allow one to better understand the phenomenon of
sensitive skin.
Skin sensitivity and skin dryness are also encountered in mature individu-
als, and questions have been asked about the correlation between the appearance
of skin sensitivity and the onset of those physiological phenomena that character-
ize aging in women.
In this chapter we summarize some of the experimental results obtained in
this field and the interpretations that have been proposed.

2 TESTING METHODS
2.1 Testing for Sensitive Skin
Many tests are available to determine whether the sensitive behavior is the conse-
quence of specific skin conditions, such as rosacea, contact dermatitis, acne, and
dry skin, or the consequence of the etiologically undefined skin sensitivity of a
given population to topically applied compounds. Among these, we would like to
recall the cumulative irritancy test [2], repeat insult patch test [3], chamber scari-
fication test [4], and the soap chamber test [5]. All these tests are performed by
topical application of compounds after a penetration-enhancing treatment of the
skin.
Sensitive Skin and Moisturization 147

2.2 Testing for Skin Moisturization

Instruments for measuring skin moisturization do exist. They measure the numer-
ical values of physical parameters of the surface of the skin which can somehow
be correlated to the content of water of the upper part of the epidermis and of the
stratum corneum. The dermal content of water can be assessed by nuclear mag-
netic resonance or by high frequency ultrasound [6], but these techniques hardly
provide information about the state of hydration of the surface. This can be as-
sessed by electrical devices able to measure the electrical impedance of the outer
part of the skin (less than 0.1 mm deep) [7] as it is understood that the conductiv-
ity increases with the content of water on the surface of the skin. It has been re-
ported that these instruments do not provide consistent results [8] and have to be
calibrated with one another.
In addition to the direct measurement of the water concentration in the top
layers of the skin, some techniques allow for the evaluation of the indirect conse-
quence of the presence of water in the stratum corneum. Measurements of the pli-
ability of the horny layer in vivo using the gas bearing electrodynamometer [9]
have been shown to correlate directly with the water content of the stratum
corneum. The advantage of this technique is that it is not subjected to all the in-
terference known to affect the direct measurement of the water content of the skin
by conductimetry (presence of hydroxyl anions or metal cations, for example).
Interestingly enough, the measure of the amount of water molecules (in the
gaseous state) above the surface is in good correlation with the electrical mea-
surements. Indeed when the conductivity is low (low content of water in the out-
er surface of the skin), the TEWL is high. It is thus not unreasonable to consider
that a high value of the concentrations of water above the skin is the consequence
of high concentrations of water below the surface (as in the case of an edema).
One could also conclude that high TEWL is associated with a poor skin barrier
function. If this conclusion holds, then one can suggest that a barrier unable to
keep the water inside will also be less efficient in maintaining molecules to which
we are continuously exposed out of the skin. Since environmental factors are of-
ten associate to phenomena of irritation or sensitivity, it might be interesting to
look for a correlation, if any, between barrier function and skin sensitivity.

3 PROPERTIES OF SENSITIVE SKIN

Experiments performed in our laboratories have allowed us to recognize that
there is a negative correlation between the self-assessed sensitivity of the skin and
the barrier function of the skin of the same individuals, measured as susceptibili-
ty to respond to standard irritant treatment [10]. Observations were performed by
comparing the results obtained in two cohorts of volunteers, one of people esti-
148 Giacomoni et al.

mating themselves as having nonsensitive skin, the other formed by people esti-
mating themselves to have sensitive skin. Female volunteers were included in the
studies, if they were in normal health, with no evidence for acute or chronic dis-
eases, including of course dermatologic and ophthalmologic problems. The test
sites were devoid of nevi, moles, scars, warts, sunburn, suntan, and active dermal
lesions. Pregnant or lactating women were not included in the study. The volun-
teers answered a questionnaire pertaining to the reactivity and sensitivity of their
skin and were then separated in two groups, sensitive and normal, according to
the answers to the questions in the questionnaire. On the day of the test, the vol-
unteers were instructed to refrain from applying any kind of product to the face.
All the tests took place in a controlled environment at 20°C +/– 1°C and 40% rel-
ative humidity.

3.1 Stripping and TEWL

In one experiment with about 100 volunteers per group, TEWL was measured on
the cheek for every other volunteer, then a sticky tape (Tesa, Rochester, NY) was
applied on the site, made to adhere with gentle strokes, and removed with an even
pulling. After measuring the TEWL in the stripped site, sticky tape was applied to
the same site and the operation repeated. In this way, the upper layers of the stra-
tum corneum were removed. The TEWL was measured after every stripping. The
average number of tape strippings necessary for doubling the TEWL was about
10 for the “sensitive skin” cohort and about 20 for the “nonsensitive skin” cohort.
The results are summarized in Fig. 1.

3.2 Stinging Test

Another experiment with two cohorts of about 40 volunteers each was performed
by randomly applying to the nasolabial fold on the two sides of the face equal vol-
umes of lactic acid (10% in phosphate buffered saline) or of saline alone. Reac-
tions (itching, burning, or stinging) were recorded 2.5 and 5 min after application.
The intensity of stinging was graded by the volunteers, as nil, mild, moderate, or
severe (scored as 0, 1, 2, or 3). The results indicated that the sting score upon lac-
tic acid challenge was 0 or 1 for more than 80% of the volunteers in the “nonsen-
sitive skin” group, whereas it was 2 or above 2, for 75% of the individuals in the
“sensitive skin” group. The results are plotted in Fig. 2.

3.3 Balsam of Peru and Blood Flow

In a third experiment, balsam of Peru, which provokes a nonimmunogenic imme-
diate contact urticaria, was applied to the skin of the cheek of the volunteers. The
blood flow was assessed before the application and at determined time intervals
after the application with a laser Doppler capillary blood flow detector. The aver-
Sensitive Skin and Moisturization 149

Reported Sensitive
Reported Nonsensitive

FIGURE 1 Trans-epidermal water loss versus stripping. Self-assessed sensi-

tive and nonsensitive individuals were stripped and the TEWL was mea-
sured. The graph plots the distribution of the number of strippings necessary
to double the TEWL in sensitive and nonsensitive individuals. (From Ref. 10.)

Reported sensitive
Reported Nonsensitive

FIGURE 2 Sting score and sensitivity. Self-assessed sensitive and nonsensi-

tive individuals were exposed to lactic acid. The graph plots the distribution
of the sting score in the two cohorts. (From Ref. 10.)
150 Giacomoni et al.

Reported Sensitive
Reported Nonsensitive

FIGURE 3 Time course of response to balsam of Peru. The distribution of the

time interval necessary to double blood flow upon application of balsam of
Peru is plotted for two cohorts of self-assessed sensitive and nonsensitive in-
dividuals. (From Ref. 10.)

age time interval necessary for doubling blood flow in the skin was slightly short-
er in individuals with sensitive skin than in individuals with normal skin. The re-
sults are displayed in Fig. 3.
From these experiments it was concluded that skin sensitivity might be as-
sociated with impaired barrier function. An alternative possibility is that sensitive
skin is associated with specific neural response, which induces more severe pain
in the stinging test and slight edema upon stripping

4 CONDITIONS ASSOCIATED WITH SENSITIVE SKIN

4.1 Skin Sensitivity and Psychological Stress
Since there seems to be a relationship between a defective barrier and a sensitive
skin condition, it was reasonable to ask whether or not the sensitive skin condi-
tions observed on people under emotional stress are the consequence of an abnor-
mal barrier function.
To answer that question we undertook a study to evaluate the role played by
acute stress on the barrier function of the skin. Twenty-seven university students
participated in a barrier recovery study. The study was organized during a period
of vacation and repeated during a period of examinations. The second period was
confirmed by an appropriate questionnaire to be more stressful than the vacation
period. Barrier function was disrupted by tape stripping until the TEWL was
about 20–30 g/m2/hr, and then was measured at 3, 6, and 24 hr poststripping. The
Sensitive Skin and Moisturization 151

rate of change of TEWL was used as an indicator of the recovery of barrier func-
tion. The results indicate that the recovery of barrier function is more rapid in a
nonstressful than in a stressful situation. These results point out that psychologi-
cal stress plays a role on the kinetics of recovery of disrupted barrier [11].

4.2 Skin Sensitivity and Age

Data published in the literature indicate that skin sensitivity declares itself or in-
creases in the years of the onset of menopause [12]. This increase in sensitivity
cannot be attributed to the thickness of the stratum corneum, which is known not
to change with age [18]. It is not even the consequence of a change in skin thick-
ness, since in three groups of premenopausal, perimenopausal, and early post-
menopausal women, the average skin thickness did not change in a significative
way (2.28 +/– 0.39, 2.18 +/– 0.35, and 2.02 +/– 0.36 mm, respectively) [14]. It is
indeed known that skin becomes thinner in the years after the onset of menopause
[15]. Other authors have explored the percutaneous absorption of xenobiotics
such as hydrocortisone or testosterone on the forearm of pre- and postmenopausal
women [16] and in two groups of young and old men [17]. They did not observe
differences in the percutaneous absorption in the two groups of women [16], but
observed that permeation of hydrocortisone, benzoic acid, acetyl salicylic acid,
and caffeine were significantly lower in the group of old men [17]. They conclud-
ed: “It is a common misconception that older skin has a diminished barrier capac-
ity, and that percutaneous absorption is therefore greater” [16].
In a study performed in our laboratory, we have analyzed the TEWL of 223
women aged between 21 and 79. The results are reported in Table 1. From these
data it appears that the TEWL is low for young women, it increases by more than
25% for women in their maturity, and returns to lower values above the age of 50.
These data can be interpreted by saying that the older individuals have functional
barrier, as already suggested by the studies of Howard Maibach [16,17], whereas
women in their maturity have impaired barrier because they live a more stressful
life, in agreement with published data [11,18]. Thirty-eight out of the 223 panelists
reported themselves as having sensitive skin. Measurements of TEWL on these
“sensitive skin” panelists are reported in Table 2. It appears that in the age groups
between 31 and 50, the vast majority of the individual levels of TEWL are above
the average of each group (see Table 1). This allows one to conclude that sensitive
skin can be associated with high trans-epidermal water loss.

5 DISCUSSION
Understanding the link between skin moisturization and skin sensitivity is of par-
ticular interest not only to the physiologist and the dermatologist, but also to the
supplier of skin care products for cosmetics.
152 Giacomoni et al.

TABLE 1 Trans-Epidermal Water Loss Versus Age

Age group Average TEWL S.E. S.D. N

21–25 7.95 0.96 2.89 9

26–30 7.60 0.57 2.14 14
31–35 9.98 0.55 2.93 28
36–40 9.67 0.59 3.18 29
41–45 9.46 0.51 2.94 33
46–50 9.09 0.45 2.71 36
51–55 7.88 0.50 2.46 24
56–60 7.10 0.54 2.84 27
61–65 6.43 0.66 2.11 10
66–79 7.20 0.63 2.27 13

Notes: A Group of 223 women participated in the study. TEWL was measured
with a Servomed EPI vaporimeter on the same region of the face (left jaw) for
all the panelists.
N, number of panelist in each age group; S.E., standard error of the mean;
S.D., standard deviation.

Data collected in our and in other laboratories indicate that sensitive skin is
associated with increased TEWL, increased penetrability, and higher susceptibil-
ity to irritants. These parameters can be measured independently and, taken to-
gether, the data agree with the hypothesis that sensitive skin is a clinical state as-
sociated with impaired barrier function. The results of the stress/barrier repair
study add to our understanding and allow us to conclude that stress impairs skin
barrier, thus providing an explanation insofar as why many stressed individuals
claim to have sensitive skin.

TABLE 2 Trans-Epidermal Water Loss and Sensitive Skin

Age group Individual TEWL Average TEWL

21–25
26–30 6.37, 6.57, 8.69, 7.03, 5.40 6.81
31–35 8.5, 12.33, 11.33, 13.77, 4.77, 15.0, 11.33, 5.1 10.2
36–40 12.33, 15.9, 14.21, 6.87, 10.0, 7.6 11.15
41–45 13, 6.4, 11.44, 6.33, 14.67, 9.77, 10.8, 8 10.05
46–50 8.97, 13.67, 9.33, 9.57, 10.33, 9.5, 10 10.19
51–55 11.33, 5
56–60 10
61–65
66–79 8.1
Sensitive Skin and Moisturization 153

When it comes to skin moisturization, not all the results published in the lit-
erature can be interpreted in such an unambiguous way. This is the consequence
of the nature of the experimental devices at hand. They allow one to measure
quantities that generally vary with more than one single variable. For instance,
conductivity values can be the consequence of more or less water on the surface
of the skin, or of more or less electrolytes in the same water content. Larger
TEWL values can be the consequence of worse barrier if moisturization is con-
stant, or of better moisturization if the barrier is constant. Paradoxically, the fact
that sensitive skin requires less tape stripping for achieving a predetermined val-
ue of TEWL could be interpreted by saying that the two types of skin have the
same barrier, but that sensitive skin is characterized by a higher state of water se-
cretion upon stripping than nonsensitive skin. This kind of paradoxical reasoning
can be carried out for all experiments in which quantities are measured that de-
pend on variables which cannot be varied or measured independently one at the
time. It is of concern here to point out that the lack of unambiguous wording adds
to the difficulty in interpreting results. When it comes to skin moisturization, dif-
ficulties are encountered because hydration is only one of the parameters playing
a role in moisturization; suppleness of the stratum corneum, smoothness of the
outer surface, and elasticity of the dermis are parameters which contribute to the
individual evaluation of one’s own skin moisturization.
The biochemical nature of the difference between sensitive and nonsensi-
tive skin is not yet understood. It is tempting to speculate that the relative amount
of lipid molecules participating in the build-up of the barrier might be different in
the two skin types. Preliminary experiments performed in our laboratory failed to
point out significative differences as far as total ethanol-extractable lipids are
concerned, as well as for squalene, free fatty acids, palmitate (16:0), palmitoleic
acid (16:1), oleic acid (18:1), and stearic acid (18:0) (unpublished).
The results reviewed in this chapter confirm the positive correlation be-
tween self-assessed skin sensitivity and increased trans-epidermal water loss. Cir-
cumstantial evidence justifies interpreting this correlation by concluding that skin
sensitivity is associated with impaired barrier function. Interestingly enough, this
correlation is particularly true for mature women. On the other hand, the question
concerning the impairment of barrier function with age remains open, and more
experimental work is needed before a clear-cut conclusion can be drawn.

6 REFERENCES
1. Draelos ZD. Sensitive skin: perceptions, evaluation and treatment. Am J Cont Der-
mat 1997; 8:67–78.
2. Partick E, Maibach HI. Predictive skin irritation tests in animal and humans in der-
mato-toxicology. In: Marzulli FN, Maibach HI, eds. Dermatotoxicology, 4th Ed.
New York: Hemisphere, 1991:211–212.