Good Times Magazine - How To Cope With Sensitive Skin, January/February 2015

Does it seem as if your skin is becoming more irritable with the passing years? Maybe you find that certain areas of your body periodically become itchy and irritated, or even break out in some kind of rash, and you have no idea why. Or perhaps your face has suddenly begun to sting or burn after a skin-care product or cosmetic that you’ve been using for years, or after doing household chores that never bothered you in the past, such as washing dishes.

For a variety of reasons, this isn’t an uncommon story after age 55. For one thing, there are certain skin conditions (such as psoriasis and rosacea) and systemic diseases (such as hyperthyroidism and certain liver problems) that frequently occur after age 55 and can cause some of these symptoms, rendering the skin more apt to become irritated by things that come into contact with it. At this stage in life, we’re also more likely to be taking medications, some of which can similarly affect the skin. But the leading suspect by far is a weakening of the skin’s protective barrier.

A number of factors can cause or at least contribute to the latter problem: the first is an age-related decline in the production of oils that act much like a plastic cover on a swimming pool – preventing moisture from escaping and keeping various substances in our environment from directly touching the inner surface.

“As we get older, our skin becomes less capable of retaining moisture, so it naturally starts to become dry,” explains Dr. Ian Landells, a St. John’s dermatologist and clinical associate professor at Memorial University of Newfoundland. “Areas of skin that are chronically sun-damaged also become dry. And the drier our skin is, the more easily things can penetrate it and irritate it.” Consequently, he says, “we can develop fragrances, wools, and other things that ordinarily are not a problem.”

In some susceptible people, when these types of substances repeatedly breach the skin’s barrier, the immune system begins attacking them during any subsequent exposure: these people, then, have developed true allergies to the materials in question. “But it’s much more common simply to be irritated by such a substance,” Landells says. (A true contact allergy and so-called irritant contact dermatitis can cause similar symptoms, including blisters or a raised red rash and itching or burning, so it can be difficult to tell the difference. One clue: irritant-triggered reactions tend to occur soon after contact, while it may take a day or two before an allergic rash begins to bloom.)

Aging isn’t the only thing that damages and depletes the skin’s protective shield, says Dr. Jason Rivers, medical director of Pacific Dermaesthetics in Vancouver and a clinical professor of dermatology at the University of British Columbia. Long hot baths and showers can strip away more of the skin’s natural oils, particularly if you also use soaps that degrease the skin. (Landells says that he often sees people with a dry, itchy scaly patch on their backs – right where the hot water from the shower beats down.) In winter, the humidity indoors typically drops sharply, and the ensuing hot dry air can leach moisture from the skin. In some cases, the skin can get so severely dry that it becomes scaly and cracked.

“Because of that, you can get what we call asteatotic dermatitis or winter itch,” Rivers says. “It becomes like a feedback loop where you scratch and itch, and scratch and itch, and that just makes it worse.”

According to Landells, other things that can contribute to skin dryness are certain medications, such as diuretics (which are often used to treat high blood pressure) and cumulative damage from the sun’s ultraviolet rays. “Areas of the skin that are chronically sun-damaged also become dry and more easily irritated,” he notes. (A number of medications, including the diuretic hydrochlorothiazide, can also make the skin more sensitive to sunlight, and therefore more easily sunburned. See sidebar on page 25 for the names of other medications that can cause increased sensitivity to UV radiation.)

Several skin conditions, such as eczema, psoriasis and rosacea, can also render the skin more sensitive to certain irritants. Other medical issues (such as diabetes and thyroid disease) can also cause dry skin. The same phenomenon that causes varicose veins – a decline in the efficiency of the one-way valves in the blood vessels that return blood from the feet and legs back to the upper body – can also cause the skin on the lower extremities to become inflamed and more easily irritated, Rivers says. “The blood can pool a bit,” he explains; this fluid build-up can lead to swelling and skin irritation – a condition known as stasis dermatitis.

With all of these potential contributors, it’s easy to see why sensitive skin is as common as it is after age 55. But that doesn’t mean that you have to resign yourself to scratching: while you can’t turn back the clock and make your skin younger, you can use some simple strategies to help minimize skin dryness, discomfort, and irritation.

Moisturize, Moisturize
The first steps in soothing and minimizing dry skin are to get a little moisture back into it, and then seal it in. So-called moisturizers don’t actually add water to the skin, but a daily short lukewarm bath helps skin soak up a little H20. “Showers are more drying than baths,” says Dr. Lisa Kellett, a Toronto dermatologist. Kellett suggests avoiding the use of soap, and adding a little Aveeno oil or something similar to the bathwater to help lock in moisture.

Applying a moisturizer all over after bathing is another strategy that helps offset the loss of your body’s natural oils, Landells says. “Even people who’ve never had to use moisturizers, as they get older, may need to do so,” he says. “Another little trick is to put moisturizer on the skin before you dry off,” Kellett says. (And when you do towel down, dab gently rather than rubbing vigorously.) Liquid moisturizers tend to evaporate more quickly, so choose a thick ointment or cream. You may have to experiment a little before you find one you like using. Kellett says that petroleum jelly is the best choice because it creates a barrier, but it’s not the most practical option. Instead, you can try products containing ceramides or urea, which are moisture-retaining substances found naturally in the skin’s protective barrier. Lubriderm, Curel and Eucerin are a few of the over-the-counter options. (You can find a list of products that are suitable for sensitive skin on the Eczema Society of Canada website: www.eczemahelp.ca.)

When it comes to choosing moisturizers, cosmetics, body washes, cleansers, and other products that come into contact with the skin (such as laundry detergents), look for options that are free of fragrances (including essential oils) and dyes, both of which are common irritants. Landells recommends skipping fabric softeners and dryer sheets altogether. According to Kellett, even some ‘unscented’ options contain fragrances: so-called masking fragrances to hide the smell of the products’ other ingredients, some of which would otherwise smell unpleasant.

Another thing you can do is look for products featuring the Canadian Dermatology Association’s ‘Skin  Health’ logo. “If that’s there, the product complies with the Skin Health Program guidelines,” Landells explains, “which means that it’s fragrance-free and doesn’t contain common contact sensitizers and allergens, and doesn’t contain any ingredients that are considered potentially toxic. It’s not perfect, but it does give people with sensitive skin some direction.”

While we’re on the subject of sensitizers and allergens, don’t assume that just because something is organic and/or natural, it’s safe for sensitive skin. “A lot of people are using things like tea tree oil and vitamin E because they’ve read that these things are good for the skin,” says Landells, “but these are notorious contact sensitizers and people can develop allergies to them.”

Another group of ingredients that can be problematic for people with sensitive skin is used in chemical peels, as well as in products that are used to remove dead skin cells and fade age spots. “In general, avoid glycolic acid, lactic acid and salicylic acid, all of which could be irritating for someone with sensitive skin,” Kellett advises. On the other hand, she says, if the skin on your face is sensitive due to cumulative sun damage, certain products containing topical vitamin A may help reverse this sensitivity to some degree. Those containing up to 1% vitamin A are available over the counter, while stronger concentrations are prescription-only. “Look for serums or liquids, not creams,” Kellett says, “because they’re less irritating.”

And while protecting your skin from the sun is the best way to keep it looking youthful, certain sunscreen ingredients can also prove irritating to some people with sensitive skin. In general, titanium oxide and zinc oxide, which physically block ultraviolet rays, are less likely to cause problems than are chemicals that prevent sun damage by absorbing UV. Nevertheless, the best sunscreen is the one you’ll actually use, so if you don’t like the feel of one, try another.

One strategy that can save you a lot of grief when you’re trying out a new cosmetic or skin-care product is patch-testing. “I tell people to use a little bit on their forearm, two or three times a day,” Kellett says. If, after several days, there’s no sign of irritation, then go ahead and use it on your face or body, she says.

Potential irritants aren’t the only things to avoid, however. While they may not be directly irritating, certain products or ingredients can contribute to sensitive skin by drying it out. Ethyl alcohols are one example: these are commonly used as preservatives and as one of the principal components of many toners. (By contrast, ‘fatty’ alcohols such as cetearyl alcohol stearyl alcohol, which are used as thickeners in moisturizers, help reduce water loss from skin.) Soaps can also be problematic: many people with sensitive skin find liquid soaps irritating, thanks to ingredients such as foaming agents and chemicals that keep the products fluid.

While some people with sensitive skin can use a mild ‘moisturizing’ soap such as Dove, others find that any soap is too drying. “It’s going to be hit-and-miss,” Kellett says. “Some people are fine with one thing and not another.” If you use soap and your skin remains dry and sensitive even after you adopt a regular regimen of bathing and moisturizing, try switching to a gentle non-soap cleanser such as Cetaphil.

Next Steps
If problems such as dryness, itching, burning and redness don’t improve after a few weeks of faithfully following the above advice, it’s worth visiting your doctor or dermatologist. With just a careful history and examination, he or she may be able to identify the underlying culprit and prescribe a corresponding treatment.

Itching (which may be particularly bad at night), redness, blistering and/or weeping, and dry, scaly, cracked skin can all signal atopic dermatitis (otherwise known as eczema) which is thought to be linked to an abnormal reaction of the skin’s immune system. While the measures previously outlined are integral to managing eczema, sometimes it’s also necessary to quiet this abnormal activity, usually starting with a topical corticosteroid cream. “Sometimes I prescribe menthol with the steroid as sort of a counter-irritant,” UBC’s Dr. Jason Rivers says. (For night-time itching that’s severe enough to interfere with sleep, oral antihistamines such as Benadryl can sometimes be helpful, too.)

On the other hand, raised bright-red patches of skin covered with silvery scales (which may be accompanied by itching) hint at psoriasis, a condition that causes skin cells to mature up to ten times faster than normal and pile up, forming thick patches called plaques. Experts believe that psoriasis is caused by an immune system malfunction (and indeed, many people with psoriasis go on to develop an autoimmune disease called psoriatic arthritis) in which a specific type of white blood cell becomes activated and triggers inflammation and the abnormally rapid replacement and shedding of skin cells. There are a variety of treatments used to control psoriasis, beginning with topical creams containing corticosteroids, derivatives of vitamin D, and coal tar. (Doctors don’t understand exactly why moderate amounts of UV light seem to improve symptoms in some people; however, sunburn can worsen the condition.)

Flushing and gradually worsening redness on areas of the face (typically the cheeks, nose, forehead and/or chin), which may be accompanied by small red bumps or pimples, can be indicative of rosacea. (Sometimes the eyes are also affected: they may appear bloodshot and feel gritty, for example.) As with eczema and psoriasis, a susceptibility to the condition – which also appears to involve the immune system – may be inherited, though environmental factors such as chronic sun exposure, and the same bacteria that causes stomach ulcers (Helicobacter pylori) are also thought to play a role. Some of the treatments for rosacea include topical preparations containing corticosteroids (these help reduce inflammation) or a vitamin A derivative called tretinoin (which prevents acne pimples and hastens the rate at which old, damaged skin cells are replaced with healthy new ones) and oral antibiotics (which are thought to help by damping down inflammation).

Rough, elevated, scaly, wart-like bumps on areas of sun-exposed skin may be growths called actinic keratoses which can potentially develop into a form of skin cancer called squamous cell carcinoma. “If you have lots of actinic damage, we can use something called photodynamic therapy,” Kellett says. This treatment involves pre-treating the damaged cells with a medication that is activated upon exposure to a certain type of light. The resulting reaction destroys the abnormal cells without harming adjacent normal tissue. “The newest thing is to use it all over the face,” Kellett explains. “In doing so, you treat all the precancerous spots and actually make your skin less sensitive.” While the treatment isn’t covered by provincial health plans, Kellett adds, “a lot of insurance companies cover it because it’s a preventative therapy for skin cancer.”

Much more rarely, other, more serious conditions can mimic some of the symptoms discussed above. Rough, scaly patches of skin resembling eczema on or around the nipple, for example, can signal a form of breast cancer called Paget disease, and a scaly red rash on areas of the skin not exposed to the sun can sometimes be a sign of a form of mycosis fungoides, a type of lymphoma.

“Any time you have dry spots that keep coming and going in the same location, or don’t respond to conventional remedies, get a physician to check it out,” St. John’s dermatologist Dr. Ian Landells stresses.

While the odds of something dire being wrong are relatively small, these dry patches are worth being evaluated by an expert, who can help you develop a management plan and perhaps even save you money on skin care products in the long run. “I like patients to come in and bring what they’re using,” Kellett says. Not only can this help identify any products that might be contributing to skin irritation, she says, “often, people are using far too many things, and I can streamline it and say, ‘This is what you need, and this is what you don’t need.’ That can be quite helpful.”