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Hot and Bothered: Treating Reactive Skin

Contact Author By Mark Lees, Ph.D., M.S., CIDESCO Diplomate
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How many of your clients have skin that gets red or breaks out easily? These clients have what skin therapists frequently call “reactive skin.” Reactive skin is not an official medical term, but is an esthetician-coined title that describes a skin that shows different types of reactions easily when exposed to certain products, ingredients, treatments or environmental factors.

Reactive skin may include genetically sensitive skin, acne-prone skin, skin with allergies, irritant reactions, ingredient sensitivities, rosacea and redness-prone clients. These clients seem to have a lot of problems finding products or treatments that don’t cause problems for their skin.

Analysis of Reactive Skin

Clients who have reactive skin will often tell you on their first visit about their issues. It is important to talk about this with the client so you can specify what type of problems they have experienced in the past.

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While many clients will tell you they have sensitive skin, the truth is that most people do not have sensitive skin. Instead, they have had some sort of reactive issue to a product in the past and believe that their skin is sensitive. Clients also often say they have sensitive skin, when they really have acne-prone skin. They break out in acne flares or have a tendency to have congested pores, but they have erroneously labeled this to be sensitive skin. They may have overused an exfoliating product such as benzoyl peroxide, had an irritant reaction and now believe they have sensitive skin.

True sensitive skin is attributable to genetics and characterized by a history of histamine reactions causing such symptoms as urticaria (hives), erythema (redness), edema (swelling), rashes, as well as subjective symptoms such as itching, stinging and burning. The subjective symptoms are indicative of nerve stimulation. These symptoms may be brought on by topical agents, fragrance components, mechanical friction (including scrubs and rough textured cloths, etc.) and even extreme temperature changes. The immune response of this sensitive skin causes the release of histamines and increased blood flow to the area, resulting in the symptoms discussed above.

Sensitive skin is thin to the look and touch. Blood vessels may be visible, and the skin has a translucent appearance. When you press on this skin, it touch-blanches easily, meaning the area pressed will quickly turn white and then quickly return to its pink tone. This simple test shows the skin therapist that the blood vessels (and nerve endings) are close to the skin surface, allowing a more sudden and pronounced immune response when irritated. Some clients will even redden when the skin is cleansed.

Genetic Factors

Clients with reactive sensitive skin often have Fitzpatrick Type I skin. This skin type burns easily, has very pale, light coloring, turns pink easily from heat or cold and looks almost translucent. These clients have blood vessels and nerve endings closer to the skin surface than other clients with non-reactive skin. Because of their skin thinness, exfoliants and peels can sometimes wreak havoc with irritant reactions. The skin becomes stimulated much faster than other skin types. They may also have redness flares from certain essential oils and fragrance components.

Many of these clients will also have red or light colored hair, and often blue or green eyes. They are likely of western European descent such as Irish, British or Scandinavian heredity.

Because they have had this skin type from birth, they are usually aware of their sensitivity, as most have already experienced irritant and inflammatory issues with their skin before they even see a skin therapist.

It should be mentioned here that darker skin types (Fitzpatrick IV–VI) can also have sensitive skin. Darker skin is prone to lipid barrier damage and may exhibit similar symptoms. Often, clients with darker skin and barrier damage will note that certain products burn and cause them skin discomfort. Redness is less recognizable on many darker skin clients, so pay attention to their observations of stinging, burning
and discomfort.

These clients with genetically thinner skin must always be careful with exfoliating chemicals or ingredients, stimulating treatments and mechanical treatments like microdermabrasion. The skin therapist is responsible for noticing this hereditary condition and taking care to avoid common irritants, allergens and being conservative with exfoliating treatments to protect this fragile skin from treatments that might cause inflammatory reactions.

Clients who have autoimmune diseases may have heightened sensitivity to various treatments, ingredients and products. Clients who have lupus, psoriasis and fibromyalgia are examples of this type of client. It is best to consult with both these clients and their physicians to determine the best course of treatment. It is advisable to start programs slowly with these clients, to introduce one product at a time to this skin, and avoid any peeling, stimulating or more aggressive treatments until you are able to have significant time to observe the responses of this skin.

Acquired/Transitional Sensitive Skin

“Acquired” sensitive skin (also known as transitional sensitive skin) is skin that has had an irritant reaction to a product or other topical agent and its lipid barrier damaged by environmental exposure or, most often, over-exfoliating or over-cleansing. The lipid barrier is the complex of lipids that fill the spaces between cells in the epidermis. These lipids are produced during the cell turnover process. The lipids keep essential moisture in the skin, prevent skin dehydration and block the penetration of potentially irritating substance, signifying what is termed barrier function.

Irritant reactions are the most frequent adverse reaction seen in an esthetics practice. They are caused by over-exfoliation and the overuse of exfoliants and surfactant foaming-type cleansers, which remove parts of the lipid barrier that fills the gaps between cells in the epidermis. These gaps allow essential moisture to escape from the epidermis, resulting in dehydration. These gaps also allow irritants to easily penetrate the skin. When irritants penetrate the epidermis, immune function is initiated, resulting in redness as well as potential histamine reactions, such as urticaria and swelling. Repeated exposure to the exfoliants and surfactant cleansers continue to further injure the lipid barrier and increase the severity of the symptoms.

Besides redness, signs of lipid barrier damage include flaking, “crinkly” dehydration, tactile roughness, lack of firmness and may also include stinging and burning, including from skin care products that do not normally cause discomfort. If a client has ever told you that everything she uses burns or stings, this is indicative of lipid barrier damage. See Products Linked to Lipid Damage for a list of products and descriptions of their actions.

Restoring the Barrier

When surfactant cleansers, exfoliating agents and stimulant ingredients are discontinued, ceramide-infused products can help the skin recover relatively quickly.

Surfactant switch. Discontinue surfactant cleansers and replace them with non- or low-foaming cleansers that have been dermatologist tested for their skin irritancy potential.

Nixing fragrances. Avoid fragranced products and products containing stimulants including stimulating essential oils. Vitamin C acid serums can also irritate.

Avoid exfoliating chemicals. Retinol, alpha hydroxy acids (glycolic, lactic, mandelic acids, etc.), proteolytic enzymes and other exfoliating ingredients should be avoided until the skin is no longer exhibiting sensitive symptoms. These exfoliating chemicals are helpful ingredients for many conditions, but their overuse or use in too high of a concentration or with too low of a pH, can wreak havoc on the epidermal lipid barrier.

Ceramides. Restoring the lipid barrier to help sensitive skin includes client use of fluid moisturizers or serums containing ceramides, lipid complexes that mimic natural lipids and work by patching gaps in the barrier function. Other lipid replacement ingredients include phospholipids, sphingolipids, essential fatty acids and cholesterol. Ceramides can be blended into sunscreens, hydrators, eye crèmes, concentrated serums and masks. Additionally, ceramides are also helpful in treating many signs of aging and sun-damaged skin.

Allergic Reactions

As previously mentioned, most adverse reactions in the skin care practice are irritant reactions, but occasionally there will be a true allergic reaction.

Not caused by over-exfoliation like most irritant reactions, allergic reactions may result in swelling, urticaria, severe erythema and will occur whenever that client is exposed to the allergen. The client’s immune system has identified the allergen as offensive and released chemicals to try block the allergen, leading to swelling and redness. Removal and discontinuation of the use of the offending agent will stop the reaction. Allergies to topical products only affect a small number of people.

The No. 1 ingredient to which clients might be allergic is fragrance. This is followed by preservatives, color agents, some sunscreen ingredients, proteins and various ingredients in nail products.

Acne- and Clog-Prone Skin

Acne and clog-prone skin can be worsened by certain ingredients. Comedogenic ingredients are most often fatty vehicle agents in skin care or cosmetic products. Because vehicles are spreading agents, they are often in the product in large concentrations. These fatty ingredients penetrate the follicle, contributing to cell buildup that eventually clogs the pore, and perhaps becomes an acne pustule or papule.

Acnegenic ingredients cause irritation and inflammation inside the follicle resulting in often overnight papules. If a client breaks out in papules or pimples after starting a new product, this is an acnegenic reaction. If you notice that this happens frequently with a certain product, that product is not appropriate for anyone with acne-prone skin.

When choosing products for acne-prone and congested skin with clogged pores, look for products that have outside dermatologic testing to show that they are unlikely to cause problems for acne-prone clients.

Take Care

Most reactions to products are caused by the wrong choice of product for the specific skin condition or overuse of a product by either the client or the esthetician. Be careful to follow manufacturer’s instructions, use products that have been properly tested and carefully follow what your clients are using at home. Severe reactions or chronic reactive skin that does not clear should be referred to a dermatologist or allergist.

Clients with red hair tend to have reactive sensitive skin.

Mark Lees, Ph.D., M.S. is the founder and owner of Mark Lees Skin Care Salon. He is a speaker, clinical skin therapist and product developer, specializing in acne, sensitive and aging skin. He is also a published author of two books.

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