The Science of Sensitive Skin: Evidence-Based Cleansing and Moisturizing Practices for Protecting and Repairing the Skin Barrier: Part 1

Sensitive skin, whether clinically validated or self-reported, represents a major and often underrecognized clinical challenge. In a Dermatology Times^® Between the Lines program, Zoe Diana Draelos, MD, a clinical and research dermatologist, and Cheri Frey, MD, an assistant professor in the dermatology department at Howard University, discussed evidence-based cleansing and moisturizing practices for sensitive skin. This summary of their discussion provides dermatologists and other health care professionals with practical insights to improve outcomes for individuals with self-perceived and clinically diagnosed sensitive skin.

The Skin Barrier

The skin barrier plays an important role in maintaining moisture in the skin. “I like to describe the skin barrier as your body shield,” said Frey. “When it’s healthy, it locks in moisture. It keeps the irritants out. But when it’s disrupted, it loses water, and so it will develop dryness, irritation, and then inflammation.” Regarding skin barrier structure, Draelos thinks of it as a brick wall “in which the bricks are the corneocytes and the mortar is the intervening intracellular lipids,” she said. Within that structure, filaggrin and natural moisturizing factor (NMF) are essential for hydration and proteostasis, while aquaporins regulate water transport. Draelos noted filaggrin’s role in producing NMF components (lactic acid, amino acids), emphasizing that the skin’s own moisturizing machinery is a key therapeutic target.

Stressors to the Skin Barrier

The experts highlighted that the skin barrier is constantly challenged by endogenous and exogenous stressors, which can contribute to the development of sensitive skin. Beyond classic external factors, such as weather, pollution, and ultraviolet radiation, sleep and lifestyle factors are increasingly recognized contributors to skin health. Skincare rituals can be another major exogenous stressor to the barrier. “[Considerable] damage can be done by the products that patients think are helping improve their skin,” shared Frey.

When the skin barrier is compromised, it can no longer trap water in the skin, which results in transepidermal water loss (TEWL). “Water escapes more easily, and that’s what leads to dryness or tightness and even sensitivity,” said Frey. “The therapeutic goal comes back to strengthening the barrier so it’s able to help maintain that water balance.” Draelos noted that TEWL operates both as a measurable biomarker and as a biologically instructive signal that triggers barrier repair pathways. “TEWL is the message that tells the body that the skin barrier has been breached,” she said. “The barrier healing process can be activated by only 1% TEWL.” This process can be leveraged with therapeutic interventions, which should reduce TEWL enough to permit repair while not completely masking the signal required for physiologic healing.

Clinically Validated vs Self-Perceived Skin Sensitivity

Sensitive skin may be either clinically validated with a diagnosable condition such as eczema, rosacea, or acne, or self-perceived with subjective symptoms (eg, stinging, burning) in the absence of visible signs. Clinically validated sensitive skin often demonstrates objective barrier dysfunction, such as elevated TEWL, erythema, and scaling, whereas self-perceived sensitive skin may have normal TEWL and yet intense symptoms triggered by specific products or exposures.

For patients who initially present with self-perceived sensitive skin, Frey emphasized the importance of making sure there is no underlying diagnosis. “[When] patients complain about these symptoms…I dig,” she said. “Even with something like rosacea, they might just have a lot of stinging and burning. And not every clinic has the tools to measure TEWL or hydration. You need to do a thorough exam to make sure the patient doesn’t have an underlying diagnosis.” For patients who do have self-perceived sensitivity, she stressed a careful history of product use and environmental changes to determine potential triggers.

A Polymeric Surfactant Technology-Based Foaming Cleanser for Sensitive Skin

The efficacy and tolerability of a foaming facial cleanser was assessed in a single-center, open-label, 4-week study involving 85 men and women with clinically diagnosed sensitive skin that was caused by atopic dermatitis, eczema, cosmetic intolerance syndrome, or acne. This cleanser contains both polymeric cleansing technologies and amphoteric and anionic surfactants, a combination that delivers mild cleansing properties while generating substantial foam.

Outcomes showed considerable improvements in visual smoothness, tactile softness, clarity, radiance, and overall skin appearance (Figure 1).¹ No increases in erythema, irritation, peeling, tactile roughness, or dryness were observed.¹ “What I find most interesting [about these findings],” said Draelos, “[is the improvements from baseline in outcomes, such as visual smoothness and tactile softness]. These are attributes that you would typically ascribe to a moisturizer. But here, we’re able to ascribe them to a cleanser, because it doesn’t cause barrier damage. You don’t have to have a moisturizer if you use a proper cleanser to see these skin benefits.” Frey reiterated the advantage of this cleanser maintaining the skin barrier and moisturizing. “Without using a moisturizer, this cleanser is repairing the skin barrier, improving hydration, and moisturizing the skin, which is then going to make the skin less sensitive.”

Part 2 coming soon