Sensitive skin is typically characterized by dryness, flaking, sensations of stinging and itching associated with skin redness. It is actually a form of dermatitis otherwise known as eczema. I see a large number of patients who come in with complaints of persistent sensitive skin. What they often do not realise is that it is a form of eczema. Eczema can be caused by genetic factors and also external factors such as a change in environment and climate, presence of pollen, animal fur and dust. In this article, I shall share a few tips that I usually expound on with my patients and hopefully shed some light on this condition.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She heads up Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Its subsidiaries, the Pi- Cosmeceutical Custom Makeup Lab and the Conscious Mask Bar are part of the Conscious Concept Pharmacy launched in December featuring environmentally sustainable makeup and skincare materials. In this series “Dermatologist Talks” she shares her top tips on common skincare topics. In this article, she tells us the science behind sensitive skin – a form of eczema.
What causes eczema?
Eczema is due to a defect in the skin barrier. The skin is best characterized by a brick and mortar model whereby the bricks of the skin cells are joined together by this cement which holds the skin cells together. People who have sensitive skin or eczema actually have defective ceramide which is the cement of the brick wall which is the skin. This is genetically determined and people who develop eczema in the later part of their lives can also have their condition triggered off by environmental factors such as differences in humidity from dry to humid weather and vice versa. The use of harsh cleansers can also cause eczema to develop over one’s lifetime.
Does ageing cause eczema?
With regards to the development of sensitive skin with age, the same concept of our body’s organ degenerating with age, our skin also degenerates. The main thing is the quality and quantity of ceramide which is produced throughout one’s lifetime decreases with age. On that note, skin can become more sensitive with age.
What should I look out for in sensitive skin products?
The ingredients that are essential for sensitive skin would be a moisturizer and a gentle cleanser. A gentle cleanser such as one that is formulated with minimal laureate sulfate content, which is the foaming component of a cleanser, would be beneficial for a patient who suffers from skin sensitivity. In addition, the use of a ceramide-containing moisturizer is essential. Traditional moisturizers contain humectants such as glycerine which trap water under the skin. Increasing research in dermatology shows that one should be replacing the defective and deficient ceramide content in the skin barrier by applying ceramide rich moisturizers. More information on using Dr.TWL’s Multi-CERAM Moisturizer for eczema treatment can be found here.
Dr.TWL Multi-CERAM Moisturizer is an ultra intensive skin moisturiser for total skin barrier repair with pharmaceutical grade ingredients. It contains phytoceramides which aids in skin barrier repair and multi-ceramide which aids in skin lipid restoration.
Dr.TWL Honey Cleanser is a blend of nature-derived emulsifiers. It is anti-flaking and supples skin. It is also recommended for all skin types as it is a gentle cleanser.
Where is ceramide from?
Sources of ceramide can be plant-derived, synthetic or from animals. Bovine ceramide is the typical source of ceramide used in moisturizers. Plant-derived ceramides which are phytoceramides is what I use in my practice. It contains these lipids which are extracted from plant seed oils.
Dr.TWL Radiance Fluide Hydrating Emulsion contains LARECEA™ Extract for regeneration and skin brightening ingredients for a dewy glow. It is specially formulated for a light-weight feel to impart a radiant glow without make-up. It also contains ceramide and grape seed oil, perfect for individuals with eczema and sensitive skin.
What ingredients should I avoid if I have sensitive skin?
The ingredients that one should avoid when you have sensitive skin will be things like astringents, so any alcohol-based gel, toners or lotions should be avoided because these tend to dry up the skin further. In addition, irritating ingredients such as alpha hydroxy acids and salicylic acids are commonly used for the treatment of acne as well as for skin exfoliation, these will definitely trigger off skin sensitivity.
In patients with Eczema, there is an inherent defect of the epidermal barrier of the skin. When this barrier is compromised, bacteria and allergens are able to enter and thus there is an increased risk of secondary infections, which, in turn, can lead to aggravation of eczematous symptoms. It is believed that the best way to manage eczema is to repair the skin barrier or prevent its dysfunction, in which ceramide moisturisers play a critical role.
According to accredited dermatologist Dr Teo Wan Lin who is an expert on sensitive skin and eczema, “I formulated the Dr Twl Dermaceuticals Multi-CERAM™ Moisturiserafter years of prescribing other brands of ceramide moisturisers which I found did not meet the underground clinical needs of patients, at a competitive price point. The high cost of manufacturing ceramide moisturisers lies in its reliance on synthetic sources of ceramide as well as bovine (cow derived) ceramide.”
“In the Dr Twl Dermaceuticals Multi-CERAM™ Moisturiser, which is very competitively priced with a high ceramide content, the novel focus and dermatological concept is on using multiple sources of ceramide for total skin lipid restoration, rather than just relying solely on the expensive synthetic and animal derived ceramide which results in low concentrations of ceramide being used in other ceramide moisturisers, or high price point which is prohibitive.
In the Multi-CERAM™ Moisturiser, phytoceramides are used — these are plant seed oil derived sources of ceramide that directly repair the skin barrier. This is in addition to containing plant anti-oxidants which incidentally combat cellulite, large amounts of glycerin which functions as a humectant, preventing trans-epidermal water loss, as well as Sodium Hyaluronate (Hyaluronic acid), a natural component of the skin, for dermal hydration,” Dr. Teo says.
What are Ceramides?
Ceramides are lipids that are naturally found in the intercellular “mortar” within the outer layer of s the statue corneum. They make up 40-50% of the lipid component of the lamellar lipids and are integral to the function of the epidermal barrier.
In patients with psoriasis, eczema and other dry skin conditions, reduced levels of Ceramides are observed.
The stratum corneum is comprised of corneocytes compressed within a lipid bilayer, which is made up of 40-45% Ceramides, 25% Cholesterol & 10-15% Free Fatty Acids. If incorporated in the wrong ratio, barrier repair may be impeded. These 3 major components of the stratum corneum bind the protein-rich corneocytes into a water impermeable protective barrier. A deficiency in Ceramides results in excessive transepidermal water loss, dry skin and increased permeability to environmental irritants, allergens and microorganisms. Thus, reduced levels of Ceramides is associated with dermatological disorders such as atopic dermatitis.
Studies show that if topical ceramides is applied in the correct ratio with cholesterol and free fatty acids, it can help to improve the epidermal barrier in people with Atopic Dermatitis (AD), thereby reinforcing barrier function. Therefore, ceramide moisturisers and cleansers have been proven to provide substantial relief from the symptoms of eczema.
Ceramide Dominant PED for Eczema
In order for ceramide-containing products to have a positive effect on the skin barrier function, ceramides should be present abundantly in an optimal ratio with other barrier repair ingredients. Our Multi-CERAM Moisturiser is uniquely formulated to ensure the delivery of an optimal ceramide, cholesterol and free fatty acid ratio. In fact, this moisturiser is formulated as a Prescription Emollient Device (PED), the gold standard in eczema management – Eichenfield et al. (2014) [on PubMed], and also the optimal moisturer for barrier protection against maskne – Teo (2020) [on PubMed].
By restoring healthy barrier function, the Dr. TWL Dermaceuticals Multi-CERAM Moisturiser helps to support ceramide synthesis and further augmenting skin barrier repair and skin health in general.
The Multi-CERAM™ Ceramide Moisturiser is uniquely formulated treat Eczema using:
Ceramide 1 (EOP) which is significantly deficient in eczema patients and Ceramide 3 (NP) which is linked to the transepidermal water loss experienced in eczema patients.
Phytoceramides which aids the repair of skin barrier
Sodium Hyaluronate for skin hydration
Ceramide complex (ceramides, cholesterol & FFA) which delivers ceramides topically in optimal ratios to aid in the reinforcement of the recovery of the skin barrier.
Management for patients with Eczema
A daily maintenance routine is vital. One of the main changes in eczema is a disruption and reduction in the layers of corneocytes in the stratum corneum. When the stratum corneum is well hydrated, it swells, allowing increased permeability of topical formulations. The key to managing eczema is through the regular use of a ceramide moisturiser with high ceramide content after showering or washing hands.
Successful management requires a holistic approach:
1. Avoid triggering factors 2. Maintain skin care through regular use of a moisturiser and a moisturising cleanser 3. Pharmacotherapy during acute exacerbations 4. Compliance of skin care products suggested by a dermatologist
Dry skin (medically known as xerosis) usually appears rough, scaly and even itchy. Xerosis can be caused by factors ranging from cold weather to frequent showering, and is also a common symptom of several chronic skin diseases. While xerosis is not a critical condition, it can cause significant discomfort, affect one’s appearance, and accelerate skin’s aging.
So what causes xerosis and how can it be managed?
What is dry skin?
In normal skin, lipids and natural moisturizing factors (NMFs) are needed to maintain barrier function and optimal skin hydration. NMFs attract water molecules while lipids controls the amount of skin that evaporates from the skin surface.
NMFs keep the skin hydrated by binding to water and holding onto it, preventing excessive water loss as the skin cells have sufficient hydration to remain turgid. An effective skin barrier keeps the skin’s water content at a healthy level of 15 to 20 per cent.
Dry or dehydrated skin has reduced NMF levels which compromises the skin’s ability to retain water. As a result, moisture is lost much faster than replenished. When the skin’s water content falls below 10 percent, visible scales form and the skin starts to have a rough dry appearance. Individuals with dry skin can also often notice cracks or experience flaking.
The precise organisation of lipids are important as it determines the amount of water that can be trapped in the skin. In healthy skin, sufficient lipids are present to keep Transepidermal Water Loss (TEWL) values low, as less water is lost to the surroundings.
What causes dry skin?
Dry skin arises largely due to abnormal epidermal differentiation.
The epidermis is produced by cells that divide and proliferate in the deeper skin layers before travelling towards the skin surface. At the surface, skin cells mature, flatten and die. These dead skin cells are sealed together with fatty lipids to form a continuous skin barrier. This process is termed epidermal differentiation.
A disruption in the skin barrier can cause epidermal differentiation to become abnormal and the skin barrier function to become damaged. This disruption can happen for a variety of reasons:
Genetics: Dry skin is a major manifestation of several skin diseases such as atopic dermatitis (eczema) or psoriasis (itch) which has a genetic component.
Aging: In aging skin, a marked decline in lipid and water content ultimately impairs skin barrier function. A decline in filaggrin, a protein that produces NMFs, is also observed as we age, leading to diminished NMF levels
Low humidity: Low humidity causes less amino acids and filaggrin to be produced in the stratum corneum, as they require optimal humidity to function well. As a result, NMF levels are lower.
For example cold dry weather often causes ‘winter itch’ where skin is rough, red and irritated. Winter xerosis is aggravated by the presence of hot, dry air from modern central heating, causing impaired desquamation and scaling. You may also experience dry skin in hot weather if most of your time is spend in air-conditioned surroundings.
Sun exposure: Ultraviolet (UV) radiation from the sun can also affect normal epidermal proliferation by compromising the skin barrier’s function and resulting in greater water loss to the environment.
Frequent bathing: Such habits, especially with hot water, can further irritate the skin and damage the skin barrier function. Hot water should be avoided, and a shorter bath duration is recommended.
Other environmental factors: Chemical agents such as soaps, lotions, perfumes or detergents can also contribute to xerosis.
How to replace skin’s water content
We often see buzz about the importance of hydrating our skin, but how exactly do we ensure our skin is hydrated enough?
Currently, the best approach to treating dry skin is to restore normal abnormal epidermal differentiation by using ingredients that can easily penetrate the skin and prompt it to produce healthy levels of lipids again. Effective ingredients are lipids, humectants and antipruritic agents:
Other types of lipids that are not found naturally in our body can also be beneficial by serving as an occlusive layer, such as petrolatum. They prevent water loss to the surroundings by trapping it. A common example of petrolatum is Vaseline.
Humectants, such as glycerol, lactic acid, hyaluronic acid and urea, attract and retain water in the skin. Glycerol or urea can improve skin elasticity and barrier function, and compensate for the lower levels of NMF in dry skin. Hyaluronic acid is a humectant capable of holding up to 1000 times their own weight in water, locking in moisture for the skin.
Antipruritic agents block histamine release to interfere with the itch sensation and break the itch-scratch cycle.
An ideal ingredient should prompt the skin to restore epidermal differentiation, reduce excessive water loss and itching. Multi-CERAM Moisturizer is dermatologist-formulated to treat eczema and dry skin with pharmaceutical grade ingredients. An ultra-intensive formulation, this moisturizer relies on ceramides, plant seed oils, sodium hyaluronate and glycerin to repair the skin barrier and restore skin moisture.
With Singapore’s humid weather, most of us fall back on body lotions and moisturizers to keep our skin smooth and hydrated all year round. Yet, faced with a multitude of choices for body moisturisers, we may never know where to begin – here are some quick tips to help guide the choice of body moisturisers.
Read the product’s ingredient list
This is no easy feat, but it pays to know what is in your product. You need not know all the ingredients in detail, a simple trick would be to scrutinise the order in which the ingredients are presented. Right at the top would be the ingredient with the highest percentage, and the concentration of each ingredient decreases with a descending order of mention in the ingredient list.
The first five ingredients or so usually make the bulk of your product. Given that, it does not necessarily translate that an ingredient has to be in greatest concentration for the most impact. Certain ingredients work well at low concentrations.
One tip would be to watch out for creams or lotions that have the highest concentration of water or plain silicones. While these constituents may give the instant feel of moisture, they quickly disappears and do not repair our skin barrier.
How do moisturizers work?
The most essential feature is to increase the water content of the stratum corneum. The ‘valleys’ between skin contour ridges smoothen with hydration, allowing the skin to be more soft and supple.
Ingredient you want in your moisturizer: ceramides
Ceramides are an essential lipid component of the stratum corneum, the outermost layer of our skin that is largely recognized as the skin barrier. Preventing unwanted materials from entering, it can be seen as our skin’s first line of defense. Ceramides contribute to the permeability of the skin barrier by mediating with cell signaling and with processes such as cell growth, differentiation, proliferation and cell death as a lipid messenger.
A deficiency of ceramides in our skin causes a decrease in water-holding capacity and barrier function. Conversely, with a topical application of phytoceramides, barrier abnormalities are improved and impaired skin barrier function can also be repaired. Thus, if you are looking for a good body lotion or moisturizer, phytoceramides definitely should be on your ingredient check list.
Phytoceramides: What are they?
Phytoceramides are derived from plant-oil and it mimics the lipid component of our skin barrier. With an equivalent function of restoring the skin integrity, we can rely on moisturizers with phytoceramides to repair our skin barrier as do synthetic ceramides do.
Ingredient you want in your moisturizer: glycerin
Glycerin is a natural humectant found in our skin and contributes to normal hydration levels of our skin. Topical glycerin helps to correct the hydration abnormality in our skin, causing glyercol to be included in topical dermatological preparations.
Humectants are hydrophilic compounds that hydrate the stratum corneum when they form hydrogen bonds with water molecules. Glycerin is a typical, yet effective water-binding agent. Humectants draw water to our skin from two difference sources: from a humid environment or from deeper layers of our skin. By absorbing water from these sources, it locks in the moisture in our skin.
According to Dr Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin and Laser Centre, she said: “Glycerin may accomplish more complex mechanism beyond water absorption. It may interact with the skin lipid structure and alter their water-binding properties. This effect causes an expansion of skin cells on the outermost skin layer, and between those cells, leading to a visible full thickness of the skin layer. With an improvement of water-holding abilities, it results in more effective moisturization of the skin.”
Repeated applications of lotions with high glycerin content have been found to improve skin hydration.
Ingredient you want in your moisturizer: squalane
Found in certain fish oils such as shark liver oil, squalene is a polyunsaturated hydrocarbon. As squalene is unstable and oxidizes easily, squalane has gained more attraction in the area of cosmetics. As a saturated derivative of squalene, squalane’s inert properties and low toxicity have paved its way into the cosmeceutical industry, favoured over its unsaturated analog, squalene. Although squalane is produced naturally by the body, we experience a slower production of this hydrocarbon when we hit thirty.
Squalane has high emollient properties, being absorbed easily by the skin without leaving an oily residue. An emollient helps keep our skin hydrated and supple by reducing water loss from the epidermis. Squalane increases skin hydration due to skin surface occlusions. Occlusives provide a layer of oil on the skin surface to reduce water loss from the stratum corneum.
These properties accentuate the moisturizing effect of squalane and coupled also with its stable nature, have contributed to a continual rise in demand for squalane in cosmeceutical approaches.
To round things up, make a mental note to check the ingredient list before you purchase your moisturiser. A good moisturiser would contain at least one of these ingredients: squalane, glycerin or ceramides. Even better, the Multi-CERAM moisturizer contains all 3 ingredients and more. This makes the Multi-CERAM a popular choice with our dry skin and eczema patients. With these points in mind, a good moisturiser can be easily differentiated from the plethora of options out there.