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We should&#44; therefore&#44; be aware of the need to identify and manage this condition and to improve the quality of life of those affected&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our aim in this article is to provide a simple and practical algorithm for the diagnosis and treatment of sensitive skin syndrome based on expert opinion and the most recent updates on the topic in the literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Sensitive Skin&#58; Definition&#44; Classification&#44; Epidemiology&#44; and Pathophysiology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Evolution of the Concept of Sensitive Skin</span><p id="par0015" class="elsevierStylePara elsevierViewall">In 2011&#44; a review by Escalas-Taberner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> listed the main definitions of the term <span class="elsevierStyleItalic">sensitive skin</span> in the literature and described the condition as a complex syndrome with a high component of subjectivity on the part of the patient&#46; In 2013&#44; the explanation of the etiology of sensitive skin was expanded to include environmental factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors of subsequent publications have noted the lack of consensus on the meaning of the term and the challenge presented by any effort to research this syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">6&#44;7</span></a> The most recent definition&#8212;and the first to achieve consensus&#8212;was published in a position paper drawn up by a group of European experts at the International Forum for the Study of Itch in 2017&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">8</span></a> The group used the Delphi method to reach a very specific definition of sensitive skin as follows&#58; <span class="elsevierStyleItalic">&#8220;A syndrome defined by the occurrence of unpleasant sensations &#40;stinging&#44; burning&#44; pain&#44; pruritus&#44; and tingling sensations&#41; in response to stimuli that normally should not provoke such sensations&#46;</span><span class="elsevierStyleItalic">These unpleasant sensations cannot be explained by lesions attributable to any skin disease&#46; The skin can appear normal or be accompanied by erythema&#46; Sensitive skin can affect all body locations&#44; especially the face&#8221;&#46;</span></p><p id="par0025" class="elsevierStylePara elsevierViewall">Moreover&#44; it has been considered necessary to distinguish between sensitive skin syndrome and selective sensitivities to specific products&#46; This led to a proposed amendment to the terminology &#40;Misery&#44; 2017 &#35;202&#41;&#44; with the suggested new term being <span class="elsevierStyleItalic">reactive skin</span>&#46; Although this new term is more accurate if we take into account what is known about the etiology and pathogenesis of the condition&#44; the use of the term <span class="elsevierStyleItalic">sensitive skin</span> is still more widespread&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Sensitive Skin Types</span><p id="par0030" class="elsevierStylePara elsevierViewall">Several studies have posited a connection between sensitive skin and a disruption of epidermal barrier function&#44; which is thought to give rise to a feeling of discomfort in the skin &#40;Draelos&#44; 1997&#59; Effendy&#44; 1995&#59; Goffin&#44; 1996&#59; Roussaki-Schulze&#44; 2005&#59; Saint-Martory&#44; 2008&#41;&#46; In terms of epidermal barrier function&#44; sensitive skin can be classified into 3 types<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">9</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Type I&#58; low barrier function</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Type II&#58; normal barrier function with inflammatory changes</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Type III&#58; normal barrier function without inflammation but with reactivity problems</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">In all 3 groups&#44; it has been observed that concentrations of nerve growth factor in the epidermis are higher than the levels observed in non-sensitive skin&#46; Furthermore&#44; in both type II and type <span class="elsevierStyleSmallCaps">III</span>patients&#44; sensitivity to electrical stimuli is high&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In terms of the factors that cause a reaction in sensitive skin&#44; the condition can be classified as follows<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">10</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">High sensitivity&#58; reactive to a wide variety of both endogenous and exogenous factors and associated with acute or chronic symptoms and a strong psychological component</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Environmental sensitivity&#58; fair&#44; dry&#44; and fine skin that has a tendency to blush and is reactive to primary environmental factors</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Cosmetic sensitivity&#58; skin that exhibits transient reactivity to specific cosmetic products&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; we propose a classification of the syndrome according to the presence or absence of associated skin diseases&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Primary sensitive skin&#44; in which the affected person has no associated underlying disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Secondary sensitive skin&#44; in which the patient has a skin condition&#44; such as seborrheic&#44; atopic&#44; or contact dermatitis&#44; rosacea&#44; or acne&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Epidemiology</span><p id="par0090" class="elsevierStylePara elsevierViewall">The prevalence of sensitive skin syndrome in Europe is high&#44; approximately 39&#37;&#44; and the condition appears to affect women more than men&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">11</span></a> The only reference to the prevalence of sensitive skin in Spain comes from a study published by Misery et al<span class="elsevierStyleItalic">&#46;</span> in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">11</span></a> In that study&#44; data were collected by telephone and through on-line surveys of representative samples of people aged 15 years or older in various European countries&#46; The findings indicate that 11&#46;6 million people in Spain could be affected by sensitive skin syndrome&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The data collected also showed a higher prevalence of the syndrome in women and no correlation with factors such as age&#44; rural or urban setting&#44; and socioprofessional category&#46; Although these data provide an initial insight into the epidemiology of sensitive skin in Spain&#44; further studies based on clinical diagnosis are needed to provide more consistent information on the prevalence of this syndrome&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pathophysiology of Sensitive Skin</span><p id="par0100" class="elsevierStylePara elsevierViewall">The mechanisms underlying sensitive skin syndrome continue to be studied and debated in the literature&#46; Current evidence indicates that individuals with sensitive skin have one of the following cutaneous alterations&#58; increased nerve fiber density&#44; increased immune response&#44; or low epidermal barrier function&#46; All of these alterations contribute to the activation of a response to several factors&#46; These factors may be environmental &#40;pollution&#44; radiation&#44; UV exposure&#44; weather&#41;&#44; lifestyle-related &#40;diet&#44; use of cosmetics&#44; alcohol consumption&#41;&#44; or endogenous &#40;psychological factors and emotional stress&#41;&#46; In the following section&#44; we will discuss the biological mechanisms activated by these different factors&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Neurosensorial Mechanisms</span><p id="par0105" class="elsevierStylePara elsevierViewall">There are several mechanisms through which the cutaneous nervous system may contribute to sensitive skin syndrome&#46; One mechanism that could contribute to the condition is hyperreactivity of the cutaneous nerve endings&#46; A lower density of intraepidermal nerve fibers&#44; especially those of the peptidergic amyelinic C-fiber type&#44; has been reported in patients with sensitive skin&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">12</span></a> This alteration would help to explain the neurogenic inflammation some people experience&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">12</span></a> irrespective of the presence of barrier function alterations&#46; Transient receptor potential &#91;TRP&#41; channels expressed on the membrane of group C nerve fibers would appear to play a central role&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">13</span></a> While the evidence remains inconclusive&#44; it appears likely that TRP channels play a central role in the perception and pathophysiology of sensitive skin as they can be activated by the many stimuli&#8212;physical&#44; chemical&#44; and thermal&#8212;that trigger sensitive skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">14&#8211;16</span></a> Vanilloid receptor 1 &#40;TRPV1&#41; appears to play a particularly important role&#44; since it mediates the response to many of these factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">16&#8211;20</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Immune Response Mechanisms</span><p id="par0110" class="elsevierStylePara elsevierViewall">The activation of TRPV1 channels in reactive skin triggers the cutaneous release of substance P and other neuropeptides and subsequently the release of proinflammatory cytokines&#44; such as interleukin &#40;IL&#41; 2&#44; tumor necrosis factor &#945;&#44; interferon &#947;&#44; IL-23&#44; and IL-31&#46; This&#44; in turn&#44; enhances the immune response by recruiting more immune cells to the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">6</span></a> All of these factors are related to the itching and burning sensations characteristic of sensitive skin syndrome&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Mechanisms Related to Altered Epidermal Barrier Function</span><p id="par0115" class="elsevierStylePara elsevierViewall">The integrity of the epidermal barrier is essential to the maintenance of the skin&#39;s structure and functions&#46; Disruption of this barrier&#44; resulting in a thinner and more permeable stratum corneum&#44;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">10&#44;13&#44;21</span></a> has been proposed as a trigger mechanism for the symptoms associated with sensitive skin&#46; A weak epidermal barrier facilitates the penetration of irritants and allergens<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">10</span></a> and is associated with poor protection of nerve endings and increased transepidermal water loss&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">22&#44;23</span></a> The integrity of the epidermal barrier is highly dependent on lipid composition&#46; In fact&#44; it is known that sensitive skin results in changes in levels of neutral lipids&#44; sphingolipids&#44; and ceramides&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Today&#44; it is also known that barrier function also depends largely on the community of microorganisms that inhabit the skin&#44; known as the skin microbiome&#46; While sensitive skin&#44; unlike dermatitis&#44; is not associated with any imbalance or dysbiosis&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">6</span></a> the microbiome is a new field of study and numerous questions remain unanswered&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Practical Recommendations for the Diagnosis of Sensitive Skin</span><p id="par0125" class="elsevierStylePara elsevierViewall">The diagnosis and treatment of sensitive skin is hindered by the lack of consensus in its definition noted by many authors&#46; The following are a series of practical recommendations which&#44; together with the algorithm proposed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; have been drawn up to serve as a guide for use in clinical practice&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Targeted Medical History&#58; The Use of Questionnaires</span><p id="par0130" class="elsevierStylePara elsevierViewall">As sensitive skin is a condition with a highly subjective component&#44; diagnosis must be based&#44; fundamentally&#44; on the interpretation of the symptoms reported by the patient and an assessment of the patient&#39;s medical history &#40;personal and family&#41;&#44; daily habits&#44; and use of cosmetics&#46; Among other aspects&#44; it is important to manage the symptoms reported and investigate other possible causes&#46; Since these patients often do not present any objective physical signs of disease&#44; questionnaires are a useful diagnostic tool in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">26</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists a series of questions that will help the specialist to reach a correct diagnosis of sensitive skin syndrome&#46; This set of questions can be divided into 3 blocks&#58; the patient&#39;s own perception of the sensitivity&#44; irritation&#44; and reactivity of their skin &#40;block I&#44; questions 1-4&#41;&#44; the skin&#39;s reaction to cosmetic products &#40;block II&#44; questions 5-7&#41;&#44; and to environmental factors &#40;block III&#44; questions 8-13&#41;&#46; The patient who gives a positive answer to at least 2 questions from block I&#44; 3 questions from block II<span class="elsevierStyleSmallCaps">&#44;</span> or 3 questions from block III is considered to have sensitive skin&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">In addition to the questionnaire proposed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; we also recommend the use of the 10-item questionnaire validated by Misery et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">27</span></a> On that scale&#44; a score between 20 and 60 points &#40;or more&#41; identifies individuals with sensitive skin&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Diagnostic Tests</span><p id="par0145" class="elsevierStylePara elsevierViewall">Although&#44; as indicated above&#44; questionnaires are still the most reliable method for diagnosing sensitive skin&#44; the results of a number of physical tests can help the specialist make a correct diagnosis&#46; A list of these tests&#44; together with their advantages and disadvantages&#44; is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Practical Recommendations for the Treatment of Sensitive Skin</span><p id="par0150" class="elsevierStylePara elsevierViewall">The care and treatment of sensitive skin remains challenging and requires the use of gentle topical products containing non-irritating ingredients&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">28</span></a> Based on the evidence we have reviewed&#44; it would appear that these products should fulfil the following 3 criteria&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Restore barrier function&#46;</span> Repairing weakened barrier function should increase the tolerance threshold and restore the protection provided by the epidermal barrier against all types of insults&#58; physical&#44; chemical&#44; mechanical&#44; immunological&#44; and microbiological&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Reduce reactivity&#46;</span>Blocking inflammatory mediators and sensory neuropeptides will help to alleviate the symptoms associated with sensitive skin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Be safe for sensitive skin&#46;</span> The use of formulas with few ingredients is recommended in products designed for the care and treatment of sensitive skin&#46; To obviate the need for preservatives&#44; it will be necessary to design containers that preserve and protect the product&#44; preventing contamination or degradation that could lead to chemical mediators or unwanted characteristics &#40;for example a change in pH&#41; that could aggravate the symptoms or destroy active ingredients beneficial to sensitive skin&#46;</p></li></ul></p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hygiene and Care</span><p id="par0170" class="elsevierStylePara elsevierViewall">Appropriate cleaning and treatment regimens are essential for the care of sensitive skin because the use of inappropriate products could exacerbate symptoms&#46; It is therefore important for these patients to use products with a pH in the physiological range &#40;5&#46;5-6&#46;0&#41; and avoid products that have a high pH or contain harsh surfactants that could damage the skin or mucous membranes&#46; Skin cleansers should be fragrance-free and contain only mild amphoteric or anionic surfactants&#46; Appropriate products may also contain hydrating elements of proven biocompatibility&#44; such as glycerin&#44; hyaluronic acid&#44; in addition to relipidization components&#44; such as vegetable oils or ceramides&#46; Patients with sensitive skin should use a gentle cleansing routine&#44; avoid scrubbing the skin with mechanical devices or exfoliating products&#46; It is recommended that they should dry drying their skin by gently dabbing it with paper tissues &#40;never cotton pads&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">10</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">These patients should use cosmetic products that have been shown to improve skin barrier function&#44; with minimal concentrations of preservatives and no surfactants&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">29</span></a> Some authors recommend the use of products with simple formulas containing very few ingredients to avoid as far as possible common sensitizing agents&#44; sensory stimulants&#44; and cutaneous vasodilators and to minimize the content of irritants&#44; such as benzoic acid&#44; cinnamic acid&#44; sodium lauryl sulfate&#44; bronopol&#44; lactic acid&#44; propylene glycol&#44; urea&#44; and sorbic acid&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">10&#44;30&#8211;32</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">It is also recommended that these patients should maintain their skin highly hydrated to reduce their susceptibility to irritation and to restore the integrity of the stratum corneum&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">33</span></a> Their regimen should include passive moisturizers &#40;vegetable oils&#44; silicones&#41; to reduce transepidermal water loss and balance the skin&#39;s acid mantle&#44; active moisturizing or hydrating products that retain water in the stratum corneum &#40;glycerol&#44; hyaluronic acid&#44; filaggrin derivatives&#44; all natural moisturizing factors&#41;&#44; and finally relipidizing agents &#40;vegetable oils&#44; ceramides&#44; and pseudoceramides&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">25&#44;34&#44;35</span></a> The formulation of the products used is also important&#58; products containing active ingredients that are non-occlusive and favor a lightweight texture will facilitate the application of the product&#44; reducing the need to rub or massage the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">36&#44;37</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Treatment</span><p id="par0185" class="elsevierStylePara elsevierViewall">Certain substances can be used to relieve the symptoms of sensitive skin&#46; For instance&#44; the efficacy of TRPV1 antagonists has been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">38</span></a> Specifically&#44; pimecrolimus&#44; a calcineurin inhibitor that acts on TRPV1&#44; was shown to improve the symptoms of sensitive skin in a study of Chinese women&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">39</span></a> Efficacy has also been achieved with neurosensine&#44; a molecule derived from a neurosensorial dipeptide naturally present in the skin&#46; Neurosensine stimulates the production of endorphins and enkephalins in keratinocytes and contributes to the creation of a barrier that protects group C nerve fibers&#44; thereby reducing stimulation of the nociceptive signaling pathways&#44; including the TRPV1 and proinflammatory mediators &#40;substance P&#41;&#46; In a clinical study&#44; a product containing neurosensine inhibited neurogenic inflammation&#44; helping to reduce the most specific symptoms of sensitive skin&#44; including burning&#44; heat&#44; itching&#44; and stinging sensations&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">40</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Another active ingredient of interest for the treatment of sensitive skin is nicotinamide&#44; which helps to restore barrier function by increasing the synthesis of epidermal lipids and ceramides&#46; This improvement in barrier function helps to reduce water loss&#46; Nicotinamide also reduces the release of proinflammatory mediators and regulates the release of histamine&#44; thereby reducing inflammation and itching&#46; It has also been observed to have probiotic properties&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">41&#44;42</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Algorithm for the Diagnosis and Treatment of Sensitive Skin</span><p id="par0195" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the diagnosis and treatment of sensitive skin in routine clinical practice continues to present a complex challenge&#46; To address this problem&#44; we propose simple algorithms based on current scientific evidence&#44; the recommendations made in the present review&#44; and the expert opinion of the authors of this article &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; The aim of these algorithms is to facilitate the diagnosis of sensitive skin syndrome and offer practical guidelines for the treatment and care of the condition&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Sensitive skin affects millions of people worldwide&#44; causing numerous disagreeable sensations that have a negative impact on quality of life&#46; These symptoms may lead those affected to consult a dermatologist&#46; As dermatologists&#44; we must be aware that sensitive skin is a syndrome&#44; a concept validated by the evidence relating to its etiology and pathogenesis&#46; We now have adequate tools to properly identify the syndrome and we can offer these patients recommendations on the most appropriate skin cleansing and care regimen&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Modern dermocosmetic brands are developing products that go beyond hydration and the reduction of certain skin components and are now incorporating ingredients capable of improving barrier function&#44; decreasing neurogenic inflammation and sensory reactivity&#44; while maintaining safety and tolerability&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">An algorithm for the diagnosis and treatment of sensitive skin&#44; such as the one presented here&#44; can be an important aid for dermatologists and greatly benefit their patients&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">L&#8216;Or&#233;al financed the work undertaken by Medical Statistics Consulting SL to support the writing of this article and facilitated author meetings&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of Interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">Leonor Prieto is an employee of L&#8217;Or&#233;al Espa&#241;a-Divisi&#243;n Cosm&#233;tica Activa&#46;</p></span></span>"
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          "identificador" => "sec0080"
          "titulo" => "Algorithm for the Diagnosis and Treatment of Sensitive Skin"
        ]
        9 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Funding"
        ]
        11 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Conflicts of Interest"
        ]
        12 => array:2 [
          "identificador" => "xack437027"
          "titulo" => "Acknowledgments"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-07-23"
    "fechaAceptado" => "2018-10-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1177555"
          "palabras" => array:4 [
            0 => "Syndrome"
            1 => "Sensitive skin"
            2 => "Barrier function"
            3 => "vanilloid receptor-1"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1177556"
          "palabras" => array:4 [
            0 => "S&#237;ndrome"
            1 => "Piel sensible"
            2 => "Funci&#243;n barrera"
            3 => "Receptor vaniloide 1"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sensitive skin has traditionally been viewed as a cosmetic problem or as a purely psychosomatic alteration with a major subjective component&#46; Different studies of its pathophysiologic etiology&#44; however&#44; have shown it to be a complex entity that several authors now consider to be a neurodermatological syndrome&#46; Because of this complexity&#44; skin sensitivity can be difficult to diagnose and treat&#44; particularly considering that it may present with another disease&#46; Simple tools applicable to clinical practice are thus necessary to identify and manage this disease as an independent entity&#46; In this study&#44; we perform a practical review of the most recent scientific advances in the area of sensitive skin that justify it being considered an individual entity&#44; and provide tools for its identification and treatment&#46; We propose diagnostic and treatment algorithms based on evidence from the literature and our experience and expertise&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Tradicionalmente&#44; la piel sensible se ha considerado como un problema cosm&#233;tico o como una alteraci&#243;n puramente psicosom&#225;tica con un fuerte componente subjetivo&#46; Sin embargo&#44; diversos estudios cient&#237;ficos sobre sus procesos fisiopatol&#243;gicos y su etiopatogenia han demostrado que se trata de una entidad compleja que ya diversos autores consideran un s&#237;ndrome neurodermatol&#243;gico&#46; Sus caracter&#237;sticas hacen que su diagn&#243;stico y tratamiento puedan resultar complicados en la pr&#225;ctica cl&#237;nica habitual&#44; siendo necesarias herramientas sencillas que se puedan usar de rutina&#44; tanto para identificar esta entidad&#44; que puede presentarse acompa&#241;ada de otra patolog&#237;a&#44; como para su manejo independiente&#46; En este trabajo realizamos una revisi&#243;n pr&#225;ctica de los avances cient&#237;ficos m&#225;s recientes el campo de la piel sensible que justifican su consideraci&#243;n individual y ofrecen herramientas para identificarla y tratarla&#46; Proponemos algoritmos de diagn&#243;stico y de tratamiento basados en las evidencias de la literatura y en la opini&#243;n de los expertos que firman este art&#237;culo&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guerra-Tapia A&#44; Serra-Baldrich E&#44; Prieto Cabezas L&#44; Gonz&#225;lez-Guerra E&#44; L&#243;pez-Estebaranz JL&#46; Diagn&#243;stico y tratamiento del s&#237;ndrome de piel sensible&#58; un algoritmo para la pr&#225;ctica cl&#237;nica habitual&#46; Actas Dermo-Sifiliogr&#225;ficas&#46; 2019&#59;110&#58;800&#8211;808&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm for sensitive skin syndrome&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Treatment algorithm for sensitive skin syndrome&#46;</p>"
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      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Block I&#58; questions 1-4&#59; Block II&#58; questions 5-7&#59; Block III&#58; questions 8-13&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you consider that you have sensitive skin&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think your skin is prone to irritation&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you have &#8220;reactive&#8221; skin&#63; &#40;Do you experience stinging&#44; burning&#44; or itching sensations with and&#47;or without associated redness&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think the skin on your face is more sensitive than on other parts of your body&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does your skin react rapidly to cosmetics and toiletries&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Are there any cosmetic products that make your skin itch or cause a stinging or burning sensation&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Have you ever experienced an adverse reaction to a cosmetic or toiletry product used on your skin&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think your skin is especially sensitive to cold&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think your skin is especially sensitive to heat&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Is your skin particularly sensitive to temperature change&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does the wind tend to make your skin itchy or cause stinging or burning sensations&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does exposure to the sun make your skin itchy or give rise to stinging or burning sensations&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does air pollution trigger a reaction in the skin on your face&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Questionnaire for the Diagnosis of Sensitive Skin&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Methodology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Assessment and Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Disadvantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tests that can be performed in the dermatology office</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sting test<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">43</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Application of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mL of 10&#37; lactic acid to one of the nasolabial grooves and distilled water at room temperature to the other &#40;variants include capsaicin&#44; sorbic acid&#44; menthol&#44; ethanol&#44; and benzoic acid&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Symptoms are classified on a scale from 1 to 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quick&#44; simple and cheap procedure Requires no specialized equipment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor reproducibility Lacks predictive value for most authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sensory perception threshold measurement<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">44</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Analysis of patient perception following topical application of 0&#46;075&#37; capsaicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Individuals with sensitive skin have a lower perception threshold due to alterations in myelinated C fibers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quick and easy procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor reproducibility and not objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Irritant reactivity test<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">45</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Objective measure of irritation after skin exposure to sodium lauryl sulfate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The irritation level is scored on visual inspection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cheap and easy to perform&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor reproducibility and not objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Experimental methods difficult to implement in the dermatology office</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transdermal analysis &#40;transdermal analyses patch&#41;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">46</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measurement of protein biomarkers on the skin surface using tape stripping&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measurement of cytokine levels as indicators of inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Provides objective data of pathophysiological alterations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Method under development&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plastic occlusion stress test &#43; measurement ofcorneal stratum permeability desorption curves<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lipids are removed from the stratum corneum using solutions of acetone&#47;ether and chloroform&#47;methanol&#46; The area is occluded using a plastic chamber&#46; Water loss is measured using an evaporimeter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Slower decline in transepidermal water loss and increased water release after withdrawal of the occlusion in patients with sensitive skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Quantitative methodMost appropriate measure of skin damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Requires expensive equipment and rigorous performance&#46; Results may be altered by the effects of temperature and humidity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Confocal microscopy &#43; dermoscopy<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">48</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Structural analysis of the stratum corneum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilated capillaries&#44; more pigmented patches&#44; rougher skin&#44; and deepened dermatoglyphs observed in patients with sensitive skin&#46; Thinner epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Simple method for qualified dermatologists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Technique under development for application in the field of sensitive skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Functional magnetic resonance imaging<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">49</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measures brain activation during a skin irritation test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specific activation is observed in individuals with sensitive skin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Functional test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cost and availability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Tests Described in the Literature for the Identification of Sensitive Skin&#46;</p>"
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          "bibliografiaReferencia" => array:49 [
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                    0 => array:2 [
                      "titulo" => "Is it possible to characterize objectively sensitive skin&#63;"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "L&#46; Diogo"
                            1 => "A&#46;L&#46; Papoila"
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                    0 => array:2 [
                      "doi" => "10.1111/j.1600-0846.2009.00404.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Skin Res Technol"
                        "fecha" => "2010"
                        "volumen" => "16"
                        "paginaInicial" => "30"
                        "paginaFinal" => "37"
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                    0 => array:2 [
                      "titulo" => "Sensitive skin&#58; A complex syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            1 => "E&#46; Gonz&#225;lez-Guerra"
                            2 => "A&#46; Guerra-Tapia"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "What is sensitive skin&#63; A systematic literature review of objective measurements"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Richters"
                            1 => "D&#46; Falcone"
                            2 => "N&#46; Uzunbajakava"
                            3 => "W&#46; Verkruysse"
                            4 => "P&#46; van Erp"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000363149"
                      "Revista" => array:6 [
                        "tituloSerie" => "Skin Pharmacol Physiol&#46;"
                        "fecha" => "2015"
                        "volumen" => "28"
                        "paginaInicial" => "75"
                        "paginaFinal" => "83"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25322670"
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitive skin&#58; An overview"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Berardesca"
                            1 => "M&#46; Farage"
                            2 => "H&#46; Maibach"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1468-2494.2012.00754.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Cosmet Sci&#46;"
                        "fecha" => "2013"
                        "volumen" => "35"
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