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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sensitive scalp is difficult to classify&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">1</span></a> Some consider it a manifestation of a specific skin disease&#44; whereas others consider it to be a clinical entity in and of itself&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The controversy surrounding the existence or not of sensitive scalp as a disease can be better understood if we compare it to that surrounding sensitive skin in its day<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">2&#44;3</span></a> and which was eventually resolved with the 2017 publication of a study providing a consensus-based definition reached using the Delphi methodology and carried out by a group of European experts at the International Forum for the Study of Itch&#46; The definition read as follows&#58; &#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; These unpleasant sensations cannot be explained by lesions attributed 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&#46;&#8221;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This statement resolved the controversy once and for all&#44; leaving sensitive skin classed as a stand-alone and independent syndrome that can affect various areas of the skin&#44; including the scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sensitive scalp is sensitive skin at a specific site&#46; The consensus-based definition of sensitive skin<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a> states this implicitly when it says that the condition can affect various areas of the skin&#46; This is stated explicitly in other studies&#44; such as that of Saint-Martory et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a> whose analysis of 400 individuals with a mean age of 40 years recruited at a dermatology clinic and a cosmetic clinic revealed that 85&#37; had sensitive skin on the face and that 70&#37; had sensitive skin at other sites&#44; as follows&#58; hands &#40;58&#37;&#41;&#44; feet &#40;34&#37;&#41;&#44; neck &#40;27&#37;&#41;&#44; trunk &#40;23&#37;&#41;&#44; back &#40;21&#37;&#41;&#44; and scalp &#40;36&#37;&#41;&#44; which is the site that interests us here&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We can classify sensitive scalp into 2 types<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Primary&#44; which manifests in isolation or alongside alopecia &#40;any type&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Secondary&#44; which occurs alongside a skin disease of the scalp such as seborrheic dermatitis&#44; psoriasis&#44; atopic dermatitis&#44; and contact dermatitis&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">The current study addresses primary sensitive scalp&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiological Data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence of sensitive scalp can be deduced from studies analyzing the prevalence of sensitive skin that refer to sensitive scalp&#46; The studies include that of Willis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a> who found a prevalence of 25&#37; in the general population&#44; and that of Misery et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">2</span></a> who found a prevalence of 70&#37;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the studies agree on the greater frequency of sensitive scalp in women&#44; which is 10&#8211;30&#37; greater than in men&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a> and some report that women perceive reactions affecting the skin more intensely than men&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">No notable statistical evidence is available with respect to age and race&#46; The differences that can be observed in clinical practice between races are likely due more to psychosocial and cultural factors&#44; such as lifestyle&#44; hygiene&#44; and pollution than to genetic factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Manifestations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical manifestations of sensitive scalp include 4 parameters&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">High subjective sensitivity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Healthy or erythematous skin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Occurrence or nonoccurrence alongside alopecia &#40;any type&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Frequent psychological comorbidity&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">High subjective sensitivity is the basic clinical criterion and the reason why the patient attends the clinic in most cases complaining of stinging&#44; itching&#44; trichodynia&#44; or other abnormal sensations&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In general&#44; the term <span class="elsevierStyleItalic">stinging</span> is closely associated with the emotional component&#46; Unlike pruritus&#44; which leads to scratching&#44; or pain&#44; which is accompanied by despondency and sadness&#44; stinging leads to uncertainty and anxiety&#44; the need for movement&#44; and avoidance of friction&#46; It usually improves with fresh air and cold water&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Pruritus of the scalp has a considerable impact on patient quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a> Scratching becomes a necessity that disrupts concentration and well-being&#46; Pruritus in a person with sensitive scalp does not usually lead to erosions and other lesions that result from scratching&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Trichodynia &#40;&#8220;hair pain&#8221;&#41; is a painful sensation on the scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a> Affected patients report that it appears when they comb their hair&#44; change their parting&#44; and&#44; sometimes&#44; spontaneously&#46; Many patients are somewhat embarrassed when they complain because they doubt that they really feel the pain and find their perception a little strange&#44; since they have never heard of anyone else experiencing this sensation&#46; Trichodynia can affect the whole scalp or specific areas coinciding with bald patches of any type and intensity&#46; Such were the findings of Willimann and Tr&#252;eb<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> in 2002&#46; These authors reported that of a total of 403 patients they examined with alopecia&#44; 20&#37; of women and 9&#37; of men complained of hair pain&#44; irrespective of its cause and activity&#46; Much more recently&#44; in 2021&#44; although consistent with the previous report&#44; Askin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a> reported data on 249 patients from a trichology unit&#44; of whom 35&#46;7&#37; claimed to have experienced trichodynia&#46; The pain was more intense in women and in cases of cicatricial alopecia&#46; As for the origin of trichodynia&#44; many authors associate the symptoms with psychological factors such as depression and anxiety&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">16</span></a> sleep disorders&#44; and stress&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">17</span></a> One study that brings together all these characteristics &#40;association with alopecia of any type&#44; female predominance&#44; association with stress&#41; was that by Kanti et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a> where women receiving chemotherapy or tamoxifen for breast cancer reported the appearance of trichodynia and pruritus with onset and duration of hair loss&#46; This psychopathological nature of the symptom is supported by the fact that there were no analytical abnormalities indicative of a metabolic change or deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">19&#44;20</span></a> Similarly&#44; there are no histological data proving peribulbar follicular inflammation&#44; a hypothesis that was put forward some years ago but has never been proven&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">21</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">The skin of a person with sensitive scalp may be normal in appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or characterized by more or less intense erythema &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In 1987&#44; Thestrup-Pedersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> considered erythema to be a basic finding&#44; albeit with a descriptive name&#8212;red scalp&#8212;and described characteristics that were identical to those we now consider as being sensitive scalp&#46; When examined using a dermatoscope&#44; sensitive scalp is formed by dilated capillaries and telangiectasias&#44; with no other specific findings&#46; The vascular patterns are those of healthy skin&#44; for example&#44; interfollicular simple red loops and arborizing red lines&#46; The finding of other abnormalities corresponds to the accompanying alopecia&#44; if present&#46; The finding of telangiectasias and high subjective sensitivity is sufficient reason for some authors to consider sensitive scalp a type of erythematotelangiectatic rosacea with an unusual location&#44; which may even improve with oral tetracyclines&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">23</span></a> However&#44; the absence of other manifestations of rosacea has led this hypothesis to be rejected&#46; Some studies on sensitive skin report a decrease in the thickness of the epidermis and disruption of the skin barrier&#46; This finding could also be attributed to sensitive scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Sensitive scalp may occur alongside some types of alopecia&#46; As mentioned above&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> alopecia&#44; or more frequently telogen effluvium and androgenetic alopecia&#44; often co-occurs with sensitive scalp&#44; especially if it is associated with trichodynia&#46; In addition&#44; the type or intensity of alopecia is not associated with the intensity of the signs and symptoms of sensitive scalp&#46; However&#44; it is often alopecia that draws attention to the scalp&#44; thus enhancing the subjective perception of sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Psychological comorbidity is common in sensitive scalp&#44; especially when the condition is associated with trichodynia &#40;see above&#41;&#46; This association has been demonstrated in various psychological evaluations of patients with sensitive scalp&#44; the findings being anxiety&#44; depression&#44; stress&#44; and emotional dysregulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">25&#8211;28</span></a> Furthermore&#44; the effects of the symptoms of sensitive skin on quality of life could lead to psychopathological abnormalities that were not initially present&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Etiology and Pathogenesis</span><p id="par0125" class="elsevierStylePara elsevierViewall">The true pathophysiology of the process remains uncertain&#46; One theory points to hyperreactivity of the cutaneous nerves&#44; mainly in the case of sensitive scalp with trichodynia&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">29</span></a> Similarly&#44; consistent with the etiology and pathogenesis of sensitive skin&#44; various authors<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">30&#8211;32</span></a> believe that activation of the transient receptor potential cation channel subfamily V member 1 expressed in nerve endings&#44; keratinocytes&#44; and cells of the immune system triggers release of substance P and other neuropeptides in the skin&#44; leading to subjective symptoms&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Triggers</span><p id="par0130" class="elsevierStylePara elsevierViewall">As in sensitive skin&#44; sensitive scalp can involve a series of triggers that are both endogenous &#40;mainly stress&#41; and exogenous &#40;environment&#41;&#46; A typical example of the latter is hair products&#44; since many formulations contain irritants&#46; Even so&#44; it is difficult to determine which is responsible for onset or worsening of sensitive scalp&#46; Thus&#44; in 2021&#44; Brenaut et al&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">33</span></a> published the results of a study of 133 women &#40;mean age&#44; 41 years&#41;&#44; of whom 74&#37; reported having sensitive scalp&#46; However&#44; no differences were observed with respect to hair products&#44; except for more frequent use of conditioner in patients with sensitive scalp&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Another exogenous factor to be considered is topical treatments&#44; both for the accompanying alopecia<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">34</span></a> &#40;minoxidil&#41; and for sensory symptoms &#40;corticosteroids&#41;&#44; which&#44; in many cases&#44; the patient has already taken when consulting&#46; It is also important to take physical procedures such as phototherapy into account&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Given the limited cutaneous manifestations of sensitive scalp&#44; diagnosis is based on the clinical history&#44; which should record hygiene habits&#44; cosmetics&#44; treatments&#44; factors considered triggers by the patient&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">35</span></a> the result of the physical examination &#40;normal or erythema&#41;&#44; and trichoscopy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Misery et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">36</span></a> proposed a new scale&#44; the 3 S questionnaire&#44; for evaluating the intensity of symptoms in sensitive scalp&#46; The questionnaire makes it possible to differentiate between patients with mildly sensitive&#44; sensitive&#44; and very sensitive scalp&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Differential Diagnosis</span><p id="par0150" class="elsevierStylePara elsevierViewall">It is first necessary to distinguish between primary sensitive scalp and secondary sensitive scalp&#44; which always involves lesions on the scalp and&#44; possibly&#44; other areas&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">It is also necessary to differentiate between sensitive scalp and scalp dysesthesia associated with lichen simplex chronicus&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">37</span></a> as well as other conditions<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">38</span></a> caused by nerve injury&#44; impingement&#44; or irritation&#44; such as trigeminal trophic syndrome&#44; or zoster-associated trigeminal first branch pain&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Lastly&#44; multiple chemical sensitivity&#44; for which no clear diagnostic evidence has yet become available&#44; should be taken into account in some cases&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><p id="par0165" class="elsevierStylePara elsevierViewall">Treatment is summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The initial approach to sensitive scalp should attempt to eliminate or diminish the triggers&#44; mainly hair products and topical treatments&#44; including mechanical devices and exfoliants&#44; which should be replaced by cleansing products with amphoteric surfactants or soft anions and no common sensitizing agents&#44; cutaneous sensory nerve-mediated vasodilators&#44; or aromas&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">39</span></a> They may contain hydrating elements with proven biocompatibility such as glycerin and hyaluronic acid and relipidizing agents such as vegetable oil or ceramides&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#44;6&#44;26</span></a> Patients receiving topical minoxidil for alopecia can switch to oral minoxidil if there are no contraindications&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">40</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In the fairly common case of a patient who has received relatively long-term therapy with topical corticosteroids&#44; thus favoring telangiectasias and thinning of the epidermis&#44; a cycle of oral corticosteroids should be administered in order to eliminate topical treatment without a rebound effect&#46; Such an approach should be taken in line with usual practice&#44; taking into account contraindications and possible adverse effects&#46; Two weeks&#8217; therapy is generally sufficient&#44; with a continued dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d during the first week and rapid tapering during the second&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">If the subjective symptoms&#8212;stinging&#44; trichodynia&#44; and pruritus&#8212;are intense&#44; oral gabapentin can be added&#44; starting at 300<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; or pregabalin&#44; at 75<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h&#46; The dose and frequency can be increased if necessary&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The implicit neurogenic inflammation can be controlled&#44; and inflammatory mediators and sensory neuropeptides neutralized&#44; with topical pimecrolimus&#44; a calcineurin inhibitor that acts on TRPV1&#46; The drug should be administered as a cream at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;g once daily&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">6&#44;41</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The integrity of the horny layer can be restored by maintaining the scalp hydrated with hyaluronic acid light-texture formulations administered once or twice daily with an interval of at least 1<span class="elsevierStyleHsp" style=""></span>h before application of pimecrolimus&#46; Below&#44; we provide an example of a transparent fluid gel formulation&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Sodium hyaluronate &#40;more stable than the acid&#41; from 0&#46;1&#37; to 0&#46;5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Glycerin 5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Hydroxypropyl methylcellulose &#40;cellulose derivative&#41; 1&#46;5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Phenonip XB &#40;preservative&#41; 0&#46;6&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Tween 20 &#40;surfactant&#41; 1&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Purified water &#40;qs&#41; 100<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">Mesotherapy with growth factor-rich plasma has several uses and few risks&#46; Some studies have shown it to be effective in multiple cutaneous conditions for improving the skin barrier and reducing its reactivity in alopecia&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">42</span></a> and&#44; specifically&#44; erythema and telangiectasia&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">43</span></a> as in sensitive scalp&#46; We have administered mesotherapy monthly&#44; with tailored intervals according to the response&#46; Outcome is favorable&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Many of these recommendations can also be applied in secondary sensitive scalp&#44; bearing in mind the accompanying peculiarities of the disease&#46; While research on sensitive scalp may yet bear much fruit&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a> we believe that management is much simpler if based on the guidelines proposed here&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sensitive scalp is sensitive skin located on the scalp&#46; Sensitivity is considered primary in the absence of an associated scalp disorder and secondary when caused by conditions such as psoriasis&#44; seborrheic dermatitis&#44; and atopic dermatitis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The clinical manifestations of primary sensitive scalp are subjective&#46; Common presenting symptoms are burning&#44; itching&#44; trichodynia&#44; and dysesthesia&#44; often coinciding with hair loss&#46; Clinically&#44; the skin appears normal or red&#46; An objective diagnosis based on laboratory or histologic findings is not possible&#46; Triggers may be endogenous &#40;e&#46;g&#46;&#44; stress and emotional or psychopathological disturbances&#41; or exogeneous &#40;e&#46;g&#46;&#44; topical products and cosmetics&#41;&#46; Treatment must be individualized&#46; Options include pimecrolimus&#44; hydration with hyaluronic acid&#44; and mesotherapy with plasma rich in growth factors&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El cuero cabelludo sensible es una piel sensible de localizaci&#243;n especial&#46; Puede ser primario&#44; cuando se presenta sin enfermedad del cuero cabelludo&#44; y secundario&#44; cuando es atribuible a procesos como psoriasis&#44; dermatitis seborreica&#44; dermatitis at&#243;pica y otros&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las manifestaciones cl&#237;nicas de la forma primaria son subjetivas&#46; El escozor&#44; el picor&#44; la tricodinia y las sensaciones disest&#233;sicas son el motivo de consulta&#44; muy a menudo coincidiendo con alopecia&#46; Cl&#237;nicamente la piel del cuero cabelludo puede ser normal o eritematosa&#46; No hay datos de laboratorio o histol&#243;gicos espec&#237;ficos para un diagn&#243;stico objetivo&#46; Los factores desencadenantes son end&#243;genos&#44; como el estr&#233;s y las alteraciones emocionales y psicopatol&#243;gicas&#44; o ambientales&#44; como los t&#243;picos inadecuados y los cosm&#233;ticos&#46; El tratamiento debe ser personalizado&#44; incluyendo pimecrolimus&#44; la hidrataci&#243;n con &#225;cido hialur&#243;nico y la mesoterapia con plasma rico en factores de crecimiento&#46;</p></span>"
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                  \t\t\t\t">1- Eliminate hair products and topical treatments&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2- Specific hair hygiene for sensitive scalp&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a&#46; Short oral corticosteroid cycle &#40;prednisone&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 7 days and rapid tapering over a further 7 days&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5- Mesotherapy with platelet-rich plasma tailored to the individual&nbsp;\t\t\t\t\t\t\n
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Practical Dermatology
Sensitive Scalp: Diagnosis and Practical Management
Cuero cabelludo sensible: diagnóstico y manejo práctico
A. Guerra-Tapiaa,
Autor para correspondencia
auroraguerratapia@gmail.com

Corresponding author.
, E. González-Guerrab
a Clínica Dermatólogas Guerra, Madrid, Spain
b Hospital Clínico San Carlos, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sensitive scalp is difficult to classify&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">1</span></a> Some consider it a manifestation of a specific skin disease&#44; whereas others consider it to be a clinical entity in and of itself&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The controversy surrounding the existence or not of sensitive scalp as a disease can be better understood if we compare it to that surrounding sensitive skin in its day<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">2&#44;3</span></a> and which was eventually resolved with the 2017 publication of a study providing a consensus-based definition reached using the Delphi methodology and carried out by a group of European experts at the International Forum for the Study of Itch&#46; The definition read as follows&#58; &#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; These unpleasant sensations cannot be explained by lesions attributed 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&#46;&#8221;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This statement resolved the controversy once and for all&#44; leaving sensitive skin classed as a stand-alone and independent syndrome that can affect various areas of the skin&#44; including the scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sensitive scalp is sensitive skin at a specific site&#46; The consensus-based definition of sensitive skin<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a> states this implicitly when it says that the condition can affect various areas of the skin&#46; This is stated explicitly in other studies&#44; such as that of Saint-Martory et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a> whose analysis of 400 individuals with a mean age of 40 years recruited at a dermatology clinic and a cosmetic clinic revealed that 85&#37; had sensitive skin on the face and that 70&#37; had sensitive skin at other sites&#44; as follows&#58; hands &#40;58&#37;&#41;&#44; feet &#40;34&#37;&#41;&#44; neck &#40;27&#37;&#41;&#44; trunk &#40;23&#37;&#41;&#44; back &#40;21&#37;&#41;&#44; and scalp &#40;36&#37;&#41;&#44; which is the site that interests us here&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We can classify sensitive scalp into 2 types<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Primary&#44; which manifests in isolation or alongside alopecia &#40;any type&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Secondary&#44; which occurs alongside a skin disease of the scalp such as seborrheic dermatitis&#44; psoriasis&#44; atopic dermatitis&#44; and contact dermatitis&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">The current study addresses primary sensitive scalp&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiological Data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence of sensitive scalp can be deduced from studies analyzing the prevalence of sensitive skin that refer to sensitive scalp&#46; The studies include that of Willis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a> who found a prevalence of 25&#37; in the general population&#44; and that of Misery et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">2</span></a> who found a prevalence of 70&#37;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the studies agree on the greater frequency of sensitive scalp in women&#44; which is 10&#8211;30&#37; greater than in men&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a> and some report that women perceive reactions affecting the skin more intensely than men&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">No notable statistical evidence is available with respect to age and race&#46; The differences that can be observed in clinical practice between races are likely due more to psychosocial and cultural factors&#44; such as lifestyle&#44; hygiene&#44; and pollution than to genetic factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Manifestations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical manifestations of sensitive scalp include 4 parameters&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">High subjective sensitivity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Healthy or erythematous skin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Occurrence or nonoccurrence alongside alopecia &#40;any type&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Frequent psychological comorbidity&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">High subjective sensitivity is the basic clinical criterion and the reason why the patient attends the clinic in most cases complaining of stinging&#44; itching&#44; trichodynia&#44; or other abnormal sensations&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In general&#44; the term <span class="elsevierStyleItalic">stinging</span> is closely associated with the emotional component&#46; Unlike pruritus&#44; which leads to scratching&#44; or pain&#44; which is accompanied by despondency and sadness&#44; stinging leads to uncertainty and anxiety&#44; the need for movement&#44; and avoidance of friction&#46; It usually improves with fresh air and cold water&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Pruritus of the scalp has a considerable impact on patient quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a> Scratching becomes a necessity that disrupts concentration and well-being&#46; Pruritus in a person with sensitive scalp does not usually lead to erosions and other lesions that result from scratching&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Trichodynia &#40;&#8220;hair pain&#8221;&#41; is a painful sensation on the scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a> Affected patients report that it appears when they comb their hair&#44; change their parting&#44; and&#44; sometimes&#44; spontaneously&#46; Many patients are somewhat embarrassed when they complain because they doubt that they really feel the pain and find their perception a little strange&#44; since they have never heard of anyone else experiencing this sensation&#46; Trichodynia can affect the whole scalp or specific areas coinciding with bald patches of any type and intensity&#46; Such were the findings of Willimann and Tr&#252;eb<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> in 2002&#46; These authors reported that of a total of 403 patients they examined with alopecia&#44; 20&#37; of women and 9&#37; of men complained of hair pain&#44; irrespective of its cause and activity&#46; Much more recently&#44; in 2021&#44; although consistent with the previous report&#44; Askin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a> reported data on 249 patients from a trichology unit&#44; of whom 35&#46;7&#37; claimed to have experienced trichodynia&#46; The pain was more intense in women and in cases of cicatricial alopecia&#46; As for the origin of trichodynia&#44; many authors associate the symptoms with psychological factors such as depression and anxiety&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">16</span></a> sleep disorders&#44; and stress&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">17</span></a> One study that brings together all these characteristics &#40;association with alopecia of any type&#44; female predominance&#44; association with stress&#41; was that by Kanti et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a> where women receiving chemotherapy or tamoxifen for breast cancer reported the appearance of trichodynia and pruritus with onset and duration of hair loss&#46; This psychopathological nature of the symptom is supported by the fact that there were no analytical abnormalities indicative of a metabolic change or deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">19&#44;20</span></a> Similarly&#44; there are no histological data proving peribulbar follicular inflammation&#44; a hypothesis that was put forward some years ago but has never been proven&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">21</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">The skin of a person with sensitive scalp may be normal in appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or characterized by more or less intense erythema &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In 1987&#44; Thestrup-Pedersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> considered erythema to be a basic finding&#44; albeit with a descriptive name&#8212;red scalp&#8212;and described characteristics that were identical to those we now consider as being sensitive scalp&#46; When examined using a dermatoscope&#44; sensitive scalp is formed by dilated capillaries and telangiectasias&#44; with no other specific findings&#46; The vascular patterns are those of healthy skin&#44; for example&#44; interfollicular simple red loops and arborizing red lines&#46; The finding of other abnormalities corresponds to the accompanying alopecia&#44; if present&#46; The finding of telangiectasias and high subjective sensitivity is sufficient reason for some authors to consider sensitive scalp a type of erythematotelangiectatic rosacea with an unusual location&#44; which may even improve with oral tetracyclines&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">23</span></a> However&#44; the absence of other manifestations of rosacea has led this hypothesis to be rejected&#46; Some studies on sensitive skin report a decrease in the thickness of the epidermis and disruption of the skin barrier&#46; This finding could also be attributed to sensitive scalp&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Sensitive scalp may occur alongside some types of alopecia&#46; As mentioned above&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> alopecia&#44; or more frequently telogen effluvium and androgenetic alopecia&#44; often co-occurs with sensitive scalp&#44; especially if it is associated with trichodynia&#46; In addition&#44; the type or intensity of alopecia is not associated with the intensity of the signs and symptoms of sensitive scalp&#46; However&#44; it is often alopecia that draws attention to the scalp&#44; thus enhancing the subjective perception of sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Psychological comorbidity is common in sensitive scalp&#44; especially when the condition is associated with trichodynia &#40;see above&#41;&#46; This association has been demonstrated in various psychological evaluations of patients with sensitive scalp&#44; the findings being anxiety&#44; depression&#44; stress&#44; and emotional dysregulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">25&#8211;28</span></a> Furthermore&#44; the effects of the symptoms of sensitive skin on quality of life could lead to psychopathological abnormalities that were not initially present&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Etiology and Pathogenesis</span><p id="par0125" class="elsevierStylePara elsevierViewall">The true pathophysiology of the process remains uncertain&#46; One theory points to hyperreactivity of the cutaneous nerves&#44; mainly in the case of sensitive scalp with trichodynia&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">29</span></a> Similarly&#44; consistent with the etiology and pathogenesis of sensitive skin&#44; various authors<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">30&#8211;32</span></a> believe that activation of the transient receptor potential cation channel subfamily V member 1 expressed in nerve endings&#44; keratinocytes&#44; and cells of the immune system triggers release of substance P and other neuropeptides in the skin&#44; leading to subjective symptoms&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Triggers</span><p id="par0130" class="elsevierStylePara elsevierViewall">As in sensitive skin&#44; sensitive scalp can involve a series of triggers that are both endogenous &#40;mainly stress&#41; and exogenous &#40;environment&#41;&#46; A typical example of the latter is hair products&#44; since many formulations contain irritants&#46; Even so&#44; it is difficult to determine which is responsible for onset or worsening of sensitive scalp&#46; Thus&#44; in 2021&#44; Brenaut et al&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">33</span></a> published the results of a study of 133 women &#40;mean age&#44; 41 years&#41;&#44; of whom 74&#37; reported having sensitive scalp&#46; However&#44; no differences were observed with respect to hair products&#44; except for more frequent use of conditioner in patients with sensitive scalp&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Another exogenous factor to be considered is topical treatments&#44; both for the accompanying alopecia<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">34</span></a> &#40;minoxidil&#41; and for sensory symptoms &#40;corticosteroids&#41;&#44; which&#44; in many cases&#44; the patient has already taken when consulting&#46; It is also important to take physical procedures such as phototherapy into account&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Given the limited cutaneous manifestations of sensitive scalp&#44; diagnosis is based on the clinical history&#44; which should record hygiene habits&#44; cosmetics&#44; treatments&#44; factors considered triggers by the patient&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">35</span></a> the result of the physical examination &#40;normal or erythema&#41;&#44; and trichoscopy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Misery et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">36</span></a> proposed a new scale&#44; the 3 S questionnaire&#44; for evaluating the intensity of symptoms in sensitive scalp&#46; The questionnaire makes it possible to differentiate between patients with mildly sensitive&#44; sensitive&#44; and very sensitive scalp&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Differential Diagnosis</span><p id="par0150" class="elsevierStylePara elsevierViewall">It is first necessary to distinguish between primary sensitive scalp and secondary sensitive scalp&#44; which always involves lesions on the scalp and&#44; possibly&#44; other areas&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">It is also necessary to differentiate between sensitive scalp and scalp dysesthesia associated with lichen simplex chronicus&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">37</span></a> as well as other conditions<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">38</span></a> caused by nerve injury&#44; impingement&#44; or irritation&#44; such as trigeminal trophic syndrome&#44; or zoster-associated trigeminal first branch pain&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Lastly&#44; multiple chemical sensitivity&#44; for which no clear diagnostic evidence has yet become available&#44; should be taken into account in some cases&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><p id="par0165" class="elsevierStylePara elsevierViewall">Treatment is summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The initial approach to sensitive scalp should attempt to eliminate or diminish the triggers&#44; mainly hair products and topical treatments&#44; including mechanical devices and exfoliants&#44; which should be replaced by cleansing products with amphoteric surfactants or soft anions and no common sensitizing agents&#44; cutaneous sensory nerve-mediated vasodilators&#44; or aromas&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">39</span></a> They may contain hydrating elements with proven biocompatibility such as glycerin and hyaluronic acid and relipidizing agents such as vegetable oil or ceramides&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3&#44;6&#44;26</span></a> Patients receiving topical minoxidil for alopecia can switch to oral minoxidil if there are no contraindications&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">40</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In the fairly common case of a patient who has received relatively long-term therapy with topical corticosteroids&#44; thus favoring telangiectasias and thinning of the epidermis&#44; a cycle of oral corticosteroids should be administered in order to eliminate topical treatment without a rebound effect&#46; Such an approach should be taken in line with usual practice&#44; taking into account contraindications and possible adverse effects&#46; Two weeks&#8217; therapy is generally sufficient&#44; with a continued dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d during the first week and rapid tapering during the second&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">If the subjective symptoms&#8212;stinging&#44; trichodynia&#44; and pruritus&#8212;are intense&#44; oral gabapentin can be added&#44; starting at 300<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; or pregabalin&#44; at 75<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h&#46; The dose and frequency can be increased if necessary&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The implicit neurogenic inflammation can be controlled&#44; and inflammatory mediators and sensory neuropeptides neutralized&#44; with topical pimecrolimus&#44; a calcineurin inhibitor that acts on TRPV1&#46; The drug should be administered as a cream at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;g once daily&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">6&#44;41</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The integrity of the horny layer can be restored by maintaining the scalp hydrated with hyaluronic acid light-texture formulations administered once or twice daily with an interval of at least 1<span class="elsevierStyleHsp" style=""></span>h before application of pimecrolimus&#46; Below&#44; we provide an example of a transparent fluid gel formulation&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Sodium hyaluronate &#40;more stable than the acid&#41; from 0&#46;1&#37; to 0&#46;5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Glycerin 5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Hydroxypropyl methylcellulose &#40;cellulose derivative&#41; 1&#46;5&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Phenonip XB &#40;preservative&#41; 0&#46;6&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Tween 20 &#40;surfactant&#41; 1&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Purified water &#40;qs&#41; 100<span class="elsevierStyleHsp" style=""></span>mL&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">Mesotherapy with growth factor-rich plasma has several uses and few risks&#46; Some studies have shown it to be effective in multiple cutaneous conditions for improving the skin barrier and reducing its reactivity in alopecia&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">42</span></a> and&#44; specifically&#44; erythema and telangiectasia&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">43</span></a> as in sensitive scalp&#46; We have administered mesotherapy monthly&#44; with tailored intervals according to the response&#46; Outcome is favorable&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Many of these recommendations can also be applied in secondary sensitive scalp&#44; bearing in mind the accompanying peculiarities of the disease&#46; While research on sensitive scalp may yet bear much fruit&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a> we believe that management is much simpler if based on the guidelines proposed here&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Clinical Manifestations"
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          "identificador" => "sec0025"
          "titulo" => "Etiology and Pathogenesis"
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        10 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Triggers"
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          "titulo" => "Differential Diagnosis"
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            0 => "Sensitive scalp"
            1 => "Sensitive skin"
            2 => "Trichodynia"
            3 => "Transient receptor potential cation channel"
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          "palabras" => array:4 [
            0 => "Cuero cabelludo sensible"
            1 => "Piel sensible"
            2 => "Tricodinia"
            3 => "Receptor de potencial transitorio vaniloide"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sensitive scalp is sensitive skin located on the scalp&#46; Sensitivity is considered primary in the absence of an associated scalp disorder and secondary when caused by conditions such as psoriasis&#44; seborrheic dermatitis&#44; and atopic dermatitis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The clinical manifestations of primary sensitive scalp are subjective&#46; Common presenting symptoms are burning&#44; itching&#44; trichodynia&#44; and dysesthesia&#44; often coinciding with hair loss&#46; Clinically&#44; the skin appears normal or red&#46; An objective diagnosis based on laboratory or histologic findings is not possible&#46; Triggers may be endogenous &#40;e&#46;g&#46;&#44; stress and emotional or psychopathological disturbances&#41; or exogeneous &#40;e&#46;g&#46;&#44; topical products and cosmetics&#41;&#46; Treatment must be individualized&#46; Options include pimecrolimus&#44; hydration with hyaluronic acid&#44; and mesotherapy with plasma rich in growth factors&#46;</p></span>"
      ]
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El cuero cabelludo sensible es una piel sensible de localizaci&#243;n especial&#46; Puede ser primario&#44; cuando se presenta sin enfermedad del cuero cabelludo&#44; y secundario&#44; cuando es atribuible a procesos como psoriasis&#44; dermatitis seborreica&#44; dermatitis at&#243;pica y otros&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las manifestaciones cl&#237;nicas de la forma primaria son subjetivas&#46; El escozor&#44; el picor&#44; la tricodinia y las sensaciones disest&#233;sicas son el motivo de consulta&#44; muy a menudo coincidiendo con alopecia&#46; Cl&#237;nicamente la piel del cuero cabelludo puede ser normal o eritematosa&#46; No hay datos de laboratorio o histol&#243;gicos espec&#237;ficos para un diagn&#243;stico objetivo&#46; Los factores desencadenantes son end&#243;genos&#44; como el estr&#233;s y las alteraciones emocionales y psicopatol&#243;gicas&#44; o ambientales&#44; como los t&#243;picos inadecuados y los cosm&#233;ticos&#46; El tratamiento debe ser personalizado&#44; incluyendo pimecrolimus&#44; la hidrataci&#243;n con &#225;cido hialur&#243;nico y la mesoterapia con plasma rico en factores de crecimiento&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">1- Eliminate hair products and topical treatments&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
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                  \t\t\t\t">2- Specific hair hygiene for sensitive scalp&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
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                  \t\t\t\t">3- Systemic treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a&#46; Short oral corticosteroid cycle &#40;prednisone&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 7 days and rapid tapering over a further 7 days&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b&#46; Gabapentin &#40;300<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41; or pregabalin &#40;75<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4- Topical treatment&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a&#46; Pimecrolimus cream 10<span class="elsevierStyleHsp" style=""></span>mg&#47;g once daily&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b&#46; Hyaluronic acid for the scalp once or twice daily with an interval of at least 1<span class="elsevierStyleHsp" style=""></span>h before application of pimecrolimus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5- Mesotherapy with platelet-rich plasma tailored to the individual&nbsp;\t\t\t\t\t\t\n
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitive skin&#58; a complex syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Escalas-Taberner"
                            1 => "E&#46; Gonz&#225;lez-Guerra"
                            2 => "A&#46; Guerra-Tapia"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ad.2011.04.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2011"
                        "volumen" => "102"
                        "paginaInicial" => "563"
                        "paginaFinal" => "571"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21757181"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitive scalp&#58; does this condition exist&#63; An epidemiological study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Misery"
                            1 => "V&#46; Sibaud"
                            2 => "M&#46; Ambronati"
                            3 => "G&#46; Macy"
                            4 => "S&#46; Boussetta"
                            5 => "C&#46; Taieb"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Contact Dermat"
                        "fecha" => "2008"
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            ]
            2 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitive skin&#58; perceptions&#44; evaluation&#44; and treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Z&#46;D&#46; Draelos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Contact Dermat"
                        "fecha" => "1997"
                        "volumen" => "8"
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                      ]
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                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Definition of sensitive skin&#58; an expert position paper from the special interest group on sensitive skin of the international forum for the study of itch"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Misery"
                            1 => "S&#46; St&#228;nder"
                            2 => "J&#46;C&#46; Szepietowski"
                            3 => "A&#46; Reich"
                            4 => "J&#46; Wallengren"
                            5 => "A&#46;W&#46; Evers"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2340/00015555-2397"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Derm Venereol"
                        "fecha" => "2017"
                        "volumen" => "97"
                        "paginaInicial" => "4"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26939643"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitive skin is not limited to the face"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; Saint-Martory"
                            1 => "A&#46;M&#46; Roguedas-Contios"
                            2 => "V&#46; Sibaud"
                            3 => "A&#46; Degouy"
                            4 => "A&#46;M&#46; Schmitt"
                            5 => "L&#46; Misery"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.08280.x"
                      "Revista" => array:6 [
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                        "fecha" => "2008"
                        "volumen" => "158"
                        "paginaInicial" => "130"
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                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and treatment of sensitive skin syndrome&#58; an algorithm for clinical practice"
                      "autores" => array:1 [
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ISSN: 00017310
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