Sensitive Skin Syndrome: An Update.

Sensitive skin syndrome is a widely reported complaint but a diagnostic challenge because of its subjective symptoms and lack of clearly visible manifestations. Epidemiological studies have shown the prevalence of sensitive skin to be as high as 60-70% among women and 50-60% among men. Patients with this syndrome usually have unpleasant sensations when exposed to physical, thermal, or chemical stimuli that normally cause no provocation on healthy skin. Recent studies and newly accepted position papers have provided a more in-depth understanding and consensus of its underlying pathophysiology, associations, diagnosis, and treatment. Since no clinical studies have been conducted about specific treatment protocols, patients with this condition should be provided with personalized skin management. Given this updated knowledge, our review offers an approach to sensitive skin syndrome, with differential diagnoses, and interventions targeting its pathophysiology.

Diagnosis and Treatment of Sensitive Skin Syndrome: An Algorithm for Clinical Practice. / Diagnóstico y tratamiento del síndrome de piel sensible: un algoritmo para la práctica clínica habitual.

Sensitive skin has traditionally been viewed as a cosmetic problem or as a purely psychosomatic alteration with a major subjective component. Different studies of its pathophysiologic etiology, however, have shown it to be a complex entity that several authors now consider to be a neurodermatological syndrome. Because of this complexity, skin sensitivity can be difficult to diagnose and treat, particularly considering that it may present with another disease. Simple tools applicable to clinical practice are thus necessary to identify and manage this disease as an independent entity. In this study, 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, and provide tools for its identification and treatment. We propose diagnostic and treatment algorithms based on evidence from the literature and our experience and expertise.

Sleep Shortage Is Associated With Postherpetic Neuralgia Development Through Hyperesthesia and Acute Pain Intensity: A Community-Based Prospective Cohort Study.

OBJECTIVES: There have been no community-based studies investigating the association between sleep duration and postherpetic neuralgia (PHN) development. The aim of the current study was to examine the association of sleep with herpes zoster (HZ) incidence and PHN. METHODS: In total, 12,329 residents (ages 50 to 103 years) of Shozu County, Japan, participated in our study from December 2009 to November 2010 and were followed up for 3 years. At baseline, the participants completed self-administered health questionnaires, including those on usual sleep duration. Three dermatologists diagnosed HZ on the basis of clinical symptoms and virus identification testing by polymerase chain reaction and serological tests, and evaluated pain using a modified Zoster Brief Pain Inventory survey form via telephone. We used a Cox proportional hazard regression model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HZ and PHN. We also performed mediation analysis to examine whether hyperesthesia and acute pain intensity mediated the association between sleep shortage and chronic pain intensity. RESULTS: During follow-up, 400 cases of HZ were identified. Of these, 55 participants developed PHN. Sleep duration was not associated with HZ incidence. Sleep shortage increased the risk for PHN (HR 2.02 [95% CI: 1.06 to 3.85]). Hyperesthesia and acute pain intensity mediated the association between sleep shortage and chronic pain intensity (indirect/total effect ratio = 50% mediation). CONCLUSIONS: Sleep shortage was associated with increased risk for PHN, and hyperesthesia and acute pain intensity appeared to mediate this association. Sleep shortage may be a novel risk factor for PHN.

Autism Traits, Sensory Over-Responsivity, Anxiety, and Stress: A Test of Explanatory Models.

The relationship between autistic traits, stress, and anxiety experienced by the general population was investigated using an adult sample that evaluated the suitability of three theoretical models proposed by Green and Ben-Sasson. Participants completed online questionnaires that were analysed using structural equation modelling and partial correlation analyses. Of the models tested, the model that proposed SOR and stress as mediators of the relationship between autistic traits and anxiety was able to explain the variance in the data better than the other models. Based on these findings, we suggest that sensory neutral environments should be considered for the prevention and management of anxiety and stress symptoms for people in the general population with higher levels of autistic traits.

Evaluation of the severity and triggering factors of sensitive scalp in Chinese females.

BACKGROUND: Sensitive scalp which has been recently proposed and assessed by several questionnaires is one of the most cosmetic concerns in sensitive skin syndrome by consumers. OBJECTIVE: This study is to investigate the prevalence and factors related to the scalp sensitivity in China. METHODS: Two well-known questionnaires including four-grade self-assessment and 3S, and a new questionnaire we proposed (10Q), were used to evaluate the severity and symptoms of sensitive scalp. RESULTS: The proportions of sensitive scalp according to self-assessment and 3S were 35.77% and 57.45%, respectively. Distributions of severity and tendency of proportion along ages were significantly different between the two methods. The 10Q questionnaire which we designed could discriminate different grade of severity of sensitive scalp with superior reliability. Moreover, triggering factors which have significant impacts on the symptoms of sensitive scalp were elucidated by logistic regression analysis, including air dryness, exercises, humidity, heat, and sun. CONCLUSION: Questionnaires with more dimensions and details such as 10Q and 3S should be used for the diagnosis, prognosis, and treatment monitoring on sensitive scalp in Chinese female.

A Prospective Evaluation of Female External Genitalia Sensitivity to Pressure following Labia Minora Reduction and Clitoral Hood Reduction.

BACKGROUND: Little research has been conducted into the effects of labiaplasty on sensitivity of external genitalia. This study aimed to determine the effect of labia minora and clitoral hood reduction using the edge resection technique on external genitalia sensitivity. METHODS: Female subjects electing to undergo labia minora and clitoral hood reduction were enrolled. Subjects underwent sensitivity testing using monofilaments at five locations (one at the clitoral hood and four labial with each labium measured 0.5 cm from the leading edge and 1.5 cm distal to the hymen) at baseline; 2 weeks; and 3, 6, and 12 months postoperatively. Self-evaluations using the Sexual Function Questionnaire were performed at baseline and 3, 6, and 12 months postoperatively. RESULTS: Thirty-seven subjects undergoing labia minora and clitoral hood reduction were enrolled. Subjects experienced a median increase in sensitivity at month 6 of 0.118 mN at the 0.5-cm right labial location (p = 0.027) and 0.059 mN at the 0.5-cm left labial location (p = 0.046) compared with baseline. No change in sensitivity was demonstrated at the clitoral hood or either of the 1.5-cm labial locations. At 6 months, an increase in the number of sexual relations was observed in 44.1 percent of subjects (p = 0.011), an improvement in orgasm frequency was exhibited by 35.3 percent of subjects (p = 0.013), and an increase in orgasm strength was observed in 35.3 percent of subjects (p = 0.006). CONCLUSION: Labia minora and clitoral hood reduction as performed by the trim/edge resection method does not result in diminished sensitivity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[Epidemiology of teeth hypersensitivity].

A clinical examination of 98 patients aged 20 to 75 years was carried out to identifyclinical and epidemiological features of hard tooth tissueshypersensitivity. The survey found out what stimuli (cold, hot, sour, mechanical, chemical) cause the appearance of dental hyperesthesia. The detailed survey of the affected area aimed to determine the presence of dental caries, gingival recession, wedge-shaped defects, erosions, microcracks and chipped enamel, as well as wear of the tooth crown. Forty-threepatients of 98 (43.88%) had tooth sensitivity. Most affected age group was 25-34 years (33%). Among patients studied with hyperesthesia 86% complained of pain. It was establishedthat dental hyperesthesia most often causes an intense, but quickly passing pain response, wherein upon exposure of several types of stimuli. Teeth with high sensitivity showed signs of abrasion (74.1%), most often--on the vestibular surface (44.4%). Patients under 45 years had notable cracks and wedge-shaped defects. In patients 45 years and older cracks and increased abrasion of hard dental tissues was seen.

[Optimization of treatment of wedge-shaped tooth defects with hyperesthesia].

Development of tooth wedge-shaped defect leads to a gradual loss of hard tissue and is characterized by pain. Most often patients complain of pain and aesthetic defect that adversely affects the emotional status and quality of life. Search for adequate means and methods of treatment providing increased resistance of dental hard tissues and reducing hyperesthesia is challenging for dentists. Wedge-shaped defect and hyperesthesia as concomitant symptom was found in the city of Ufa in the 5.65 and 63.0% of dental patients, respectively. Analysis of the questionnaires revealed a relationship between the sociological parameters (gender, age, profession) and the patient's quality of life. Improvement of all clinical manifestations was observed in the result of complex treatment.

[Transition from acute to chronic postsurgical pain. Physiology, risk factors and prevention]. / Chronifizierung postoperativer Schmerzen. Physiologie, Risikofaktoren und Prävention.

Chronic postsurgical pain (CPSP) is defined as pain persisting for longer than 3 months postoperatively. The frequency of occurrence ranges from 5 % to 60 % in all types of surgery and 1-3 % of patients with CPSP will suffer from severe pain and pain-related interference with daily activities. The pathological mechanisms which lead to the development of CPSP are complex and have not yet been analyzed. Neuropathic pain after surgical nerve lesions has been reported. Many patients with CPSP, however, do not present with any neuropathic pain characteristics. Peripheral and central sensitization are the essential mechanisms of the development of pain chronicity in the postoperative period. As treatment of CPSP is demanding it is attempted to prevent central sensitization before CPSP develops. New scientific findings on the development of CPSP, perioperative risk factors and the potential of preventative interventions are discussed.

Transient neurological symptoms after spinal anaesthesia with levobupivacaine 5 mg/ml or lidocaine 20 mg/ml.

BACKGROUND: Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine. METHODS: Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs. RESULTS: In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade. CONCLUSION: After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

Clinical significance of brush allodynia in emergency patients with migraine.

BACKGROUND: Cutaneous brush allodynia may be a practical and readily assessable marker of progression of an acute migraine attack. We determined the relative frequency of this finding in emergency department (ED) patients with acute migraine and tested the hypothesis that the presence of cutaneous brush allodynia prior to initial treatment in the ED could predict poor 2-hour and 24-hour pain intensity outcomes. METHODS: As part of a multicenter ED-based clinical trial testing the benefit of dexamethasone vs placebo for the adjuvant parenteral treatment of acute migraine, cutaneous brush allodynia was assessed prior to treatment using an established methodology. In addition to dexamethasone or placebo, all patients received intravenous metoclopramide + diphenhydramine as primary treatment for their migraine. Pain intensity outcomes were assessed in the ED 2 hours after medication administration and again by telephone 24 hours after medication administration. RESULTS: An assessment of cutaneous brush allodynia was performed in 182 migraineurs from 3 different EDs, of whom 26 (14%, 95% CI: 10-20%) had cutaneous brush allodynia. A pain-free state within 2 hours of medication administration was achieved by 46% of the allodynic patients and by 47% of the nonallodynic patients (P = .91). Median headache intensity over the 24 hours after ED discharge, as measured on a pain intensity scale from zero to 10, was 3 in the allodynic patients and 3 in the nonallodynic patients (P = .23). CONCLUSIONS: Cutaneous brush allodynia is an uncommon finding in the ED, occurring in fewer than 1 in 5 migraineurs. It does not seem to have prognostic relevance for the ED-based management of the acute migraine attack.

Cold hypersensitivity 6 to 10 years after replantation or revascularisation of fingers: consequences for work and leisure activities.

We investigated cold hypersensitivity and activity in 81 adults (male/female 76/5), 6 to 10 years after finger replantation/revascularisation (mean age at injury 43 (SD 15) years). Questionnaires included the McCabe Cold Sensitivity Severity Scale, Potential Work-Exposure Scale and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Eighty per cent of the respondents were cold hypersensitive; 20% were severely or extremely cold hypersensitive. Of the 74 patients employed at injury, 7% had changed work and 4% were not working due to cold hypersensitivity. The median score for cold exposure at work at follow-up was 153 (scale 0-300). The correlation between cold sensitivity and DASH work was low. One-third of the respondents experienced limitations in their leisure activities because of cold complaints. Long-term cold sensitivity was mild or moderate for most patients. Many cold hypersensitive patients managed to continue to work even under cold conditions and cold hypersensitivity was a greater problem in leisure activities.

Age-dependent development of chronic neuropathic pain, allodynia and sensory recovery after upper limb nerve injury in children.

Forty-nine children with distal upper limb nerve injury were studied at a mean follow-up of 2 years 3 months. Patients who were aged 5 years or younger at the time of nerve injury (15/49) had no chronic neuropathic pain symptoms or allodynia. Patients with allodynia on quantitative sensory testing but no spontaneous pain (8/49) were all older than 5 years and those reporting spontaneous chronic neuropathic pain (5/49) were all older than 12 years at the time of injury. Previous studies of adults with similar nerve injuries report chronic hyperaesthesia in up to 40% of cases. Semmes-Weinstein monofilament testing showed a positive correlation between age at injury and abnormal sensory threshold (r = 0.60, P<0.0001). These findings indicate that young children show better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults following nerve injury.

Tactile perception in adults with autism: a multidimensional psychophysical study.

Although sensory problems, including unusual tactile sensitivity, are heavily associated with autism, there is a dearth of rigorous psychophysical research. We compared tactile sensation in adults with autism to controls on the palm and forearm, the latter innervated by low-threshold unmyelinated afferents subserving a social/affiliative submodality of somatosensation. At both sites, the groups displayed similar thresholds for detecting light touch and innocuous sensations of warmth and cool, and provided similar hedonic ratings of the pleasantness of textures. In contrast, increased sensitivity to vibration was seen in the autism group on the forearm, along with increased sensitivity to thermal pain at both sites. These findings suggest normal perception along with certain areas of enhanced perception in autism, consistent with previous studies.

The incidence of mechanical allodynia in patients with irreversible pulpitis.

The mechanisms of odontogenic pain are complex and incompletely understood. Cases of irreversible pulpitis are thought to represent a localized inflammatory response to bacterial challenge in dental pulp tissue. The presenting symptoms are classically defined by exaggerated painful episodes to thermal stimuli that may linger after cessation of the stimulus. However, the associated incidence of mechanical allodynia, defined as reduced mechanical pain threshold to masticatory forces, has not been characterized. This study evaluated pain intensity ratings and the presence of mechanical allodynia reported by 993 consecutive dental patients presenting for tooth extraction in a community health center. After clinical and radiographic examinations, the pulpal/periradicular diagnostic categories were normal pulp/normal periradicular (n=792 patients), irreversible pulpitis/normal periradicular (n=86), or irreversible pulpitis/acute periradicular periodontitis (n=115). The rank order for the mean values of pain intensity ratings was irreversible pulpitis/acute periradicular periodontitis > irreversible pulpitis/normal periradicular > normal/normal (p<0.05 for all comparisons). The incidence of mechanical allodynia in patients presenting with irreversible pulpitis was 57.2%, indicating that periradicular mechanical allodynia contributes to early stages of odontogenic pain because of inflammation of vital pulpal tissue.

Improved identification of allodynic migraine patients using a questionnaire.

Using quantitative sensory testing (QST), we found that many migraineurs seeking secondary and tertiary care exhibit cutaneous allodynia whenever they undergo a migraine attack, but not interictally (i.e. between attacks). When such patients were questionned interictally in the clinic about symptoms of skin sensitivity in past attacks, 76% of them were 'correctly' classified either as allodynic (>or=1 symptom) or non-allodynic (zero symptoms) in line with the QST analysis. In this study, patients were classified as allodynic if they documented any one symptom of allodynia during an actual migraine attack which they had already cited in an earlier interictal interview. Of a total of 151 patients, 77% were classified as allodynic, citing on average four symptoms of skin hypersensitivity, three of which were consistently cited in the interictal interview and again during an attack. Among the remaining 23% of patients who were classified as non-allodynic, half cited zero symptoms as expected, while the other half cited between one and five symptoms, each of which was cited either interictally or during an attack, but not in both. Further analysis showed that 97% of patients citing two or more symptoms during an attack consisted of the patients labelled as allodynic, and that 75% of those citing just one symptom during an attack consisted of patients labelled as non-allodynic. Short of QST analysis, the results suggest that about 90% of all patients can be identified as allodynic or non-allodynic depending on whether or not they (i) consistently cited the same item(s) both interictally and during an attack or, alternatively, (ii) cited two or more symptoms during an attack.

Identifying cutaneous allodynia in chronic migraine using a practical clinical method.

Cutaneous allodynia is common in migraine. In the majority of previous studies on allodynia in migraine, only patients with episodic migraine (EM) were included. Little is known on patterns of allodynia in chronic migraine (CM). Since the presence of allodynia is associated with a poor response to triptans, a clinically practical method to test migraine patients for allodynia would be useful to the clinician. The aim of this study was to assess the prevalence of dynamic mechanical (brush) allodynia (BA) in CM, using a clinically practical method. Eighty-nine CM patients were prospectively recruited. Patients were given a structured questionnaire regarding demographic data and migraine characteristics. Allodynia was tested using a 10 x 10-cm gauze pad to brush various areas of the skin lightly. The prevalence of BA in the entire study population and in different patient subgroups was calculated. BA was present in 42.7% (38/89) of the patients. The presence of allodynia was unrelated to age, disease duration or to the occurrence of an acute headache exacerbation at the time of testing. Allodynia was positively associated with a history of migraine aura. BA was most common in the cephalic area, but was also seen in cervical dermatomes. BA is common in CM and, unlike in EM, is not significantly affected by the occurrence of an acute headache exacerbation. This suggests that central trigeminovascular neurons are chronically sensitized in patients experiencing migraine headache >15 days per month. The testing of BA in the clinical setting is possible using a simple and brief approach. It allows the clinician to determine whether the patient is sensitized, a diagnosis that affects treatment decisions.

Prevalence of hyperesthesia detected by current perception threshold test in subjects with glucose metabolic impairments in a community.

OBJECTIVE: Recent studies reported that hyperesthesia may be an indicator of early diabetic polyneuropathy. Using the current perception threshold (CPT) test, which stimulates peripheral sensory nerve fibers by three different frequencies (2,000, 250, and 5 Hz), we investigated the relationship between hyperesthesia and glucose metabolic impairment in a community. METHODS: The number of subjects, aged 40 to 79 years, was 2,074. The CPT values at each frequency were classified into three categories (hyperesthesia, normal, and hypoesthesia). Subjects were also subgrouped into three groups (normal, insulin resistance, and diabetes) according to glucose metabolic status, and those with hypoesthesia at each frequency were excluded in the analyses. RESULTS: The prevalence of hyperesthesia at 2,000, 250, and 5 Hz in male diabetic subjects were 14.1, 15.6, and 7.7%, respectively, and 22.2, 24.5, and 16.4% respectively in female diabetic subjects. In logistic regression analysis adjusted for age, females with diabetes showed a significantly high odds ratio (OR) for hyperesthesia at 2,000 Hz (OR, 2.42; 95% confidence interval (95%CI), 1.18 to 4.97) and 250 Hz (OR, 2.65; 95%CI, 1.31 to 5.37). In male diabetic subjects, a significantly high odds ratio for hyperesthesia was seen at 250 Hz (OR, 2.09; 95%CI, 1.07 to 4.05). CONCLUSION: Our results suggested that hyperesthesia may emerge coupled with developing diabetes, supporting the precedent hypothesis.

Saphenous neuralgia after coronary artery bypass grafting.

OBJECTIVE: To determine the incidence, extent and site of saphenous neuralgia (anaesthesia, hyperaesthesia and pain) in the lower limb after harvesting of great saphenous vein (GSV) for coronary artery bypass grafting (CABG). METHODS: Thirty-two consecutive patients (39 lower limbs) aged 58+/-16 years undergoing CABG were prospectively reviewed. All patients were assessed pre-operatively to establish the presence of normal sensation, then at 3 days, 6 weeks and 20+/-4 months post-operatively for symptoms or signs of saphenous neuralgia. The data were recorded on serial diagrammatic representations, and the area of sensory loss for each site was recorded at each review. The decrease in areas of sensory loss over time was investigated with statistical analysis. RESULTS: Thirty-five (90%) of the lower limbs examined showed some degree of anaesthesia at 3 days with 23 (72%) still symptomatic at a mean follow up of 20 months. Hyperaesthesia and pain were infrequently noted. Anaesthesia was generally confined to three main areas, which were denoted sites A, B and C for descriptive purposes. The mean area of sensory loss in the lower limb at 3 days post-surgery was 53.4 cm2, for an incision of mean length 42+/-22 cm from the medial malleolus. This area reduced to 31.7 cm2 by 20 months, and the decrease in area over time for each site was found to be statistically significant using analysis of variance for repeated measures and the Freidman-Rubin test. CONCLUSIONS: This study demonstrates that saphenous neuralgia after harvest of GSV for CABG is common. The main symptom is anaesthesia and certain areas may persist for some considerable time post-operatively.