The COVID-19 pandemic has led to a marked increase in wearing of masks of many different types, both in and out of healthcare settings. Mask related acne (colloquially termed ‘maskne’) and irritant contact dermatitis are the 2 most common facial dermatoses associated with mask wearing. A recent prospective cross sectional study of 833 medical school staff in Thailand, including healthcare and non-healthcare workers, showed a self-reported prevalence of 54% adverse skin reactions to surgical and cloth masks.
Why do face masks cause skin problems?
Masks cause a problem because they compromise the skin barrier due to increased humidity and temperature, created from breathing in a closed environment under a face mask. This causes follicular occlusion, increases sebum secretion, and changes skin microflora. Mechanical effects are due to friction and pressure.
Further contributory factors include:
- Type of mask
- N95 respirator masks > surgical mask > cloth mask
- Duration of mask wearing
- Prolonged wearing and re-use of disposable masks
- Pre-existing skin problems
- Acne, rosacea, seborrhoeic dermatitis, atopic dermatitis.
What are the clinical features of mask-related skin problems?
Common skin symptoms associated with face mask usage
Facial itch, redness, rash, dryness and peeling, swelling and numbness, pain and tingling, and oily skin are commonly reported symptoms related to face mask usage, particularly when a mask is worn for more than 4 hours daily.
Mechanical skin damage
Mechanical skin damage can initially present as pressure indentations around the nose from a metal nose clip, or itching, redness, and scaling behind the ears due to the earloops.
Friction may also cause exacerbation of a pre-existing skin condition such as psoriasis and vitiligo.
Mechanical skin damage may progress to erosions, ulceration, post-inflammatory hyperpigmentation and scarring. Secondary infection can develop wherever the skin is broken given the accumulation of bacteria on masks combined with perfect humid growing conditions as this published paper indicates https://www.mattioli1885journals.com/index.php/actabiomedica/article/view/11873/10389
Mask wearing can induce or exacerbate acne. It is the commonest skin rash related to face masks and particularly affects the cheeks.
Underlying skin conditions such as atopic dermatitis increase the risk of developing irritant contact dermatitis (ICD) due to a pre-existing defective skin barrier.
Allergic contact dermatitis (ACD) is a less common cause of mask reactions. Identifying the allergen can be difficult due to the variety of constituents used by manufacturers and the lack of publicly available information. Mask‐induced allergic contact dermatitis (ACD) can mimic other diseases, and may be misdiagnosed as acute cutaneous lupus erythematosus, seborrhoeic dermatitis, and sarcoidosis etc
Reported causes of ACD related to masks include:
- Rubber accelerators in the elastic bands of the mask
- Metal eg, nickel, from the nose piece/strip
- Antimicrobials in surgical masks eg, formaldehyde, bromo-2-nitropropane-1,3-diol (a formaldehyde-releaser)
- preservatives found in some adhesives used in the construction of N95 respirators and surgical face masks
- Polyurethane sponge strip in N95 respirators.
This may present over the bridge of the nose due to pressure from nasal strips, or behind the ears due to tension with movement from mask straps. Contact from the mask itself can also cause irritation.
Cheilitis is tightness and chapping of the lips, most commonly at the corners of the mouth where movement from talking and eating causes already irritated lips to crack and become inflamed.
Exacerbation of pre-existing skin conditions
Worsening of seborrhoeic dermatitis may present with increased itch, redness, and peeling, particularly with prolonged mask-wearing. This can be be due to the overgrowth of malassezia yeasts under the mask.
Facial eczema is very common, especially in young children. Symptoms are often uncomfortable, painful and itchy. It can occur anywhere on the face, but is most often found on the chin and cheeks. Adults can also develop eczema under the mask area.
Any face mask can cause facial eczema in those who are susceptible, but the risk increases with wear masks that are too tight or made of fabric that is scratchy or uncomfortable, causing irritation. Absorbent masks can dry out your skin, and as they get wetter, they let less air through. When you’re breathing out into such a face mask, your own airflow is directed back onto your face which can then create a humid environment over the skin.
Prolonged face mask use can also cause stress which is a known eczema trigger.
N95 masks are made from synthetic plastic fibres, usually polypropylene (PP). They fit tightly which reduces airflow. More than one-third of healthcare workers reported facial itch, rash or acne after wearing N95 masks daily for several months according to the American Academy of Dermatology (AAD)
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