 Abstract | | |
”Maskne” has been one of the negative spinoffs of the universally acceptable and effective role of face mask in containing the ongoing pandemic of SARS-CoV-2 virus or COVID 19. Several factors contribute to its aetiopathogenesis including heat, humidity, mechanical friction and microbiome dysbiosis in a complex interplay under the occlusive area of the mask. Clinically, the morphology is not very different from acne vulgaris with comedones and inflammatory acne, but in a characteristic distribution over a roughly circular area of face covered by mask. Since the use of face masks is likely to continue in the near future, measures like wearing a comfortably fitting mask of appropriate fabric, using disposable masks, increasing mask-free period when at safer places, avoiding unnecessary use of personal care products over the occluded skin, proper and gentle cleaning of the affected areas, intermittent mopping off of the excessive sebum and sweat and use of specific, topical and systemic therapy could help in its resolution.
Keywords: Acne mechanica, acne variants, adverse effects, COVID pandemic, face mask, maskne, personal protective equipment
How to cite this article:
Rathi SK, Dsouza JM. Maskne: A new acne variant in Covid-19 era. Indian J Dermatol 2022;67:552-5 |
| Introduction | |  |
Among the effective measures adopted universally to contain the ongoing pandemic due to SARS-CoV-2 virus or COVID 19, Mask has been the regular use of personal protective equipment (PPE), in particular the face mask which has contributed in reducing the person-to-person transmissibility of the virus. But in the process, it has brought with it new set of problems, from the physical and psychological discomfort of actually wearing a mask to headaches and impaired cognition to aggravation of several cutaneous eruptions including rosacea, folliculitis, atopic dermatitis, contact dermatitis, perioral dermatitis, acne, etc.[1],[2] Among these, acne is probably the only dermatoses which has received a new nomenclature as the “Maskne”, which encompasses both a de-novo eruption of acne or the exacerbation of acne of varying severity in a previously predisposed individual predominantly within the area covered by a face mask.[2],[3] Interestingly this terminology was not used for acne eruptions due to mask reported during 2003 SARS outbreak.[4] The intense media interest this time in reporting the difficulties faced by Health care workers and the illnesses they have endured during this pandemic has something to do with this as the term “Maskne” first appeared in print media in Italian[5] and English.[6] Mask-related acne and irritant contact dermatitis are the most common facial dermatoses happening due to mask wearing as per descriptive reports in literature.[7],[8]
Epidemiology
It is highly likely that the prevalence of Maskne is underreported as the reported data is mainly limited to questionnaire-based survey of health care workers. It is likely that acne lesions qualifying as Maskne in general public may pass over as a normal phenomenon in those who otherwise have acne vulgaris or is not considered as enough priority by them to report to a dermatologist. The prevalence of acne after the use of mask was reported to be in the range of 10–59.6% in limited sample-sized studies.[4],[9],[10],[11] Females happen to be more affected than males.[9],[12],[13] It was found to be more common and more severe in those who wore N95 mask and surgical masks compared to cotton mask.[4],[9],[11],[14] The duration of wearing mask also appeared to increase the tendency to acne[15],[16] though this was not observed in other studies.[3],[9],[13] It also happened more in previously acne susceptible individuals, and those with oily skin.[9]
Aetiopathogenesis
The exact aetiopathogenesis of Maskne remains a puzzle but various hypothesis has been put forward in the literature.[3] It is thought to be a subtype of acne mechanica due to textile skin friction and pressure of a tight fit required for the face mask to be effective.[16],[17] The high temperature and humidity on the facial skin surface due to exhaled air could lead to increase in sebum secretion and sweating.[3],[18] The poral hydration and occlusion of pilosebaceous duct near surface due to increased humidity and sweating results in swelling of the epidermal keratinocytes leading to acute obstruction and acne flare.[19] The increased humidity, in turn may also increase the squalene in the skin resulting in localised outbreak of acne in the covered area.[18] There could also be microflora imbalance consequent to skin barrier disruption due to changes in sebum composition and skin hydration, so called microbiome dysbiosis[20] (heat, pH, moisture from biofluids). Dysbiosis of the skin microbiota results in relative overgrowth of virulent and pathogenic Cutibacterium acnes strains and activation of innate immunity causing exacerbation of inflammatory acne.[21] Some of these factors would intensify with increase in the duration of mask wearing. In one study median time of mask wearing needed was found to be 8 h.[22] On the other hand, Han et al.[3] in their study of 24 patients, 5 of whom had no previous history of acne, noted no significant correlation between skin lesions and mask wearing time.
Clinical features
Clinically Maskne resembles classical acne vulgaris with presence of comedones and inflammatory papules in the characteristic distribution involving area of face covered by mask in both de novo cases and those having previous history of acne [Figure 1] and [Figure 2]. The cheeks, nose and chin are predominantly affected with the frequency of distribution being different in different studies.[9],[13],[15],[23] More severe features of acne vulgaris including nodular and cystic lesions are generally not seen. Repeated touching of the face due to irritation caused by occlusion due to mask may predispose to superadded infection. Clinical criteria to diagnose Maskne have been suggested, that is, acne occurring de novo after regular wearing of mask for 6 weeks or worsening of pre-existing acne in mask covered areas with distinct pattern, referred to as “O” zone [[Figure 3] – sketch image], due to regular mask wearing, after excluding the main differential diagnosis (seborrheic dermatitis, perioral dermatitis, pityrosporum folliculitis, and acne rosacea).[16] | Figure 3: Line sketch image showing common 'O area of distribution' of acne lesions due to mask wearing. (Line sketch courtesy Kanika Fernandes, Udaipur.)
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Prevention and treatment
Preventive measures like increasing duration of mask-free interval is being recommended wherever feasible to reduce the total mask wearing time. Desai et al.[24] have recommended to take a break of 15 min after every 2 h use of mask but sometimes it may not be practical especially for health care workers on ground duties. For N95 and surgical masks, it is advisable to change the masks regularly. Han et al.[3] advised to replace the surgical mask every 4 h and N95 mask every 3 days. Cotton masks though less effective against Covid transmission is gentle on skin and can be washed frequently.[17] To take care of the excessive sweat build up inside the mask, two layers of gauze can be placed inside the mask.[3] Similarly people with oily skin can regularly wipe their faces with a wet towel containing moisturizers.[3]
Another option which if can be exercised in our context is correctly choosing the fabric of face mask. Ideally Ultraviolet protection factor (UPF) 50 + fabric masks should be used which will also offer photoprotection.[16] The natural cotton fibre would initially be very comfortable as it offers better control of moisture compared to synthetic fibres, and will help the skin become dry with less growth of microorganism,[17] but because it has increased fluid saturation, it will soon be sticky and uncomfortable. This will not be a problem in synthetic biofunctional material which will have a high evaporation/cooling coefficient and are water resistant.[16],[17] The other important element is to have a fabric with high thread count and which is tightly woven as it causes less friction and has higher UPF. Also, fabric masks should omit the abrasive metallic nose clip which can cause nickel sensitization.[25] Development of biofunctional textiles for use in masks is underway and holds promising result.[17]
Use of cosmetic products under the mask is likely to cause irritation and flare of acne and thus should be avoided. Similarly physical sunscreen should be preferred over chemical sunscreens which could cause irritation and promote comedogenicity under mask.[16]
Guidelines from National Health Service (NHS), in addition to the above measures, advise application of a light emollient for at least 30 min before applying facial PPE, wiping skin under PPE with a silicon-based barrier wipe to provide a protective film, taking adequate time to fit the mask and to ensure it is not over tight, taking regular breaks from the mask (preferably every 1 h for respirators) to relieve the pressure and prevent moisture build up, staying well hydrated and maintaining oral hygiene.[26] Very importantly, simple general measures like hand washing before and after using mask should not be forgotten.
Just like regular acne, mild acne lesions can be managed with topical antibiotics, benzoyl peroxide and retinoid; while for moderate and severe grade of acne we may need additional oral antibiotic or oral retinoid.[16],[27] However, caution is to be used when prescribing benzoyl peroxide, retinoid, salicylic acid as they might lead to irritant contact dermatitis due to mask acting as occlusion device.[28] Hydrogel carrier formulations help to reduce the irritation and increase the tolerance and can be used.[16] Similarly, the use of traditional systemic pharmacotherapy like isotretinoin in Maskne may cause complications due to its inherent irritant potential when used for acne vulgaris.[29] Evidence-based botanical active ingredients with anti-inflammatory effect, sebum regulator and antimicrobial activity are also an option to manage Maskne.[16]
| Conclusion | | |
'Maskne' is a new term used for a type of acne due to regular wearing of mask in this pandemic era. The exact cause remains unanswered in literature, but it is probably multifactorial including heat, sweat, mechanical stress and microbiome dysbiosis. It can affect acne prone individuals, but may start de novo after use of mask for around 6 weeks with lesions mostly on 'O' zone of face. Preventive measures that would help includes following suitable skin care, avoiding irritating products, regular washing of cloth mask or frequent change of N95 and surgical masks as per recommendation, use of a well-fitted mask with insertion of two layers of gauze inside the mask to take care of excess sweat. For treatment, conventional topical and oral medication as used in acne vulgaris can be followed depending on acne severity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3] |
