Maskne: Comparison
View Latest Version
Please note this is a comparison between Version 1 by Cristina Beatrice Spigariolo and Version 2 by Rita Xu.

The term maskne comes from the contraction of mask-related acne. It means a form of mechanical acne resulting from the continuous adherence and friction between skin and facial mask. It typically appeares as mild papular eruption accompained by comedones and seborrhea on the O-area of the face, especially on chin and cheecks. The prolonged use of mask generates also a hot-humid microclimate on skin surface modifyng sebum production and consequently microbiota.

  • maskne
  • acne
  • mask
  • pandemic
  • SARS-CoV-2
  • COVID-19

1. Introduction

In last two years of the SARS-CoV-2 outbreak, people have had to modify their daily routine, introducing new habits and devices to reduce the risk of infection. Among all personal protective equipment (PPE), facial masks are the most employed and effective instrument to maintain a state of health [1]. Their use, first only among healthcare workers and then among general population, has led to an increase of facial dermatoses, i.e., acne, rosacea, seborrheic dermatitis, and contact dermatitis. This phenomenon was so prevalent that a new description term, maskne, has been coined. Maskne is a contraction of mask-related acne and describes a form of acne in the O-area secondary to the prolonged use of facial masks [2]. Although effective prevalence is unknown, there is currently an increasing request for consultations due to acne onset or its worsening [3].
In a Turkish survey, conducted from December 2020 to February 2021, 101 healthcare workers (HCW) were screened for facial dermatoses and it emerged that acne prevalence was present in 55.4% of participants [4]. Similar findings resulted from another survey among HCW from Pakistan [5]. Acneiform eruptions have been documented in two larger cohorts of 454 [6] and 400 [7] subjects, where prevalence was respectively assessed to 39.9% and 43% of all adverse skin reactions due to prolonged face mask use.
Additional studies confirmed that rosacea, irritant contact dermatitis, and acne [8][9][8,9] worsened after mask use, even among children [10]. It is also acknowledged that acne could contribute to mask-induced itch [11].
Moreover, some risk factors, such as greater stress, the sleep deprivation HCW undergo during their shifts in COVID wards, and the consequent increasing in cortisol secretion may contribute to the development of acne [12].

2. Definition and Pathogenesis

Maskne is a form of mechanical acne [6][13][6,14]. resulting from continuous textile–skin adherence and friction [14][15]. Furthermore, prolonged mask use determines a hot-humid microclimate on the skin surface, thus modifying sebum production and consequently microbiota [15][16]. The term maskne refers both to new diagnoses and to aggravation of pre-existing acneiform eruption [16][17].

2.1. The Role of Microbiota

Mask use is responsible of the disruption of skin microbiota balance causing bacterial dysbiosis. It has been demonstrated that cutaneous microbiota develops with the age [17][18]: infant skin is more sensitive to inflammatory diseases such as atopic dermatitis and diaper dermatitis and to infections such as S. Aureus and candidiasis. Maturation of microbiota from childhood to adulthood has been demonstrated to have a pivotal role in preventing inflammatory skin diseases. During the transition through puberty, sebum overproduction has been linked to colonization by Cutibacterium acnes, while its decrease seems to be related with the lower sebum secretion observed in aging skin.
The main actor in acne is Cutibacterium acnes, which, as the most prevalent species, accounts for 90% of microbiota of the pilo-sebaceous unit. Its density varies with age, increasing from adolescence to middle adult age and then decreasing from 40–50 years old. C. acnes is involved in a double mechanism: on one hand, colonies of C. acnes use sebum lipids as a metabolic intermediate to promote their growth, on the other, they favor sebum production by increasing the activity of diacylglycerol acyltransferase. Moreover, the porphyrins released by C. acnes are catalytic factors for the oxidation of squalene, a main component of sebum [18][19]. Dysbiosis seems to select pathogen species of C. acnes and activates innate immunity causing cutaneous inflammation [19][20]. A recent study [20][21] suggests that the severity of inflammation in acne may be explained by the loss of diversity of C. acnes phylotypes with the selection of phylotype IA1, which enhances the innate immune system, thereby promoting the release of inflammatory cytokines.
In any case, if correctly balanced, C. acnes is considered a fundamental commensal for skin health because of its role in maintaining low pH, thus preventing Staphylococcus aureus and Streptococcus spp. proliferation.
The significance of Malassezia in acne is not totally clear, though it is known for its pathogenetic role in seborrheic dermatitis and in Pityrosporum folliculitis, a clinical mimic of acne. Malassezia hydrolyzes free fatty acids in sebum, which may affect the abnormal keratinization of hair follicles and promote the secretion of pro-inflammatory cytokines from keratinocytes and monocytes [18][19].
Dysbiosis is also responsible of other skin diseases; in particular, flare-ups of eczema are significantly related to S. Aureus colonization, Gram-negative folliculitis may aggravate acne, Fusobacteria are involved in perioral dermatitis, and Demodex follicolorum seems to be linked to rosacea [18][19].

2.2. The Microenvironment: Temperature and pH

Different studies have reported the aggravation of acne during the summer season in relation to higher temperature. In particular, the most severe cases have been observed in tropical and subtropical climates, likely due to humidity [14][17][15,18].
The close correlation between high temperature and acne flare can be explained by the effect of higher temperature on the sebum excretion rate. Sebum excretion increases by 10% for each 1 °C rise. Furthermore, squalene could become significantly greater in surface lipids when temperature increases [18][19]. Moreover, the increase of humidity plays a role through the poral occlusive effect, irritation, and swelling of the skin. Both sweat and increased humidity may cause acute obstruction and aggravate acne [19][20].
The same alterations are reproduced by the facial mask use because:
  • It makes the air temperature between skin and mask higher due to the restricted area and its closes adherence to the skin, particularly at the boundaries;
  • It increases sweat retention, especially in people affected by hyperhidrosis;
  • It reduces air recirculation, favoring the deposition of exhaled damp hair and toxins.
Therefore, masks may produce a microclimate similar to a greenhouse, thus favoring microbiota that contribute to the development of acne.
A study conducted on 20 participants aimed to compare facial skin temperature and heat flow using medical-surgical equipment [21][22]. A statistically significant difference in humidity, heat, breathing difficulty, and discomfort was present. Infrared thermography images demonstrated temperature changes at the perioral region and superior lip immediately after removal of the mask, compared with baseline conditions in both types of PPE, while no temperature augmentations were observed on the forehead, cheeks, and nose/mouth.
As far as the pH of skin, there is no consensus if lower pH contributes the development of acne [22][23]; However, changes in pH contribute to dysbiosis and thus promote the development of this disease.
Finally, mask-wearing might create a new intertriginous area where different type of microorganisms can grow [23][19].[13,20]

2.3. Characteristics of Masks

FFP2/KN95 masks are greater risk factors for the development of acne than surgical masks because of their higher humidity, occlusion, and temperature [4].
In the study of Techasatian et al. [6], it emerged that four types of masks are frequently used by the general population: surgical masks, cloth masks, surgical masks covered by a piece of cloth, and N95/FFP2 mask. This paper [6] showed that different factors are responsible for skin side effects. The first one is the mask type: surgical masks and surgical masks covered by a piece of cloth are related to major risks; immediately followed by the duration of mask wearing (especially over 4–6 h/day) and reutilization of the same mask. In addition, the use of sanitizers for masks seemed to have a dual effect: direct skin irritation and predisposition to the occlusion mechanism.
This discrepancy between the causative role of surgical masks and KN95/FFP2 might be explained by the fact that KN95 are more utilized by healthcare workers and less among the general population.
Cloth masks were more involved than surgical and FFP2/KN95 masks in the development of acne in an Indian study [24]. The explanation given by the authors is that people used cloth masks for many days without adequate washing and hygiene practices, with a consequent accumulation of sweat and environment dirt.
It has been also demonstrated that textile dyes, rubber, rubber antioxidants, chemical adhesives, and formaldehyde may influence the development of allergic (ACD) and irritant contact dermatitis (ICD) over areas in contact with face masks [25][26][25,26].

3. Clinical Features of Maskne

Acne related to masks occurred more frequently on the chin than the cheeks and it appeared as mild papular eruptions, accompanied by comedones and seborrhea [1][4][1,4].

4. Diagnostic Criteria

AuthorsWe propose five diagnostic criteria for maskne:
  • Appearance of acne after six weeks of mask-use or aggravation of pre-existing acne in the mask area [14][15][15,16];
  • Elementary lesions as papules, pustules, and comedones;
  • Localization in the area of mask or O-area;
  • Temporal relationship with mask use: aggravation/development of acne with prolonged usage (>4–6 h/day [6]) and improvement when not worn for a long period;
  • Exclusion of other dermatoses such as perioral dermatitis, rosacea, seborrheic dermatitis, ICD, and ACD [14][15]
Given the similarities between acne related to mask and acne vulgaris, maskne classification may reflect the one adopted for acne according to European Guidelines [27].
 

References

[1] Giacalone S, Minuti A, Spigariolo CB, Passoni E, Nazzaro G. Facial dermatoses in the general population due to wearing of personal protective masks during the COVID-19 pandemic: first observations after lockdown. Clin Exp Dermatol. 2021;46(2):368-369. doi:10.1111/ced.14376

[2] Drozdowski R, Gronbeck C, Feng H. Mask-related acne in the COVID-19 pandemic: an analysis of Twitter posts and influencers. Clin Exp Dermatol. 2021;46(5):943-945. doi:10.1111/ced.14608

[3] Yan Y, Chen H, Chen L, et al. Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019. Dermatol Ther. 2020;33(4):e13310. doi:10.1111/dth.13310

[4] Altun E, Topaloglu Demir F. Occupational facial dermatoses related to mask use in healthcare professionals [published online ahead of print, 2021 Aug 27]. J Cosmet Dermatol. 2021;10.1111/jocd.14415. doi:10.1111/jocd.14415

[5] Yaqoob S, Saleem A, Jarullah FA, Asif A, Essar MY, Emad S. Association of Acne with Face Mask in Healthcare Workers Amidst the COVID-19 Outbreak in Karachi, Pakistan. Clin Cosmet Investig Dermatol. 2021;14:1427-1433. Published 2021 Oct 7. doi:10.2147/CCID.S333221

[6] Techasatian L, Lebsing S, Uppala R, et al. The Effects of the Face Mask on the Skin Underneath: A Prospective Survey During the COVID-19 Pandemic. J Prim Care Community Health. 2020;11:2150132720966167. doi:10.1177/2150132720966167

[7] Aravamuthan R, Arumugam S, «Clinico-epidemiological study of mask induced acne due to increased mask use among health care workers during COVID pandemic in a tertiary care institute», Int. J. Res. Dermatol., vol. 7, pag. 48, dic. 2020, doi: 10.18203/issn.2455-4529.IntJResDermatol20205594.

[8] Damiani G, Gironi LC, Grada A, et al. COVID-19 related masks increase severity of both acne (maskne) and rosacea (mask rosacea): Multi-center, real-life, telemedical, and observational prospective study. Dermatol Ther. 2021;34(2):e14848. doi:10.1111/dth.14848

[9] Montero-Vilchez T, Cuenca-Barrales C, Martinez-Lopez A, Molina-Leyva A, Arias-Santiago S. Skin adverse events related to personal protective equipment: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2021;35(10):1994-2006. doi:10.1111/jdv.17436

[10] Dinulos JE, Dinulos JG. Cutaneous coronavirus disease 2019 in children: a clinical primer for diagnosis and treatment. Curr Opin Pediatr. 2021;33(6):691-703. doi:10.1097/MOP.0000000000001076

[11] Szepietowski JC, Matusiak Ł, Szepietowska M, Krajewski PK, Białynicki-Birula R. Face Mask-induced Itch: A Self-questionnaire Study of 2,315 Responders During the COVID-19 Pandemic. Acta Derm Venereol. 2020;100(10):adv00152. Published 2020 May 28. doi:10.2340/00015555-3536

[12] Xerfan EMS, Facina AS, Andersen ML, Tufik S, Tomimori J. Acne flare-up due to mask wearing: A current pandemic scenario and its relationship with sleep. Skin Res Technol. 2021;27(5):1002-1003. doi:10.1111/srt.13048

[13] Foo CC, Goon AT, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome--a descriptive study in Singapore. Contact Dermatitis. 2006;55(5):291-294. doi:10.1111/j.1600-0536.2006.00953.x

[14] Hadžavdić A, Bukvić Mokos Z. Maskne: A New Entity in the COVID-19 Pandemic. Acta Dermatovenerol Croat. 2021;29(3):148-153

[15] Teo WL. Diagnostic and management considerations for "maskne" in the era of COVID-19. J Am Acad Dermatol. 2021;84(2):520-521. doi:10.1016/j.jaad.2020.09.063

[16] Rudd E, Walsh S. Mask related acne ("maskne") and other facial dermatoses. BMJ. 2021;373:n1304. Published 2021 Jun 7. doi:10.1136/bmj.n1304

[17] Özkesici Kurt B. The course of acne in healthcare workers during the COVID-19 pandemic and evaluation of possible risk factors. J Cosmet Dermatol. 2021;20(12):3730-3738. doi:10.1111/jocd.14530

[18] Luna PC. Skin Microbiome as Years Go By. Am J Clin Dermatol. 2020;21(Suppl 1):12-17. doi:10.1007/s40257-020-00549-5

[19] Xu H, Li H. Acne, the Skin Microbiome, and Antibiotic Treatment. Am J Clin Dermatol. 2019;20(3):335-344. doi:10.1007/s40257-018-00417-3

[20] Teo WL. The "Maskne" microbiome - pathophysiology and therapeutics. Int J Dermatol. 2021;60(7):799-809. doi:10.1111/ijd.15425

[21] Dréno B, Dagnelie MA, Khammari A, Corvec S. The Skin Microbiome: A New Actor in Inflammatory Acne. Am J Clin Dermatol. 2020;21(Suppl 1):18-24. doi:10.1007/s40257-020-00531-1

[22] Tucker SB. Occupational tropical acne. Cutis. 1983;31(1):79-81.

[23] Sardana K, Sharma RC, Sarkar R. Seasonal variation in acne vulgaris--myth or reality. J Dermatol. 2002;29(8):484-488. doi:10.1111/j.1346-8138.2002.tb00313.x

[24] Han C, Shi J, Chen Y, Zhang Z. Increased flare of acne caused by long-time mask wearing during COVID-19 pandemic among general population. Dermatol Ther. 2020;33(4):e13704. doi:10.1111/dth.13704

[25] Scarano A, Inchingolo F, Lorusso F. Facial Skin Temperature and Discomfort When Wearing Protective Face Masks: Thermal Infrared Imaging Evaluation and Hands Moving the Mask. Int J Environ Res Public Health. 2020;17(13):4624. Published 2020 Jun 27. doi:10.3390/ijerph17134624

[26] Brambilla L, Brena M, Tourlaki A. Textiles in dermatology: our experience and literature review. G Ital Dermatol Venereol. 2016;151(3):266-274.

[27] Nast A, Dréno B, Bettoli V, et al. European evidence-based (S3) guideline for the treatment of acne - update 2016 - short version. J Eur Acad Dermatol Venereol. 2016;30(8):1261-1268. doi:10.1111/jdv.13776

 

© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)
Video Production Service
Feedback