Diagnostic and management considerations for “maskne” in the era of COVID-19
Authors: Wan-Lin Teo
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: "Maskne," coined during the coronavirus disease 2019 (COVID-19) pandemic, is a variant of acne mechanica, previously associated with headgear or personal protective equipment. This report focuses on the widespread use of reusable fabric masks and the impact of the skin microenvironment and mechanical factors (ie, textile-skin friction), which to my knowledge has not been previously evaluated. Our understanding of maskne is largely observational, although it is likely a disorder of follicular occlusion and directly related to mechanical stress1Boer J. Nazary M. Riis P.T. The role of mechanical stress in hidradenitis suppurativa.Dermatol Clin. 2016; 34: 37-43Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar (pressure, occlusion, friction) and microbiome dysbiosis2Naik H.B. Piguet V. Standardizing hidradenitis suppurativa skin microbiome research: the methods matter.J Invest Dermatol. 2020; 140: 1688-1690Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar (heat, pH, moisture from biofluids). Both of these are affected by increased duration of mask wear. Tropical climates and outdoor exposure (increased sweating) are risk factors for acne-susceptible populations (active young adults, seborrhea, genetic predisposition). Clinical criteria proposed for maskne: onset of acne within 6 weeks of start of regular face mask wear or exacerbation of acne over the masked area, distinct pattern, referred to as the O-zone in this report (Fig 1), and exclusion of differential diagnoses, including perioral dermatitis, seborrheic dermatitis, pityrosporum folliculitis, and acne rosacea. Special consideration for skin care should include antibacterial gentle cleansers and moisturizers formulated as prescription emollient devices, which help maintain a healthy skin barrier/microbiome. Spot acne treatment with benzoyl peroxide, salicylic acid, sulfur, α-hydroxy acids, and retinoids predispose to irritant contact dermatitis under occlusion. Botanical actives with anti-inflammatory, antioxidant, sebum regulation, and antimicrobial properties are preferred. Hydrogel carrier formulations of retinoid/antibiotic combination topicals can minimize local irritation by ensuring better drug tolerance and efficacy. Chemical sunscreen sensitivity and comedogenicity increase under occlusion. Ultraviolet protection factor (UPF) 50+ fabric masks should replace the wearing of sunscreen (eliminates constant reapplication) as a practical photoprotective measure for the lower half of the face, to improve compliance to sun protection and incentivize mask wearing. Dermatologists' prescribing patterns for maskne may potentially influence the development of antibiotic resistance worldwide. Dermatologists can advise on design of face masks, encouraging patient compliance. Natural fibers wick moisture but have increased fluid saturation, heightening discomfort and stickiness sensation (accumulated stickiness magnitude).3Tang K.M. Chau K.H. Kan C.W. Fan J.T. Assessing the accumulated stickiness magnitude from fabric-skin friction: effect of wetness level of various fabrics.R Soc Open Sci. 2018; 5: 180860Crossref PubMed Scopus (20) Google Scholar Synthetic biofunctional textiles have a high evaporation/cooling coefficient and are water resistant, preventing biofluid spread. High thread count and tightly woven fabrics have higher UPF and minimize textile-skin friction, relevant to individuals with atopic conditions. Light/reflective colors disperse heat (Fig 2). Reusable fabric masks should allow for movement while speaking, with minimal displacement over orifices. Fabric masks should omit abrasive metallic parts that also cause nickel sensitization. Allergic contact dermatitis and transcutaneous absorption of potential carcinogens can occur from textiles used for fabric face masks, which is currently unregulated. The skin microbiome is influenced by genetic and external factors (ie, environment, pH, and temperature), which are modified with mask wearing. Microbiome dysbiosis is implicated in the pathogenesis of eczema, acne, perioral dermatitis, seborrheic dermatitis, pityrosporum folliculitis, and rosacea. Biofunctional textiles with UPF, antioxidant, and antiaging benefits may incentivize mask wearing. Copper oxide polyesters are associated with reduced facial wrinkles,4Baek J.H. Yoo M.A. Koh J.S. Borkow G. Reduction of facial wrinkles depth by sleeping on copper oxide-containing pillowcases: a double blind, placebo controlled, parallel, randomized clinical study.Cosmet Dermatol. 2012; 11: 193-200Crossref Scopus (20) Google Scholar elevation of elastin, procollagen 1, and transforming growth factor-β1 levels.5Ogen-Shtern N. Chumin K. Cohen G. Borkow G. Increased pro-collagen 1, elastin, and TGF-β1 expression by copper ions in an ex-vivo human skin model.J Cosmet Dermatol. 2020; 19: 1522-1527Crossref PubMed Scopus (19) Google Scholar Textiles that incorporate silver, zinc oxide, and copper oxide have broad-spectrum biocidal properties that are therapeutic for dermatologic conditions, besides reducing antibiotic resistance in acne treatment. Importance of nose wires in face masks: A reply to "Diagnostic and management considerations for "maskne" in the era of COVID-19"Journal of the American Academy of DermatologyVol. 85Issue 3PreviewTo the Editor: We read with great interest Teo's recent publication on the diagnosis and management of "maskne," a form of acne mechanica due to face mask use during the COVID-19 pandemic.1 To help combat maskne and other mask-related skin problems, Teo proposed several innovative ideas for the "ideal fabric face mask."1 These suggestions include the use of tightly woven, high-thread-count fabrics to minimize friction and increase the ultraviolet protection factor; bright colors to dissipate heat; and silver, zinc oxide, and copper oxide-impregnated fibers to confer antimicrobial and antiaging benefits. Full-Text PDF