Clinical manifestations and patch test results for facial dermatitis associated with disposable face mask use during the COVID-19 outbreak: A case-control study
Authors: Seok Young Kang, Bo Young Chung, Jin Cheol Kim, Chun Wook Park, Hye One Kim
Journal: Journal of the American Academy of Dermatology (2021)

To the Editor: Due to the recent COVID-19 pandemic, people are wearing disposable masks more often than ever. The prolonged use of disposable masks has markedly increased cases of facial dermatitis, including irritant contact dermatitis, allergic contact dermatitis, and exacerbations of preexisting atopic dermatitis.1Aerts O. Dendooven E. Foubert K. Stappers S. Ulicki M. Lambert J. Surgical mask dermatitis caused by formaldehyde (releasers) during the COVID-19 pandemic.Contact Dermatitis. 2020; 83: 172-173Crossref PubMed Scopus (58) Google Scholar Patch tests help differentiate possible etiologies and exclude allergic contact dermatitis; however, objective data are lacking to help determine the validity of positive allergens.2Choi S.Y. Hong J.Y. Kim H.J. et al.Mask induced dermatoses during COVID-19 pandemic: a questionnaire-based study in 12 hospitals of Korea.Clin Exp Dermatol. 2021; Crossref Scopus (14) Google Scholar Here, we undertook an observational study to investigate the clinical manifestation and patch test results of patients with facial dermatitis induced by wearing disposable masks. Korean patients older than 18 years of age with facial dermatitis diagnosed by dermatologists from the Department of Dermatology at Kangnam Sacred Heart Hospital after the outbreak of COVID-19 between January 2020 and July 2020 were included in the study. Clinically, 27 patients whose lesions and symptoms worsened after wearing a mask wereestablished as the mask group and 70 patients who developed facial dermatitis due to other causes were established as the control group. Both groups were recruited and distinguished using a questionnaire.2Choi S.Y. Hong J.Y. Kim H.J. et al.Mask induced dermatoses during COVID-19 pandemic: a questionnaire-based study in 12 hospitals of Korea.Clin Exp Dermatol. 2021; Crossref Scopus (14) Google Scholar Demographic features, clinical manifestations, objective bioengineering measurements (transepidermal water loss and stratum corneum hydration), and patch test (Korean standard series)3Yu D.S. Kim H.J. Park Y.G. Bae J.M. Kim J.W. Lee Y.B. Patch-test results using Korean standard series: a 5-year retrospective review.J Dermatolog Treat. 2017; 28: 258-262Crossref PubMed Scopus (10) Google Scholar results were analyzed in this study. The mean duration of disease was 6.24 months among the patients in the mask group and 22.87 months in the control group (Table I). The distribution of skin lesions was similar in both groups except for the chin area, where skin lesions were more frequently observed in the mask group (14.81%; 4 of 27 patients). Erythema and papules were the most common characteristics of the skin lesions in both groups; however, hyperkeratosis (22.22%; 6 of 27) and xerosis (11.11%; 3 of 27) were significantly more frequent in the mask group.Table IComparison between mask group and group induced by other causes with clinical manifestationClinical manifestationInduced by mask(n = 27)Induced by other causes(n = 70)Disease duration, mean (SD), month∗P value < .05.6.24 ± 6.0022.78 ± 30.37Mean stratum corneum hydration (SD), A.U.61.93 ± 21.0358.94 ± 19.33Mean TEWL (SD), g/m2/hr16.98 ± 6.5321.11 ± 20.88Patients, Number (%) Distribution∗P value < .05.Centrofacial18 (66.66)9 (33.33)Peripheral45 (64.28)25 (35.71)Location of eczematous skin lesions Forehead8 (29.62)23 (32.85) Nose3 (11.11)7 (10) Perioral6 (22.22)17 (24.28) Chin∗P value < .05.4 (14.81)4 (5.71) Ears4 (14.81)10 (14.28) Cheek13 (48.14)38 (54.28) Others3 (11.11)8 (11.42)Cutaneous signs Erythema19 (70.37)46 (65.71) Hyperkeratosis∗P value < .05.6 (22.22)3 (4.28) Pustule3 (11.11)18 (25.71) Papule6 (22.22)22 (31.42) Excoriation02 (2.85) Vesicle2 (7.40)10 (14.28) Xerosis∗P value < .05.3 (11.11)1 (1.42) Hyperpigmentation1 (3.70)10 (14.28) Edema∗P value < .05.2 (7.40)0Cutaneous symptoms Itching15 (55.55)51 (72.85) Flushing∗P value < .05.6 (22.22)4 (5.71) Stinging/heating sensation4 (14.81)11 (15.71)Each patient has 1 or more skin lesions, cutaneous signs, or symptoms.A.U., Arbitrary unit; SD, standard deviation; TEWL, transepidermal water loss.∗ P value < .05. Open table in a new tab Each patient has 1 or more skin lesions, cutaneous signs, or symptoms. A.U., Arbitrary unit; SD, standard deviation; TEWL, transepidermal water loss. In patch test results (Table II), the mask patch tested positive more frequently to potassium dichromate (25.92%; 7 of 27) and 4-tert-butylphenol-formaldehyde resin (14.81%; 4 of 27). Positive reactions to N-isopropyl-N-phenyl-4-phenylenediamine (7.40%; 2 of 27), formaldehyde (11.11%; 3 of 27), and thimerosal (14.81%; 4 of 27) were more common in the mask group, but the difference was not statistically significant. Interestingly, these substances are known components of disposable facial masks. In addition, 11 patients in the control group (15.71%; 11 of 70) had negative reactions to all the items in the patch tests, while only 1 patient in the mask group did (3.70%; 1 of 27).Table IIComparison between the mask group and control group in the patch test resultsPatch test itemsInduced by mask (n = 27)Induced by other causes (n = 70)1. Nickel (II) sulfate hexahydrate15 (55.55%)31 (44.28%)2. Lanolin alcohol (wool alcohol)1 (3.70%)2 (2.85%)3. Neomycin sulfate02 (2.85%)4. Potassium dichromate∗P value < .05.7 (25.92%)7 (10%)5. Mercury ammonium chloride05 (7.14%)6. Fragrance mix I1 (3.70%)6 (8.57%)7. Colophonium1 (3.70%)2 (2.85%)8. Imidazolidinyl urea01 (1.42%)9. Clinquinol01 (1.42%)10. Myroxylon pereirae resin (Balsam Peru)2 (7.40%)4 (5.71%)11. IPPD2 (7.40%)012. Cobalt (II) chloride hexahydrate3 (11.11%)2 (2.85%)13. PTBP∗P value < .05.4 (14.81%)014. Paraben mix1 (3.70%)015. Captan2 (7.40%)3 (4.28%)16. Budesonide02 (2.85%)17. Methylisothizolinone + methylcholoroisothizolinone01 (1.42%)18. Quaternium-151 (3.70%)019. MBT01 (1.42%)20. PPD07 (10%)21. Formaldehyde3 (11.11%)2 (2.85%)22. Mercapto mix1 (3.70%)1 (1.42%)23. Thimerosal4 (14.81%)5 (7.14%)24. Thiuram mix1 (3.70%)1 (1.42%)25. Tixocortol-21-pivalate01 (1.42%)IPPD, N-Isopropyl-N-pheynyl-4-phenylenediamine; MBT, 2-Mercaptobenzothiazole; PPD, p-phenylenediamine; PTBP, 4-tert-butylphenol-formaldehyde resin.∗ P value < .05. Open table in a new tab IPPD, N-Isopropyl-N-pheynyl-4-phenylenediamine; MBT, 2-Mercaptobenzothiazole; PPD, p-phenylenediamine; PTBP, 4-tert-butylphenol-formaldehyde resin. These results would infer that the chemical components of disposable masks and residues of disinfectants or cosmetics can cause allergic and irritant reactions. Further, given the occlusive, humid environment within a facial mask, it can be assumed that these substances could more easily penetrate the skin and cause facial dermatitis. Since the COVID-19 pandemic started, our living and medical environments have significantly changed, as have the frequency and types of exposure to allergens.4Warshaw E.M. Schlarbaum J.P. Maibach H.I. et al.Facial dermatitis in male patients referred for patch testing: retrospective analysis of North American Contact Dermatitis Group data, 1994 to 2016.JAMA Dermatol. 2020; 156: 79-84Crossref PubMed Scopus (15) Google Scholar,5Xie Z. Yang Y.X. Zhang H. Mask-induced contact dermatitis in handling COVID-19 outbreak.Contact Dermatitis. 2020; 83: 166-167Crossref PubMed Scopus (43) Google Scholar Consequently, patch tests are essential for determining the correct diagnosis in patients with facial dermatitis. Our study could be a useful index for determining the causative allergens in patients with facial dermatitis induced by disposable masks. None disclosed.