Importance of nose wires in face masks: A reply to “Diagnostic and management considerations for “maskne” in the era of COVID-19”
Authors: Bina Kassamali, Kylee J.B. Kus, Michelle S. Min, Gabriela A. Cobos, Avery H. LaChance, Daniel R. Mazori
Journal: Journal of the American Academy of Dermatology (2021)

To 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.1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar To help combat maskne and other mask-related skin problems, Teo proposed several innovative ideas for the "ideal fabric face mask."1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar 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.1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Teo posited that biofunctional textiles may incentivize mask wearing,1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar which is crucial for reducing the spread of COVID-19.2CDCImprove How Your Mask Protects You. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/your-health/effective-masks.htmlDate accessed: March 14, 2021Google Scholar,3WHOCoronavirus Disease (COVID-19): Masks.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-masksDate accessed: March 19, 2021Google Scholar Notably, Teo specified that the ideal fabric face mask should have "no metallic parts at the nose bridge" in order to minimize friction and nickel sensitization.1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Indeed, in a survey of 542 physicians and nurses during the COVID-19 pandemic, it was found that the nasal bridge was the most common site of skin damage due to personal protective equipment.4Lan J. Song Z. Miao X. et al.Skin damage among health care workers managing coronavirus disease-2019.J Am Acad Dermatol. 2020; 82: 1215-1216Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar Although we understand these concerns, we respectfully point out that a face mask without a nose wire contradicts the guidelines of the US Centers for Disease Control and Prevention.2CDCImprove How Your Mask Protects You. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/your-health/effective-masks.htmlDate accessed: March 14, 2021Google Scholar According to the Centers for Disease Control and Prevention, face masks should include a nose wire or "metal strip along the top of the mask," and it should be bent over the nose to fit close to the face and prevent air leakage from the top of the mask.2CDCImprove How Your Mask Protects You. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/your-health/effective-masks.htmlDate accessed: March 14, 2021Google Scholar The Centers for Disease Control and Prevention goes 1 step further, recommending that a mask fitter or brace be worn over a face mask in order to prevent air leakage from the sides.2CDCImprove How Your Mask Protects You. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/your-health/effective-masks.htmlDate accessed: March 14, 2021Google Scholar The World Health Organization also recommends the use of face masks with a nose wire, but only for certain individuals, including people aged ≥60 years, those with underlying health conditions, and health care workers.3WHOCoronavirus Disease (COVID-19): Masks.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-masksDate accessed: March 19, 2021Google Scholar This raises the question of whether a face mask can be designed in adherence to public health agency guidelines while also addressing the concerns that Teo rightfully raised. Instead of omitting the nose wire altogether, can it be redesigned like an everyday twist tie with a metal core and plastic, poly, or paper coating? Perhaps the core itself can also be made from plastic, poly, or a non-nickel metal. Others have proposed that mask wearers apply a barrier film spray or soft silicone, paraffin, or extrathin hydrocolloid dressing over their nose prior to wearing a mask.5Oranges T. Janowska A. Dini V. Reply to: "Skin damage among health care workers managing coronavirus disease-2019".J Am Acad Dermatol. 2020; 82: e233-e234Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Although all these solutions may prevent nasal bridge injuries, they have an unknown effect on face mask seal.5Oranges T. Janowska A. Dini V. Reply to: "Skin damage among health care workers managing coronavirus disease-2019".J Am Acad Dermatol. 2020; 82: e233-e234Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Studies investigating how any of these adjustments affect mask integrity would be incredibly valuable. In summary, Teo's article shows the value of dermatologist input in designing face masks.1Teo W.L. Diagnostic and management considerations for "maskne" in the era of COVID-19.J Am Acad Dermatol. 2021; 84: 520-521Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Given the importance of wearing masks to decrease the spread of COVID-19 as well as the associated potential dermatologic benefits and side effects, we are excited about the ways in which our specialty can contribute to face mask design during this ongoing pandemic. None disclosed. Diagnostic and management considerations for "maskne" in the era of COVID-19Journal of the American Academy of DermatologyVol. 84Issue 2PreviewTo 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. Full-Text PDF Design elements in face masks can provide an effective fit to prevent droplet spread: A reply to "Importance of nose wires in face masks"Journal of the American Academy of DermatologyVol. 85Issue 3PreviewTo the Editor: I appreciate the interest of Kassamali et al1 in my article and am writing in response to the concerns raised. Mask-wearing recommendations to prevent the spread of the contagion must be driven by evidence supporting the complex phenomena of droplet or airborne spread, reflecting the aerodynamic trajectories and practicalities that affect their compliance. Textile-skin friction and discomfort or pain sensations are likely to impact the course of dermatoses via a neuroimmune interface, relevant to skin ecobiology. Full-Text PDF