International Academic Journal of Applied Bio-Medical Sciences ISSN Print : 2709-328X | ISSN Online : 2709-3298 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iajabms Review Article

The Basic Understandings and Managements of Maskne

Article History Abstract: Maskne is an emerging terminology within the society, derived from Received: 30.04.2021 the word „Mask‟ and „Acne‟ that refers to the occurrence of Acne cause by Revision: 10.05.2021 wearing a mask. Maskne is a novel problem occur in the society due to the current Accepted: 20.05.2021 global mask-wearing activity which is strictly recommended during the pandemic. Published: 30.05.2021 Essentially, maskne is a part of mechanical acne, resulted from occlusions, Author Details frictions, and microenvironmental changes of the skin. The underlying mechanism of Maskne is almost identical to the general Acnogenesis, including increased Mikhael Aditya sebum production, hypercornification of the pilosebaceous ducts, abnormal Authors Affiliations bacteria colonization, and the process of inflammation. Therefore, management Faculty of Medicine and Health Sciences and prevention of Maskne should be focused on reducing the potential impact of Atma Jaya Catholic University of Indonesia, acne formation based on the acknowledged mechanism. Jl. Pluit Raya No.02, Jakarta 14440 Indonesia Keywords: Maskne, Acne Mechanica, Acne Vulgaris, Basic Science, Corresponding Author* Management, Prevention, COVID-19 pandemic. Mikhael Aditya How to Cite the Article: INTRODUCTION Mikhael Aditya. (2021); The Basic Understandings and Managements of Maskne. Int The world is going through a pandemic of the Severe Acute Aca. J App Biomed Sci. 2(3) 23-29 Respiratory Syndrome Coronavirus-2 (SARS CoV-2) infection which Copyright @ 2021: This is an open-access article cause the Coronavirus Disease-19 (COVID-19) since 2019. By March distributed under the terms of the Creative 2020, the World Health Organization (WHO) stated the disease as a Commons Attribution license which permits pandemic due to its global spread and announce some recommendation of unrestricted use, distribution, and reproduction health protocols, such as wearing a mask and keeping personal hygiene. in any medium for non commercial use (NonCommercial, or CC-BY-NC) provided the This is related to the transmission of the disease through droplets and air original author and source are credited. that people breathe. (Hidajat, 2020; Rosner, 2020)

The mask wearing activity become a serious concern of the internet users by the reported adverse effects of daily mask usage, including the acne outbreaks.(Drozdowski et al., 2021; Hidajat, 2020; Kosasih, 2020) The internet then called the outbreaks as Maskne, derived from the word Mask and Acne.(Hidajat, 2020) Furthermore, the phenomenon become a global issue over the internet, as the outbreaks reported is worsen, particularly among the medical workers. This phenomenon lead to confusion and hesitation among the society to continue wearing their mask (Drozdowski et al., 2021).

Maskne could bring a significant impact on people, physically and psychologically.(Kosasih, 2020) Physically, Maskne makes the patients feel uncomfortable and suffer from the sensations of the Acne, making it more difficult to maintain using the mask.(C. Han et al., 2020; Hidajat, 2020; Rosner, 2020) On the other hand, the psychological adverse effect could lead patients to further feel low on self-esteem, anxiety, and even depression.(Hidajat, 2020; Kosasih, 2020; Tahir, 2010) This phenomenon concerns clinicians, to be able to communicate the basic mechanism, management, and also ways to prevent the outbreak of Maskne.(Drozdowski et al., 2021) The right management and explanations would be beneficial to embrace the global society to keep wearing their mask and prevent further transmission of the disease.

DISCUSSION Definition of Acne Acne is a disease of the skin, manifested as an acute to chronic inflammation.(Dorland, 2019) National Institute of Arthritis and Musculoskeletal and Skin Disease enhances the definition of Acne as an inflammation caused by hair follicle blockage due to dead skin cells and oil clogs, which later causing an outbreak on the skin surface.(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2020) It is also characterized by the appearance of comedones papules, pustules, or even nodules and cysts in the more severe degrees of the disease.(Tahir, 2010) Acne predominantly found on the area in which hair follicles exist. It is commonly known as Acne Vulgaris (Dorland, 2019).

Available: https://iarconsortium.org/journal-info/iajabms 23

Mikhael Aditya; Int Aca. J App Biomed Sci; Vol-2, Iss- 3 (May-Jun, 2021): 23-29 Prevalence of Acne The enhancement of sebum production is the most Acne is a highly prevalent skin disease. It is essential factor in the Acne outbreak mechanism. The previously expected to be the eighth most prevalent production of the sebum is determined by the stimulus disease worldwide.(Common et al., 2019) Acne occurs of Androgen hormone that is also influenced by the in 85-95% of adolescence with various endocrine system. This is due to the sebaceous gland is degrees.(Common et al., 2019; Tahir, 2010) The one of the end organs of the Androgens. The greater prevalence is more likely to occur at the age of 12-24, amount of Androgen regulated to the pilosebaceous contributed as much as 85% of the Americans.(Tahir, glands involved, the more sebum is produced. (Sitohang 2010) The number, however, expected to decrease over & Wasiatmadja, 2017; Tahir, 2010)This regulation 25 years old. There are a lot of discussions among occurs in both male and female individuals, even though studies to significant differences between sexes in the female adolescences are the most susceptible. (Common prevalence of Acne (Common et al., 2019). et al., 2019)

Due to its common widespread globally, Indonesia Hypercornifiaction of the pilosebaceous ducts also reported the similarly high number of disease The Androgens also play contribution to the prevalence among the society. Sibero, et al., (2019) proliferation of the pilosebaceous unit, including the reported the prevalence of the disease among sebaceous glands. The greater number of cells that are Indonesians as high as 90% in the 2009, increased as proliferated and died, followed by the excess sebum much as 30% within three years, with 60% prevalence production, end up blocking the pilosebaceous ducts and in 2006.(Sibero et al., 2019) Kristiani, et al., (2017) also therefore, the sebum release pathway. This mechanism reported that 80% of the adolescences in Indonesia had led to the formation of comedones, a clogged the disease. The Incidence of Acne in Indonesia was pilosebaceous duct, which further complicate the sebum also presented to occur among the 14-17 years old excretions. female teenagers and 16-19 years old male teenagers, which accounted up to 60% (Kristiani et al., 2017). The comedones start as a microcomedones which invisible to the plain sight. Furthermore, comedones Types of Acne start to develop into a non-inflammatory lesion called Acne presented in a lot of different types, which can comedone, which manifested as oxidized opened be indistinguishable by the manifestation of the signs blackheads, or the closed whiteheads. Microscopically, and symptoms. Different types of Acnes shared similar comedones can be viewed as a dilated pilosebaceous characteristics to Acne Vulgaris as the bigger term of ducts, filled with a mixture of cornified follicular the disease. Several studies classified acne types based epithelium, sebum, and microorganism. The formation on their etiologies, including Occupational Acne, Drug- of comedones also play a role for the clinicians to induced Acne, Cosmetic Acne, or Mechanical Acne. determine whether a lesion of inflamed skin is an acne (Sitohang & Wasiatmadja, 2017) Another common way eruption by simply looking at the appearance of to classify Acnes are based on their appearance, such as comedones. (Common et al., 2019; Sitohang & Acne Conglobata, or based on the patients, such as Wasiatmadja, 2017; Tahir, 2010) Neonatal Acne, Infantile Acne, Tardive Acne, or Juvenile Acne (Hidajat, 2020). Abnormal bacterial colonization Human skin is a home of trillions of Basic Mechanisms of Acne microorganisms, and most of them are commensal The exact Mechanism of Acne has not been well bacteria, such as Staphylococcus, Corynebacterium, and established. There are a lot of factors contributing to the Propionibacterium. Microenvironmental changes of the disease pathogenesis, and not every aspect of the skin, can directly alter the structure of the skin flora mechanism is well understood. However, some studies balance and develop a disease.(Kumar et al., 2016) The hypothesized that there are four contributing factors that most well-known microorganism contributes to the are postulated as the major pathway of Acnogenesis. pathogenesis of the Acne is Propionibacterium acnes The four main factors that contribute to the occurrence (Kumar et al., 2016; Sitohang & Wasiatmadja, 2017). of Acne include: Increased sebum production, hypercornification of the pilosebaceous ducts, Propionibacterium acnes (P.acnes) is one of the two Abnormal bacterial colonization, and Inflammation highly suspected microorganisms that determined the process (Sitohang & Wasiatmadja, 2017; Tahir, 2010). occurrence of Acne, along with the Staphylococcus aureus (S.aureus) which also a commensal bacteria of Increased sebum production the skin. P. acnes known as an anaerobic bacterium and Sebaceous gland is a part of pilosebaceous unit. expected to metabolize lipid-rich sebum in the They mainly contribute to produce lipid-rich excreted obstructed pilosebaceous ducts. The similar solute called sebum. The sebaceous glands drain the characteristic also occur on S.aureus, a facultative sebum to the hair follicles through the pilosebaceous anaerobic, Gram-positive bacteria, which also have the ducts. Most of the sebaceous glands are found at the lipid-breaking enzyme Lipase to fulfil their metabolism Acne-prone regions, such as cheeks, forehead, nose, needs (Kumar et al., 2016; Tahir, 2010). back, and chest. 24

Mikhael Aditya; Int Aca. J App Biomed Sci; Vol-2, Iss- 3 (May-Jun, 2021): 23-29 The colonization of the bacteria due to the imbalance Gomolin, et al., (2020) further explained the main of microenvironmental conditions and the lipid-rich difference between Maskne and Acne Vulgaris is due to sebum occlusion of the pilosebaceous duct create a great the uncommon symptoms or milder degree of burning condition for the bacteria to grow and rapidly colonize, and pruritus sensation in Maskne, besides the limited creating more damage towards the skin. The latter is region in which Maskne occurs (Gomolin et al., 2020). shown by the activation of the immune system in response of the colonization, that creates local However, there are still some controversies in which inflammations and further damage the skin (Tahir, they should classify the Maskne. Some studies 2010). happened to approve the classifications, which particularly explains the limited regions of the Inflammation process outbreaks, (Damiani et al., 2021; H. S. Han et al., 2021; The colony of the bacteria expected to trigger Hidajat, 2020) rather than the discrete locations in inflammatory reactions and the rupture of the which pilosebaceous units are commonly found, such as comedones. This is possible because the bacteria have the face, chest, and shoulders, which Acne Vulgaris their own chemotactic factors as they produce low normally appears. (Kumar et al., 2016) Nevertheless, molecular weight polypeptides that attract innate some studies also hypothesize Maskne as a part of Acne immune systems with more immune cells to attack the Tropicalis, due to their shared condition that involve bacteria colonization. tropical-climate alike microenvironment changes, (Hidajat, 2020; Kosasih, 2020) or Occasional Acne, as The immune responses and the polypeptides, along they are self-limited and occasionally appear and with the chemotactic factors produced by the bacteria, resolved (Hidajat, 2020). attract more immune response, creating local inflammations of the comedones and rupture of the Maskne Pathogenesis follicles. This process further attracts the adaptive The exact mechanism of Maskne is also not yet immune system to create a more extensive inflammation established, since Maskne is also derived from the Acne to the skin. This further inflammation manifested as itself. Therefore, some studies expect the exact advance dermatoses, such as papules, pustules, or even mechanism would be similar to Acne Vulgaris nodules or cysts from the inflamed comedones pathogenesis. Moreover, other studies also seem to (Common et al., 2019; Kumar et al., 2016; Sitohang & notice another supplementary key feature that probably Wasiatmadja, 2017; Tahir, 2010). play a bigger role in the pathogenesis of Maskne.

Maskne Terminology Mask wearing activity apparently alter the skin Maskne is a novel terminology, appear as the global condition and create a tropical sensation which later pandemic of COVID-19 arises, which regulates people create a warm and more humid environment.(Hidajat, of the global society to wear mask as a daily habit to 2020; Teo, 2021a) Han, et al., (2021) explained that prevent the transmission of the disease. Based on the medical mask such as N95 respirator increased humidity root terminology, it simply refers to Acne that occurs as much as 93% within one hour of usage, which also due to the mask wearing activity. The idea is gaining described as pampered-like condition of the facial lots of notice, particularly among the medical workers, skin.(H. S. Han et al., 2021) This lead us to understand due to the occurrence of Acne on the mask-covered area the probable correlation of the mask wearing duration (Gomolin et al., 2020; Teo, 2021b). and the occurrence of Acne.

Maskne globally challenges the world along with the The increase of temperature and humidity lead to an risk of COVID-19. The terminology has become an increment of sebum production. This theory was internet trend since March 2020 as more social media explained in some other studies, that a rise of skin users reported the outbreak (H. S. Han et al., 2021; surface temperature as much as one degree of Celsius, Hidajat, 2020) The regions that are first determined was lead to a rise of sebum excretion rate (SER) up to notably at the nasolabial folds and middle cheeks,(H. S. 10%.(C. Han et al., 2020; H. S. Han et al., 2021; Han et al., 2021) while on some other mask-user, it also Hidajat, 2020) furthermore, continuous rise of SER occurs at the mandible, neck, and perioral eventually lead to epidermal keratinocytes swelling and regions.(Kosasih, 2020; Teo, 2021a) Furthermore, some pilosebaceous follicle enlargement (Gomolin et al., studies called the Maskne-prone regions as the O-Zone 2020). (Teo, 2021a). Increased SER, along with pilosebaceous glands Maskne Classification enlargement led to further obstruct the ducts and Based on the mechanism and manifestations, facilitate the formation of comedones. The swelling of Maskne is classified as Mechanical Acne. Maskne is keratinocytes and frictions of mask material on the skin expected to occur due to the frictions between the skin surface may later lead to production of more dead skin surface with the mask material, and the alterations of tissues, resulting in more build up debris and comedones skin microenvironments that lead to the outbreak of the formation.(Gomolin et al., 2020; Hidajat, 2020) Acne.(Gomolin et al., 2020; Hidajat, 2020; Teo, 2021b) Additionally, The friction of the mask also play role in 25

Mikhael Aditya; Int Aca. J App Biomed Sci; Vol-2, Iss- 3 (May-Jun, 2021): 23-29 irritating the skin surface, creating microinflammations beneficial for further growth of skin bacteria within the skin. This condition worsen the comedones colonization, particularly P.acnes. formation that lead to Acnogenesis, along with increased risk of other dermatoses as dermatitis, skin Mask fabric material is also expected to play role in disruptions, or even ulcer formation (Hidajat, 2020; acne development. Teo (2021) further explained that Teo, 2021b). unbreathable, unhygienic, and rough surface of materials used, might further aggravates the acne Finally, mask-wearing activity also disrupt the skin development. Unsuitable mask material irritates the skin microenvironment balance by increasing SER and surfaces that promotes cells hyperplasia as well as cell humidity. Increased trans-epidermal water loss (TEWL), apoptosis. Personal factor such as allergic or other dehydration, and pH also lead to microorganism immunologic conditions might also play role in further dysbiosis, creating a more suitable environment for susceptibility to acne and further skin inflammations bacteria to grow and further mechanism towards Acne such as contact or seborrheic dermatitis. Besides, mask- development.(Gomolin et al., 2020; H. S. Han et al., user habit of touching faces with unhygienic hands, 2021) Moreover, mask-covered area would lead to poor rubbing and adjusting the mask continuously, along oxygen circulation within the skin surface, which is with the use of comedogenic cosmetics also aggravate the risk (Damiani et al., 2021; Teo, 2021b, 2021a). (Figure 1)

Figure 1. Simplified Chart of Acnogenesis

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Mikhael Aditya; Int Aca. J App Biomed Sci; Vol-2, Iss- 3 (May-Jun, 2021): 23-29 The diagram above explained the simplified history of acne, and being excluded from any pathogenesis of Acne. Started from the mechanism in differential diagnoses, such as dermatitis or ways of Acne may occur (white boxes) through the main folliculitis.(Damiani et al., 2021; Teo, 2021a) It is also four factors of Acnogenesis (colored stars): 1. Increased essential to know the duration of daily mask-wearing, sebum productions, 2. Hypercornification of the considering maskne commonly occurs within the pilosebaceous ducts, 3. Abnormal bacterial colonization, prolonged users (Rosner, 2020) that use the mask and 4. Inflammation process.(Kumar et al., 2016; beyond the recommended duration (H. S. Han et al., Sitohang & Wasiatmadja, 2017; Tahir, 2010) Mask- 2021; Toomey et al., 2020). related risk factors also play contributions in Acnogenesis through its various pathways that resulted Risk Factors of Maskne in the four main factors, creating the occurrence of Some aggravating risks of Maskne development are Maskne (blue-colored box). Bacterial colonizations such classified into internal individual‟s skin condition and as Propionibacterium acnes and Streptococcus aureus genetics, and also the external behavior, habit-related have the ability to produce polypeptides, such as lipase factors, as well as other factors involved. The internal and hyaluronidase.(Kumar et al., 2016) Individual individual skin‟s condition defined as the previous factors are including genetics, previous medications, condition of someone‟s skin before wearing the mask. previous history of illnesses, and personal susceptibility This includes the history previous acne and other skin to Acne.(Hidajat, 2020) FFA = Free Fatty Acid; NKC = diseases, the type of the skin based on the basic SER, Natural Killer Cells; PMN = Polymorphonuclear cells; and individual‟s genetically susceptibility towards acne SER = Sebum Excretion Rate. development.(C. Han et al., 2020; Hidajat, 2020; Teo, 2021b) This also included personal history of diseases Manifestations and Diagnosis of Maskne or any medications that might as well interacted with the Based on the pathogenesis, Maskne can have similar acne development. clinical manifestations as Acne Vulgaris. Some common The behavior-related and other factors are classified signs might appear as comedones, papules, pustules, or as external factors. These include duration of mask rarely nodulocystic lesions at the mask-covered area. wearing activity, the habit of daily changing or The masked area includes cheeks, nasolabial folds, nose cleansing the mask, face-washing routines, and skin- and nose-bridge, mandible, perioral, and some of the care products usage.(C. Han et al., 2020; Hidajat, 2020; upper neck, or simply the O-zone (C. Han et al., 2020; Teo, 2021b) Other factors such as fabric-mask Hidajat, 2020; Teo, 2021a). materials, type of the masks, environmental conditions, including ultraviolet (UV) exposures, might also play an Han, et al., (2020) explained that Maskne commonly important roles (Teo, 2021b). seen as papules and pustules, while nodulocystic lesions are less commonly seen at the forehead, submaxilla, and MANAGEMENT OF MASKNE neck. This might related to the size of the pilosebaceous unit and follicles. Greater grades of inflammation also Non-pharmacological approach play a role in defining the severity of the disease. (C. Management of Maskne might happen as simple as Han et al., 2020; Hidajat, 2020) The appearance of cleansing the face using antibacterial active ingredients comedones also pathognomonic to define the soap. Facial soap is beneficial, not only to reduce the dermatoses as acne lesions (Hidajat, 2020). colonization of bacteria, debris, dead skin tissues, but also to increase the penetration of acne medication into Patients might also complain about the itch and the skin. It is not recommended to use body or regular burning sensations that occur as well oily skins and soap, for its high pH could lower skin‟s natural acidity other several dermatoses at the mask-covered area.(C. and disrupt the skin barrier.(Hidajat, 2020; Teo, 2021b) Han et al., 2020) Moreover, some mask-wearing related Alcohol, retinols, salicylic acid, and alpha hydroxy-acid issues might also complained by the patients, such as containing skin care should be avoided, for its skin breakdowns and facial skin rashes..(Gomolin et al., susceptibility to irritant dermatitis.(Gomolin et al., 2020; C. Han et al., 2020; Hidajat, 2020; Rosner, 2020) 2020; Teo, 2021b) It is recommended to wash the face It is also important to clinically address the systemic twice a day for a better result (Hidajat, 2020). manifestations, such as headache, impaired cognition and disorientation, impaired vision, sleep deprivation, It is also recommended to gently apply non-oily, head and neck muscle strains, chest discomfort and non-comedogenic moisturizers to maintain skin dyspnea, and emotional distress. Those manifestations moisture and keep the microenvironment balanced. would lead us to acknowledge the habit of prolonged Natural ingredients moisturizers, sodium hyaluronate, use of the masks (Rosner, 2020). and polyglutamic acid are recommended, due to their ability to maintain skin barriers and non-comedogenic Based on those manifestations, some studies also characteristics. However, it is not recommended to use formulated diagnostic criteria for Maskne which later lanoline, petrolatum oil, mineral oil, or glycerol diagnosed as Mechanical Acne. Those criteria include containing moisturizers, for their comedogenicity and the occurrence of Acne at the O-Zone, six weeks prior susceptibility to occlude skin pores. Humectants and the initial mask wearing activity, deterioration previous other prescription emollient devices (PED) such as 27

Mikhael Aditya; Int Aca. J App Biomed Sci; Vol-2, Iss- 3 (May-Jun, 2021): 23-29 ceramide are still allowed, as there is no hypersensitivity exposures and the risk of Maskne.(C. Han et al., 2020) or contraindication acknowledged (Teo, 2021b, 2021a). It is also essentials to prevent prolong using the surgical mask to more than six hours, as the WHO Sunscreen is recommended to be applied along with recommendation.(Toomey et al., 2020) In addition, the the moisturizers as moisturizing agents and prevent other negative adverse effects on physical and mental post-inflammation hyperpigmentation.(Hidajat, 2020) health related to the prolonged use of the mask also However, it is not recommended to use 50+ Sun need to be considered (Damiani et al., 2021, p. 19; Protective Factors (SPF) sunscreen and reapply multiple Rosner, 2020). times daily for it is inconvenience. SPF has the characteristic of photodegradation while interacting with CONCLUSION sweat and moistures under occlusion. It is advisable to choose Ultraviolet Protective Factors (UPF) 50+ made Maskne is a global phenomenon that rises along for fabric-covered skin instead, and gently apply it at the with the usage of mask-wearing activity due to the lower half of the head. Water-resistant and lipophilic pandemic. It is important to address the problem by sunscreen is not advisable as they are highly knowing the mechanism and ways to manage the comedogenic, particularly under occlusion (Hidajat, disease to prevent further issues among the global 2020). society. Similar to the bigger terminology of the disease, Maskne has an almost identical mechanism as the Acne, Pharmacological approach as it was addressed as a part of Mechanical Acne. Medical Management of Maskne is similar to the general type of Acne. While it is recommended to use Further education should also be addressed to the botanical active agents, antioxidants, sebum regulating society, particularly in the era of the pandemic, which agents, and antimicrobial properties, the practice of spot people are recommended to wear a mask as a part of acne treatment is not recommended. Spot acne treatment ultimate health protocols. Proper explanations would with such as benzoyl peroxide, salicylic acid, Sulphur, also acknowledge a better understanding towards the alpha-hydroxy acids, and retinoids are not society to better handle and manage the problems. Lack recommended as they could trigger contact dermatitis of information would lead to hesitation of wearing the under occlusions. However, it is allowed to use the mask and also globally impact the transmission of the treatment while not wearing a mask (Teo, 2021a). disease.

It is recommended to apply the topical medications Acknowledgements: for at least eight weeks using while not under Atma Jaya Catholic University of Indonesia for being occlusions, based on the severity of the disease. Topical the place I learn the basic science of dermatology retinoids, and topical antimicrobial properties, such as and literature writing, along with my family who benzoyl peroxide, clindamycin, and erythromycin, is supported me to publish this article. recommended for mild to medium degree of Maskne. Higher degree of Maskne might be eligible for using REFERENCES stronger medications such as systemic antibiotics and 1. Common, J. E. A., Barker, J. N., & van Steensel, oral isotretinoin, while topical spot acne treatment is M. A. M. (2019). What does acne genetics teach us allowed to be given as well. Furthermore, it is about disease pathogenesis? British Journal of recommended to use topical retinoids as a maintenance Dermatology, 181(4), 665–676. measure of the post-acne flare treatment (Hidajat, 2020). https://doi.org/10.1111/bjd.17721 2. Damiani, G., Gironi, L. C., Grada, A., Kridin, K., Preventive measures Finelli, R., Buja, A., Bragazzi, N. L., Pigatto, P. D., Han, et al., (2020) shared some behavioral & Savoia, P. (2021). COVID-19 related masks recommendations on preventing Maskne, such as increase severity of both acne (Maskne) and replacing surgical mask every four hours, replacing N95 rosacea (Mask rosacea): Multi-center, real-life, respirator every three days, washing both hands before telemedical, observational prospective study. and after wearing or touching the mask, daily rubbing Dermatologic Therapy, 34(2), 1–5. face with wet towel and moisturizers before and after https://doi.org/10.1111/dth.14848 wearing a mask, and using oil-control containing 3. Dorland. (2019). Dorland’s Illustrated Medical ingredients to cleanse the face. It is also recommended Dictionary (33rd ed.). Elsevier Health Sciences. to put in sheets of wipes inside the respirator or masks, 4. Drozdowski, R., Gronbeck, C., & Feng, H. (2021). to absorb excess fluids, vapors, or oils as ventilations Mask-Related Acne in the COVID-19 Pandemic: occurs (C. Han et al., 2020). An Analysis of Twitter Posts and Influencers. Clinical and Experimental Dermatolog. The preventive measures of Maskne should not be https://doi.org/10.1111/CED.14608 limited to the facial issues. It is also important to focus on the duration of mask-using activity as well as the environmental factors. Rosner (2020) advised that there should be a plausible work shift hours to reduce the 28

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