PRACTICE King’s College Hospital, London, UK PRACTICE POINTER Correspondence to E Rudd emilyclaire BMJ: first published as 10.1136/bmj.n1304 on 7 June 2021. Downloaded from [email protected] Cite this as: BMJ 2021;373:n1304 Mask related acne (“maskne”) and other facial dermatoses http://dx.doi.org/10.1136/bmj.n1304 Published: 07 June 2021 Emily Rudd, Sarah Walsh What you need to know prescribed, over-the-counter, and complementary medicines • Not all facial dermatoses related to personal Temporal relationship with mask protective equipment are “maskne” • wearing—establish if periods without mask • Irritant contact dermatitis is the most common cause wearing alleviate or improve the problem, eg, • Maintenance of the skin barrier and regular “mask allergic contact dermatitis should improve with a breaks” are important aspects of management, in period of no mask wearing, while acne, once addition to standard medical treatment of the skin established, may not respond so readily condition • Symptoms of itch, soreness, and appearance of The covid-19 pandemic has led to a marked increase pustules or papules in the use of personal protective equipment (PPE) • Duration of PPE exposure each day both in and out of healthcare settings. The term Ask if “mask breaks” (periods of time when facial “maskne” has become increasingly popular during • PPE is removed entirely) are allowed or taken the pandemic, particularly in the media, where it is used to describe several facial dermatoses. • Assess the impact on the patient’s mood, work, Individuals often buy expensive but potentially and social life to assess severity and decide further ineffective treatments for these conditions. management. The effect of PPE related dermatoses on the life quality of healthcare workers can be In this practice pointer we summarise the most substantial3 common causes of facial eruptions associated with wearing facial PPE, and highlight the key areas to Examination should focus on the morphology of the cover when assessing someone with new or eruption, the distribution, and whether it is present worsening pre-existing facial dermatoses that they at sites other than the face. attribute to the use of facial PPE. http://www.bmj.com/ What are the common causes and how should “Facial PPE” in this article includes full face shields, they be treated? visors, safety spectacles, surgical masks (fluid resistant surgical mask, FRSM type IIR), and Each condition described below may appear de novo respirator masks (eg, FFP3, FFP2, and N95).1 or be exacerbated by wearing facial PPE. Exacerbation tends to result from the development of a warm, How common is “maskne”? moist, occlusive environment around the face, Facial dermatoses related to PPE have been well particularly during mask use. Added to this is the on 18 June 2021 by guest. Protected copyright. described, but data about their prevalence are frictional effect of the material held in place with limited, and often a descriptive terminology is used elastic. rather than specific diagnoses. Based on the limited General measures to prevent PPE related facial available evidence, mask related acne and irritant dermatoses are outlined in the box and are advised contact dermatitis are the most common facial 2 -5 in the treatment of all conditions listed below. dermatoses associated with mask wearing. Additional standard medical treatment for each During the covid-19 pandemic, a prospective cross dermatosis is discussed separately. When sectional study of 833 medical school staff in post-inflammatory hyperpigmentation or scarring Thailand, including healthcare and non-healthcare occurs, a more aggressive treatment approach is workers, showed a self-reported prevalence of 54% required to prevent irreversible skin changes. Referral adverse skin reactions to surgical and cloth masks.6 to specialist care is warranted at this stage if no improvement occurs. How should facial dermatoses be assessed? Irritant contact dermatitis Typically, a patient presents with new onset facial eruption, or exacerbation of a pre-existing dermatosis Irritant contact dermatitis (ICD) is the most common 3 that is most pronounced in the area covered by the occupational and mask related dermatosis. ICD is a mask. Ideally, such an assessment would take place form of exogenous eczema caused by direct physical in person, but video consultation provides an or chemical injury. Pressure ICD related to facial 4 acceptable alternative. masks is commonly described over the cheeks and nasal bridge.3 5 It is associated with prolonged mask Key information to elicit in a “maskne” history wearing (>6 hours) and its severity depends on the 3 • Relevant history and family history of skin disease irritant and chronicity of exposure. Presentation and a comprehensive drug history that includes ranges from a discrete, dry, scaly patch to oedema and vesicles, erosions, and ulceration.3 5 People with the bmj | BMJ 2021;373:n1304 | doi: 10.1136/bmj.n1304 1 PRACTICE atopic dermatitis, who already have a defective skin barrier, are Allergic contact dermatitis particularly at risk of developing ICD.7 Allergic contact dermatitis (ACD) (fig 1) is a delayed type IV Enabling restoration of the skin barrier is key to treating ICD, and hypersensitivity reaction to an external allergen, and is much less BMJ: first published as 10.1136/bmj.n1304 on 7 June 2021. Downloaded from regular mask breaks (every hour for respirators) is one way to do common than ICD.9 10 Typically, it occurs after exposure to this.8 For broken skin, a silicon backed dressing such as Mepilex preservatives such as formaldehyde11 and dibromodicyanobutane,12 Border Lite can be applied to protect the skin and ensures that the but thiuram, a rubber accelerator found in the elastic straps on mask seal remains intact.9 surgical masks,13 is also a recognised allergen. Metal wires are used to mould the mask to the face; nickel and cobalt have both been reported as causes of facial ACD.14 http://www.bmj.com/ on 18 June 2021 by guest. Protected copyright. Fig 1 | Allergic contact dermatitis ICD and ACD can be clinically indistinguishable. Both usually Atopic eczema manifest as localised dermatitis but well demarcated areas of Atopic eczema is a very common dermatitis that affects up to 20-30% inflammation and redness are more suggestive of ACD, while a more of children and 2-10% of adults.15 diffuse pattern is more commonly seen in ICD. Treatment involves a short course of a mild to moderate potency corticosteroid, such Wearing a mask may have an irritant effect on the more delicate as hydrocortisone 1% ointment. Avoiding allergens prevents further facial skin of a patient with eczema, plus the occlusive, moist episodes, and therefore identification of causative agents is key. environment favoured by mask wearing may have a deleterious This can be achieved by patch testing, indicated where well effect on the skin, favouring the worsening of eczema. demarcated areas are seen clinically and in cases of severe disease. 2 the bmj | BMJ 2021;373:n1304 | doi: 10.1136/bmj.n1304 PRACTICE Seborrhoeic eczema Management involves regular antifungals such as ketoconazole 2% shampoo and/or short courses of mild topical corticosteroids such This dermatosis (fig 2) affects approximately 1-3% of the adult 17 as hydrocortisone 1% ointment. As with atopic eczema, the warm, BMJ: first published as 10.1136/bmj.n1304 on 7 June 2021. Downloaded from population and usually starts in young adult life.16 On examination, moist, occlusive environment created by mask wearing may a dermatitis with greasy yellow scale predominantly affecting the predispose to development of seborrhoeic dermatitis. scalp, eyebrows, glabellar, and nasolabial folds is common. http://www.bmj.com/ on 18 June 2021 by guest. Protected copyright. Fig 2 | Seborrhoeic eczema Periorificial dermatitis antibiotics such as erythromycin will suffice for milder cases but often a four week course of a tetracycline, such as lymecycline 408 Periorificial dermatitis consists of a patchy erythema with tiny mg once daily, is needed.18 papulopustules, affecting the periocular and perioral skin of young women (with sparing of the vermilion border). It can be idiopathic, Urticaria or is caused by the use of cosmetics or topical corticosteroids directly Both pressure and contact urticaria (fig 3) are uncommon or indirectly (via fingers that are applying the agent elsewhere). complications of PPE.11 19 Pressure urticaria is caused by the Mask wearing may predispose to the development of periorificial downward pressure of the mask and is characterised by the dermatitis for reasons similar to those listed for atopic and formation of wheals, immediately or delayed (4-6 hours), after a seborrhoeic dermatitis. Management involves stopping the pressure stimulus. A well fitted mask that is not over tight is implicated cream and simplifying the skin care regimen. Topical recommended, or alternatively a change in PPE.19 the bmj | BMJ 2021;373:n1304 | doi: 10.1136/bmj.n1304 3 PRACTICE BMJ: first published as 10.1136/bmj.n1304 on 7 June 2021. Downloaded from http://www.bmj.com/ Fig 3 | Urticaria Contact urticaria is an immediate reaction to an offending allergen Acne such as latex or formaldehyde. It typically resolves within 24 hours Acne vulgaris (fig 4) is a chronic inflammatory disease of the of removal of the contact trigger. Regular non-sedating H1 pilosebaceous unit. PPE related acne, which may be considered a antihistamines such as loratadine are the mainstay of treatment for subtype of acne mechanica, occurs in people with a previous history on 18 June 2021 by guest. Protected copyright. inducible urticaria.20 of acne vulgaris as well as in those previously unaffected. It has been associated with surgical masks and N95 respirators.2 3 21 4 the bmj | BMJ 2021;373:n1304 | doi: 10.1136/bmj.n1304 PRACTICE BMJ: first published as 10.1136/bmj.n1304 on 7 June 2021. Downloaded from Fig 4 | Acne http://www.bmj.com/ The pathogenesis of PPE related acne is thought to be threefold: Rosacea 18 Creation of a humid microclimate inside the mask Rosacea (fig 5) typically affects adults aged 30-50 with fair skin.