PracticalDermatology

The COVID-19 pandemic led to a dramatic shift in personal protection behaviors, including the regular use of face masks. While necessary for protection against the virus, regular use of face masks has been associated with a dramatic increase in the number of facial dermatoses. Commonly referred to as “maskne,” mask-related acne as well as mask-related rosacea and perioral dermatitis have been increasingly seen by dermatologists over the past year.

It has been suggested that maskne be defined as the onset of acne within six weeks of regular use of a face mask. Patients may experience new or worsening of acne in areas covered by the mask, mainly the zone of skin around the mouth, chin, and nose.¹ In a study performed in Thailand evaluating 883 patients wearing face masks, 54.5 percent of patients experienced face mask-related adverse skin reactions. Acne was the most frequent, occurring in almost 40 percent of patients. A higher risk of skin reactions was observed in those wearing surgical masks compared to cloth masks. Wearing the mask for more than four hours/day and reusing face masks also increased the risk for skin reactions.²

Face masks have both direct and indirect effects on the skin. Mechanical friction directly promotes inflammation, a phenomenon referred to as acne mechanica. Originally described in athletes from chin straps and helmets, the close contact of the strap, or in this case the mask, traps sweat, dirt, oil, and makeup on the skin.^3,4 Studies have shown that wearing surgical masks is associated with a decrease in skin hydration, increase in trans-epidermal water loss (TEWL), increase in pH, and increase in sebum production.⁵ Moreover, additional dressings or moisturizing agents used with masks to prevent pressure-related dermatoses can further promote conditions like acne. These were initially seen almost exclusively in healthcare workers, but the widespread use of masks has led to similar reactions in the general population.⁶

Indirect effects of face masks are caused by the trapping of exhaled breath on the skin. The mask modifies the external environment by increasing humidity and temperature.⁶ This is thought to alter the skin’s natural microbiome leading to dysbiosis, which has been implicated in the pathogenesis of a variety of skin conditions including acne, perioral dermatitis, and rosacea. The microbiome is the collection of microbes that live on the skin. An alteration of the microbiome can impact skin barrier function and immunity.⁷ The balance of the microbes on the skin limits the development of acne in most people.⁸S. epidermidis limits C. acnes overgrowth, via succinic acid, a product of fatty acid fermentation. Moreover, S. epidermidis suppresses production of inflammatory mediators including Interleukin-6 (IL-6) from C. acnes and Tumor Necrosis Factor-alpha (TNF-α) from keratinocytes. C. acnes itself plays a role in skin health, not just the development of acne. It limits overgrowth of S. aureus and S. pyogenes, maintains an acidic pH in pilosebaceous unit, hydrolyses sebum triglycerides, and secretes propionic acid which has antimicrobial and pH regulating properties. Dysbiosis leads to overgrowth of C. acnes, alters this balance, and promotes the development of acne. C. acnes produces lipases, proteases, hyaluronidases, and neutrophil chemotactic factors. In addition, it stimulates keratinocyte toll-like receptor 2 activity, defensins, and Matrix metallopeptidase 9 expression. Finally, C. acnes induces pro-inflammatory cytokine release from monocytes, including IL-1 and TNF-α.⁹

The treatment of “maskne” involves recommendations for the mask itself and for the skin.¹⁰ While we are lacking consensus guidelines for the treatment of “maskne,” the following is the author’s expert opinion for consideration.

Managing Maskne

Cleansers. Gentle, hydrating cleansers to maintain skin barrier function are important before wearing a mask. The goal of cleansing is to remove soiling from the skin without compromising the integrity of the skin barrier. This increases the risk of potential irritation from frictional forces of the mask on the skin. Consideration may be given to those products that have data showing improvement in the microbiome. To fully remove soiling, exfoliating moisturizers that contain ingredients like salicylic acid are ideal for use at the end of the day after a face mask will not be placed back on the skin.

Moisturizers. Light breathable lotions, gels, and cream-based moisturizers are a good option under a face mask. Heavier, occlusive-based moisturizers may help protect and repair the skin but in some cases, especially when they contain heavy vegetable oils, they can promote acne breakouts. As in the case of cleansers, moisturizers shown to be of benefit in restoring a healthy microbiome may be considered.

Leave-on acne treatments. While benzoyl peroxide is effective, it has the potential to bleach fabrics, including fabric masks. For this reason, it may be best used in the evening. Topical retinoids, while a mainstay of acne treatment, lead to thinning of the stratum corneum and make the skin more sensitive to friction. If using retinoids, consider those with an emollient base and/or combine them with a moisturizer.

Topical antibiotics and topical dapsone are not known to lead to irritation and can be easily applied under a face mask. The use of hypochlorous acid for the treatment of acne and other facial dermatoses is growing in popularity, and it can be applied under a face mask. There’s some suggestion hypochlorous acid may help restore a balanced microbiome, but more data are needed.

Oral acne treatments. Oral antibiotics have a relatively quick onset and can be effective in addressing maskne. Best practice means limiting use to three to four months and combining it with benzoyl peroxide to minimize bacterial resistance. In women, hormonal therapies like oral contraceptive pills and spironolactone are effective, but slow to work. Results often take up to three months to be observed. Isotretinoin can be considered in severe cases, although it is known to cause skin dryness and sensitivity, which can be problematic when wearing a face mask.

Sunscreen. Chemical sunscreens are aesthetically appealing but are more likely to lead to sensitization as compared to mineral options. Zinc oxide-based sunscreens are a good fit under a face mask as they provide UV protection and also form a breathable barrier over the skin. Zinc oxide is a known skin protectant and the main ingredient found in diaper creams. The latest generation of zinc-based sunscreens provides sheer protection and can be fully rubbed into the skin without leaving behind a white cast. While tinted formulas may be used, they will lead to staining of a fabric face mask.

Face masks. When possible, multi-layer fabric face masks are preferred as they are more breathable than synthetic masks. The newest textiles contain antimicrobial elements like silver, zinc, or copper for antimicrobial effects, which may be beneficial in addressing skin conditions like acne or rosacea.¹¹ Masks should be washed regularly, like any other garment that comes in direct contact with the skin.

Dye-free, fragrance-free detergents are preferred, as they are less likely to lead to allergic contact dermatitis. Detergents should not be overused in washing machines, as detergent surfactants may become trapped within the weave of the fabric leading to an irritant contact dermatitis. Disposable masks should be changed regularly and actually disposed of when they are soiled.

Remain Vigilant

The best way to treat “maskne” is to remove the mask. As more of the population becomes vaccinated and we develop herd immunity, this will become a reality in the near future. However, the “new normal” will likely include face masks in some form in the future, so proper diagnosis and treatment of mask-related acne and other facial dermatoses will continue to be an important duty for dermatologists.

1. Wan-Lin T, et all. Diagnostic and management considerations for “maskne” in the era of COVID-19. J Am Acad Dermatol. 2021 Feb; 84(2): 520–521. Published online 2020 Oct 1. doi: 10.1016/j.jaad.2020.09.063

2. Leelawadee T, et al. The Effects of the Face Mask on the Skin Underneath: A Prospective Survey During the COVID-19 Pandemic. J Prim Care Community Health. 2020 Jan-Dec; 11: 2150132720966167. Published online 2020 Oct 21. doi:

10.1177/2150132720966167

3. Basler RS, Hunzeker CM, Garcia MA. Athletic skin injuries: combating pressure and friction. Phys Sportsmed. 2004;32:33-40.

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5. Hua W, Zuo Y, Wan R, et al. Short-term skin reactions following use of N95 respirators and medical masks. Contact Dermatitis. 2020;83(2): 115-121

6. Damiani G, et al. COVID‐19 related masks increase severity of both acne (maskne) and rosacea (mask rosacea): Multi‐center, real‐life, telemedical, and observational prospective study. Dermatol Ther. 2021 Feb 19 : e14848. doi: 10.1111/dth.14848 [Epub ahead of print]

7. Lee YB, et al. Potential Role of the Microbiome in Acne: A Comprehensive Review . J. Clin. Med. 2019, 8(7), 987; ; JEADV 2017,31(Suppl. 5),8–12

8. Dreno B. What is new in the pathophysiology of acne, an overview. JEADV. 2017;31 (Suppl. 5): 8–1

9. Strauss JS, Kligman AM. Arch Dermatol 1960;82:779-91.

10. Leyden JJ, et al. Propionibacterium levels in patients with and without acne vulgaris. J Invest Dermatol 1975 Oct; 65(4):382-4

11. Teo Wan-Lin, et al. The “Maskne” microbiome – pathophysiology and therapeutics. Int J Dermatol. 2021 Feb 12 : 10.1111/ijd.15425.doi: 10.1111/ijd.15425 [Epub ahead of print]