Maskne and Beyond: Effects on the Skin and Implications of Occlusion and Friction

With mandates across the US reduced but not eliminated, dermatologists will continue to see the cutaneous effects of mask wearing on patients. Professor Jerry Tan of the University of Western Ontario is chair of the working group on clinical practice guidelines of the Canadian Dermatology Association and co-Chair for the Rosacea International Consensus Group (ROSCO) and the Acne Core Outcomes Research Network (ACORN). He is facilitating a series of webinars focused on the effects of mask wearing on facial dermatoses. He spoke with Practical Dermatology® magazine about the effects of mask wearing on patients.

More information on the webinar series, supported by the Galderma Excellence Multichannel Medical Education (GEMME) program, is available online at gemme-unmasking-webinars.events.

What are some of the primary cutaneous health effects of mask wearing?

Jerry Tan, MD: Facial erythema, skin hydration, transepidermal water loss, increased skin pH, increased sebum excretion have been demonstrated with use of facial protective equipment (Contact Dermatitis; 83(2):115-121). Increased facial temperatures at perioral regions have also been recorded—higher with N95 versus standard medical surgical masks. Furthermore, N95 masks were associated with significantly higher levels of humidity, heat, breathing difficulty, and discomfort (Int J Environ Res Public Health; 17(13):4624).

Skin issues related to mask wearing include skin irritation and indentations from the pressure effects of the masks and their straps. Adverse skin reactions included facial indentations, itching, hyperpigmentation, ulceration, crusting, irritation, and infection. (J Drugs Dermatol; 19(9):858-864.)

Can mask wearing have non-physical impacts on patients with acne and rosacea?

Dr. Tan: Non-physical impacts Include anxiety concerning possible aggravation or initiation of skin irritation or worsening of pre-existing dermatosis, including eczema, seborrheic dermatitis, folliculitis, acne, and rosacea.

Furthermore, the irritation from impairment in skin barrier under masks can lead to even greater irritation with topical therapy for acne and rosacea. Thus, patients may find it difficult to continue on treatments for these conditions, contributing to guilt due to non-adherence.

What are some other common—but perhaps overlooked—instances in which friction/occlusion can exacerbate acne and rosacea that dermatologists should consider and counsel patients about?

Dr. Tan: Both acne and rosacea are associated with impaired skin barrier function. This is aggravated with use of face masks. The importance of gentle non-irritating cleansers along with frequent use of moisturizers is imperative to reduce potential risk of compounding irritation. In acne patients, it may be reasonable to reduce the use of potentially irritating cleansers containing benzoyl peroxide or salicylic acid unless these are contained in moisturizing vehicles.

Medications for topical use in both acne and rosacea may require further attention to minimizing any further skin barrier disruption and risk of additional irritation.

Other common causes for friction that may exacerbate acne, folliculitis, and rosacea include tight clothing and straps; for occlusion includes comedogenic moisturizers, sweat, hair grooming products including conditioners, sprays, and gels; along with sports equipment such as helmets and pads.

What fundamentals of care for acne and/or rosacea has the problem of mask-ne highlighted, and how can dermatologists best learn the lessons from this experience?

Dr. Tan: This issue has highlighted the importance of addressing skin barrier compromise. The importance of skin barrier repair and fortification has been highlighted. This should include the use of non-soap cleansers and hydration/moisturizer skincare products. Furthermore, there are also unanswered aspects including microbiome changes in mask-related dermatoses.

When masks can be put away, patients with facial dermatoses may feel their conditions are “uncovered.” How can dermatologists help patients on the road to managing skin diseases?

Dr. Tan: Ongoing management of skin diseases is critical during this difficult time. There has never been a better opportunity to improve skin self-care, and we can encourage this by counseling and educating on best skincare practices. The latter should focus on skin barrier reparative products that are gentle and fragrance free, skin pH adjusted, and non-irritating.

Additionally, encouraging medical contact and treatment is important for ongoing care—cutaneous and psychosocial.