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Around half the people who wear face masks may develop acne, facial dermatitis, itch, or pressure injuries, and the risk increases with the length of time the mask is worn, according to a recently published systematic review and meta-analysis.
“This report finds the most statistically significant risk factor for developing a facial dermatosis under a face mask is how long one wears the mask. Specifically, wearing a mask for more than 4 to 6 hours correlated most strongly with the development of a facial skin problem,” Jami L. Miller, MD, associate professor of dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, told Medscape Medical News. Miller was not involved in the study.
“The type of mask and the environment were of less significance,” she added.
Mask wearing for infection control has been common during the COVID-19 pandemic and will likely continue for some time, study coauthors Lim Yi Shen Justin, MBBS, and Yik Weng Yu, MBBS, MPH, PhD, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, wrote in an email to Medscape Medical News. And cross-sectional studies have suggested a link between mask wearing and various facial dermatoses.
To evaluate this link as well as potential risk factors for facial dermatoses, the researchers reviewed 37 studies published between 2004 and 2022 involving 29,557 adult participants self-reporting regular use of any face mask type, across 17 countries in Europe and Asia. (The mask types commonly studied in the papers they analyzed included surgical masks and respirators.)
Facial dermatoses were self-reported in 30 studies (81.1%), and were diagnosed by trained dermatologists in seven studies (18.9%).
Justin and Yu found that:
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Overall prevalence of facial dermatoses was 55%
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Individually, facial dermatitis, itch, acne, and pressure injuries were consistently reported as facial dermatoses, with pooled prevalence rates of 24%, 30%, 31%, and 31%, respectively
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The duration of mask wearing was the most significant risk factor for facial dermatoses (P < .001)
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Respirators, including N95 masks, were not more likely than surgical masks to be linked with facial dermatoses
“Understanding risk factors of mask wearing, including situation, duration, and type of mask, may allow for targeted interventions to mitigate problems,” Yu said.
He advised taking a break from mask wearing after 4 to 6 hours to improve outcomes.
Yew acknowledged limitations, including that most of the reviewed studies relied on self-reported symptoms.
“Patient factors were not investigated in most studies, therefore, we were not able to ascertain their contributory role in the development of facial dermatoses from mask wearing,” he said. “We were also unable to prove causation between risk factors and outcome.”
Four Dermatologists Welcome the Findings
Miller called this an “interesting, and certainly relevant” study, now that mask wearing is common and facial skin problems are fairly common complaints in medical visits.
“As the authors say, irritants or contact allergens with longer exposures can be expected to cause a more severe dermatitis than short contact,” she said. “Longer duration also can cause occlusion of pores and hair follicles, which can be expected to worsen acne and folliculitis.”
“I was surprised that the type of mask did not seem to matter significantly,” she added. “Patients wearing N95 masks may be relieved to know N95s do not cause more skin problems than lighter masks.”
Still, Miller had several questions, including if the materials and chemical finishes that vary by manufacturer may affect skin conditions.
Olga Bunimovich, MD, assistant professor, department of dermatology, University of Pittsburgh School of Medicine, Pennsylvania, called this study “an excellent step towards characterizing the role masks play in facial dermatoses.”
“The study provides a window into the prevalence of these conditions as well as some understanding of the factors that may be contributing to it,” Bunimovich, who was not part of the study, added. But “we can also utilize this information to alter behavior in the work environment, allowing ‘mask-free’ breaks to decrease the risk of facial dermatoses.”
Elma Baron, MD, professor and director, Skin Study Center, department of dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio, expected skin problems to be linked with mask wearing but didn’t expect the prevalence to be as high as 55%, which she called “very significant.”
“Mask wearing is an important means to prevent transmission of communicable infections, and the practice will most likely continue,” she said.
“Given the data, it is reasonable to advise patients who are already prone to these specific dermatoses to be proactive,” she added. “Early intervention with proper topical medications, preferably prescribed by a dermatologist or other healthcare provider, and changing masks frequently before they get soaked with moisture, will hopefully lessen the severity of skin rashes and minimize the negative impact on quality of life.”
Commenting on Justin and Yu’s study, Susan Massick, MD, dermatologist and clinical associate professor of internal medicine, The Ohio State University Wexner Medical Center, Westerville, told Medscape Medical News that she urges people to wear masks, despite these risks.
“The majority of concerns are straightforward, manageable, and overall benign,” she said. “We have a multitude of treatments that can help control, address, or improve symptoms.”
“Masks are an effective and easy way to protect yourself from infection and they remain one of the most reliable preventions we have,” Massick noted. “The findings in this article should not preclude anyone from wearing a mask, nor should facial dermatoses be a cause for people to stop wearing their masks.”
Contact Dermatitis. Published online August 18, 2022. Abstract
The study received no funding. The authors, as well as Baron, Miller, Bunimovich, and Massick, who were not involved in the study, reported no relevant financial relationships. All experts commented by email.
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