Skin Deep: What is Maskne?

Article | Julie Van Onselen, Lecturer Practitioner Dermatology Education Partnership Ltd.

‘Maskne’ has emerged as a facial skin condition, resulting from prolonged personal protective equipment (PPE) use (facial mask wearing).

Health care professionals (HCPs) often present with facial skin symptoms, due to lengthy facial mask usage, whether they have had no previous facial irritation or have a predisposing skin condition.

What is Maskne?

Maskne is a new terminology which relates to facial skin symptoms caused by the need for prolonged use of facial masks as PPE. Maskne can occur due to the continued use of any protective facial mask, including full face shields, visors, safety spectacles, surgical masks, fluid resistant surgical masks and respirator masks.

Maskne is an umbrella term for any facial symptom, which may include dryness, scaling, itching, redness, erosions, papules and pustules, with irritant contact dermatitis (ICD) and acne being the most common. In people with skin of colour, inflammation appears as hyperpigmented darker patches.

ICD can also include friction from pressure, which is more likely with close fitting or respirator masks, seen on the bridge of the nose and cheeks. ICD is a cutaneous response to the physical/toxic effects of a wide range of environmental exposures.

This may be acute (toxic dermatitis) or cumulative (insult dermatitis). Maskne can cause ICD due to the humid and warm environment; presentations range from a discrete, dry, scaly patch to oedema and vesicles, erosions and ulceration.

Occasionally, an individual may develop a contact allergy to a face mask, for example, the mask material or straps. Allergic contact dermatitis (ACD) is an eczematous reaction that occurs as an immunological response following exposure to a substance to which the immune system has previously been sensitised.

It is more common in individuals with a history of or current atopic eczema [1] . If ACD is suspected, referral to dermatology for patch testing to confirm the allergy is advised.

Acne related to PPE can occur in people with an acne history as well as those who have been previously unaffected. The humid, occlusive environment causes the skin to become more oily (due to the over production of sebum), which then blocks the sebaceous gland duct, resulting in papules and pustules.

The humid microclimate of the mask environment is thought to encourage mucosa to be colonised by bacteria which may increase bacterial load on the surrounding skin.

Acne caused by pressure or friction from mask wearing is considered a subtype of acne mechanica.

How Common is Maskne in HCPs?

Maskne appears to be extremely common in HCPs. An occupational report of self reported skin symptoms due to PPE in HCPs in London and Manchester, found high rates of irritant facial and pressure dermatitis (due to filtering face piece [FFP3] respirator masks), which had not been observed in HCPs and had only been previously reported by fighter pilots.

ICD was observed due to sanitising reusable masks. A prospective study of occupational dermatoses in the COVID-19 pandemic found 16.6% developed acne, which was attributed to all types of facial masks.

How to Treat Maskne

Skin assessment of the affected HCP is important to correctly diagnose skin symptoms, as treatment of ICD and acne will be different.

When taking a patient’s history, ask about existing skin conditions exacerbated by PPE, for example, atopic or seborrheic eczema and rosacea, or the development of new skin conditions including perioral dermatitis, folliculitis (where facial hair is present) or urticaria (which can be caused by pressure).

An assessment of the duration of mask wearing is important to help diagnose maskne. Examination of the face and any other areas of the body affected by skin symptoms should be documented with a diagnosis of maskne (or other facial dermatosis), and a treatment plan developed according to evidencebased dermatology guidelines. ICD should be treated with emollients (for washing and moisturising) and mild-to-moderate topical steroids (applied for a 2-week treatment).

Acne should be treated with antimicrobial facial washes, salicylic acid or retinoid topical treatment, applied daily for 2 months. If skin breakdown has occurred, a silicone-based dressing (for example Mepilex) is helpful for pressure distribution and protection.

Recommended treatment for acne mechanica is topical retinoids, such as adapalene cream alone or in combination with benzoyl peroxide cream once daily, which can be used for mild cases, with the addition of an oral tetracycline, such as lymecycline 408 mg once daily for up to 12 weeks, for moderate-to-severe cases

How to Prevent Maskne

Skin care and avoiding prolonged mask wearing where possible are both essential to preventing maskne. Maskne may also be prevented by applying a protective layer of emollient and lip balm before wearing a mask.

Generally, a lotion formulation is preferable, as thicker emollients may block skin pores. Silicon barrier films are also recommended for HCPs with no pre-existing eczema.

Following prolonged mask wearing, cleanse the face with bland emollients and avoid soap and cosmetic washes. Moisturise the face with bland medical emollients (if skin is dry and scaly a cream formulation would be preferrable) before bedtime, or several times a day, if possible, to treat dry and scaly skin.

For additional skin protection, silicone tape, removed at each doffing to prevent contamination, can be applied over the bridge of the nose and cheeks and can be used for additional protection from FFP3 masks. HCPs should ensure regular breaks from wearing a mask to prevent moisture build up and also to prevent pressure with FFP3 masks.

Outside the clinical workplace, wearing masks with soft breathable fabric, with a cotton inside layer that will absorb oily residue, can prevent facial skin irritation and maskne.

Washing cotton masks daily is important to remove oil and skin cell residue, which will further aggravate maskne.

PPE and facial masks will continue in clinical environments. HCPs can help prevent maskne by the skin care measures discussed in this article. If maskne symptoms become clinically significant, assessment, diagnosis and treatment will be required, according to dermatology guidance.

Julie Van Onselen

Lecturer Practitioner Dermatology Education Partnership Ltd.

Julie has worked as a dermatology clinical nurse specialist in both primary and secondary care for 30 years.

Dermatology Education Partnership Ltd focuses on dermatology educational projects and training courses in practical dermatology. Julie works for skin support groups and in an NHS primary care dermatology service for SkinHealth UK. She is passionate about improving care and support for people with skin conditions through developing educational initiatives.

www.dermatologyeducation.co.uk