The COVID-19 pandemic has led to mandatory mask-wearing. Many mask-wearers have complained of “maskne” which refers to acne caused by wearing their masks for too long. What are the possible causes of this? Is it due to the material of the mask or accumulated sweat? In this article, I shall share my dermatological expertise on maskne, including common skin conditions that arise from a face mask and maskne treatment.
Masking Up: A Dermatologist’s Guide to Maskne by Dr. Teo Wan Lin is written as a guide to the phenomenon, with skincare, makeup tips for the “new normal” of mask-wearing, as well as information on how to choose the right fabric mask. Sold on Amazon Kindle and Kinokuniya.
What is maskne?
Maskne is a variant of acne mechanica or occlusion acne, which previously prior to the COVID-19, was most commonly seen in athletes who wear headgear (helmets, face guards), amongst medical staff (surgical mask, N95 mask in infectious disease settings), motorcyclists and construction workers who wear helmets. It is a disorder arising from the occlusion of hair follicles, directly related to mechanical stress (pressure, occlusion, friction) and microbiome dysbiosis (from the imbalance with heat, pH, moisture from biofluids including sweat). Both of these are affected by increased duration of mask-wear.
Besides mask acne, what other types of skin diseases can arise from prolonged mask wearing?
Several other skin diseases can be associated with prolonged mask-wearing, due to increased heat and moisture, and may also mimic symptoms of maskne. For example, eczema, rosacea and heat rash may manifest as red bumps and red patches which one may perceive as skin irritation. In my private dermatology practice, we do not do epidemiological studies regarding the number of cases, which should be assessed on a national level. Suffice to say, there has certainly been a very significant increase across the board in incidence of skin diseases associated with mask-wearing.
For those who wear their masks for prolonged periods of time, is there a possibility that the bacteria trapped inside the mask could cause skin infection or irritation?
Mask wearing creates an occlusive microenvironment and this changes the normal microbiome of healthy skin. The term microbiome refers to the balance of germs-bacteria, viruses, fungi, mites, that work with our body to keep it healthy. These germs have to be present for our immune system to work and self-regulate. It is formed at birth, changes as one age, varying in terms of each location i.e. the germs on our scalp are vastly different from that in our oral cavity, our nose, and the rest of the skin. Various dermatological conditions have now been shown to be linked to microbiome dysbiosis, which relates to an imbalance in the skin flora.
What are some of the severe forms of skin disease that could result from prolonged mask wearing?
There are other conditions apart from maskne that can arise from prolonged mask wearing. Individuals with preexisting conditions such as acne vulgaris, perioral dermatitis, eczema of the face and rosacea, may have their conditions aggravated and suffer serious flare ups. This is due to disruptions of the barrier function and microbiome of the skin as a result of prolonged mask wearing which impacts the skin microenvironment and involves also mechanical factors, such as textile-skin friction.
For example, the unique microenvironment created by a face mask causes exposure of the skin to biofluids such as the nasal and respiratory droplets which can alter the pH and microbiome of the skin. With this, individuals who are already prone to greasy skin and acne may find that their acne gets infected more seriously, leading to painful cysts and pustules. In another case, when one is speaking with the mask on, saliva inevitably gets onto the mask.
Saliva itself contains various digestive enzymes. Constant exposure to saliva may cause a form of facial eczema or dermatitis in individuals. In addition, constant contact with mask material also known as textile-skin friction, leads to frictional dermatitis, a form of eczema. It causes redness and results in post inflammatory hyperpigmentation.
For individuals with sensitive skin, what kind of mask material should they opt for, in order for better breathability?
Firstly, individuals with sensitive skin are actually atopic individuals with eczema. It is important to understand that these individuals perceive friction, as well as changes in skin temperatures and other sensations much more acutely. The ideal fabric mask is not just in the material but also in the design, as I have proposed in my white paper on maskne, the Diagnostic and Management Considerations of Maskne in the Era COVID-19, published in the Journal of American Academy of Dermatology1.
The ideal fabric mask design for maskne treatment should encompass details which have been published in the paper. This is a design that minimizes textile-skin friction, omits elastic ear straps which cause additional pressure over the back of the ears, and also allows adequate coverage with the use of a UPF protective biofunctional textile.
In terms of material, we know that natural fibres such as cotton has long been the material of choice for individuals with sensitive skin.
In my white paper, I covered a few key points about the material of face masks affecting the skin. Firstly, natural fibres like bamboo, cotton and silk can wick moisture away, keeping skin dry. However, they retain fluids and become heavy. This is known as increased fluid saturation. This makes mask wear more uncomfortable. It can also create a sticky feeling. Natural fibres also disintegrate easily with wear, making it ineffective as a face covering to prevent fluid spread. On the other hand, synthetic materials that have been treated with biofunctional properties, examples are dri-fit, or what we incorporate in our biofunctional textiles can cool skin rapidly by enhanced evaporation. They are also water-resistant, minimising spread of contagious droplets.
The OSMIUM BLUE™ anti-aging fabric mask with nanoparticle technology is incorporated with CUIONS™ nanoparticles, which are rigorously lab tested for the active release of copper metallic ions clinically effective for anti-ageing by promoting collagen production and reducing skin pigmentation.
What are some of the additional skincare features that can be incorporated into a face mask?
In my paper on the ideal face mask design, I discussed the novel incorporation of ultra-violet protective factor, UPF into the mask material. This solves the problem of wearing sunscreen under the face mask which can increase comedogenicity -i.e. acne formation. To reduce heat retention and flare-ups of heat-related skin conditions such as miliaria rubra and facial hyperhidrosis, choose light or reflective colours.
The ZINCOOL™ zinc nanoparticle impregnated fabric is self-cleaning with whiter than white technology, and incorporates superior skin cooling, creating a highly breathable skin microenvironment, with super evaporation coefficient. It has anti-inflammatory, bactericidal and sebum control functions to treat maskne, and offers benefits for individuals who have facial eczema or are acne prone
In addition, these biofunctional textiles with metallic nanoparticles like copper and zinc have additional anti-oxidant and anti-ageing benefits. The CUIONS technology for biofunctional face masks by Dr. TWL Biomaterials includes copper oxide polyesters associated with reduced face wrinkles. While a lot of masks tout anti-bacterial benefits, these metallic ion textiles with copper, zinc and silver kill bacteria and are considered “bactericidal”. This reduces antibiotic resistance in acne treatment1 as well.
What are your recommendations for maskne treatment?
When it comes to maskne treatment, I would suggest to avoid conventional acne spot creams with synthetic active ingredients such as retinoids, benzoyl peroxide, sulfur, salicylic acid as these will cause increased skin irritation (irritant contact dermatitis) when applied under the occlusion of a face mask. Individuals who apply retinoids for night acne treatment may find that wearing a mask in the day increases the risk of retinoid dermatitis, a form of eczema that leads to redness and flaking on the skin.
Benzoyl peroxide is also known to bleach fabrics and may alter the structural integrity of the face mask, rendering it less effective for control of droplet spread. Anti-inflammatory acne spot creams are recommended for maskne treatment. Acne formulations with botanical actives such as Chlorella Vulgaris work by regulating sebum production, whilst natural moisturizing factors like amino acids fight inflammation and have additional moisturizing properties to protect the skin barrier. Special consideration for skincare as makskne treatment should include anti-bacterial gentle cleansers, moisturisers formulated as Prescription Emollient Devices (PEDs) that help maintain a healthy skin barrier/microbiome.
- Teo WL. Diagnostic and Management Considerations for ‘Maskne’ in the Era of COVID-19 [published online ahead of print, 2020 Oct 1]. J Am Acad Dermatol. 2020;S0190-9622(20)32664-5. doi:10.1016/j.jaad.2020.09.063