In the presence of an airborne pathogen such as a coronavirus, which is carried by aerosol droplets released by infected individuals while breathing and speaking, wearing a mask is not an option—it is a requirement. Wearing a mask is the single best way to avoid contaminating one’s neighbor, it is an act of kindness, a civic duty, a showing of care for others, and the best way to avoid spreading the disease. The mode of action of masks is simple and straightforward. It is depicted in Figure 1 and the picture is self-explanatory.

A relatively minor undesirable consequence of wearing masks—when compared to the paramount importance of protecting others against a contamination originating from us—is skin discomfort. This consequence has been observed and analyzed in healthcare professionals who typically wear masks for several hours without interruption.

In Spring 2020 in New York, 314 healthcare professionals on the COVID-19 frontline answered a questionnaire with 21 questions relative to adverse effects of personal protection equipment. More than 9 in 10 (91%) of the respondents were female, 60% of the respondents were using N95 masks and 40% were using surgical masks. Among the respondents, 175 experienced skin breakdown and 182 reported acne. Previous history of skin sensitivity (n = 164) and acne (n = 121) were found in some respondents. As possible palliative interventions for future management of adverse effects related to prolonged mask use, the author of the study recommends frequent breaks, improved hydration, skin care and comfortable masks.¹

Feel the Heat
A study has tackled the question relative to what a comfortable mask may be. The authors measured skin temperature in individuals wearing either a surgical mask or an N95 mask and observed that after one hour under the surgical mask, the temperature of the skin is lower than after one hour under an N95 mask. The results suggest that N95 masks induce increased facial skin temperature, greater discomfort and lower wearing adherence when compared to the medical surgical masks. In the very words of the authors, “The N95 mask produces a major increase in skin facial temperature with major discomfort, and volunteers have shown greater adherence in the use of the surgical mask rather than N95.”²

Dr. Girish Mohan of the Hartford Health Care Center for Dermatology has been quoted as saying: “The masks are a great way to protect ourselves and others from COVID-19 and are recommended by the Centers for Disease Control, but they can cause repetitive friction and redirect your own airflow against the face. Each time we inhale and exhale, moisture accumulates and the mask traps it against the skin of the face. This can lead to acne flares and to skin that can get dry, itchy, red and starts to peel. Also, the cloth rubbing against the skin can irritate.”

Possible Interventions
The wearing of a mask can exacerbate the undesired consequences of a skin that is acne prone or with other pre-existing conditions such as a history of rosacea, rashes etc., but can also provoke new effects because of increased temperature, brushing, occlusion or increased environmental humidity.

A consistent skin care routine can help to prevent problems. Mohan has been quoted as suggesting a daily skin care regimen to soothe the skin for all mask wearers, as follows. A fragrance-free cleanser can be used to remove oil, dirt, bacteria and irritants. After cleansing, the skin moisture balance can be maintained with a fragrance-free facial moisturizer while avoiding makeup in the areas covered by the mask since the cosmetic components can act as an additional irritant under the pressure from the mask.

For specific skin conditions, Mohan suggests the following:

Dry skin: Some masks can absorb the natural moisture and dry out skin. One can apply creams containing ceramides to rehydrate the skin. Ceramides can help restore the skin moisture balance that is disrupted in dry skin.

Dermatitis: Dermatitis is characterized by an itchy rash, dry or scaly skin, bumps and blisters, and/or swelling and burning. One can try using a different mask, and may apply a topical over-the-counter hydrocortisone 1%. If the dermatitis persists, one might need to consult a dermatologist.

Acne: Acne-prone people may experience an exacerbation while wearing masks. One can try using over-the-counter benzoyl peroxide-containing or salicylic acid-containing acne washes as well as topical niacinamide or adapalene.

Rosacea: Heat and sweating can trigger rosacea, which is characterized by redness, enlarged blood vessels and firm or fluid-filled bumps, most commonly on the cheeks and chin. Since wearing a mask increases the temperature of the skin and increases sweating, rosacea-prone skin may flare. A dermatologist can prescribe a variety of medications to treat rosacea.

Time Factor?
Northwestern Medicine Dermatologist Dr. Walter J. Liszewski has been quoted as saying that the duration of time wearing a mask doesn’t directly correlate to acne development.

“I’m seeing as much mask acne in people who work in health care and wear a face mask for eight hours a day as in people who are just wearing their mask to the grocery store,” he said.

To reduce the amount of acne-causing bacteria on your skin, Liszewski suggests washing the face with a cleanser containing 2% to 5% benzoyl peroxide. The benzoyl peroxide solution should sit on the skin for two to three minutes before rinsing it away and a non-comedogenic moisturizer should be applied after washing. If the acne doesn’t clear up, it may be helpful to see a dermatologist for additional treatment.
Remember, dropping the mask is not an option: wearing a mask is vital to your health and others during the pandemic.

The use of masks can provoke skin irritation for many people.

“Frictional or irritant dermatitis can be easily relieved by minimizing pressure of the mask on the face, or using thick barrier creams to protect the skin from chafing,” says Liszewski.

Rashes due to allergies are not common with masks. If one suspects having a skin allergy to the mask, consulting a dermatologist is more than just a good idea.

Last but not least, people working outdoors should wear a sunscreen under the mask. Dermatologist Orit Markowitz, director of pigmented lesions and skin cancer at Mount Sinai Hospital in New York City, observed, “A typical cloth face mask gives you the equivalent sun protection of only SPF 7 or so.”

Fabrics do indeed offer only a small SPF³ and the possible undesired side effects of wearing a mask could be exacerbated by exposure to sunlight. 

References

1. E. Rosner (2020) Adverse effects of Prolonged Mask Use among Healthcare Professionals during Covid-19. J Infect Dis Epidemiol. 6 : 130
2. Scarano, A, Inchingolo F, Lorusso, F (2020) Facial Skin Temperature and Skin Discomfort when Wearing Protective Face Masks: Thermal Infrared Imaging Evaluation and Hands Moving the Mask. Int J Environ Res Public Health 17: 4624
3. Driscoll CMH (2001) Artificial Protection against Solar Radiation – Fabrics. In (PU Giacomoni, Editor) Sun Protection in Man, Elsevier, Amsterdam, pages 457-486

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Paolo Giacomoni, PhD
Insight Analysis Consulting
[email protected]
516-769-6904

Paolo Giacomoni acts as an independent consultant to the skin care industry. He served as executive director of research at Estée Lauder and was head of the department of biology with L’Oréal. He has built a record of achievements through research on DNA damage and metabolic impairment induced by UV radiation as well as on the positive effects of vitamins and antioxidants. He has authored more than 100 peer-reviewed publications and has more than 20 patents.