Impact of mask wear on the skin of clinical year medical students during the COVID-19 pandemic: A cross-sectional study

INTRODUCTION

With the identification of the novel coronavirus SARS-CoV-2 in 2019 and the declaration of the pandemic in March 2020, the COVID-19 disease has spread across the globe, making lockdowns, social distancing, and mask wearing the new norm. Wearing a mask has been found to be extremely beneficial in combating this disease and can be used to protect oneself when in contact with an infected person or worn to control the source of infection hence preventing further transmission.^[1] Despite all the advantages of mask use, long-term use of masks has led to an increase in skin damage and worsening of pre-existing skin disorders such as acne, rosacea, dermatitis, and the incidence of acne, termed as “Maskne” is the most frequently reported.^[2-4] Maskne is a type of mechanical acne, caused due to mechanical injury as a result of long-term mask use.^[5] Frequency of Maskne has exponentially risen in the current times due to masks now being accepted as the “new normal.”^[6]

In a study conducted in 2020, the results showed that wearing a face mask for more than 4 h/day was associated with a higher risk of adverse skin reaction. Mask usage for more than 8 h/day reflected a much greater risk of an adverse skin reaction and reuse of face masks increased the risk of face mask related skin reactions up to 1.5 times.^[4] In yet another study conducted in 2021, they observed worsening acne and rosacea in patients after 6 weeks of mask and quarantine.^[2] Nodular acne was prevalent in healthcare workers wearing N95 for longer periods, especially over cheeks, chin, and perioral area.^[7]

In accordance with the existing literature and our own subjective observation, we hypothesize that an increased mask use has caused worsening of acne and new breakouts in its wearers, therefore to evaluate this hypothesis and the extent of acne in the same population, we conducted a cross-sectional study in clinical year students (4, 5, and 6 years) of Georgian Medical Universities. There is a distinct lack of the literature in this field, especially with our target demographic, therefore with this study, we aim to bring a greater degree of awareness in combating this adverse dermatological manifestation.

MATERIAL AND METHODS

An online cross-sectional study was conducted and shared through social media platforms among the clinical year medical students of year 4, 5, and 6 in Tbilisi, Georgia, between the age group of 18–30 from February 27, 2022, to April 18, 2022. A total of 24 questions were asked. Some of the questions asked were demographic information, gender, age, skin type, what type of mask was used, how often they change their mask, if they have any pre-existing skin conditions or comorbidity, if they follow any skincare routine, and more. Informed consent was obtained from the participants at the beginning of the survey. The criteria for diagnosis of Maskne are as follows: Onset of acne within 6 weeks of start of mask use, exacerbation of acne at the Ozone, and the exclusion of the differential diagnosis. Statistical analysis was conducted through the Chi-square test.

RESULTS

A total of 152 responses were collected from clinical (4^th, 5^th, and 6^th) year of medical students from Georgia, among which were 69.5% (n = 105) females and 30.5% (n = 46) males, aged 18–30 years. Number of participants from the 4^th year 30.5% (n = 46), 5^th year 48.1% (n = 62), and 6^th year 28.5% (n = 43).

Symptoms

About 65.8% (n = 52) stated that they have closed comedones (whiteheads), 43% (n = 34) of students have pustules, 26.6% (n = 21) of the students have papules, 25.3% (n = 20) of the students have open comedones (blackhead), 24.1% (n = 19) of the students experience itching, 0.9% (n = 11) of the students have nodules, 12.7% (n = 10) of the students have erythema (redness), 12.7% (n = 10) of the students have cysts, 3.8% (n = 3) have beard dandruff, 1.3% (n = 1) have telangiectasia, and 13.9% (n = 11) stated that they do not have any skin symptoms.

Most of the students, 65.8% (n = 52), stated that they experience acne/rosacea on the cheeks, some students on the chin and jawline at 44.3% (n = 35), then the forehead at 11.4% (n = 9), and 22.8% (n = 18) on the nose (T-zone) [Figure 1].

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Figure 1:

Face map depicting the areas most prone to acne/rosacea as reported by the participants.

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About 40.8% (n = 31) of the students have been experiencing acne/rosacea for more than a year, 32.9% (n = 25) of the students for 2–6 months, 15.8% (n = 12) of the people for over a month, and 10.5% (n = 8) of the students for 7–12 months.

When asked how often students bleach/dye their skin, 94.9% (n = 75) of the students responded that they have never bleached/dyed their skin, 3.8% (n = 3) responded every year, and only 1.3% (n = 1) said that they bleach or dye their skin every 6 months.

COVID-19

About 51.9% (n = 41) of the students stated that they had tested positive for COVID-19, compared to 48.1% (n = 38) who did not. About 10.5% (n = 4) of the students stated that their acne/rosacea is worsened after COVID-19 infection.

DISCUSSION

Mandated wearing of facemasks since the onset of the COVID-19 pandemic has led to the new subtype of acne mechanica, popularly coined as “Maskne.” Maskne is an umbrella term that may not be associated with acne only, but other facial dermatoses as well.^[8] While there is an abundance of literature available on the effect of personal protective equipment on the skin of front line healthcare workers during the COVID-19 pandemic, the information available on this subject related to medical students is comparatively scarce.

About 51.4% (n = 76) of our participants had reported new acne or exacerbation of the previous acne since wearing masks. About 59.2% of these participants were female compared to 33.3% of males. Vural’s study on Turkish medical students reported a similar trend where females were 2.361 times more at risk of developing AV lesions than men.^[9] Aravamuthan and Arumugam and Altun and Demir also reported a female predominance in acne development due to mask wear among health-care professionals.^[10,11]

Multiple mechanisms can contribute to the disruption of the skin barrier due to mask wear. These include friction and sweating, local temperature rise causing an increase in sebum production, increased skin humidity that can increase the amount of skin squalene, increased skin pH, and transepidermal water loss (TEWL).^[12,13] TEWL, skin dehydration, and increased sebum production are known pro-comedogenic factors promoting Cutibacterium acnes multiplication and inflammatory immune responses, leading to the development of papules and pustules. Friction may also lead to increased levels of interleukin-1a, which is involved in the pathogenesis of this condition.^[8] In our study, the most common symptoms reported were closed and open comedones, pustules, papules, itching, and erythema with the predominant site being the cheeks 65.8% (n = 52) followed by the chin 44.3% (n = 35). This is in accordance with the study carried out by Vural where lesions were most common on the cheeks (51%) and chin (45.5%).^[9] These areas are described as the Ozone or U-zone that is in contact with the mask.^[14]

Furthermore, the incidence and the severity of Maskne are associated with the type of mask worn, duration, and frequency of usage. A higher risk is associated with a duration of wear of more than 4 h/day.^[4] Therefore, frequent breaks from mask wearing are recommended to shorten the duration of contact between mask and skin.^[12] Breaks of 15 min from mask wear are recommended every 2 h for mask-related acne.^[15] Vural found prolonged mask use to be associated with the development of acne vulgaris, P = 0.001.^[9] However, our study found no significant relationship between the duration of daily mask wear and the incidence of facial dermatoses (P = 0.0669). Han et al. reported similar findings in the general population with no significant correlation between acne severity and total duration of wearing masks.^[14] On another note, reusing masks increase the risk of skin reactions up to 1.5 times, so it is advised to replace surgical masks every 4 h and N95 masks every 3 days.^[4,16]

One of the ways to manage and prevent mask acne is to protect the skin barrier and reduce TEWL by moisturizing the epidermis. Moisturizers were the most frequent skincare product added by our participants to their skincare routines since they started wearing masks 52.3% (n = 79) followed by cleansers 45.7% (n = 69) and sunscreen 27.8% (n = 42). In addition, topical acne treatments such as benzoyl peroxide, exfoliants (AHA/BHA), and retinoids have also been added to the skincare routine, but these may increase the risk of irritation under mechanical occlusion. Instead, hydrogel carrier formulations are recommended to reduce local irritation.^[17,18]

Although some medical students experienced mask acne, our results are not significant enough to say that wearing facial masks may lead to exacerbation of, or new-onset acne, in clinical year students of Georgian Medical Universities. Therefore, our hypothesis is not proven. Similar results have been obtained in a cross-sectional study done in students of the Faculty of Medicine, University of Diponegoro, Indonesia, where there was no significant relationship observed between the use of face masks and the incidence of acne vulgaris.^[19]

CONCLUSION

With the beginning of the COVID-19 pandemic in 2020, wearing a mask is now widely accepted as the new normal. Using a mask is an integral part of prevention of the COVID-19 disease. Although it has multiple benefits, mask wearing has proved to worsen acne and rosacea as reported by various different studies.

Majority of clinical year medical students of Georgia report having new acne or exacerbation of previous acne since wearing masks, with closed and open comedones, pustules, papules, itching, and erythema on the cheeks most frequently reported on the cheeks, chin, and the jawline. Despite these findings, our results are not significant enough to prove our hypothesis. This study was conducted using an online questionnaire; hence, future research should be further aimed at an objective analysis and diagnosis rather than self-reporting techniques to find out the exact type and extent of mask acne.

Acne affects more than just the skin and is an important determinant of a person’s identity. With the widespread and normalized use of masks, acne flare-ups have worsened causing a negative impact on a person’s self-perception and self-esteem, which are why we believe further research in this field is important to determine the exact causes, the extent of mask acne and ways to combat this new age dermatological problem.