Unraveling the hidden epidemic of mask related acne/maskne: An observational study

The prevalence of mask related acne (maskne) has been rocketing in past 2 years of COVID-19 pandemic.1 Still, there is a dearth of available data over maskne. Keeping the above in mind, we aimed at conducting a study describing the clinico-epidemiological pattern of maskne and its risk factors. This prospective cross-sectional study included 234 subjects. Inclusion criteria included patients (>15 years old) with new onset acne lesions after mask use, presence of temporal relationship with mask use, lesions localized to area of mask and without concomitant involvement of chest, back, arm, and forehead. Exclusion criteria included patients with history of smoking and alcoholism, history of drug consumption known to trigger acne, have any other facial dermatoses such as rosacea, folliculitis, seborrhea, and contact dermatitis, consuming special diets (i.e., vegans, fasting and keto diet) which could potential cause inflammation, patients with comorbidities capable to trigger acne flares, patch test positivity for formaldehyde, a common allergen in mask, findings of concomitant abnormal hormonal screening in females (serum total/free testosterone, serum prolactin, FSH:LH ratio on Day 2 or 3 of menstrual cycle, thyroid profile), and patients already using any form of topical and/or systemic therapies for acne.2 Out of 234 patients, most affected age group was 20–25 years of age (Table 1). Mean age of participants was 21.5 years. Among 234 participants, 78 (33.4%) were males and 156 (66.7%) were females. The most common mask used was respirator mask (N95 or KN95) followed by cotton mask (including both homemade and store bought). Most common mask associated with maskne was N95 mask. There was a statistically significant association between type of mask and grade of acne (p = 0.043; Figure 1A). Han et al.3 reported association between duration of mask wearing and number of lesions and grade of acne. In our study, mean duration of mask exposure each day was 4.8 h. There was a statistically significant association between number of lesions and duration of mask wearing with number of lesions increasing significantly with hours of mask wearing (p < 0.00001; Figure 1B). However, the association between grade of acne and duration of mask usage was statistically insignificant (p = 0.9). Grade 2 of acne was most common (51.7%) followed by grade 1 (29.91%). In our study, the most common symptom reported was itching while the most common lesions were comedones. Most common site predominantly involved was chin followed by cheeks and jawline (Figure 1B). The most common mask associated with chin and perioral lesions was cloth mask without nose fixation metal bridge, while most common mask associated with cheeks and jawline was N95/KN95 mask owing to configuration and positioning of mask on face. Among 234 patients, 128 were using cosmetic products beneath the mask. Out of these, 69 (53.9%) were using oil-based cosmetics, 28 (21.8%) were using gel-based coemetics, and 31 (24.2%) were using powder-based cosmetics. There was a statistically significant association between type of cosmetic used beneath the mask and grade of acne with oil-based cosmetics more commonly implicated probably due to occlusive and comedogenic action (p < 0.00001). Rudd and Walsh4 postulated that the use of oil-based moisturizers on the face prior to use of mask is significantly comedogenic and risk of maskne increases with mask wearing time. Maskne is clinically characterized by new onset acne, or exacerbation of a pre-existing lesions, most commonly involving the mask line and lower face. A unique feature of mask related acne is the temporal association with mask wearing and alleviation of symptoms with intermittent periods of no mask wearing.4, 5 Our study contributes significantly to the understudied subject of maskne. The statistically significant predictors of the prevalence of maskne included type of mask used, daily wearing time, type of cosmetic used. None. Institutional ethical approval was obtained prior to study initition. All patients gave written informed consent to be a part of the study.