Skin reaction in patients with head-and-neck cancer due to the use of a face mask as COVID-19 protective equipment: A case report

Head-and-neck cancer is the most common cancer in India, accounting for around 30% of all cancers.[1] Since 60-80% of patients with head-and-neck cancer have advanced disease, radiotherapy is one of the most common treatments.[2] Common adverse events are radiation-induced skin reactions, which have an impact on both quality of life and treatment outcomes. Due to severe skin toxicity, treatment may be interrupted at times.[3] Acute radiation morbidity scoring criteria developed by the Radiation Therapy Oncology Group (RTOG) classify skin toxicities into the following categories: Grade I: follicular, faint or dull erythema/epilation, or dry desquamation; Grade II: tender or bright erythema or patchy moist desquamation/moderate edema; Grade III: moist desquamation other than skin folds, pitting edema, bleeding from minor trauma or abrasion; Grade IV: skin necrosis or ulceration of full-thickness dermis may have spontaneous bleeding from the affected area.[4] Skin toxicity is painful for patients with higher grades (grades III or IV) and frequently causes the treatment to be discontinued temporarily or permanently.[3,5] There are many factors that impact the skin reaction including physical factors such as the delivered dose, dose per fraction, skin friction, and patient-related factors like their biological characteristics, age, race, pre-existing skin disease, comorbidities, etc. Of these factors, skin friction is the most common. On December 11, 2019, a new coronavirus was found in Wuhan, China, and on February 11, 2019, the World Health Organization (WHO) named it COVID-19.[6] Because of the virus’s strong transmission properties, the health and welfare department of the Indian government mandated the use of protective equipment such as face masks, preferably N95.[7] The elastic band of a mask constantly rubs against the skin behind the ears, causing rashes. Radiation dermatitis can cause inflammation, erythema, and dry or moist desquamation, and when these patients wear masks, particularly the varieties that have elastic bands that circle behind the ear, the constant friction may cause a severe skin reaction and ulceration. As a result, a string tie mask with no loops behind the ears is advantageous. A 77-year-old woman with hypertension, diabetes, and hypothyroidism but no history of substance abuse presented with a 2 × 1 cm ulcerative growth, extending from the left canine to the second molar and bleeding for one month from the left lower alveolus. The growth was restricted to the left lower gingivobuccal mucosa sulcus, with no extension across the midline. The plain and contrast enhanced computed tomography (CT) scan images of the left lower alveolus showed a bulky soft tissue growth with extensive adjacent cortical erosion in the mandible. The overlying skin appeared to be infiltrated at levels Ib and II, with a few enlarged lymph nodes. A high-resolution CT scan of the lungs revealed no lung metastases. The histopathology report revealed that it was a moderately differentiated squamous cell carcinoma (disease had not infiltrated the skin) and 0/57 lymph nodes were positive (pT4aN0). Segmental mandibulectomy with tracheostomy and left modified neck dissection (MND) and right selective neck dissection (SND) from levels I-IV were performed. Adjuvant ipsilateral neck irradiation with volumetric arc therapy (VMAT) under image guidance was planned. The radiation dose was 60 gray (Gy) in 30 fractions using 6 million volts (MV) unflattened beam over six weeks with no concurrent chemotherapy. Planning target volume measured 330.4 cm3, 96.6% dose received by 95% of the target volume with maximum dose of 107.8%. All organs at risk doses were within the specified tolerance. Figure 1a (left panel) depicts the dose distribution in the relevant axial image. In the affected region, the point dose was around 44 Gy in 30 fractions, resulting in 133 cGy per fraction. The patient tolerated the treatment well during the first and second weeks, with no complications. During the third week, the patient developed mild pain in the left border of the tongue and was prescribed analgesic medication and antiseptic gargles. The patient developed RTOG skin toxicity Grade (Gr)-I and mucositis in the fourth week.[4] She developed RTOG Gr-II skin toxicity in the lower area behind the left ear, during the last week of treatment, progressing to Gr-III, as shown in Figure 1b.[4]Table 1 shows the timeline of the clinical events.Figure 1: (a) Dose distribution in the axial plane box indicating point dose. (b) Skin reaction due to the friction of the mask strapTable 1: Timeline of the clinical eventsThis limited area of Grade II-III radiation dermatitis was due to the friction between the skin and the elastic string of the mask used by the patient. All other irradiated areas showed skin toxicity in the range of Gr 0-I. The patient was using an N-95 mask where the strings looped over the ear as shown in Figure 2a.Figure 2: (a) String loop behind the ear. This is not a recommended choice of mask for patients with head-and-neck cancer, due to the expected skin reaction behind the ear due to the friction of the mask string. (b) String loop behind head: Mask of choice during head-and-neck radiotherapyDue to the long course of treatment, patients with head-and-neck cancer have a high risk of developing skin dermatitis and mucositis. We did not find any reason other than friction between the skin and mask string that resulted in a Grade II-III skin toxicity in the limited area for the reported patient.[8] We have seen a few other patients, mostly elderly, develop Grade II-III skin toxicity because of friction between the mask strings, particularly behind the ear. Skin care is an important factor in reducing undesirable skin toxicity, which may lead to unplanned treatment interruption.[3] Therefore, it is advisable to use a string mask that does not loop behind the ear, rather than using the masks which loop behind the head as shown in Figure 2b. In conclusion, both the treating physician and the radiation therapist should be aware of such incidents. It is necessary to educate the patient about the types of masks that they will need to wear during their treatment. We strongly suggest the use of a mask with the strings looping behind the head, for patients with head-and-neck cancer. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.