PPE Related Skin Complications and Maskne

Prolonged use of personal protective equipment (PPE) has become essential—especially in healthcare environments—to prevent infection. However, wearing masks and other PPE for extended periods can lead to a range of skin complications, many of which have been collectively highlighted under terms like “maskne” alongside other irritant or pressure-related dermatoses.

Common Skin Complications

Nurses who wear tight masks for extended periods often experience various skin complications due to friction, pressure, and moisture buildup. Here are some common issues:

Maskne (Mask-Related Acne)

• What It Is: “Maskne” refers to acne or acneiform eruptions that develop predominantly in the areas covered by the mask. Although often thought of simply as acne, it is typically a form of acne mechanica—triggered not only by occlusion but also by friction and an altered microbiome due to humidity under the mask.
• Why It Happens: The closed environment under a mask increases temperature and moisture retention, which, coupled with friction, can block pores and promote inflammation. This creates the perfect storm for acne breakouts and exacerbation of pre-existing acne vulgaris .

Irritant Contact Dermatitis

• Characteristics: The repetitive friction and pressure imposed by masks—especially along the nasal bridge, cheeks, and behind the ears—can damage the skin’s natural barrier. This results in dryness, peeling, erythema (redness), and in some cases, a rash.
• Mechanism: Unlike an allergic reaction, irritant contact dermatitis is non-immunologic and results from the continuous physical and sometimes chemical irritation from mask materials and adhesives 2.

Allergic Contact Dermatitis and Pressure Injuries

• Allergic Contact Dermatitis: Some individuals develop a true allergic reaction to components in the mask such as adhesives, dyes, or metals (like the nose clip). This often presents with itching, redness, and sometimes vesicular eruptions.
• Pressure Injuries: Prolonged pressure from tight-fitting respirator masks can lead to skin breakdown, particularly on bony prominences like the nasal bridge and behind the ears, which in severe cases may progress to ulceration.

Contributing Factors

Several factors contribute to PPE-related skin complications, including:

• Extended Duration of Use: Long shifts and the necessity of constant mask-wearing can magnify frictional and occlusive effects.
• Improper Fit or Reuse of PPE: Masks that are too tight or are reused too often may not only fail to protect optimally but also cause repetitive trauma to the skin.
• Environmental Factors: Increased humidity and heat below the mask lead to sweat and sebum accumulation, altering skin pH and microflora.
• Pre-existing Skin Conditions: Conditions such as acne, rosacea, or eczema can be exacerbated by the stresses imparted by prolonged PPE use 2.

Prevention and Management Strategies

Preventing and managing maskne involves a combination of skincare practices and mask hygiene. Here are some effective strategies:

Skincare Regimen

• Gentle Cleansing: Washing with a mild, non-stripping cleanser helps remove sweat and sebum buildup without damaging the skin barrier.
• Moisturization: Use non-comedogenic moisturizers to maintain hydration and support the skin’s barrier function. This can also prevent dryness and irritation that often go hand-in-hand with mask-induced friction.

Barrier Protection

• Barrier Films and Protective Wipes: Application of an alcohol-free barrier film or a liquid acrylate dressing before wearing the mask can help reduce friction and protect vulnerable areas. Some studies have found that while padded dressings might work for face shields, they should be used cautiously under tight respirators to avoid compromising their seal .

Optimizing Mask Fit and Usage

• Proper Fit: Ensuring that masks are appropriately sized for the individual and are worn correctly can reduce undue pressure on certain areas.
• Scheduled Breaks: Where possible, taking periodic “mask breaks” in a safe and controlled environment allows the skin to breathe and recover from continuous pressure and friction.

Environmental Considerations

• Temperature and Humidity Control: In controlled settings, regulating the ambient environment may help reduce excessive sweating and moisture accumulation that can exacerbate skin issues.

Management Strategies:

1. Spot Treatments: Use over-the-counter products with salicylic acid or benzoyl peroxide for mild breakouts.
2. Hydrate and Nourish: Drink plenty of water and maintain a balanced diet to support skin health.
3. Barrier Creams: Apply a thin layer of barrier cream to areas prone to friction, like the nose bridge and cheeks.
4. Consult a Dermatologist: For persistent or severe maskne, seek professional advice for tailored treatments.

Tips to Prevent Maskne

Nurses often face unique challenges with maskne due to prolonged mask-wearing during long shifts. Here are some tailored tips to help prevent and manage maskne:

Maintain a Skincare Routine: Consistency is key. Incorporate products that strengthen your skin barrier, such as those containing ceramides or hyaluronic acid.

Cleanse Gently: Use a mild, fragrance-free cleanser to wash your face before and after shifts. Avoid harsh scrubbing, as it can irritate the skin further.

Moisturize Strategically: Apply a non-comedogenic moisturizer to create a protective barrier between your skin and the mask. Focus on areas where the mask rubs, like the nose bridge and cheeks.

Choose Skin-Friendly Masks: Opt for masks made of breathable, natural fabrics like cotton. Ensure they fit well but aren’t too tight to minimize friction.

Take Mask Breaks: When safe and possible, remove your mask for short periods to let your skin breathe. This can help reduce humidity and irritation.

Avoid Makeup Under the Mask: Makeup can clog pores, especially under a mask. If makeup is necessary, choose lightweight, non-comedogenic products.

Hydrate and Nourish: Drink plenty of water and maintain a balanced diet to support overall skin health. Foods rich in antioxidants and omega-3 fatty acids can be particularly beneficial.

Spot Treat Acne: Use gentle, over-the-counter treatments like salicylic acid or benzoyl peroxide for breakouts. Avoid applying these products right before wearing a mask to prevent irritation.

REFERENCES

1. Jose S, Cyriac MC, Dhandapani M. Health Problems and Skin Damages Caused by Personal Protective Equipment: Experience of Frontline Nurses Caring for Critical COVID-19 Patients in Intensive Care Units. Indian J Crit Care Med. 2021 Feb;25(2):134-139. doi: 10.5005/jp-journals-10071-23713. PMID: 33707889; PMCID: PMC7922454.
2. Zhou NY, Yang L, Dong LY, Li Y, An XJ, Yang J, Yang L, Huang CZ, Tao J. Prevention and Treatment of Skin Damage Caused by Personal Protective Equipment: Experience of the First-Line Clinicians Treating 2019-nCoV Infection. Int J Dermatol Venereol. 2020 March
3. Centers for Disease Control and Prevention (2020). Coronavirus disease 2019 (COVID-19) strategies for optimizing the supply of N95 respirators. Retrieved January 14, 2021 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html
4. Kelechi, T.J., Brunette, G. & Lee, L.W. (2020). Personal protective equipment-related equipment dermatitis. Journal of Wound, Ostomy and Continence Nursing. 47(4), 324-325. https://www.doi.org/10.1097/WON.0000000000000673   
5. Pacis, M., Azor-Ocampo, A., Burnett, E., Tanasapphaisal, C., & Coleman, B. (2020). Prophylactic dressings for maintaining skin integrity of healthcare workers when using N95 respirators while preventing contamination due to the novel coronavirus, a quality improvement project. Journal of Wound, Ostomy and Continence Nursing, 47(6), 551-557. https://www.doi.org/10.1097/WON.0000000000000713   
6. Sinha, A. & Singh, A.R. (2020). An unforeseen hazard of masks being in vogue. International Journal of Occupational and Environmental Medicine, 11, 213-214. https://www.doi.org/10.34172/ijoem.2020.2211    
7. Teo, W. (2021). Diagnostic and management considerations for “maskne” in the era of COVID-19. Journal of the American Academy of Dermatology, 84(2), 520-521. https://doi.org/10.1016/j.jaad.2020.09.063
8. Wound, Ostomy and Continence Society (WOCN) Board of Directors Task Force. (2020). Guidance for maintaining skin health when utilizing protective masks for prolonged time intervals.  Journal of Wound, Ostomy and Continence Nursing, 47(4), 317-318. https://www.doi.org/10.1097/WON.0000000000000677  
9. Goon ATJ, Leow Y-H, Goh C-L Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome–a descriptive study in Singapore. Contact Dermatitis2006;55:291-4. doi:10.1111/j.1600-0536.2006.00953.x pmid:17026695

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