Many mask-wearers have complained of maskne which refers to occlusion-type acne that has appeared from prolonged wearing of face masks. In this article, accredited dermatologist at TWL Specialist Skin and Laser Centre Dr. Teo Wan Lin goes through the possible causes of maskne, the types of face masks that can prevent acne, and silk mask for maskne. She also answers the questions does a silk mask for maskne really work? Dr. Teo is the inventor of the biofunctional textile reusable fabric face mask to treat and prevent maskne. Her concept was published in the Journal of the American Academy of Dermatology as the ideal fabric face mask design for sensitive skin users in October 2020.
Is maskne due to the material of the mask? What role does sweat and heat play in maskne?
Maskne is a variant of acne mechanica or occlusion acne, which previously prior to the COVID-19, was most commonly seen in athletes who wear headgear (helmets, face guards), amongst medical staff (surgical mask, N95 mask in infectious disease settings), motorcyclists and construction workers who wear helmets. It is a disorder arising from the occlusion of hair follicles, directly related to mechanical stress (pressure, occlusion, friction) and microbiome dysbiosis (from the imbalance with heat, pH, moisture from biofluids including sweat). Both of these are affected by increased duration of mask-wear.
What other types of skin diseases have you seen in patients due to prolonged mask wearing? Have you seen more patients with mask-related skin conditions?
Several other skin diseases can be associated with prolonged mask-wearing, due to increased heat and moisture, and may also mimic symptoms of maskne. For example, eczema, rosacea, perioral dermatitis and heat rash (miliaria rubra) may manifest as red bumps and red patches. These are all symptoms that you may perceive as skin irritation from the face mask, but may be indicative of an underlying dermatological condition. In my private dermatology practice, we do not have epidemiological studies about the number of cases, which ideally should be assessed on a national and international level. Suffice to say, there has certainly been a significant increase across the board in the incidence of skin diseases that links with mask-wearing.
Does wearing masks for prolonged periods of time increase the possibility of germs trapped inside the mask? Can mask wearing cause irritation?
Mask wearing creates an occlusive microenvironment and this changes the normal microbiome of healthy skin. The term microbiome refers to the balance of germs-bacteria, viruses, fungi, mites, that work with our body to keep it healthy. These germs have to be present for our immune system to work and self-regulate. They form at birth, changes as one age, varying in terms of each location. For example, the germs on our scalp are vastly different from that in our oral cavity, our nose, or the rest of the skin. Various dermatological conditions have now been shown to be linked to microbiome dysbiosis. This relates to an imbalance in the skin flora.
What are some of the severe forms of skin disease that could result from prolonged mask wearing?
There are other conditions apart from maskne that can arise from prolonged mask wearing. Individuals with preexisting conditions such as acne vulgaris, perioral dermatitis, eczema of the face and rosacea, may have their conditions aggravated and suffer serious flare ups. This is due to disruptions of the barrier function and microbiome of the skin. As a result of prolonged mask wearing which impacts the skin microenvironment. Additionally, it also involves also mechanical factors, such as textile-skin friction.
For example, the unique microenvironment created by a face mask causes exposure of the skin to biofluids such as the nasal and respiratory droplets. These can alter the pH and microbiome of the skin. With this, individuals who are already prone to greasy skin and acne may find that their acne gets a more serious infection, leading to painful cysts and pustules. In another case, when one is speaking with the mask on, saliva inevitably gets onto the mask. Saliva itself contains various digestive enzymes. Constant exposure to saliva may cause a form of facial eczema or dermatitis in individuals. In addition, constant contact with mask material also known as textile-skin friction, leads to frictional dermatitis, a form of eczema. It causes redness and results in post inflammatory hyperpigmentation.
Silk masks have been recommended for sensitive skin. Do you recommend that? For individuals with sensitive skin, what kind of mask material should they opt for better breathability?
Many recommend a silk mask for maskne prevention. Because, we consider natural silk a fibre that is breathable, lightweight and comfortable on skin.
My personal assessment is that silk face masks are unsuitable as a fabric face mask in the context of a pandemic. The reason is because it does not fulfill the primary function of being water repellant/ droplet-resistant – the primary function of wearing a face covering. While cotton masks are not water-resistant they can absorb moisture, silk face masks are not absorbent at all.
The problem with natural silk masks
Reusable fabric masks made of true silk will not just saturate with moisture and sweat. Additionally, it will leak fluids all around and through the fabric. Most importantly, respiratory droplets and saliva will permeate the fabric and spread your biofluids to the environment.
Besides, it is not durable and will not withstand even repeated hand washing with a mild detergent. A reusable fabric face masks in this case are ideal to reduce environmental pollution and waste. The primary health measure in the pandemic is to ensure that all individuals mask-up. This is to reduce environmental droplet contamination. Silk cannot be laundered at high temperatures. Even with hand washing, the structure is very likely to disintegrate, rendering the mask ineffective.
Instead, I recommend synthetic silk masks with silk-like features instead of a traditional silk mask for maskne. These derivatives of polyester are engineered to have an ultra smooth and soft finish. Treated synthetic silk fabrics will have improved evaporation coefficient so it doesn’t get saturated with sweat or moisture. This maintains a cool and dry skin microenvironment which is beneficial for treatment and prevention of maskne.
In summary, synthetic silk face masks in this case have a silk-like beneficial effect on skin. At the same time, they are waterproof and also durable enough to launder daily at high temperatures.
Individuals with sensitive skin actually have a form of eczema. It is important to understand that these individuals perceive friction and changes in skin temperatures and other sensations much more acutely. The ideal fabric mask is not just in the material but also in the design. I have proposed this in my white paper on Maskne, the Diagnostic and Management Considerations of Maskne in the Era COVID-19, published in the Journal of American Academy of Dermatology. The ideal silk mask for maskne of fabric mask design should encompass details which have been published in the paper. This is a design that minimizes textile-skin friction, omits elastic ear straps which cause additional pressure over the back of the ears. Furthermore, it also allows adequate coverage with the use of a UPF protective biofunctional textile.
Can we treat maskne? How do I prevent dermatological conditions from flaring up due to mask-wear?
When it comes to maskne, I would suggest to avoid conventional acne spot creams with synthetic active ingredients such as retinoids, benzoyl peroxide, sulfur, salicylic acid as these will cause increased skin irritation (irritant contact dermatitis) when applied under the occlusion of a face mask. Individuals who apply retinoids for night acne treatment may find that wearing a mask in the day increases the risk of retinoid dermatitis, a form of eczema that leads to redness and flaking on the skin.
Benzoyl peroxide also bleaches fabrics and may alter the structural integrity of the face mask, rendering it less effective for control of droplet spread.
Instead, I recommend anti-inflammatory acne spot creams. Acne formulations with botanical actives such as Chlorella Vulgaris work by regulating sebum production, whilst natural moisturizing factors like amino acids fight inflammation and have additional moisturizing properties to protect the skin barrier. Anti-bacterial gentle cleansers such as the Miel Honey Cleanser formulated with anti-inflammatory Arnica Montana and medical grade honey can help maintain a healthy skin microbiome.
Moisturisers formulated as Prescription Emollient Devices (PEDs) have an optimal lipid ratio and anti-inflammatory botanical actives that help maintain a healthy skin barrier.
My invention of the ideal reusable synthetic silk mask for maskne, by Dr. TWL Biomaterials
In my white paper on maskne, I proposed the rationale behind my invention of ultraviolet protective (UPF50+) biofunctional textiles for fabric face masks. The primary reason is due to the fact that wearing sunscreen under the face mask is not as effective. You should reapply traditional sunscreens, even waterproof formulations, every three to four hours for optimal efficacy.
The constant moist environment would render sunscreens under a face mask less effective. Having to constantly reapply sunscreen under a face mask is also cumbersome and unhygienic in the midst of a pandemic. Additionally, sunscreens are formulated in an oil vehicle for optimal efficacy, especially for UVA-blockers. When used under occlusion, the comedogenicity (acne-causing potential) of sunscreens increases, which means that it is much more likely to cause acne flares.
The location of diseases of facial pigmentation commonly occur over the cheeks – exactly the area covered by the face mask. Melasma, solar lentigo (sun spots), eczema, autoimmune-related photosensitive conditions, present with lesions over the cheek area due to the natural prominence of the cheekbones which undergo sun exposure. The face mask I designed with a UPF 50+ biofunctional textile offers maximum photoprotection without the need for re-application (of sunscreen), and without risk of comedogenicity.
Additionally, the biofunctional component with impregnated metal nanoparticles are self-cleaning i.e. copper and zinc exerts bactericidal (kills bacteria on contact) effects as opposed to typical anti-microbial linings which simply inhibit bacterial growth. When used as part of therapy for diseases like maskne, rosacea, perioral dermatitis, this can restore the skin microbiome balance without the use of antibiotics and associated problems like antibiotic resistance.
Teo WL. Diagnostic and Management Considerations for ‘Maskne’ in the Era of COVID-19 [published online ahead of print, 2020 Oct 1]. J Am Acad Dermatol. 2020;S0190-9622(20)32664-5. doi:10.1016/j.jaad.2020.09.063
Teo WL. The “Maskne” microbiome – pathophysiology and therapeutics. Int J Dermatol. 2021 Feb 12:10.1111/ijd.15425. doi: 10.1111/ijd.15425. Epub ahead of print. PMID: 33576511; PMCID: PMC8013758.