Increased Flare of Acne Caused by Long-Time Mask

Wearing During COVID-19 Pandemic among General

Population
Short title: Long-time mask wearing increased flare of acne
Word count: 600
Type of article: Letters: Note & comments
Number of table & figures: 1 table; 1 figure

Number of references: 5
Name of authors:
Changxu Han
Jialiang Shi
Yan Chen

Zhenying Zhang
Authors’affiliation:
Department of Dermatology, HongKong University Affiliated Shenzhen
Hospital, Guangdong Province, PRC
E-mail IDs of authors:

Changxu Han: hancx@hku-szh.org

Jialiang Shi: shijl@hku-szh.org
Yan Chen: cheny8@hku-szh.org
Zhenying Zhang: zhangzy@hku-szh.org
Correspondence: Dr. Zhenying Zhang

Dermatology Clinic 2, HongKong University Affilated Shenzhen Hospital, No.1

Haiyuan 1 Road, Shenzhen, Guangdong Province, PRC
Tel: 008618307556911

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which
may lead to differences between this version and the Version of Record. Please cite this
article as doi: 10.1111/dth.13704

This article is protected by copyright. All rights reserved.

Email: zhangzy@hku-szh.org
A statement of all funding sources that supported the work: None.
Any conflict of interest disclosures: None.

Increased Flare of Acne Caused by Long-Time Mask

Wearing During COVID-19 Pandemic among General

Population
To Editor：
Wearing a mask is encouraged for preventing dispersal of droplets during talking, sneezing and coughing. Therefore,
it’s thought to reduce the ris k of environmental contamination by SARS-CoV-2 (COVID-19) based on the precautionary
principles. However, long-time mask w earing could increase the flare of acne due to higher temperature and humidity
on the surface of facial skin caused by expired air and the perspiration [1-2]. We herein reported 5 patients w ith acne
initial attack among general population due to long-time mask w earing.

From 15th April to 4th May in 2020, w e diagnosed two dozens of patients w ith the flare of acne. All the patients w ere
involved in any healthcare-associated occupations. Most of them had acne relapse or obvious exacerbation, however,
five patients presented initial attack of acne.[Table 1] Five patients were all diagnosed with adult acne and two patients
were less than 25 years old. The severity of acne ranged from mild to moderate. All five patients admitted wearing
for more than 4 hours per day over 2 month. How ever, there was no signific ant correlation between acne severity and
total duration of wearing masks even when correlation between skin lesion numbers and mask-wearing time w as
analyzed by person test analysis using the data of 24 patients.（P>0.05, data not shown）The most reported symptoms
were itching sensation and excessive seborrhea. The most common signs were comedones, papules on cheek and
nose, instead of nodules or cysts on forehead, submaxill and neck. [Figure 1] Some advice about skin care were given
and all five patients had good response to adapalene gel or AHA peeling.

Higher temperature has a close correlation w ith the flare of acne, which can be explained by the effect of higher
temperature on the sebum excretion rate (SER). The SER varies directly when local temperature changes, and sebum
excretion increases by 10% for each 1℃ ris e. Furthermore, squalene could become significantly more in surface lipid
w hen temperature increases [3].

The ambient high humidity precipitates acne is mainly due to poral occlusive effect of skin hydration and irritation to
upper parts of pilosebaceous duct. In addition, sweat and increased humidity might cause swelling of epidermal
keratinocytes, thus affecting the keratinocytes of the pilosebaceous follicle and causing acute obstruction and acne
aggravation [4]. Moreover, changes in both surface sebum composition and skin hydration could contribute to

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disruption of skin barrier, leading to bacterial microflora imbalance.

Long-time mask w earing during COVID-19 pandemic may lead to increased flare of acne, but what should be noticed
is that the patients with acne may be tempted to touch their face follow ing removal of mask for itch and annoying
pimples, w hich could increase the risk of COVID-19 transmission through respiratory route [5].

The surgical mask and N95 mask should be replaced every 4 hours and 3 days respectiv ely. Washing hands before
wearing and after removing the mask is recommended. The patients should control the time of mask w earing and put
tw o layers of gauze inside the mask to reduce the amount of water vapor exhaled from the mouth and the perspiration.
The patients w ith oily skin need to wipe their face with a wet towel containing moisturizing ingredients regularly. It is
also suggested to apply cleansing products and emollients containing oil control ingredients. By employing these
nonpharmacologic maneuvers, the condition of mask-related acne might be relieved. How ever, the patients should
consult dermatologists for topical or oral medication if the acne lesions sustain or aggravate.

Although wearing mask is extremely important to our fight against COVID-19, general public should be aware of
proper and rational mask w earing.

References
1. Foo CC, Goon AT, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute
respiratory syndrome-a descriptive study in Singapore.Contact Dermatitis. 2006 Nov;55(5):291-4.
2. Gheisari M, Araghi F, Moravvej H, Tabary M, Dadkhahfar S. Skin Reactions to Non-glove Personal Protective
Equipment: An Emerging Issue in the COVID-19 Pandemic.J Eur Acad Dermatol Venereol. 2020 Apr 17.doi:
10.1111/jdv.16492. Online ahead of print.
3. Narang I, Sardana K, Bajpai R, Garg VK. Seasonal aggravation of acne in summers and the effect of temperature
and humidity in a study in a tropical setting. J Cosmet Dermatol. 2019 Aug;18(4):1098-1104.
4. Kabir Sardana, Ravi C. Sharma and Rashmi Sarkar. Seasonal Variation in Acne Vulgaris--Myth or Reality. J
Dermatol. 2002 Aug;29(8):484-8.
5. Gupta MK, Lipner SR. Personal Protective Equipment Recommendations Based on COVID-19 Route of
Transmission. J Am Acad Dermatol. 2020 Apr 21:S0190-9622(20)30683-6. doi: 10.1016/j.jaad.2020.04.068. Online
ahead of print.

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 No. Age/ Time of Types of Symptoms Signs Time of Number Treatment
Gender AcneDuration Acne mask of skin
wearing lesions
A38 36/Male 1Month Adult acne excess Papules on 9-10 hrs per 3 0.1% Adapalene Gel

685 seborrhea cheek and day for 3 month

74 and itch nose

Accepted Article
AK9 25/Female 4Months Adult acne Itch Comedones, 7-8 hrs per day 39 0.1% Adapalene Gel，

447 papules on for 4.5 months 20% Peeling with Alpha

772 cheek Hydroxy Acids

AK5 26/Female 2Months Adult acne Itch Comedones, 8-9hrs per day 19 0.1% Adapalene Gel

040 papules on for 3 months

049 cheek

AK4 22/Male 1Month Adult acne Itch Comedones, 4hrs per day for 34 0.1% Adapalene Gel,

177 papules on 3 months 20% Peeling with Alpha

129 cheek Hydroxy Acids

AK8 21/Female 1Month Adult acne N Comedones, 12hrs per day 21 0.1% Adapalene Gel

603 papules on for 2 months

869 cheek

Table 1: Demographic and clinical profile of five patients with initial attack of acne after
long-time mask wearing.

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Mark-acne often presents mild to moderate in severity, consisting mainly of comedons or papules on cheek
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