What Causes Maskne & Face Mask Skin Problems? Complete Guide

Maskne is a term coined during the COVID-19 pandemic as a specific form of acne that occurs over the part of the face covered by the face mask. In conjunction with the Dermatological Society of Singapore, accredited dermatologist Dr. Teo Wan Lin answers commonly asked questions about maskne, or acne caused by wearing a face mask, for World Skin Health Day 2022. What causes maskne? How do I know if I have maskne? How to get rid of mask acne? Find out the answers to these essential questions about maskne and more in the transcript below.

Hello good morning, I’m Dr.Teo Wan Lin, a board-certified dermatologist practising at TWL Specialist Skin and Laser Centre. Today is World Skin Health Day and first of all, I would like to thank the organizing committee for inviting me to be part of this wonderful series of talks by my fellow colleagues on important dermatology related topics. I will be speaking on the topic of mask acne – what causes maskne and also how to treat it. I’m sure many of you have heard of maskne but here’s a little bit of background as to what exactly it is and how dermatologists approach it.

What causes maskne?

Well, this actually is not a novel condition. Rather, it is a form of occlusion acne or acne mechanica, which had previously been reported in individuals who had to wear for example – headgear, sporting helmets and also in healthcare workers who were used to working with infectious disease patients and needed to wear the N95 mask for long hours.

Essentially, what causes maskne is that it develops when there is a change in the local skin environment. We call that the microenvironment. The key here is that there is a good balance of bad bacteria as well as healthy bacteria that lives on everyone’s skin. When the skin microenvironment changes, it has the ability to affect the composition of good and bad bacteria. This is exactly what happens and is what causes maskne. The microbiome is disturbed and that’s when individuals who previously did not get acne may find that they start developing acne.

What is the difference between acne and maskne?

There are also those who already suffer from acne. It may be mild and they find that their acne gets much worse with the wearing of a face mask for long periods of time. So, what exactly is happening here? Essentially when you occlude the skin with a face mask for long periods of time, it increases the humidity and it allows accumulation of sweat and saliva for example when you’re speaking it inadvertently gets on to the face mask. That together with Singapore’s climate which is very hot and humid, all that creates the perfect microenvironment to breed bacteria.

Acne itself is directly linked to bacteria. You may have heard of P.acnes (Propionibacterium acnes) and that has been identified as the main bacteria that causes pimples in individuals who are genetically predisposed, being what causes maskne and acne for that matter. We’ve always spoken about acne being mainly a genetic condition driven by inflammation but we also know that the presence of this bacteria on the skin of acne sufferers actually is directly responsible for acne flare ups. In the case of what causes maskne, face mask occlusion directly impacts the rate of growth of these harmful microorganisms on skin.

How do I know if I have maskne?

Could the skin problems I’m seeing be due to skin sensitivity or any other form of skin condition? That’s a really critical question and it is important for you to note first of all, that many of these conditions can only be distinguished by an accredited dermatologist. However, these are some basic guidelines that may help you to figure out if you may have maskne, or it could be something else.

What causes maskne? Well, the definition of maskne is essentially the onset of acne pimples over the area occluded by the face mask within a period of four to six weeks after starting to wear a face mask. Essentially, this is based on the principle that acne doesn’t appear overnight. The process known as comedogenesis, comedone formation is actually the scientific way dermatologists explain how pimples occur. You may have heard of blackheads, whiteheads but before they appear on the surface of your skin, they are actually existing as microcomedones.

Microcomedones are at the bottom of the skin layer. When they arise to the surface, that’s when you develop a visible blackhead or whitehead. This is also when it can get infected with superficial skin bacteria and you can get red looking angry bumps known as papules. It can develop into a cyst which is often a larger bump that is painful, swollen and often requires treatment say with an injection by a dermatologist or it can also develop into a pustule where you see bits of pus at the surface of your skin.

Where does maskne develop?

The key here is that maskne doesn’t look at all different from regular acne apart from the fact that there is a history of mask wearing, and also the location where it develops. In this case we describe that as the O-Zone – the area conveniently attributed to the part of the face that is covered by a face mask. This is useful for dermatologists because traditionally we do describe the distribution of acne being slightly different in acne sufferers.

For example, many of you may have heard of the T-zone which is the area over the forehead, to your nose and the chin area. That is the commonest area affected when it comes to physiologic acne, which is teenage acne basically. The U-Zone, the area around the jaw line has been associated more commonly with adult acne sufferers.

It’s also linked to the term hormonal acne but there isn’t really a big difference in terms of how and why these acne bumps form other than the fact that in hormonal acne there could be in certain cases, a condition known as polycystic ovarian syndrome. The short name for that is PCOS. It occurs in adult females who may also have irregular menstrual cycles and increased hair growth condition known as hirsutism as well as adult onset acne. Maskne in this sense can overlap with these different types of acne.

Other face mask skin problems that can be mistaken for maskne

Eczema

One of the face mask skin problems you may encounter is dermatitis, better known as eczema. Facial eczema is a condition where there is increased redness, flaking or they could even be skin swelling and some bumps occurring over the area that’s covered by the face mask. There are actually many factors that increase your chance of developing facial eczema when you wear a face mask and these would be the very fact that the face mask covers your mouth and your nose.

In this case, we want it to stop the respiratory droplets from excessively disseminating to your environment and hopefully that reduces the transmission rate. But the very fact that your salivary and nasal secretions get on your skin is not actually a natural or normal thing that happens all the time and this is why it causes problems. For example, the moisture alone from these secretions makes the microenvironment highly suitable for bacteria to thrive and contributes to what causes maskne.

In addition, the saliva contains digestive enzymes that’s meant to help us digest our food but when it is coming in contact with your skin and prior to the COVID 19 pandemic, we would see that most commonly in young children/toddlers who drool and that would lead to irritant contact dermatitis forming on the surface of the skin where it’s always in contact with saliva.

In an adult who has a family history or personal history of sensitive skin, allergic nose, sinus problems, they may have what we call atopy, which is a constellation of symptoms that increase your risk of developing skin conditions like eczema and that ultimately boils down to the skin barrier being deficient.

So you can imagine the process as when your saliva comes into contact with your skin, the salivary enzymes are actually partially digesting the superficial layer of skin cells. Over time with the increased accumulation of sweat, bacteria, humidity and occlusion, it does increase your risk of developing facial eczema or dermatitis that can appear specifically over the area covered by the mask.

Rosacea

Another one of the face mask skin problems you may face is a condition that can be worsened by mask wearing but is not itself maskne – rosacea. Rosacea is a condition where the skin’s blood vessels are hypersensitive and it expands excessively and persistently in response to heat, spicy foods, emotions and it can reach a state where even in the absence of these triggers, skin appears persistently red. There is a direct correlation with the symptoms of rosacea and mask wearing which leads to occlusion.

As we discussed earlier, occlusion itself creates a rather unnatural and we know is unhealthy skin microenvironment. There is research that explains to us how in conditions like rosacea, there could actually be a disturbance in the skin microbiome itself which is what causes maskne and other mask-related skin conditions. This is another reason why we may observe worsening of skin conditions that are not maskne over the area covered by the face mask.

Find out more on how to get rid of maskne in Part Two of this series.