Singapore Dermatologist’s Maskne Tips

Episode 2: ‘Maskne’ – How to Treat Breakouts Under Your Mask

Dermatology Weekly Flash Briefing – As the world shifts to the use of face masks to help curb the COVID-19 pandemic, a form of acne mechanica – ‘Maskne’ – has become more widespread. Dr. Teo Wan Lin discusses her latest research paper which is due to be published in the November issue of the Journal of the American Academy of Dermatology. As a maskne dermatologist, she will walk us through what causes Maskne, treatment for Maskne, and the best face masks to prevent it. 

Chelsea: Hi everyone! Welcome to 2nd episode of our podcast Dermatologist Talks – Science of Beauty. I’m Chelsea, and I’m really looking forward to having a chat with Dr. Teo Wan Lin, accredited dermatologist, on continuing our dive into how COVID-19 is changing the beauty, skincare, and dermatology world. The topic we’re going to be touching on today, is something more and more people are experiencing as we face a new normal of wearing face masks in public – Maskne.

For our listeners, Dr. Teo recently published the first scientific paper on the Diagnostic and Management Considerations of Maskne in the top dermatology journal, the Journal of the American Academy of Dermatology – also on her novel area of research biofunctional textiles, also known as materials for skincare. Face masks have become a necessary byproduct of the pandemic. I’ve found myself struggling with maskne too, and I’m sure many of our listeners have the same concerns.

As a dermatologist that treats maskne, can you tell us a little bit more about maskne? What are some tips on how to deal with it?

Dr. TWL: Thanks Chelsea. So maskne itself is a new term that was coined in 2020 in the midst of the COVID 19 pandemic. It is referring to acne that develops in relation to the wearing of fabric face masks. Face mask wearing is now recommended as the primary public health intervention to reprevent the spread of the COVID virus. It is not a new condition, it is really known as acne mechanica, which is a type of inflammatory acne. Before COVID 19 we’ve seen it in athletes who are wearing facial head gear. Similarly, in healthcare workers who have to wear the N95 masks for long periods of time when they’re dealing with airbone infectious agents.

What is maskne, according to a maskne dermatologist?

The key thing about maskne that’s different from other types of acne mechanica is the impact of the textile – the fabric mask on skin and its microenvironment. Specifically, we’re going to talk about the concept of textile skin friction, and that’s really what’s different in maskne.

We do know now that there are various factors that contribute to the development of acne. But in maskne, we’re talking about how these factors are in relation to the skin microenvironment. When you’re wearing a face mask, there is an accumulation of moisture from the respiratory and salivary droplets that are recirculating in an enclosed environment. In tropical Singapore, it becomes incredibly humid and warm because of the external temperatures and humidity. So these are the environmental factors that will change the balance of bacteria on the skin. This is something we call the skin microbiome.

The root of maskne distinguishes it from traditional types of inflammatory acne and other types of acne mechanica.

A maskne dermatologist shares: treatment of maskne

When we are treating maskne, one has to bear in mind a few epidemiologic factors as well. This means that it’s going to be a lot more widespread. Even someone who never had acne before can start to get maskne. This is because of the chronic textile skin friction and the microenvironment that’s created. This leads to an imbalance of bacteria.

Another point to make is that as we are dermatologists, if we were to treat all the cases of maskne with traditional topical antibiotic combinations, or retinoid combinations, I’m going to find ourselves in a bit of trouble in 5-10 years from now, or maybe even earlier. Infectious diseases doctors have long warned that the use of topical antibiotics in dermatology can lead to systemic antibiotic resistance.

This is also something that has not been borne our of effective use in clinical practice. Why do I say that? For the treatment of acne, we sometimes prescribe topical antibiotics such as clindamycin gels in combination with benzoyl peroxide, or a retinoid. In the short term, this usually can bring the symptoms of mild acne down. But what happens between the 2nd and 3rd month, based on what I found in clinical practices, is that the individual stops responding to these topical antibiotic formulations.

This is why I have moved away from using these synthetic formulas to focus on botanical antioxidants, which has been proven to have an anti-inflammatory effect.

For example, we use an algae extract, Chlorella, to treat the symptoms of hyperseborrhea – which controls oil production and is also anti-inflammatory. The other thing to consider in maskne, is that in dermatology, the occlusive effect in certain environments can lead to increased absorption of anything you’re applying to your skin. In the case of using the traditional anti-acne agents, benzoyl peroxide, retinoids. These will all cause irritant contact dermatitis when its worn under a face mask, especially given our humid climate in Singapore.

If you do not suffer from acne, have dry skin, or have been diagnosed with eczema before, you might start to get bumps around your face.

Dermatology PEARLS: If you’re wondering what causes maskne, according to Dr. Teo, an accredited dermatologist- is that the skin microenvironment matters. Skin microbiome imbalances cause bacterial dysbiosis, which may be triggered by a humid tropical climate like Singapore. In the research letter published in the Journal of the American Academy of Dermatology, Dr. Teo states that botanical actives with anti-inflammatory properties are preferred in maskne treatment. Traditional anti-acne agents like benzoyl peroxide, retinoids are not suitable for maskne treatment as they may cause irritation in the occlusive environment of a face mask.

Is it really maskne?

It’s really critical for the public to realize that not all bumps or rashes that appear under your face mask are maskne. There is a list of differential diagnoses that a dermatologist will run through before making a diagnosis of maskne. I proposed the first clinical criteria for the diagnosis of maskne in this JAAD research letter. It includes first of all, the onset of the symptoms. We consider the time frame of comedogenesis, which is the development of visible comedones, to be around 4-6 weeks. The first thing is that it has to fit is the timing of wearing a face mask. You would start to develop these acne-like  bumps under your skin probably between 4-6 weeks of wearing a face mask. Especially for a prolonged period of time, which is commonplace in the current pandemic.

Distribution of maskne

Also, the distribution is over the region I characterize as the ‘O-zone’. So how is the distribution of acne bumps relevant? In physiological acne, we have the characteristic T-zone predominance. This is because the forehead and nose are more seborrheic areas, which means that there is a higher concentration of oil glands. In adult acne, we have a pattern that has previously been characterized as the U-zone. This is seen in clustering of the acne-like lesions around the jawline. It is especially common in adult women who may have have hormonal issues like polycystic ovaries, but may experience exacerbation in their acne related to their menstrual cycle. The O-zone is a visual representation of the area the face masks covers. 

Diagnosis of Maskne: Dr. Teo Wan Lin, the first dermatologist to publish a white paper on maskne, proposes the first clinical criteria for the diagnosis of maskne in her research letter. She characterizes the region as the ‘O-zone’, a visual representation of the area the face mask covers.

Maskne prevention

Moving on to the proposed interventions that can be of significant value in combating the issues relating to maskne. This would be the concept of biofunctional textiles in Dr. TWL Biomaterials for which I am the chief scientific officer. It was borne out of my intense interest and research into the arena of textile cosmeceuticals. As a branch, our from our main cosmeceutical research and development arm, Dr. TWL Dermaceuticals. We work with material scientists and a pharmaceutical engineer, who is also a qualified chemical engineer, to come up with novel textiles with skin benefits.

In this research letter, I spoke about the potential of the use of such textiles. We do know of our copper infused nanoparticle fabric face mask that is made of a synthetic silk mimic. That means it is a lot more durable than ordinary silk, which I do not recommend as a face mask. Simply because it’s not very durable. The function of a face mask is that it has to be able to withstand laundering. Laundering is an important aspect of maintaining hygiene, for both your skin and for preventing the spread of COVID.

Key features of a face mask

The last thing you want in a fabric face mask is structural disintegration. As a face mask is meant for you to keep your fluids to yourself. This copper silk alternative has the benefit of stimulating collagen production, based on the benefits of copper. It also has broad spectrum antimicrobial effects. This means it can control the balance of microorganisms, germs, and in particular, the bacteria that’s involved in acne.

We’ve heard about p. acnes, but we’ve also known that from recent dermatological research, that there is also an evolving organism known as c. acnes. Hence, an important thing is, instead of using various topical antibiotics which are of questionable long term efficacy, we should switch to preventive measures. Because of the very nature of textiles having the longest contact time with the skin, it is a reasonable alternative for us to focus our research efforts into. 

Chelsea: You’re absolutely right, prevention is always better than cure. Thank you again for sharing all these tips with us. That about sums up our episode. Thank you guys for tuning in, and we’ll see you guys in the next episode.

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Read more about Dr. Teo’s latest research paper here:

Tips from a maskne dermatologist

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