Skin changes attributed to protective measures against COVID-19: A compilation

The influence of N95 and surgical masks on carbon dioxide levels: A comprehensive systematic review and meta-analysis

Objectives

This study aimed to assess the impact of wearing N95 and surgical masks on carbon dioxide (CO2) concentrations during various activity levels, to understand the implications for mask use in different settings, especially in light of the COVID-19 pandemic.

Study design

Systematic Review and Meta-Analysis.

Methods

A systematic review was conducted, retrieving 6798 articles from PubMed, Web of Science, and Scopus databases. Twenty-nine articles met the inclusion criteria. Mask types were categorized into N95 and surgical masks, while activities were classified as low, medium, and high.

Results

The meta-analysis revealed CO2 concentrations (mmHg) for different scenarios: No mask (37.91, 95 % CI: 36.46, 39.35), N95-low (36.83, 95 % CI: 33.57, 40.10), N95-moderate (37.85, 95 % CI: 36.51, 39.20), N95-high (39.51, 95 % CI: 38.00, 41.02), N95 with exhalation valve (35.82, 95 % CI: 32.89, 38.75), N95 without exhalation valve (38.45, 95 % CI: 37.10, 39.81), surgical mask-low (38.31, 95 % CI: 34.48, 42.14), surgical mask-moderate (35.05, 95 % CI: 31.12, 38.97), surgical mask-high (36.07, 95 % CI: 34.18, 37.96).

Conclusions

Our findings indicate that N95 masks lead to higher CO2 accumulation during various activities compared to surgical masks. Moreover, surgical masks exhibit higher CO2 concentrations during low activity compared to moderate and high activities. Notably, CO2 concentrations are higher in N95 masks without an exhalation valve compared to those with a valve. No significant difference was observed between not wearing a mask and wearing either N95 or surgical masks in terms of CO2 accumulation. These results provide important insights for mask selection and usage recommendations in different scenarios.

A highly soluble form of rutin for instant resolution of mask-wearing related disorders

BACKGROUND

The COVID-19 pandemic brought about a new normal, necessitating the use of personal protective equipment (PPE) like face shields, surgical masks, gloves, and goggles. However, prolonged mask-wearing introduced skin-related issues due to changes in the skin's microenvironment, including increased humidity and temperature, as well as pressure on the skin. These factors led to skin deformation, vascular issues, edema, and inflammation, resulting in discomfort and cosmetic concerns. Clinical reports quickly highlighted the consequences of long-term mask use, including increased cases of "maskne" (mask-related acne) or mask-wearing related disorders such as rosacea flare-ups, skin-barrier defects, itching, erythema, redness, hyperpigmentation, and lichenification. Some of these issues, like inflammation, oxidative stress, and poor wound healing, could be directly linked to acne-related disorders or skin hypoxia.

AIM

To address these problems, researchers turned to rutin, a well-known flavonoid with antioxidant, vasoactive, and anti-inflammatory properties. However, rutin's poor water solubility presented a challenge for cosmetic formulations. To overcome this limitation, a highly water-soluble form of rutin was developed, making it suitable for use at higher concentrations.

METHODS

In vitro and ex vivo tests were conducted, as well as an innovative clinical trial including volunteers wearing surgical masks for at least 2 h, to evaluate the biological activity of this soluble rutin on the main skin concerns associated with mask-wearing (inflammation, oxidative stress, skin repair, hyperpigmentation, and skin redness).

RESULTS

The in vitro results showed that the active ingredient significantly reduced oxidative stress, improved wound healing, and reduced inflammation. In dark skin explants, the active ingredient significantly reduced melanin content, indicating its lightening activity. This effect was confirmed in the clinical study, where brown spots decreased significantly after 4 days of application. Moreover, measurements on volunteers demonstrated a decrease in skin redness and vascularization after the active ingredient application, indicating inflammation and erythema reduction. Volunteers reported improved skin comfort.

CONCLUSION

In summary, the COVID-19 pandemic led to various skin issues associated with mask-wearing. A highly soluble form of rutin was developed, which effectively addressed these concerns by reducing inflammation, oxidative stress, and hyperpigmentation while promoting wound healing. This soluble rutin offers a promising solution for the rapid treatment of maskne-related disorders and other skin problems caused by prolonged mask use.

Guarding skin under PPE: Mechanistic insights and technological innovations

In the presence of diseases transmitted through respiratory droplets and direct contact, healthcare workers (HCWs) necessitate the use of personal protective equipment (PPE). For optimal safety, PPE should securely conform to the skin during extended wear. However, conventional PPE often lacks adequate air permeability and hygroscopicity, trapping heat and moisture emitted by the body within the enclosure. Such a hot and humid internal environment can induce skin damage, such as erythema, rash, pruritus, and itching among others, leading to microbial growth on the skin surface, the production of inflammatory mediators at the wound site and an increased risk of infection. This review strives to comprehensively elucidate the fundamental mechanisms triggering adverse skin reactions and their resultant manifestations. Furthermore, we explore recent advancements aimed at inhibiting these mechanisms to effectively mitigate the occurrence of skin lesions.

The Protective Effects of Moisturizer Containing Potentilla anserina Extract in the Topical Treatment of Skin Damage Caused by Masks

The use of face masks during the COVID-19 pandemic resulted in significant societal changes, particularly for individuals with sensitive skin. To address this issue, the researchers explored traditional medicine and identified Potentilla anserina extract as a potential solution due to its anti-inflammatory and moisturizing effects. This research investigated how this extract influences skin hydration, barrier function, and itching. The findings revealed that the extract had a hydrating effect by elevating Aquaporin-3 (AQP3) expression. Additionally, the study demonstrated that the extract improved skin barrier function, with Filaggrin (FLG) expression being approximately three times higher (p < 0.001) in the Potentilla-anserina-extract-treated group compared to the control group and the genes associated with itching being reduced. In this process, we researched and developed HPβCD (hydroxypropyl-β-cyclodextrin)-Liposome containing Potentilla anserina extract, gradually and sustainably releasing the active components of the Potentilla anserina extract. During four weeks of clinical trials involving individuals wearing masks for over 6 h a day, a moisturizer containing Potentilla anserina extract demonstrated a notable reduction in skin redness. Hemoglobin values (A.U.), which serve as indicators of skin redness, showed decreases of 5.06% and 6.74% in the test area inside the mask after 2 and 4 weeks, respectively, compared to the baseline measurements. Additionally, the moisturizer containing Potentilla anserina extract notably decreased Trans Epidermal Water Loss (TEWL), with reductions of 5.23% and 9.13% observed in the test area inside the mask after 2 and 4 weeks, respectively. The moisturizer, especially in the test area treated with the extract-containing moisturizer, significantly enhanced skin hydration compared to the control group. The Corneometer values (A.U) exhibited notable increases of 11.51% and 15.14% in the test area inside the mask after 2 and 4 weeks, respectively. These discoveries emphasize the potential of Potentilla anserina extract and its utility in tackling skin issues caused by mask wearing, including enhancing moisture, fortifying the skin's barrier, and alleviating itching. These results indicate that moisturizers incorporating specific ingredients provide greater benefits compared to conventional moisturizers.

Mask-Wearing Behaviors after Two Years of Wearing Masks Due to COVID-19 in Korea: A Cross-Sectional Study

In Korea, wearing masks in public places has become the norm during the prolonged coronavirus disease 2019 (COVID-19) pandemic. This cross-sectional study investigated the mask-wearing behavior of Koreans (n = 433) via online mode living in Seoul and Gwangju after wearing a mask in public spaces for two years due to COVID-19. The respondents selected their face masks based on season, gender, age, occupation, mask-wearing hours, mask filter performance, mask shape, and mask color. The general discomfort caused by wearing a mask was divided into physical and speech discomfort, and it was not correlated with anxiety when not wearing a face mask. Speech discomfort caused by wearing a mask was correlated with general discomfort, clear speech, vocal pain, anxiety, and only-indoor mask-off plans. Anxiety when not wearing a mask appeared to affect both indoor and outdoor mask-off plans. The more uncomfortable and less anxious respondents were when not wearing a mask, the sooner they wanted to discontinue wearing masks indoors and outdoors. It is expected that the use of masks will continue in the future and that there may be differences in the place and time of use of masks in Korea and around the world due to new infectious diseases and fine dust. Facial masks can be worn more comfortably and conveniently if the discomfort and anxiety of wearing a mask are improved by considering various behaviors when wearing a mask in the future.

The face behind the Covid-19 mask - A comprehensive review

The threat of epidemic outbreaks like SARS-CoV-2 is growing owing to the exponential growth of the global population and the continual increase in human mobility. Personal protection against viral infections was enforced using ambient air filters, face masks, and other respiratory protective equipment. Available facemasks feature considerable variation in efficacy, materials usage and characteristic properties. Despite their widespread use and importance, face masks pose major potential threats due to the uncontrolled manufacture and disposal techniques. Improper solid waste management enables viral propagation and increases the volume of associated biomedical waste at an alarming rate. Polymers used in single-use face masks include a spectrum of chemical constituents: plasticisers and flame retardants leading to health-related issues over time. Despite ample research in this field, the efficacy of personal protective equipment and its impact post-disposal is yet to be explored satisfactorily. The following review assimilates information on the different forms of personal protective equipment currently in use. Proper waste management techniques pertaining to such special wastes have also been discussed. The study features a holistic overview of innovations made in face masks and their corresponding impact on human health and environment. Strategies with SDG3 and SDG12, outlining safe and proper disposal of solid waste, have also been discussed. Furthermore, employing the CFD paradigm, a 3D model of a face mask was created based on fluid flow during breathing techniques. Lastly, the review concludes with possible future advancements and promising research avenues in personal protective equipment.

Adverse effects associated with the use of N95 mask among health-care workers at the COVID-19 care units: A cross-sectional study in Sulaimani city, Iraq

BACKGROUND

Health-care workers have to use the N95 mask as a part of the protection kit during the COVID-19 pandemic. The adverse effects of such practice are not fully elucidated. The study aims to evaluate negative impacts of N95 face masks on health-care personnel at COVID-19 care units.

MATERIALS AND METHODS

One hundred and twenty-two health-care workers (aged 20-58 years) from various health-care settings in Sulaimani, Iraq, from January to August 2020, were enrolled in this prospective, cross-sectional study. The physiological variables (blood pressure, heart rate, and oxygen saturation) were recorded before putting on the N95 mask and postremoval of the mask. The incidence of adverse effects such as headache, difficulty breathing, redness, irritation, and dizziness were also reported as a number and percent at the end of the work shift.

RESULTS

There was a statistically significant difference in the physiological parameters after removal of the mask compared with baseline. Only diastolic pressure was significantly lower in those working >6 h when compared to those working 1-6 h. The changes in physiological markers were poorly and nonsignificantly associated with the duration of wearing the mask. Moreover, 67.2%-70.5% of the participants complain of headaches and breathing difficulties, while 45.9%-51.6% reported signs of itching, redness, and irritation. However, health-care workers who put on the face mask >6 h showed signs of headache, breathing difficulties, and itching at the exposed areas higher than those working for 1-6 h.

CONCLUSION

N95 mask negatively impacts the physiological variables of health-care providers. The adverse effects may lead to excessive exhaustion after long shifts in the intensive care unit during treatment of COVID-19 patients.

The effects of wearing a face mask and of subsequent moisturizer use on the characteristics of sensitive skin

Background

COVID‐19 is a serious respiratory disease, and wearing masks has become essential in daily life. Nevertheless, the number of people complaining of skin problems caused by wearing masks is increasing. Therefore, we investigated the characteristics of changes in sensitive skin caused by wearing a mask.

Materials and methods

Twenty healthy Korean women with sensitive skin participated in this study. To determine any skin‐related changes caused by mask‐wearing, we evaluated redness, hydration, transepidermal water loss (TEWL), and moisture at 2.5 mm below the surface before and 4 h after wearing a Korea Filter 94 mask. In addition, we tested whether applying a moisturizer for 30 min after mask removal could reverse any mask‐induced changes.

Results

Skin redness and TEWL were significantly increased at 4 h after wearing a mask (p < 0.05), otherwise skin hydration and the 2.5 mm moisture were significantly decreased (p < 0.05). After applying the moisturizer, skin redness and TEWL were significantly decreased compared to their values 4 h after wearing masks (p < 0.05), whereas skin hydration and the 2.5 mm moisture were significantly increased (p < 0.05). Moreover, after applying the moisturizer, skin redness and TEWL were significantly reduced compared to the pre‐masking baseline (p < 0.05), whereas skin hydration was significantly increased (p < 0.05); the 2.5 mm moisture showed no significant change.

Conclusion

We observed that wearing masks causes physiological changes in sensitive skin, whereas applying a moisturizer after removing the mask improved skin conditions.

Association of Acne with Face Mask in Healthcare Workers Amidst the COVID-19 Outbreak in Karachi, Pakistan

Background

In the wake of coronavirus (COVID-19) global alert, people have begun to practice safety measures in order to reduce the exposure to life-threatening disease. The largest at risk population is undoubtedly the frontline healthcare workers (HCWs) who are using personal protective equipment (PPE), essentially face masks, to battle against this deadly virus. This study was conducted with the prime intention to reveal an association between face mask and acne and measure the prevalence of acne amongst HCWs amidst COVID-19 outbreak in Karachi. Furthermore, this study aimed to identify the type of mask generating acne, locate the common sites, assess the severity and establish an association of mask use with the skin type.

Methods

This cross-sectional study was carried out at Medicare Cardiac and General Hospital, Jinnah Medical College Hospital, Jinnah Postgraduate Medical Centre and Jamal Noor Hospital located in Karachi, Pakistan. A total of 348 HCWs were interviewed, of which only 193 met the inclusion criteria. All information was recorded on a predesigned proforma and analyzed using SPSS 25.0.

Results

Among 193 participants, acne was prevalent in 103 (53.4%) participants with maximum cases reported in female HCWs, and in doctors (p<0.05). Out of 73 HCWs using N-95 masks, 46 (44.7%) developed acne, with a p-value of 0.036. Skin type and past history of acne also yielded statistically significant results. Among all the skin types, HCWs with oily skin (64, 62.1%) were prone to face resurgence of acne or new-onset acne. The most common sites of eruption of acne were along the cheeks (45.1%) followed by the nose (40.9%). Majority of the population suffered from mild acne. Moderate and severe acne eruption was particularly observed in those wearing N-95 and surgical masks.

Conclusion

The use of face masks is associated with high rates of acne eruption. Disseminating the guidelines and indications of World Health Organization (WHO) regarding proper use of mask, encouraging awareness among HCWs and following proper doffing and donning protocol as endorsed by Centers for Disease Control and Prevention (CDC) will possibly minimize the adverse reactions.

Sulfasalazine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) with concomitant acute chikungunya virus infection: possible role of new viral trigger

Drug reaction with eosinophilia and systemic symptoms (DRESS) is designated as a potentially lethal adverse drug effect with characteristic signs and symptoms such as skin rash, fever, leucocytosis with eosinophilia or atypical lymphocytes, lymphadenopathy and liver or renal dysfunction. In addition to most commonly implicated drug category (aromatic anticonvulsants), lamotrigine, sulfonamides, dapsone and abacavir may also induce this syndrome. We describe here a case a sulfasalazine-induced DRESS with coexisting chikungunya fever. The shared presentation of fever with rash in both conditions made it a challenging diagnosis. Sulfasalazine hypersensitivity manifesting as DRESS has rarely been reported. Furthermore, we document chikungunya virus (CV) as a possible triggering agent for DRESS. To the best of our knowledge, CV as a viral aetiology in DRESS has not been reported previously in the literature.

Dermatological manifestations associated with COVID-19: A comprehensive review of the current knowledge

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a significant health problem globally. The virus has spread widely and become a global pandemic. The pathophysiology for SARS-CoV-2 has not been explained clearly. It has been associated with several multiorgan symptoms, among which its dermatological manifestations are of great interest. Primarily, there has been no report of skin features among COVID-19 patients. Nevertheless, recently there have been several reports regarding COVID-19 patients who presented with cutaneous manifestations. In the current review, we focus on the various cutaneous manifestations of COVID-19 infection.

An Observational Survey to Appraise the Influence of COVID-19 Pandemic on Dermatology Training Programs in India: Residents' Standpoint

Background:

Given the all-encompassing foothold of COVID-19, it is plausible that the pandemic would have a long-lasting impact on medical training programs, including dermatology. We conducted a survey amongst the residents of dermatology (across India) to assess the impact of COVID-19 pandemic on their teaching and education programs.

Materials and Methods:

An online semi-structured English questionnaire was prepared on the Google-forms platform and the link was circulated among the residents. The questionnaire comprised of five sections (demographic details, impact on clinical training, procedural training, academic curriculum, and research activities). Appropriate statistical tests were carried out to analyze the data obtained.

Results:

Three-hundred and seventy-eight responses were taken into consideration. A majority of the respondents (63.5%) were engaged in both COVID-19-related duties and departmental work (out-patient and in-patient duty). Around two-thirds of the trainees (65.1%) claimed a reduction in patient footfall (greater than 50% compared to pre-COVID times). Sixty-nine percent reported a decline of more than 50% in in-patient admission; 47.6% felt that the discontinuity in patient care had severely affected their residency training; 50.8% highlighted that no procedures were being performed in their department; 54.5% opined that academic activities were relatively unhampered as regular seminars were being conducted through online web-based applications; and 65.1% of the trainees were not able to devote any time to their thesis-related work.

Conclusion:

Since the after-effects of this pandemic will last long, it is advisable that residents and faculties adapt themselves to web-based learning programs in the academic curriculum so that the training of the future consultants does not get jeopardized. Our survey, being the first of its kind in dermatology, will throw some light on the perspective of residents and the way forward to combat the untoward consequences on their training programs.

Changes in skin wrinkles and pores due to long-term mask wear

Background

The spread of COVID‐19 has made mask wear essential. Expecting that long‐term mask wear would change the characteristics of skin, this study investigated changes in skin wrinkles and pores caused by long‐term mask wear and whether or not use of moisturizers has an effect on any changes.

Materials and methods

The study participants were 20 women who were instructed to wear a mask for at least 6 hours a day for 4 weeks. Measurements of skin wrinkles and pores were obtained before and after the 4 weeks of mask wear. The effects of application of a moisturizer were assessed by applying moisturizer within the mask‐wearing area. They completed a questionnaire about skin changes at the end of the study period.

Results

After wearing the mask for 4 weeks, there was a significant increase in the skin wrinkles and pores; both variables decreased significantly in skin areas where a moisturizer had been applied. The results of the questionnaire‐based survey indicated the study participants considered that long‐term wearing of a mask had affected their skin.

Conclusion

Wearing a mask for extended periods increases skin wrinkles and pores and using a moisturizer when wearing the mask helps to reduce this problem.

Skin Damage Induced by Enhanced Protective Measures in Frontline Doctors During Covid-19 Pandemic: A Web-Based Descriptive Study

Background:

Frontline doctors engaged in COVID-19 duties have to adopt enhanced protective measures to minimize their risk of exposure. However, these measures may lead to several skin problems, thereby affecting their performance.

Objectives:

To analyze skin changes induced by enhanced protective measures and explore possible risk factors.

Materials and Methods:

A web-based descriptive study was conducted among 212 frontline COVID-19 doctors. Data were collected regarding their demography, duty, use of enhanced protective measures including prophylactic hydroxychloroquine, recent skin changes with affected sites, and possible risk factors.

Results:

Skin changes were reported by 41.5% of respondents (mean age 34.8 ± 5.6 years) across 210 sites. Hands were involved most commonly in 77.3% of doctors, followed by nasal bridge, cheeks, and retroauricular area. Dryness (84.1%) and skin peeling (79.5%) were the commonest clinical features. Regression model showed prolonged PPE wear (>6 h) adjusted odd's ratio (AOR) 2.9, P = 0.005], heavy sweating [AOR 12.8, P = 0.001] and frequent hand hygiene (>10 times/day) [AOR 3.1, P = 0.0006] to be significant risk factors. Hydroxychloroquine prophylaxis was deemed safe as treatment-emergent adverse events were uncommon (17.4%).

Conclusion:

Frontline doctors have an increased risk of developing skin damage due to enhanced protective measures. Appropriate steps should be taken to address the risk factors and minimize skin damage. Persistent cases mandate dermatology referral for optimum management.

Effect of face mask on skin characteristics changes during the COVID-19 pandemic

Background

Previous studies have demonstrated the possibility of adverse effects of prolonged wearing of personal protective equipment in healthcare workers. However, there are a few studies about the effects on skin characteristics after wearing a mask for non‐healthcare workers. In this study, we evaluated the dermatologic effects of wearing a mask on the skin over time.

Materials and Method

Twenty‐one healthy men and women participated in the study. All participants wore masks for 6 hours consecutively. Three measurements were taken (a) before wearing the mask, (b) after wearing the mask for 1 hour, and (c) after wearing the mask for 6 hours. Skin temperature, skin redness, sebum secretion, skin hydration, trans‐epidermal water loss, and skin elasticity were measured.

Results

The skin temperature, redness, hydration, and sebum secretion were changed significantly after 1 and 6 hours of wearing a mask. Skin temperature, redness, and hydration showed significant differences between the mask‐wearing area and the non–mask‐wearing area.

Conclusion

Mask‐wearing conditions and time can change several skin characteristics. In particular, it is revealed that the perioral area could be most affected.