Mask-Induced Facial Dermatoses in the Saudi Arabian Population During the COVID-19 Pandemic: A Cross-Sectional Study

Background The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) emerged in 2019 and was responsible for noteworthy morbidity and death throughout the world. Due to preventive measures, various adverse reactions to the skin occurred which were associated with prolonged use of wearing a face mask. Objectives The study aimed to determine the incidence and assess the clinical features of mask-induced dermatoses. Methods A cross-sectional study was conducted involving both healthcare and non-healthcare individuals in Saudi Arabia. A questionnaire was designed that included mask-related problems, preexisting skin conditions, frequency and duration of use of face masks, type of face mask, and demographic information. Further information on their clinical symptoms was collected. Results This study included 2326 participants. Participants who refused to participate in the study and did not wear masks (232) were excluded from the study. Redness, itchiness, and acne were the most reported symptoms. 37.8% of the total wore the mask daily with 58.2% using their face mask for more than two hours per day. 44.4% of the participants had mask-induced dermatosis. Almost half of the participants (46.8%) had the cheek as the most affected area. Contact dermatitis was significantly less in non-healthcare workers as compared to healthcare workers (p<0.001). Similarly, conditions like nonspecific erythema (p=0.004) and rosacea (p=0.027) were also significantly less in non-healthcare workers as compared to healthcare workers. Conclusion There was a strong relationship between the frequency of mask use and facial dermatosis during the pandemic. The prevalence or pattern of mask-induced facial dermatoses was not significantly different between healthcare workers and non-healthcare workers. However, contact dermatitis and nonspecific erythema were significantly more common in healthcare workers.


Introduction
Coronaviruses were first discovered in humans in 1962 causing upper respiratory tract infections and later it was discovered that they can affect the lower respiratory tract. Coronaviruses fit in the coronavirus family which has multiple subtypes known as alpha, beta-gamma, and delta types viruses. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a beta type of coronavirus [1].
At the end of 2019, an infectious respiratory pandemic began in the district city of Wuhan, China, and was known as SARS-CoV-2 or coronavirus disease 2019 . Globally, 3.5 million people have been infected with this virus which has caused the mortality of more than 0.24 million people around the globe [2].
The virus itself has emerged from cross-species transmission to humans like its predecessors. Once the outbreak occurred, it primarily transported itself from one human to another through the small respiratory droplets of the infected person. The droplets can be exhaled by a cough/sneeze of the infected person and can be transmitted via direct contact with the mucosal membrane of the healthy person. However, the droplets are not able to pass more than 6 feet. Various studies further suggest that it can also be transmitted via fecal or blood swabs [3]. The incubation time for the disease is 14 days with characteristic symptoms like fever, sore throat, dry cough, GI upset, and loss of sense of smell and taste [4].
After the incidence of the pandemic, one of the key approaches taken to prevent the transmission of this disease was to use personal protective equipment (PPE) i.e., face masks, and face helmets as the shield for the protection of respiratory symptoms among healthcare workers (HCWs) as well as the local population. This period of use of PPEs against COVID-19 was prolonged and continued till the end of this pandemic [5]. The extended use of face masks in turn caused multiple skin-related problems like an increase in the progression of existing dermatosis, contact, seborrheic dermatitis, and acne among various health workers [6,7]. Various other studies have provided evidence of facemask-associated damage to the skin as it can trigger rosacea flares and acne as well. Furthermore, a new phenomenon has emerged called maskinduced Koebner [8].
Even though it was mandatory for healthcare professionals throughout the world to use face masks, the authorities have also encouraged individuals of the local population to use them to reduce the transmission of the virus and prevent local outbreaks. Since this use of face masks was applied worldwide, the period of use of face masks also increased which brought attention to the occurrence of face mask-induced dermatosis in the local population [9]. Currently, there are very few research studies present based on a large-scale population on the adverse reaction on the skin due to prolonged use of face masks among the general population. Therefore, the focus of this study was to increase the understanding of the prevalence, clinical characteristics, and treatment options for mask-induced dermatoses among HCWs and non-healthcare workers (non-HCWs).

Study design and setting
This is a cross-sectional electronic questionnaire-based study that was distributed via social media.

Study participants
The sample size was determined via Raosoft online calculator. The recommended sample size was 385 with a confidence interval of 95% and a 5% margin of error. However, 2326 people responded to the questionnaire. The study's inclusion criteria were people over 18 years old, both healthcare workers and non-healthcare workers who live in Saudi Arabia, those who confirmed their agreement, and those who completed the questionnaire. Participants who refused to participate in the study and did not wear masks (232), people not living in Saudi Arabia, those under 18 years old, those who did not confirm their agreement, and those who did not complete the questionnaire were excluded from the study.

Data collection process
To guarantee that each participant was represented correctly, similar links were distributed to each participant. The questionnaire's content was identical across all links. In addition, besides the link provided via social media, a brief introduction of the study's goals and objectives was displayed. The participants were enlightened that participation was completely voluntary and anonymous and that all information would be kept completely private. Following that, participants must confirm their involvement in the study by selecting either "agree" to continue with the study or "disagree". The data collection period was from April to June 2022.

Instrument development
The questionnaire included four parts. The first part was about the participant's demographics, including the participant's place of residence, gender, age, occupation, marital status, and education level. In the second part, participants were asked about how often they wear a facial mask per week, the estimated duration of mask-wearing per day, the type of facial mask, whether the facial mask was fitting perfectly, and if they reused a disposable mask or not. In the third part, we evaluated the prevalence and presentation of face maskinduced facial dermatoses among individuals. Participants were asked about the skin conditions that they have been diagnosed with, whether they have been diagnosed with these conditions before or after using face masks, was the condition aggravated/worsened by using face masks, how many times did they get mask induced dermatoses during the COVID-19 pandemic, and the facial area that was involved. In the fourth part, we evaluated risk factors associated with the incidence of mask-induced dermatoses. Participants were asked if they had an allergy to a specific type of face mask. In addition, they were asked about their adherence to the general measures that prevent mask use-related facial dermatoses and their skin type. Also, some mask pictures were added to the questionnaire. This questionnaire was validated using a method that included focus group discussions, expert appraisal, pilot research, reliability, and validity testing. Three dermatology experts and one biostatistician worked together to validate our questionnaire. For reliability and validity analysis, data from a pilot study with 21 individuals were used. The content and face validity of the questionnaire were assessed using expert review and focused group discussion. An exploratory factor analysis was used to examine the questionnaire's construct validity. Internal consistency was examined for questionnaire reliability, and Cronbach's result was 0.81. If the Cronbach's value is more than 0.7, the questionnaire is considered internally consistent. All of the questionnaire items were translated into Arabic by a healthcare practitioner and a translator specialist who is skilled in both Arabic and English. Two more specialists who were fluent in both languages then translated the Arabic questionnaire into English. The back-translated version of the questionnaire was compared to the original English version to confirm the quality of the translation.

Data analysis
The results of the questionnaires were displayed in an Excel version 16.16.23 (Microsoft, Redmond, WA, USA) and data were analyzed statistically using SPSS)version 26 (IBM Corp., Armonk, NY, USA). To test the relationship between variables, qualitative data were expressed as numbers and percentages, and the Chisquared test (χ2) was used. A p-value of less than 0.05 was considered statistically significant.

Ethical considerations
Ethical approval was provided by the institutional review board (IRB) at Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia (HAP-01-R-059). Table 1 shows that 63.6% of the participants had an age that ranged from 18-25 years, 73.5% were females and 29.7% were married. Also, 81.6% of them had a university level of education or higher and only 9.2% were HCWs. About 26% of the participants were from the Eastern region of Saudi Arabia.   Table 2 shows that 37.8% of the participants were wearing the face mask every day, 29.8% were wearing it for five to seven hours and the majority (86.8%) were using a procedure/surgical mask. About half of the participants (50.4%) reported that the mask was well fit. 29.2% of them reported that they never re-use a disposable mask, and 23.8% mentioned that they do this sometimes.

No. (%)
How often do you wear a face mask per week?     Table 3 shows that among participants having mask-induced dermatoses (No.:928), 80.5% got mask-induced dermatoses during the COVID-19 pandemic one to three times. Most of them (46.8%) had the dermatoses on their cheeks and the most common symptoms were redness (51%), itching (49.5%), acne (43.7%), and blisters (38.6%). The most commonly used measures to prevent mask use-related facial dermatoses were maintaining oral hygiene (66.1%), cleansing skin with a gentle soap-free cleanser (58.6%), and taking regular breaks from the mask to relieve the pressure and prevent moisture build-up (54.2%). Only 44.7% of the participants were allergic to face masks, and the procedure/surgical mask was the most common allergic type (45.4%). Most participants with facial mask-induced dermatosis (51.3%) were cleaning their faces after using facial masks and 31.1% reported applying cosmetics. The most common skin type among them was the combination type.

Variable No. (%)
How many times did you get mask induced dermatoses during COVID pandemic?    Table 5 shows that HCWs had a significantly higher percentage of those who were presented with contact dermatitis and nonspecific erythema compared to non-HCWs (p=<0.05). At the same time, HCWs had a significantly higher percentage of those who had a combination skin type (p=<0.05). On the other hand, a non-significant difference was found between HCWs and non-HCWs according to other presentations or the prevalence of mask-induced facial dermatoses (p=>0.05).

Discussion
One of the most effective protections against COVID-19 is wearing a mask. Therefore, wearing a face mask in public areas is required in many countries including Saudi Arabia [10]. Previous studies have revealed that wearing a face mask for a prolonged period of time promotes friction, occlusion, and hyperhidrosis, and this compromises the skin and epidermal integrity and appears as facial dermatosis [11]. The most frequent adverse effects of face masks include itching, stinging, and dryness. Additionally, contact dermatitis and acne are the two most common skin diseases [12]. In this study, we aimed to assess face mask-induced facial dermatoses in terms of clinical presentation and factors associated with mask use among the Saudi population during the COVID-19 pandemic.
One of the research aspects was to assess mask-wearing habits among participants. Among 2326 participants, 37.8% wore their masks daily, and 25.4% used their masks five to six days a week. Moreover, most participants (58.2%) used their face masks for more than two hours per day. 29.8% of them used masks between five and seven hours per day. These findings suggest that most of the participants used masks for most of the week for long hours and this would increase the risk of mask-induced dermatosis and its complications [13]. Furthermore, concerning results demonstrates that 51% of the participants re-used their masks regularly and 23.8% reported that they "sometimes" re-used a disposable mask, only 29.1% of the respondents answered that they "never" re-used a disposable face mask. Centers for Disease Control and Prevention (CDC) guidelines do not recommend reusing disposable face masks [14]. Re-used disposable face masks can contain dead skin cells, debris, microbe, and sweat or might be improperly stored which can be a source of contamination and infection [15,16]. When comparing mask use patterns between HCWs and non-HCWs, results showed that over half of HCWs (51.8%) used the face mask daily and they are less likely to wear the face mask for a lesser frequency per week. Only 7.8% of them used their masks one to two times per week when comparing them to non-HCWs (20.6%). This is probably due to the nature of their work, and a higher level of knowledge of the face mask's role in infection prevention [17]. Moreover, the face maskwearing duration was longer in HCWs in comparison to non-HCWs. Among HCWs, 50.8% wore a mask for over eight hours per day. This could be due to longer working hours among HCWs.
In this study, 44.4% of the study participants had mask-induced dermatosis and that is similar to a previous study done by Bukhari et al. in Saudi Arabia in which they found that 48.6% had dermatological manifestations associated with face mask use [10]. Furthermore, when observing the overall prevalence of face mask-induced dermatosis, it was noted that 42.6% of participants had masks followed by nonspecific erythema (18.7%). Maskne probably was the commonest presentation since acne on its own is one of the most common dermatological diseases worldwide [11]. Nonspecific erythema might be associated with mask friction on the face and inflammatory processes [18]. Maskne was also the highest presentation associated with mask-induced dermatosis in previous research such as the one done by Althobaiti et al. [19] but differs from a study done by Choi et al. in South Korea in which their most common presentation was found to be contact dermatitis [12]. In our study, maskne was the commonest presentation among both HCWs and non-HCWs (46.6% and 42.2%, respectively). Contact dermatitis (12.4%) and nonspecific erythema (26.4%) were more prevalent among HCWs than non-HCWs.
Most affected face parts and dermatosis distribution were assessed among participants. Results showed that almost half of the participants (46.8%) reported that the cheeks were the most affected face part, and the least is the nose (11.2%). This finding is similar to many previous studies like the ones done by Althobaiti et al. and Bakhsh et al. [19,20]. Furthermore, symptoms associated with mask-induced dermatosis were evaluated in this research. The three most reported symptoms were redness (51%), itchiness (49.5%), and acne (43.7%). The least reported symptoms were tightness or stinging. These outcomes are congruent with the most reported presentations among the studied participants which were reported to be acne and nonspecific erythema. These findings are slightly different from previous research done by Bukhari et al. and Althobaiti et al. [10,19]. Almost half of the participants did follow the preventative measure to prevent mask-induced dermatosis with oral hygiene (66.1%) being the most applied preventative measure and silicon-based barrier tape being the least followed preventative measure. This might be due to the lesser popularity of silicon-based barrier tape among the general population. Moreover, 45.4% reported that surgical/procedural masks induced allergies. This could be because surgical/procedural masks were the most commonly used masks among our population (86.8%).
Among the studied participants, 36.3% had a combination skin type and 32.5% had oily skin. It is suggested that participants' skin type had a role in developing acne as acne was the most common dermatosis among the current study participants [21]. This is partially similar to the research done by Althobaiti et al. as the commonest skin types among their participants were combination and normal skin [19]. The possible limitation of this study is that the majority of the participants were females and only 9.2% of the participants were HCWs.

Conclusions
In conclusion, our paper studied mask-induced dermatosis from different aspects including associated demographic features, face mask-use pattern, prevalence, presentation, disease characteristics, and associated factors. There was a strong link between the frequency of mask use and facial dermatosis with redness, itching, and acne being the most prevalent symptoms. Moreover, across all mask varieties, the surgical mask was the main cause of allergy. Additionally, contact dermatitis and non-specific erythema were more common in HCWs. Therefore, future studies on prevention/treatment, the establishment of diagnostic criteria related to mask-induced dermatosis, and exploring the dermatosis concerning the type of mask materials are needed.

Additional Information
Disclosures