Association of perioral dermatitis with facial mask usage during the COVID-19 pandemic: A retrospective study

To the Editor: With the onset of the COVID-19 pandemic in December 2019, facial masks (FMs) were ultimately recommended to prevent SARS-CoV-2 infection. Reports during that period have associated FMs with many facial reactions, including perioral dermatitis (POD).1Darlenski R. Kazandjieva J. Tsankov N. Prevention and occupational hazards for the skin during COVID-19 pandemic.Clin Dermatol. 2021; 39: 92-97https://doi.org/10.1016/j.clindermatol.2020.12.017Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,2Damiani G. Gironi L.C. Grada A. et al.COVID-19 related masks increase severity of both acne (maskne) and rosacea (mask rosacea): multi-center, real-life, telemedical, and observational prospective study.Dermatol Ther. 2021; 34e14848https://doi.org/10.1111/dth.14848Crossref Scopus (55) Google Scholar There are few reports associating increased POD incidence with FMs during the COVID-19 pandemic.3Olisova O.Y. Teplyuk N.P. Grekova E.V. Lepekhova A.A. Dermatoses caused by face mask wearing during the COVID-19 pandemic.J Eur Acad Dermatol Venereol. 2021; 35: e738-e741https://doi.org/10.1111/jdv.17546Crossref PubMed Scopus (6) Google Scholar We report the results of a retrospective study comparing the incidence of POD diagnosed by dermatologists before and during the COVID-19 pandemic. Analysis was conducted on a review of 15,177 patient encounters with diagnosis codes inclusive of rosacea, acne, and POD at NYU Langone Health from the periods of April 1to December 31, 2019 (pre-COVID n = 7184) and April 1 to December 31, 2020 (mid-COVID n = 7993). A total of 637 encounters (491 patients) for POD were identified. The percentage of POD encounters increased between 2019 (n = 262) and 2020 (n = 375) (3.65%-4.69% P = 0.0014), as did mentions of mask use (0.43%-10.53%; P < .0001) (Table I). The rate of POD was generally greater in 2020 relative to 2019, though POD was more common in December 2019 than in December 2020 (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/tjgj2n69rk.1). The rate of mask use never exceeded 1% in 2019, while the rate of mask use rose steadily throughout 2020 from 3.1% in April to 12.2% in December (Supplementary Fig 2, available via Mendeley at https://doi.org/10.17632/tjgj2n69rk.1). Multivariable logistic regression revealed mask use was associated with 2.54 times the odds of POD (95% confidence interval: 1.98-3.25) with no difference in the likelihood of POD when controlling for the years 2019 and 2020 (P = .24) (Table II).Table IEncounter characteristics by pre- and mid-COVID periods∗Median (IQR).Encounter-level analysis20192020P-valueN = 7184N = 7993Mask use31 (0.43)842 (10.53)<.0001POD262 (3.65)375 (4.69).0014Age31.0 (24.0, 46.0)30.0 (24.0, 43.0)<.0001Age, y<.0001 12-17767 (10.68)815 (10.20) 18-343383 (47.09)4135 (51.73) 35-441107 (15.41)1207 (15.10) 45-54704 (9.80)705 (8.82) 55-64567 (7.89)500 (6.26) 65-74470 (6.54)462 (5.78) 75+186 (2.59)169 (2.11)Sex<.0001 Female4941 (68.78)5978 (74.79) Male2243 (31.22)2015 (25.21)Month<.0001 April852 (11.86)653 (8.17) May933 (12.99)746 (9.33) June780 (10.86)923 (11.55) July833 (11.60)965 (12.07) August873 (12.15)890 (11.13) September757 (10.54)1022 (12.79) October962 (13.39)1085 (13.57) November791 (11.01)1109 (13.87) December403 (5.61)600 (7.51)IQR, Interquartile range.∗ Median (IQR). Open table in a new tab Table IIMultivariable analysis of factors associated with likelihood of having perioral dermatitisEncounter-level analysisOR95% CIP-valueMask use No mask1.00 Mask mentioned2.541.98-3.25<.0001Year 20191.00 20201.110.93-1.32.24Age, y 12-170.410.26-0.66.0003 18-341.00 35-441.631.32-2.03<.0001 45-541.371.04-1.80.025 55-641.951.48-2.57<.0001 65-741.621.19-2.20.0020 75+1.240.74-2.09.41CI, Confidence interval; OR, odds ratio. Open table in a new tab IQR, Interquartile range. CI, Confidence interval; OR, odds ratio. FMs may account for the significant increase in incidence of POD from the pre- to mid-COVID-19 periods. Our data demonstrate a significant increase in the incidence of POD during the mid-COVID-19 period. Reports of mask use increased dramatically mid-COVID and appeared to correlate significantly with an increased likelihood of POD. We hypothesize that the use of protective FMs during the COVID-19 pandemic is contributing to an increased incidence of POD. The possible mechanisms behind this relationship may include dysbiosis, mechanical stress, increased use of nasal sprays for congestion, and emotional stress.4Lipozencic J. Hadzavdic S.L. Perioral dermatitis.Clin Dermatol. 2014; 32: 125-130https://doi.org/10.1016/j.clindermatol.2013.05.034Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Marked microbiome dysbiosis also has been seen with mask usage.3Olisova O.Y. Teplyuk N.P. Grekova E.V. Lepekhova A.A. Dermatoses caused by face mask wearing during the COVID-19 pandemic.J Eur Acad Dermatol Venereol. 2021; 35: e738-e741https://doi.org/10.1111/jdv.17546Crossref PubMed Scopus (6) Google Scholar Skin temperature, erythema, hydration, and sebum secretion are dramatically changed by mask wearing.5Park S.R. Han J. Yeon Y.M. Kang N.Y. Kim E. Effect of face mask on skin characteristics changes during the COVID-19 pandemic.Skin Res Technol. 2021; 27: 554-559https://doi.org/10.1111/srt.12983Crossref PubMed Scopus (39) Google Scholar These characteristic changes with mask usage could account for the exacerbation of POD. Despite controlling for multiple covariates available in the charts, the findings may result from an unidentified confounder and not a true association between the likelihood of POD and risk factors. For example, the term mask use is not clear and is not binary, and it is unlikely for physicians to be querying mask use before the pandemic. This was a retrospective cohort study examining the relative incidence of POD and its associated risk factors during the identical periods of pre- and mid-COVID-19. A significant increase in the incidence of POD occurred during the mid-COVID-19 period, with a significant association with FM usage. As the COVID-19 pandemic continues, it is unlikely that mask wearing will disappear entirely from daily life. None disclosed.