key: cord-0845135-z1yk65yr authors: Park, S.J.; Han, H.S.; Shin, S.H.; Yoo, K.H.; Li, K.; Kim, B.J.; Seo, S.J.; Park, K.Y. title: Adverse skin reactions due to use of face masks: a prospective survey during the COVID‐19 pandemic in Korea date: 2021-07-02 journal: J Eur Acad Dermatol Venereol DOI: 10.1111/jdv.17447 sha: d793473148335b974607f11b64a3d93b7548e703 doc_id: 845135 cord_uid: z1yk65yr We can no longer live in a world without facial masks. Due to the COVID-19 pandemic,1 mask-associated dermatitis is no longer limited to occupational diseases, occurring in the general population as well. This study aimed to estimate the prevalence of and factors associated with mask-associated dermatitis. We can no longer live in a world without facial masks. Due to the COVID-19 pandemic, 1 mask-associated dermatitis is no longer limited to occupational diseases, occurring in the general population as well. This study aimed at estimating the prevalence of and factors associated with mask-associated dermatitis. From December 2020 to March 2021, a self-administered online survey was conducted through the intranet system of Chung-Ang University Hospital. Overall, 303 individuals participated in this study. Table 1A shows the study population characteristics. The overall prevalence rate of skin lesions caused by facial masks was 59.4% (180/303). Acne (folliculitis) was the most frequent, followed by rashes and scales. In patients with pre-existing dermatoses, the prevalence of skin lesions induced by wearing facial masks was 71.31%, which is higher than the overall prevalence of 59.4%. The most common pre-existing dermatitis was acne vulgaris (65/303, 21.45%), followed by urticaria, contact dermatitis, atopic dermatitis and rosacea. In particular, 21/26 patients with a history of contact dermatitis complained of skin lesions, and 13/15 patients with a history of atopic dermatitis complained of dermatitis lesions caused by masks. We constructed a questionnaire to separate skin lesions and symptom complaints. The overall prevalence rate of skin symptoms caused by facial masks was 58.09% (176/303). The most frequent symptoms associated with mask use were itching, followed by dryness/tightness, stinging sensation and flushing. Table 1B ,C show a bivariate analysis among factors associated with skin lesions and symptoms associated with mask use. The factor associated with adverse skin lesions in the study population was a history of pre-existing dermatosis. Female participants, longer mask use and pre-existing dermatosis showed significant association with adverse skin symptoms on the face. This study focused on mask-related facial skin complications and associated factors. Although our research revealed no sexrelated difference in the skin lesion occurrence, female sex showed a high prevalence of skin symptoms induced by mask use. Women complained of more unpleasant symptoms than men, consistent with a previous report on sensitive skin. 2 The working site was not associated with prevalence. As the N95 and KF94 masks provide higher air impermeability than the surgical mask, a higher prevalence of skin reactions due to N95 and KF94 use is expected. The present study showed that surgical masks showed lower skin lesion prevalence, consistent with the findings of Hua et al. 3 However, the difference was not statistically significant. Concurrently, facial masks worn for longer durations resulted in more frequent skin lesions than those worn for shorter time, as shown in previous studies. [4] [5] [6] [7] We confirmed that the extended duration of face mask wearing was associated with a higher risk of adverse skin symptoms than skin lesions. Bothra et al. 8 reported that their patients presented with an exacerbation of pre-existing dermatoses during mask use. In our study, people with pre-existing dermatoses had a significantly higher incidence of mask-related dermatitis. Moreover, individuals Letters to the Editor e629 with a history of atopic dermatitis, rosacea and contact dermatitis were found to be susceptible to dermatitis induced by masks. The exact pathobiology of mask-induced dermatitis remains relatively unexplored. However, frequent friction, trapping of sweat and elevation of temperature may be the causative factors. Hua et al. showed that skin reaction to a mask is characterized by a compromised skin barrier function, as indicated by increased TEWL. 3 Individuals with a history of atopic dermatitis, contact dermatitis and rosacea experienced compromised skin barrier function. Therefore, these people were more susceptible to increased temperature, extreme moisture and friction induced by their masks. Physicians need to educate the general population with a history of pre-existing dermatosis regarding their susceptibility to mask-induced dermatitis. A different type of second wave: a predicted increase in personal protective equipment-related allergic contact dermatitis as a result of coronavirus disease 2019 The prevalence of sensitive skin Short-term skin reactions following use of N95 respirators and medical masks The effects of the face mask on the skin underneath: a prospective survey during the COVID-19 pandemic Personal protective equipment-related equipment dermatitis: a view from here Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions The prevalence, characteristics, and prevention status of skin injury caused by personal protective equipment among medical staff in fighting COVID-19: a multicenter, cross-sectional study Retroauricular dermatitis with vehement use of ear loop face masks during COVID-19 pandemic Chilblain-like lesions after BNT162b2 mRNA COVID-19 vaccine: a case report suggesting that 'COVID toes' are due to the immune reaction to SARS Several skin manifestations have been described in association with the COVID-19 pandemic since March 2020. Acral chilblain-like lesions (CBLL), usually referred to as 'COVID toes', are among the most common and characteristic ones, even though the direct causative role of SARS-CoV-2 has been debated. Indeed, although some authors have reported the detection of SARS-CoV-2 within the lesions with immunohistochemistry and electron-microscopy, 1,2 the majority of patients with CBLL have had negative tests for SARS-CoV-2 (including serological tests and nasopharyngeal and in situ-skin PCR). 3 A more likely hypothesis for the causation of CBLL in the setting of the COVID-19 pandemic is the development of a high interferon response to the virus, leading to a very efficient antiviral response and the development of CBLL, similar to the scenario observed in type 1 interferonopathies. 4, 5 The recent observations of CBLL following anti-SARS-CoV-2 vaccination in patients with no COVID-19 infection 6,7 support this hypothesis. We present a new case of CBLL that developed shortly after vaccination with the BNT162b2 mRNA COVID-19 vaccine and discuss the significance of this and similar observations from the literature.An 82-year-old non-smoker woman had a history of psoriasis and had been treated with methotrexate for more than 10 years. She had no history of chilblains or Raynaud's syndrome. She denied any symptoms suggestive of COVID-19 since the beginning of the pandemic and had not been in contact with patients suffering from COVID-19. She consulted urgently in our department for slightly painful lesions on both hands and feet that occurred 24 h after the first injection of the BNT162b2 mRNA vaccine. Physical examination revealed macular violaceous and erythematous lesions of the fingers and toes, suggestive of CBLL (Fig. 1) . The patient reported neither general symptoms nor unusual exposure to cold. Laboratory workup yielded normal results, concerning namely markers of inflammation, renal and hepatic function and tests for autoimmunity (antinuclear antibodies, cryoglobulinaemia, complement levels, D-dimers). Histological examination of a skin biopsy taken from a lesion of the hand showed a characteristic aspect of CBLL, 8 including namely a partly necrotic epidermis overlying a dense dermal lymphocytic infiltrate forming rather well-circumscribed aggregates around blood vessels, eccrine sweat glands and occasionally