N95 acne

Abstract

Two women, aged 27 and 45 years, presented to the Dermatology Outpatient Clinic with acne vulgaris. Both had nodular acne in a similar distribution over the cheeks, chin, and perioral areas (Fig. 1). Each had a history of acne vulgaris as a teenager. Both were healthcare assistants working in the Singapore General Hospital throughout the severe acute respiratory syndrome (SARS) crisis, had worn N95 masks continuously for about 3 months whilst on the wards, and had suffered an outbreak of acne of the skin occluded by the mask. They were treated with topical retinoid and systemic antimicrobials, and both responded well.

Figure 1.

Twenty‐seven‐year‐old woman with acne papules and nodules on the face over the area occluded by the N95 mask

Discussion

Singapore was one of several countries affected by severe acute respiratory syndrome (SARS). The outbreak in Singapore started in March 2003. The Centers for Disease Control (CDC) advisory against travel to Singapore was lifted on May 4th, 2003 and the alert was terminated on June 4th, 2003. ¹ There were 205 recovered cases, 33 deaths, and 238 probable cases in Singapore between March and May. ² A number of these were healthcare workers infected with the SARS‐associated coronavirus. Apart from SARS infection, healthcare workers were also affected in other ways. Skin disorders were seen as a consequence of the various measures instituted to curb the transmission of SARS. The two patients with acne vulgaris reported here are representative of several seen during and after the SARS period.

Acne vulgaris is a self‐limiting, multifactorial disorder affecting the sebaceous glands and pilosebaceous follicles. It is a common problem in Singapore. There are several clinical subgroups of acne, ³ including tropical acne. This is a well‐known entity which occurs in hot and humid climates. It is particularly common in soldiers ⁴ and affects mainly the trunk and buttocks.

In the two patients reported here, there was localized exacerbation of acne on the part of the face covered by the N95 mask. During the SARS period, N95 masks were recommended by the CDC and World Health Organization (WHO) for use when healthcare workers came into contact with confirmed or suspected SARS patients. They provided at least 95% filtration against oil‐free particles and needed to be worn tightly against the face to be effective. It was not surprising to see acne occurring in the regions of the face covered by the masks. Donning of these masks over prolonged periods of time creates a humid “tropical” skin microclimate conducive to a flare‐up of acne. Alternatively, the flare‐up could have been a consequence of simple pilosebaceous duct occlusion due to local pressure on the skin from the close‐fitting masks.

Apart from the risk of contracting SARS, the disease also affected healthcare workers in other physical and psychologic ways. ⁵ Acne vulgaris resulting from the wearing of tight‐fitting masks over prolonged periods of time was one of the physical hazards. We will no doubt continue to see this condition as long as we need to take precautions to prevent another SARS epidemic.