Retroauricular dermatitis with vehement use of ear loop face masks during COVID‐19 pandemic

To the Editor

The coronavirus disease 2019 (COVID‐19) pandemic forged the exponential use of masks of various kinds, not just by health workers but also by general population as a personal protective equipment (PPE). Although contact dermatitis due to PPE is well reported, mask induced dermatitis is a relatively unexplored phenomenon. In this article, we report a preliminary data of patients experiencing retroauricular dermatitis due to ear loop face masks.

From 1st April to 30th April, we came across 14 patients including both healthcare workers and general population who complained of itching, redness and/or scaling involving the retroauricular region following the use of ear loop face masks. The history, clinical features including onset, duration, pre‐existing dermatoses, type and duration of mask used, and material of the straps were recorded, and a clinical diagnosis was made. The patients were treated with emollients, topical corticosteroids and/or oral anti‐histamines.

Out of the 14 cases, 5 (35.7%) patients were diagnosed to have irritant contact dermatitis (ICD), four (28.5%) patients were diagnosed with allergic contact dermatitis (ACD), three (21.4%) patients developed sweat dermatitis and one patient diagnosed to have pressure urticaria. ¹ Patient presented with exacerbation of pre‐existing dermatoses. The patch test could not be performed due to the prevailing dire pandemic. N95 masks were the most commonly used mask in 35.7% of patients, having thermoelastic polymer straps. Sweat dermatitis was observed due to associated headgear use or using nylon cloth masks. Reusing masks after application of disinfectant resulted in ICD in three patients. Latex was the commonest strap material resulting in dermatoses in four (28.5%) patients. Pre‐existing dermatoses were present in seven (50%) patients including atopic dermatitis in four, seborrheic dermatitis in two and chronic urticaria in one. The most common symptoms reported were itching and dryness, whereas the most common signs seen were erythema, scaling and papules (Table 1; Fig. 1).

Table 1.

Patients' demography, clinical profile, type and material of mask used

S.No.	Age/Sex	Clinical description	Diagnosis	Pre‐existing dermatoses	Type of mask	Material of strap	Duration of wear
1	34/M	Erythema, excoriation, spreading to infra‐auricular region	Allergic contact dermatitis	Nil	N95	Thermoplastic elastomer	3 days
2	27/M	Erythema, papules, scaling localized to the area of contact	Irritant contact Dermatitis	Nil	N95 mask reused after chlorhexidine application	Thermoelastic polymer	4 days
3	14/F	Erythema, scaling, excoriation	Allergic contact dermatitis	Atopic Dermatitis	Surgical mask	Rubber	1 1/2 days
4	32/M	Erythema, scaling, maceration	Sweat Dermatitis	Nil	N95 mask with headgear	Thermoelastic polymer	10 days
5	58/F	Oedematous wheals	Pressure Urticaria	Chronic urticaria	N95	Thermoelastic polymer	3 h
6	41/M	Erythema, scaling	Irritant contact dermatitis (frictional)	Nil	Double surgical mask	Latex	2 days
7	22/M	Erythema, oozing, crusting	Allergic contact dermatitis	Seborrheic dermatitis	KN 95 mask	Latex	5 days
8	36/F	Erythema,maceration	Sweat dermatitis	Nil	Homemade cloth mask	Nylon	9 days
9	16/M	Erythema, scaling	Allergic contact dermatitis	Atopic dermatitis	Homemade cloth mask	Rubber	6 days
10	24/M	Erythema, maceration, oozing	Sweat dermatitis	Seborrheic dermatitis	FFP 2 mask with headgear	Thermoelastic polymer	8 days
11	19/F	Erythema, papules, scaling, fissuring	Irritant contact dermatitis	Nil	Homemade cloth mask (? Cloth Dye culpable)	Cotton‐Polyester	2 days
12	37/M	Erythema, oozing, crusting	Exacerbation of atopic dermatitis	Atopic dermatitis	Surgical mask with n‐propanol application	Latex	2 days
13	53/M	Erythema, scaling	Irritant contact dermatitis (frictional)	Nil	Double surgical mask	Latex	3 days
14	62/F	Erythema, papules, scaling, fissuring	Irritant contact dermatitis	Atopic dermatitis	N95 reused after 70% isopropyl alcohol application	Thermoelastic polymer	5 days

Figure 1.

Erythema and Scaling involving retroauricular area following ear loop mask.

A study by Foo et al. ¹ from Singapore mentioned adverse skin reactions in 35.5% practitioners using N95 masks, of which 51.4% developed facial itch and 35.8% skin rash. Donovan et al. ² reported three persons developing contact urticaria and two persons with ACD following N95 masks. ² Contact dermatitis to rubber and dibromodicyanobutane present in the adhesive of polyester foam strip was reported by the use of surgical mask. ³ ACD to thiuram present in elastic ear strap has been documented. ⁴ Komericki et al. ⁵ reported cocopropylenediamin–guanidium–diacetate, used to disinfect medical instruments and apparatus, responsible for ACD to non‐disposable face masks. ⁵ Similar effects on the face by PPE in healthcare workers managing COVID‐19 cases have been documented, but no study has elaborated the retroauricular involvement. ⁶ Frequent frictions due to the straps, trapping of sweat, use of disinfectant to reuse masks and application of dyes to colour homemade masks are frequent causes of dermatitis using ear loop face masks. The strap material including thermoelastic polymer, rubber and latex further leads to contact dermatitis. Moreover, the masks can cause exacerbation of pre‐existing dermatoses.

The authors would like to suggest the use of headband face masks for healthcare professionals using the mask for prolonged periods. The general population using homemade face masks should use cotton cloth based masks with gaiters of appropriate elasticity and avoid any disinfectant application. Persons with pre‐existing dermatoses including atopic dermatitis, seborrheic dermatitis and chronic urticaria need to take special precautions, and use of disposable surgical masks should be encouraged. Donning of masks should be done after proper absorption of the emollient to prevent leeching of strap polymers.

Funding source

None.

Conflict of interest

None.