Personal protective equipment use and face acne in health care providers during the COVID‐19 pandemic in Romania: A new occupational acne type?

Conflict of interest

SC, MD and SRG report no conflicts of interest. CMS declares the following, not related to the work: royalties from Springer Nature, consulting fees from Vichy International and support for attending meetings from Leo Pharma.

Funding sources

No funding was received for the following work.

Dear Editor,

During the COVID‐19 pandemic, acne was a commonly reported adverse reaction to medical face mask use amongst healthcare providers (HCP). ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸

A cross‐sectional, online survey applied to HCP was conducted from 17 December 2020 until 17 February 2021. This study was approved by University’s Ethical Committee and conducted according to the principles of the Declaration of Helsinki. The 41‐item questionnaire developed using Google Forms, focusing on acne lesions included HCP in various medical centres from Romania. Questions specifically referred to the state of emergency (March–May 2020), when lockdown measures were instituted, and to the following 7–9 months.

Descriptive statistics, within‐ and between‐subject tests and association measures were used for statistical analyses. Microsoft Excel 16 and IBM SPSS version 28 were considered.

We recorded 134 answers, 116 (86.6%) coming from female HCP with 107 (79.9%) being medical doctors; median age was 29 years old. Because different generations may exhibit distinct behaviours, and participants were grouped into generational birth cohorts, with categories provided by Pew Research: Baby Boomers (1946–1964), Generation X (1965–1980), Millennials (1981–1996) and Generation Z (1997–2012). ⁹ , ¹⁰

To analyse the evolution of acne during and after the lockdown, we used an exact McNemar’s test which indicated significant differences in the proportion of people with acne between the two time frames, P < 0.001. New lesions or acne worsening were reported by 56.0% of subjects during the state of emergency and by 67.5% in the following 7–9 months. This effect becomes more stringent with younger generations (/Table 1), to the extent that an association between acne worsening, and generation is observed as a long‐term effect, as the period of time in which people were required to wear PPE extended – χ² (3) = 8.308, P = 0.040.

Table 1.

Cross‐tabulations showing acne worsening in younger generations as time in the pandemic period extended

			Generation				Total
			Baby Boomers	Generation X	Millennials	Generation Z
Ever having acne lesions	No	Count	3	4	25	2	34
		% within Generation	42.9%	25.0%	25.0%	40.0%	26.6%
	Yes	Count	4	12	75	3	94
		% within Generation	57.1%	75.0%	75.0%	60.0%	73.4%
Acne during lockdown moths (March 2020–May 2020)	No	Count	5	10	42	2	59
		% within Generation	71.4%	62.5%	42.0%	40.0%	46.1%
	Yes	Count	2	6	58	3	69
		% within Generation	28.6%	37.5%	58.0%	60.0%	53.9%
Acne in the following 7–9 months after lockdown	No	Count	5	9	31	1	46
		% within Generation	71.4%	56.3%	31.0%	20.0%	35.9%
	Yes	Count	2	7	69	4	82
		% within Generation	28.6%	43.8%	69.0%	80.0%	64.1%
Total (†)			7	16	100	5	128

^†6 respondents did not specify their birthday and were thus ignored in the analysis of acne worsening per generation.

Common facial areas affected were chin (70.1%), cheeks (41.8%), nose (34.3%) and neck (34.3%). The predictive model used for lesions development is highly suggestive for acne occurring on mask‐affected areas. Regions concurrently involved in the same subject were cheeks, nose, chin (15.7% of cases) and cheeks, chin, neck (14.2% of cases). Chi‐squared tests were run to determine the association between acne and various emotional impacts for the two‐time frames. The results showed that acne lesions had the highest emotional impact, compared with the pandemic itself and PPE usage. (Table 2). An association between lesion excoriation and acne was observed, χ²(4) = 49.113, P < 0.001 during the lockdown and χ² (4) = 45.030, P < 0.001 after it. Acne in the context of medical face mask usage is a distinct subtype of acne mechanica. Management should consider irritation and decreased skin barrier function, which may increase the risk of side‐effects on treatment. ⁶ In contrast to previous studies, we present an in‐depth analysis of acne evolution in subjects for the time frames presented. Our model based on frequency‐mining algorithms found that the most frequent co‐occurring regions were based on proximity. Limitations of our study include a small cohort, imbalance in genders and generations and absence of clinical evaluation.

Table 2.

Chi‐Squared tests between various emotional impacts and acne (during and after the lockdown)

	Acne during lockdown moths (March 2020–May 2020)		Acne in the following 7–9 months after lockdown
	χ2(4)	P	χ2(4)	P
Emotional impact caused by the pandemic	15.760	0.003	5.692	0.223
Emotional impact caused by PPE	11.174	0.025	3.184	0.528
Emotional impact of lesions	70.576	<0.001	75.707	<0.001

HCPs in Romania commonly reported acne lesions in the areas covered by medical face masks, more intensely with the increase in the number of months during which PPE use was required to be permanent.

This subtype of acne should be regarded as an occupational disease. More regulatory efforts are needed to prevent it and limit its impact on affected HCP.