Face mask - induced itching during the COVID-19 pandemic: Are we heading towards a silent epidemic?

Dear Editor,

The COVID-19 pandemic came with many lifestyle modifications such as social distancing, hand hygiene, regular usage of personal protective equipment (PPE.), including face masks, eye goggles, and gloves.[1] Changes in everyday routines, work cultures, and new lifestyle adaptations have unwanted sequelae like reduced physical activities, obesity, worsening glycemic controls, anxiety-related issues, digital eye strain, and myopia.[2] Few of these have been intensively studied and researched worldwide. But there are some issues as simple as itching, which are often ignored and considered insignificant. Mask-related problems like breakouts, rashes, acne, allergies, worsening dermatosis, xerosis, nasal bridge scarring have been reported.[3] The question is, aren’t we neglecting all these mask-related issues, which have been a significant complaint, especially among medical professionals. Are we seeing a silent epidemic of mask-related itching? In the pre-COVID era, surgical masks were mainly meant for health care workers, especially surgeons, to prevent pathogens in the surgical area. In the current COVID-19 period, face masks have taken a front role in preventing viral transmission from human to human.[4] The prolonged and regular use of PPE can harm the skin. Limited research has concentrated on prolonged use of PPE, especially of face masks. Itching is a pervasive dermatological disorder, and people with dry skin or underlying allergies are more predisposed to such issues.[5] Itching, if severe, can lead to a negative psychosocial impact. According to the International Forum for the Study of Itch, itching is defined as a sensation leading to scratching.[6] This may be a symptom of both dermatological and systemic disorders.

Literature review shows that although itching in present times is more commonly seen as an adverse effect of face mask use, little is known about the predisposing risk factors and correlations.[7] Han et al.[8] hypothesized that the face covered by the mask leads to high temperature, with each 1°C rise, and increase of sebum excretion by 10%. Berardesca et al.[9] proposed that itching might be induced by mast cell degranulation associated with stress. People with atopic predispositions suffered more from itching. Aerts et al.[10] reported an interesting case of occupational allergic contact dermatitis caused by formaldehyde and 2-bromo-2-nitropropane-1,3-diol (bronopol) contained in a polypropylene surgical mask. Krajewski et al.,[3] in their analysis of 1156 health care workers (HCWs) and 1173 students, found that itching was present in 25.8% (602) of the participants. The prevalence was statistically higher among HCWs than students [365 (31.6%) and 237 (20.2%), respectively) (P < 0.001)]. Similarly, Szepietowski et al.[11] surveyed 2307 participants from the general public and found that approximately 20% (273) had a complaint of itching. Ständer et al.[12] found that, in comparison to men, women suffer from higher itch intensity with a larger impact on their quality of life. Zuo et al.[13] documented itching due to face masks in 14.9% of HCWs, a burning sensation in 3.7%, and pain/pricking in 3.2% of subjects. Szepietowski et al.,[10] in their analysis, found that respirators (50%) were reported to be associated with more itching, as compared to N95 (23.3%) or cloth masks (20%). Krajewski et al.[3] also found that itching was most common among those wearing respirators (N95/FFP2) (32.6%), whereas cloth masks caused itch only in 20% of users (P < 0.001). Roberge et al.[14] reported three-layered surgical mask to be the most convenient and best-tolerated type in regards to itching.

Thus, itching is a prevalent complaint in these COVID times, and the problem is faced more strongly with prolonged hours of use. It is essential to take care as people scratching faces touch the uncontaminated outer surface of the mask and many times lower down their masks, making it highly contagious and thus losing the sole purpose of wearing masks. A few essential tips to prevent mask-related itching are choosing a natural fiber-cloth mask, cotton or polyester blends, such as T-shirt or pillowcase fabrics, using unscented laundry products, ensuring that mask fits appropriately, and it should neither be too loose to cause chafing nor too tight. Oil, nasal mucus, saliva, and sweat can contaminate the face mask wherever it touches the face, so it is crucial to wash the mask with gentle, non-irritating soap and dry it in the dryer after each use. A good, bland moisturizer at night or a barrier cream or spray, such as petroleum jelly or zinc oxide, can also help. Unnecessary cosmetics should be avoided; frequent shaving can also prevent irritation around follicles and ingrown hairs. We believe that these recommendations will help prevent this silent mask-related itching epidemic besides effectively combating the deadly COVID-19 infection.

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