To the Editor:
During the coronavirus disease 2019 (COVID-19) pandemic, routine use of surgical loop face masks among health care workers in the outpatient setting has become vital. Unfortunately, adverse reactions to face masks, including acne, pruritus, rash, and skin breakdown in the postauricular area, have been reported.1–3
We compared application of hydrocolloid dressing (DUODERM), padded dressing (MOLESKIN), and 20% zinc oxide ointment to be used with surgical loop masks behind the ears to determine the optimal material to combat skin irritation behind the ears. Fifteen staff from the Penn State Dermatology Clinic participated in this institutional review board–approved, interrupted time-series study with a 2-week control period, followed by three 2-week intervention periods from April 20, 2020, to June 12, 2020.
Of the 50 voluntary surveys completed by our 15 participants with 6.6 average mask wear hours per day in a given 40-hour workweek, pain, pruritus, and rash were reported in 42% (n = 21). Of the participants who reported pain, the hydrocolloid dressing group (23%, n = 3) reported the highest mean pain scale (4.7 out of 10), followed by the padded dressing group (30%, n = 3) with a mean of 3.7 and the control (25%, n = 5) with a mean of 2. Of those who reported pruritus, the control (15%; n = 3) and the padded dressing group (10%; n = 1) had equivalent mean pruritus scale of 2 out of 10. Only the hydrocolloid dressing group reported rash (8%; n = 1). The zinc oxide group reported no adverse events. The padded dressing group had the highest rate of intervention discontinuation (40%; n = 4) followed by the hydrocolloid dressing group (8%, n = 1). Some respondents specifically noted “pain behind the ears,” “pulling of hair” with the padded dressing, and an “unwelcome residue” with the hydrocolloid dressing (Table 1).
TABLE 1.
Incidence and analysis of adverse events associated with mask interventions
| Control (Total = 20) | Hydrocolloid (Total = 13) | Padded Dressing (Total = 10) | Zinc Oxide (Total = 7) | |
|---|---|---|---|---|
| Pain, n (%) | 5 (25) | 3 (23) | 3 (30) | 0 (0) |
| Mean pain score (out of 10) | 2 | 4.7 | 3.7 | N/A |
| Pruritus, n (%) | 3 (15) | 0 (0) | 1 (10) | 0 (0) |
| Mean pruritus score (out of 10) | 2 | N/A | 2 | N/A |
| Rash, n (%) | 0 (0) | 1 (8) | 0 (0) | 0 (0) |
| Discontinued intervention, n (%) | N/A | 1 (8) | 4 (40) | 0 (0) |
| Theme(s) | None | Unwelcome residue | Pain behind ears and pulling of hair | None |
| Representative quote(s) | None | “There is a lot of residual stickiness from the Duoderm.” | “I stopped wearing it because my ears felt sore.” “Stopped because it was hurting my ears.” “It hurts to take off and it pulls hairs out!” “I stopped wearing it because it pulled my hairs out.” |
None |
N/A indicates not applicable.
Although we aimed to evaluate these materials as prophylactic strategies to combat skin problems, we found that there were more deleterious effects to use them. Moreover, participant attrition was high, likely due in part to the low incidence of baseline discomfort and the effort required to apply the interventions. In this study, zinc oxide ointment was the only intervention that was not associated with any of the prespecified adverse events. Simplicity and commonality of applying ointments may explain this observation.
Furthermore, a recent article by Yan et al4 recommends using zinc oxide ointment as a moisturizer and barrier cream to reduce skin breakdown. Therefore, zinc oxide ointment may be an inexpensive and accessible solution for individuals who develop skin irritation from the surgical loop mask. Along with a thin layer of clear zinc oxide ointment to help reduce postauricular discomfort, masks with adjustable ear loop lengths and masks with ties as opposed to ear loops may serve as alternatives if adequate mask fit can be ensured. For future studies, other materials, such as cloth and foam padding, could be investigated to reduce postauricular discomfort from surgical loop masks.
Surav M. Sakya, BS
Penn State College of Medicine, Hershey, PA
Ryan M. Svoboda, MD, MS
Yesul Kim, MD
Alexandra Flamm, MD
Department of Dermatology, Penn State Milton S. Hershey Medical
Center, PA
Footnotes
The authors have no conflicts of interest to declare.
Funding received from the Penn State Hershey Dermatology Endowment.
Contributor Information
Ryan M. Svoboda, Email: rsvoboda@pennstatehealth.psu.edu.
Yesul Kim, Email: ykim4@pennstatehealth.psu.edu.
Alexandra Flamm, Email: aflamm@pennstatehealth.psu.edu.
REFERENCES
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