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Letter to Editor | DOI: https://doi.org/10.31579/2578-8949/084
Department of Dermatology, University of HongKong Shenzhen Hospital, Guangdong Province, PRC, China.
*Corresponding Author: Zhenying Zhang, Department of Dermatology, University of Hong Kong-Shenzhen Hospital, Haiyuan, Shenzhen, Guangdong Province, PRC, China.
Citation: J Shi, C Han, Y Chen, Z Zhang. (2021). Flushing Associated with Prolonged Mask Wearing During Covid-19 Pandemic among the General Population. J. Dermatology and Dermatitis. 6(3); Doi:10.31579/2578-8949/084
Copyright: © 2021 Zhenying Zhang, This is an open-access article distributed under the terms of The Creative Commons. Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 21 August 2021 | Accepted: 30 August 2021 | Published: 03 September 2021
Keywords: flushing; mask wearing; covid-19; skin barrier
Wearing mask was encouraged to prevent dispersal of droplets and to reduce the risks of environmental contamination by COVID-19 during COVID-19 pandemic. However, we noticed a rise in the initial attack, relapse or exacerbation of flushing among general population due to long-time mask wearing. In this manuscript, we reported the characters of the mask-related flushing, and attempted to explain the reasons and put forward some precautions for that. We suggested that general public should be aware of proper and rational mask wearing to avoid inducing and aggravating flushing. We hope that our findings will contribute to increase the awareness about mask related flushing.
To Editor
Wearing mask was encouraged to prevent dispersal of droplets during talking, sneezing, and coughing, and to reduce the risks of environmental contamination by COVID-19 based on the precautionary principles. However, wearing mask for a long time increased flushing due to higher temperature. We aim to report these rising cases of flushing among the general population.
From 15th April 2021 till 15th May 2021, we diagnosed 22 patients (7 males and 15 females) of facial flushing who were not involved in any healthcare-associated occupations. The diagnosis was based on visible skin redness accompanied by warmth sensation excluding idiopathic anaphylaxis, carcinoid syndrome, mastocytosis, pheochromocytoma, medullary thyroid carcinoma, pancreatic cell tumor, renal cell carcinoma, and neurologic flushing. Eleven patients with a history of rosacea relapsed or exhibited aggravated flushing. The other eleven patients with or without a history of acne presented the initial attack of flushing. All patients admitted have worn masks for over 2 hours per day more than 1 month and denied alcohol-, drug-, pregnancy-, or emotion-related and climacteric flushing. Flushing is not only limited to the area covered by the masks but also to the glabellum and the forehead, which is different from allergic or irritant contact dermatitis. The most common symptoms reported were drying, itching, tingling, and burning sensation besides warmth. Signs and symptoms improved after removing the mask for 30 minutes in those cases without any history and for longer than 3 hours in those patients with acne, while persistent facial redness with or without telangiectases existed until effective treatments were taken in those patients with rosacea.
Flushing reactions could be resulting from the direct action of vasodilator agents and those mediated by autonomic nerves. The most common autonomic neural-mediated flushing reactions are the thermoregulatory flushing reactions [1]. Wearing a mask creates a closed space on the surface of facial skin, where local temperature significantly increased. Patients who are sensitive to the varieties of hyperthermia are most likely to develop episodic flushing attacks, and repetitive episodes over long periods may result in a constant facial erythema with telangiectases. Moreover, humid environments caused by water in exhaled air may cause skin barrier damage and lead to subsequent skin dryness and itch.
Patients might touch their faces after removing the masks due to itch and drying, which increases the risks of COVID-19 transmission through respiratory route [2]. Mehak also suggested skin barrier dysfunction might create a route of entry for COVID-19, because angiotensin-converting enzyme 2 - which acts as the cell receptors for COVID-19, are presented abundantly in the basal layer of the epidermis, capillaries of the skin and eccrine glands [3].
A cold gel pack around the neck and forehead, or a cooling fan blowing directly on the face might relieve the flushing. Holding ice chips in the mouth without chewing or swallowing is also recommended, it helps to achieve maximum cooling effectiveness. Chilling oral cavity reduces the temperature at the anterior, it increases the hypothalamic threshold and stimulates oropharyngeal receptors leading to the physiologic reaction of vasoconstriction [4]. Hot beverages and food should be avoided or followed with a cooling drink to relieve oral thermal-induced flushing. Control the time of wearing a mask and put two layers of tissue or gauze inside the mask to reduce humidity [5]. Clean face with cold water and weak acidic or neutral foamless cleansing products. Applying emollients containing hyaluronic acid, ceramide, vitamin E or other repairing ingredients are recommended before donning and after doffing masks to reduce the sustained damage of skin barrier [6]. By employing these nonpharmacologic maneuvers, the condition of mask-related flushing might be relieved. Topical brimondine, oral tetracyclines, intense pulse light and pulse dye laser were usually administrated for those patients with constant flushing.
A statement of all funding sources that supported the work:
This study was supported by the Shenzhen Innovation and Technology Commission Foundation (Grant No. JCYJ20180306173356306).
None
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