With the increased wearing of facial masks, skin conditions like dermatitis are becoming more common and studies are showing that the microenvironment created by mask-wearing is leading to microbiome dysbiosis (an imbalance in the delicate microbial ecosystem of the skin), which is linked to various dermatological conditions including contact dermatitis, perioral dermatitis, rosacea and eczema [1].  In this blog post, I am going to give a brief overview of the condition and how to treat and prevent these skin irritations.

I have been noticing an increase in the number of people who have asked my advice lately on the dry, sensitive skin around the jaw and nose, and acne that won’t heal. I am not a doctor and don’t offer medical advice, but I know from my own experience with perioral dermatitis that what they are suffering from results from a damaged moisture barrier and is more likely dermatitis rather than acne, which is why the acne treatments they are using is making the condition worsen. What I remember most is how the painful, inflamed, red rash takes a long time to heal, or in some cases, appears to get worse over time. Eventually, the red sores had spread to the left side of my mouth, (known as perioral dermatitis) and eventually spread over my eyelids (referred to as periocular dermatitis). Anytime I opened my mouth, the skin at the corners of my mouth would crack. After seeing a dermatologist, they confirmed that I had perioral dermatitis, a painful but noncontagious facial rash that often shows up as clusters of tiny, scaly, red, uncomfortable bumps around inflamed and irritated skin that is often mistaken for acne. 

This was what my skin looked like when I was diagnosed with perioral dermatitis. Note that although it appears to resemble acne, the dry, crusty lesions around the corners of the mouth are characteristic of the type of moisture barrier breach that leads to inflammation, secondary bacterial infections and slow wound healing. 

 The reason why this type of dermatitis has worsened since the pandemic started is that wearing masks alters the skin's natural environment, and the friction created from the mask rubbing against the skin can also cause irritation and dehydration to the skin. Stress also influences the skin's microbiological balance, and this can cause immune responses typically seen in these types of skin conditions. 

What Causes Dermatitis?

 Although it looks like acne, there are differences in the causes and the best course of treatment. With mask-induced acne, your pores get clogged with dirt, dead skin cells or oil, giving rise to inflamed pustules. By contrast, perioral dermatitis is more of a long-lasting and scaly, inflammatory rash. There are often multiple causes, but it tends to be triggered by a disruption of your skin’s protective moisture barrier. The humidity and reduced airflow caused by wearing a mask for extended periods may also assist in the proliferation of perioral dermatitis. This environment can alter the face’s natural microbial balance, contributing to perioral dermatitis and related conditions. This can alter the growth of helpful bacteria and assist in the growth of pathogenic microbes like bacteria and yeast, which may be involved in perioral dermatitis and cause the immune system to become reactive causing inflammation.

The skins moisture barrier provides critical protection and acts as the first line of defense, keeping good things in like moisture, and bad things out like harmful microorganisms pollutants, and other irritants. Chronic inflammation occurs when the skin's barrier is damaged, making it vulnerable to infection from microorganisms, pollution, toxins, UV radiation and increased cortisol levels. This means the skin is working harder to defend against stressors. And, over time, this increased inflammation leads to sensitivity, irritation, redness, and multiple inflammatory skin conditions like dermatitis.

How to prevent and treat dermatitis

Since perioral dermatitis may have many causes and aggravating factors, it can be challenging to treat and may take a long time to heal. The list below is a good place to start, but patience is required. 

Simplify Your Skincare Routine

When skin is inflamed and irritated using too many skincare products can cause extra stress to the skin that is trying hard to heal itself. A study published in the Australian Journal of Dermatology found that those who wore foundation, night cream and moisturizer were 13 times more likely to develop perioral dermatitis than those who only used a moisturizer [2]. Our simplified 3-step route is perfect for supplying the skin with antioxidants, anti-inflammatory and soothing and healing ingredients without overburdening irritated skin.

Use Slightly Acidic Skincare 

The skin is naturally acidic, any alkaline or neutral pH products that come into contact with it delay the biochemical reactions until the pH of the skin returns to normal levels. A study published in the Journal of Cosmetic Sciences found that the use of cleansers and cosmetics has a profound influence on skin surface pH, and even the use of plain tap water can increase skin pH up to six hours after application before returning to its natural value [3]. 

Support the repopulation of the microbiome

By using topical prebiotics, probiotics, and postbiotics to support the trillions of microbes that help to maintain pH balance and protect the skin.  All Eunoia’s products contain prebiotics and postbiotics to work in harmony and support the microbiome of the skin.

Eliminate Sensitizing and Irritating Ingredients

Irritating ingredients like SLS, fragrance, essential oils, triclosan and alcohols dry out the moisture barrier leaving the skin dry and vulnerable to irritation. In addition, they alter the balance of bacteria on the skin and can disrupt the sensitive microbiome leading to an increased risk of contact dermatitis [1].

Avoid Exfoliation

While the skin is irritated, using an exfoliator too frequently or one that is too abrasive can cause your skin to be immediately inflamed and irritated, allowing for a secondary bacterial infection to enter through the already damaged protective barrier of the skin. 

Take Supplements and Eat a Healthy Diet

Zinc is an essential micronutrient for collagen synthesis, cell proliferation and immune function. The recommended daily allowance of zinc for adults 19 years and older is 8 mg for women and 11 mg for men,[3].  Zinc demand is thought to be the highest from the time of wound healing throughout the early inflammatory phase, and inadequate zinc status during this period delays wound healing [5].  Oral probiotics can also support the immune system.  This study published in The American Journal of Clinical Dermatology found the use of some strains of probiotics for symptomatic and clinical improvement in atopic dermatitis [6].

Add moisture back to the skin

By using an occlusive moisturizer, the water the skin is losing through the damaged skin barrier can be 'trapped' within the skin. Moisturized skin allows for the free-flowing of bioactive molecules and allows the skin structure to heal faster. “Moisturizers are essential in the maintenance of a healthy skin barrier function and reduce the disruption of the skin microbiome, besides acting as a shield against external triggers” [1].  The treatment of choice is “prescription emollient devices” which include ceramide lipid mixtures with anti-inflammatory ingredients, as well as humectants that reduce transepidermal water loss without causing irritation.  These include natural moisturizing factors like amino acids, urea, and sodium hyaluronate [1]. The entire Eunoia range fits these requirements and has incorporated these ingredients as a base for our range of products.  

Protect against UV Radiation

Always wear an SPF to protect the vulnerable skin. Most people with sensitive skin will find mineral-based (zinc oxide and titanium dioxide) sunscreens are a lot better tolerated as chemical sunscreens can block pores and induce sensitization because of photodegradation [1].

Practice good mask hygiene

Masks are currently a public health requirement, and they are one of the best preventative measures against Coronavirus but cleaning them regularly may help prevent or reduce the severity of skin conditions like dermatitis and acne. When you remove your mask, wash your face with a gentle, fragrance and sulphate-free cleanser, like our Gentle Cleanser. It is also important to regularly was the mask with a gentle face wash and allow it to dry in the sun.

Chose the correct mask material

Natural fibres, such as cotton, linen, and silk offer greater breathability compared to synthetic fibres and are more efficient at wicking moisture away from the skin, preventing microbial overgrowth. Dark colours retain additional heat and increase skin temperature, which affects skin comfort and worsens heat‐sensitive conditions such as dermatitis, and rosacea [1].

Limit makeup

If you can avoid it, try to skip makeup while the skin is healing. If you must wear makeup, try to stick to brands that are alcohol-free and wear as little as possible, or try mineral makeup or tinted mineral sunscreen. 

Eliminate SLS and Fluoride from Your Home

Look at the ingredient list of every product that could come into contact with your skin. Even your laundry detergent. Get rid of anything with Sodium Lauryl Sulfate or any Sulfate derivative containing products. Only SLS shampoo should be used as this is likely to contact the skin. Also, seek out fluoride-free toothpaste.  Fluorides have a well-established ability to cause and aggravate inflammation and have demonstrated an increased inflammatory response when fluoride is placed on previously damaged skin [7,8].

Avoid Steroid-Based Treatments

Many people use steroidal anti-inflammatory medications, like hydrocortisone cream, to manage symptoms of perioral dermatitis, this is now discouraged although it's not known why this makes dermatitis worse in the long term, it is thought that steroid creams might allow for an overgrowth of bacteria due to their immune-suppressing properties.  A systematic review published in the Journal of Cosmetic Dermatology found the strongest evidence to support topical corticosteroid misuse was the principal causative factor in the pathogenesis of perioral dermatitis [9].

The change in the appearance and overall health of my skin in the four years since I learned to to repair my skin barrier and nurture my microbiome. By eliminating all sensitizing ingredients from my routine and working out what skincare ingredients my skin responds to, I no longer suffer from sensitized skin prone to irritation and dermatitis. 

We know how much your skin can affect your self-confidence, health, and enjoyment of life. Wearing a mask when you have a skin condition can be frustrating, but by wearing your mask, you are not only protecting yourself, but you are also protecting others and showing respect for them.

 References:

1. Teo WL. The "Maskne" microbiome - pathophysiology and therapeutics. Int J Dermatol. 2021;60(7):799-809. doi:10.1111/ijd.15425
2. Malik R, Quirk CJ. Topical applications and perioral dermatitis. Australas J Dermatol. 2000 Feb;41(1):34-8. doi: 10.1046/j.1440-0960.2000.00385.x. PMID: 10715898.
3. Lambers H, Piessens S, Bloem A, Pronk H, Finkel P. Natural skin surface pH is on average below 5, which is beneficial for its resident flora. Int J Cosmet Sci. 2006;28(5):359–370
4. National Institutes of Health, Office of Dietary Supplements. Dietary supplement fact sheet: zinc. https://ods.od.nih.gov/factsheets/list-all/Zinc. Updated September 20, 2011. Accessed December 10, 2011. 
5. Senapati A, Thompson RP. Zinc deficiency and the prolonged accumulation of zinc in wounds. Br J Surg. 1985;72(7):583-584.
6. Notay M, Foolad N, Vaughn AR, Sivamani RK. Probiotics, Prebiotics, and Synbiotics for the Treatment and Prevention of Adult Dermatological Diseases. Am J Clin Dermatol. 2017 Dec;18(6):721-732. doi: 10.1007/s40257-017-0300-2. PMID: 28681230.
7. Stone OJ, Willis CJ: The effect of stannous fluoride and stannous chloride on inflammation. Toxicol Appl Pharmacol13:322-338, 1968.
8. Stone OJ, Willis CJ: Enhancement of inflammation by fluoride. Texas Rep Biol Med 25:601-606, 1967.
9. Searle, T., Ali, F.R. and Al-Niaimi, F. (2021), Perioral dermatitis: Diagnosis, proposed etiologies, and management. J Cosmet Dermatol, 20: 3839-3848. https://doi.org/10.1111/jocd.14060.
10. Prakash C, Bhargava P, Tiwari S, Majumdar B, Bhargava RK. Skin Surface pH in Acne Vulgaris: Insights from an Observational Study and Review of the Literature. J Clin Aesthet Dermatol. 2017;10(7):33-39.
11. Gomolin, T. A., Cline, A., & Russo, M. (2020). Maskne: Exacerbation or Eruption of Acne During the COVID-19 Pandemic. SKIN The Journal of Cutaneous Medicine, 4(5), 438–439. https://doi.org/10.25251/skin.4.5.7.
12. Xie Z, Yang YX, Zhang H. Mask-induced contact dermatitis in handling COVID-19 outbreak. Contact Dermatitis. 2020;83(2):166-167. doi:10.1111/cod.13599