‘Mask-ne,’ or acne caused by wearing masks, is becoming more prevalent as the COVID-19 pandemic continues. Julie Harper, MD, shares tips on how to prevent mask-ne, as well as how she counsels patients and the benefits of telemedicine.
Dr Harper is a clinical associate professor of dermatology at the University of Alabama, Birmingham and consultant for Galderma.
Melissa: Hello, everyone. Today, I’ll be speaking with Dr Julie Harper about mask‑ne and how to prevent it, as well as the treatment of acne during the COVID‑19 pandemic. Dr Harper is a clinical associate professor of dermatology at the University of Alabama, Birmingham and consultant for Galderma. Thank you so much for speaking with me today, Dr Harper.
Dr Julie Harper: Thank you so much.
Melissa: What comments are you hearing the most from patients?
Dr Harper: Mask‑ne is real. This is something that we’re definitely seeing. We see it both in people who’ve had acne and they’re seeing a flare of acne in that masked distribution on the lower part of the face. We’re also seeing it in people who don’t routinely have acne. Now they’re getting that random bump that comes up also in that area under the mask.
I even had one of my own employees today say, “Look, I’ve got mask‑ne.” She pulled her mask down a little bit and, yes, on her cheek she had a little acne lesion. She is somebody who does not routinely struggle with acne. I do think there’s a couple of groups of people where we’re seeing this.
Melissa: What are your hypotheses for what’s causing that acne?
Dr Harper: My hypothesis, I’ve got to use that word because I don’t think we have it completely figured out. This is from the occlusion and the moisture that’s underneath that mask.
If you’re wearing that mask, particularly for long periods of time, and you’re still, of course, breathing in that mask, there is moisture that’s being trapped under that mask that can affect the follicles and can start to trigger a little irritation in those follicles, and then potentially even plugging up the follicle, and then the rest of the pathogenesis of acne.
It’s just about moisture and occlusion. I think this is analogous to something that we dermatologists and dermatology providers have dealt with a long time. That is like that acne we’ll see athletes get under a chinstrap, for example, or under a helmet. Anywhere where you are trapping moisture or sweat and you can’t clean it frequently, that’s a risk for developing acne.
Melissa: What are your tips for reducing mask‑related acne?
Dr Harper: A couple of things. I would say make sure you are wearing a clean mask and change it as much as you can. If you’re somebody, for example, like a healthcare provider or someone who works in a healthcare office, we have to wear the masks all day long without much interruption, if you can take a break at some point in the day and use a general cleanser to wash your face, that’s a great idea.
I would also minimize what you’re putting under the mask. Many of us might have a multistep regimen that we do in the morning. I might take that regimen down by a step or two, for example. Just put on what you have to put on. Personally, I’m still putting on my moisturizer in the morning that has a little bit of sunscreen in it.
I’m saving money right now because I’m not putting makeup from about my eyes down. I put that on and not much else. As far as acne medications, if you’re already on a regimen, I would really, really encourage you to stay consistent with that. I wouldn’t put that acne medication on and then immediately cover it with a mask.
What could happen is that you drive too much of that medicine into the skin and then you could get irritation from that. If you have a product, the one I’ll use as the example is the retinoid class of drugs that are largely believed to be a real cornerstone of treating acne, both getting it clear and keeping it clear, and many of those products do better at bedtime anyway. For example, Aklief, which is a product that was recently FDA‑approved for acne. It’s the newest retinoid molecule that we’ve had in about 20 years. That product was studied being used every night at bedtime. If you can separate when you apply the product from the time period where you’re going to have that mask on, that’s a reasonable idea, too.
Melissa: What have been some of the challenges for treating acne during the pandemic?
Dr Harper: It’s the same barrier, the same struggles we have whether it’s pandemic or not. That is getting people to be consistent, and persistent with their treatment, and being patient. We know we can see some early improvement with Aklief. I’m using that because it’s a relatively new product. In the 12‑week setting, we were able to see significant improvement as early as 2 weeks. Really, you’re going to see more of the improvement as you are patient, and you wait over time, and you continue to use the product. If we can get people to be patient.
Also, use the product all over. That’s something that I see people do wrong all the time. They take that medicine and they put it on the blemishes that they see now. If you think about it, when you do that, all you’re doing is getting rid of the acne lesions once they come up. We’d rather be in the business of preventing next month’s acne. Every time you use that acne medication—this is regardless of what medication you’re using—you want to treat the whole effected area because you also want to try to prevent the acne that might be coming next month.
Melissa: Has telehealth improved access for patients with acne?
Dr Harper: It definitely has. I will tell you, in Alabama, we’re already reverting back to where most people are coming into the clinic again. We saw acne telehealth patient again last week. Probably, in my experience, it is the best dermatologic diagnosis to see via telehealth. We can do a very good job with that.
There are so many things in dermatology that we can’t do over telemedicine, for example, biopsying a lesion or even freezing a wart. We can do a good job with acne.
Even when our state was shut down for a period of time, those were the patients we were still able to see and continue to prescribe medications for the patients, continue to monitor their improvement, teach them how to use new medications, set the proper expectations. We were able to continue to do all of that for our acne patients because of telemedicine.
Melissa: Were there any challenges for that?
Dr Harper: Sure, there were challenges because we weren’t used to doing it. Again, I would say, in my experience, it was the very best diagnosis to see. I don’t want to always treat acne like that. I like the face‑to‑face interaction. I like to be able to touch the patient.
When we did telemedicine, some of the language I would use is I would say to the patient and sometimes their parent if it was a young patient, I would say, “You’re going to have to do the physical exam for me. I can see you right now, but I want you to reach up and touch your cheek and tell me how much of that you can still feel.”
As you know, when we treat acne and acne gets better, a lot of times the active acne itself is gone but we’re left with some either, what we call post‑inflammatory erythema or pigmentation. We treat that a little bit differently. Having the patient help with the exam by touching the skin, that was helpful.
Other things that I thought were particularly interesting, not necessarily a challenge but they were interesting, is I could say, “OK, what are you putting on at bedtime?” If they couldn’t remember, in this case you could say, “Well, why don’t you go get it and show me which one you’re putting on when?” You could even say, “Show me how much you’re using.”
Often, in the clinic, they haven’t brought those tubes of medicine with them or the bottle of pills, whatever it is they’re on. I thought that was a particularly nice thing about using telemedicine is they could run to their bathroom real quick, and get the tube, and then put it in the camera and show me exactly what they were using when.
Melissa: How do you counsel patients to set them up for success with their treatment?
Dr Harper: That’s one of the most important parts about treating acne well is, first of all, teaching them what’s behind acne. I don’t do this in every single visit, but I do it a lot. So often, to treat acne well, we’re going to have to use a combination of treatments. It’s not just one thing.
Explaining a little bit about why I just chose those two medicines together or why I did Aklief, the retinoid, and then a systemic antibiotic, or why I added benzoyl peroxide. Explaining to the patient why we’re treating can be very helpful. That’s number one.
Number two, teaching people how to use the medications. With topical medicines, in particular, I always look at the patient and I say, “There’s three things that everybody does wrong when they treat acne. One is they use too much medicine.” With these topical medicines, when we say use a small, pea‑size amount to your whole face, we mean a small, pea‑size amount. Use a very small amount.
If you use more than that, you’re more likely to get irritation from the medicine. The second thing everybody does wrong is they spot treat. Again, we already talked about that. If you spot treat, we’re just chasing acne. We want to get ahead of it. The third thing everybody does wrong is that they quit too soon. Please, don’t give up at two or three weeks. The medicines are just getting going.
We really need to counsel and then cheerlead our patients that they’re going to have to stick with this for usually 3 to 4 months to see the real benefit of these medications.
Then, even when we reach that point, we can tell them at visit number one, “When we get you clear, there will be a maintenance phase with this too. We’re going to clear you up with this medicine or this cluster of medicines, and then we’re going to keep you clear over time by skinnying that regimen down and picking probably one topical product to maintain the improvement over time.”
It’s explaining why we’re using the medicines we are, encouraging the patients to stick with them and be patient, and telling them right upfront that even when they’re better, there will be a maintenance phase that we will continue to treat.
Melissa: There’s been a lot of studies about the association between acne and depressive symptoms. Have you noticed any symptoms in your patients and how are you counseling them about their mental health?
Dr Harper: I have. I do think that that’s something that’s difficult for we dermatologists and we should do even better on that. We know. We absolutely have the data that acne is associated with an increased risk of depression and we can see signs of that in clinic.
It is important if this is something that we think the patient is struggling, talking to the patient or if they’re a minor, even talking to the parents in the room as well. I have to brag on my own medical assistants. Oftentimes, this is something that they are particularly good at, too.
It doesn’t have to be the provider. In a team approach where it’s multidisciplinary in the clinic, having the medical assistant who so often is getting the coupons, making sure the prescriptions go to the right place. I’ve had medical assistants bring up to the patient too, “You know, you really seem down about this. Is this something that we need to help with that, too? Because we can set you up and get you to talk with somebody else if you need that.” I do think we have to be aware of it. It is a part of having acne for many of our patients.
Melissa: Do you have anything else you’d like to add?
Dr Harper: Just that treating acne is so important for so many of the reasons that we talked about. It’s very, very bothersome to our patients and it doesn’t take a lot of acne to bother people a great deal.
It’s important that we learn how to treat it effectively and that means medications that work, medications that are cost‑effective, medications that our patients can tolerate. I would just encourage people to treat early and treat aggressively.
Melissa: Thank you so much for joining us today. Thank you for listening. If you have any questions for Dr Harper, please, submit them in the feedback box below.