10.5826/dpc.1304a230
Introduction: During the COVID-19 pandemic, personal protective equipment, particularly face masks, has become an essential requirement to engage in social activities. Several articles reported an increase of recurrences of dermatologic facial diseases (i.e., acne, rosacea) related to mask use.
Objectives: To evaluate the number of recurrences of rosacea related to face mask use.
Methods: This prospective study was conducted on adult patients with a pre-pandemic diagnosis of mild and moderate papulopustular rosacea. All patients had previously achieved either partial or complete remission after a 4-month treatment with ivermectin in 2019. We collected data in two different phases characterized by different intensity of mask use during the pandemic and post-pandemic period. We collected data through clinical assessment of the disease, questionnaires on personal habits and standardized skin surface biopsy to study the Demodex mites count.
Results: We enrolled a total of 30 patients. In the pandemic period, 5/30 patients had a relapse of mild papulopustular rosacea; the Demodex sample resulted positive in 4/5 relapsed patients.  In the post-pandemic period, 4/30 patients reported a relapse of mild (3 patients) and moderate papulopustular rosacea (1 patient). At the Demodex exam, 1/4 relapsed patients resulted positive.
Conclusions: We did not find a significant increase in relapses of papulopustular rosacea during the pandemic. An appropriate anti-parasitic treatment may reduce the number of recurrences due to mask use.
text/xml
2160-9381
3252
en
Aurora Parodi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
SARS-CoV-2
Has the Use of the Mask Exacerbated Rosacea During the Pandemic?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-02-15
2023-10-31
2024-01-15
e2023230
Dermatol Pract Concept
Introduction: During the COVID-19 pandemic, personal protective equipment, particularly face masks, has become an essential requirement to engage in social activities. Several articles reported an increase of recurrences of dermatologic facial diseases (i.e., acne, rosacea) related to mask use.
Objectives: To evaluate the number of recurrences of rosacea related to face mask use.
Methods: This prospective study was conducted on adult patients with a pre-pandemic diagnosis of mild and moderate papulopustular rosacea. All patients had previously achieved either partial or complete remission after a 4-month treatment with ivermectin in 2019. We collected data in two different phases characterized by different intensity of mask use during the pandemic and post-pandemic period. We collected data through clinical assessment of the disease, questionnaires on personal habits and standardized skin surface biopsy to study the Demodex mites count.
Results: We enrolled a total of 30 patients. In the pandemic period, 5/30 patients had a relapse of mild papulopustular rosacea; the Demodex sample resulted positive in 4/5 relapsed patients.  In the post-pandemic period, 4/30 patients reported a relapse of mild (3 patients) and moderate papulopustular rosacea (1 patient). At the Demodex exam, 1/4 relapsed patients resulted positive.
Conclusions: We did not find a significant increase in relapses of papulopustular rosacea during the pandemic. An appropriate anti-parasitic treatment may reduce the number of recurrences due to mask use.
Aurora Parodi
2023/10/31
10.5826/dpc.1304a230
e2023230
Section of Dermatology - Department of Health Sciences, University of Genoa, IRCCS - Ospedale Policlinico San Martino, Genoa, Italy
2160-9381
SARS-CoV-2
en
e2023230
Yan Y, Yao Q, Lu Y, et al. Association Between Demodex Infestation and Ocular Surface Microbiota in Patients with Demodex Blepharitis. Front Med (Lausanne). 2020;7:592759. DOI: 10.3389/fmed.2020.592759. PMID: 33251239. PMCID: PMC7672197.
Has the Use of the Mask Exacerbated Rosacea During the Pandemic?
https://dpcj.org/index.php/dpc/article/download/3252/2394
       Has the Use of the Mask Exacerbated Rosacea
                   During the Pandemic?
       Ilaria Trave1, Ilaria Salvi1, Emanuele Cozzani1, Rebecca Donadoni1, Aurora Parodi1


1 Section of Dermatology - Department of Health Sciences, University of Genoa, IRCCS - Ospedale Policlinico San Martino, Genoa, Italy



Key words: rosacea, mask, COVID-19, SARS-COV-2
Citation: Trave I, Salvi I, Cozzani E, Donadoni R, Parodi A. Has the Use of the Mask Exacerbated Rosacea During the Pandemic?
Dermatol Pract Concept. 2023;13(4):e2023230. DOI: https://doi.org/10.5826/dpc.1304a230
Accepted: April 19, 2023; Published: October 2023
Copyright: ©2023 Trave et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Dr Emanuele Cozzani, Section of Dermatology - Department of Health Sciences, University of Genoa,
IRCCS - Ospedale Policlinico San Martino, Genoa, Italy. Telephone number: 0105555750; Email: Emanuele.cozzani@unige.it




  ABSTRACT             Introduction: During the COVID-19 pandemic, personal protective equipment, particularly face
                       masks, became an essential requirement to engage in various activities. Several articles reported an
                       increase of recurrences of dermatologic facial diseases (ie, acne, rosacea) related to mask use.
                       Objectives: To evaluate the number of recurrences of rosacea related to face mask use.
                       Methods: This prospective study was conducted on adult patients with a pre-pandemic diagnosis
                       of mild and moderate papulopustular rosacea. All patients had previously achieved either partial or
                       complete remission after a 4-month treatment with topical ivermectin in 2019. We collected data
                       in two different phases characterized by different intensity of mask use during the pandemic and
                       post-pandemic period. We collected data through clinical assessment of the disease, questionnaires on
                       personal habits and standardized skin surface biopsy to study the Demodex mites count.
                       Results: We enrolled a total of 30 patients. In the pandemic period, 5/30 patients had a relapse of
                       mild papulopustular rosacea; the Demodex sample resulted positive in 4/5 relapsed patients. In the
                       post-pandemic period, 4/30 patients reported a relapse of mild rosacea (3 patients) and moderate pap-
                       ulopustular rosacea (1 patient). At the Demodex exam, 1/4 relapsed patients resulted positive.
                       Conclusions: We did not find a significant increase in relapses of papulopustular rosacea during
                       the pandemic. An appropriate anti-parasitic treatment may reduce the number of recurrences due to
                       mask use.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023230                                                                          1
Introduction                                                      flushing and ocular manifestations). For each patient, we
                                                                  evaluated the degree of erythema, telangiectasias, papules
During the COVID-19 pandemic, personal protective equip-          and pustules and phyma with validated scales [8-10].
ment (PPE), particularly face masks, had become an essential         Each patient was asked to fill out a questionnaire during
requirement to engage in various activities. Since the begin-     the pandemic and post-pandemic visits covering the follow-
ning of the pandemic, several articles reported an increase       ing information: oral, nasal and ocular signs and symptoms
of inflammatory dermatitis relapses linked to the use of face     due to masks, type of mask used and daily hours of usage.
masks [1-5]. As far as rosacea is concerned, there are no spe-    The presence of flushing was assessed according to Global
cific studies conducted on patients with this dermatological      Flushing Severity Score (GFSS) [8], erythema was evaluated
disease, but several Authors, among whom Damiani et al [6],       using Clinician Erythema Assessment (CEA) [9] and the
reported an increase of recurrences.                              disease severity of papulopustular rosacea was classified
                                                                  by Investigator Global Assessment score (IGA score) [10]).
                                                                  IGA score defines disease severity from 0 to 4: IGA 0 = no
Objectives
                                                                  inflammatory lesions, no erythema; IGA 1 = very few small
In this study, we aimed to evaluate the number of recur-          papules/pustules, very mild erythema; IGA 2 = few small
rences of papulopustular rosacea related to face mask use in      papules/pustules, mild erythema; IGA 3 = several small or
a group of patients followed for this disease in our Centre.      large papules/pustules, moderate erythema; IGA 4 = numer-
                                                                  ous small or large papules/pustules, severe erythema. Due to
                                                                  the lack of validated scales for telangiectasias and phyma,
Methods                                                           we adopted a graded clinical scoring from 0 to 3 for the first
This prospective study was conducted at the Dermatology           and a graded classification from 0 to 1 for the second (0 =
Centre of Ospedale Policlinico San Martino IRCCS in Ge-           absent, 1 = present).
noa (Italy) from March 1, 2020 to December 31, 2022. We              In order to study the Demodex mites count, a standard-
included adult patients (>18 years old) with a pre-pandemic       ized skin surface biopsy (SSSB) was performed by a trained
diagnosis of mild and moderate papulopustular rosacea             dermatologist on the target area. SSSB is a sampling method
(PPR); all these patients had been treated with a 4-month         in which 1 cm2 of the superficial layer of the stratum cor-
period with topical ivermectin in 2019. As a result of this       neum and its follicular content is recovered for analysis [11].
treatment, all patients had achieved either partial or com-       Samples obtained by SSSB were examined with an optical
plete remission.                                                  microscope at × 10 and × 40 magnifications. Samples with
    To study the effect of face masks on rosacea, we collected    ≥5 Demodex/cm2 (D/cm2) were considered positive (D+). Af-
data in two different phases: pandemic period from September      ter treatment in 2019, all patients resulted negative to Demo-
to December 2020, during which the use of personal protec-        dex sample. Descriptive statistical analyses were performed,
tive equipment in public spaces was enforced by the Italian       and data was shown as median (range), mean (SD), or num-
government and post-pandemic period from September to             ber (percentage). Relapse rates and the number of relapse
December 2022, characterized by a more limited use of PPE.        times were evaluated for patients divided by IGA score and
Also, during the post-pandemic period, mask use was still         analyzed using the Kaplan-Meier method and log-rank test.
necessary to engage in several activities.                        Patients who relapsed were considered censored in the anal-
    In this study, only patients with a reported minimum          ysis. For categorical variables, data was analyzed using the
daily use of the face mask of 6 hours during the pandemic         χ2 test and Fisher exact test.
period and of 3 hours in after-pandemic period were in-              The study was approved by the local Ethical Review
cluded. We aimed to avoid including patients with daily but       Board (Comitato Etico Regione Liguria. N. Registro CER
extremely limited mask use, which could have been a con-          Liguria: 156/2022)
fusing factor. In addition, other studies have adopted similar
thresholds [7]. The patients did not receive any treatment        Results
during the study, did not use antiparasitic face wash gel and
were advised to wear a disposable mask, which had to be           A total of 30 patients (26 females, 4 males) were enrolled in
changed daily.                                                    this study, with an average age of 59.0-years old. The mean
    The diagnosis of rosacea was made by an experienced           results are reported in Table 1. Analyzing the data collected
dermatologist and based on the following National Rosacea         through the questionnaire, 8/30 rosacea patients reported
Society (NRS) expert panel criteria [8]: fixed centro-facial      a subjective association between mask wearing and flares
erythema in a characteristic pattern that may periodically in-    of rosacea. Patients reported of having worn a FFP2 mask
tensify; papules and pustules (with or without telangiectasias,   for an average time of 9 h/day during the pandemic and for



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(4):e2023230
                                           Table 1. Clinical featuring of patients.
              Rosacea                     Pre-pandemic                   Pandemic                         Post-pandemic
                                                                    September 2020-                      September 2020-
                                               2019                  December 2020                        December 2020
                                           (30 patients)               (30 patients)                       (30 patients)
 Erythema                                        19                           25                                 24
 CEA 4                                           0                              1                                 2
 CEA 3                                           1                              4                                 1
 CEA 2                                           4                              5                                 4
 CEA 1                                           14                           15                                 11
 CEA 0                                           11                             5                                 6
 Teleangectasias                                 18                           20                                 22
 Grade 3                                         1                              1                                 0
 Grade 2                                         5                              1                                 3
 Grade 1                                         12                           18                                 19
 Grade 0                                         12                           10                                  8
 Flushing                                        10                           14                                 12
 GFSS 10                                         0                              0                                 0
 GFSS 7-9                                        0                              0                                 0
 GFSS 4-6                                        3                              3                                 2
 GFSS 1-3                                        7                            11                                 10
 GFSS 0                                          20                           16                                 18
 Phyma                                           3                              3                                 3
 Grade 1                                         3                              3                                 3
 Grade 0                                         27                           27                                 27
 Papulopustules                                  0                              5                                 3
   IGA 3                                         0                              0                                 1
   IGA 2                                         0                              5                                 2
   IGA 0-1                                       30                           25                                 27
   Demodex positive                              0                              5                                 2

CEA = Clinician Erythema Assessment; GFSS = Global Flushing Severity Score; IGA score = Investigator Global Assessment score.


an average time of 4.6 h/day in the post-pandemic period.                   Table 2. Eye, nose and mouth symptoms.
Signs and symptoms caused by mask-wearing are reported
                                                                         Additional signs and                The pandemic
in Table 2.
                                                                              symptoms                          Total = 30
    In the pandemic period out of the 30 patients, 25 had
                                                                                                             N patients, (%)
erythema, 20 had telangiectasias, 14 had flushing and 3 had
                                                                      Eye                                       16 (53.3)
phyma. The average results of the disease assessment are re-
                                                                      Burning                                   11 (36.7)
ported in Table 1. Five of the 30 patients had a relapse of
                                                                      Tearing                                   11 (36.7)
IGA 2 papulopustular rosacea; they wore a FFP2 mask for
                                                                      Itching                                    5 (16.7)
an average time of 7h/day during the pandemic. The Demo-
dex sample resulted positive in 4/5 relapsed patients and in          Foreign body sensation                     4 (13.3)

1/25 stable patients.                                                 Redness                                     2 (6.7)
    In the post-pandemic period, 24 patients had erythema,            Nose                                        9 (30)
22 telangiectasias, 12 flushing and 3 phyma. The average of           Secretions                                 5 (16.7)
the results of the disease assessment are reported in Table 1.        Itching                                     2 (6.7)
Four/30 patients who wore a FFP2 mask for an average time             Burning                                     1 (3.3)
of 4h/day reported a relapse of IGA 2 (3 patients) and IGA 3          Mouth                                      4 (13.3)
PPR (1 patient). At the SSSB, 1/4 relapsed patients and 1/26          Burning                                     2 (6.7)
stable patients resulted positive.                                    Itching                                     1 (3.3)


Original Article | Dermatol Pract Concept. 2023;13(4):e2023230                                                                  3
    All the patients were either retired or indoor workers,        demonstrate an etiopathological association between relapse
so they received minimal sun exposure during work. All the         of rosacea and Demodex proliferation.
patients were non-smokers, and occasional alcohol drinkers            Regarding the typical signs and symptoms of rosacea,
(less than 3 times a week). None of the patients significantly     such as erythema, telangiectasias, and phyma, we did not
changed their habits during the study.                             observe a significant worsening. On the contrary, we found
                                                                   only a slight increase in the frequency of flushing, which was
                                                                   reportedly related to mask use, with resolution within a few
Conclusions
                                                                   hours in the evening.
This is the first study which compares the clinical course of         Regarding other symptoms reported since the beginning
rosacea before, during and after the pandemic. The other           of the pandemic, ocular alterations were the most frequent
studies reported in the literature on this topic are inhomo-       (16/30), followed by nasal (9/30) and oral (4/30) symptoms.
geneous and difficult to compare. For example, Consasu et          Ocular symptoms are a relatively common manifestation
al (5) conducted a study exclusively on medical staff who          of rosacea, which have also been associated with Demodex
wore masks during the Covid-19 pandemic, reporting a               proliferation [16]. In these already susceptible patients, the
39.1% increase in the risk of rosacea [5]. Damiani et al ex-       use of face masks may have promoted a microbiome dysbi-
amined patients before and after the pandemic, reporting an        osis, with a probable increase of proliferation of Demodex
increase of rosacea flares [6]. Singh et al reported an increase   mites in the eyes [17]. However, further research is needed to
in rosacea-like lesions due to a change in skin environment        investigate this hypothesis.
[2]. In contrast with the literature data, we did not find a          To monitor our patients over time, we performed an
significant increase in relapses of PPR during the pandemic.       additional follow-up visit after discontinuation of the mask
Only 5/30 patients had a relapse with IGA2 PPR, and none           requirement; we did not observe significant differences in
of them linked the relapse to prolonged mask use. It may be        relapses from previous periods. All patients who relapsed
possible that the observed relapses were simply due to the         during and post COVID-19 were treated with antibiotics
normal course of the disease, which is typically characterized     and topical ivermectin with the result of complete clinical
by phases of exacerbation and remission [12]. However, we          remission and of SSSB negative for Demodex after 3 months
hypothesize that an appropriate treatment of the inflamma-         of therapy.
tory stage of PPR and the control of Demodex folliculorum             In conclusion, we reported cases of good control of
proliferation before the pandemic, reduced the number of           mild-to-moderate rosacea during COVID-19 due to appro-
recurrences. Topical ivermectin is considered an effective and     priate anti-parasitic and anti-inflammatory treatment, which
well-tolerated drug which is used not only in moderate to          allowed control of proliferation by Demodex folliculorum
severe PPR but also in almost clear/mild rosacea with a low        before intensive mask use. The use of topical anti-parasitic
number of clinical relapses over the time [13]. In our patients,   and systemic antibiotics ensures control of the inflammation
topical ivermectin not only achieved complete resolution of        and restitution ad integrum. It would be interesting in the
the inflammatory phase of rosacea in 66.67% of patients            future to compare the results presented in this study with
and partial resolution in 33.33% before the onset of the           new data collected after the end of mask use to assess the
pandemic, but we assume it also reduced recurrences during         effective role of the mask on the proliferation of Demodex
the period of mask use. In addition, controlling the initial       folliculorum.
hyperproliferation of Demodex folliculorum with topical
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Original Article | Dermatol Pract Concept. 2023;13(4):e2023230                                                                              5
