DERM DILEMMA by Dylan Dominguez 1 ; Chris Schach , MD
1 . UAMS College of Medicine , Class of 2025
A 17-year-old girl presents with a chief complaint of " maskne ." The rash has been present for four months and has been peeling , red , and irritated . The patient reports that she wears a protective face mask most of the day and finds that her condition worsens with mask usage and improves with discontinuation . Examination shows grouped 1-2 mm erythematous papules , a few pustules , xerosis , and scaling in a perioral , perinasal , and periocular distribution .
What is the most likely diagnosis and appropriate intervention ?
A . Allergic contact dermatitis due to her mask and / or facial cosmetic products . Apply topical 2.5 % hydrocortisone cream BID , use a white cotton mask , and discontinue cosmetic products .
B . Acne worsened by mask usage ( acne mechanica ). Begin minocycline 100mg QD and tretinoin 0.01 % gel QHS for six-eight weeks .
C . Seborrheic dermatitis exacerbated by mask usage . Start ketoconazole cream mixed equally with hydrocortisone 2.5 % cream and applied BID for seven days , then as needed .
D . Perioral dermatitis induced or exacerbated by mask usage . Begin clindamycin 1 % lotion applied BID and oral minocycline 100mg QD for 6-8 weeks .
E . Rosacea induced or exacerbated by mask usage . Prescribe metronidazole 0.75 % gel applied BID and oral minocycline 100mg QD for 6-8 weeks .
Answer : D . The patient is experiencing perioral dermatitis ( POD ), also known as periorificial dermatitis , which was likely induced and exacerbated by prolonged periods of occlusion by her face mask . The colloquial term “ maskne ” ( mask induced acne ) popularized during the COVID-19 pandemic , refers to an acneiform facial eruption initiated or perpetuated by friction , moisture , warmth , and occlusion . Environmental and mechanical forces can induce or worsen a number of
facial dermatoses , such that “ maskne ” is not limited to an underlying diagnosis of acne .
Although the etiology of POD is unknown , the condition is thought to be multifactorial based on genetic , environmental , and hormonal factors . Possible pathways that lead to the development of POD include skin barrier impairment , atopic diathesis , and altered cutaneous microbiota .
Perioral dermatitis is predominately seen in young women , aged 20-45 , though cases in men and children have been reported . It is most often noted around the mouth but may also involve perinasal and periocular skin ( thus , the alternative designation “ periorificial dermatitis ”). POD shares some overlapping clinical features with rosacea , acne , atopic dermatitis , and seborrheic dermatitis . POD classically is characterized by the presence of grouped 1 – 2 mm inflammatory papules or papulopustules on an erythematous , slightly scaly base , clustered in the typical distribution . Stinging or burning sensations are common complaints . In the case presented , the involvement of the periocular are more consistent with POD , as mechanically induced acne (“ acne mechanica ”) generally spares this area . Acne is also characterized by the presence of comedones as well as generally larger papules and pustules . Perioral dermatitis is sometimes induced or exacerbated using inhaled corticosteroids , and topical corticosteroids should be avoided when managing this condition . Topical corticosteroids may initially result in improvement but will perpetuate the condition and , upon discontinuation , result in a “ steroid rebound .” Some studies have suggested that colonization with Candida albicans , fusiform bacteria , or Demodex mites may play an etiologic role , but unlike seborrheic dermatitis , Malassezia yeast has not been implicated .
Potential cleansing and cosmetic irritants should be minimized , and soap-less cleansers and bland emollients recommended . Topical preparations containing metronidazole , erythromycin , sulfur preparations , azelaic acid , tacrolimus and pimecrolimus may be prescribed . More persistent disease may require oral agents , such as doxycycline , and some females respond to oral contraceptives . Isotretinoin has been used in recalcitrant cases .
220 • The Journal of the Arkansas Medical Society www . ArkMed . org