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Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 483-487
Comparison of malassezia colonization of ‘Maskne’ patients with seborrheic dermatitis cases and healthy individuals

1 Department of Health Sciences, İstanbul Kent University, İstanbul, Turkey
2 Department of Dermatology, Istanbul Başakşehir Çam and Sakura City Hospital, Başakşehir, Turkey
3 Department of Dermatology, Cerrahpaşa Medical Faculty, İstanbul University-Cerrahpaşa, İstanbul, Turkey
4 Department of Medical Microbiology, Medical Faculty, Pamukkale University, Denizli, Fatih/İstanbul, Turkey

Date of Web Publication29-Dec-2022

Correspondence Address:
Defne Özkoca
İÜC. Cerrahpaşa Tıp Fakültesi Yerleşkesi Kocamustafapaşa Cd. No: 53 Cerrahpaşa 34098 Fatih/İstanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_237_22

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Background: With the Covid-19 pandemic, the use of masks has increased the frequency of 'maskne' cases. Local physiological changes due to the use of mask have caused changes in the presence of yeasts in the environment, such as acne and seborrheic dermatitis. Objectives: The aim is to compare the differences of Malassezia species in the maskne region. Materials and Method: A total of 408 subjects wearing masks at least 4 h a day for 6 weeks or longer, compromised of 212 acne patients, 72 seborrheic dermatitis sufferers, and 124 healthy volunteers were included in this study. Swab samples were taken for Malassezia cultures from nasolabial area and their control retro auricular region. The Statistical Package for Social Sciences (SPSS) version 22 was used for the statistical analysis. Results: Malassezia species was most frequently found in the nasolabial region of the seborrheic dermatitis group. Malassezia species were more commonly isolated from the nasolabial region of acne and seborrheic dermatitis patients, compared to the retroauricular region of each patient, than the healthy subjects. The rate of M. globosa isolated from the nasolabial region was high in all groups, the isolation rate of M. restricta was low (P < 0.05). Conclusion: As Malassezia species are more commonly isolated from the nasolabial region of acne and seborrheic dermatitis patients, the increasing numbers of Malassezia species will trigger inflammation with an antibody reaction against these yeasts. Treatment of resistant acne and seborrheic dermatitis will be facilitated with the knowledge of this inflammation.

Keywords: COVID-19, Malassezia, maskne, seborrheic dermatitis

How to cite this article:
Atsu AN, Caf N, Türkoğlu Z, Özkoca D, Yıldırım O, Ergin &. Comparison of malassezia colonization of ‘Maskne’ patients with seborrheic dermatitis cases and healthy individuals. Indian J Dermatol 2022;67:483-7

How to cite this URL:
Atsu AN, Caf N, Türkoğlu Z, Özkoca D, Yıldırım O, Ergin &. Comparison of malassezia colonization of ‘Maskne’ patients with seborrheic dermatitis cases and healthy individuals. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 1];67:483-7. Available from:

   Introduction Top

With the world adapting to the COVID-19 pandemic, the daily use of surgical masks has become part of our lives. The use of protective equipment, such as masks, led to an increase in skin diseases and changes in their clinical presentation. The term 'maskne' has been used to describe the mechanic acne that emerged during this pandemic.[1]

'Maskne' is seen in the areas covered by the mask and occurs with the pressure of the equipment, occlusion of the pilosebaceous unit, increase in heat and humidity, and stress imposed by pandemic conditions. In addition, the fact that masks are not used in optimal conditions, such as excessive touching and reuse, and increased contact of hands with the face, may affect the microbiome of the face and create the basis for the formation of maskne conditions.[2]

Fabric masks play an important role in some 'new' dermatoses with facial hyperhidrosis by causative microorganisms. Whether the cause is increased temperature or textile-skin friction, the dysbiotic microbiome eventually dominates.[3] Malassezia are the most common fungal species in the skin flora and coexist with the other microorganisms mentioned. Although colonization of healthy skin is within the normal mycobiome, Malassezia yeasts, which play a role in the development of seborrheic dermatitis, also mimic clinical acne.[3] Resistant acne cases have been reported to be due to Malassezia and not due to Cutibacterium acnes, which has been often widely accepted beforehand. In addition, it was observed that acne lesions regressed with the use of antifungal drugs, which compliments this knowledge.[4]

Malassezia yeasts have 18 species and M. restricta and M. globosa are more dominant in the skin flora than the other species.[5] Malassezia is a commensal yeast and although its does not always cause skin pathologies, it has the potential to cause some dermatoses given that it can invade the stratum corneum, the uppermost layer of the skin, when the suitable conditions are provided.[6] It is known that seborrheic dermatitis is a multifactorial skin disease that progresses with erythematous scaly plaques. It has been known for many years that Malassezia yeasts also play a role in the aetiopathogenesis of this dermatosis.[7],[8]

The aim of this study is to compare the colonization of Malassezia among the patients with 'maskne' complaints, the existing Malassezia in patients with seborrheic dermatitis, and healthy individuals.

   Patients and Method Top

Study Design

Seborrheic dermatitis and acne patients who applied to the dermatology outpatient clinic were included in this study respectively without random sampling. The main inclusion criterion was that the participants wore conventional surgical masks for at least 4 h a day. Smoking, additional dermatological diseases, immunosuppression, having laser epilation or waxing of the face, history of an endocrinopathy, using drugs that may affect ovarian hormones or cause hirsutism, special nutritional problems including the deficiency of vitamins and minerals, pregnancy and lactation were the exclusion criteria. In addition, patients who had received systemic or local anti-acne and antifungal treatment in the last 15 days and those with a history of oral isotretinoin use were excluded.

The subjects were divided into three groups: acne sufferers, seborrheic dermatitis patients and healthy volunteers. The diagnosis of 'maskne' was based on mask-related complaints of a patient for 6 weeks or longer, or the worsening of existing acne lesions with mask use. Volunteers who applied to the dermatology outpatient clinic with diseases other than inflammatory dermatosis (such as routine nevus examination, cosmetic product/procedure advice or calluses) were included in the healthy individuals' group.

The retroauricular region, where there was no mask and outside the retroauricular crest, was considered as the self-control for each patient.

Informed consent form was obtained from all participants before the study. Consent was obtained from both the patients and their parents for the patients <18 years.

Microbiological analysis

Two swab samples were taken from each participant. The first was taken from the nasolabial region, which is covered by the surgical mask, and the second was taken from the retroauricular regions.

The swab, which was moistened with sterile saline for sample collection, was rubbed for 10–20 sec on the skin, rotating on its own axis, after it was wetted, and excess solution was poured. Swabs were transferred into the transport media (0.075 mol/L phosphate buffer saline containing 0.2% Tween and 0.4% chloramphenicol) to be sent to the laboratory at room temperature. The samples were inoculated on mDixon agar (with 0.2 g/L chloramphenicol) and FastFung agar (4.3% Schædler agar, 2% peptone, 1% glucose, 1% yeast extract, 0.5% desiccated ox-bile, 0.5% Tween 60, 0.2% oleic acid and 0.25% glycerol; supplemented with 0.2 g/L chloramphenicol, pH = 6) medium. All plates were incubated aerobically in a humid environment at 32°C for 10 days and examined daily for yeast growth.[9] Colonies were confirmed as yeast by native microscopic examination, and then inoculated on Sabouraud's dextrose agar (SDA) medium. Utilization of Tween compounds (Tween 20, Tween 40, Tween 60, Tween 80) was done following the absence of growth in SDA medium. Identification was made based on determination of urease, catalase and β-glucosidase (splitting of esculin) activities and PEG-35 castor oil assimilation.[10]

Statistical analysis

The Statistical Package for Social Sciences (SPSS) version 22.0 was used for statistical analysis. Frequency and mean values of the demographic characteristics of the participants were calculated. Pearson Chi-square (χ2) test was used to test the relationship between the categorical data in the study. McNemar test was used for two-related samples and binary logistic regression was used for group analysis. Less than 5% P value was accepted as statistically significant.

Ethical approval

Ethics committee approval for the study was obtained from Istanbul Kent University (approval number = 2021-04) and was conducted in accordance with the Declaration of Helsinki.

   Results Top


Among the 408 subjects, 51.9% had acne, 17.6% had seborrheic dermatitis and 30.4% were healthy individuals. The age of the subjects ranged between 12 and 40; and the mean age was 23.07 ± 5.92. About 68% of the patients were female and 32% were male.

[Table 1] shows the distribution of Malassezia species in the nasolabial and retro auricular regions of patients and healthy controls. In the samples taken from all groups, a statistically significant correlation was found between the nasolabial regions and the retroauricular regions at a confidence level of 95% (P < 0.05). There was no statistically significant difference between the Malassezia cultures of the nasolabial or retroauricular regions according to the groups of the participants in the study [[Table 1], P > 0.05]. There was no statistically significant difference between the positive or the negative nasolabial and retroauricular regions and the gender of the participants (P > 0.05).
Table 1: Malessezia growth on patients and healthy individuals

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Comparing the nasolabial and the retroauricular regions in each individual, acne and seborrheic dermatitis patients had a higher isolation of Malassezia sp. in the nasolabial region than healthy volunteers (26.8% vs 20.2% retrospectively, P < 0.05). While the isolation rate of M. globosa isolated from the nasolabial region which is accepted as 'maskne' region in this study, the isolation rate of M. restricta was low [[Figure 1], P < 0.05]. This similarity was not present for M. furfur and others. [Figure 1] demonstrates the distribution of the Malassezia sp. among the study groups.
Figure 1: Malessezia species by study groups

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   Discussion Top

Mechanical acne, on the one hand, is a type of acne vulgaris and may lead to symptoms such as itching, burning, and stinging. 'Maskne', on the other hand, was defined as a form of mechanical acne that was created by the COVID-19 pandemic. The use of mask may not solely cause acne, but may also cause dysbiosis in the microbiome of the skin by increasing sweating and humidity and causing alterations in sebum balance.[11],[12]

Malassezia skin mycobiome differs by sex, body site, and season. Generally, in male subjects, M. restricta and M. globosa are most predominant, followed by M. dermatis, M. furfur, and M. sympodialis. In female subjects M. globosa and M. sympodialis are the most predominant, followed by M. dermatis, M. restricta, and M. furfur.[13] In a study by Abdali et al., it was reported that the protective equipment used for COVID-19 may cause changes in the flora of the skin by affecting the temperature and permeability of the skin, and that Malassezia yeasts may proliferate and cause worsening of seborrheic dermatitis. In addition, it has been stated that seborrheic dermatitis is exacerbated in 46.5% of people who use face masks for 6–10 h a day.[14]

The short-term effects of surgical masks and other personal protective equipment are facial erythema, altered sebum production, increase in skin acidity and moisture, and increased transepidermal water loss. In addition to these the rubber of the mask equipment has an irritant effect in the retro auricular area.[15]

Masks used during the COVID-19 pandemic period increase transepidermal water loss and skin temperature in the short term, while in the long term they lead to enlarged pores, decreased skin elasticity and increase in acne formation.[16] The increase in yeast detected in our study can be attributed to the increase in skin functions detected in the studies of Kim et al. The areas where the heat and dryness of the skin increase and the pores are enlarged are more suitable environments for the proliferation of yeasts.[17],[18]

Seborrheic dermatitis is one of the most common dermatoses and its aetiology is multifactorial. It has been reported that M. restricta also plays a dominant role in the aetiology, and the disease improves with antifungals.[5] The fact that the masks increase humidity as well as their occlusive and heat-increasing effects, suggested that it might have changed the colonization balance in these patients. To reveal this relationship in patients using masks on a daily basis, large series of studies are needed, including the duration of mask use and the frequency of mask replacement. In addition, it would be beneficial to evaluate colonization in the lesion and perilesional skin separately.

In a study conducted on young individuals with acne, it was reported that M. globosa and M. restricta can be isolated. In our study, individuals with acne had the highest colonization M. furfur, but M. globosa, M. restricta and M. slooffiae were also isolated. The reason for the increase in M. furfur colonization may be the increased temperature and humidity in individuals with masks, and increased hand–face contact. Interestingly, M. globosa and M. restricta have greater isolation in the 'maskne' region than their retroauricular control [Figure 1]. However, the same coexistence was not found for M. furfur. This may be related to the skin changes of acne and seborrheic dermatitis. Additionally, an increased presence of M. furfur may have more dependence on 'maskne' conditions. Further studies are needed to establish a causal relationship to confirm this hypothesis.

The reason for the increase in M. furfur colonization may be increased temperature and humidity in individuals with masks, and increased hand–face contact. Higher M. globosa and M. restricta culture rates may be related to the skin changes of acne and seborrheic dermatitis. Additionally, increased presence of M. furfur may have greater dependence on 'maskne' conditions.

In this study, acne severity of acne patients was not evaluated with any index such as Global Evaluation of Acne (GEA), and the relationship between yeast colonization and acne severity was also not evaluated, only the causal relationship between acne lesions and the mask was investigated. In addition, although all the patients wore masks for 4 h or more, daily net mask usage time was not evaluated and the relationship of this time with colonization was also not evaluated. In addition, factors such as the frequency of daily mask change of the patients, and whether occlusive make-up was applied for female patients, were not questioned, and whether the moisturizers used were oil- or water-based and their usage status was also not questioned. These are the limitations of the study. The microbiological limitation of the study is that the study was culture-based. Although a major sampling bias is present in skin mycobiome studies, molecular approach could give a more precise idea of the prevalence of Malassezia species.[4],[19],[20]

Malassezia yeasts are at the forefront of the pathogenesis of acne resistance, yeast acne, and seborrheic dermatitis. Numerical differences and species differences were found in skin with and without lesions in different studies, and in this study, higher colonization was found in individuals with 'maskne', and with seborrheic dermatitis, compared to healthy individuals. Increasing numbers of Malassezia species will trigger inflammation with an antibody reaction against these yeasts. Knowing the cause of this inflammation, which is responsible for resistance in acne and seborrheic dermatitis, will also facilitate treatment.

   Conclusion Top

Seborrheic dermatitis and acne are inflammatory dermatoses, which are rapidly affected by the environmental stimulus changes. In the light of the results of this study, an effective increase is present in Malassezia species, which are thought to play an active role in the pathogenesis of acne and seborrheic dermatitis. To our knowledge this is the first study to investigate this subject in the current literature and constitutes a step towards wider studies, which will contribute, to the treatment spectrum of these diseases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms.

Statement of ethics

We conducted our research according to the World Medical Association Declaration of Helsinki and obtained the approval of local ethics committee.

Author contributions

Nilhan Atsu, Nazlı Caf and Zafer Türkoğlu were involved in the conception and design of the study. Nazlı Caf, Ozan Yıldırım and Çağrı Ergin were involved in acquisition of data. Nazlı Caf, Defne Özkoca and Çağrı Ergin involved in the analysis and/or interpretation of data. Nazlı Caf, Nilhan Atsü and Defne Özkoca were involved in the literature search and authorship.

Financial support and sponsorship

Financial support was received for this study from İstanbul Kent University Scientific Research Projects Unit (Project ID: 2021004).

Conflicts of interest

There are no conflicts of interest.

   References Top

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Agrawal S, Jaiswal S, Mishra DB, Rathi S. Dermatological manifestation due to preventive measures used during COVID-19 pandemic. Indian Dermatol Online J 2020;11:838-41.  Back to cited text no. 2
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  [Figure 1]

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