dermatosis

皮肤病
  • 文章类型: Journal Article
    这项研究的目的是(I)评估密度的影响,血统,年龄,和背部表面温度的一天中的时间,以及(ii)评估密度和谱系对肉鸡烤架性能和car体谴责的影响。评估是在谷仓里用黑屋系统进行的,有两种密度,17和19鸡/m2和两个谱系,科布和罗斯.在7,14,21,23,25和27日龄时,用红外热成像法测定鸡的背部温度,一天四次.平均每日体重增加,饲料转换,死亡率,部分car体谴责,以及那些由于关节炎和皮肤病也进行了评估。在以17只鸡/m2的密度饲养的Cobbs和以19只鸡/m2的密度饲养的Ross中观察到最高的背表面温度。与相同密度的Ross相比,以17只鸡/m2的密度饲养的Cobbs显示出最低的饲料转化率。在14、21和27天,与Cobbs相比,Ross的背侧表面温度更高。与罗斯相比,科布斯显示出更高的部分car体谴责和关节炎百分比。黑屋系统中密度较高的肉鸡烤架不会影响背部表面温度,性能,皮肤病,关节炎,和部分尸体谴责。
    The aims of this study were (i) to evaluate the effect of density, lineage, age, and time of day on dorsal surface temperature and (ii) to evaluate the effect of density and lineage on performance and carcass condemnations in broiler grillers. The evaluations were carried out in barns with the Dark House system, with two densities, 17 and 19 chickens/m2 and two lineages, Cobb and Ross. The dorsal surface temperature of the chickens was measured by infrared thermography at 7, 14, 21, 23, 25 and 27 days of age, four times a day. The average daily weight gain, feed conversion, mortality, partial carcass condemnations, as well as those due to arthritis and dermatosis were also evaluated. The highest dorsal surface temperatures were observed in Cobbs housed at a density of 17 chickens/m2, and in Ross housed at a density of 19 chickens/m2. Cobbs housed at a 17 chickens/m2 density showed the lowest feed conversion compared to Ross at the same density. Ross showed higher dorsal surface temperatures when compared to Cobbs at 14, 21, and 27 days. Cobbs showed higher percentages of partial carcass condemnation and arthritis compared to Ross. The higher density of broiler grillers in the Dark House system does not influence the dorsal surface temperature, performance, dermatosis, arthritis, and partial carcass condemnations.
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  • 文章类型: Case Reports
    扁平苔藓(LP)是一种常见的T细胞介导的自身免疫性皮肤病,其确切病因尚不清楚。通常,它会影响后备箱,挠曲表面,和粘膜。我们报告了一名67岁女性中罕见的涉及两个眼睑的LP发现。一位67岁的沙特女性,有糖尿病病史,甲状腺功能减退症和类风湿性关节炎均有3个月的双眼皮瘙痒性皮疹病史。她没有相关的肌肉骨骼症状或疲劳,也没有过敏症的病史或家族史。病人有暴力倾向,薄,鳞状斑块局限于两个眼睑。口腔粘膜,生殖器,头皮,指甲没有受到影响。右下眼睑的组织病理学证实了LP的诊断。丙型肝炎病毒血清学检查阴性。通过眼科检查患者以排除LP的结膜受累。她只有干涩的眼睛。她最初使用0.1%他克莫司外用软膏治疗,但由于严重反应而无法耐受。她耐受0.1%丙酸莫米松乳膏,缓解瘙痒,部分改善病变。虽然罕见,在眼睑皮炎的鉴别诊断中必须考虑眼睑的LP。它可以被限制,或者它可能同时涉及身体的其他部位。眼睑的LP也可以延伸到结膜,因此,通过眼科筛查患者以排除可能的眼部受累是很重要的。这是沙特患者LP局限于眼睑的首例病例报告。涉及眼睑的LP的管理具有挑战性。治疗选择包括局部类固醇,他克莫司软膏,光疗和口服类维生素A(依定)。
    Lichen planus (LP) is a common T-cell-mediated autoimmune skin disease, and its exact etiology is unknown. Typically, it affects the trunk, flexural surfaces, and the mucosa.We report a rare finding of LP involving both eyelids in a 67-year-old female. A 67-year-old Saudi female with a medical history of diabetes mellitus, hypothyroidism and rheumatoid arthritis presented with a three-month history of pruritic skin eruptions in both eyelids. She had no associated musculoskeletal symptoms or fatigue and no medical or family history of atopy. The patient had violaceous, thin, scaly plaques confined to both eyelids. Oral mucosa, genitalia, scalp, and nails were not affected. Histopathology from the right lower eyelid confirmed the diagnosis of LP. Hepatitis C virus serology was negative. Patient was examined by ophthalmology to rule out conjunctival involvement of LP. She had dry eyes only. She was initially managed by topical tacrolimus 0.1% ointment and didn\'t tolerate it due to severe reaction. She tolerated mometasone propionate 0.1% cream, which relieved the itch and partially improved the lesions. Although rare, LP of the eyelids must be considered among differential diagnoses of eyelid dermatitis. It can be confined, or it may concomitantly involve other parts of the body. LP of the eyelid may also extend to the conjunctiva, so it\'s important to screen patients by ophthalmology to rule out possible ocular involvement. This is the first case report of a Saudi patient with LP confined to the eyelid. The management of LP involving the eyelids is challenging. Treatment options include topical steroids, tacrolimus ointment, phototherapy and oral retinoids (etretinate).
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  • 文章类型: Journal Article
    微量元素是维持身体稳态所必需的,它们的特殊作用已经在皮肤生理学中得到证实。其中最重要的微量元素是锌,铜,和铁。微量元素的缺乏或过量可能与皮肤病的风险增加有关,因此,增加他们的补充或限制摄入量可能有助于皮肤病治疗。此外,它们在各种类型的生物材料中的水平的测定可以用作皮肤病治疗中的附加测试。本文介绍了这些元素在皮肤生理中的作用,并总结了有关锌的数据,铜,和铁在选定的过程中,以下皮肤病:牛皮癣,寻常型天疱疮,特应性皮炎,寻常痤疮和脂溢性皮炎。此外,这项工作确定了微量元素作为皮肤病学辅助测试的潜力。根据初步研究,锌含量异常,铜,在许多皮肤病中观察到铁和铁,它们在血清或头发中的测定可用作各种皮肤病过程中的辅助和预后测试。然而,由于某些条件的数据是冲突的,明确定义微量元素作为辅助测试或需要限制/补充的元素的潜力需要进一步研究。
    Trace elements are essential for maintaining the body\'s homeostasis, and their special role has been demonstrated in skin physiology. Among the most important trace elements are zinc, copper, and iron. A deficiency or excess of trace elements can be associated with an increased risk of skin diseases, so increasing their supplementation or limiting intake can be helpful in dermatological treatment. In addition, determinations of their levels in various types of biological material can be useful as additional tests in dermatological treatment. This paper describes the role of these elements in skin physiology and summarizes data on zinc, copper, and iron in the course of selected, following skin diseases: psoriasis, pemphigus vulgaris, atopic dermatitis, acne vulgaris and seborrheic dermatitis. In addition, this work identifies the potential of trace elements as auxiliary tests in dermatology. According to preliminary studies, abnormal levels of zinc, copper, and iron are observed in many skin diseases and their determinations in serum or hair can be used as auxiliary and prognostic tests in the course of various dermatoses. However, since data for some conditions are conflicting, clearly defining the potential of trace elements as auxiliary tests or elements requiring restriction/supplement requires further research.
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  • 文章类型: Journal Article
    在新生儿生命周期中,各种皮肤病是常见的。与成年人的皮肤相比,新生儿皮肤在生命的第一周更容易受到感染。这些感染通常会导致许多皮肤病皮肤并发症,并在父母中令人担忧。因此,尽早诊断和管理受影响的新生儿至关重要。这项研究旨在突出和估计许多皮肤病的发生,并评估新生儿生理和病理上发生的各种皮肤变化。
    在这项横断面观察研究中,474例新生儿被纳入新生儿重症监护病房。整个新生儿皮肤表面,包括手掌和鞋底,头皮,粘膜,生殖器,头发,和指甲,在足够的光线下仔细检查,观察并记录皮肤上发生的所有变化。样本量估算是从皮肤皮肤病最不普遍的参考文献中进行的:多毛症脱屑和餐巾皮肤病。进行了卡方检验等统计分析,以将皮肤病的类型与年龄参数相关联,性别,交货类型,出生体重。
    在总共474例病例中,90例(18.98%)单发皮肤病,而其余384人(81.01%)患有一种以上的皮肤病。在384起案件中,皮脂腺增生(SGH)105例(22.15%),爱泼斯坦珍珠在50(10.54%),新生儿中毒红斑(ETN)40例(8.43%),生理脱皮25例(5.27%),胎毛在20(4.21%),miliaria在22(4.64%),鲑鱼片13(2.74%),摇篮帽/脂溢性皮炎6(1.26%),Vernixcaseosa在12(2.53%),新生儿短暂脓疱黑变病13例(2.74%),先天性黑素细胞痣20例(4.21%),15例血管瘤(3.16%),新生儿痤疮5例(1.05%),餐巾皮炎10(2.10%),在第6位(1.26%)中,米利亚在2(0.42%)国际3(0.63%),火棉胶宝宝在2(0.42%),新生儿枕部脱发2例(0.42%),分别。
    本研究的结果代表了特定的种族/地理分布,并将有助于增加或比较新生儿皮肤病与其他地理区域的患病率,因为新生儿的皮肤病学特征阵列随时间和地点而变化。这项研究旨在深入了解新生儿皮肤病学领域的未来意义,并避免进一步的皮肤并发症。
    UNASSIGNED: During the neonatal life cycle, various dermatological conditions are common. In comparison to the skin of adults, neonates\' skins are more susceptible to infections in the first week of their lives. These infections often lead to many dermatological skin complications and create worrisome among parents. Hence, it is crucial to diagnose and manage such affected neonates at the earliest. This study aimed to highlight and estimate the occurrence of numerous dermatoses and assess various skin changes that occurred physiologically and pathologically in neonates.
    UNASSIGNED: In this cross-sectional observational study, 474 neonates were enrolled in the neonatal intensive care unit. The whole newborn skin surface, comprising the palms and soles, scalp, mucous membranes, genitalia, hair, and nails, was scrutinized under adequate light, and all changes that occurred over the skin were observed and recorded. The sample size estimation was undertaken from the references that have the least prevalent cutaneous dermatosis: hypertrichosis desquamation and napkin dermatosis. A statistical analysis like the Chi-square test was performed to associate the type of dermatosis with the parameters of age, gender, delivery type, and birth weight.
    UNASSIGNED: Of the total 474 cases, 90 (18.98%) had single dermatosis, while the remaining 384 (81.01%) had more than one form of dermatosis. Among the 384 cases, sebaceous gland hyperplasia (SGH) in 105 (22.15%), Epstein pearls in 50 (10.54%), erythema toxicum neonatorum (ETN) in 40 (8.43%), physiological desquamation in 25 (5.27%), lanugo hair in 20 (4.21%), miliaria in 22 (4.64%), salmon patch in 13 (2.74%), cradle cap/seborrheic dermatitis in 6 (1.26%), vernix caseosa in 12 (2.53%), transient neonatal pustular melanosis in 13 (2.74%), congenital melanocytic nevus in 20 (4.21%), hemangioma in 15 (3.16%), neonatal acne in 5 (1.05%), napkin dermatitis in 10 (2.10%), cutis marmorata in 6 (1.26%), milia in 2 (0.42%) intertrigo 3 (0.63%), collodion baby in 2 (0.42%), and neonatal occipital alopecia in 2 (0.42%) neonates each and others, respectively.
    UNASSIGNED: The findings from the present study were representative of a specific racial/geographic distribution and will assist in adding or comparing the prevalence of neonatal dermatosis with other geographic regions as the array of dermatological characterizations in neonates varies as per time and place. This study aims to provide insight into the future implications in the neonatal dermatology domain and avoid further skin complications.
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  • 文章类型: Journal Article
    中性粒细胞性皮肤病(ND)是一组非感染性疾病,其特征是存在无菌的中性粒细胞浸润而没有血管炎的组织病理学。他们的病理生理学尚未完全了解。中性粒细胞性皮肤病与自身炎性疾病之间的关联导致一些作者提出两者是相同疾病谱的一部分。NDs的分类取决于临床和组织病理学特征。这篇综述集中在这些疾病的治疗的最新进展。
    Neutrophilic dermatoses (NDs) are a group of noninfectious disorders characterized by the presence of a sterile neutrophilic infiltrate without vasculitis histopathology. Their physiopathology is not fully understood. The association between neutrophilic dermatoses and autoinflammatory diseases has led some authors to propose that both are part of the same spectrum of diseases. The classification of NDs depends on clinical and histopathological features. This review focuses on the recent developments of treatments in these pathologies.
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  • 文章类型: Journal Article
    背景:瘙痒性荨麻疹丘疹和妊娠斑块(PUPPP)是最常见的诊断为妊娠特异性皮肤病。它表现为强烈的瘙痒,可能难以管理,这鼓励母亲们向社交媒体寻求友情和建议。
    目的:这项研究旨在表征Instagram帖子的来源和主题内容,以定义有影响力的用户组。我们的目标是确定围绕PUPPP的在线话语的状态,并通过创建致力于为患者人群传播信息的Instagram帐户来阐明医疗保健提供者干预的任何潜在空间。
    方法:选择了三个标签类别(#PUPPP,#PUPPPs,和#PUPPPrash),并按来源和主题内容对每个职位的最高公共职位进行了分析和组织。还记录了喜欢和评论的数量。
    结果:在每个标签类别的前150个帖子中,总共只有428个职位符合这项分析的资格.大多数(316/428,73.8%)的职位是由经历过PUPPP的母亲创建的。这些帖子本质上是证词账户。一小部分帖子(14/428,3.3%)是由医生帐户生成的。来自博客的帖子以喜欢和评论的形式获得了最多的关注。
    结论:经历PUPPP的母亲包括在所选主题标签下发布的大多数帐户。最常见的主题包括皮疹和个人证词的图片。博客文章下的帖子平均收到的喜欢和评论最多。当谈到围绕PUPPP的话语时,医生和医疗保健专家有空间来改善他们的社交媒体存在。患者正在社交媒体上寻找社区,像Instagram一样,以便回答问题并获得管理建议。拥有大量追随者的账户往往有更多的喜欢和更多的评论,鼓励信息传播和意识。因此,我们建议医生创建内容,并可能与博客类型的账户合作,以改善外展.
    Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most commonly diagnosed pregnancy-specific dermatosis. It presents with intense pruritus and can be difficult to manage, which encourages mothers to look to social media for camaraderie and advice.
    This study aimed to characterize the sources and thematic content of Instagram posts in order to define influential groups of users. Our goal was to determine the status of online discourse surrounding PUPPP and elucidate any potential space for health care provider intervention via creation of Instagram accounts dedicated to information dissemination for patient populations.
    Three hashtag categories were selected (#PUPPP, #PUPPPs, and #PUPPPrash), and the top public posts from each were analyzed and organized by source and by thematic content. The numbers of likes and comments were also recorded.
    Among the top 150 posts in each hashtag category, only 428 posts in total were eligible for this analysis. Majority (316/428, 73.8%) of posts were created by mothers who experienced PUPPP. These posts were testimonial accounts in nature. A small fraction of posts (14/428, 3.3%) were generated by physician accounts. Posts from blogs with extensive followings garnered the most attention in the form of likes and comments.
    Mothers experiencing PUPPP comprised the majority of accounts posting under the hashtags selected. The most common themes included pictures of the rash and personal testimonies. Posts under blog posts received the most likes and comments on average. There is space for physician and health care specialists to improve their social media presence when it comes to discourse surrounding PUPPP. Patients are seeking out communities on social media, like Instagram, in order to have questions answered and obtain advice on management. Accounts with large followings tend to have more likes and more comments, which encourages information dissemination and awareness. Thus, we suggest that physicians create content and potentially partner with blog-type accounts to improve outreach.
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  • 文章类型: Journal Article
    肠相关性关节炎-皮肤病综合征(BADAS)是一种罕见的嗜中性皮肤病,于1971年首次在因肥胖而接受搭桥手术的患者中被描述。多年来,与医学胃肠病相关的报告病例数,特别是炎症性肠病(IBD),逐步增加。迄今为止,文献中没有关于BADAS的系统综述。先验协议的设计基于PRISMA指南,并对PubMed和Scopus数据库进行了搜索,以查找1971年至2023年之间发表的与该主题相关的文章。本系统综述分析了51篇文献,包括113例BADAS患者。减肥手术和IBD是BADAS最常见的原因,占所有病例的63.7%和24.7%,分别。总共85%的病例表现出典型的皮肤病学表现,包括以膀胱柱为中心的荨麻疹斑丘疹性病变,大部分病变位于上肢(73.5%)。多发性关节痛或局部关节炎总是存在。非典型的表现包括蜂窝织炎,结节性红斑样,甜综合征样和脓皮病-坏疽样表现。在IBD相关病例中经常观察到胃肠道症状(67.9%)。组织病理学显示嗜中性粒细胞浸润(96.6%)。最常用的治疗方案包括全身性皮质类固醇,甲硝唑和四环素,单独或组合。在52.1%的患者中观察到复发缓解过程。总之,BADAS是一种中性粒细胞性皮肤病,表现为多种皮肤表现,既典型又非典型。经常观察到胃肠道症状,尤其是与IBD相关的病例。与其他嗜中性皮肤病相比,组织病理学清晰但不特异。诊断可能具有挑战性,但是复发-缓解过程以及与多关节痛和胃肠道疾病的强烈关联可以帮助诊断。
    Bowel-associated arthritis-dermatosis syndrome (BADAS) is a rare neutrophilic dermatosis that was first described in 1971 in patients who underwent bypass surgery for obesity. Over the years, the number of reported cases associated with medical gastroenterological conditions, particularly inflammatory bowel disease (IBD), has progressively increased. To date, there are no systematic reviews in the literature on BADAS. The design of an a priori protocol was based on PRISMA guidelines, and a search of PubMed and Scopus databases was conducted for articles published between 1971 and 2023 related to the topic. Fifty-one articles including 113 patients with BADAS were analyzed in this systematic review. Bariatric surgery and IBD were the most frequently reported causes of BADAS, accounting for 63.7% and 24.7% of all cases, respectively. A total of 85% of cases displayed the typical dermatological presentation, including urticarial maculopapular lesions centered by a vesicopustule, with the majority of lesions located on the upper limbs (73.5%). Polyarthralgia or localized arthritis were always present. Atypical presentations included cellulitis-like, erythema-nodosum-like, Sweet-syndrome-like and pyoderma-gangrenosum-like manifestations. Gastrointestinal symptoms were frequently observed in IBD-related cases (67.9%). The histopathology showed a neutrophilic infiltrate (96.6%). The most commonly used treatment regimens consisted of systemic corticosteroids, metronidazole and tetracyclines, either alone or in combination. A relapsing-remitting course was observed in 52.1% of patients. In conclusion, BADAS is a neutrophilic dermatosis that presents with a wide variety of cutaneous manifestations, both typical and atypical. Gastrointestinal symptoms are frequently observed, particularly in cases related to IBD. The histopathology is clear but not specific compared with other neutrophilic dermatoses. The diagnosis can be challenging, but the relapsing-remitting course and the strong association with polyarthralgia and gastrointestinal disease can aid in the diagnosis.
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  • 文章类型: Journal Article
    远程皮肤病学已经变得非常流行,不仅仅是由于SARS-CoV-2大流行。职业性皮肤病(OSD)患者也可以从远程皮肤科服务中受益,作为其后续护理的一部分,但是对于患者和皮肤科医生来说,机遇和挑战,特别是关于质量和满意度,需要探索。在这个单中心可行性研究中,215名参加OSD三级预防计划的患者被邀请参加。获得同意后,与该中心的皮肤科医生进行了后续视频咨询预约。通过患者和皮肤科医生填写的完全标准化的在线问卷来评估咨询的质量和满意度。10名皮肤科医生对42例患者进行了68次远程皮肤科随访咨询。一半的皮肤科医生(50.0%)和87.6%的患者对视频咨询感到满意。然而,缺乏体检似乎是一个问题,特别是从医生的角度来看(75.8%)。共有66.1%的皮肤科医生和87.5%的患者将视频咨询视为面对面咨询的有用补充。我们的可行性研究结果表明,患者和医生对职业皮肤病学的远程皮肤病学会议的总体满意度,特别是作为面对面咨询的有益补充。
    Teledermatology has become very popular, and not only due to the SARS-CoV-2 pandemic. Patients with occupational skin diseases (OSDs) could also benefit from teledermatology services as part of their follow-up care, but the opportunities and challenges for patients and dermatologists, especially regarding quality and satisfaction, need exploration. In this single-center feasibility study, 215 patients taking part in a tertiary prevention program for OSD were invited to participate. After obtaining consent, a follow-up video consultation appointment with the center\'s dermatologists was made. Quality and satisfaction with the consultations were evaluated by fully standardized online questionnaires filled in by the patients and dermatologists. A total of 68 teledermatological follow-up consultations were conducted by 10 dermatologists on 42 patients. Half of the dermatologists (50.0%) and 87.6% of the patients were satisfied with the video consultations. However, the lack of physical examination seems to be a problem, especially from the physicians\' point of view (75.8%). A total of 66.1% of the dermatologists and 87.5% of the patients saw video consultations as useful supplements to face-to-face consultations. The results of our feasibility study indicate general satisfaction of patients and physicians with teledermatological sessions in occupational dermatology, especially as a useful supplement to face-to-face consultation.
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  • 文章类型: Case Reports
    Sweet综合征(SS)是一种罕见的非血管中性粒细胞性皮肤病。发烧,触痛的红斑和结节的突然出现,皮肤活检中偶尔出现囊泡和脓疱,以及密集的嗜中性粒细胞浸润是该病的标志。在受影响的人群中突然出现了温和的斑块或结节以及其他全身性表现,这被认为是由于免疫介导的超敏反应而发生的。我们报告了一名55岁女性在巴基斯坦出现的Sweet综合征病例。由于该地区此类案件很少见,因此值得报告。患者经过深入的调查后被诊断出,并接受了皮质类固醇治疗。
    Sweet syndrome (SS) is a rare non-vasculitic neutrophilic dermatosis. Fever, the abrupt emergence of tender erythematous plaques and nodules, with an occasional presentation of vesicles and pustules along with dense neutrophilic infiltrates on skin biopsy are the hallmarks of the illness. Tender plaques or nodules develop along with other systemic manifestations suddenly in affected people which is considered to occur due to immune-mediated hypersensitivity. We report a case of Sweet syndrome in Pakistan presenting in a 55-year-old female. It is worth reporting due to the rarity of such cases in this region. The patient was diagnosed after profound investigations and was treated with corticosteroid therapy.
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  • 文章类型: Journal Article
    2019年冠状病毒病是一种严重的急性呼吸道综合症,戴口罩是重要的预防措施。然而,长期使用会导致maskne,或面膜诱发的痤疮。这项研究评估了患病率,临床特征,使用在线问卷,面罩诱发的痤疮的严重程度及其对预先存在的皮肤病的影响。问卷包括关于6个主要主题的15个问题:人口统计数据,面膜的类型,使用口罩后的皮肤病症状,预先存在的皮肤病,使用的持续时间,以及使用口罩对现有皮肤病的影响。我们包括1,025名参与者;48.6%的人在使用口罩后出现皮肤病症状。最常见的症状是红色丘疹(33.8%)和瘙痒(27.2%)。每天戴口罩超过4小时的人出现了更多的皮肤病症状,例如,医疗保健提供者,与其他职业的参与者相比,他们患口罩相关皮肤病的风险更高。此外,口罩显着增加酒渣鼻的严重程度,接触性皮炎,和脂溢性皮炎.这些结果表明,经过董事会认证的皮肤科医生应在大规模研究中评估患者,以确定适当的管理策略。
    Coronavirus disease 2019 is a severe acute respiratory syndrome, and wearing a mask is an important preventive measure. However, long-term use can cause maskne, or mask-induced acne. This study evaluated the prevalence, clinical characteristics, and severity of mask-induced acne and its effect on pre-existing dermatosis using an online questionnaire. The questionnaire comprised 15 questions on 6 primary topics: demographic data, type of face mask, dermatological symptoms after using a mask, preexisting dermatological conditions, the duration of use, and the effects of mask use on existing dermatological conditions. We included 1,025 participants; 48.6% had dermatological symptoms after using masks. The most common symptoms were red papules (33.8%) and itching (27.2%). Individuals who wore masks for more than 4 hours daily experienced more dermatological symptoms, for example, healthcare providers, who had a higher risk of maskrelated dermatosis than participants with other occupations. Moreover, masks significantly increased the severity of rosacea, contact dermatitis, and seborrheic dermatitis. These results suggest that board-certified dermatologists should assess patients in larger-scale studies to determine adequate management strategies.
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