Literature Search and Selection Criteria

In order to gather relevant information, an extensive literature search was conducted using PubMed and Google Web Browser. Key terms such as “face mask”, “surgical face mask”, “elastic ear loops”, “pressure injury”, “ear injury”, “pinna injury”. The search results were thoroughly assessed to verify their pertinence to the subject. Literature was selected and analyzed from the initial pool of literature, a total of 34 peer-reviewed research articles were selected for inclusion in this study.

Discussion

Technique:

●  A strip of wool can be knitted in a rectangular fashion and two big buttons can be sewn at either end of the woolen knitted piece (Fig 1).

●  Place this woolen strip on the middle part of the occipital bone or on the back of neck (Fig 2).

●  The buttons can be used to hook the elastic flexible bands of the face mask on either each side of the knitted woolen strip (Fig 3).

●  Thus, by adjusting the elastic flexible bands of the face mask on the buttons, damage to the ear's skin caused by pressure can be avoided.

Wearing facial masks has been taken as a worldwide method to safeguard oneself and others amid the COVID-19 outbreak. Many surgical masks have stretchy components that go around the ear and apply pressure to this sensitive region. The elastic and flexible parts of many surgical masks go around the ear, apply pressure on this vulnerable region. Skin injury caused by pressure may occur if the mask is overly tight or worn for an extended period of time [10-11]. Because the post-auricular region is concealed behind the ear and/or covered in hair, it is possible to overlook or delay the diagnosis of injuries and dermatological conditions there [12-13]. Long-term use may result in pressure damage to the skin caused by a medical device (MDRPI) [13]. Throughout the COVID-19 pandemic, post-auricular dermatitis and contact dermatitis have also been extensively documented in the literature [3]. A pressure injury is a confined injury to the skin and underlying structures caused by extended pressure. When wearing a face mask for an extended period of time, the pressure from the flexible elastic straps near the ears can cause indentations on the skin that may lead to irritation on the skin or pressure injuries [14].

The architecture of the ear makes it more susceptible to pressure injury [12]. Given that it covers the cartilage laterally, muscle, tendon, and bone medially, the post auricular region is anatomically distinct. Moreover, due to the fact that it possesses the thinnest skin on the facial area, it is susceptible to pressure injuries [12].

Dermatological complications can arise from extended face mask use. These skin injuries, ranging from lesions to open wounds are of great concern, Complications associated with disposable ear loop masks include contact dermatitis, psoriasis, and acute shear stress on the outer ear leading to ulceration [12, 15]. Individuals with preexisting skin conditions like psoriasis, who are at risk of experiencing the Koebner phenomenon (new psoriatic lesions appear in previously unaffected skin areas after injury or trauma in psoriasis patients) after wearing mouth mask for prolonged period.

Adhesives, rubber found in straps, free formaldehyde released from non-woven polypropylene, and metal in clips have the potential to result in contact dermatitis and contact urticaria. [16-17], some individuals may have a reaction to thiuram, a substance present in the ear loops of surgical masks [18].

Bothra et al., [3] reported preliminary data on patients with retro-auricular dermatitis from wearing ear loop face masks. Gyapong et al., [2] evaluated the adverse reactions of wearing masks for extended periods among regular and occasional face mask users worldwide using an online structured questionnaire cited 22% respondent the most common complaints of discomfort included experiencing pain in the ear area. Users frequently touch their face masks as a result of their extreme discomfort, which increases the risk of cross-contamination between the hands and the mask and further spreads diseases [19]. Rosner E[4] in their online survey to evaluate the adverse effects of continued mask wearing on healthcare workers amid the COVID-19 pandemic cited 32.1% of the respondents reported skin breakdown behind the ears. Also, Hu K et.al [20] reported the adverse skin reactions of health care workers using personal protective equipment for COVID-19 in their survey cited 11% of the respondents had indentation and ear pain while wearing masks. A similar study by Purushothaman PK [19] reported in their survey, 45.2% had experienced pain behind the ear, likely caused by masks that are too tight. Venecija et al., [21] in their Webropol^® Online survey conducted in Finland among healthcare workers on their perspectives and experiences with using surgical masks. Many respondents reported (R26) as “In some surgical masks, the rubber bands of ear loops are so thin that they abrade the skin, irritating the area behind the ears. The pain caused by the rubber bands reduces the concentration on work.”

 Damage to the pinna can range from mild skin erosion on the postauricular side to skin damage brought on by pressure from a medical device (MDRPI) [12].  Few cases have been reported in literature regarding injury to post-auricular area the external ear/ pinna by the straps or ear loop of the surgical masks [6, 12, 14] to as severe as the pinna was torn off from the crus of the helix and the cartilage was revealed and broken into fragments [22] and a case where both ears are perforated from wearing a mask for too long in a patient with phobia to corona virus [23] Zanotti B et. al. [7] highlighted the auricular cartilage of pre-adolescent children who are still developing and less resistant to disfigurement; therefore, extended pressure from the flexible elastic bands of the mask on the antihelix level can affect the proper development and angulation of the external ear.

Preventive measures to avoid discomfort and damage to the pinna by fastening the mask ear straps behind the occiput, one can utilize a "ear saver" mask strap to prevent pressure or contact on pinnae [6]. Strap-secured masks should be taken into consideration as a different option to ear loop masks, adjustable straps provide comfort and reduce skin pressure for the user. Suggestions have been made to use hairpins to suspend elastic bands and other types of bands that go around the back of the neck, where the mask loops can be attached. [15]

Many commercially available similar items are available which can be used along with the surgical masks to prevent pressure on the ears. We present a very simple solution by using a woolen strap with buttons. The advantage of this rectangular based woolen fabric with buttons is it can easily be knitted especially by females and it will avoid irritation and injury to the skin of the auricle by taking off the pressure of the elastics. Also, this woolen fabric can be disinfected and reused again. Traditionally, females have been knitting woolen fabrics for years. It can be used whenever these commercial items are not available, especially in rural places.

Prevention strategy to prevent pressure injuries on the skin behind the ears

The National Pressure Injury Advisory Panel discussed a variety of ways to shield skin against friction caused by masks, such as the utilization of protective creams, moisturizers, skin sealants, and frequent PPE offloading [28]. In a study that was conducted recently, participants’ skin-PPE shear stress was minimized by using a lubricant made of 20% beeswax, 40% mineral oil, and 40% olive oil [29].

The literature has previously discussed recommendations. The first is the inclusion of division of work schedule into shifts for more opportunities to wear masks for shorter periods of time [30-31]. Second recommendation is to take preventative actions such using barrier creams, emollients, and moisturizers to stop skin deterioration. It is important to take precautions to make sure that bandages, lotions do not impact the seal of the mask and decrease its effectiveness in protecting against infectious particles [4]. A third recommendation is to develop masks designed to prioritize comfort, safety, and tolerability [32].

When wearing a face mask for longer than four to six hours each day, there are significant risk factors associated with adverse skin reactions. It has been recommended to encourage people who wear masks for more than 4 hours to have breaks without wearing a mask and to change masks at least once a day [33].

Tables and Figures

Conclusion