Letters to the Editor: August 2022

Perioral Dermatitis Caused by Improper Use of Activated Oxygen in CPAP users and its Complexity

J Clin Aesthet Dermatol. 2022;15(8):14

Dear Editor:

We read the original and exciting report by Roberts M et al.1 The authors report three cases of dermatitis associated with ozone application for the purpose of disinfecting continuous positive airway pressure (CPAP) masks. Chemicals used for disinfection of CPAP masks and interfaces can cause tissue damage when in contact with the skin for a prolonged time, and safe disinfection practices have yet to be standardized to prevent such damage. We applaud the observations by Roberts et al; further, we believe that in the spectrum of skin injury that occurs during CPAP use in patients with obstructive sleep apnea (OSA), other mechanisms that can cause or aggravate this complication could be helpful to study and incorporate in this topic. 

While we believe that the authors have considered a differential diagnosis of device-related pressure ulcers (DRPU), contributing factors and pathophysiology of the DRPU are vital to consider from a management point of view. The incidence of DRPU is nearly 28 percent, with Grade 1 being the most common type.2 The authors have described the cases well, and we agree with the diagnosis. However, the absence of pruritus in all cases has a background of irritant origins and strong clinical resemblance of DRPU Grade 1 with dermatitis hints that the dermoscopic findings might be helpful as a second-line approach in the table-side clinical examination for establishing the diagnosis.3,4

CPAP masks are well known to cause such injuries in long-term users.5 The level of mask fixation and the type of mask material in which these interfaces are built must also be considered. The use of active humidification in CPAP devices is also critical, as altered humidity and temperature might predispose and exacerbate skin trauma by altering the microclimate.6 Similarly, oxygen flow supply in CPAP devices is another factor—whether these patients have oxygen incorporated into their device. Oxygen-deprived flow can lead to skin lesions.7 Repetitive use of noninvasive ventilation (NIV) interfaces can compromise the efficiency of the mask, and while using it, patients might tie the mask with higher pressure than required, causing skin lesions. 

The authors have managed the cases well. As the authors mentioned, ozone has a half life of 25.4 hours; delaying the use until four hours following disinfection is unlikely to reduce the ozone content to a significant amount. Instead, we must consider other effective ways to decrease the residual ozone. We could recommend alternating between two masks, allowing adequate time following disinfection. Changing the interface type to another type and multidisciplinary approach adopted by the authors is commendable. Further, applying some protective layers, maintaining the humidity and temperature, and avoiding excessive pressures might be adjuncts to management.8 Nevertheless, the authors’ report highlights the need to establish a rigorous control in the disinfection methods for NIV interfaces. 

With regard,

Ghazal Ahmed, MD, DNB; Subhadeep Pal, MSc, RT, FNIV;
Antonio M. Esquinas, MD, PhD, FCCP, FNIV, FAARC; and
Habib MD Reazaul Karim, MD, DNB, IDCCM, FNIV

Affiliations. Dr. Ahmed is with the Department of Dermatology, Venereology and Leprosy, and All India Institute of Medical Sciences in Raipur, India. Dr. Pal is with the Symbiosis Institute of Health Sciences, Symbiosis International University, Pune Intensive Care Unit, Bharati Vidyapeeth Hospital and Research Center in Pune, India. Dr. Esquinas is with the Intensive Care Unit at Hospital Morales Meseguer in Murcia, Spain. Dr. Karim is with the Department of Anesthesiology, Critical Care and Pain Medicine at All India Institute of Medical Sciences in Raipur, India

Funding. No funding was provided for this article.

Disclosures. The authors report no conflicts of interest relevant to the content of this article.

Correspondence. Habib Md Reazaul Karim, MD, DNB, IDCCM, FNIV; Email: drhabibkarim@aiimsraipur.edu.in; drhabibkarim@gmail.com 

Keywords. Continuous positive airway pressure, dermatitis, face mask, ozone, pressure ulcers


  1. Roberts M, Roy DB, Goodman M, et al. Case Series of Perioral Dermatitis Caused by Improper Use of Activated Oxygen. J Clin Aesthet Dermatol. 2021;14(11):38–40.
  2. Brophy S, Moore Z, Patton D, et al. What is the incidence of medical device-related pressure injuries in adults within the acute hospital setting? A systematic review. J Tissue Viability. 2021;30(4):489–498.
  3. Inui S, Ikegawa H, Itami S. Dermoscopic evaluation of erythema associated with pressure ulcers. Int J Dermatol. 2011;50(8):945–947.
  4. Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol. 2012;166(6):1198–1205.
  5. Yamaguti WP, Moderno EV, Yamashita SY, et al. Treatment-related risk factors for development of skin breakdown in subjects with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respir Care. 2014;59(10):1530–1536.
  6. Gefen A, Alves P, Ciprandi G, et al. Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020;29(Sup2a):S1–S52.
  7. Straseski JA, Gibson AL, Thomas-Virnig CL, et al. Oxygen deprivation inhibits basal keratinocyte proliferation in a model of human skin and induces regio-specific changes in the distribution of epidermal adherens junction proteins, aquaporin-3, and glycogen. Wound Repair Regen. 2009;17(4):606–616. 
  8. Alqahtani JS, AlAhmari MD. Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers. Saudi Med J. 2018;39(5):443–452.