Practice Perfect 704
Should Docs Shave Their Beards for Better Mask Fit and Performance?

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A few weeks ago, in Practice Perfect 701 we talked about the details behind the N95 mask, one of the best and most sought after personal protective equipment (PPE) around. All of my clinical encounters occur with an N95 mask, and that PPE is becoming as much a part of my daily clinical dress as my scrubs. In fact, I’m almost getting used to that upper respiratory infection feeling in the sense that the mask squishes my nares, making me an obligate mouth-breather. As such, I can’t help but think more about the mask. Obviously, facial hair is very common in healthcare providers, and I wonder if this presents a problem. Should male healthcare workers be clean-shaven, or is a beard safe? What about versions of beards? Is a goatee safer than a full beard? Let’s take a look at the evidence.

Looking way back to 1984, Skretved and Loschiavo¹ performed qualitative and quantitative fit testing in 370 males. They found a 330-fold decrease in protection in those individuals with beards. Moving a little forward in time to 1988, a literature review of 14 studies found the presence of facial hair increased mask leakage by 20-1000 times².

More recently in 2017, Floyd, et al performed quantitative fit testing on 19 subjects with beards 0.5 inches long who were then shaved to 0.25, 0.125, 0.063 inches and clean-shaven and fit tested, creating 285 total tests³. They found beard length and density decreased mask fit. It’s looking pretty bad for beards.

Longer beard length and greater density did adversely affect mask fit.

Let’s take a slight detour and consider how clean all this facial hair is. Wakeam and associates looked at this in 2014 when they examined bacterial colonization rates in 408 male healthcare workers, 199 with facial hair and 209 without⁴. They performed swab cultures of this predominantly hospital-based population and found no significant difference in bacterial colonization rates between those with or without facial hair. They did find a difference in the organisms that colonized these different populations with a decrease in Staphylococcus aureus and methicillin resistant Staph epidermidis. Let’s say that again: those with facial hair had LESS of these staph species than those who were clean shaven! The authors explain this as resulting from the skin microtrauma that occurs as a result of shaving with a razor in much the same way that surgical site infections increase after preoperative skin shaving. Both clean-shaven and those with facial hair increased the rate of bacterial shedding after touching their faces.

Those with facial hair had LESS of staph species than those who were clean shaven. Microtrauma from shaving may promote growth of Staph.

Moral of this story: beards have less staph, but don’t touch your face!

Getting back to our original question, just this year, Sandaradura and colleagues, out of Australia, performed a study to evaluate the fit of N95 respirators on 105 male healthcare workers. I can’t help but point out that the study is named the “BEARDS” trial (BEnchmarking Adequate Respiratory DefenceS). How creative is that?

These researchers categorized facial hair by amount, from clean shaven to stubble to goatee, all the way to a full beard. Two reviewers classified the facial hair, and they then performed quantitative fit testing (the kind all healthcare workers have to undergo now). They found a fit factor for each person, requiring a score of 100 to pass. Overall, only 34 of 105 people (32%) achieved an adequate fit and none of those with a full beard achieved adequate fit. They found the length of hair inversely correlated with quality of mask fit⁵. I find it very interesting that only 47% of the clean-shaven subjects achieved adequate fit, which tells us something about the fit of these masks overall. Not the best news to report.

Only 47% of the clean-shaven subjects achieved adequate fit. It’s not just the beard. It’s the mismatch between the face shape and the mask.

The verdict? If you want to increase the chance that your N95 mask actually fits you well, and subsequently protect you the way you think it does, you’re better off without a beard. If you must have facial hair, then a short goatee appears better than a beard. If it fits within your N95 mask, then it will likely create the best seal. Sorry, men. Although a beard appears to be cleaner than being clean-shaven (ironic choice of terms, huh?), it reduces the protection your mask provides. Maybe we should bring back the mustache?