Experts share their tips for how to fit PAP masks for patients who sport beards or mustaches. Shaving does not have to be a patient’s default choice.
“Beards are back in style.” So says David Warkentin, RPSGT, lead sleep technologist for St. Charles Hospital’s Sleep Disorders Center.
That’s why he and other leaders in the industry are hesitant to tell men with facial hair that they need to shave in order to have their CPAP mask stay in place through the night and work effectively. “While shaving is an option, today’s men don’t want to give up their beards,” he says.
And according to the experts, they don’t have to.
“Masks should be chosen to fit a specific face, rather than the other way around,” says Philips Respironics’ chief medical liaison Teofilo Lee-Chiong, Jr, MD. “Having facial hair should not preclude the use of any type of mask, although the challenges with each may vary. Having a variety of masks at hand to try might be helpful in patients with large amounts of facial hair to assure a good seal.”
So which masks do experts recommend?
Nasal and nasal pillow masks that do not rest on top of the lip are ideal for patients with facial hair, says Fisher & Paykel’s (F&P’s) OSA mask senior product manager Matt Caughey. The F&P Opus 360, he says, would cater to that group of clients.
He warns, though, that mouth breathers would be more comfortable and better served by a mask like F&P’s Forma or the FlexiFit HC432, which has a seal that sits under the chin and, hence, mitigates any leaks.
Manufacturers including Hans Rudolph also offer full-face masks as an option for men with facial hair. That’s what Deb Hughes of Mid America Sleep Services often suggests to men with facial hair, describing the product as having a “large, more pliable sealing flange [that] goes completely under the chin, which creates a better seal and will not allow the mask [to] slip up” on the beard or mustache.
Having a mask that reaches the chin takes care of two issues, Hughes explains. “One, the beard is able to be covered and provide less air leak around the chin area, and two, the seals on them have never failed me with a male patient with a ‘Duck Dynasty’ style beard. That being said, if it covers the long, less shaped beards, it works excellent on trimmed and manicured beards.”
Hughes also is a believer in RemZzzs, a cloth liner that she attests will stop leaks.
ResMed inside clinical specialist Susie Justus is another advocate for RemZzzs and comparable mask liner products. “The material helps to keep the facial hair flattened, and sometimes if the beard is very coarse, this helps to prevent holes in the cushion,” she says.
Justus adds that she doesn’t ever advise men to shave their beards completely as a first-line recommendation. “If the patient states he gets a heavy 5 o’clock shadow, I would recommend he consider trying to shave nightly to maintain a good seal all night long. If the person has a beard and we have exhausted every option, including the possibility of dental appliance, then I would suggest the patient consider shaving his facial hair,” she says.
And it’s not just about the type of mask; it’s about the fit.
For instance, Daniel D. Lane, RPSGT, CCSH, president of the Board of Registered Polysomnographic Technologists (BRPT), who thinks the nasal pillow is optimal for CPAP patients with beards, advises: “When determining a comfortable fit, it is recommended to begin with the smaller size and advance to the next size until a proper seal is achieved.”
Lane notes that the right PAP pressure is established with the proper fit. “If a mask does not fit properly, excessive leaking will reduce the set pressure, and the wearer will not benefit fully from PAP therapy. If the straps are too tight, the wearer will experience discomfort and possible skin allergies. For men with facial hair, tight headgear in combination with full-face masks will cause thinning and patches of baldness to their beards and mustaches.”
Even with all of the suggested remedies, sleep doctors and product providers agree some men with facial hair might not require special treatment or fittings at all. But, they say, make sure to keep trying for those patients who do request multiple fittings before it’s exactly right.
“It’s too important to one’s health to just stop using the PAP therapy,” says ResMed’s Justus, who predicts that will be the result if the patient isn’t comfortable.
Patients do often need encouragement to identify a treatment plan, especially since there are, of course, downsides associated to some masks. As an example, Warkentin says that the nasal pillows are a good choice for men with facial hair, but “some patients do not like the sensation of the air forced up each nostril. Others develop irritation over time inside the nares.” As for the full-face masks, he points out that some patients might feel claustrophobic with a mask that covers his mouth and nose, among other complaints.
Justus adds, “The bottom line is the patient’s health, future, and how important is it to them to try and ensure optimal successful therapy. Sometimes reviewing the consequences of untreated apnea tailored to their medical profile may convince them otherwise.”
With treated or untreated apnea, there are also bed partners to consider, Warkentin says. If a mask is leaking, not only will it cause discomfort to the patient but sometimes it could “make squealing or other noises that wake the patient or bed partner….It must be explained to the patient why they need to continue trying—for their sake, and their bed partner. It is not only their health that is impacted by nightly snoring and apnea.”
He points to a study from the Mayo Clinic of Rochester, Minn, that estimates the spouse of a snorer loses more than an hour of sleep per night.1 “It is therefore important to let the patient know that there are several options and they should not give up until a solution has been found,” Warkentin says.
Alas, some patients are more difficult to convince than others.
For example, Warkentin found in his research on athletes’ performance as it relates to sleep that the Cleveland Indians’ Mike Napoli was diagnosed with sleep apnea but could not tolerate CPAP or oral appliances. Notably, Warkentin says, Napoli sports a sizable beard. “Perhaps part of his intolerance was due to his bushy beard and the leaks he experienced trying to keep it seated with that beard,” Warkentin speculates.
Ultimately, Napoli reportedly opted for “a very painful solution” in 2015: bimaxillary reconstruction surgery where doctors broke his upper and lower jaw to move them forward.
“Yikes! I think I would have shaved and tried a few more masks,” Warkentin says.
Stephanie Forshee is a New York-based journalist. This is her fourth article for Sleep Review.
1. Beninati W, Harris CD, Herold DL, Shepard Jr JW. The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74(10):955–58.