You are in: eMedicine Specialties > Dermatology > DISEASES OF THE DERMIS Cutaneous Manifestations of SmokingArticle Last Updated: Jan 23, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 6
  Author: Jeffrey B Smith, MD, Mohs Surgery, Kaiser Permanente, San Jose, CA Jeffrey B Smith is a member of the following medical societies: American Academy of Dermatology Coauthor(s): Sidney B Smith, MD, Medical Director, Dermatologist, Dermatology, Dermacare Laser and Skin Care Clinics of Tri-Cities Editors: Peter Fritsch, MD, Chair, Department of Dermatology and Venereology, University of Innsbruck, Austria; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: smoking and skin, smoker's face, wrinkles, cigarettes, tobacco, nicotine, wound healing, hidradenitis suppurativa, palmoplantar pustulosis, skin cancer, psoriasis, anogenital cancer INTRODUCTIONSection 2 of 6
  Cigarette smoking is the number one preventable cause of death in the US. It is an addictive habit that is associated strongly with serious internal diseases such as cancer, lung disease, and cardiovascular disease. Smoking also has external or cutaneous manifestations. Knowledge of the cutaneous manifestations of smoking can be an important tool for physicians attempting to educate and motivate individuals to quit. This article reviews skin conditions associated with or influenced by smoking. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education articles Cancer of the Mouth and Throat and Cigarette Smoking. SKIN CONDITIONSSection 3 of 6
Poor wound healing Clinicians have long suspected that smoking has a deleterious effect on healing wounds, especially postsurgical flaps and grafts. In 1977, Mosely and Finseth demonstrated the detrimental effect of smoking on healing hand wounds. Many studies have since confirmed that smoking is harmful to a healing wound. Goldminz and Bennett reviewed 916 flaps and full-thickness grafts and found that 1-pack-per-day smokers had 3 times the frequency of necrosis as nonsmokers and that 2-pack-per-day smokers had necrosis 6 times more frequently than nonsmokers. The mechanism of these harmful effects likely is multifactorial. The nicotine in cigarettes causes vasoconstriction of cutaneous blood vessels with resultant decreased tissue oxygenation. Smoking also increases carboxyhemoglobin, increases platelet aggregation, increases blood viscosity, decreases collagen deposition, and decreases prostacyclin formation, which all negatively affect wound healing. In addition, vasoconstriction associated with smoking is not a transient phenomenon. Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes; hence, a pack-a-day smoker remains tissue hypoxic for most of each day. Although no official guidelines have been established, many dermatologic surgeons consider it prudent to advise patients to quit smoking for a minimum of 1 week before and after surgical procedures, especially if cutaneous flaps or grafts are involved. Wrinkles No one has ever died of wrinkles, yet none of the cutaneous manifestations of smoking generate as much interest and attention as wrinkles. In many smokers, the threat of facial wrinkling is a greater motivator to quit than the threat of lung cancer or other life-threatening smoking-related diseases. In 1965, Ippen and Ippen found that when compared to female nonsmokers, most female smokers had cigarette skin, which they defined as gray, pale, and wrinkled. In a large study, Daniell confirmed previous findings that smokers have premature and increased facial wrinkling compared to nonsmokers. The term smoker's face describes this phenomenon. Women may be more susceptible to the wrinkling effects of smoking, but the confounding variable of sun exposure may be partially responsible for this observation. Favre-Racouchot syndrome, a condition characterized by deep wrinkles and comedones formation, was found by Keough et al to be more common in smokers than in nonsmokers. The exact mechanism by which smoking causes wrinkling is poorly understood. Elastin from non–sun-exposed skin in smokers is thicker and more fragmented than in nonsmokers. Chronic ischemia of the dermis from the vasoconstrictive effects of smoking likely is a factor in this. Decreased collagen synthesis from chronic ischemia also may be a factor. Prooxidant effects of smoking also may contribute to premature facial wrinkling. Since not all smokers have smoker's face, genetic factors also may be involved. Hidradenitis suppurativa A study by Breitkopf et al evaluated 149 patients with hidradenitis suppurativa and found that 84% of women and 85% of men with this condition were smokers at disease onset. Although the mechanism underlying this strong association is unclear, the study's authors proposed that smoking may contribute to hidradenitis suppurativa by altering neutrophil function, altering sweat gland activity, excreting toxic tobacco constituents in the sweat, and promoting poor wound healing. Palmoplantar pustulosis Several studies have looked at smoking and palmoplantar pustulosis (PPP). The largest of these evaluated 216 patients with PPP and found that 80% were smokers at disease onset. Smokers had 7.2 times the risk of developing PPP compared to nonsmokers. Other studies have documented that most patients with PPP (80-100%) are smokers. Unfortunately, smoking cessation does not always translate into clinical improvement of PPP, but mention the possibility of smoking cessation and pursue it as part of the treatment regimen. The connection between smoking and the pathogenesis of PPP is unclear, but altered neutrophil function likely is a factor. Psoriasis Many studies have examined the connection between smoking and psoriasis, and although it is clear that a positive and significant association exists, it is not nearly as strong as the association between smoking and PPP. Studies found an increased incidence of smokers among psoriatic patients, but the connection between smoking and psoriasis is not understood fully. Squamous cell skin cancer Several studies found that smokers are at increased risk for squamous cell carcinoma (SCC) of the skin compared to nonsmokers. The first study to find an association took place more than 35 years ago and found keratoacanthomas to be more common in smokers than nonsmokers. More recently, several studies found a clear association between smoking and SCC of the skin. Risk of cutaneous SCC increases with the number of packs smoked daily and the duration of the smoking habit. Smokers are at increased risk for SCC of the skin, which may be a result of the immunosuppressive effects of smoking (see Squamous Cell Carcinoma). Basal cell skin cancer Most studies have found no association between smoking and basal cell carcinoma (BCC). A recent study by Smith and Randle stratified BCCs according to size and did find an association between smoking and BCC tumors larger than 1 cm but not in those smaller than 1 cm (see Basal Cell Carcinoma). Melanoma Although no evidence exists that associates smoking with an increased risk of melanoma, several studies suggest that when compared to nonsmokers, smokers (1) are more likely to have metastases on initial presentation, (2) have lower disease-free survival rates after diagnosis, (3) are more likely to have visceral metastases, and (4) are more likely to die from the melanoma than nonsmokers. Smokers probably have a poorer prognosis with melanoma because of the adverse effects of smoking on the immune system, including impaired immunosurveillance and a lowered capacity to mount an immune response to transplanted melanoma tumors. Anogenital cancer Several studies on anogenital cancers and smoking revealed that smoking is significantly higher among patients with anogenital cancers compared to controls. The most recent study evaluated 903 patients with anogenital cancer located at all sites (vulvar, vaginal, cervical, anal, penile) and found that current smokers had increased risk of cancer in all 5 areas. Of these 5 anogenital sites, the 3 most highly associated with smoking also were the most accessible to dermatologic examination (vulva, anus, penis). Oral lesions Many oral lesions, including lip cancer, are significantly more common in smokers. Smoking is a risk factor for lip cancer, and when combined with excess sun exposure, the two are synergistic. Oral cancer has been linked overwhelmingly to smoking, and when combined with excess alcohol consumption, the risk is increased further. All forms of tobacco abuse, including smokeless tobacco and reverse smoking (placing the lit end inside the mouth), increase the risk of oral cancer. Leukoplakia occurs much more commonly in smokers, and a small percentage of patients with leukoplakia undergo malignant transformation (see Leukoplakia, Oral). Leukokeratosis nicotina palati, also termed smoker's palate, is seen exclusively in smokers and especially pipe smokers. It is a uniform keratosis of the hard palate with multiple red umbilicated papules that represent inflamed salivary glands. Leukokeratosis nicotina glossi, also termed smoker's tongue, is a similar phenomenon found on the dorsal tongue. All reported patients had concurrent smoker's palate. Acute necrotizing ulcerative gingivitis, also termed trench mouth, is characterized by punched out lesions of the interdental papillae and often is associated with pain, bleeding, and a fetid mouth odor. It occurs almost exclusively in smokers and correlates highly with the amount of tobacco used per day. Miscellaneous skin lesions Buerger disease (thromboangiitis obliterans) with its attendant skin lesions (eg, erythema, blanching, ulceration, necrosis) is associated strongly with cigarette smoking. Yellow and brown stains on the fingers and nails of the hand that holds the cigarette are a skin finding in many smokers, especially heavy smokers. Smoker's mustache is analogous to smoker's nails. A brownish and/or yellowish discoloration of the distal hairs of the mustache occurs in a heavy smoker with a gray or white mustache secondary to heavy smoking. Cigarette smoking has also been found to be a risk factor for the development of discoid lupus erythematosus. A recent study by Mosley et al found that both male and female smokers are more likely than nonsmokers to have prematurely gray hair. Several reports have documented irritant as well as allergic contact dermatitis to the nicotine patch in some patients attempting to quit smoking (see Contact Dermatitis, Irritant; Contact Dermatitis, Allergic). Negative associations Although in most cases smoking is associated with increased incidence of skin conditions, a few skin diseases exist in which smoking appears to decrease incidence or lessen severity. In most cases, isolated studies or case reports exist, and further study is needed to confirm whether a true negative association exists. One study found recurrent herpes labialis to be less prevalent in smokers than in nonsmokers. Another study found vulvar lichen sclerosus to be more common in nonsmokers. One study negatively associated acne with smoking, and the same author in a later study found that patients with rosacea were more likely to be nonsmokers (see Rosacea). Finally, a recent study by Smith et al found that patients with dermatitis herpetiformis were more likely to be nonsmokers compared to the general population in that region (see Dermatitis Herpetiformis). Aphthous stomatitis also appears more common in nonsmokers. Smoking may decrease the incidence and severity of aphthous ulcers. Although these findings are intriguing, the obvious risks of smoking clearly outweigh any possible benefits. NICOTINE AS THERAPYSection 4 of 6
Nicotine is a pharmacologically active substance, and in some patients, this activity may have an apparently beneficial effect on treatment, while in others, it has affected therapy negatively. Wolf has reported the successful treatment of pyoderma gangrenosum using nicotine patches. Mehta et al reported on a man with pemphigus vulgaris whose disease flared when he quit smoking and improved when he returned to smoking. Two different groups, Rahman et al and Jewell et al, found that patients with cutaneous lupus who smoke are less responsive to antimalarial therapy than nonsmokers. CONCLUSIONSection 5 of 6
Skin is not exempt from the deleterious effects of smoking. While many effects are benign and primarily of cosmetic concern, others have the potential for significant morbidity and may affect the patient's quality of life significantly. Knowledge of the cutaneous manifestations of smoking may help physicians convince patients to quit smoking, especially those patients more concerned about outward appearance and less inspired by the more life-threatening consequences of smoking. REFERENCESSection 6 of 6
Cutaneous Manifestations of Smoking excerpt Article Last Updated: Jan 23, 2007 |
