How Smoking Damages the Skin
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.
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.
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.
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. Decreased collagen synthesis from chronic ischemia also may be a factor. Prooxidant effects of smoking also may contribute to premature facial wrinkling.
Many studies have examined the connection between smoking and psoriasis. Studies found an increased incidence of smokers among psoriatic patients, but the connection between smoking and psoriasis is not understood fully.
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.
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.
Although no evidence exists that associates smoking with an increased risk of melanoma, several studies suggest that when compared to nonsmokers, smokers are more likely to have metastases on initial presentation, have lower disease-free survival rates after diagnosis, are more likely to have visceral metastases, and 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.
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