Cigarette smoking affects all systems of body and is associated with significant morbidity and mortality. It is the most common preventable cause of death in United States. Apart from affecting internal organs and causing heart, lung problems and cancers, it also affects skin in many adverse ways. It can cause many diseases of skin and also affect some preexisting diseases and results of tests done for skin diseases. Knowledge of cutaneous manifestations of smoking will help physicians to motivate patient for smoking cessation and also helps to convince patients. Here we will review the skin conditions associated with or affected by smoking.

Apart from nicotine many other toxic chemicals are present in cigarette smoke like polycyclic aromatic hydrocarbons, nitrosamines, and heterocyclic amines, phenol, catechol, quinoline, aniline, toluidine, nickel, N-nitrosodimethylamine, benzopyrenes, benzanthracene and 2-naphthylamine, carbon dioxide, carbon monoxide, hydrogen cyanide, nitrogen oxides, acetone, formaldehyde, acrolein, ammonium, pyridine, 3-vinylpyridine, N-nitrosodimethylamine, and N-nitrosopyrrolidine etc.

Mucoctaneous manifestations of smoking

Heavy smokers can typically be identified by characteristic cutaneous and mucosal manifestations like smoker’s nail, smokers mustache, smokers tongue, smokers palate, black hairy tongue, tobacco pouch keratosis etc.

Precocious aging is another manifestation of smoking. A smoker’s face characteristically has prominent wrinkles, a gauntness of facial features with prominence of the underlying bony contours, an atrophic, gray appearance of the skin, and a plethoric complexion and skin appears thin and fragile, tending to sag. There is a synergistic effect of smoke with sun exposure on skin aging. Apart from oxidative damage caused by smoke due to production of free radicals, smoking also down regulates synthesis of type I and type III collagens and accelerates elastin and collagen degradation leading to decrease in extracellualr matrix. All these factors contribute to wrinkle formation. Fine lines appearing on face at young age can be referred as smoker’s wrinkles.

Skin cancers

Many studies have confirmed role of smoking as an independent risk factor for cutaneous squamous and basal cell carcinomas. There is some evidence to suggest relationship between smoking and even melanoma and anogenital cancers.

Poor wound healing

Smokers carry a greater complication risk for surgical wounds. Smoking within eight weeks of surgery increases the risk of skin flap necrosis. The pathobiological effects of tobacco products on wound healing are similar to those eliciting precocious skin aging. Smoking can also cause delayed wound healing secondary to decreased blood flow.

Buerger’s disease

More than 90% of patients with ulceration due to Buerger’s disease (thromboangiitis obliterans) are smokers. Long periods of disease quiescence are associated with tobacco cessation, whereas recurrence is associated with resumption of tobacco use.

Skin diseases affected by smoking

Many preexisting or de novo skin diseases may be affected negatively by smoking which include Contact dermatitis Cigarette and snuff usage are known risk factors for developing allergic contact dermatitis.

Hand eczema and atopic dermatitis

Smoking has been reported to be an independent risk factor for hand eczema & Atopic dermatitis

Psoriasis

It is well documented that there is a significant positive association between psoriasis and smoking. Smoking is an independent risk factor for psoriasis.

Palmoplantar pustulosis (PPP)

PPP is one of the most common inflammatory skin diseases associated with smoking. Among patients with PPP, 95% are smokers, and the majorities are heavy smokers. Smoking cessation leads to significant improvement

Cutaneous lupus erythematosus

It is an autoimmune disease with increased sunlight sensitivity. Studies reveal a statistically significant association between active smoking and development of cutaneous lupus erythematosus.

Hair disorders

Smoking is associated with premature graying of hair in both men and women, as well as hair loss in men at an earlier onset.

Skin ulcers

Smoking is a risk factor for developing pressure ulcers and ulcers complicated by infections in patients with diabetes.

There is some evidence for positive association with generalized urticaria and necrobiosis lipoidica diabeticorum.

Apart from this smoking can also affect treatment of some skin diseases. For example treatment efficacy of antimalarial group of drugs is decreased by smoking in patients of lupus erythematosus.

Smoking can also affect results of skin allergy test like patch test for nickel may turn false positive in smokers and serum IgE (a marker of allergic tendencies) may be higher in smokers.

Smoking is also shown to have some positive effect in certain skin conditions like pemphigus vulagris, aphthous ulcers, herpes simplex infections, pyoderma gangrenosum etc. Nicotine patches have been used succesfully in pyoderma gangrenosum and Burger’s disease as a treatment. But considering the risk-benefit ratio, apart from nicotine patches, active smoking should not be considered as a treatment for any disease.

Remember passive smoking is more dangerous than active smoking. Smoker’s also cause harm to others.