Tobacco Use and Skin Disease

Melody Vander Straten, MD, Daniel Carrasco, MD, Martha S. Paterson, MD, Monica L. Mccrary, MD, Diane J. Meyer, MD, Stephen K. Tyring, MD, PhD, Galveston, Tex 

South Med J. 2001;94(6) 

In This Article

Direct Effects of Cigarette Smoking

Cosmetic Effects

"Attractiveness" studies suggest that appearance is important in obtaining social advantages that improve the quality of life.[3] Furthermore, the psychologic impact of appearing older than one's chronologic age can be significant, especially with regard to self-perception.[4] Cigarette smoking can alter a person's physical appearance in some dramatic ways.

Although facial wrinkling is an inevitable part of aging, cigarette smoking can accelerate the process. Kadunce et al[5] found that cigarette smoking is an independent risk factor for the development of accelerated facial wrinkling and that the risk is dose dependent to smoking exposure. Smokers with a greater than 50 pack-year history were noted to be 4.7 times more likely to have wrinkles than nonsmokers, controlling for age, sex, skin pigmentation, and sun exposure. The risk was increased even further when subjects were exposed to both excessive sunlight and smoking. In another study, Ernster et al[6] found that the increased risk of wrinkling was equivalent to approximately 1.4 years of aging in smokers when compared with nonsmokers. In addition, Ernster et al[6] found that pack-years were positively associated with facial wrinkle scores in women aged 40 to 69 and men aged 40 to 59. Although there are vast differences in the data concerning this issue, all agree that smoking causes increases in facial wrinkling.

The typical smoker's face (Fig 1) was described by Model[7] as being distinguished by one or more of the following characteristics: facial wrinkles radiating at right angles from the upper and lower lips or corners of the eyes; a subtle gauntness of the facial features with prominence of the underlying bony contours; an atrophic, slightly pigmented gray appearance of the skin; and a plethoric, slightly orange, purple, and red complexion. Chemosis is also frequently observed in smokers' faces.

Figure 1.

Smoker's facial wrinkles radiating at right angles from lips.

Several mechanisms have been proposed for the changes seen in the smoker's face. The wrinkling around the mouth and eyes could be due to repetitive facial movements such as pursing the lips to smoke cigarettes, and squinting the eyes to avoid irritating cigarette fumes. However, these mechanical factors are not widely accepted as causes for the increased wrinkling. Another factor is the increase of mean relative area, number, and thickness of the dermal elastic fibers seen in the non-sun-exposed skin of smokers, which are similar to changes seen in solar elastosis.[8] Elastotic skin is less elastic, dryer, darker, and more erythematous than normal skin,[9] which could account for some of the smoker's skin changes, especially in sun-exposed areas. Also, under investigation are changes in the microvasculature of skin exposed to cigarette smoke, which include chronic reduced blood flow to the skin.[10] This process, which includes nicotine-induced vasoconstriction, could result in premature aging. There is some evidence that premature resorption of facial bones, possibly due to an antiestrogenic effect of smoking,[11,12] could help explain the smoker's gaunt and wrinkled appearance, but these antiestrogenic effects are poorly understood and slightly controversial. Finally, several studies link smoking with significant decreases in skin moisture,[13] which also could contribute to a dry wrinkled appearance.

Another direct cosmetic effect of cigarette smoking is the yellow pigmentation of the fingernail plate, commonly referred to as the "nicotine sign" (Fig 2). Tobacco by-products from cigarette smoke actually stain the nails. Verghese et al[14] described another nail sign that occurs when a long-time smoker suddenly ceases smoking due to illness (commonly a stroke). A distinct line of demarcation is seen between the distal, yellowed nail and the newly grown proximal nonpigmented nail. This sign is termed "harlequin nail." According to the authors, the date a patient has ceased smoking can be deduced by measuring the distance between the nail base and the line of demarcation. This could be a useful tool when patients are unable to volunteer information about the onset of illnesses.

Figure 2.

"Nicotine sign"--yellow pigmentation of fingernail plate and sclerodactyly in a man with 100 pack-year history of cigarette smoking.

Nicotine Stomatitis

Nicotine stomatitis, otherwise known as smoker's palate or leukokeratosis nicotine palati, is an asymptomatic stomatitis usually seen in chronic smokers. It is described as an inflamed, reddened mucosa that progresses to a multinodular, papular, gray-white keratinized mucosa[15] and usually only involves the palate. The papules are inflamed and sometimes plugged salivary glands. The red central spot represents the salivary duct orifice.


An important and often unappreciated health effect of smoking is the cigarette-initiated fire. Cigarettes are, by far, the leading cause of deaths from residential fires.[16] In an epidemiologic study of fires, cigarettes were determined to be the ignition source of 55% of fatal fires investigated.[17] The odds ratio for fire injury in households where members collectively smoked 1 to 9 cigarettes per day was 1.5 compared with households with no smokers; for 10 to 19 and more than 20 cigarettes per day the ratio was 6.6 and 3.6, respectively.[18] The resulting burns can range from minor superficial thermal injury to severe, extensive skin loss, and death. In addition, the resulting scars have an increased rate of squamous cell carcinoma.[19]


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