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Smoking and Your Skin: Beyond the Smoke and Mirrors

Tobacco contains more than 7000 chemicals, including 250 toxins and carcinogens.  Nicotine, the main ingredient in tobacco, is absorbed at 1mg per cigarette.  After inhalation, nicotine enters the brain after 10-20 seconds, causing the neurostimulatory effects that maintain addiction.  Smoking for 6-8 hours a day leads to persistently elevated nicotine levels due to the slow release of nicotine from body tissues even after smoking (i.e. while sleeping, etc).  Cigarette smoke also contains carbon monoxide, which decreases the delivery of oxygen from the blood cells to the tissue.

What is a “smoker’s face”?  How does smoking age the skin?

The relationship between premature skin aging and smoking was first described in 1856.  The “smoker’s face” has been defined as facial wrinkling with prominence of underlying bony contours, very thin skin, and an orange/purple complexion.  In a study of identical twins, the aging process of the smoking twin was compared to the non-smoking twin.  The investigators concluded that 10 years of smoking aged the smoking twin by 2.5 years more than their non-smoking twin.  Proposed mechanisms of aging include UV-activated toxic properties of tobacco smoke, reduced collagen production and synthesis, increased collagen breakdown, and increased free radical formation.

Does smoking increase the risk of skin cancer?

Although tobacco is an independent risk factor for oral and laryngeal squamous cell carcinoma (SCC), the association between smoking and skin cancer is controversial.  A recent study suggested a correlation between packs per day and smoking years and increased development of skin SCC.  When analyzed by sex, the data showed greater SCC risk for women than men.  There is no clear association between tobacco and basal cell carcinoma, which statistically is the most common skin cancer type.

How does smoking affect skin rashes?

  • Psoriasis: Smoking is well-known to increase the development, persistence, and severity of psoriasis.  Smokers are also more likely to have hand and foot involvement with pustule formation.
  • Hidradenitis suppurativa (HS):  Smoking is thought to alter sweat gland function and increase inflammation and therefore is also strongly correlated to development of HS.
  • Lupus: It has been well-documented that smoking increases the development and severity of systemic, discoid, and cutaneous lupus erythematosus.  At the same time, smoking reduces the effectiveness of one of the first-line oral lupus treatments, plaquenil (hydroxychloroquine). 

How does smoking affect wound healing after surgery?

  • Decreased oxygen delivery:
    • Blood vessels shrink in diameter within minutes after smoke inhalation.
    • Peripheral blood flow in legs and arms decreases by 30-40%.
    • Carbon monoxide decreases oxygen delivery by red blood cells to tissue.
  • More clots form in blood vessels because nicotine makes platelets stickier.  (This is also why smokers are at higher risk for strokes and heart attacks.)  Clot formation leads to dead tissue.
  • Decreased development of new blood vessels in wound bed, which makes it difficult for the nutrients to be delivered for wound healing.
  • Impaired wound contraction
  • Impaired collagen production
    • Fibroblasts (the collagen production factories) are inhibited by nicotine.
    • Lower levels of vitamin C are found in smokers’ tissue.  Vitamin C is vital to the assembly of new collagen.

For smokers trying to quit, does nicotine in the smoking cessation therapies (patch, gum, etc) affect wound healing?

Not to our knowledge.  Use of the nicotine patch or gum is not associated with decreased wound-tissue oxygen levels.  This is thought to be a result of the lower concentrations of nicotine in these products and their slower rate of nicotine release compared with smoked nicotine.

What should smokers do before surgery to get the best healing results?

Not surprisingly, wound breakdown, dead skin grafts, prolonged healing time, and infections are increased in smokers.  There is no uniform agreement on pre-operative recommendations for smokers.  The following recommendations for smoking cessation before dermatologic surgery were published in the January 2013 JAAD (Journal of the American Academy of Dermatology).

  • Try to quit at least 2 weeks before surgery and 1 week after surgery.  Okay to use nicotine patch or gum during this time period.  (Studies in rats show that wound healing of a nicotine-dependent rat was equal to a control rat after stopping nicotine injections 2 weeks prior to surgery.)
  • Can’t quit? Try to cut down to less than 1 pack per day (PPD).  (Studies show that smokers who cut down to less than 1 PPD had much better wound healing success that those that smoke 2 PPD.  The effect appears to be very dose-dependent.)
  • Make sure to tell your surgeon that you are a smoker.  The surgeon may modify their technique to involve less tissue manipulation or may choose a different way to repair the skin that has better success in smokers.

Resource:  Gill, et al. “Tobacco smoking and dermatologic surgery.” JAAD. Vol 68, Num 1. Jan 2013.

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