3.14 Skin

Last updated: June 2021
Suggested citation: Purcell, K, Winnall, WR, Greenhalgh, EM & Winstanley, MH. 3.14 Skin. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from  http://www.tobaccoinaustralia.org.au/3-14-effects-of-smoking-on-the-skin

 

Smoking adversely affects the skin. Delayed wound healing is discussed in Chapter 3, Section 3.15.1.2 and other smoking-associated skin conditions are detailed in this section.

3.14.1 Facial appearance and premature skin ageing

Smoking affects facial appearance in men and women, independent of sun exposure and age. Increased wrinkling1-5 and altered complexion colour1 have been attributed to smoking, as have elastosis (loss of elasticity in the skin resulting from degeneration of connective tissue) and, in men, telangiectasia (dilatation of fine blood vessels in the skin visible as fine red lines).6 Smoking is also associated with looking older than a person’s age.7 One study found that smokers appear up to 4.7 years older than non-smokers.8 Two studies of twins have also confirmed that smokers tend to look older.9, 10

Studies have shown that in the majority of cases smokers and non-smokers could be correctly distinguished as such by examining photographs of the face and temple region.8, 11 A twin study found that participants judged the faces of the non-smokers more attractive compared with smokers.11, 12

Visible wrinkling is most evident in older smokers, but even smokers aged in their 20s and 30s may show evidence of microscopic superficial wrinkling.4 Smoking is associated with an increased severity of wrinkles including forehead, crow's feet, and glabellar lines (vertical lines between the eyebrows); under-eye puffiness and lines around the mouth.13 Combined exposure to both sunlight and tobacco smoke causes a greater degree of damage than exposure to one agent alone,14 possibly through the phototoxic effects of tobacco smoke condensate, which increase the skin’s vulnerability to UV radiation.15 Even non-facial, non-sun-exposed skin may be more wrinkled in smokers than non-smokers.16

A possible mechanism for premature wrinkling is that smoke affects the function of human skin fibroblasts (cells present in connective tissue that produce collagen and elastin), thereby accelerating the appearance of ageing.3, 17, 18 Exposure to tobacco smoking and sunlight can also cause changes to the structure and amount of elastic fibres and fibrillar collagens in the dermal extracellular spaces.19 Heavy smokers (>40 per day for 5 years) have signs of damage to their skin structure and function compared to non-smokers. Heavy smokers had changes to their skin’s elastic fibre network and increased stiffness of the dermis and epidermis layers of their skin.20 A genetic study showed that the skin of smokers had differences in the use of genes that indicated a possible increase in permeability of the skin.21 Studies also suggest a connection between wrinkling in smokers and the development of chronic obstructive pulmonary disease (COPD). Smokers with severe facial wrinkling may have a higher susceptibility to developing COPD; possible mechanisms being damage to collagen and elastin, which are important to both skin and lung function.22

3.14.2 Acne and other sebaceous conditions

A review of smoking-associated skin conditions published in 2010 noted that the evidence linking acne to smoking is conflicting. Only two of the five studies reviewed reported an association.23 Another study, published after the review, found a higher prevalence of comedonal post-adolescent acne in women who were smokers compared with non-smokers.24

The evidence linking some other sebaceous conditions with smoking is stronger. Smokers appear to be more at risk for hidradenitis suppurativa (clusters of chronic abscesses or cysts in areas of sweat or sebaceous glands).23 A large retrospective cohort analysis found that the incidence of hidradenitis suppurativa in smokers is double that of non-smokers (overall incidence of HS was 0·20% among tobacco smokers and 0·11% among non-smokers.25 Current smokers have more severe disease than non-smokers and also have a poorer response to first line treatment such as oral antibiotics, topical antibiotics, intralesional corticosteroids, or antibacterial washes/creams/lotions compared with never smokers.26

A case–control study found smoking was a risk factor for epidermal inclusion cysts in men, but not in women.27

3.14.3 Dermatitis

Multiple studies have concluded that there is relationship between smoking and dermatitis. A 2016 US study of 1,301 participants, aged 20–59 years using the 2003–2004 National Health and Nutrition Examination Survey (NHANES) database found that smoking has a significant association with active hand dermatitis.28 A dose response relationship was observed in this study. Heavy smokers (>15 g tobacco daily) were 5.11 times more likely to have active hand dermatitis compared with non-smokers. Those with serum cotinine >3 ng/ml (a biomarker indicating nicotine exposure) were also more likely to have active hand dermatitis, compared with those with lower serum cotinine.28

A 2016 systematic review and meta-analysis included 86 studies, with 20 studies having valid data to assess the effects of active smoking, 66 for passive exposure to tobacco smoke, and 23 for maternal smoking during pregnancy.29 Atopic dermatitis was associated with both active smoking and exposure to second-hand smoke, but not maternal smoking during pregnancy.29 The association between active smoking and atopic dermatitis was significant in both children and adults.29 A 2017 systematic review found that seven of eight articles described a positive relationship between smoking and allergic or irritant contact dermatitis, while nine of nineteen articles found a positive association between smoking and hand eczema and concluded that smoking may be an important risk factor for both allergic and irritant contact dermatitis as well as hand eczema.30 A secondary analysis of cross sectional data in Korea examined the relationship between smoking, atopic dermatitis and asthma found that atopic dermatitis prevalence in women but not men was associated with current smoking status.31

Cigarettes themselves have been reported to induce allergic contact dermatitis in both occupational and non-occupational settings.23, 32

3.14.4 Psoriasis

Psoriasis is a chronic autoimmune disease, the most common type being plaque psoriasis, characterised by scaly patches on the top layer of the skin.23, 33-35 Smoking is a well-established risk factor for psoriasis. Higher intensity smoking is associated with clinically severe disease,23, 36, 37 and psoriasis is less responsive to treatment in smokers.23, 38 In a meta-analysis from 2015, eight of 11 studies with data on smoking and the severity of psoriasis suggested that severity increases with smoking status, number of cigarettes smoked and pack-years of smoking.34 The risk of developing psoriasis decreases progressively with increased time since smoking cessation.38 A later meta-analysis from 2020 showed that the prevalence of ever smoking was increased 1.84-fold in people with psoriasis compared with the general population.39 People who were ever-smokers (1.60), current smokers (1.63) or former smokers (1.36) were at higher risk of psoriasis than non-smokers in a meta-analysis of 34 studies from 2020.40 Smokers were also less likely to respond to six months of treatment for psoriasis.40

A 2015 twin study found that smoking and childhood exposure to second hand smoke are significantly associated with psoriasis,41 and that the risk for psoriasis increased substantially for smokers with a history of >5 pack-years.41 Another study found that current smoking increased the risk of psoriasis, particularly for smokers who smoked >25 cigarettes per day and for >20 pack-years.42

Multiple mechanisms are thought to explain the association between smoking and psoriasis. Smoking enhances the expression of genes known to confer an increased risk of psoriasis. It increases oxidative damage—the free radicals in cigarette smoke, for example, triggering a cascade of systemic reactions.38 Nicotine also promotes a chronic pro-inflammatory state by activating innate immune cells and T-lymphocytes.38

The form of psoriasis known as palmoplantar pustulosis (which is confined to the hands and soles and is also known as ‘pustular psoriasis of the extremities’) is strongly associated with smoking;23 in one study, the prevalence of ever-smoking was 36 times higher among those with palmoplantar pustulosis than among those with other dermatologic patients.43 High severity palmoplantar pustulosis was more likely to occur in those addicted to smoking and with higher pack number per year smoked, in a study of 51 people with this condition.44

3.14.5 Lupus erythematosus

Lupus erythematosus is a chronic autoimmune condition that has numerous different types. The systemic form is referred to as systemic lupus erythematosus (SLE). Other types of lupus erythematosus often only involve the skin (cutaneous). Skin symptoms are often a rash and sometimes scaly patches or ulcers. Systemic symptoms may include fever, joint and muscle pain, weight loss, fatigue and many others.45

A meta-analysis of seven case–control studies and two cohort studies found smoking to be associated with SLE. Current smokers have about a 50% increased risk of SLE compared with never smokers.46 The risk was not elevated for ex-smokers in this study. Smokers also have increased SLE disease activity,47 and poorer health-related quality of life has been reported.48 The extent of skin manifestations of SLE and skin damage were associated with smoking exposure (in pack-years) in a dose-dependent manner.49 However, there are studies that failed to find similar results. In 2014, the US Surgeon General’s report concluded that there is mixed and therefore inadequate evidence that smoking causes SLE, or affects its severity or treatment.50 The report noted that, at the time, while seven studies had found an association, four had not, and that many of the studies were small and underpowered.50

Since the release of the US Surgeon General’s report in 2014, several meta-analyses have been published. A 2019 meta-analysis of twelve eligible studies comprising 3,234 individuals who developed SLE and 288,336 control subjects revealed a significant association between SLE occurrence and current-smoking status. The association between SLE and former smoking was not significant.51 Another 2019 meta-analysis of nine case-controls studies found an increased risk of SLE in current-smokers compared to never-smokers, while former-smokers were not at increased risk of SLE. Smoking also influences the disease course and reduces the effectiveness of some therapeutic treatments for SLE.52 A 2017 study of 5,018 patients with SLE and 25,090 age- and sex-matched controls also found a significant association between smoking and SLE.53 A large female cohort study in 2017 found that an increased risk of SLE associated with smoking >10 pack-years compared with never smokers.54

Smoking is independent predictor of retinal damage in SLE patients55 and may be associated with more rapid cumulation of end-organ damage.56 Smoking may also be associated with distinct clinical phenotypes of SLE. Heavy smokers with SLE were more likely to have neurological disorder, discoid rash and photosensitivity, and less likely to have haematological disorder, renal disorder and non-erosive arthritis, compared to non-smokers with SLE.57

The 2014 US Surgeon General’s report concluded that smoking is a risk factor for cutaneous lupus, but noted that the evidence is too limited to determine if it is a cause.50 Numerous studies predict that smoking increases the risk of developing some of the cutaneous forms of lupus23, 53, 54, 58, 59 and has been reported to decrease the effectiveness of the antimalarial drugs that are sometimes prescribed for cutaneous lupus.60

3.14.6 Other skin conditions

Smoking is a risk factor for the development of alopecia (hair loss, usually from the scalp) and may increase the likelihood of premature grey hair.23

For information about anal fistula, see Section 3.17.2.


Relevant news and research

For recent news items and research on this topic, click  here. (Last updated June 2022)

 

References

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