Smoking skin lesions F17.1 + Hauterkrankung

Cutaneous changes usually induced by long-term tobacco consumption. With around 140,000 deaths per year in Germany, smoking is now the most common preventable cause of death. This is mainly due to diseases of the cardiovascular system and oncological diseases.

Chronic noise has the following effects on the skin:

• General effects:
  • Skin aging is accelerated
  • Wound healing is delayed
  • Induction of inflammatory responses/initiation or exacerbation of disease (Thomsen SF et al 2010):
    • Pustulosis palmaris et plantaris (smokers suffer more often from pustulosis palmoplantaris than non-smokers)
    • Psoriasis vulgaris (clear connection)
    • Dermatitis atopische (connection not clear)
    • Dyshidrotic dermatitis - heavy smokers/serum nicotine level >3 ng/ml - suffer from chronic (dyshidrotic)hand dermatitis 5x more often than non-smokers - Lai YC et al 2016).
    • Acne inversa/hidradenitissuppurativa (confirmed association; smoking is a contributory trigger. 89% of patients with acne inversa are smokers).
    • Acne vulgaris (correlation possible but not confirmed; in postpubertal acne in women, the proportion of smokers - compared to non-smokers - is significantly higher)
    • pyoderma gangraenosum
    • Type IV sensitizations (nicotine itself does not cause type IV sensitizations. More commonly, "tobacco allergies are found in tobacco retailers, couriers, and cigar makers-Bonamonte D et al. 2016).
    • Lupus erythematosus
• Induction of chronic vascular disease:
  • Endangiitis obliterans
  • Arterial occlusive disease (confirmed association;

    smokers with pAVD-related leg ulcerations are at increased risk for soft tissue infections).

Induction of malignant tumors of the skin and mucous membranes:

• Melanoma, malignant
• Precancerous and squamous cell carcinomas:
  • Leukedema (Irritative, usually symmetrical, reversible, whitish-opal discoloration in the oral mucosa, which may occur as a preliminary stage of leukoplakia).
  • Leukokeratosis nicotinica palati (smoking-induced smoker's leukokeratosis as a precancerous condition induced by smoking).
  • Leukoplakia, oral
  • Carcinoma of the lip (tobacco condensate has a phototoxic effect!)
  • Carcinoma of the oral mucosa
  • Anogenital carcinoma
  • Vulvar carcinoma
  • Anal carcinoma
  • Penile carcinoma.
• Other:
  • Lingua nigra
  • Infections with human papilloma viruses(verrucae vulgares; condylomata acuminata- the incidence is increased in both women and men)
  • Dupuytren's contractures (connection with smoking not confirmed)

  • Suppression of the immune system (smoking suppresses the immune system)

In Central Europe, about 40% of men and 30% of women smoke. The average cigarette consumption per day is 15 cigarettes. 75 to 80% of all smokers meet the criteria of nicotine dependence:

• Compulsive smoking
• Tolerance development
• Physical withdrawal symptoms with abstinence
• Continued tobacco consumption despite consequential damage
• Changes in lifestyle to maintain tobacco consumption
• Limited control over smoking behaviour

The clinical effects of tobacco consumption on the skin have been known in part since the introduction of the tobacco plant in Europe in the 16th century. The alkaloid nicotine contained in the plant, named after its discoverer Jean de Nicot, is considered the main toxin of cigarette smoke. Each cigarette is inhaled with approximately 2 - 3 mg. If the amount inhaled is constant, the level of nicotine concentration in the blood varies from person to person. It depends on various factors such as the pH of the urine or the metabolism by microsomal liver enzymes.

About 5000 different substances can be detected in cigarette smoke extracts, 43 of which are classified as carcinogenic (criteria of IARC = International Agency for Research on Cancer). It is therefore difficult to attribute the effects of smoking on the skin and the whole organism to a single ingredient or to a single effect. They rather result from complex summation effects, partly in combination with environmental factors.

Even at a relatively young age, heavy smokers sometimes appear significantly prematurely aged. The skin of long-term smokers appears wrinkled, the complexion sallow, the face gray and less well supplied with blood. The link between extrinsic skin ageing and high cigarette consumption (pack-years) is well established (Vierkötter A et al. 2010; Puri P et al. 2017).

Actinic elastosis: It is known that tobacco smoke has a phototoxic effect due to various components (aromatic hydrocarbons). This also explains the frequent occurrence of actinic elastosis and Favre-Racouchaud's disease in intensive smokers. Responsible for this effect are the influences of tobacco inhalates, sometimes in combination with sunlight, on the epithelium and skin connective tissue. Experiments have shown that an extract of cigarette smoke inhibits cell division and the growth of fibroblasts.

Circulatory disorders: Nicotine leads to vasoconstriction. Furthermore, the carbon monoxide contained in cigarette smoke impedes oxygen transport and thus oxygenation of the tissue. At the same time, inflammatory cytokines such as interleukin-1, interleukin-6, interleukin-8 and TNF-alpha are released. Video capillaroscopy has shown disturbances in microcirculation caused by tobacco components, which are apparently irreversible (Scardina GA et al. 2019).

Smoking causes a reduction in the hydration of the stratum corneum. In addition, the proliferation rate of the basal cells is reduced. Furthermore, nicotine influences keratinocyte proliferation, differentiation and apoptosis via the nicotinic and muscarinic acetylcholine receptors (ACh-R / nACh-R) (Ortiz A et al. 2012). Since nACh-R is also found in sweat glands and sebaceous glands, a stimulating effect on sweat and sebum secretion is likely.

Smoking and allergies: Contact allergies(nickel allergies) are more common in smokers than in non-smokers.

Smoking and autoimmune diseases: A slightly higher incidence (factor 2.0) of systemic lupus erythematosus is known, which is more severe in smokers than in non-smokers. It has also long been known that the effect of chloroquine is lower in smokers than in non-smokers. This must be taken into account in the treatment of autoimmune diseases.

Nicotine and components of cigarette smoke can induce the following effects:

• Increase in the concentration of carbon monoxide, leading to reduced oxygen binding and consequently to a poorer oxygen supply in the blood
• Stimulation of the sympathetic nervous system and increased release of catecholamines leads to vasoconstriction
• Reactive oxygen species and free radicals lead to oxidative stress
• Inhibition of fibroblasts and myoblasts leads to delayed tissue formation
• Polycyclic aromatic hydrocarbons, nitrosamines, heterocyclic aromatic amines, cadmium, benzene and formaldehyde in tobacco inhalates have an oncogenic and partly photosensitizing effect.
• Induction of MMPs and inhibition of TIPMs lead to the degradation of elastic fibers and collagen
• Wound healing disorders: impaired collagen production and reduced tissue perfusion lead to poorer wound healing (Balaji SM 2008; Frick WG et al. 1994). Smokers developed postoperative wound healing disorders in 48.2% of cases, whereas non-smokers only in 21.0% of cases. When smoking was stopped 6 weeks before surgery, this was still 30.8% of patients (Goertz O et al. 2012). It is advisable to stop smoking 6-8 weeks before a planned operation. Smokers are also likely to have a higher complication rate (flap necrosis, dehiscence) for flap surgery.

Data from the USA shows that 440,000 Americans die every year from diseases associated with cigarette consumption.

Smokers die on average 13 or 14 years earlier than non-smokers. The treatment of these diseases costs 75 billion dollars per year in the USA.

Cigarette smoking can promote the development of carcinomas in the throat, kidneys, pancreas, esophagus, bladder and stomach as well as lead to aneurysms of the abdominal aorta, granulocytic leukemia, heart disease, vascular disease (atherosclerosis), cataracts and impaired lung function.

The influence of "second-hand smoke" on smokers and non-smokers should not be underestimated.

E-cigarettes: Electronic cigarettes (e-cigs) account for a significant and increasing proportion of the consumption of tobacco products. They now pose a problem for oral health. Flavored e-cigs have been shown to cause increased oxidative/carbonyl stress and inflammatory cytokine release in human periodontal ligament fibroblasts and epigingival epithelium.

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