Printer Friendly
The Free Library
22,719,120 articles and books

Tobacco Use and Skin Disease.


Background. The primary objective of this review is to evaluate the mucocutaneous mucocutaneous /mu·co·cu·ta·ne·ous/ (-ku-ta´ne-us) pertaining to or affecting the mucous membrane and the skin.

Of or relating to the skin and a mucous membrane.
 manifestations of tobacco use.

Methods. Computerized literature searches were conducted for English language articles related to skin/mucous membrane disease and use of tobacco. The primary criterion for assessing data quality and validity was the demonstration of a causal relationship between tobacco use and skin/mucous membrane disease.

Results. This review of the literature shows that a number of disorders and diseases of the skin and mucous membranes are related to tobacco use.

Conclusions. Since millions of persons use tobacco despite its well publicized relationship to increased mortality, knowledge of the mucocutaneous morbidity associated with tobacco use may help physicians in counseling their patients.

CIGARETTE SMOKING is the largest preventable cause of death in the United States according to the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . [1] Furthermore, it is well known that cigarette smoking contributes to an increased risk of cancer, coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. , stroke, chronic pulmonary disease, and aortic aneurysm. Approximately 1.1 billion people smoke, and smoking kills 1 in 10 adults worldwide. [2]

Fortunately, the annual prevalence of cigarette smoking among adults in the United States declined 40% between 1965 and 1990. [1] However, it has remained practically unchanged during 1990 and 1999 with current estimates of smoking prevalence among men of 28.0% and among women of 22.5%. [1] There has also been an increase in the use of smokeless tobacco between 1970 and 1987 among white men 34 years of age. [1]

The latency associated with many tobacco-related diseases ensures that tobacco-induced health problems will continue for many years to come. Although the association between tobacco and cardiovascular disease, pulmonary disease, and cancer is well known to health care professionals, the many skin diseases caused by tobacco use may be less recognizable. In this paper, we outline some of the direct and indirect effects of smoking and smokeless tobacco use that can be detected on dermatologic examination (Table 1).


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 packyear history were noted to be 4.7 times more likely to have wrinkles than nonsmokers, controlling for age, sex, skin pigmentation pigmentation, name for the coloring matter found in certain plant and animal cells and for the color produced thereby. Pigmentation occurs in nearly all living organisms. , 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 w rinkling.

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 so as to form a right angle or right angles, as when one line crosses another perpendicularly.

See also: Right
 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 plethoric adjective Fluid-filled, edematous , slightly orange, purple, and red complexion. Chemosis is also frequently observed in smokers' faces.

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 erythematous

characterized by erythema.
 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 microvasculature /mi·cro·vas·cu·la·ture/ (-vas´kul-ah-cher) the finer vessels of the body, as the arterioles, capillaries, and venules.  of skin exposed to cigarette smoke, which include chronic reduced blood flow to the skin. [10] This process, which includes nicotineinduced vasoconstriction vasoconstriction /vaso·con·stric·tion/ (-kon-strik´shun) decrease in the caliber of blood vessels.vasoconstric´tive

, could result in premature aging. There is som e evidence that premature resorption resorption /re·sorp·tion/ (re-sorp´shun)
1. the lysis and assimilation of a substance, as of bone.

2. reabsorption.

 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 line of demarcation
A zone of inflammatory reaction separating gangrenous from healthy tissue.
 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.

Nicotine Stomatitis

Nicotine stomatitis, otherwise known as smoker's palate or leukokeratosis nicotine palati, is an asymptomatic stomatitis Stomatitis Definition

Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth.
 usually seen in chronic smokers. It is described as an inflamed, reddened mucosa that progresses to a multinodular, papular papular

characterized by the development of epidermal or oral mucosal papules.

bovine papular stomatitis
a benign stomatitis caused by a poxvirus in the genus Parapoxvirus.
, gray-white keratinized mucosa [15] and usually only involves the palate. The papules Papules
Firm bumps on the skin.

Mentioned in: Smallpox
 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 squamous cell carcinoma
A carcinoma that arises from squamous epithelium and is the most common form of skin cancer. Also called cancroid, epidermoid carcinoma.
. [19]


Atopic Dermatitis

Although previous studies have linked childhood dermatitis with maternal smoking, recently Mills et a1 [20] reported no apparent difference in the prevalence of atopic dermatitis in smokers or control patients.


Many researchers have shown a relationship between smoking and psoriasis, especially palmopustular psoriasis. O'Doherty et al [21] showed that palmopustular psoriasis was associated with a high prevalence of smoking. In addition, Mills et al [22] showed that in plaque psoriasis, there was a significantly higher prevalence of current smoking (46%) as compared with matched controls (24%), and more patients with psoriasis had smoked before the onset of psoriasis (55%) as compared with controls (32%). Finally, the daily consumption of cigarettes correlated with the risk of developing psoriasis, with the higher number of cigarettes smoked (more than 20 cigarettes per day) being associated with greater risk. This was confirmed by Poikolainen et al, [23] who found that among psoriatic women the mean number of cigarettes smoked was 8.6 compared with 4.7 for controls. It should be noted that some treatments for psoriasis are flammable and therefore may pose a danger to smokers.

Crohn's Disease

Cigarette smoking has been recognized as a risk factor in Crohn's disease. Relative risk for ever-smokers versus never-smokers is 4.0, and the risk increases with the number of cigarettes smoked and the duration of the habit. [24] A retrospective study from the University of Calgary in Alberta further shows that cigarette smoking strongly influences disease activity after surgery. [25] The recurrence rate 10 years after surgery for Crohn's disease was 70% for smokers and 41% for nonsmokers. In comparison, the risk of ulcerative colitis appears to decrease in smokers and increase in former smokers. [26]

Cutaneous lesions develop in up to 15% of patients with Crohn's disease. [27] Although more common in ulcerative colitis, pyoderma gangrenosum has been shown to occur in approximately 1.2% of patients with Crohn's disease. [28] Ulceration, fistula fistula (fĭs`chlə), abnormal, usually ulcerous channellike formation between two internal organs or between an internal organ and the skin.  formation, and cutaneous abscesses of the perineum perineum /peri·ne·um/ (-ne´um)
1. the pelvic floor and associated structures occupying the pelvic outlet, bounded anteriorly by the pubic symphysis, laterally by the ischial tuberosities, and posteriorly by the coccyx.
 are common in patients with Crohn's disease. [29] A persistent fistula may, in tact, be the presenting complaint in Crohn's disease.

Aphthous ulcers, often intractable, are seen in up to 9% of patients with Crohn's disease and are the most common oral manifestation of the disease [30] (However, smokers have been shown to have fewer aphthous ulcers than nonsmokers. [31]) Other oral manifestations include gingival gingival (jin´jv  or buccal cobblestoning, scarring, and elongated e·lon·gate  
tr. & intr.v. e·lon·gat·ed, e·lon·gat·ing, e·lon·gates
To make or grow longer.

adj. or elongated
1. Made longer; extended.

2. Having more length than width; slender.
 ulcers and nodules Nodules
A small mass of tissue in the form of a protuberance or a knot that is solid and can be detected by touch.

Mentioned in: Leprosy

Granulomas occur in Crohn's disease around the anus and at scar, fistula, and colostomy colostomy

Surgical formation of an artificial anus by making an opening from the colon through the abdominal wall. It may be done to decompress an obstructed colon, to allow excretion when part of the colon must be removed, or to permit healing of the colon.
 sites. A relatively rare dermatologic manifestation is termed metastatic Crohn's disease, in which granulomatous granulomatous /gran·u·lom·a·tous/ (-lom´ah-tus) containing granulomas.
Resembling a tumor made of granular material.
 cutaneous lesions are found in areas remote from the gastrointestinal tract. [32] These lesions can appear as erythematous plaques, nodules, or ulcers and usually involve the lower extremities.

Other cutaneous manifestations of Crohn's disease include erythema nodosum, necrotizing necrotizing /nec·ro·tiz·ing/ (nek´ro-tiz?ing) causing necrosis.
Causing the death of a specific area of tissue. Human bites frequently cause necrotizing infections.
 vasculitis Vasculitis Definition

Vasculitis refers to a varied group of disorders which all share a common underlying problem of inflammation of a blood vessel or blood vessels. The inflammation may affect any size blood vessel, anywhere in the body.
, nutritional changes, finger clubbing, and palmar erythema. [33] An association between Crohn's disease and psoriasis has been found. The frequency of psoriasis in patients with Crohn's disease is 7.6 times the normal rate. [34] Vitiligo vitiligo
 or leukoderma

Skin disorder manifested by smooth, white spots on various parts of the body. Though the pigment-making cells of the skin, or melanocytes, are structurally intact, they have lost the ability to synthesize the pigment.
 has also been noted in patients with Crohn's disease, though the association may merely represent a chance occurrence. [35]

One report describes an unusual cutaneous manifestation of Crohn's disease involving an erythematous malar malar /ma·lar/ (ma´lar)
1. buccal; pertaining to the cheek.

2. zygomatic.

Of or relating to the cheekbone or the cheek.

The cheekbone.
 plaque that followed the clinical course of the bowel disease but was not granulomatous. [36] Histologically, the lesion was described as an "atypical Sweet's-like eruption with giant cells." The lesion possibly represents a previously unrecognized pattern of Crohn's disease affecting the skin.


Aside from nutritional deficiencies that can arise in patients with Crohn's disease, cigarettes have some effects on the nutritional status of smokers. In the United States, the second National Health and Nutrition Examination Survey (NHANES NHANES National Health and Nutrition Examination Survey (US CDC)  II) of 1976 to 1980, showed that serum vitamin C levels were lower in smokers for each level of dietary vitamin C intake. [37] An analysis of the data from the NHANES II confirms the association between smoking and decreased serum vitamin C levels, even while correcting for other factors that also affect vitamin C levels such as age, sex, race, and body mass index. [38] The risk of severe hypovitaminosis C ([less than]0.2 mg/dL) is increased in smokers, especially those not taking supplements. The authors propose several theories on what causes this lowered vitamin C level in smokers, including impaired absorption or increased turnover, but a definitive mechanism has not yet been proven.

The serum level of vitamin C sufficiently low to produce clinical signs of scurvy scurvy, deficiency disorder resulting from a lack of vitamin C (ascorbic acid) in the diet. Scurvy does not occur in most animals because they can synthesize their own vitamin C, but humans, other primates, guinea pigs, and a few other species lack an enzyme  is not well defined, but levels in reported cases have been 0.4 mg/dL or less. [39] The dermatologic manifestations of deficient vitamin C status include follicular fol·lic·u·lar
1. Relating to, having, or resembling a follicle or follicles.

2. Affecting or growing out of a follicle or follicles.
 hyperkeratosis hyperkeratosis /hy·per·ker·a·to·sis/ (-ker?ah-to´sis)
1. hypertrophy of the stratum corneum of the skin, or any disease so characterized.

2. hypertrophy of the cornea.
, "corkscrew" hairs, and perifollicular and closed space hemorrhages. [40] Oral manifestations include gingival hypertrophy hypertrophy (hīpûr`trəfē), enlargement of a tissue or organ of the body resulting from an increase in the size of its cells. Such growth accompanies an increase in the functioning of the tissue.  with friable friable /fri·a·ble/ (fri´ah-b'l) easily pulverized or crumbled.

1. Readily crumbled; brittle.

2. Relating to a dry, brittle growth of bacteria.
 gums. Another particularly important result of hypovitaminosis C is poor wound healing. In the absence of vitamin C, in fact, an eightfold eightfold

1. having eight times as many or as much

2. composed of eight parts


by eight times as many or as much

Adj. 1.
 increase in wound dehiscence dehiscence /de·his·cence/ (de-his´ins) a splitting open.

wound dehiscence  separation of the layers of a surgical wound.

 has been shown to occur." Therefore, lower vitamin C levels may contribute to the healing problems seen in smokers.

Response to Antimalarials

Cigarette smoking interferes with the effectiveness of antimalarial antimalarial /an·ti·ma·lar·i·al/ (-mah-lar´e-al) therapeutically effective against malaria, or an agent with this quality.

Preventing or relieving the symptoms of malaria.
 therapy for cutaneous lupus erythematosus. One report showed a significant difference (P[less than] .0002) in the antimalarial response rate between smokers (40%) and nonsmokers (90%) in a group of 61 patients with lupus erythematosus. [42]


As with aphthous ulcers, smoking or some component of cigarette smoke may have a protective effect against the development of acne. Mills et al [43] interviewed 165 patients with acne (96 male and 69 female) and compared these individuals' smoking habits to national statistics. Only 19.7% of the male subjects and 12.1% of the female subjects were smokers, which is much lower than the expected national prevalence of 34.5% and 32.7%, respectively. The findings support the hypothesis that some component of cigarette smoke, possibly nicotine, has an anti-inflammatory action on acne. Another factor may be that patients who seek treatment for acne are more attuned at·tune  
tr.v. at·tuned, at·tun·ing, at·tunes
1. To bring into a harmonious or responsive relationship: an industry that is not attuned to market demands.

 to health issues and are less likely to smoke. Whatever the reason may be, physicians would not be willing to encourage acne sufferers to smoke just to improve this non-life-threatening disorder. This study looked only at patients with serious acne and the results may not apply to patients with moderate acne.


An important consideration in dermatologic operations (especially cutaneous flaps) is the effect that smoking has on healing. Evidence suggests that cigarette smoking can impede healing. Patients who smoked before and after face lifts showed a statistically greater incidence of wound slough than nonsmokers. [44] Smoking also has been associated with a decreased healing rate after surgical removal of impacted teeth, [45] and chronic smoking was shown to adversely affect periodontal healing after surgery for periodotitis. [46] Rugg et al [47] observed that patients who smoked during radiotherapy for head and neck cancers (which are commonly caused by smoking) took 21 weeks to heal the resulting mucositis, compared with 13 weeks in those not smoking during treatment. Mosely and Finseth [48] described a patient with a nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.

2. not directed against a particular agent, but rather having a general effect.


 arteritis arteritis

Inflammation of the arteries. It occurs in diseases including syphilis, tuberculosis, and lupus erythematosus. Varieties not closely associated with systemic disease or disease of an organ outside the cardiovascular system have been described as temporal arteritis,
 whose fingertip ulcer would not heal for 5 months until smoking was discontinued. Goldminz and Bennett [49] showed that high-level smokers (defined as [greater than or equal t o] 1 pack per day) had necrosis of flaps and full-thickness grafts at approximately three times the rate of never smokers, low-level smokers, or former smokers. Also, once tissue necrosis had developed, the median percentage of the visibly necrosed ne·crose  
intr. & tr.v. ne·crosed, ne·cros·ing, ne·cros·es
To undergo or cause to undergo necrosis.

[Back-formation from necrosis.]
 flap or graft tissue was threefold greater among current smokers (regardless of number of packs smoked per day) than never smokers.

Animal experiments confirm the results of the clinical investigations. Nolan et al [50] found that skin flaps on rats exposed to cigarette smoke after surgery showed a significantly greater mean percent area of flap necrosis compared with sham-exposed groups or control groups not exposed. Lawrence et al [51] found that 75.2% of flaps in the control rats survived for 7 days, compared with 48.1% in the rats exposed to intermittent cigarette smoke. Blood gas values in the smoke-exposed rats showed an elevation of car-boxyhemoglobin similar to that in human smokers. Rees [52] also found that hamsters exposed to cigarette smoke before and after flap surgery showed a significant increase in flap necrosis.

Cigarette smoking has been shown to reduce blood flow, especially to the extremities. Using the ultrasonic Doppler flow meter, Sarin sarin (zärēn`), volatile liquid used as a nerve gas. It boils at 147°C; but evaporates quickly at room temperature; its vapor is colorless and odorless.  et al [53] concluded that smoking a single cigarette reduced mean blood flow velocity by 42% in the digital vessels of male volunteers. Mosely and Finseth [48] showed via angiogram an·gi·o·gram
An angiographic x-ray of blood vessels used in diagnosing pathological conditions of the cardiovascular system.//An x-ray of one or more blood vessels produced by angiography and used in diagnosing pathology in the cardiovascular
 that smoking a single cigarette produced severe vasoconstriction in a patient.

The two constituents of cigarette smoke that have been studied and appear to affect healing and flap survival are nicotine and carbon monoxide. Several well-known effects of these constituents are described. Nicotine stimulates the sympathetic ganglia, causing peripheral vasoconstriction. Nicotine also stimulates chemoreceptors of the carotid and aortic body and causes release of catecholamines Catecholamines
Family of neurotransmitters containing dopamine, norepinephrine and epinephrine, produced and secreted by cells of the adrenal medulla in the brain.
 and further vasoconstriction. [50] These catecholamines also act as cofactors in the formation of chalones, which in turn inhibit epithelialization epithelialization /ep·i·the·li·al·iza·tion/ (-the?le-al-i-za´shun) healing by the growth of epithelium over a denuded surface.

ep·i·the·li·al·i·za·tion or ep·i·the·li·za·tion
. [54]

Carbon monoxide binds with great affinity to hemoglobin, reducing the amount of oxygen carried. Because of the shift to the left in the oxyhemoglobin oxyhemoglobin /oxy·he·mo·glo·bin/ (-he?mo-glo´bin) hemoglobin that contains bound O2, a compound formed from hemoglobin on exposure to alveolar gas in the lungs.

 dissociation curve, oxygen that is carried is not released effectively to tissues. Carbon monoxide also increases platelet adhesiveness, [55] and the increase in carboxyhemoglobin carboxyhemoglobin /car·boxy·he·mo·glo·bin/ (-he´mo-glo?bin) hemoglobin combined with carbon monoxide, which occupies the sites on the hemoglobin molecule that normally bind with oxygen and which is not readily displaced from the molecule.  seen in smokers has been shown to induce significant endothelial changes. [56]

Reduction of blood flow due to nicotine effects and impairment of oxygenation oxygenation /ox·y·gen·a·tion/ (ok?si-je-na´shun)
1. the act or process of adding oxygen.

2. the result of having oxygen added.
 due to the carbon monoxide could impair the healing process. [48] Certainly, other mechanisms by which tobacco impairs healing exist, but they have been less thoroughly studied thus far.

Because of overwhelming evidence of the effects of cigarette smoking on healing, it is advised that patients refrain from smoking at least 12 waking hours before surgery, since it takes that long to clear carbon monoxide and bring carboxyhemoglobin levels to near normal. [57] Furthermore, smoking abstinence should be continued during the immediate postoperative period to prevent a "wound disaster." [53]

Atherosclerotic Peripheral Vascular Disease Peripheral Vascular Disease Definition

Peripheral vascular disease is a narrowing of blood vessels that restricts blood flow. It mostly occurs in the legs, but is sometimes seen in the arms.

Cigarette smoking is the most powerful risk factor for atherosclerotic peripheral vascular disease, and smoking cessation is the most important intervention in managing the problem. [58] In one study, pack-years of cigarettes smoked was found to be strongly associated with large vessel peripheral arterial disease. [59] Diabetics who smoke cigarettes have the highest risk for lower extremity arterial disease and amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly . [58] Lithner [60] reported that practically all diabetics less than 60 years old who had gangrene gangrene, local death of body tissue. Dry gangrene, the most common form, follows a disturbance of the blood supply to the tissues, e.g., in diabetes, arteriosclerosis, thrombosis, or destruction of tissue by injury.  were cigarette smokers, and those diabetics who stopped smoking for at least 2 years had a 30% lower prevalence of lower extremity arterial disease than those who continued smoking.

A strong association between cigarette smoking and development of diabetic neuropathy in patients with insulin-dependent (type I) diabetes has also been observed. [61] A dose-response relationship was found between lifetime cigarette smoking and neuropathy. Patients with [greater than or equal to]30 pack-year histories of smoking were 3.32 times more likely to have neuropathy than patients smoking less than this amount. The mechanism proposed for this effect is that tissue hypoxia hypoxia

Condition in which tissues are starved of oxygen. The extreme is anoxia (absence of oxygen). There are four types: hypoxemic, from low blood oxygen content (e.g., in altitude sickness); anemic, from low blood oxygen-carrying capacity (e.g.
 produced by cigarette smoking results in injury to the neural microvasculature. Peripheral neuropathy can render the diabetic's foot insensitive to the presence of an ulceration, leading to delayed treatment and potentially dlisastrous sequelade. [61]

The major clinical manifestations of peripheral vascular disease are those of ischemia. Intermittent claudication Intermittent Claudication Definition

Intermittent claudicationis a pain in the leg that a person experiences when walking or exercising. The pain is intermittent and goes away when the person rests.
 may be accompanied by muscle atrophy of the foot, calf, or thigh. Examination of the foot in peripheral vascular disease reveals several typical dermatologic findings. [62] The foot is cold to the touch, and the skin is shiny, dry, and atrophic. No hair will be present on the feet or toes. Fat pads of the heel and toes may atrophy. Color depends on position: it may show blanching with elevation and cyanotic Cyanotic
Marked by bluish discoloration of the skin due to a lack of oxygen in the blood. It is one of the types of congenital heart disease.

Mentioned in: Congenital Heart Disease
 redness with dependency With severe ischemia, the skin ulcerates, usually starting at the tips of the digits. These painful ulcers are shallow, with a sloughing dark base. A characteristic necrotic crack may form on the heel, which gradually ulcerates. Nail growth is slowed; cracking of the nail plate and pterygium pterygium /pte·ryg·i·um/ (te-rij´e-um) pl. ptery´gia   [Gr.] a winglike structure, especially an abnormal triangular fold of membrane in the interpalpebral fissure, extending from the conjunctiva to the cornea.  formation may occur. [63]

Atheromatous ath·er·o·ma  
n. pl. ath·er·o·mas or ath·er·o·ma·ta
A deposit or degenerative accumulation of lipid-containing plaques on the innermost layer of the wall of an artery.
 emboli emboli /em·bo·li/ (em´bo-li) plural of embolus.
Plural of embolus. An embolus is something that blocks the blood flow in a blood vessel.
 may also cause multiple, small ulcers. These can cause recurrent episodes of painful blue toes, petechiae Petechiae
Tiny purple or red spots on the skin associated with endocarditis, resulting from hemorrhages under the skin's surface.

Mentioned in: Endocarditis, Hantavirus Infections, Hemorrhagic Fevers, Idiopathic Thrombocytopenic Purpura

, or livedo reticularis. [82]

Thromboangiitis Obliterans

Thromboangiitis obli terans (Buerger's disease) (Fig 3) is an obstructive vascular disease caused by segmental inflammatory and proliferative lesions of the tunica media of small arteries and weins. [64] The cause is unknown, but the disease is strongly associated with smoking. Almost all patients with this disease have a history of heavy cigarette smoking, and cessation and resumption of smoking have been documented to produce remission and exacerbation of the discase [65] A case has been reported relating smokeless tobacco use to Buerger's disease as well [66] It appears that some constituent in tobacco, whether smoked or chewed, acts as a cofactor cofactor

An atom, organic molecule, or molecular group that is necessary for the catalytic activity (see catalysis) of many enzymes. A cofactor may be tightly bound to the protein portion of an enzyme and thus be an integral part of its functional structure, or it may
 in the development of the disease.

An autoimmune mechanism is suggested in Buerger's disease by a study in which approximately 50% of patients had significant levels of anticollagen antibodies in their blood, and 77% of patients exhibited cellular sensitivity to human type I and type II collagen. [67] A genetic predisposition also appears to be present, since patients with the disease have a high prevalence of HLA-A9 and HLA-B5 antigens [68]

This disease occurs predominantly in young men and usually affects the lower extremities and, less often, the upper extremities. Occasionally, visceral arteries are involved such as coronary, cerebral, renal, or mesenteric arteries. In addition, the first case of Buerger's disease involving orofacial vessels has been reported. [65]

Physical examination in Buerger's disease reveals impaired distal pulses in the affected limb such as the radial, ulnar ulnar /ul·nar/ (ul´ner) pertaining to the ulna or to the ulnar (medial) aspect of the arm as compared to the radial (lateral) aspect. , dorsalis pedis, and posterior tibial pulses. [64] Palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis.  of proximal pulses, however, is normal. Manifestations of distal limb ischemia include cyanosis cyanosis (sī'ənō`sĭs), bluish coloration of the skin, mucous membranes, and nailbeds, resulting from a lack of oxygenated hemoglobin in the blood. , pallor pallor /pal·lor/ (pal´er) paleness, as of the skin.

Paleness, as of the skin.
, or persistent erythema erythema (ĕr'əthē`mə), more or less diffuse redness of the skin due to concentration of an abnormally large amount of blood within the small vessels of the skin (hyperemia), as in burns.  with an associated change in temperature. Postural changes in color are noted, as are ulcerations Ulcerations
Breaks in skin or mucous membranes that are often accompanied by loss of tissue on the surface.

Mentioned in: Hypersplenism
 or localized gangrene of the digits. Edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts.  of the foot is common. Intermittent claudication in the lower extremities occurs, especially in the arch of the foot. Cold sensitivity with paresthesias Paresthesias
A prickly, tingling sensation.

Mentioned in: Autoimmune Disorders
 and development of secondary Raynaud's phenomenon are common. Superficial thrombophlebitis can be migratory and is manifested as tender, red, inflamed segments of superficial veins.

Raynu Syndrome

Digital ischemia caused by either vasospasm vasospasm /vaso·spasm/ (va´zo-) (vas´o-spazm) angiospasm; spasm of blood vessels, causing vasoconstriction.vasospas´tic

 or obstruction causes the typical Raynaud's episode. This syndrome, seen more often in women, usually involves the hands and fingers, and often is a response to cold temperature or other stimuli.

The usual attack begins with blanched digits, due to cessation of arterial blood flow, followed by cynanosis on rewarming. Later, erythema occurs, caused by reactive hyperemia.

The vasospastic episodes are generally induced by cold temperature, but can be induced by nicotine or caffeine use. Alternatively, the obstructive episodes are most often due to an underlying disease process such as atherosclerosis, trauma, connective tissue disorder, or Buerger's disease. It is obvious that cigarette smoking can aggravate and initiate this condition directly by causing vasospasm and indirectly by involvement in some obstructive diseases.

Cigarette smoking may have a role in irreversible tissue injury sometimes found in Raynaud's syndrome. One study suggests that ascorbic acid and selenium deficiencies may predispose toward irreversible tissue damage in these patients [R] As previously mentioned, ascorbic acid deficiency is known to occur in smokers.


The 1989 Surgeon General's Report concluded that cigarette smoking causes lung cancer, laryngeal cancer, oral cancer, and esophage al cancer. Furthermore, recent studies have established that passive smokers also have an increased risk of lung cancer. [70,71] The 1989 Surgeon General's Report [58] also recognized cigarette smoking to be a contributing factor in cancer of the bladder, pancreas, lip (Fig 4), and kidney and to be associated with cancer of the stomach and uterine cervix. The estimated contribution of cigarette smoking to all cancer deaths is 30%. [58] The cutaneous manifestations of the many cancers associated with cigarette smoking are too numerous to cover completely, but some of the most interesting are described in Table 2.

Skin metastases occur in 0.7% to 9.0% of all patients with cancer. [72] In fact, skin metastases can be the first sign of visceral cancer; in one study, they were the presenting sign in 3.7% of men and in 6% of women. [73] All of the cancers associated with cigarette smoking have been known to metastasize me·tas·ta·size
To be transmitted or transferred by or as if by metastasis.

Spread of cells from the original site of the cancer to other parts of the body where secondary tumors are formed.
 to the skin. Metastatic spread from a distant primary tumor to the skin can be one aspect of diffuse metastatic disease or can be the first sign of malignancy in an otherwise asymptomatic patient. [74] As a general rule, in tumors that metastasize via the lymphatics, such as squamous cell carcinoma of the oral cavity and transitional cell carcinoma tran·si·tion·al cell carcinoma
A malignant neoplasm derived from transitional epithelium and occurring primarily in the urinary bladder, ureters, or renal pelvises.

transitional cell carcinoma Bladder cancer, see there
 of the bladder, skin metastases appear late in the course of the disease and frequently appear in the skin overlying overlying

suffocation of piglets by the sow. The piglets may be weak from illness or malnutrition, the sow may be clumsy or ill, the pen may be inadequate in size or poorly designed so that piglets cannot escape.
 the primary lesion. Tumors that metastasize hematogenously, such as carcinoma of the kidney and lung, often first present cutaneous metastases in an otherwise asymptomatic patient and appear in the skin at distant sites from the primary (Fig 5).

Paraneoplastic syndromes frequently produce dermatologic effects. Lung cancer, especially small cell lung carcinoma, is the most common tumor causing ectopic ectopic /ec·top·ic/ (ek-top´ik)
1. pertaining to ectopia.

2. located away from normal position.

3. arising from an abnormal site or tissue.

 ACTH ACTH: see adrenocorticotropic hormone.
 in full adrenocorticotropic hormone

Polypeptide hormone made in the pituitary gland.
 production. [75] Classic features include generalized hyperpigmentation Hyperpigmentation Definition

Hyperpigmentation is the increase in the natural color of the skin.

Melanin, a brown pigment manufactured by certain cells in the skin called melanocytes, is responsible for skin color.
, cutaneous striae, centripetal centripetal /cen·trip·e·tal/ (sen-trip´e-t'l)
1. afferent (1).

2. corticipetal.

1. Moving or directed toward a center or axis.
 obesity, buffalo hump, and moon facies. This syndrome is only rarely the presenting sign of underlying malignancy, but these signs are useful in determining the success of treatment. Carcinoma of the lung has also been known to elaborate gonadotropins, producing painful gynecomastia gynecomastia

Breast enlargement in a male. It usually involves only the nipple and nearby tissue of one breast. More rarely, the whole breast grows to a size normal in a female. True gynecomastia is related to an increase in estrogens.
. [76]

Paraneoplastic paraneoplastic /para·neo·plas·tic/ (-ne?o-plas´tik) pertaining to changes produced in tissue remote from a tumor or its metastases.


auxiliary to neoplasia.
 acrokeratosis (Bazex syndrome) has been associated with many cancers caused by tobacco use, including neoplasia of the lower lip, tongue, esophagus, pharyngolaryngeal region, and upper third of the lung. Skin changes are characterized by violaceous violaceous /vi·o·la·ceous/ (vi?o-la´shus) having a violet color, usually describing a discoloration of the skin.  erythema with a slight psoriasiform scaling that first appears on the fingers and toes Fingers and Toes
See also anatomy; body, human; hands.


a birth defect in which one or more fingers or toes are missing.


a digit; a finger or toe. See also measurement.
. The nails frequently become hypertrophic Hypertrophic

Mentioned in: Heart Failure


characterized by a state of hypertrophy.

hypertrophic pulmonary osteoarthropathy
see hypertrophic osteopathy.
 with onycholysis onycholysis /on·y·chol·y·sis/ (on?i-kol´i-sis) loosening or separation of a nail from its bed.

The separation or loosening of a fingernail or toenail from its nail bed.
 during the initial stages. Next, a pityriasiform scaling and violaceous erythema develop on the aural helices hel·i·ces  
A plural of helix.
 and nose. Eventually, all surfaces of the hands and feet may become involved, and psoriasiform lesions may develop on the legs, arms, scalp, and face. [77] These skin lesions usually precede symptoms of the underlying malignancy, so an extensive examination is warranted if they are observed.

Present evidence strongly suggests an association between cigarette smoking and leukemia. A large prospective study has shown a significant increase in the risk of leukemia, especially acute nonlymphocytic leukemia acute non·lym·pho·cyt·ic leukemia
See acute myelogenous leukemia.
. [78] This study further shows a dose-response relationship between cigarettes smoked and risk. An additional recent case-control study showed that smokers had a twofold increased risk of acute, nonlymphocytic leukemia compared with nonsmokers. [70] Another study showed the risks of leukemia and myeloma increase with duration of smoking? Whether the association between leukemia and cigarette smoking represents a cause-and-effect relationship remains to be seen, and a mechanism is yet to be identified. [81]

The myeloid leukemias infiltrate the skin more frequently than other leukemias. They usually are manifested as papules or nodules from 1 to 20 mm in diameter and vary in color from normal skin tone to deep purple. The trunk is usually involved with relative sparing of the face, scalp, and extremities. [82] These lesions can produce a leonine facies as well. [83] Although skin involvement usually develops well after the diagnosis of leukemia, it can at times be the first manifestation, often months before peripheral blood involvement. [82] Another point to be made is the difficulty in diagnosing the skin infiltrations in leukemia. Monoclonal antibodies for myeloid myeloid /my·eloid/ (mi´e-loid)
1. medullary; pertaining to, derived from, or resembling bone marrow or the spinal cord.

2. having the appearance of myelocytes, but not derived from bone marrow.
 cells must be included in the diagnostic panel of skin biopsies. [84]

Acute myelogenous leukemia acute myelogenous leukemia
n. Abbr. AML
Myelogenous leukemia characterized by rapid abnormal increase in the number of myeloblasts and progression of symptoms.
 is the most common malignancy to be associated with acute febrile neutrophilic dermatosis dermatosis /der·ma·to·sis/ (der?mah-to´sis) pl. dermato´ses   any skin disease, especially one not characterized by inflammation.  (Sweet's syndrome). [85] Cutaneous manifestations of the leukemias are varied, and additional skin findings include hemorrhagic Hemorrhagic
A condition resulting in massive, difficult-to-control bleeding.

Mentioned in: Hantavirus Infections


pertaining to or characterized by hemorrhage.
 lesions, generalized pruritus pruritus /pru·ri·tus/ (proo-ri´tus) itching.prurit´ic

pruritus a´ni  intense chronic itching in the anal region.

pruritus hiema´lis  xerotic eczema.
, exfoliative ex·fo·li·a·tive
Marked by exfoliation, desquamation, or profuse scaling.
 erythroderma, pyoderma gangrenosum, urticaria urticaria /ur·ti·ca·ria/ (ur?ti-kar´e-ah) hives; a vascular reaction of the upper dermis marked by transient appearance of slightly elevated patches (wheals) which are redder or paler than the surrounding skin and often attended by , erythema multiforme, erythema nodosum, panniculitis, hyperpigmentation, and morbilliform eruptions. [84]

One case is reported of a patient with follicular mucinosis and mycosis fungoides. One week after this diagnosis, myeloblasts were seen in the peripheral blood. [88]

Although cutaneous metastases from transitional cell bladder cancer have been considered rare, Spector et al [87] reported three cases in a 3-year period from their community hospital, with an average incidence of bladder cancer. They suggested that the apparent increased occurrence they had reflects added longevity in patients who have been successfully treated. These metastases usually present themselves as multiple firm, red, fixed papules and nodules. [88] They usually appear metachronously long after the primary bladder lesion has been diagnosed, at a time when multiple organ metastases have occurred.

Acquired ichthyosis Ichthyosis Definition

Derived from two Greek words meaning "fish" and "disease," ichthyosis is a congenital (meaning present at birth) dermatological (skin) disease that is represented by thick, scaly skin.
 has been associated with lung and cervical cancer. [89] Cutaneous changes are usually noted after the primary disease is diagnosed. Parallel fluctuations in the malignancy and the skin disorder suggest that this dermatosis may be useful in monitoring the course of the underlying malignancy. It is manifested by generalized dry skin and pruritus, and generalized scaling is seen on physical examination. Ichthyosis, unlike xerosis xerosis /xe·ro·sis/ (ze-ro´sis) abnormal dryness, as of the eye, skin, or mouth.xerot´ic

xerosis generalisa´ta
, will not respond to topical emollients Emollients
Petroleum or lanolin-based skin lubricants.

Mentioned in: Ichthyosis

Erythroderma, which presents as a diffuse erythema, induration induration /in·du·ra·tion/ (in?du-ra´shun)
1. sclerosis or hardening.

2. hardness.

3. an abnormally hard spot or place.
, and scaling of the skin, is usually associated with hematologic malignancies. [90] In patients with carcinoma of the lung or pancreas, erythroderma usually occurs in the later stages of disease.

Vascular abnormalities can signal an internal malignancy as well. Leukocytoclastic vasculitis can be a presenting sign in squamous cell carcinoma of the bronchus bronchus: see lungs. . [91] Digital ischemia manifested as Raynaud's phenomenon or gangrene may be a marker for carcinoma of the pancreas or kidney. [92] Migratory superficial thrombophlebitis is strongly associated with lung, pancreas, and gastric carcinomas, and is probably related to a hypercoagulable state.

When a patient has dermatomyositis Dermatomyositis Definition

Dermatomyositis (DM) is a rare inflammatory muscle disease that leads to destruction of muscle tissue usually accompanied by pain and weakness.
, a directed search for malignancy is justified, including thorough history, physical examination, and screening laboratory tests followed by workup work·up
n. Abbr. w/u
A thorough medical examination for diagnostic purposes.
 of any abnormality found. [93] The reported frequency of cancer in dermatomyositis is variable, ranging anywhere from 10% to more than 50%. [94] Two recent studies reported that 41% [95] and 43% [94] of patients with dermatomyositis had an associated malignancy. The frequency of tumor types is similar to that found in the general population. [93] The cutaneous manifestations of dermatomyositis include a purplish-red periorbital discoloration, or heliotrope rash, which is prominent on the upper eyelids. The dermatitis is erythematous, scaly, macular macular adjective Related to 1. A macule 2. The macula  and papular, involving the forehead, malar area, neck, and extensor surfaces of the extremities. Poikiloderma, areas of atrophy, vitiligo, or hyperpigmentation, may develop from the original cutaneous lesions. Erythema and infarction of dilated capillaries at the nail margins are commo n as well. [99]

Generalized pruritus, along with the lesions induced by the subsequent rubbing or scratching, is only rarely associated with malignancy, but it has been seen with pancreatic tumors. [97]

Erythema gyratum repens (Fig 6) is almost always associated with an underlying neoplasm neoplasm or tumor, tissue composed of cells that grow in an abnormal way. Normal tissue is growth-limited, i.e., cell reproduction is equal to cell death. , most commonly of the lung. It has also been seen in association with carcinomas of the cervix, bladder, tongue, and hypopharynx. It presents as concentric, raised, erythematous bands that advance rapidly over the skin in a "woodgrain" pattern. [98]

Subcutaneous fat necrosis can be seen in acinar cell carcinoma Acinar cell carcinoma
A malignant tumor arising from the acinar cells of the pancreas.

Mentioned in: Pancreatic Cancer, Exocrine
 of the pancreas. The lesions are painful subcutaneous nodules that are skin colored to violaceous, and normally occur over the trunk, buttocks buttocks /but·tocks/ (but´oks) the two fleshy prominences formed by the gluteal muscles on the lower part of the back. , and legs. [91]

Hypertrichosis lanuginosa acquisita has been reported in association with tumors of the lung [99] and pancreas. [100] Multiple eruptive seborrheic keratoses (the sign of Leser-Trelat) have been associated with lung carcinomas. [101]

Karagas et al [102] studied patients with previous nonmelanoma cancer and found that these individuals had an increased risk for a new tumor of the same histologic type. They also found that those individuals with previous squamous cell carcinoma of the skin had an even greater risk of having another similar tumor if they smoked cigarettes. Compared with those who had never smoked, the rate of subsequent squamous cell skin cancer was higher among current smokers (rate ratio, 2.01) and former smokers (rate ratio 1.62) and increased with both duration and amount smoked.

The nails can provide clues to internal malignancies caused by cigarette smoking. Clubbed nails, or hippocratic nails, are frequently associated with malignant bronchopulmonary bronchopulmonary /bron·cho·pul·mo·nary/ (-pool´mah-nar?e) pertaining to the bronchi and the lungs.

Relating to the bronchial tubes and the lungs.
 disease. Clubbing develops in 5% to 12% of patients with bronchogenic carcinoma. [83] This nail sign develops as a fibrovascular fibrovascular

both fibrous and vascular.

fibrovascular papilloma
see malignant fibrous histiocytoma.
 network that forms between the nail matrix and bone, subsequently elevating the matrix. [103] Lovibond's angle, an angle [greater than]180[degrees], is created between the proximal nail fold and the nail plate. This syndrome can progress to hypertrophic pulmonary osteoarthropathy hypertrophic pulmonary osteoarthropathy
Expansion of the distal ends or entire shafts of the long bones, which is sometimes associated with erosion of the articular cartilages, thickening and villous proliferation of the synovial membranes, and
, in which the clubbing is accompanied by painful periostitis periostitis /peri·os·ti·tis/ (-os-ti´tis) inflammation of the periosteum.

per·i·os·ti·tis or per·i·os·te·i·tis
Inflammation of the periosteum.
 of the long bones and occasionally polyarthritis. [75]

Another nail deformity that has been associated with malignancy is the yellow nail syndrome yellow nail syndrome A clinical complex characterized by slow-growing indurated flavescence of all or the distal part of the nail with the loss of the lunula, onycholysis, primary lymphedema of the face and extremities, idiopathic pleural effusions, chronic . Although the association has not been proven, a case has been reported of yellow nail syndrome and concurrent squamous cell carcinoma of the bronchus. [104] In a reported case of carcinoma of the larynx and yellow nail syndrome, the patient's nails regrew normally after laryngectomy Laryngectomy Definition

Laryngectomy is the partial or complete surgical removal of the larynx, usually as a treatment for cancer of the larynx.

Normally a laryngectomy is performed to remove tumors or cancerous tissue.
. [105] Yellow nail syndrome, in contrast to the previously mentioned yellowish staining of nails by tobacco byproducts, is characterized by a striking yellow to green color, and is accompanied by other nail findings in addition to the coloration. The nails are thickened and have transverse ridging, as well as increased transverse curvature with formation of a hump. They also have slowed growth, absent lunulae and cuticles, and onycholysis. [106]

Human Papillomavirus

Cigarette smoking appears to be associated with several infectious processes that can be discovered upon dermatologic examination. Heavy cigarette smoking is a predisposing factor for development of oral yeast infections. [107] Cigarette smoking has been associated with condyloma acuminatum as well. [108,109]

Daling et al [108] found that in women who had ever smoked, the risk of condyloma condyloma /con·dy·lo·ma/ (kon?di-lo´mah) pl. condylo´mata   an elevated lesion of the skin.condylo´matous

condyloma acumina´tum  pl.
 was 3.7 times that of women who had never smoked. Adjustment was made for factors such as number of sexual partners, history of other sexually transmitted diseases Sexually transmitted diseases

Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely
, and duration of oral contraceptive use. In women who smoked for 3 years or more, the relative risk of condyloma rose to 4.3. One possible factor in the development of condyloma in smokers is that nicotine appears to have a toxic effect on the epithelium, which may facilitate the entry of human papilloma virus human papilloma virus
n. Abbr. HPV
A DNA virus of the genus Papillomavirus, certain types of which cause cutaneous and genital warts in humans, including condyloma acuminatum.
. [109] Another possible explanation for an increase of such infections in smokers is the effect that smoking has on the immune response. Leukocytes from cigarette smokers have reduced natural killing capacity compared with leukocytes from nonsmokers. [110]

Human Immunodeficiency Virus human immunodeficiency virus

Human immunodeficiency virus (HIV)
A transmissible retrovirus that causes AIDS in humans.

Dermatologic disease is a common occurrence in the individual infected with the human immunodeficiency virus (HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. ). These patients have an increased risk for development of many cutaneous disorders, including Kaposi's sarcoma, eosinophilic folliculitis, psoriasis, molluscum contagiosum, seborrheic dermatitis, candidiasis candidiasis (kăn'dĭdī`əsĭs), infection of the mucous membranes caused by the fungus Candida albicans. Other terms for candidiasis are yeast infection, moniliasis (after a former name of the fungal genus), and thrush, the , oral hairy leukoplakia oral hairy leukoplakia (loo´kōplā´kē , genital warts, genital herpes, and herpes zoster.

Although cigarette smoking has long been known to affect CD4 lymphocytes in immuno-competent individuals, [111] recent studies reveal that smoking plays a role in HIV infection and acquired immunodeficiency syndrome acquired immunodeficiency syndrome, see AIDS.  (AIDS). Evidence indicates that cigarette smoking may affect the immune system response to HIV-1 infection and natural progression of the disease.

Patients with AIDS who smoked were found to be more likely to have HIV-1 infiltration of the lung. This condition can often be detected in patients having respiratory episodes and is associated with a more rapid progression to death. [112] Another study found that in HIV-1 infected individuals who smoked, Pneumocyctis carinii pneumonia (PCP PCP
1. phencyclidine

2. primary care physician

Pneumocystis carinii pneumonia (PCP) 
), an AIDS-defining diagnosis, developed more rapidly than in nonsmokers, with a median time to PCP of 9 months, compared with 16 months for nonsmokers. [113]

Burns et al [114] assessed AIDS risk in 202 homosexual men and found that among subjects who were initially seronegative seronegative /se·ro·neg·a·tive/ (-neg´ah-tiv) showing negative results on serological examination; showing a lack of antibody.

, smokers were more likely than nonsmokers to become HIV-1 sero-positive. Data reveal not only that smoking may be a marker for high-risk behavior in homosexual men, but also that smoking may alter the immune system, thus allowing infection.

Finally, HIV-1 seropositive seropositive /se·ro·pos·i·tive/ (-poz´i-tiv) showing positive results on serological examination; showing a high level of antibody.

 individuals who smoke seem to have a reduced progression time to AIDS. Neiman et al [113] found that progression time of HIV-1 infection to the development of AIDS was 8.17 months in smokers and 14.5 months in nonsmokers. This trend is probably related to the increased number of respiratory problems seen in HIV-1 infected individuals who smoke, and these patients should be strongly encouraged to quit.

Smokeless Tobacco

Use of smokeless tobacco, including snuff and chewing tobacco, was introduced to the United States by colonists in the 17th century, and the practice remained popular throughout the 18th and 19th centuries. In the late 1800s, leaders in medicine, such as Pasteur and Lister, associated the habit with germs and communicable disease transmission, and the practice of chewing and spitting gradually became supplanted by cigarette smoking. [115] Since the 1970s, the trend has reversed. Between 1970 and 1980, the increase in sales of smokeless tobacco was estimated at 11% per year, [116] with an estimated total of 12 million American users in 1985. [117] In the early 1970s, the majority of users were men over the age of 50, [118] but more recently, in 1987 and 1991, use was most prevalent among white men aged 18 to 24. These facts are cause for concern, because the increase in use and the decrease in age at start of habit formation could lead to increasing incidences in the cancers associated with smokeless tobacco.


The association between smokeless tobacco and cancer was noted back in 1761 by a British physician whose patients had "nasal polypuses" that he attributed to the use of dry snuff nasally. [119] Since the early 1800s, reports have described mouth cancers in those using tobacco orally.

In a key study of women in North Carolina, Winn et al [120] showed that the risk of oral cancer in nonsmokers was 4.2 times greater for those who used snuff than those who did not. Those women who used snuff for 50 years or longer were 48 times more likely to have cancer of the gum and buccal mucosa than were nonusers. In this study, the cancers were more likely to occur in those locations of the mouth where the snuff was placed; the risk grew with increasing duration of snuff use; and factors such as diet, dental hygiene, alcohol intake, and cigarette smoking were found not to be responsible for the association. The Advisory Committee to the Surgeon General concluded from this and other case-control studies that the relationship between oral cancer and smokeless tobacco is causal. [117]

The carcinogenic effects of smokeless tobacco (Table 3) are not limited to the mucous membranes of the oral cavity, as illustrated in the case of a 58-year-old man who placed snuff in his left ear for several hours daily to weekly over a period of 40 years. Upon examination for complaints of burning and tingling in the left ear, a 3 x 4 cm squamous cell carcinoma was found at the upper part of the left ear along with particles of snuff in the left auditory canal. [121] Similarly, in areas of the world where snuff is inhaled and the tobacco comes in direct contact with the nasal cavity, high rates of nasal cancer have been reported. [122]

Other tissues that come in contact with constituents of smokeless tobacco in a diluted form include the esophagus, larynx (Fig 7), and stomach, and studies of cancers at these sites show an association with smokeless tobacco use. [117] Other cancers and their associations with smokeless tobacco use have been studied, but results at this time are inconclusive.

Leukoplakia leukoplakia /leu·ko·pla·kia/ (-pla´ke-ah)
1. a white patch on a mucous membrane that will not rub off.

2. oral l.

atrophic leukoplakia  lichen sclerosus in females.

Smokeless tobacco can cause oral leukoplakia (Fig 8) . [117] In a study of 1,109 professional baseball players, leukoplakia and erythroplakia were strongly associated with smokeless tobacco use. Of the current users, 46.3% had leukoplakia. Risk for leukoplakia was found to be associated with amount of tobacco used, recency of use, and type and brand of snuff used. The leukoplakia lesions seemed to occur rapidly with tobacco use but often resolved quickly after cessation. [123]

Greer and Poulson [124] formulated a classification system for grading the mucosal changes of adult smokeless tobacco users. Degree 1 is a superficial lesion with color similar to the surrounding mucosa, with slight wrinkling but no obvious thickening. Degree 2 is a superficial whitish or reddish lesion with moderate wrinkling but no obvious thickening. Degree 3 is described as a red or white lesion with intervening furrows of normal mucosal color and obvious thickening and wrinkling.

Some smokeless tobacco-induced leukoplakia lesions have been shown to undergo transformation to dysplasia [125] and have developed into carcinomas. [126] Clinically, one cannot accurately distinguish dysplastic from benign lesions, and therefore biopsy is necessary to determine whether malignant transformation has occurred.

Other Oral Manifestations

Smokeless tobacco has also been associated with a localized gingival recession and increased caries caries
 or tooth decay

Localized disease that causes decay and cavities in teeth. It begins at the tooth's surface and may penetrate the dentin and the pulp cavity.
 in those users with coexisting gingivitis gingivitis (jĭn'jəvī`tĭs), inflammation of the gums. It may be acute, subacute, chronic, or recurrent. The gums usually become red, swollen, and spongy, and bleed easily.  (Table 3). [127] Other effects on the oral tissues linked to smokeless tobacco use include halitosis halitosis (hăl'ĭtō`sĭs), unpleasant odor carried on the breath. It is usually the result of gum disorder, tooth decay, smoking, indulgence in aromatic foods, or a mild digestive upset. , discoloration of the teeth, and excessive wear on the teeth due to abrasives in the tobacco. [128]


Recognition of dermatologic signs of tobacco use can certainly be a clue to many of the serious underlying systemic diseases associated with smoking and smokeless tobacco use. We suggest that the recognition of these dermatologic manifestations can, in addition, be used as a tool to encourage smoking cessation in patients. In a study by Curry et al, [129] the graphic picturing of health effects of smoking was rated by smokers to be an important motivational factor for smoking cessation. For many users of tobacco, however, the more immediate and visible effects of this drug such as wrinkling, yellow teeth, and bad breath may provide a more compelling stimulus for smoking cessation than the knowledge that tobacco kills. [130] The physician can point out the visible effects of tobacco use in the patient and use this to initiate a discussion on the patient's tobacco use and the associated health effects. Although education of the patient on the health effects of tobacco use is an important start, addictions, lik e other diseases, are not cured by a few choice words. All physicians need to follow discussions on tobacco use with recommendations on how to treat the addiction. Physicians need to be aware of the cessation techniques available and know how to choose the one most helpful to the individual. [131] This may include referral to a community smoking cessation program or treatment with physician follow-up and support via behavioral approaches or pharmacologic interventions. Physicians currently find it easier to deal with the consequences of tobacco use, such as pulmonary and cardiac disease, than to deal with the addiction. [132] It is important that physicians learn to intervene and help their patients quit using tobacco.


(1.) Centers for Disease control and Prevention: Tobacco use-- United States, 1990-1999. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg,  1999; 48:986-993

(2.) Satcher D: The framework convention on tobacco control: a report for the 52nd world Health Assembly. JAMA JAMA
Journal of the American Medical Association
 1999; 282:424

(3.) Johnson DF: Appearance and the Elderly in the Psychology of Cosmetic Treatments. New York, Praeger, 1985

(4.) Fenske NA, Albers SE: cosmetic modalities for aging skin: what to tell patients. Geriatrics 1990; 45:59-67

(5.) Kadunce DP, Burt R, Gress RE, et al: Cigarette smoking as a risk factor for facial wrinkling. Ann Intern Med 1991; 114:840-844

(6.) Ernster VL, Grady D, Miike R, et al: Facial wrinkling in men and women, by smoking. Am J Public Health 1995; 85:78-82

(7.) Model D: Smoker's face. an underrated clinical sign? BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift  1985; 291:1760-1762

(8.) Frances C, Boisnic S, Hartman DJ, et al: changes in the elastic tissue of the non-sunexposed skin of cigarette smokers. Br J Dermatol 1991; 125:43-47

(9.) Adhoute M, DeRigal J, Marchand JP, et al: Influence of age and sun exposure on the biophysical properties of the human skin: an in vivo study. Photodermatol Photoimmunol Photomed 1992; 9:99-103

(10.) Krupsi WC: The peripheral vascular consequences of smoking. Ann Vasc Surg 1991; 5:291-304

(11.) Basu J, Mikhail MS, Palan PR, et al: Endogenous estradial and progesterone concentrations in smokers on oral contraceptives. Gynecol Obstet Invest 1992; 33:224-227

(12.) Daniel M, Martiz AD, Drinkwater DT: Cigarette smoking, steroid hormones, and bone mineral density bone mineral density
See bone density.

bone mineral density A measurement of bone mass, expressed as the amount of mineral–in grams divided by the area scanned in cm2. See Bone densitometry.
 in young women. Calcif Tissue Int 1992; 50:300-305

(13.) Wolf R, Tur E, wolf D, et al: The effect of smoking on skin moisture and surface lipids. Int J Cosm Sci 1992; 14:83-88

(14.) Verghese A, Krish G, Howe D, et al: The harlequin nail. a marker for smoking cessation. Chest 1990; 97:236-238

(15.) Archard HO: Biology and pathology of the oral mucosa. Dermatology in General Medicine. New York, McGraw-Hill, 3rd Ed, 1987, pp 1193-1194

(16.) Fire in the United States. Washington, DC, Federal Emergency Management Agency The Federal Emergency Management Agency (FEMA) is the federal agency responsible for coordinating emergency planning, preparedness, risk reduction, response, and recovery. The agency works closely with state and local governments by funding emergency programs and providing technical , 6th Ed, 1987

(17.) Mierley MC, Baker SP: Fatal house fires in an urban population. JAMA 1993; 249:1466-1468

(18.) Ballard JE, Koepsell TD, Rivara F: Association of smoking and alcohol drinking with residential fire injuries. Am J Epidemiol 1992; 135:26-34

(19.) Treres N, Pack GT: The development of cancer in bum scars. analysis and report of thirty-four cases. Surg Gynecol Obstet 1930; 51:749

(20.) Mills CM, Irivasravo ED, Harvey JM, et al: Cigarette smoking is not a risk facor in atopic dermatitis. Int J Dermatol 1994; 33:33-34

(21.) O'Doherty CJ, MacIntyre C: Palmoplantar pustulosis and smoking. BMJ 1985; 291:861-864

(22.) Mills CM, Irivastava ED, Harvey JM, et al: Smoking habits in psoriasis: a case control study. Br J Dermatol 1992; 127:18-21

(23.) Poikolainen K, Reunala T, Karvanen J: Smoking, alcohol and life events related to psoriasis among women. Br J Dermatol 1994; 130:473-477

(24.) Franceschi S, Panza E, LaVecchia C: Nonspecific inflammatory bowel disease inflammatory bowel disease
n. Abbr. IBD
Any of several incurable and debilitating diseases of the gastrointestinal tract characterized by inflammation and obstruction of parts of the intestine.
 and smoking. Am J Epidemiol 1987; 125:445-452

(25.) Sutherland LR, Ramcharan S, Bryant H, et al: Effect of cigarette smoking on recurrence of Crohn's disease. Gastroenterology 1990; 98:1123-1128

(26.) Greenstein AJ, Janowitz HD, Sachar DB: The extra-intestinal complications of Crohn's disease and ulcerative colitis: a study of 700 patients. Medicine 1976; 55:401-412

(27.) Graham-Brown RAC See remote access concentrator. , Rathbone B, Marks J: The skin and disorders of the alimentary tract. Dermatology in General Medicine. New York, McGraw-Hill, 5th Ed, 1999, p 1912

(28.) Gitnick G: Inflammatory bowel diseases: Part II. Extraintestinal involvement and management. Am Fam Physician 1989; 39:225-233

(29.) Pincus SH: Cutaneous diseases of the female genitalia. Dermatology in General Medicine. New York, McGraw-Hill, 3rd Ed, 1987, p 1264

(30.) Croft CB, Wilkinson AR: Ulceration of the mouth, pharynx pharynx (fâr`ĭngks), area of the gastrointestinal and respiratory tracts which lies between the mouth and the esophagus. In humans, the pharynx is a cone-shaped tube about 4 1-2 in. (11.43 cm) long. , and larynx in Crohn's disease of the intestine. Br J Surg 1972; 59:249-252

(31.) Muzyka BC, Glick M: Major apthous ulcers in patients with HIV disease. Oral Surg Oral Med Oral Pathol 1994; 77:116-120

(32.) Shum DT, Guenther L: Metastatic Crohn's disease. Arch Dermatol 1990; 126:645-648

(33.) Burgdorf W: Cutaneous manifestations of Crohn's disease. J Am Acad Dermatol 1981; 5:689-695

(34.) Yates VM, Watkins MG, Kelman A: Further evidence for an association between psoriasis, Crohn's disease and ulcerative colitis. Br J Dermatol 1982; 1006:323-330

(35.) Monroe EW: Vitiligo associated with regional enteritis. Arch Dermatol 1976; 112:833-834

(36.) Smoller BR, Weishar M, Gray MH: An unusual cutaneous manifestation of Crohn's disease. Arch Pathol Lab Med 1990; 114:609-610

(37.) Smith JL, Hodges RE: Serum levels of vitamin C in relation to dietary and supplemental intake of vitamin C in smokers and non-smokers. Ann N Y Acad Sci 1987; 498:144-152

(38.) Schectman G, Byrd JC, Gruchow HW: The influence of smoking on vitamin C status in adults. Am J Public Health 1989; 79:158-162

(39.) Reuler JB, Broudy VC, Cooney TO: Adult scurvy. JAMA 1985; 253:805-807

(40.) Miller SJ: Nutritional deficiency and the skin. J Am Acad Dermatol 1989; 21:1-30

(41.) Crandon JH, Landau JB, Mikal S, et al: Ascorbic acid economy in surgical patients as indicated by blood ascorbic acid levels. N Engl J Med 1958; 253:805-808

(42.) Jewell ML, McCauliffe DP: Patients with cutaneous lupus erythematosus who smoke are less responsive to antimalarial treatment. J Am Acad Dermatol 2000; 42:983-987

(43.) Mills CM, Peters TJ, Finlay AY: Does smoking influence acne? Clin Exp Dermatol 1993; 18:100-101

(44.) Rees TD, Liverett DM, Guy CL: The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg 1994; 73:911-915

(45.) Sweet JB, Butler DP: The relationship of smoking to localized osteitis osteitis /os·te·itis/ (os?te-i´tis) inflammation of bone.

condensing osteitis  osteitis with hard deposits of earthy salts in affected bone.
. J Oral Surg 1979; 37:732-735

(46.) Preber H, Bergstrom J: Effect of cigarette smoking on periodontal healing following surgical therapy. J Clin Periodontol, 1990; 17:324-328

(47.) Rugg T, Saunders MI, Dische S: Smoking and mucosal reactions to radiotherapy. Br J Radiol 1990; 63:554-556

(48.) Mosely LH, Finseth F: Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand 1977; 9:97-101

(49.) Goldminz D, Bennett R: Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol 1991; 127:1012-1015

(50.) Nolan J, Jenkins RA, Kurihara K, et al: The acute effects of cigarette smoke exposure in experimental skin flaps. Plast Reconstr Surg 1984; 75:550-551

(51.) Lawrence WT, Murphy RC, Robson MC, et al: The detrimental effect of cigarette smoking on flap survival: an experimental study in the rat. Br J Plastic Surg 1984; 37:216-219

(52.) Rees TD, Liverett DM, Guy G: The effect of cigarette smoking on skin flap survival in the facelift patient. Plast Reconstr Surg 1984; 73:991-996

(53.) Sarin CL, Austin JC, Nickel WO: Effects of smoking on digital blood-flow velocity. JAMA 1974; 229:1327-1328

(54.) Sherwin MA, Gastwirth CM: Detrimental effect of cigarette smoking on lower extremity wound healing. J Foot Surg 1990; 29:84-87

(55.) Birnstingl MA, Brinson K, Chakrabarti R: The effect of short-term exposure to carbon monoxide on platelet stickiness. Br J Surg 1971; 58:837

(56.) Astrup P, Kjeldsen K: Carbon monoxide, smoking and atherosclerosis. Med Clin North Am 1973; 58:323

(57.) Anderson ME, Belani KG: Short-term preoperative smoking abstinence. Am Fam Physician 1990; 41:1191-1194

(58.) US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
: Advances in knowledge of the health consequences of smoking. reducing the health consequences of smoking: 25 years of progress. a report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS DHHS Department of Health & Human Services (US government)
DHHS Dana Hills High School (Dana Point, California)
DHHS Deaf and Hard of Hearing Services
DHHS Deaf and Hard of Hearing Services
 Publication No. (CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
) 89-8411, 1989, pp 63-64

(59.) Criqui MH, Browner D, Fronek A, et al: Peripheral arterial disease in large vessels is epidemiologically distinct from small vessel disease small vessel disease Neurology Cerebrovascular disease due to stenoses in small arteries of the brain. See Ministroke. . Am J Epidemiol 1989; 129:1110-1119

(60.) Lithner F: Is tobacco of importance for the development and progression of diabetic complications? Acta Med Scand 1983; 687:33-36

(61.) Mitchell BD, Hawthorne VM, Vinik AI: Cigarette smoking and neuropathy in diabetic patients. Diabetes Care 1990; 13:434-437

(62.) Edwards EA, Coffman JD: Cutaneous changes in peripheral vascular disease. Dermatology in General Medicine. New York, McGraw-Hill, 3rd Ed, 1987, pp 1997-2022

(63.) Wright AL: Nails. BMJ 1988; 296:106-109

(64.) Kontos HA: Vascular diseases of the limbs. Cecil's Textbook of Medicine. Philadelphia, WB Saunders Co, 18th Ed, 1988, pp 382-383

(65.) Farish SE, EI-Mofty SK, Cohn SJ: Intraoral manifestation of thromboangiitis obliterans (Buerger's disease). Oral Surg Oral Med Oral Pathol 1990; 69:223-226

(66.) O'Dell JR, Linder J, Markin RS, et al: Thromboangiitis obliterans (Buerger's disease) and smokeless tobacco. Arthritis Rheum rheum (rldbomacm) any watery or catarrhal discharge.

A watery or thin mucous discharge from the eyes or nose.


any watery or catarrhal discharge.
 1987; 30:1054-1056

(67.) Adar R, Papa MZ, Halpem Z, et al: Cellular sensitivity to collagen in thromboangiitis obliterans. N Engl J Med 1983; 308:1113-1116

(68.) McLoughlin GA, Helsby CR, Evans CC, et al: Association of HLA-A9 and HLA-B5 with Buerger's disease. BMJ 1976; 2:1165-1166

(69.) Herrick AL, Reiley F, Scholfield D, et al: Micronutrient mi·cro·nu·tri·ent
A substance, such as a vitamin or mineral, that is essential in minute amounts for the proper growth and metabolism of a living organism.
 antioxidant status in patients with primary Raynaud's phenomenom and systemic Sclerosis. J Rheum 1994; 21:1477-1483

(70.) Miller GH, Golish JA, Cox CE, et al: Women and lung cancer: a comparison of active and passive smokers with nonexposed nonsmokers. Cancer Detect Prevent 1994; 18:421-430

(71.) Fontham ET, Canea P, Reynolds P, et al: Environmental tobacco smoke environmental tobacco smoke (ETS/passive smoke),
n the gaseous by-product of burning tobacco products, including but not limited to commercially manufactured cigarettes and cigars; contains toxic elements harmful to the health of adults and children
 and lung cancer in nonsmoking women, a multicenter study. JAMA 1994; 271:1752-1759

(72.) Willis RA: The Pathology of Tumors. London, Butterworth and Co, 1960, p 179

(73.) Spencer PS, Helm TN: Skin metastases in cancer patients. Cutis cutis /cu·tis/ (ku´tis) the skin.

cutis anseri´na  transitory elevation of the hair follicles due to contraction of the arrectores pilorum muscles; a reflection of sympathetic nerve discharge.
 1987; 39:119-121

(74.) Brownstein MH, Helwig EB: Metastatic tumors of the skin. Cancer 1972; 29:1298-1307

(75.) Ihde DC: Paraneoplastic syndromes. Hosp Pract 1987; 22:105-124

(76.) Omenn GS: Ectopic polypeptide hormone production by tumors. Ann Intern Med 1970; 72:136-138

(77.) Jacobsen FK, Abildtrup N, Laursen SO, et al: Acrokeratosis paraneoplastica (Bazex syndrome). Arch Dermatol 1984; 120:502-504

(78.) Kinlen LJ, Rogot E: Leukemia and smoking habits among United States veterans. BMJ 1988; 297:657-659

(79.) Severson RK, Davis S, Heuser L, et al: Cigarette smoking and acute non-lymphocytic leukemia. Am J Epidemiol 1990; 132:418-422

(80.) Miller K, Newell GR, Beeson WL, et al: History of cigarette smoking and risk of leukemia and myeloma: results from the Adventist Health Study. J Natl Cancer Inst 1990; 82:1832-1836

(81.) Wald N: Smoking and leukemia Am Cancer Soc J 1988; 13:4-5

(82.) Hainsworth JD, Greco FA: Unrecognized leukemia cutis. Saudi Med J 1987; 80:663-664

(83.) Leong CH: Cutaneous Clues to Systemic Diseases. Kent Ridge, Singapore University Press, 1986

(84.) Horlick HP, Silvers DN, Knobler EH, et al: Acute myelomonocytic leukemia presenting as a benign-appearing cutaneous eruption. Arch Dermatol 1990; 126:653-656

(85.) Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
 PR, Kurzrock R: Sweet's syndrome and malignancy Am J Med 1987; 82:1220-1226

(86.) Habboush HW, Lucie NP, Mackie RM, et al: Follicular mucinosis, mycosis fungoides, and acute myeloid leukemia. J Clin Pathol 1990; 43:347

(87.) Spector JI, Zimbler H, DeLeo M, et al: Skin metastases from transitional cell bladder cancer. Umlogy 1987; 29:215-217

(88.) Beautyman EJ, Garcia CJ, Sibulkin D, et al: Transitional cell bladder carcinoma metastatic to the skin. Arch Dermatol 1983; 119:705-707

(89.) Flint GL, Flam M, Soter NA: Acquired ichthyosis. a sign of non-lymphoproliferative malignant disorders. Arch Dermalot 1975; 111:1446-1447

(90.) Nicolis CD, Hetwig EB: Exfoliative dermatitis. Arch Dermatol 1973; 108:788

(91.) Maurice TR: Carcinoma of the bronchus presenting with Henoch-Schonlein purpura. BMJ 1978; 2:831

(92.) McLean DI, Haynes HA: Cutaneous aspects of internal malignant disease. Dermatology in General Medicine. New York, McGraw-Hill, 3rd Ed, 1987, pp 1917-1937

(93.) Richardson JB, Callen JP: Dermatomyositis and malignancy. Med Clin North Am 1989; 73:1211-1220

(94.) Cox NH, Lawrence CM, LangtryJAA, et al: Dermatomyositis. Arch Dermatol 1990; 126:61-65

(95.) Basset-Sequin N, Roujeau JC, Gherardi R, et al: Prognostic factors and predictive signs of malignancy in adult dermatomyositis. Arch Dermatol 1990; 126:633-637

(96.) Mills JA: Dermatomyositis. Dermatology in General Medicine New York, McGraw-Hill, 3rd Ed, 1987, p 1835

(97.) Newbold PCH PCH Paroxysmal cold hemoglobinuria, see there : Skin markers of malignancy. Arch Dermatol 1970; 102:680-692

(98.) Appell ML, Ward WQ Tyring SK: Erythema gyratum repens: a cutaneous marker of malignancy Cancer 1988; 62:548-550

(99.) Ikeya T, Izumi A, Suzuki M: Acquired hypertrichosis lanuginosa Dermatologica 1978; 156:274-282

(100.) McLean DI, Macauley JC: Hypertrichosis lanuginosa acquisita associated with pancreatic carcinoma. BR J Dermatol 1977; 96:313

(101.) Doll DC, McCagh MF, Welton WA: Sign of Leser Trelat JAMA 1977; 238:236-237

(102.) Karagas MR, Stukel TA, Greenberg ER, et al: Risk of subsequent basal cell carcinoma basal cell carcinoma
A slow-growing, locally invasive, but rarely metastasizing neoplasm of the skin derived from basal cells of the epidermis or hair follicles. Also called basal cell epithelioma.
 and squamous cell carcinoma of the skin among patients with skin cancer. JAMA 1992; 267:3305-3310

(103.) Kabongo ML, Bedell Bedell could refer to

A person:
  • The conventional spelling for the role of bedel at the University of Cambridge.
  • Frederick Bedell, cofounder of Physical Review, the first American journal of physics.
 AW: Nail signs of systemic conditions. Am Fam Physician 1987; 36:109-116

(104.) Thomas PS, Sidhu B: Yellow nail syndrome and bronchial carcinoma Chest 1987; 92:191

(105.) Guin JD, Elleman JH: Yellow nail syndrome. Arch Dermatol 1979; 115:734-735

(106.) Franks AG: Cutaneous aspects of cardiopulmonary disease. Dermatology in General Medicine. NewYork. McGraw-Hill, 3rd Ed, 1987, p 1988

(107.) Oksala E: Factors predisposing to oral yeast infections. Acta Odontol Scand 1990; 48:71-74

(108.) Daling JR, Sherman KJ, Weiss NS: Risk factors for condyloma acuminatum in women. Sex Transm Dis 1986; 13:16-18

(109.) Singer A, Walker PC, McCance DJ: Genital wart virus infection. nuisance or potentially lethal? BMJ 1984; 288:735-736

(110.) Ferson M, Edwards A, Lind A, et al: Low natural killer-cell activity and immunoglobubin levels associated with smoking in human subjects. Int J Cancer 1979; 23:603-609

(111.) Tollerand DJ, Clark JW, Morris B, et al: The effects of cigarette smoking on T-cell subsets. Clin Rev Respir Dis 1989; 139:1446-1451

(112.) Clarke JR, Taylor IK, Fleming J, et al: The epidemiology of HIV-1 infection of the lung in AIDS patients. AIDS 1993; 7:555-560

(113.) Neiman RB, Fleming J, Coker RJ, et al: The effect of cigarette smoking on the development of AIDS in HIV-1 seropositive individuals. AIDS 1993; 7:705-710

(114.) Burns DN, Kramer A, Yellin F, et al: Cigarette smoking: a modifier of human immunodeficiency virus type 1 infection? J Acquir Immune Defic Syndr 1991; 4:76-83

(115.) Christen AG, Swanson BZ, Clover ED, et al: Smokeless tobacco: the folklore and social history of snuffing, sneezing, dipping and chewing. J Am Dent Assoc 1982; 105:821-829

(116.) Christen AG: The case against smokeless tobacco: five facts for the health professional to consider. J Am Dent Assoc 1980; 101:464-469

(117.) US Department of Health and Human Services: The health consequences of using smokeless tobacco. A report of the Advisory Committee to the Surgeon General. NIH "Not invented here." See digispeak.

NIH - The United States National Institutes of Health.
 Publication No. 86-2874, 1986

(118.) Squier CA: The nature of smokeless tobacco and patterns of use. CA Cancer J Clin 1988; 38:226-229

(119.) Redmond DE Jr: Tobacco and cancer: the first clinical report, 1761. N Engl J Med 1970; 282:18-23

(120.) Winn DM, Blot WJ, Shy CM: Snuff dipping and oral cancer among women in the southern United States The Southern United States—commonly referred to as the American South, Dixie, or simply the South—constitutes a large distinctive region in the southeastern and south-central United States. . N Engl J Med 1981; 304:745-749

(121.) Root HD, Aust JB, Sullivan A Jr: Snuff and cancer of the ear. report of a case. N Engl J Med 1960; 262:819-820

(122.) Higginson J, Oettle AG: Cancer incidence in the Bantu and Cape colored races of South Africa: report of a cancer survey in the Transvaal. J Natl Cancer Inst 1960; 24:589-671

(123.) Grady D, Greene J, Daniels TF, et al: Oral mucosal lesions found in smokeless tobacco users. J Am Dent Assoc 1990; 121:117-123

(124.) Greer RO Jr, Poulson TC: Oral tissue alterations associated with the we of smokeless tobacco by teenagers. I. Clinical findings. Oral Surg 1983; 56:275-284

(125.) Tyldesley WR: Tobacco chewing in English coalminers. malignant transformation in a tobacco-induced leukoplakia. Br J Oral Surg 1976; 14:93-94

(126.) Roed-Peterson B, Pindborg JJ: A study of Danish snuff-induced oral leukoplakia. J Oral Pathol Med 1973; 2:301-313

(127.) Offenbacher S, Weathers DR: Effects of smokeless tobacco on the periodontal, mucosal and caries status of adolescent males. J Oral Pathol 1985; 14:169-181

(128.) Council on Scientific Affairs: Health effects of smokeless tobacco. JAMA 1986; 255:1038-1044

(129.) Curry S, Edward HW, Grothaus LC: Intrinsic and extrinsic motivation for smoking cessation. J Consult Clin Psychol 1990; 58:310-316

(130.) Silvis GL, Perry CL: Understanding and deterring tobacco use among adolescents. Pediatr Clin North Am 1987; 34:363-379

(131.) Ockene JK: Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness, Prev Med 1987; 7:723-737

(132.) Peters JA: Nicotine-replacement therapy in cessation of smoking. Mayo Clin Pmc 1990; 65:1619-1623
TABLE 1.  Dermatologic Effects of Cigarette Smoking
Direct Effects            Indirect Effects
Facial wrinkling          Poor wound healing
Facial gauntness          Psoriasis
Complexion color changes  Atherosclerotic peripheral vascular disease
Decreased skin moisture   Buerger's disease
Yellowed nails            Raynaud's disease
Harlequin nails           Diabetic foot disease
Halitosis                 Oral yeast infections
Nicotine stomatitis       Condyloma acuminatum
Skin burns                Cutaneous findings in HIV and AIDS,
                          Crohn's disease, and malignancies
TABLE 2. Dermatologic Findings in Smoking-Related Malignancies
Dermatologic Findings                Related Malignancy
Skin metastases                      All smoking related malignancies
Clubbed nails                        Bronchogenic carcinoma
Raynaud's syndrome                   Pancreatic or lung carcinoma
Acute febrile neutrophilic           Acute myelogenous leukemia
Leonine facies                       Myelogenous leukemias
Leukocytoclastic vasculitis          Bronchogenic carcinoma
Migratory superficial                Pancreatic or lung carcinoma
Acquired ichthyosis                  Cervical or lung carcinoma
Erythroderma                         Hematologic malignancies
Generalized pruritus                 Pancreatic carcinoma
Acrokeratosis paraneoplastica        Carcinoma of esophagus, lip,
                                      tongue, pharynx-larynx, or upper
                                      third of lung
Erythema gyratum repens              Lung carcinoma
Subcutaneous fat necrosis            Pancreatic carcinoma
Gynecomastia                         Lung carcinoma
Hypcrtrichosis lanuginosa acquisita  Pancreatic or lung carcinoma
Multiple eruptive seborrheic         Lung carcinoma
Cushing's features                   Lung carcinoma (small cell)
TABLE 3. Dermatologic Effects of Smokeless Tobacco
Direct Effects                Indirect Effects
Localized gingival recession  Oral carcinoma
Increased dental caries       Esophageal carcinoma
Halitosis                     Pharyngolaryngeal carcinomas
Tooth discoloration           Gastric carcinoma
Tooth abrasions
Oral leukoplakia


* Dermatologic effects of cigarette smoking include facial wrinkling, facial gauntness, complexion color changes, decreased skin moisture, yellowed nails, harlequin nails, halitosis, nicotine stomatitis, and skin burns.

* Indirect effects of cigarette smoking include poor wound healing; psoriasis; atherosclerotic peripheral vascular disease; Buerger's disease; Raynauds disease; diabetic foot disease; oral yeast infections; condyloma acuminatum; and cutaneous findings in HIV and AIDS, Crohn's disease, and malignancies.

* Recognition of dermatologic signs of tobacco use can be a clue to many of the serious underlying systemic diseases associated with smoking and also with use of smokeless tobacco.

* Physicians need to be aware of the cessation techniques available and know how to choose the one most helpful to an individual.
COPYRIGHT 2001 Southern Medical Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2001, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

 Reader Opinion




Article Details
Printer friendly Cite/link Email Feedback
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Jun 1, 2001
Previous Article:Changing Antibiotic Sensitivity Patterns at a University Hospital, 1992 Through 1999.
Next Article:Pulmonary Hypertension Associated With HIV Infection.

Related Articles
Tobacco plants enlisted in war on cancer.
Health & Science.
Questions and Answers About Lichen Sclerosus.
What a drag. (Tip Sheet).
U.S. hampers global anti-tobacco treaty. (Environmental Intelligence).
Selected annotated bibliography. (Featured CME Topic: Adverse Effects of Smoking).
Experts call on Asian governments to remove lead from gasoline. (EH Update).
Pemphigus vulgaris: an acquired blistering disease. (Case Report).
Tobacco policy: addressing Public enemy number one.

Terms of use | Copyright © 2014 Farlex, Inc. | Feedback | For webmasters