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CHAPTER 6 PHOTOAGING 41
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CHAPTER 7 Cigarettes and Aging Skin
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While there remains a good deal to learn about the mechanisms and factors related to intrinsic skin aging, scientists have a stronger grasp of the numerous exogenous factors implicated in the aging of skin, among them sun exposure and lifestyle choices such as smoking, drinking, and poor nutrition Of course, the internal ramifications of smoking are much better known than are the external results, but more than two decades of epidemiologic research findings indicate that smokers indeed manifest greater facial aging and skin wrinkling than nonsmokers1 This chapter reviews the literature and discusses what is known about the effects on skin of chronic cigarette smoking
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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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FIGURE 7-1 Smokers characteristically develop lines around the mouth
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HISTORICAL PERSPECTIVE
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A relationship between smoking and skin wrinkling was observed as long ago as 18561 3 Despite this relatively early recognition, scant research has focused on the effects of smoking on the skin and skin disease Therefore, the effects of smoking on skin are not nearly as well understood as the strong correlation between smoking and lung cancer, emphysema, chronic bronchitis, heart disease, and other serious systemic conditions3,4 Recent studies have succeeded, though, in filling in significant gaps in knowledge regarding the typical cutaneous manifestations of the systemic alterations wrought by smoking, and the potential mechanisms behind such changes
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SYMPTOMS
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The characteristics typically cited as evidence of smoker s face (Fig 7-1) or cigarette skin include increased facial wrinkling; a slightly red/orange complexion; an ashen, pale, or gray overall skin appearance; puffiness; and gauntness2,3 A prematurely older appearance is also a typical symptom of chronic smoking Boyd et al reported that yellow, irregularly thickened skin forms from the breakdown of the skin s elastic
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fibers as a result of smoking2 In 1999, Demierre et al noted that case control studies and other reports suggest a higher prevalence of facial wrinkling among smokers and that smokers, more often than nonsmokers, appear older than their stated age1 A significant association between smoking and gray hair was also observed in a different study1 A German literature review article from the mid-1990s concluded that smoking is at least culpable for promoting, if not actually causing, various skin changes5 This report noted the strong association between cigarette smoking and yellowed fingers as well as increased facial wrinkling, particularly in women An elevated incidence of precancerous lesions and squamous cell carcinomas on lips and oral mucosa, as well as vasospasms and deterioration in large arteries and microvasculature were also linked to cigarette smoking in this report In addition, smoking has recently been shown in an observational study to have a strong correlation with androgenetic alopecia by dint of a multifactorial array of mechanisms6
HIGHLIGHTS OF SOME OF THE MAJOR STUDIES
Results of a 1998 study suggest that smokers do indeed incur a greater risk of facial wrinkling and that this risk is not mitigated by the introduction of hormone replacement therapy (HRT)7 In this study, researchers set out to exam-
ine the combined effects on the skin of a protective factor (HRT) and a deleterious factor (smoking) by evaluating three different groups of postmenopausal women differentiated by smoking status: lifelong nonsmokers, current smokers, and former smokers Results from direct questioning (on smoking and HRT status) and standardized visual assessment revealed a relative risk of moderate to severe wrinkling for current smokers to be over twice that for lifelong nonsmokers Further, lifelong nonsmokers on HRT exhibited lower facial wrinkle scores than lifelong nonsmokers who had never received HRT, but HRT had little general effect on the facial wrinkle scores of current smokers Boyd et al echoed these results in reporting that women seem to be more affected than men, and light skin more than dark skin They also found that while sun exposure, age, weight change, and social status do not appear to play a role in cutaneous manifestations of smoking, the duration and amount of smoking are significant factors in wrinkle development Further, in a study by Daniel, it was found that people who had smoked for less than 15 years and those who had smoked less than half a pack daily were just slightly more likely to exhibit salient wrinkling These individuals were far less likely to be wrinkled than smokers of the same age and sex who had smoked a greater amount or over a longer period of time8 Daniel hypothesized that genetic predisposition may also play a role in
increasing the likelihood that some smokers will develop facial wrinkling He stated that the cutaneous vasculature of those who develop more wrinkles may be more susceptible to damage from the chemicals in tobacco products2 This, however has not yet been proven In a 1995 cross-sectional study of 299 subjects who never smoked, 551 former smokers, and 286 then-current smokers, aged 30 to 69 years, a positive association was observed between pack-years and facial wrinkling in women and men between the ages of 40 and 69 years This finding buttressed previous evidence that facial wrinkling is more prominent among smokers than people who have never smoked9 In 1971, Daniel noted much greater facial wrinkling among smokers than nonsmokers across several demographic scales (age, sex, and sunexposure groups), and concluded that smoking, more than sun exposure, was responsible for the subjects facial wrinkling8 In a more recent study to evaluate the risk of premature facial wrinkling caused by cigarette smoking, investigators considered the cigarette smoking status, weight changes, average recreational and occupational sun exposure in 1 month, as well as past medical and facial cosmetic surgery as identified in selfquestionnaires answered by 123 nonsmokers, 160 current smokers, and 67 past smokers, aged 20 to 69 years In line with what has emerged as the prevailing sentiment regarding the cutaneous sequelae of smoking, current smokers exhibited a greater degree of facial wrinkling and average skin roughness as compared to nonsmokers and past smokers, even those past smokers who had smoked heavily at a younger age Notably, microscopic superficial wrinkling was observed in the facial skin of young current smokers aged 20 to 39 years10 In 1991, Kadunce et al reported on a study of 132 adult smokers and nonsmokers The researchers controlled for age, sex, skin pigmentation, and sun exposure and determined that sun exposure and pack-years of smoking were independently related to the observed prevalence of premature wrinkling, which increased with increased packyears of smoking11 Those individuals considered heavy smokers (greater than 50 pack-years) were 47 times more likely to be wrinkled as compared with nonsmokers The risk of excessive wrinkling was elevated over three-fold for those subjects with more than 50,000 lifetime hours of sun exposure Kadunce et al, unlike Daniel, identified sun exposure as the greater risk factor for prema-
ture wrinkling, but also noted a multiplicative effect in subjects who smoked and absorbed significant sun exposure11 In a 1999 study of 82 smokers who smoked more than 10 cigarettes per day and 118 nonsmokers who had smoked fewer than 100 lifetime cigarettes, O Hare et al found that smoking accounted for only 6% of the explained variance after controlling for solar risk behavior The researchers concluded that if smoking is implicated in wrinkling, its role is minor and that other studies were unblinded or failed to consider potential confounding variables12 Conversely, Smith and Fenske had previously found that the weight of the evidence suggests that cigarette smoking causes premature aging and wrinkling3 In a British study, investigators evaluated a random sample of 792 individuals aged 60 years or older (71 was the mean age of participants) registered with general practitioners in Wales, UK, to ascertain the key etiologic factors in skin wrinkling and assess the viability of using skin wrinkling as an objective measure of cumulative sun exposure Researchers gathered data between 1988 and 1991 during home visit interviews, in which subjects were asked to estimate their average outdoor time during three periods of life, and via examination of the face, neck, and dorsal hand by an experienced dermatologist Multiple logistic regression models revealed that chronologic age and daily cigarette smoking were the only factors significantly linked to visible cutaneous aging In addition, the effects of smoking 20 cigarettes daily were deemed by the investigators to equate roughly to a decade of natural intrinsic aging13 In a study of the effects of smoking on wrinkling and aging in males living in Northern Finland, where there is a low, cumulative sun exposure, eight panelists estimated the smoking status, age, and facial wrinkling of 41 smokers and 48 nonsmokers Although clinical assessment and computerized image analysis revealed no significant differences in skin wrinkling, smokers appeared older than their age (an average of 21 years older) to the panelists, who were able to identify most of the smokers based solely on their facial features14 In another study, investigators conducting a literature review on Medline covering articles published from 1966 to 2004 that pertained to the cutaneous effects of smoking found strong correlations between smoking and a wide array of dermatologic conditions, including wrinkling and premature skin aging, as
well as poor wound healing, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, and oral cancers15 The same review also found that smoking affects the skin lesions associated with AIDS, diabetes, and lupus In a recent study, 82 subjects aged 22 to 91 years were assessed for the effects of smoking on photoprotected skin of the inner arm Forty-one subjects (50%) had a history of previous or current smoking Subjects were followed for 1 year and the evaluation was based on a 9-point scale in which 0 and 8 represented no fine wrinkling and severe fine wrinkling, respectively Results were studied by a multiple regression model in order to determine skin aging with controlling variables such as chronologic aging and hormone therapy Packs of cigarettes smoked daily were found to be associated with wrinkling and to be a predictive variable of aging in photoprotected skin16
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