3.14 Skin

Last updated: March 2015
Suggested citation: Hurley, S, Greenhalgh, EM & Winstanley, MH. 3.14 Skin. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-14-effects-of-smoking-on-the-skin


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

3.14.1 Facial appearance and premature skin ageing

Smoking affects facial appearance in men and women, independent of sun exposure and age. Increased wrinkling1-5 and altered complexion colour1 have been attributed to smoking, as have elastosis (loss of elasticity in the skin resulting from degeneration of connective tissue) and, in men, telangiectasia (dilatation of fine blood vessels in the skin visible as fine red lines).6 One recent study found that smokers appear up to 4.7 years older than non-smokers, and in the majority of cases smokers and non-smokers could be correctly distinguished by examining photographs of the face and temple region.7 Two studies of twins have confirmed that smokers tend to look older.8, 9

Visible wrinkling is most evident in older smokers, but even smokers aged in their 20s and 30s may show evidence of microscopic superficial wrinkling.4 Combined exposure to both sunlight and tobacco smoke causes a greater degree of damage than exposure to one agent alone,10 possibly through the phototoxic effects of tobacco smoke condensate, which increase the skin's vulnerability to UV radiation.11 Even non-facial, non-sun-exposed skin may be more wrinkled in smokers than non-smokers.12

A possible mechanism for premature wrinkling is that smoke affects the function of human skin fibroblasts (cells present in connective tissue that form collagen and elastin), thereby accelerating the appearance of ageing.3 Recent research has suggested a connection between wrinkling in smokers and the development of chronic obstructive pulmonary disease (COPD). Smokers with severe facial wrinkling may also have a higher susceptibility to developing COPD; possible mechanisms being damage to collagen and elastin, which are important to both skin and lung function.13

3.14.2 Acne and other sebaceous conditions

A review of smoking-associated skin conditions published in 2010 noted that the evidence linking acne to smoking is conflicting. Only two of the five studies reviewed reported an association.14 Another study, published after the review, found a higher prevalence of comedonal postadolescent acne in women who were smokers compared with non-smokers.15

The evidence linking some other sebaceous conditions with smoking is stronger. Smoking appears to cause hidradenitis suppurativa (clusters of chronic abscesses or cysts in areas of sweat or sebaceous glands); up to 98% of patients with this condition are smokers.14, 16, 17 A case–control study found smoking was a risk factor for epidermal inclusion cysts in men, but not in women.18

3.14.3 Dermatitis

The 2010 review of smoking and the skin concluded that the evidence linking smoking to dermatitis and eczema remains controversial.14 A small case–control study published after the review found that smoking increased the risk of adult-onset atopic dermatitis in smokers and members of their family who were exposed to environmental tobacco smoke.19 Cigarettes themselves can cause allergic contact dermatitis in both occupational and non-occupational settings.14, 20

3.14.4 Psoriasis

Smoking is a well-established risk factor for psoriasis, a chronic autoimmune disease, the most common type being plaque psoriasis, which is characterised by scaly patches on the top layer of the skin.14, 21 Higher intensity smoking is associated with clinically severe disease,14, 22, 23 and psoriasis is less responsive to treatment in smokers.14, 24 The risk of developing psoriasis decreases progressively with increased time since smoking cessation.24

Multiple mechanisms are thought to explain the association between smoking and psoriasis. Smoking enhances the expression of genes known to confer an increased risk of psoriasis. It increases oxidative damage—the free radicals in cigarette smoke, for example, trigger a cascade of systemic reactions. Smoking also promotes inflammatory changes by suppressing immune cell processes and nicotine depletes calcium stores in T lymphocytes, probably impairing their function.24

The form of psoriasis known as palmoplantar pustulosis (which is confined to the hands and soles and is also known as 'pustular psoriasis of the extremities') is strikingly correlated with smoking; up to 95% of patients are smokers when the disease is diagnosed.14, 25

3.14.5 Lupus erythematosus

Lupus erythematosus is an autoimmune condition that can manifest as a systemic disease, involving many different organs, or as a cutaneous disease, involving only the skin. The systemic form is referred to as systemic lupus erythematosus (SLE). It often involves a rash, and sometimes involves scaly patches or ulcers.

A meta-analysis of seven case–control studies and two cohort studies has confirmed that smoking is associated with SLE. Current smokers have around a 50% increased risk of SLE compared with never smokers.26 The risk is not elevated for ex-smokers. Smokers also have increased SLE disease activity,27 and poorer health-related quality of life has been reported.28 In 2014, the US Surgeon General’s report found that there is mixed and therefore inadequate evidence that smoking causes SLE, or affects its severity or treatment.29

Smoking also increases the risk of developing some of the cutaneous forms of lupus14, 30 and has been reported to decrease the effectiveness of the antimalarial drugs that are sometimes prescribed for cutaneous lupus.31 The 2014 US Surgeon General’s report concluded that smoking is a risk factor for cutaneous lupus, but the evidence is too limited to determine if it is a cause.29

3.14.6 Other skin conditions

Smoking is a risk factor for the development of alopecia (hair loss, usually from the scalp) and may increase the likelihood of premature grey hair.14

A retrospective survey of more than 58 000 women in Denmark found an increased risk of genital warts in smokers, which the authors concluded could be due to immunosuppressive effects or uncontrolled confounding.32

For information about anal fistula, see Section 3.17.2.

Recent news and research

For recent news items and research on this topic, click here (Last updated March 2018)    


1. Model D. Smoker's face: an underrated clinical sign? British Medical Journal 1985;291:1760-2. Available from: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1419177&blobtype=pdf

2. Ernster V, Grady D, Miike R, Black D, Selby J and Kerlikowske K. Facial wrinkling in men and women, by smoking status. American Journal of Public Health 1995;85:78-82. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=7832266

3. Yin L, Morita A and Tsuji T. Skin ageing induced by ultraviolet exposure and tobacco smoking: evidence from epidemiological and molecular studies. Photodermatology Photoimmunology Photomedicine 2001;17:178-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11499540

4. Koh JS, Kang H, Choi SW and Kim HO. Cigarette smoking associated with premature facial wrinkling: image analysis of facial skin replicas. International Journal of Dermatology 2002;41(1):21–7. Available from: http://www3.interscience.wiley.com/journal/118906869/abstract?CRETRY=1&SRETRY=0

5. Leung W and Harvey I. Is skin ageing in the elderly caused by sun exposure or smoking? British Journal of Dermatology 2002;147:1187-91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12452869

6. Kennedy C, Bastiaens M, Bajdik C, Willemze R, Westerndorp R, Bouwes Bavinck J, et al. Effect of smoking and sun on the aging skin. Journal of Investigative Dermatology 2003;120:548-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12648216

7. Raitio A, Kontinen J, Rasi M, Bloigu R, Röning J and Oikarinen A. Comparison of clinical and computerised image analyses in the assessment of skin ageing in smokers and non-smokers. Acta Dermato Venereologica 2004;84:422-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15844630

8. Guyuron B, Rowe D, Weinfeld A, Eshraghi Y, Fathi A and Iamphongsai S. Factors contributing to the facial aging of identical twins. Plastic and Reconstructive Surgery 2009;123(4):1321–31. Available from: http://journals.lww.com/plasreconsurg/pages/articleviewer.aspx?year=2009&issue=04000&article=00019&type=abstract

9. Martires K, Fu P, Polster A, Cooper K and Baron E. Factors that affect skin aging: a cohort-based survey on twins. Archives of Dermatology 2009;145(12):1375–9. Available from: http://archderm.ama-assn.org/cgi/content/full/145/12/1375

10. Kadunce D, Burr R, Gress R, Kanner R, Lyon J and Zone J. Cigarette smoking: risk factor for premature facial wrinkling. Annals of Internal Medicine 1991;114:840-4. Available from: http://www.annals.org/content/114/10/840.extract

11. Placzek M, Kerkmann U, Bell S, Koepke P and Przybilla B. Tobacco smoke is phototoxic. British Journal of Dermatology 2004;150:991-3. Avilable from: http://www.ncbi.nlm.nih.gov/pubmed/15149514

12. Helfrich Y, Yu L, Ofori A, Hamilton T, Lambert J, King A, et al. Effect of smoking on ageing of photoprotected skin. Archives of Dermatology 2007;143:397-402. Available from: http://archderm.ama-assn.org/cgi/content/full/143/3/397

13. Freiman A, Bird G, Metelitsa A, Barankin B and Lauzon G. Cutaneous effects of smoking. Journal of Cutaneous Medical Surgery 2004;8(6):415–23. Available from: http://www.springerlink.com/content/p172v6547r1p3231/

14. Metelitsa A and Lauzon G. Tobacco and the skin. Clinics in Dermatology 2010;28(4):384–90. Available from: http://www.cidjournal.com/article/PIIS0738081X10000453/fulltext

15. Capitanio B, Sinagra J, Bordignon V, Fei P, Picardo M and Zouboulis C. Underestimated clinical features of postadolescent acne. Journal of the American Academy of Dermatology 2010;63(5):782–8. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20619486

16. Simonart T. Hidradenitis suppurativa and smoking. Journal of the American Academy of Dermatology 2010;62(1):149–50. Available from: http://www.eblue.org/article/S0190-9622%2809%2900239-4/fulltext

17. Canoui-Poitrine F, Revuz J, Wolkenstein P, Viallette C, Gabison G, Pouget F, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. Journal of the American Academy of Dermatology 2009;61(1):51–7. Available from: http://www.eblue.org/article/PIIS0190962209002394/fulltext

18. Lin S, Yang Y, Chen W and Wu W. Facial epidermal inclusion cysts are associated with smoking in men: a hospital-based case-control study. Dermatologic Surgery 2010;36(6):894–8. Available from: http://www3.interscience.wiley.com/user/accessdenied?ID=123429583&Act=2138&Code=4719&Page=/cgi-bin/fulltext/123429583/HTMLSTART

19. Lee C, Chuang H, Hong C, Huang S, Chang Y, Ko Y, et al. Lifetime exposure to cigarette smoking and the development of adult-onset atopic dermatitis. British Journal of Dermatology 2010;164(3):483–9. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2010.10116.x/pdf

20. Glick ZR, Saedi N and Ehrlich A. Allergic contact dermatitis from cigarettes. Dermatitis 2009;20(1):6–13. Available from: http://www.bcdecker.com/pubMedLinkOut.aspx?pub=AJCDO&vol=20&iss=1&page=6

21. Wolk K, Mallbris L, Larsson P, Rosenblad A, Vingard E and Stahle M. Excessive body weight and smoking associates with a high risk of onset of plaque psoriasis. Acta Dermato-Venereologica 2009;89(5):492–7. Available from: http://adv.medicaljournals.se/article/pdf/10.2340/00015555-0711

22. Attwa E and Swelam E. Relationship between smoking-induced oxidative stress and the clinical severity of psoriasis. Journal of the European Academy of Dermatology and Venereology 2010;[Epub ahead of print] Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2010.03860.x/full

23. Gerdes S, Zahl V, Weichenthal M and Mrowietz U. Smoking and alcohol intake in severely affected patients with psoriasis in Germany. Dermatology 2010;220(1):38–43. Available from: http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=000265557

24. Armstrong A, Armstrong E, Fuller E, Sockolov M and Voyles S. Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory, and genetic mechanisms. The British Journal of Dermatology 2011;[Epub ahead of print] Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2011.10526.x/pdf

25. Miot H, Miot L, Lopes P, Haddad G and Marques S. Association between palmoplantar pustulosis and cigarette smoking in Brazil: a case-control study. Journal of the European Academy of Dermatology and Venereology 2009;23(10):1173–7. Available from: http://www3.interscience.wiley.com/user/accessdenied?ID=122372044&Act=2138&Code=4719&Page=/cgi-bin/fulltext/122372044/HTMLSTART

26. Costenbader KH, Kim DJ, Peerzada J, Lockman S, Nobles-Knight D, Petri M, et al. Cigarette smoking and the risk of systemic lupus erythematosus: a meta-analysis. Arthritis and Rheumatism 2004;50(3):849–57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15022327

27. Ghaussy NO, Sibbitt W, Jr., Bankhurst AD and Qualls CR. Cigarette smoking and disease activity in systemic lupus erythematosus. Journal of Rheumatology 2003;30(6):1215–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12784392

28. Barta Z, Harrison M, Wangrangsimakul T, Shelmerdine J, Teh L, Pattrick M, et al. Health-related quality of life, smoking and carotid atherosclerosis in white British women with systemic lupus erythematosus. Lupus 2010;19(3):231-8. Available from: http://lup.sagepub.com/cgi/rapidpdf/0961203309351032v1

29. US Department of Health and Human Services. The health consequences of smoking - 50 years of progress. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress

30. Boeckler P, Cosnes A, Frances C, Hedelin G and Lipsker D. Association of cigarette smoking but not alcohol consumption with cutaneous lupus erythematosus. Archives of Dermatology 2009;145(9):1012–6. Available from: http://archderm.ama-assn.org/cgi/content/full/145/9/1012

31. Rahman P, Gladman DD and Urowitz MB. Smoking interferes with efficacy of antimalarial therapy in cutaneous lupus. Journal of Rheumatology 1998;25(9):1716–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9733451

32. Hansen B, Hagerup-Jenssen M, Kjaer S, Munk C, Tryggvadottir L, Sparen P, et al. Association between smoking and genital warts: longitudinal analysis. Sexually Transmitted Infections 2010;86(4):258–62. Available from: http://sti.bmj.com/content/86/4/258.long

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