Medscape is available in 5 Language Editions – Choose your Edition here.


Cutaneous Manifestations of Smoking

  • Author: Andrew M Basnett, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Sep 12, 2014


Healthcare providers should be aware of dermatologic conditions associated with or worsened by cigarette smoking. In the context of medical and cosmetic skin health, providers can play a key role in counseling patients on tobacco cessation to minimize smoking-related dermatologic surgical complications and severity of skin disorders.

This article reviews skin conditions associated with or influenced by cigarette smoking.


Wound Healing and Premature Skin Aging

Poor wound healing

Smoking has repeatedly been shown to have deleterious effects on healing skin wounds. Cigarette smoking has been linked with numerous postoperative complications, including wound infections, dehiscence, flap and graft necrosis, and decreased wound tensile strength.[1] In a study from Wahie and Lawrence, smokers showed a much higher rate of wound infection and dehiscence (64% vs 12%) compared with nonsmokers after skin biopsies.[2]

When flaps or grafts are used, smokers have a higher risk of necrosis. Goldminz and Bennett reviewed 916 flaps and full-thickness skin grafts and found that 1 pack-per-day (ppd) smokers had 3 times the frequency of necrosis as nonsmokers. Patients who smoked 2 ppd had necrosis 6 times more frequently than nonsmokers.[3]

Smoking likely causes delayed wound healing and wound-related complications through many mechanisms, such as the following:

  • Vasoconstriction: Peripheral blood flow decreases by 30-40% within minutes after smoke inhalation, compromising tissue oxygenation and wound healing. [4]
  • Prothrombotic effects: Nicotine increases platelet adhesiveness by inhibiting prostacyclin, leading to microvascular occlusion and tissue ischemia. [5]
  • Altered wound inflammation and contraction: Tobacco inhibits endothelial cell and fibroblast function, nitric oxide synthase activity, vascular endothelial growth factor production, and collagen synthesis. [6]

Although no set guidelines have been established, recent literature by Gill et al recommends the following[6] :

  • Counsel patients on smoking cessation and potential complications prior to surgery.
  • Recommend patients discontinue smoking at least 2 weeks before and 1 week after surgery. Nicotine replacement therapy can be used.
  • For heavy smokers who have difficulty with cessation, reduce smoking to less than 1 ppd.
  • The dermatologic surgeon may consider limiting tissue dissection and extensive undermining in the deep subcutaneous plane.
  • For larger flaps, the dermatologic surgeon may consider using a delayed phenomenon method to increase flap viability.

Rhytides (wrinkles) and skin aging

The association between smoking and rhytides has been long established and can be a cause of significant distress among tobacco users. In many smokers, the threat of facial wrinkling is a greater motivator to quit than the threat of lung cancer or other life-threatening smoking-related diseases.[7]

In 1985, the clinical features of a "smoker's face" were described (see the image below), including prominent facial wrinkles, prominence of underlying bony contours, atrophic skin, and plethoric, slightly orange, purple, or red complexion.[8] Women appear to be more susceptible to the wrinkling effects of smoking than men. Ippen and Ippen found that when compared with female nonsmokers, most female smokers had "cigarette skin", which they defined as gray, pale, and wrinkled.[9] Cigarette smoking is an independent risk factor for rhytides; however, sun exposure has a synergistic effect on skin aging.[10]

Facial features consistent with "smoker's face" ch Facial features consistent with "smoker's face" characterized by prominent facial rhytides, dyschromia, atrophic skin, and prominence of underlying bony contours.

Favre-Racouchot syndrome (see image below), a condition characterized by deep wrinkles and comedone formation, was found by Keough et al to be more common in smokers than in nonsmokers.[11]

Favre-Racouchot syndrome is a condition characteri Favre-Racouchot syndrome is a condition characterized by deep rhytides and comedone formation linked with smoking and solar damage.

The exact mechanism by which smoking causes wrinkling is poorly understood. Some proposed mechanisms include the following[6, 12, 13] :

  • Ultraviolet-activated phototoxic properties of tobacco smoke
  • Altered connective tissue: Elastin from non–sun-exposed skin in smokers is more fragmented than in nonsmokers.
  • Increased reactive oxygen species, which are implicated in accelerated skin aging
  • Increase in matrix metalloproteinases leading to breakdown of collagen, elastic fibers, and proteoglycans

Skin Conditions

Oral and mucocutaneous disorders

Tobacco has been shown to be an independent risk factor for oral squamous cell carcinoma. Risk is further increased with excess alcohol consumption. All forms of tobacco, including smokeless tobacco, increase the risk of oral cancer.[1, 14, 15]

Smoking is associated with numerous characteristic mucocutaneous changes, such as the following:

  • Nicotine stomatitis (smoker's palate) - Hard palate discoloration, fissuring, and minor salivary gland edema caused by increased heat [16] ; more common in pipe smokers
  • Leukokeratosis nicotina glossi (smoker’s tongue) - Black hairy tongue
  • Smoker’s melanosis - Gingival hyperpigmentation due to increased melanin in basal layer of epidermis [17]
  • Acute necrotizing ulcerative gingivitis
  • Periodontitis
  • Painful palatal erosions and tooth abrasions [1]
  • Oral leukoplakia

Nail and hair disorders

Smoking has been associated with several hair and nail disorders, such as the following:

  • Smoker’s nails - Yellow and brown discolored fingernails
  • Harlequin nail or quitter’s nail - Demarcation between distal pigmented nail and proximal normal nail upon smoking cessation [18]
  • Androgenetic alopecia [1]
  • Premature gray hair
  • Smoker's mustache - Analogous to smoker's nails; yellow or brown discolored facial hair [19]

Hidradenitis suppurativa

Hidradenitis suppurativa, a chronic inflammatory skin disease in apocrine glands, occurs more frequently in smokers. It is characterized by recurrent boil-like nodules, sinus tract formation, and subsequent scarring primarily in intertriginous areas of skin.

A study by Breitkoph et al evaluated 149 patients with hidradenitis suppurativa and found that 84% of females and 85% of males were smoker’s at disease onset.[20] A recent larger study of 302 patients with hidradenitis suppurativa and 906 controls showed 76% of hidradenitis suppurativa patients were current smokers versus 25% for controls.[21] The mechanism of this association is still unclear, but it has been suggested nicotine alters immune cell function and epidermal hyperplasia, leading to occlusion and rupture of hair follicles.[22]


Smokers are at increased risk of developing psoriasis and show lower rates of clinical improvement with treatment. Patients who smoke are more likely to have greater disease severity.[23, 24] Palmoplantar pustulosis, a variant of psoriasis, has been shown to have a stronger association with smoking. In one study, 95% of patients were current or former smokers at onset of palmoplantar pustulosis.[25] Female smokers have a 74 times higher risk of developing palmoplantar pustulosis compared with nonsmoking women of the same age.[26]


Development of systemic lupus erythematosus, as well as increased disease severity, has been associated with smoking.[27, 28] Cutaneous lupus erythematosus, including discoid lupus erythematosus and subacute cutaneous lupus erythematosus, are more prevalent among smokers.[29, 30] The association of smoking and subacute cutaneous lupus erythematosus appears to be much more prominent in men. Perhaps more importantly, smoking has been shown to interfere with efficacy of antimalarial therapy for cutaneous lupus erythematosus.[31, 32]

Vascular disorders

Buerger disease (thromboangiitis obliterans), a nonatherosclerotic segmental occlusive disease affecting multiple extremities, is associated strongly with cigarette smoking. It is most commonly seen in men aged 20-40 years who smoke heavily. Smoking cessation is the single most important therapeutic intervention in prevention of disease progression and morbidity. In continued smokers, at least 43% will require amputations.[33]


Cigarettes are a known risk factor for allergic contact dermatitis. Numerous potential allergens from cigarettes can be found in filters, paper, and tobacco.[34] Dermatitis involving the hands, face, and neck should prompt patch testing in a smoker. In addition to standard patch test series, specific allergens such as cocoa, menthol, licorice, formaldehyde, and cigarette components should be used.[1] Several reports have documented irritant as well as allergic contact dermatitis to the nicotine patch in some patients attempting to quit smoking (see Irritant Contact Dermatitis and Allergic Contact Dermatitis).


Skin Cancer

Despite multiple carcinogens present in tobacco smoke, the relationship between smoking and skin cancer remains controversial. Two recent studies did not show an increased risk of squamous cell carcinoma in smokers.[35, 36] However, a separate recent study found a correlation between packs per day and smoking years with the development of squamous cell carcinoma, particularly in women.[37] Some evidence supports an increased risk of keratoacanthomas in smokers.[38] Overall, more studies need to be conducted to evaluate the role of smoking in the development of skin cancer.

No clear association has been proven between smoking and the development of basal cell carcinoma. One study by Smith et al did find an increased prevalence between smoking and basal cell carcinoma tumors larger than 1 cm.[39]

No conclusive evidence exists that associates smoking with an increased risk of melanoma.

Smokers are at an increased risk of developing anogenital cancers. In a study evaluating anogenital cancer and smoking, the 3 sites most highly associated with smoking were the vulva, anus, and penis.[40]


Skin Conditions Improved with Smoking

Smoking appears to decrease the prevalence or lessen the severity of several skin diseases. More extensive research is needed to further evaluate these associations.

  • Aphthous stomatitis: This condition is less common in smokers than nonsmokers. Tobacco causes increased keratinization of oral mucosa, which may offer a protective effect. [41]
  • Behçet disease: Smoking has also been shown to improve oral and genital ulcers in individuals with Behçet disease, although these changes may be due to nicotine. [42, 43]
  • Pyoderma gangrenosum: Wolf et al has reported the successful treatment of pyoderma gangrenosum using nicotine patches. [44]
  • Pemphigus vulgaris: Mehta et al reported a man with pemphigus vulgaris whose disease flared when he quit smoking and improved when he returned to smoking. [45]


Skin is not exempt from the deleterious effects of smoking. Raising awareness of smoking related conditions and skin changes may provide incentive to patients to quit smoking. Knowledge of the cutaneous manifestations of smoking is important to aid clinicians in smoking prevention and cessation, reducing procedure complications, and lowering the occurrence and severity of smoking-related skin conditions.

Contributor Information and Disclosures

Andrew M Basnett, MD Resident Physician, Department of Dermatology, Naval Medical Center San Diego

Andrew M Basnett, MD is a member of the following medical societies: American Academy of Dermatology, American Society for MOHS Surgery, Pacific Dermatologic Association, American Society of Dermatology, San Diego Dermatological Society

Disclosure: Nothing to disclose.


Kendall M Egan, MD, FAAD Dermatologist, Veteran's Affairs Medical Center; Dermatologist, Spruce Health, Dermatologist, DermOne

Kendall M Egan, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.


Peter Fritsch, MD Chair, Department of Dermatology and Venereology, University of Innsbruck, Austria

Peter Fritsch, MD is a member of the following medical societies: American Dermatological Association, International Society of Pediatric Dermatology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Jeffrey B Smith, MD Mohs Surgery, Kaiser Permanente, San Jose, CA

Jeffrey B Smith, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Surgery

Disclosure: Nothing to disclose.

Sidney B Smith, MD Medical Director, Dermatologist, Dermatology, Dermacare Laser and Skin Care Clinics of Tri-Cities

Sidney B Smith, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

  1. Metelitsa AI, Lauzon GJ. Tobacco and the skin. Clin Dermatol. 2010 Jul-Aug. 28(4):384-90. [Medline].

  2. Wahie S, Lawrence CM. Wound complications following diagnostic skin biopsies in dermatology inpatients. Arch Dermatol. 2007 Oct. 143(10):1267-71. [Medline].

  3. Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol. 1991 Jul. 127(7):1012-5. [Medline].

  4. Jensen JA, Goodson WH, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Arch Surg. 1991 Sep. 126(9):1131-4. [Medline].

  5. Wennmalm A, Alster P. Nicotine inhibits vascular prostacyclin but not platelet thromboxane formation. Gen Pharmacol. 1983. 14(1):189-91. [Medline].

  6. Gill JF, Yu SS, Neuhaus IM. Tobacco smoking and dermatologic surgery. J Am Acad Dermatol. 2013 Jan. 68(1):167-72. [Medline].

  7. Fan GB, Wu PL, Wang XM. Changes of oxygen content in facial skin before and after cigarette smoking. Skin Res Technol. 2011 Nov 14. [Medline].

  8. Model D. Smoker's face: an underrated clinical sign?. Br Med J (Clin Res Ed). 1985 Dec 21-28. 291(6511):1760-2. [Medline]. [Full Text].

  9. Ippen M, Ippen H. Approaches to a prophylaxis of skin aging. J Soc Cosmet Chem. 1965. 16:305-8.

  10. Chung JH, Lee SH, Youn CS, Park BJ, Kim KH, Park KC, et al. Cutaneous photodamage in Koreans: influence of sex, sun exposure, smoking, and skin color. Arch Dermatol. 2001 Aug. 137(8):1043-51. [Medline].

  11. Keough GC, Laws RA, Elston DM. Favre-Racouchot syndrome: a case for smokers' comedones. Arch Dermatol. 1997 Jun. 133(6):796-7. [Medline].

  12. Just M, Ribera M, Monso E, Lorenzo JC, Ferrandiz C. Effect of smoking on skin elastic fibres: morphometric and immunohistochemical analysis. Br J Dermatol. 2007 Jan. 156(1):85-91. [Medline].

  13. Morita A. Tobacco smoke causes premature skin aging. J Dermatol Sci. 2007 Dec. 48(3):169-75. [Medline].

  14. Barasch A, Morse DE, Krutchkoff DJ, Eisenberg E. Smoking, gender, and age as risk factors for site-specific intraoral squamous cell carcinoma. A case-series analysis. Cancer. 1994 Feb 1. 73(3):509-13. [Medline].

  15. Macfarlane GJ, Zheng T, Marshall JR, Boffetta P, Niu S, Brasure J, et al. Alcohol, tobacco, diet and the risk of oral cancer: a pooled analysis of three case-control studies. Eur J Cancer B Oral Oncol. 1995 May. 31B(3):181-7. [Medline].

  16. Thoma KH. Stomatitis nicotine and its effect on the palate. Am J Orthod. 1941. 27:38-47.

  17. Hedin CA. Smokers' melanosis. Occurrence and localization in the attached gingiva. Arch Dermatol. 1977 Nov. 113(11):1533-8. [Medline].

  18. Ortiz A, Grando SA. Smoking and the skin. Int J Dermatol. 2012 Mar. 51(3):250-62. [Medline].

  19. Smith SB, Smith JB. Smoker's mustache. J Geriatr Dermatol. 1998. 6:92.

  20. Breitkopf C, Bockhorst J, Lippold A. Pyoderma fistulans sinifica (Akne inversa) und Rauchgewohnheiten. Hautkr. 1995. 70:332-4.

  21. Revuz JE, Canoui-Poitrine F, Wolkenstein P, Viallette C, Gabison G, Pouget F, et al. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies. J Am Acad Dermatol. 2008 Oct. 59(4):596-601. [Medline].

  22. Matusiak L, Bieniek A, Szepietowski JC. Hidradenitis suppurativa and associated factors: still unsolved problems. J Am Acad Dermatol. 2009 Aug. 61(2):362-5. [Medline].

  23. Fortes C, Mastroeni S, Leffondré K, Sampogna F, Melchi F, Mazzotti E, et al. Relationship between smoking and the clinical severity of psoriasis. Arch Dermatol. 2005 Dec. 141(12):1580-4. [Medline].

  24. Li W, Han J, Choi HK, Qureshi AA. Smoking and risk of incident psoriasis among women and men in the United States: a combined analysis. Am J Epidemiol. 2012 Mar 1. 175(5):402-13. [Medline]. [Full Text].

  25. Michaëlsson G, Gustafsson K, Hagforsen E. The psoriasis variant palmoplantar pustulosis can be improved after cessation of smoking. J Am Acad Dermatol. 2006 Apr. 54(4):737-8. [Medline].

  26. Hagforsen E, Michaëlsson K, Lundgren E, Olofsson H, Petersson A, Lagumdzija A, et al. Women with palmoplantar pustulosis have disturbed calcium homeostasis and a high prevalence of diabetes mellitus and psychiatric disorders: a case-control study. Acta Derm Venereol. 2005. 85(3):225-32. [Medline].

  27. Takvorian SU, Merola JF, Costenbader KH. Cigarette smoking, alcohol consumption and risk of systemic lupus erythematosus. Lupus. 2014 May. 23(6):537-44. [Medline].

  28. Miot HA, Bartoli Miot LD, Haddad GR. Association between discoid lupus erythematosus and cigarette smoking. Dermatology. 2005. 211(2):118-22. [Medline].

  29. Boeckler P, Milea M, Meyer A, Uring-Lambert B, Heid E, Hauptmann G, et al. The combination of complement deficiency and cigarette smoking as risk factor for cutaneous lupus erythematosus in men; a focus on combined C2/C4 deficiency. Br J Dermatol. 2005 Feb. 152(2):265-70. [Medline].

  30. Callen JP. Clinically relevant information about cutaneous lupus erythematosus. Arch Dermatol. 2009 Mar. 145(3):316-9. [Medline].

  31. Ezra N, Jorizzo J. Hydroxychloroquine and smoking in patients with cutaneous lupus erythematosus. Clin Exp Dermatol. 2012 Jun. 37(4):327-34. [Medline].

  32. Piette EW, Foering KP, Chang AY, Okawa J, Ten Have TR, Feng R, et al. Impact of Smoking in Cutaneous Lupus Erythematosus. Arch Dermatol. 2011 Nov 21. [Medline].

  33. William D. James, Timothy G. Berger, Dirk M. Elston. Andrew's Diseases of the Skin: Clinical Dermatology. 11. 2011. 835-836.

  34. Glick ZR, Saedi N, Ehrlich A. Allergic contact dermatitis from cigarettes. Dermatitis. 2009 Jan-Feb. 20(1):6-13. [Medline].

  35. Odenbro A, Bellocco R, Boffetta P, Lindelöf B, Adami J. Tobacco smoking, snuff dipping and the risk of cutaneous squamous cell carcinoma: a nationwide cohort study in Sweden. Br J Cancer. 2005 Apr 11. 92(7):1326-8. [Medline]. [Full Text].

  36. McBride P, Olsen CM, Green AC. Tobacco smoking and cutaneous squamous cell carcinoma: a 16-year longitudinal population-based study. Cancer Epidemiol Biomarkers Prev. 2011 Aug. 20(8):1778-83. [Medline]. [Full Text].

  37. Rollison DE, Iannacone MR, Messina JL, Glass LF, Giuliano AR, Roetzheim RG. Case-control study of smoking and non-melanoma skin cancer. Cancer Causes Control. 2012 Feb. 23(2):245-54. [Medline].

  38. Miot HA, Miot LD, da Costa AL, Matsuo CY, Stolf HO, Marques ME. Association between solitary keratoacanthoma and cigarette smoking: a case-control study. Dermatol Online J. 2006 Feb 28. 12(2):2. [Medline].

  39. Smith JB, Randle HW. Giant basal cell carcinoma and cigarette smoking. Cutis. 2001 Jan. 67(1):73-6. [Medline].

  40. Daling JR, Sherman KJ, Hislop TG, Maden C, Mandelson MT, Beckmann AM, et al. Cigarette smoking and the risk of anogenital cancer. Am J Epidemiol. 1992 Jan 15. 135(2):180-9. [Medline].

  41. Chattopadhyay A, Chatterjee S. Risk indicators for recurrent aphthous ulcers among adults in the US. Community Dent Oral Epidemiol. 2007 Apr. 35(2):152-9. [Medline].

  42. Rizvi SW, McGrath H Jr. The therapeutic effect of cigarette smoking on oral/genital aphthosis and other manifestations of Behçet's disease. Clin Exp Rheumatol. 2001 Sep-Oct. 19(5 Suppl 24):S77-8. [Medline].

  43. Kalayciyan A, Orawa H, Fimmel S, Perschel FH, González JB, Fitzner RG, et al. Nicotine and biochanin A, but not cigarette smoke, induce anti-inflammatory effects on keratinocytes and endothelial cells in patients with Behçet's disease. J Invest Dermatol. 2007 Jan. 127(1):81-9. [Medline].

  44. Wolf R. Nicotine for pyoderma gangrenosum. Arch Dermatol. 1998 Sep. 134(9):1071-2. [Medline].

  45. Mehta JN, Martin AG. A case of pemphigus vulgaris improved by cigarette smoking. Arch Dermatol. 2000 Jan. 136(1):15-7. [Medline].

Facial features consistent with "smoker's face" characterized by prominent facial rhytides, dyschromia, atrophic skin, and prominence of underlying bony contours.
Favre-Racouchot syndrome is a condition characterized by deep rhytides and comedone formation linked with smoking and solar damage.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.