Joshua R. Dimmick, MD Resident Department of Dermatology
Richard F. Wagner, Jr, MD Edgar B. Smith Professor of Dermatology
The University of Texas Medical Branch Galveston
Many physical stigmata and behaviors have been associated with cigarette smoking. Identifying features of nicotine users include a thin body frame, raspy voice, halitosis, and cough. Other signs are discolored nails, stained teeth, and wrinkled skin. Although none of these classic characteristics of chronic cigarette smoking is particularly life-threatening, most are socially unappealing. Ironically, it is the social impact of cigarette use,1 not its deleterious long-term effects on health, that is often an effective tool for targeting smoking prevention and cessation programs at younger populations. One smoking-cessation program based on physical attractiveness and oral health generated sufficient motivation for 21 of 37 (57%) teenaged smokers to sign up for treatment and for 4 of the program participants to quit.2
An extensive review of the literature on the dermatologic consequences of nicotine use found strong correlations between smoking and poor wound healing, skin wrinkling and premature aging, squamous-cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions.3
Typical smoker’s facies include wrinkles radiating from the lips and eyes; prominent bony contours; atrophic and slightly grayish skin; and a plethoric complexion, with orange, purple, and red hues.4 The likelihood of skin wrinkling has been shown to be 4.7 times higher in individuals with a 50 pack-year smoking history compared with nonsmokers.5 Even in the absence of increased wrinkling, smokers appear an average of 2.1 years older than their true age.6 Reports linking hair loss7 and premature graying8 to tobacco use, in particular, add to the list of unwanted effects on appearance.
The “nicotine sign” is often used to describe the unsightly yellow staining of smokers’ nail plates.9 Another finding in some smokers is the “harlequin nail,” manifested as an abrupt line of demarcation between the proximal, normal-appearing nail and the distal, yellow-pigmented nail.10 The harlequin nail may be observed in smokers who have abruptly ceased nicotine use, often as a result of a severe illness or injury that makes smoking impossible.
As the following report illustrates, another cosmetic issue arising from nicotine use is “smoker’s mustache.”
Case Presentation A white-haired, 55-year-old white man presented with a 1.3-cm primary basal-cell carcinoma of the left posterior ear. Both ears demonstrated several actinic keratoses consistent with early actinic damage that was exacerbated by his red hair phenotype when he was younger. In the past he had multiple nonmelanoma skin cancers at different locations that were treated with electrodesiccation and curettage. The basal-cell carcinoma on the left posterior ear was successfully removed with Mohs micrographic surgery, and the wound was repaired with a split-thickness skin graft harvested from the left upper lateral thigh.
Physicians also noted that the midline region of his white mustache displayed a peculiar yellowish pigmentation on the distal portions of the involved hairs, with the proximal portions of the hair shafts spared (Figure), suggesting an exogenous origin. When questioned, the patient said that he had smoked three fourths of a pack of cigarettes daily for the past 35 years, and that he always held his cigarettes directly below this area of his mustache when he smoked. He was counseled to stop smoking because of the negative impact on wound healing, general health, and appearance. No follow-up was scheduled.
Discussion Yellow hair discoloration has been observed in lightly pigmented hair of tobacco users.11 It is thought to be caused by the exogenous pigment deposition on closely adjacent hair from tar in the plume of combusted tobacco or from tobacco-staining residue mixed with saliva. Other substances may also result in exogenous hair dyspigmentation (Table). Probably the most famous and well-studied is the greenish hue imparted by copper, often in combination with chlorine,12 which is best seen in light-colored hair. Extensive swimming pool use is the most common culprit,13 but green hair has also been documented to occur from high levels of copper in tap water.14
Table
Some causes of exogenous hair-shaft discoloration
Color
Agent*
Uses/Contact
Blue
Cobalt11
Textile industry
Green
Copper12,14
Water supply with copper plumbing
Algaecide in swimming pools
Selenium sulfide17
Shampoos
Yellow
Dithranol11
Psoriatic drug (anthralin)
Picric acid11
Explosives (homemade)
Tar from cigarettes and cigars11
Tobaccoproducts
MDA15
Plastics industry
Resorcin19
Adhesives, photography
Reddish-brown
Iron15
Water supply
TNT19
Explosives
Purple-brown
Permanganate19
Pool disinfectant, Chemical laboratory (titrations)
Most exogenous color changes, including those resulting from copper exposure, have limited significance outside of cosmesis. There are, however, instances when color change may reveal exposure to something more hazardous. One report described yellow skin and hair staining among workers in a molded plastics factory.15 Tests showed that the chemical linked to the effect was 4,4l-methylenedianiline, a hepatotoxic and carcinogenic chemical often used in manufacturing. Of note, none of the workers in that study showed any signs of systemic toxicity.
Stained hair secondary to tobacco use is a good example of a color change caused by a hazardous exposure. The dermatologic signs of tobacco use can be a valuable clue to other associated and serious systemic diseases.9 The diagnostic value of stained hair is exemplified by another case report, in which an abnormal hair finding pointed to the diagnosis of tobacco-related amblyopia, a painless, progressive eye disease.16 The examining physician noted that the patient had a yellow forelock, and questioning revealed that he had smoked a pipe for many years. Testing showed that hair from his forelock contained 4 times the amount of nicotine as hair from his occipital region. The smoking history of that patient suggested the diagnosis of tobacco-induced amblyopia. Additional causes of exogenous hair discoloration include selenium sulfide,17 iron,18 resorcin, permanganate, and chrysarobin.19
Conclusion Cigarette smoking results in a wide array of cutaneous manifestations. Many of these effects, although not intrinsically harmful, may be used by clinicians to discourage tobacco use, capitalizing on the patient’s cosmetic concerns as well as the associated social stigma. The optimal treatment for smoker’s mustache is smoking cessation, which will allow unstained hair to grow out into a normal-appearing mustache. It remains controversial what, if any, special periodic medical testing for occult tobacco-related diseases should be performed in asymptomatic smokers.
References 1. Silvis GL, Perry CL. Understanding and deterring tobacco use among adolescents. Pediatr Clin North Am. 1987;34:363-379.
2. Semer N, Ellison J, Mansell C, et al. Development and evaluation of a tobacco cessation motivational program for adolescents based on physical attractiveness and oral health. J Dent Hyg. 2005;79(4):9.
3. Freiman A, Bird G, Metelista AI, et al. Cutaneous effects of smoking. J Cutan Med Surg. 2004;8: 415-423.
4. Model D. Smoker’s face: an underrated clinical sign? Br Med J (Clin Res Ed). 1985;291:1760-1762.
5. Kadunce DP, Burr R, Gress R, et al. Cigarette smoking: risk factor for premature facial wrinkling. Ann Intern Med. 1991;114:840-844.
6. Raitio A, Kontinen J, Rasi M, et al. Comparison of clinical and computerized image analyses in the assessment of skin aging in smokers and nonsmokers. Acta Derm Venereol. 2004;87: 422-427.
7. D’Agostini F, Balansky R, Pesce C, et al. Induction of alopecia in mice exposed to cigarette smoke. Toxicol Lett. 2000;114:117-123.
8. Mosley JG, Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for health education? BMJ.1996;313:1616.
9. Vander Straten M, Carrasco D, Paterson MS, et al. Tobacco use and skin disease. South Med J. 2001;94:621-634.
10. Verghese A, Krish G, Howe D, et al. The harlequin nail. A marker for smoking cessation. Chest. 1990;97:236-238.
11. Dawber RPR, deBerker D, Wojnarowska FT. Disorders of hair. In: Champion RH, Burton JL, Burns DA, et al, eds. Rook/Wilkinson/ Ebling Textbook of Dermatology. Vol 4. 6th ed. Oxford, England: Blackwell Science; 1998:2869-2965.
13. Biel K, Kretzschmar L, Muller C, et al. Green hair caused by frequent swimming pool use [in German]. Hautarzt. 1997;48:568-571.
14. Munkvad S, Weismann K. Copper-induced green hair. Treatment with a penicillamine containing shampoo [in Danish]. Ugeskr Laeger. 1996;258:3791-3792.
15. Cohen SR. Yellow staining caused by 4,4l-methylenedianiline exposure: occurrence among molded plastics workers. Arch Dermatol. 1985;121:1022-1027.
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