Hip Fractures Disorders of Mineral Metabolism and Bone

[498–500] ,฀ibroblasts,฀endothelial฀cells฀ [501] ,฀melanocytes฀ [502] ฀and฀lymphocytes฀ [503] .฀ Filaggrin,฀a฀humectant฀which฀improves฀skin฀texture,฀is฀formed฀in฀this฀way฀in฀keratinocytes฀by฀ Ca 2+ -mediated฀secretion฀ [504] .฀Nicotine฀disturbs฀the฀equilibrium฀between฀cell฀proliferation,฀ growth฀arrest฀and฀apoptosis,฀but฀this฀need฀not฀be฀connected฀with฀tumour฀growth-promoting฀ activity฀cf.฀the฀indings฀reported฀by฀Heeschen฀ [505] . A฀suggested฀role฀for฀nicotine฀in฀the฀pathogenesis฀of฀palmoplantar฀pustulosis฀PPP฀was฀ investigated฀but฀the฀observed฀alteration฀in฀the฀nAChR฀subtypes฀a 7 -฀and฀a 3 -subtype฀was฀ not฀clearly฀demonstrated฀because฀ex-smokers฀were฀used฀in฀the฀ex฀vivo฀experiments฀ [506] ฀ and฀differentiation฀between฀the฀causes฀nicotine฀or฀tobacco฀smoke฀was฀impossible.฀The฀ enhanced฀occurrence฀of฀PPP฀in฀smokers฀seems฀to฀be฀conclusive฀ [507] . The฀constituents฀of฀tobacco฀and฀the฀toxic฀substances฀formed฀during฀the฀process฀of฀com- bustion฀see฀Sect.฀3.1฀in฀Chap.฀3฀are฀capable฀primarily฀of฀forming฀haemoglobin฀adducts.฀ Polynuclear฀aromatic฀hydrocarbons฀pose฀a฀particular฀danger฀to฀the฀skin฀and฀mucosa,฀in฀ addition฀to฀the฀lungs.฀The฀most฀noticeable฀indings฀in฀smokers฀are: Yellow฀staining฀of฀the฀fingers •฀ Wrinkling,฀especially฀on฀the฀facial฀skin฀of฀women •฀ Precancerous฀lesions฀and฀squamous฀cell฀carcinomas฀of฀the฀lips฀and฀buccal฀mucosa •฀ Delayed฀wound฀healing฀ •฀ [508] Frequent฀and฀premature฀necrosis฀of฀skin฀grafts฀ •฀ [509–511]

7.8.1 Skin Changes

As฀long฀ago฀as฀the฀1850s,฀during฀the฀assessments฀for฀insurance฀purposes,฀it฀was฀remarked฀ that฀smokers’฀skin฀was฀pale฀yellow฀and฀wrinkled฀ [512] .฀Around฀the฀same฀time,฀in฀contrast฀ with฀non-smokers,฀similar฀symptoms฀were฀noted฀in฀smokers฀among฀British฀army฀oficers฀ who฀had฀served฀in฀colonial฀India฀ [513] .฀Skin฀ageing฀is฀encouraged฀by฀smoking฀and฀expo- sure฀to฀sunlight฀ [514] .฀The฀skin฀of฀cigarette฀smokers฀has฀been฀characterised฀as฀pale฀and฀ thickened,฀with฀a฀greyish฀hue฀but฀without฀any฀change฀in฀pigmentation.฀In฀some฀cases,฀ evidence฀of฀wrinkling฀of฀the฀entire฀skin฀surface฀is฀visible฀in฀the฀cheeks.฀This฀skin฀type฀is฀ encountered฀in฀79฀of฀female฀smokers฀and฀only฀19฀of฀female฀non-smokers฀ [514] .฀In฀this฀ context,฀cigarette฀smoking฀is฀a฀factor฀that฀operates฀independently฀of฀other฀noxious฀agents฀ [515,฀516] .฀Heavy฀smokers฀50฀pack-years฀are฀affected฀more฀than฀less-intensive฀smok- ers.฀The฀increased฀risk฀for฀facial฀wrinkling฀has฀been฀reported฀as฀dose-dependent฀pack- years,฀ but฀ BMI,฀ alcohol฀ consumption฀ and฀ sun฀ exposure฀ total฀ 50,000฀ h฀ are฀ also฀ important,฀as฀well฀as฀age฀and฀gender฀ [515] . The฀development฀of฀these฀changes฀can฀be฀attributed฀to฀the฀effects฀of฀combustion฀products฀ of฀tobacco฀on฀the฀epidermis฀and฀dermis฀via฀the฀blood฀supply.฀In฀the฀facial฀region,฀the฀reduced฀ moisture฀of฀the฀stratum฀corneum฀is฀a฀major฀factor฀ [517] .฀Changes฀involving฀the฀lips฀may฀be฀ related฀to฀mechanical฀factors฀due฀to฀pursing฀of฀the฀lips฀and฀contact฀with฀combustion฀products฀ during฀smoking.฀Smokers฀have฀also฀been฀reported฀to฀exhibit฀elastosis฀independently฀of฀sun฀ exposure,฀as฀demonstrated฀by฀skin฀biopsies฀ [518] .฀Both฀the฀number฀and฀thickness฀of฀the฀