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Clinical Investigations

Free Access

Palmar Telangiectasias: A Cutaneous Sign for Smoking

Levi A.a, b · Shechter R.c · Lapidoth M.a, b · Enk C.D.c

Author affiliations

aPhotodermatosis Clinic and Laser Unit, Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, bSackler Faculty of Medicine, Tel Aviv University, Tel Aviv, and cDepartment of Dermatology, Hadassah Medical Organization - The Hebrew University Medical School, Jerusalem, Israel

Corresponding Author

Assi Levi

Photodermatosis Clinic and Laser Unit, Department of Dermatology

Rabin Medical Center, Beilinson Hospital

39, Ze'ev Jabotinsky Rd, Petah Tikva, 4941492 (Israel)

E-Mail docalevi@gmail.com

Related Articles for ""

Dermatology 2017;233:390–395

Abstract

Background: Telangiectasias are permanent dilations of blood capillaries which appear in a variety of medical conditions. Cutaneous palmar telangiectasias have been postulated to be associated with smoking. Objective: To determine whether a significant correlation exists between palmar telangiectasias and smoking habits. Patients and Methods: A total of 124 volunteers participated in this observational study by allowing physical evaluation of their palms and by completing a questionnaire. Results: Palmar telangiectasias were found to be associated with current or past smoking. Neither age nor gender was found to be a co-contributor. Discussion: Palmar telangiectasias were found to constitute highly specific and sensitive markers for prolonged smoking.

© 2017 S. Karger AG, Basel


Introduction

Telangiectasias are permanent dilations of blood capillaries [1]. They might appear in various body organs and tissues [2].

Telangiectasias are divided into primary and secondary ones. Primary telangiectasias include unilateral nevoid telangiectasia, generalized essential telangiectasia, angioma serpiginosum, and others [3,4,5]. Secondary telangiectasias are associated with a whole range of medical conditions such as actinic damage [6], basal cell carcinoma [7], rosacea [8], poikiloderma [9], and drugs including oral contraceptives [10], corticosteroids [11], and epidermal growth factor receptors [12]. Other conditions such as collagen vascular diseases (dermatomyositis [13], systemic lupus erythematosus [14], rheumatoid arthritis [15], and scleroderma [16]), genetic-congenital conditions (Bloom syndrome [17], ataxia telangiectasia [18], and hereditary hemorrhagic telangiectasia [19]), metabolic disturbances (pregnancy [20], Graves disease [21], hepato-pulmonary-cutaneous syndrome [22], and liver insufficiency [23]), and hepatitis B infection [24] have all been linked with telangiectasias.

Telangiectasias associated with specific anatomical locations are rare and include palmar telangiectasias [25]. Although the latter may be confused with palmar erythema, they represent different entities. Interestingly, whereas smoking has been associated with palmar erythema [26,27] and other skin conditions such as accelerated skin aging [28], delayed wound healing [29], and psoriasis [30], no such association with palmar telangiectasias has been demonstrated.

The aim of the current study is to determine whether smoking is associated with palmar telangiectasias and to further characterize this association.

Patients and Methods

For further details, see the supplementary material (see www.karger.com/doi/10.1159/000481855 for all online suppl. material) (Fig. 1, 2; Appendix).

Fig. 1

Flowchart of Patients and Methods.

/WebMaterial/ShowPic/907295

Fig. 2

a, b Presence of discrete palmar (hypothenar) telangiectasias on both palms.

/WebMaterial/ShowPic/907294

Results

A total of 124 consecutive patients were recruited to the study (Fig. 1). Three were excluded due to systemic use of corticosteroids, pregnancy, or prior liver transplantation.

The participants' main demographic characteristics are summarized in Table 1. Sixty-four participants were female and 57 were male. The average age was 40.9 years (range: 25-75). Thirty participants (24.9%) were current smokers and 16 (13.2%) were past smokers. Twenty-five participants had palmar telangiectasias. Out of the 30 current smokers, 50% demonstrated palmar telangiectasias. Out of the 16 past smokers, 5 (31.2%) exhibited palmar telangiectasias. The average time passed since discontinuation of smoking was 3.6 years (range: 1-17 years). Out of the 75 nonsmoking participants, only 5 (6.7%) had palmar telangiectasias (Table 2; Fig. 1).

Table 1

Main demographic characteristics of patients (n = 121)

/WebMaterial/ShowPic/907297

Table 2

Presence of palmar telangiectasias in relation to smoking status

/WebMaterial/ShowPic/907296

Statistical analysis revealed a statistically significant association between past (p = 0.004) and present (p = 0.0002) smoking and the presence of palmar telangiectasias (p < 0.0001 for the above 2 combined groups). Number of smoking years and average amount of smoked cigarettes per day were not found to correlate with the presence of palmar telangiectasias in current smokers (p = 0.78 and p = 0.37, respectively). In past smokers, no correlation was found between the presence of palmar telangiectasias and the average amount of smoked cigarettes per day (p = 0.86) or the time passed since cessation of smoking (p = 0.71). However, the number of smoking years did correlate with the presence of palmar telangiectasias, i.e., the higher the number of years, the greater the likelihood of the presence of palmar telangiectasias (p = 0.04). It should be noted that the presence of palmar telangiectasias was not statistically associated with either age (p = 0.27) or gender (p = 0.92).

Sensitivity of palmar telangiectasias as an indicator of smoking was only 43%, yet specificity was 93%. The positive predictive value of a person having palmar telangiectasias to be a past or present smoker was 80%, and the negative predictive value was 73%.

Discussion

The field of dermatology is abundant with various skin signs such as Nickolsky's sign in bullous dermatoses, Hutchinson's sign in congenital syphilis, Auspitz's sign in psoriasis, and many more. Only rarely have these cutaneous signs of systemic diseases been statistically validated, and Auspitz's sign, generally accepted as being associated with psoriasis, actually carries low sensitivity and specificity [31].

Smoking is a well-known independent contributor to skin wrinkling [32,33]. Kennedy et al. [28] have evaluated the impact of smoking on skin aging in regard to the existence of elastosis and facial telangiectasias. They found the 2 items associated only in men, although past and current smoking incidence rates were much higher in men than in women (23% compared to 17% of current smokers, and 58% compared to 36% of past smokers).

In this report we demonstrated a statistically significant correlation between present and past smoking and a dermatological sign of palmar telangiectasias. Furthermore, the appearance of this dermatological sign is highly specific for smoking. These observations also suggest that once palmar telangiectasias appear they tend to remain permanent and do not fade away with cessation of smoking. This association was independent of age or gender. In past smokers it was, however, associated with the average number of smoking years, an association which was not found in regard to present smokers.

The exact mechanism by which smoking causes cutaneous telangiectasias is still not fully understood [28]. The postulated mechanism involves a vasoconstrictive effect induced by smoking [34]. The systemic increase of nicotine levels occurring after smoking causes an increment of vasoconstrictive agents such as vasopressin [35]. The vasoconstriction decreases blood flow in the dermis, which leads to chronic ischemia [36]. Chronic ischemia may lead to the compensatory development of small cutaneous blood vessels manifesting as telangiectasias.

Interestingly, Amichai and Grunwald [37] reported a 63-year-old patient referred to their dermatology clinic due to asymptomatic sudden appearance of palmar telangiectasias, which later was found to be the presenting symptom of a deadly small cell carcinoma of the lung. The smoking status of that patient was not reported. Although the question of whether both the reported lung cancer and the presence of palmar telangiectasias were associated with smoking remains unanswered, our findings regarding the high specificity and sensitivity of this cutaneous sign combined with the known association between smoking and lung cancer may lead to the assumption that smoking, lung cancer, and palmar telangiectasias in this patient are indeed related.

Conclusion

The presence of palmar telangiectasias should prompt the physician to ask the patient about his/her smoking habits.

Key Message

The presence of palmar telangiectasias is highly indicative of past or present smoking.

Statement of Ethics

The study was conducted in accordance with the Helsinki Declaration of 1964 and was approved by the institution's ethics board.

Disclosure Statement

The authors declare no conflicts of interest. There was no funding for this work.

Appendix 1

Study Questionnaire

/WebMaterial/ShowPic/907298


References

  1. Brown GR: Cutaneous telangiectasias on lips and extremities. Arch Intern Med 1963;112:889-891.
  2. Alam MA, Sami S, Babu S: Successful treatment of bleeding gastro-intestinal angiodysplasia in hereditary haemorrhagic telangiectasia with thalidomide. BMJ Case Rep 2011;2011:bcr0820114585.
  3. Guedes R, Leite L: Unilateral nevoid telangiectasia: a rare disease? Indian J Dermatol 2012;57:138-140.
  4. Gordon Spratt EA, DeFelice T, O'Reilly K, Robinson M, Patel RR, Sanchez M: Generalized essential telangiectasia. Dermatol Online J 2012;18:13.
  5. Kalisiak MS, Haber RM: Angioma serpiginosum with linear distribution: case report and review of the literature. J Cutan Med Surg 2008;12:180-183.
  6. Stern RS: Clinical practice. Treatment of photoaging. N Engl J Med 2004;350:1526-1534.
  7. Cheng B, Erdos D, Stanley RJ, Stoecker WV, Calcara DA, Gómez DD: Automatic detection of basal cell carcinoma using telangiectasia analysis in dermoscopy skin lesion images. Skin Res Technol 2011;17:278-287.
  8. Cribier B: Pathophysiology of rosacea: redness, telangiectasia, and rosacea. Ann Dermatol Venereol 2011;138(suppl 3):S184-S191.
  9. Tierney EP, Hanke CW: Treatment of Poikiloderma of Civatte with ablative fractional laser resurfacing: prospective study and review of the literature. J Drugs Dermatol 2009;8:527-534.
  10. Foldes EG: Pharmaceutical effect of contraceptive pills on the skin. Int J Clin Pharmacol Ther Toxicol 1988;26:356-359.
  11. Hameed AF: Steroid dermatitis resembling rosacea: a clinical evaluation of 75 patients. ISRN Dermatol 2013;2013:491376.
  12. Ehmann LM, Ruzicka T, Wollenberg A: Cutaneous side-effects of EGFR inhibitors and their management. Skin Therapy Lett 2011;16:1-3.
  13. Dourmishev LA, Dourmishev AL, Schwartz RA: Dermatomyositis: an association of gingival telangiectasias and anti Jo-1 antibody in the adult. Acta Dermatovenerol Alp Panonica Adriat 2007;16:67-72.
  14. Guinovart RM, Vicente A, Rovira C, Suñol M, González-Enseñat MA: Facial telangiectasia: an unusual manifestation of neonatal lupus erythematosus. Lupus 2012;21:552-555.
  15. Ghosh SK, Bandyopadhyay D, Biswas SK, Darung I: Mucocutaneous manifestations in patients with rheumatoid arthritis: a cross-sectional study from Eastern India. Indian J Dermatol 2017;62:411-417.
  16. Halachmi S, Gabari O, Cohen S, Koren R, Amitai DB, Lapidoth M: Telangiectasis in CREST syndrome and systemic sclerosis: correlation of clinical and pathological features with response to pulsed dye laser treatment. Lasers Med Sci 2014;29:137-140.
  17. Kaneko H, Kondo N: Clinical features of Bloom syndrome and function of the causative gene, BLM helicase. Expert Rev Mol Diagn 2004;4:393-401.
  18. Ambrose M, Gatti RA: Pathogenesis of ataxia-telangiectasia: the next generation of ATM functions. Blood 2013;121:4036-4045.
  19. Mei-Zahav M, Letarte M, Faughnan ME, Abdalla SA, Cymerman U, MacLusky IB: Symptomatic children with hereditary hemorrhagic telangiectasia: a pediatric center experience. Arch Pediatr Adolesc Med 2006;160:596-601.
  20. Henry F, Quatresooz P, Valverde-Lopez JC, Piérard GE: Blood vessel changes during pregnancy: a review. Am J Clin Dermatol 2006;7:65-69.
  21. Casadio R, Santi V, Mirici-Cappa F, Magini G, Cacciari M, Bernardi M, Trevisani F: Telangiectasia as a presenting sign of Graves' disease. Horm Res 2008;69:189-192.
  22. Capodicasa E, De Bellis F, Muscat C: The hepato-pulmonary-cutaneous syndrome: description of a case and suggestion of a unifying hypothesis. Case Rep Gastroenterol 2010;4:273-278.
  23. Hazin R, Abu-Rajab Tamimi TI, Abuzetun JY, Zein NN: Recognizing and treating cutaneous signs of liver disease. Cleve Clin J Med 2009;76:599-606.
  24. Wang G, Chen H, Yang Y, Wu K, Sun J: Telangiectasia macularis multiplex acquisita accompanied by hepatitis B infection. Australas J Dermatol 2017;58:e5-e7.
  25. Nabatian A, Suchter MF, Milgraum S: Palmar telangiectasias as a manifestation of Graves' disease. Cutis 2012;89:84-88.
  26. McArthur G, Firkin BG: Smoking - another cause of palmar erythema? Med J Aust 1992;156:71.
  27. Serrao R, Zirwas M, English JC: Palmar erythema. Am J Clin Dermatol 2007;8:347-356.
  28. Kennedy C, Bastiaens MT, Bajdik CD, Willemze R, Westendorp RG, Bouwes Bavinck JN: Effect of smoking and sun on the aging skin. J Invest Dermatol 2003;120:548-554.
  29. McRobert J: Smoking and its effects on the healing process of chronic wounds. Br J Community Nurs 2013;18:S20-S23.
  30. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ: Psoriasis and smoking: a systematic review and meta-analysis. Br J Dermatol 2014;170:304-301.
  31. Bernhard JD: Auspitz sign is not sensitive or specific for psoriasis. J Am Acad Dermatol 1990;22:1079-1081.
  32. Kadunce DP, Burr R, Gress R, Kanner R, Lyon JL, Zone JJ: Cigarette smoking: risk factor for premature facial wrinkling. Ann Intern Med 1991;114:840-844.
  33. Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K: Facial wrinkling in men and women, by smoking status. Am J Public Health 1995;85:78-82.
  34. Monfrecola G, Riccio G, Savarese C, Posteraro G, Procaccini EM: The acute effect of smoking on cutaneous microcirculation blood flow in habitual smokers and nonsmokers. Dermatology 1998;197:115-118.
  35. Tur E, Yosipovitch G, Oren-Vulfs S: Chronic and acute effects of cigarette smoking on skin blood flow. Angiology 1992;43:328-335.
  36. Richardson D: Effects of tobacco smoke inhalation on capillary blood flow in human skin. Arch Environ Health 1987;42:19-25.
  37. Amichai B, Grunwald MH: Palmar telangiectasias and lung carcinoma: a possible association? J Eur Acad Dermatol Venereol 2002;16:185-186.

Author Contacts

Assi Levi

Photodermatosis Clinic and Laser Unit, Department of Dermatology

Rabin Medical Center, Beilinson Hospital

39, Ze'ev Jabotinsky Rd, Petah Tikva, 4941492 (Israel)

E-Mail docalevi@gmail.com


Article / Publication Details

First-Page Preview
Abstract of Clinical Investigations

Received: June 08, 2017
Accepted: September 25, 2017
Published online: December 07, 2017
Issue release date: February 2018

Number of Print Pages: 6
Number of Figures: 2
Number of Tables: 2

ISSN: 1018-8665 (Print)
eISSN: 1421-9832 (Online)

For additional information: https://www.karger.com/DRM


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References

  1. Brown GR: Cutaneous telangiectasias on lips and extremities. Arch Intern Med 1963;112:889-891.
  2. Alam MA, Sami S, Babu S: Successful treatment of bleeding gastro-intestinal angiodysplasia in hereditary haemorrhagic telangiectasia with thalidomide. BMJ Case Rep 2011;2011:bcr0820114585.
  3. Guedes R, Leite L: Unilateral nevoid telangiectasia: a rare disease? Indian J Dermatol 2012;57:138-140.
  4. Gordon Spratt EA, DeFelice T, O'Reilly K, Robinson M, Patel RR, Sanchez M: Generalized essential telangiectasia. Dermatol Online J 2012;18:13.
  5. Kalisiak MS, Haber RM: Angioma serpiginosum with linear distribution: case report and review of the literature. J Cutan Med Surg 2008;12:180-183.
  6. Stern RS: Clinical practice. Treatment of photoaging. N Engl J Med 2004;350:1526-1534.
  7. Cheng B, Erdos D, Stanley RJ, Stoecker WV, Calcara DA, Gómez DD: Automatic detection of basal cell carcinoma using telangiectasia analysis in dermoscopy skin lesion images. Skin Res Technol 2011;17:278-287.
  8. Cribier B: Pathophysiology of rosacea: redness, telangiectasia, and rosacea. Ann Dermatol Venereol 2011;138(suppl 3):S184-S191.
  9. Tierney EP, Hanke CW: Treatment of Poikiloderma of Civatte with ablative fractional laser resurfacing: prospective study and review of the literature. J Drugs Dermatol 2009;8:527-534.
  10. Foldes EG: Pharmaceutical effect of contraceptive pills on the skin. Int J Clin Pharmacol Ther Toxicol 1988;26:356-359.
  11. Hameed AF: Steroid dermatitis resembling rosacea: a clinical evaluation of 75 patients. ISRN Dermatol 2013;2013:491376.
  12. Ehmann LM, Ruzicka T, Wollenberg A: Cutaneous side-effects of EGFR inhibitors and their management. Skin Therapy Lett 2011;16:1-3.
  13. Dourmishev LA, Dourmishev AL, Schwartz RA: Dermatomyositis: an association of gingival telangiectasias and anti Jo-1 antibody in the adult. Acta Dermatovenerol Alp Panonica Adriat 2007;16:67-72.
  14. Guinovart RM, Vicente A, Rovira C, Suñol M, González-Enseñat MA: Facial telangiectasia: an unusual manifestation of neonatal lupus erythematosus. Lupus 2012;21:552-555.
  15. Ghosh SK, Bandyopadhyay D, Biswas SK, Darung I: Mucocutaneous manifestations in patients with rheumatoid arthritis: a cross-sectional study from Eastern India. Indian J Dermatol 2017;62:411-417.
  16. Halachmi S, Gabari O, Cohen S, Koren R, Amitai DB, Lapidoth M: Telangiectasis in CREST syndrome and systemic sclerosis: correlation of clinical and pathological features with response to pulsed dye laser treatment. Lasers Med Sci 2014;29:137-140.
  17. Kaneko H, Kondo N: Clinical features of Bloom syndrome and function of the causative gene, BLM helicase. Expert Rev Mol Diagn 2004;4:393-401.
  18. Ambrose M, Gatti RA: Pathogenesis of ataxia-telangiectasia: the next generation of ATM functions. Blood 2013;121:4036-4045.
  19. Mei-Zahav M, Letarte M, Faughnan ME, Abdalla SA, Cymerman U, MacLusky IB: Symptomatic children with hereditary hemorrhagic telangiectasia: a pediatric center experience. Arch Pediatr Adolesc Med 2006;160:596-601.
  20. Henry F, Quatresooz P, Valverde-Lopez JC, Piérard GE: Blood vessel changes during pregnancy: a review. Am J Clin Dermatol 2006;7:65-69.
  21. Casadio R, Santi V, Mirici-Cappa F, Magini G, Cacciari M, Bernardi M, Trevisani F: Telangiectasia as a presenting sign of Graves' disease. Horm Res 2008;69:189-192.
  22. Capodicasa E, De Bellis F, Muscat C: The hepato-pulmonary-cutaneous syndrome: description of a case and suggestion of a unifying hypothesis. Case Rep Gastroenterol 2010;4:273-278.
  23. Hazin R, Abu-Rajab Tamimi TI, Abuzetun JY, Zein NN: Recognizing and treating cutaneous signs of liver disease. Cleve Clin J Med 2009;76:599-606.
  24. Wang G, Chen H, Yang Y, Wu K, Sun J: Telangiectasia macularis multiplex acquisita accompanied by hepatitis B infection. Australas J Dermatol 2017;58:e5-e7.
  25. Nabatian A, Suchter MF, Milgraum S: Palmar telangiectasias as a manifestation of Graves' disease. Cutis 2012;89:84-88.
  26. McArthur G, Firkin BG: Smoking - another cause of palmar erythema? Med J Aust 1992;156:71.
  27. Serrao R, Zirwas M, English JC: Palmar erythema. Am J Clin Dermatol 2007;8:347-356.
  28. Kennedy C, Bastiaens MT, Bajdik CD, Willemze R, Westendorp RG, Bouwes Bavinck JN: Effect of smoking and sun on the aging skin. J Invest Dermatol 2003;120:548-554.
  29. McRobert J: Smoking and its effects on the healing process of chronic wounds. Br J Community Nurs 2013;18:S20-S23.
  30. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ: Psoriasis and smoking: a systematic review and meta-analysis. Br J Dermatol 2014;170:304-301.
  31. Bernhard JD: Auspitz sign is not sensitive or specific for psoriasis. J Am Acad Dermatol 1990;22:1079-1081.
  32. Kadunce DP, Burr R, Gress R, Kanner R, Lyon JL, Zone JJ: Cigarette smoking: risk factor for premature facial wrinkling. Ann Intern Med 1991;114:840-844.
  33. Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K: Facial wrinkling in men and women, by smoking status. Am J Public Health 1995;85:78-82.
  34. Monfrecola G, Riccio G, Savarese C, Posteraro G, Procaccini EM: The acute effect of smoking on cutaneous microcirculation blood flow in habitual smokers and nonsmokers. Dermatology 1998;197:115-118.
  35. Tur E, Yosipovitch G, Oren-Vulfs S: Chronic and acute effects of cigarette smoking on skin blood flow. Angiology 1992;43:328-335.
  36. Richardson D: Effects of tobacco smoke inhalation on capillary blood flow in human skin. Arch Environ Health 1987;42:19-25.
  37. Amichai B, Grunwald MH: Palmar telangiectasias and lung carcinoma: a possible association? J Eur Acad Dermatol Venereol 2002;16:185-186.
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