Electronic cigarettes in dermatology: a systematic review of the literature

Abstract

Introduction

Electronic cigarettes (e-cigarettes) have been gaining worldwide popularity for several years now, making vaping a major alternative to regular tobacco smoking.

Aim

There is still a lack of data on the occurrence of dermatological diseases due to e-cigarettes, so the research was performed.

Methods

A systematic review of the literature was performed in Embase and Medline databases. The search included EMTREE and MESH approaches and was conducted according to the PRISMA guidelines.

Results

Electronic cigarettes were identified both as an initiating and aggravating factor in several dermatological diseases. Vaping resulted in impaired wound healing and thermal injuries in the healthy skin.

Conclusions

Electronic cigarettes have been reported to contribute to the development of various skin diseases and be a source of thermal injury. Lack of data and poor compliance concerning reporting the side effects of vaping make this topic an important issue to monitor.

Introduction

Electronic cigarettes (e-cigarettes) are hand-held devices that vaporize a liquid, most often containing nicotine, propylene glycol, glycerine, and flavourings, producing an aerosol that when inhaled is meant to mimic smoking regular cigarette products [1]. They were invented in China in 2003, launched in 2004, and have been gaining worldwide popularity since then, making vaping a major alternative to regular tobacco smoking. They are widely regarded as a safer and healthier substitute for nicotine-containing products, and useful in the process of quitting conventional smoking. The use of e-cigarettes has increased dramatically in recent years by both smokers and previous non-smokers. Although e-cigarettes were considered a safer option, their negative effects on health, including dermatological conditions, have been reported. Vaping itself reduces cell viability, thus affecting the ultrastructure of the skin and stimulating the release of pro-inflammatory cytokines (IL-6, IL-8, and IL-10) in human keratinocytes [2]. However, the literature still lacks specific data on their health effects, including their possible impact on the development and course of various dermatological diseases. The authors conducted a systemic review of the reported effects of e-cigarettes, both on the healthy skin and in various dermatological diseases.

Aim

The aim of the study was to research the possible effects of e-cigarette smoking on the skin and the potential development of dermatological diseases. Given the lack of data from large randomized control trials, variety of products available, poor consensus on reporting the side effects of vaping, short time on the market, and the lack of long-term observations on health effects make this topic an important issue to monitor in the future.

Methods

A literature review was conducted in Embase and Medline databases, including keywords such as “e-cigarettes”, “electronic cigarettes”, “vaping”, “skin diseases”, “dermatology” and “skin”. The search was as broad as possible, inclusive of EMTREE and MESH approaches, conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Figure 1). The following inclusion criteria were used: original studies, case reports, and case series, with or without accompanying treatments, published in English from the time the database was created until January 2024. The search was repeated by the co-author to avoid bias, and the references were reviewed to find all relevant papers.

Figure 1.

PRISMA flowchart for screening search results

Results

Thirty-five results were identified and further analysed. Eleven articles were included in the final analysis that are presented in Table 1.

Table 1.

Research demonstrating dermatological conditions caused by e-cigarette use

Condition	Sex/Age	Clinical aspect	Year	Reference
Contact dermatitis	Female/52	Erythematous, itchy, scaly dermatitis, slightly lichenified and limited to the right thumb and index finger	2015	[3]
	Female/37	Mild hand and lips dermatitis	2017	[1]
	Female/38	Pruritic patches on both hands	2018	[4]
	Female/38	Erythematous, scaly dermatitis, with lichenification on both hands	2019	[5]
	Female/54	Itchy, eczematous dermatitis of the perioral region	2022	[6]
Morphoea	Female/63	Multiple patches of tight, shiny skin on her left breast and abdomen associated with pruritus and tenderness	2023	[7]
Discoid lupus	Female/34	Hyperpigmented plaque, central pink atrophy on the upper lip and hyperpigmented, pruritic patches on the bilateral lower extremities	2019	[8]
Thermal and chemical injuries	16 males/average age of 41	Second or third degree burn injuries. The average burned area was 5% TBSA. The burnt areas were the hands, buttocks, thorax, thighs and genital areas	2020	[9]
	Male and female/average age of 30	Different anatomical locations. The lower limbs were most commonly affected	2019	[10]
	Male and female/age range 19–66	Four research papers outlining thermal injuries associated with e-cigarettes in different anatomical locations, mostly thighs, face, hands	2019	[12]
Wound healing	Male and female/NS*	The negative effect on wound healing, as with regular cigarettes	2023	[11]

^*Not specified, systematic review of several articles.

Discussion

To date, no published scientific research has shown the positive effects of e-cigarettes on the skin and cutaneous conditions. Although widely regarded as a healthier alternative to regular cigarettes, electronic cigarettes can cause many dermatological conditions.

The various components of an e-cigarette are separate sources of risk of dermatological diseases. The outer part of the device, the steel shell, can lead to contact allergies due to the presence of nickel in it [1, 3–5]. The source of the nickel is the heating coil, and it is then carried through the device, so often the dominant hand used to hold the e-cigarette is irritated first. Maridet et al. reported the first case of contact dermatosis associated with e-cigarettes and nickel. The patient with confirmed nickel allergy presented with itchy erythematous dermatitis on the right dominant hand, which started 2 months after she started smoking e-cigarettes. Analysis of the patient’s device was performed and yielded a positive reaction in the dimethylglyoxime (DMG) nickel spot test. Subsequently, a total of eleven e-cigarette devices were analysed and four devices were found to be positive in the DMG nickel spot test [3]. Ormerod et al. showed a similar case of a woman with a nickel allergy, observed after contact with jewellery and belt buckles, who developed mild dermatitis of the hands and lips several months after starting to smoke e-cigarettes. The DMG nickel spot test was also positive in this case report [1]. Shim et al. demonstrated another case of contact dermatitis caused by nickel release from e-cigarettes. Both patients showed erythematous, scaly, and itchy patches on the hands and facial lesions in one of them [4]. A similar case was also observed in the study by Azevedo et al. A common feature of all these clinical situations is the resolution of skin lesions after cessation of e-cigarette smoking [5]. Therefore, e-cigarettes have become a new source of nickel release, and smoking patients with a confirmed allergy on patch tests to this metal should be educated to avoid those devices containing nickel.

But it is not just nickel that has been the cause of vaping-related dermatoses, but also the liquids used to refill the devices. They contain several ingredients, among which propylene glycol and fragrances are the most likely cause of allergies [6]. Moreover, their composition is also not fully known. These liquids can be irritating and cause contact allergic reactions. Corraza et al. hypothesized that the persistence of aerosolized aromas on the face and the heat vaporization may cause increased permeability of the skin to the allergens and therefore result in contact dermatosis [6].

The use of electronic cigarettes has been correlated with several dermatological conditions, including morphea [7], and discoid lupus [8]. Harrington et al. described the only case to date of vaporization-induced morphea. Although the specific cause of the disease was not fully proven in this research, one of the possible causes was a wick in the patient’s device made of silica, material that is no longer used due to health concerns [7]. Peterson et al. described the case of a patient whose development of discoid lupus on the upper lip may have been associated with koebnerization secondary to heat exposure with the use of electronic cigarettes [8].

E-cigarettes contain lithium-ion batteries, which carry a known risk of exploding and causing thermal injury. Boissiere et al. reported twelve cases of burns caused by exploding e-cigarette batteries and demonstrated that the explosion occurs most often when the e-cigarette is placed in a clothing pocket or when it is being charged (80% of cases) [9]. There are two hypotheses about the triggers of the “thermal runaway” reaction. One hypothesis implies that the interaction between lithium deposits on the battery terminal and moisture resulting from the location of the device, e.g. pants pocket, leads to the formation of lithium hydroxide and hydrogen. The second one is that holding other metal objects next to the electronic cigarette can generate a short circuit and cause the battery to overheat [10]. In addition, when the device’s batteries explode, chemical burns may occur due to the leak of alkaline substances from the lithium battery, and the explosion itself may also cause burns and damage to the respiratory tract [9].

A systematic review by Thieman et al. found that electronic cigarettes have similar negative effects on wound healing as traditional cigarettes. The mechanism of their negative impact on the healing of injuries includes several factors, such as nicotine-induced vasoconstriction and the subsequent creation of a hypoxic tissue environment [11].

Conclusions

The effect of traditional cigarettes on the development of skin diseases is well known. Dermatological conditions that can be caused by cigarette smoking include wrinkling and premature skin aging, skin cancer, psoriasis, atopic and contact dermatitis, acne, hidradenitis suppurativa, alopecia, or systematic lupus erythematous. Some studies, however, point to a rather controversial but possible positive effect of cigarettes on diseases such as pemphigus. As for e-cigarettes, on the other hand, despite the now outdated attitude that they are a safer and healthier alternative to traditional cigarettes, they have been shown to have an impact on many diseases including skin diseases. As mentioned earlier in this systematic review, e-cigarettes exert several cytological changes in the cells. In addition, their negative effects on neutrophil function are a negative factor in the course of psoriasis and other systemic diseases [12]. Considering the impact of e-cigarettes on the development of many diseases, and at the same time the still small number of research on the subject, the investigation of the impact of e-cigarettes on human health needs to be further expanded and emphasized, especially considering the growing popularity of vaping and the still existing misconception that e-cigarettes are a healthier version of regular cigarettes.

Funding Statement

Funding The publication was funded by the Silesia Medical University in Katowice, Poland.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.