Picture Quiz: A smoker's hand

A 64 year old man with a 40 pack year smoking history presented to an outpatient clinic after an acute asthma attack. He had no other relevant medical history. Upon general examination, however, doctors noted abnormalities on his right hand (see figure). He described a loss of sensation confined to this area that had lasted for 10 years. But, for the past couple of years, this area of his hand had become dry and itchy. The man was a painter-decorator. He said that he did not always wear gloves when decorating and that he used white spirit to remove paint.

Questions

1. Describe the abnormality seen in the picture.
2. What are the differential diagnoses?
3. What aspects of the patient's history are important?

Answers

1. There is an area of erythema (redness) running mid-way up the dorsal (back) surface of the middle finger of the right hand.
2. Differential diagnoses:
   • Burns - thermal, chemical, sunburn
   • Irritant dermatitis - unlikely, the history would contain information of prolonged exposure to an antigen
   • Psoriasis - unlikely, doesn't have classical features of psoriasis (dry, silver scales) and has an abnormal distribution (psoriasis usually affects extensor surfaces)
   • Cellulites - unlikely, area is usually swollen and commonly follows injury.
3. In patients presenting with such a confined area of erythema, you should take a general medical history, concentrating on events surrounding the onset of the skin lesions, the onset of pain, itch, or loss of sensation in and around the area and their progression. A careful enquiry into the current and previous drug history, a possible family history of skin disorders, and details of the patient's occupation and hobbies are important. As is often the way in medicine, the more difficult the diagnosis the more important the history.

Discussion

Importance of history

In this man, the cause of the erythematous area soon became clear after taking a thorough history. He was a heavy smoker and doctors use pack years to estimate this. The number of pack years smoked is a method of readily quantifying the amount that someone has smoked in their lifetime, for which one pack year is equivalent to 20 cigarettes (one pack) smoked a day for one year. For example, someone smoking a pack a day for 40 years would have a 40 pack year history and someone smoking two packs a day for 20 years would also have a 40 pack year history.

On questioning, the man described a 30 year long habit of using domestic bleach to remove the tar staining from his hands; this had caused the rash. His reason for this extreme action was that he worried about what people would think, and his occupation had given him the inspiration. He also described this similar behaviour in a number of his friends also in the decorating trade and with a history of smoking.

Dental staining caused by tobacco use has been well studied, but there is little literature describing staining of the skin.^{1 3}Furthermore, there is less literature describing the behaviour of smokers that feel stigmatised and feel the need to conceal their habit.⁴ This is possibly explained by public health advertising campaigns that portray smoking in a negative light. Data from Chapple and colleagues showed that non-smokers with lung cancer felt unjustly stigmatised as the disease was so strongly associated with smoking.⁵

How would the patient best be treated?

The man's finger is scarred, limiting treatment options. But he could use barrier creams, in particular a simple non-perfumed moisturiser. He should wear appropriate gloves during painting and other jobs that risk long exposure to corrosive elements. Due to scarring, the use of corticosteroid creams would not be effective in this case. Corticosteroid cream is effective for the treatment of psoriasis and seborrheic dermatitis occurring on the scalp. It works by reducing swelling, redness, and itching and for dampening an active inflammatory process. The man insisted that he is "not bothered" by the scar left on his finger.

The man's concern over how he thinks he is perceived as a smoker needs to be tackled. This can be achieved by taking a full history, paying particular attention to the patient's ideas and concerns. He may be under pressure from family, friends, or work, who make him feel socially unaccepted, as if he needs to hide his smoking. If there were such pressures he could be referred to a smoking cessation councillor who could look at these issues in more depth and decide on an appropriate management plan with the patient. There are a number of support groups available to help him stop smoking (see box) and there are local stop smoking groups which meet regularly to discuss issues and offer advice.

The man could also be advised about the different types of nicotine replacement therapy if he expresses an interest in stopping smoking as users of these therapies are twice as likely to quit smoking.⁶ Many different types of therapies are available, including nicotine patches, gum, lozenges, inhalers, and nasal sprays. They work by combating the physical addiction to nicotine by controlling the patient's daily exposure and reducing their withdrawal symptoms. Typically patients start off with a high dose (in relation to their smoking habit) as they become accustomed to daily activities without smoking; they may take large patches or chew gum and may stay at this level for a number of weeks and then, gradually over time, taper the dose down until they stop completely. Further information on smoking cessation can be found at www.hda-online.org.uk/hdt/0101/evidence.htm.

Rameen Shakur, fifth year medical student,

Ashraf Khan, fourth year medical student,

Mohammed Atcha, third year medical student,

Nikhil Hirani, consultant and senior lecturer in respiratory medicine, University of Edinburgh

Faheem Shakur, fourth year medical student, University of Sheffield


studentBMJ 2005;13:221-264 June ISSN 0966-6494

1. Watt RG, Daly B, Kay EJ. Prevention. Part 1: smoking cessation advice within the general dental practice. Br Dent J 2003;194:665-8.
2. Reibel J. Tobacco and oral diseases: update on the evidence, with recommendations. Med Princ Pract 2003;12(suppl 1):S22-32.
3. Ness L, Rosekrans DL, Welford JF. An epidemiologic study of factors affecting extrinsic staining of teeth in an English population. Community Dent Oral Epidemiol 1977;5:55-60.
4. Puskar M. Smoking cessation in women: findings from qualitative research. Nurse Pract 1995;20:80, 83-6, 89.
5. Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ 2004;328:1470.
6. Cummings KM, Hyland A. Impact of nicotine replacement therapy on smoking behavior. Ann Rev Pub Health2005;26:583-99.