Is nicotine a vasoconstrictor? Smoking and rosacea.

After I followed a thread on the rosacea forum about smoking versus facial flushing, I read some more about it and tried it out myself. One poster, DatJellyfish, mentioned that his/her flushing worsened significantly after he (assuming it is a he for now) stopped smoking. The question was whether the smoking might have curbed the flushing and rosacea or if these symptoms came from nicotine withdrawal.

Forum members including myself joined in and wondered if the nicotine could have been narrowing the blood vessels of this person for all those years. The quiting could have opened those vessels up again perhaps? Or removed the 'break' on the rosacea?  Things you see with smokers is usually dull, pale yellow skin. I assume that the lack of blood flow to the extremities (including the facial skin) is partly responisble, and that together with the toxins it creates premature wrincles as well. The lack of oxygen rich blood flow would theoretically mean that smoking could be benificial for rosaceans. There are however people who reported either worsening or improvement when they smoked for their rosacea. Link to a forum post on the matter. Reading more about this, it became clear that there is conflicting information out there about the positive or negative effects of smoking on rosacea. I will try to make a selection of arguments and scientific statements in favour and against it.

PRO arguments, suggesting smoking might be favourable for rosacea 

A medscape study that researched the cutaneous manifestations of smoking, states that smoking has a negative effect on wound healing, caused premature and increased facial wrinkling (probably through decreased collagen and elastin), might worsen or cause psoriasis, increases risks of skin and other types of cancer. Smoking is associated with an increased incidence of skin conditions, however one study negatively associates acne with smoking, and the same author in a later study found that patients with rosacea were more likely to be non-smokers. Source The study doesn't say that smoking will prevent rosacea, and perhaps people with rosacea will stop smoking a lot sooner when their symptoms start, in a bid to life a healthy lifestyle and this could explain the lower smoking incidence under rosaceans. Another explanation might be that smoking acts as an anti-inflammatory. David Pascoe writes on his excellent rosacea forum that smokers are "Much less likely to get rosacea". He states that some recent research conducted in the UK has found that smoking is associated with a substantially reduced risk of developing rosacea. The study was epidemiological which means that it used statistics to match the incidence of rosacea in smokers and non-smokers in a random grouping of individuals. An epidemiological study can’t say why such associations exist, and can only prove their existence. It is the task of further research to establish the reason and any subsequent implications for treatment etc.

"We learnt in 2008 from some NRS funded research that “The activation of nicotine receptors appeared to be associated with a significant increase in intracellular calcium, and also stimulated two major signaling proteins that may trigger a cascade of biochemical reactions associated with rosacea." So there will certainly be some debate about what the statically significant reduction in rosacea is smokers in the UK really means." 

The study states this: 
"We identified 60,042 rosacea cases and 60,042 controls (61.5% women). The overall incidence rate for diagnosed rosacea in the UK was 1.65 / 1,000 person-years. Rosacea was diagnosed in some 80% of cases after the age of 30 years. Ocular symptoms were recorded in 20.8% of cases at the index date. We observed a significantly reduced relative risk of developing rosacea among current smokers (odds ratio 0.64, 95% CI 0.62-0.67). (So smoking seems to lower your chances of developing rosacea!) Alcohol consumption was associated with a marginal risk increase. We quantified incidence rates and characteristics of rosacea patients diagnosed in clinical practice in a large epidemiological study using primary care data from the UK. Smoking was associated with a substantially reduced risk of developing rosacea. (Source 1 and 2)

Against, suggesting smoking might be unfavourable for rosacea

One of the most outspoken articles I read about why smoking is bad for rosacea can be found here. I cite some passages of it:  "One of the most adamant no-no’s when it comes to those afflicted with Rosacea is smoking cigarettes. Not only has it been known to trigger rosacea in someone who is already genetically predisposed to the skin disease, it will definitely make an onset of the skin flare-up even worse. Smoking affects the blood vessels adversely, and finding a way to stop is an automatic treatment for Rosacea, and should obviously be a part of the overall treatment plan for those afflicted. You simply cannot expect to use the range of known treatments which help you lessen the impact of the skin disease, such as topical steroids, various moisturizers and creams, and an increase in vitamin D, and still maintain a smoking lifestyle. Smoking is so bad that even if you do all those other things, the negative effects from this single trigger will outdo all the positive effects that the others can muster." "Although smoking has certain anti-inflammatory effects, it also robs your body of the crucial vitamin C, which has many very important skin functions. Some of these skin functions have been identified by doctors as being crucial to the maintenance of the underlying blood vessels, which we now know play a direct part in the causes of Rosacea. Just as importantly, you should avoid being around people who smoke, because second-hand smoke is even worse for Rosacea than taking one to the head yourself. The free radicals it causes directly attack the stuff that makes up your blood vessels, which we all know by now is precisely where Rosacea symptoms come from. It inhibits the flow of essential nutrients to the skin as well, further increasing the chance of Rosacea flare-ups and worsening of ongoing episodes of the skin disease. The only relevant ingredient of cigarette smoke is, of course, nicotine. This infamous substance ultimately sets off a series of reactions in your body that constricts your blood vessels, which means that less blood and nutrients are getting to the surface. Your body will react to this by sending a message to the blood vessels to expand, so that you can get the oxygen you need. This, of course, is precisely what you don’t need if you are genetically marked for Rosacea, as it will almost certainly increase the frequency of flare-ups. As you can see, there simply isn’t anything positive about the correlation between Rosacea and smoking, and you would be far better off kicking the habit and avoiding second-hand inhalation."

In her article "Rosacea Facts - Smoking and Rosacea

(link), Joanne Faulkner arguments firstly in a confusing way that smoking might be a rosacea cure, instead of a cause or a trigger. She bases her statement on studies that have claimed that for certain inflammatory diseases, including Rosacea, the anti-inflammatory qualities of cigarette smoke could have a beneficial impact on the condition. "Smoking interferes with the body's vascular system. Nicotine, the component of cigarette smoke which most of us are familiar with, interrupts natural vascular function causing the tiny blood vessels that nourish the skin to constrict and reduce blood flow to the skin. The body notices that the skin is becoming starved of the oxygen and nutrients being transported in the blood and sends out a signal to compensate. It does this by enlarging the existing vessels and also growing new ones. This then leads to an increase in facial flushing and a raise in the frequency and intensity of Rosacea flare ups." She summarizes that while there may be a very slight chance that smoking could help your Rosacea, because cigarette smoke is thought to be anti-inflammatory, the negative impacts on the condition are huge. 

Dermatologist Dr. Jason Rivers from the US writes the same thing: 

"Nicotine itself interferes with our vascular system’s functioning by constricting and reducing blood flow to the skin. When you inhale cigarette smoke, oxygen is taken away from the blood cells. In order to compensate, our existing blood vessels enlarge and grow new ones, leading to increased flushing and subsequently rosacea flare-ups."





Another study also suggest that smoking is linked to rosacea and comes with the same arguments as just mentioned: "From exposure to heat to cigarette smoking, new studies are tracing the effects of rosacea triggers in the search for the cause or causes of this widespread, often life-disruptive disorder. In interim results of a new study funded by the National Rosacea Society, Dr. Kent Keyser, professor of vision sciences, University of Alabama at Birmingham, noted that:

"Nicotine may be linked to the redness and visible blood vessels of rosacea." 

Smoking has been identified as the single most important cause of many vascular diseases," Dr. Keyser noted. "Although smoking would seem to discourage flushing as it acts to constrict the blood vessels, recent studies have shown that nicotine, acting in receptors on the cells that line blood vessels, can cause new blood vessels to form in the skin. This is a process known as neo-vascularization, and can induce the networking of capillaries." In the study, researchers cultured blood vessel lining cells with and without nicotine and analyzed them with fluorescent imaging. The activation of nicotine receptors appeared to be associated with a significant increase in intracellular calcium, and also stimulated two major signaling proteins that may trigger a cascade of biochemical reactions associated with rosacea. "The increase in intracellular calcium is especially significant as it is a very potent force in triggering cellular reactions that may lead to the formation of new blood vessels," Dr. Keyser said. The study is continuing in order to determine the potential short-term effects of nicotine on gene expression and the consequences of long-term exposure. In the same article there is another study included, that is not linked to smoking, but is interesting (although not quite relevant to this post topic, but I will mention it nevertheless :) A recent study in the Journal of the American Academy of Dermatology also documented that the skin of individuals with rosacea is significantly more sensitive to heat. Patients with rosacea "often complain of increased skin sensitivity and frequently describe a burning sensation," said Dr. Daniela Guzman-Sanchez and colleagues of the Wake Forest University School of Medicine.1 The scientists noted that although this heightened sensitivity is well recognized in practice, there had been no formal research on the phenomenon.

In their study of 24 individuals, 16 had rosacea, half with subtype 1 (erythematotelangiectatic) rosacea, characterized by redness and flushing, and half with subtype 2 (papulopustular) rosacea, characterized by bumps and pimples. The remaining eight individuals served as a control group without rosacea. All of the study subjects were exposed to a device that warmed the skin of the cheek beginning at almost 90 degrees Fahrenheit, with a potential high of about 122 degrees. Individuals were asked to rate their perception of burning, and skin blood flow and skin temperature were also measured. The researchers found that individuals with both subtypes of rosacea had significantly greater sensitivity to heat pain on symptomatic skin, compared to skin without symptoms and to the skin of individuals without rosacea. Moreover, when patients rated pain themselves, there was a significantly greater perception of pain in the subtype 1 group with flushing than in those with subtype 2 rosacea. Skin blood flow was significantly higher in areas with bumps and pimples than in normal skin.

Rosacea Forum posts on this topic 

On the Rosacea Forum TheMediumDog wrote: "Over the past month, I experimented with smoking to see if it might reduce the inflammation in my skin to some degree, and help my rosacea symptoms. My rosacea took a turn for the worse when I gave up (some years ago), so (with some dread, since I don't want to be a smoker) I thought I'd give it a try. Almost immediately, I got a few p&p's. And they were without doubt due to the smoking rather than anything else: I'm controlling my lifestyle very severely at the moment, to ascertain causes. I also tried using nicotine patches, to see if all the disparate ingredients in cigarettes might be responsible, or the heat of the smoke, rather than nicotine itself. If anything, this was worse. Despite their claims, I think the patches deliver most of their nicotine rather immediately, instead of slowly throughout the day. I got a few large p&p's upon beginning the patches, and the general condition of the skin was more inflamed. There is evidence that nicotine is anti-inflammatory. Possibly due to its immunosuppressive effects, or possibly more directly through its effects on so-called 'nicotinic receptors' (I was surprised to discover we've got nicotine receptors!). Its being studied for its effects on other inflammatory diseases; they're trying to isolate the active element, to see if they can get the benefits without the toxic effects of nicotine. I think smoking has a double-faced effect on rosacea. In the long term, I think it makes it significantly worse - and my experience of getting p&p's directly upon beginning attests to this. But I think the anti-inflammatory effects may mask this, especially if you've been smoking long-term. In light of the fairly dramatic effect (I was only smoking 4-6 cigarettes per day, 0.5mg nicotine content), I'm very inclined to think that smoking precipitated my rosacea in the first place.

And on the forum davem81 wrote: "I believe that when I smoked, my body had no ongoing demodex mite population, because benzene kills demodex. Benzene is found in cigarette smoke and therefore, was probably ever-present in my system while I smoked. Upon quitting smoking, it would probably take a while for me to become re-infested by demodex. They would then have to build up their population on my skin to the level that would cause me a problem....which they are free to do, they are no longer being eradicated by the benzene that I was previously constantly inhaling. So a few months later (9 months in my case)..........hello rosacea!

Squibbins adresses the same matter: "Coincidentally, or maybe not, my rosacea experience started after I gave up smoking. I always thought there might be a tenuous link, something to do with blood vessels maybe, but just put it down to coincidence. Like the guy above, I was a heavy smoker, and following a collapsed lung decided to quit about 12 years ago, and haven't smoked since (yes, it makes me feel sick also). After quitting, I began getting 'seasonal' flare-ups for a few years until I had a child which propelled my rosacea into a much more permanent and severe papulopustular state, and 8 years on I am still on Tetracycline. Thats an interesting theory about the benzene/demodex link. Is it possible to get benzene in another, safer form?"

And Mistica confirms: "Nicotine has immunosuppressive and anti-inflammatory properties."

In the discussion Rose states: "I have found the opposite to be true, myself. My skin was so much     worse when I smoked. The healthier my body is, the better my rosacea is."

GJ writes: "Hey David. It’s been a long time. It’s fun to play around with these sorts of findings.. because it’s epidemiology and we can. Say we think there’s something meaningful – a lesson – here:  We might say that smokers tend to be less obese and obesity is inflammatory. Say we don’t think there’s anything meaningful here: We might say that smokers don’t care much about their health and are unlikely to visit their GP… But when they do visit their GP they are often dying. On those occasions they will not be complaining about pustules and ruddiness about the cheeks but about dying. The GP will be apt to diagnose ‘dying’ and not ‘dying with concomitant rosacea.’ From personal experience, the skin of smokers comes in two types: either dead looking or highly florid with lots of broken vessels. The first (I guess) is a result of hypoxia and the second, a result of the body’s response to hypoxia (new vessel growth). Neither are great looks."

PTas writes: "I gave up smoking -unsuccessfully- three (3) years ago. I was a smoker for at least ten (10) years, with no rosacea symptoms. I first i saw a red face during my two (2) non smoking years! I am currently a smoker (again), with no rosacea improvement during this year. So my conclusion is this: Somehow, my body had developed a way to adapt my smoking habbit and discard those cancer cells produced by it. When I quit, my body had an overplus of immune cells than triggered my rosacea (I’m not a doctor, I’ m just making an assumption). So my advice is this. If you are not a smoker, DONT START SMOKING! If you are, try a more gradual reduction of smoking cause as far as I can tell, no sharp change is a good change for your body, even if this change aims to improve your health."

Coniston writes: "I stopped smoking 20 years ago without every having rosacea. Became healthy and walked my dog 3 times a day .But wondered why my eyes were always red I was tested for dry eyes which I did have 13 years ago. Seborreic derm and rosacea with pustules nearly 3 years . Wondering if the dry eyes were the start. Recently saw a new eye consultant 10 days ago recommended omega 3 and flaxseed, will it help all 3 if they are caused by inflamation."

DaveM81 writes: "This article reinforces a strong, long-held belief of mine. My own rosacea symptoms began severely, overnight, 6-9 months after I gave up smoking. I always suspected, at first just a gut feeling, that the two were somehow linked.This is not the first medical research article I have seen confirming my suspicions. I suffer from ‘type II’ rosacea symptoms – P&P’s ONLY. My own theory is that these are caused or aggravated by the presence of demodex mites. Where smoking fits in to the puzzle is, that cigarette smoke contains, among many other things, BENZENE. Benzene is known to kill demodex mites. Therefore, I suspect that smoking kept me free from mites. Once the effect of smoking finally made their way out of systems, the mites were free to return – hence the beginning of my symptoms just a few months after quitting. Many people don’t seem to want to accept this finding, but as far as I can see, more knowledge can only help in the quest against rosacea. I’m not advocating smoking – I haven’t returned to the habit myself in spite of my theory, and the extreme despair rosacea has caused me. But there is nothing to be gained in denying the link."

Plumage writes: "I can see a reason why this works. Smoking causes constriction of the vascular system- that is what causes people to lose the circulation in their extremities after continuous smoking. But let’s be frank smoking will kill you (a 50% chance) so don’t go there. I’d rather keep my rosacea than wreck my health."

MsLux writes: "This is waffle. Many folks with rosacea have circulation problems and Raynauds, smoking exacerbates this beyond belief. Posting articles like this is slightly daft. What is the point exactly? Much if the worst rosacea I’ve seen was on smokers. I don’t care. I’d rather articles on cosmetic treatments, medical advances and laser etc. This is bad science."

Witchnellie68 writes: "Well, isn’t that typical? I gave up smoking 5 years ago, partly for health but mainly to spite the (UK)taxman. I’d always flushed but never more than that. About a year after giving up my skin started to worsen – I actually decided it was part of the detox, as was the hacking cough 6 months before. It eventually became clear there was more to it than that; so I’ve been on Metrosa gel for a year now, which has eliminated the pustules but I’ve got a permanently ‘sunburnt’ look. Oh, the temptation…"

 


A few reactions selected from this post:

Oldredlady: "Thank you to everyone for being so supportive. After reading the article, I realized my biggest rosacea issues (redness and capillaries) are the ones directly linked to smoking. Much as I will miss it after 25+ years, I realize it's time to try yet again to say goodbye to cig's for good. Am going to use the patches and lots and lots of sugarless gum and hopefully this time it will take. Amethystice, maybe you should show the above to your derm., he might then speak with his rosacea patients about the dangers of smoking. I only wish I'd known about this years ago, I might have made better decisions. Wrinkles have never scared me all that much, as I'm pretty much wrinkle free, but this is a major bummer. Will let you know if it helps my rosacea, I think it probably will. At any rate it can't hurt anything."

And on forum for smokers, there is a thread about rosacea versus smoking, or 'vaping': sucking on an e-cigarette, on which a light-emitting diode causes the tip to glow and the atomizer turns the liquid nicotine into a vapor -- thus it is called vaping instead of smoking. “Let me start by saying I'm not a doctor or scientist. But

Based on my experience and the fact that I can reproduce the symptoms, I believe that vaping triggers skin conditions, namely Rosacea acne. And I think it's the nicotine. So here is my story.

I began vaping in June of 2010. I started with pre-filled cartos in a KR808 battery. I was vaping PG, 18-24 mg. Things went fine but after a number of weeks I began breaking out. I didn't think much of it at first and attributed it to the fact that I quit smoking. Anyway, as time went on the breakouts became far worse and of a different nature. This wasn't like, a pimple here and there kind of thing. It would be a lot of small pimples in a cluster that would eventually form heads and ooze. Nasty. So I went to the dermatologist. She told me it wasn't acne or an allergic reaction, but that it was Rosacea. I didn't believe her since I've never displayed symptoms of it before and I'm 42, plus I did not have the typical "red cheeks" that is predominant in Rosacea sufferers. Nevertheless, I do have the correct ethnic background for it (Scottish). So she put me on Doryx (antibiotic) 1x/day and Finacea (topical) 2x/day. So I took the meds and creme as directed for months. There was no improvement. During this time I never went back to smoking cigarettes and continued to vape. I read up on the forums here, and thought maybe I was allergic to PG. So I switched suppliers and went to VG. My skin appeared to improve a little, but then nope, back to horrible breakouts. Now while this was going on I was also experiencing what I now know to be gallbladder attacks. That is unrelated to vaping, but it lead me to discover something. I had my gallbladder removed in May of this year and the doctor prescribed Oxycodone for pain. By the third day post-surgery my throat had swelled up. I was having difficulty eating and swallowing. I stopped vaping altogether. When the throat issues did not subside we began tests. I saw my surgeon first, then my GP. We did a barium swallow, nothing. Anyway, it was on near a month post surgery and no relief and I was freaking out. It's scary when you can't swallow, plus I couldn't sing and I am a singer, I thought my voice was ruined by the removal of the endotracheal tube. So I saw an ENT. He looked down my throat and saw that my tongue was swollen. He said "you are having an allergic reaction". Turns out I was allergic to the Oxycodone. Interesting, and I'll tell you why later. I also had a rash on my stomach from it. He prescribed a course of treatment and in a short time when the oxycodone was flushed out of my system the throat swelling completely dissipated. Now all that time I was not vaping, and what happened? Yep, my skin cleared up completely. Hmmm...

I returned to my dermatologist and told her what had happened. Now she knew the antibiotics and Finacea gel were not working, so she attributed my skin issues to my gallbladder disease. Makes sense right? Bad gallbadder, bad skin, remove gallbladder, good skin. BUT... I began vaping a few weeks ago. I'd been feeling stressed out. So I ordered 100% VG from my old supplier. And in about 6 days what happened? I started breaking out again. Within 3 weeks it was full-blown once again, clusters of small pimples that broke and oozed. So I stopped vaping AGAIN. It's been 4 days. No new pimples, and the existing clusters are drying up - my skin is nearly clear. Ok so do you see what I see here? Vape, break out, stop vaping, stop breaking out. And the only common ingredient in all of my juices, since I have used both PG and VG and different suppliers and flavors, is the nicotine, as far as I know. Does nicotine trigger Rosacea? I don't know. But if it does why didn't I get it before when I was smoking? I don't know, but I do know that since I have quit smoking I have discovered that I am now allergic to Oxycodone (which I have taken in the past without allergic reaction), and cat dander (I own 3 cats, and have owned cats since I was 18). I know that because I went to see an allergist. Am I now allergic to nicotine? Is it because the nicotine delivery in vaping is far different from the delivery from a cigarette? I suppose I could easily test out my theory by buying 0 Nic E-juice but I don't want to waste any more of my money in case I have a reaction to it and have to toss it. I wanted to share my experience with other users because I know many people have had skin issues since they began vaping. I am curious to get to the bottom of this. All in all it's better and cheaper for me to not vape at all, but sometimes when I feel stressed out it would be nice to know that I could vape for a bit without suffering these skin problems. I had to put my cat of 19 years down last week, and it was heartbreaking. I wanted a cigarette so badly. But I haven't smoked now in nearly 1.5 years so I wasn't going to throw that away. I want to vape, but I can't do that either. Would love to hear your experiences and thoughts on the matter. Thanks. Donna”

Fernand said: “Hmm. My wife is having the same trouble, worsening since she started vaping 2-3 months ago. Acne, rosacea, becoming annoying, with the acne component far worse than she's ever had. I have had an occasional pimple, but nothing unusual, and have been vaping for over a year. It seems some people (with rosacea predisposition?) are reacting to SOMETHING in vaping, and I'm starting to be concerned, as we have heard this acne business too many times. My wife suffers from rosacea anyway, but the pustules are something new. The only way to figure it out is by trial and error, as you have been doing, very logically and competently I might add.”

Heatherina: “Mine is worse than it has been in many years and never even thought it may be caused by vaping, drat!”

Fernand: “My wife has been on limited vaping, using VG-only, for a few days now, and it seems her skin is improving. I can't really demand that she vape up a storm using the VG-only carto, though it would make it easier to draw conclusions. I do rather believe my skin gets more red and oily when I vape more than usual, but I'm not really sure, and it doesn't lead to pustules or anything obvious in my case.”

And later: “Early-forties is "getting old"? She doesn't seem terribly old to me, I'm 20 years older. So far so good. No question her skin is better. She's only vaping a little of the pure VG carto. I wish she were REALLY vaping that VG, so we could really conclude it's not the carto or the glycerin.”

My own small scale 'experiment'

This one existed of only one day and 4 cigarettes, haha. So far from a scientific experiment really. Just thought I'd give it a try, as my flushing triggers are pretty straight forward and direct. I put the pics below each other, going from first cigarette before it was lit, and down to the last and the hours afterwards. I bought Marlboro light ciggies and later worried that they have actually more harmful toxins than straight forward 'shag' (rough cigarette material). But anyway, I felt light headed after 3 puffs and hoped it would be the from the blood vessels constricting. I stayed light headed for a few hours, got a head ache, felt nauseous and after 2 hours I felt like I had less air in my lungs. Most was probably due to my careful paying attention. The taste was disgusting but it felt also kind of 'cool' in a very weird messed up way I guess. I felt more hot in my face all part of the late afternoon and was way more flushed and red all evening. I even have a massive break out by now. Still have the nasty smell of it in my throat and all in all I am not very optimistic about this trial. I hoped it would make me burn less, and I wasn't even too red to start with (the first pic is a bit flattering as I have a 'soft skin' option on my new camera and I was more red than here in fact). Apologies for the grinding looks. It was rather disgusting btw. ;)

The National Rosacea Society published this study:

Rosacea May Be Linked to Smoking, New Study Finds
Posted: 02/22/2016

A recent study in Turkey found that increased risk of rosacea, particularly the redness of subtype 1 (erythematotelangiectatic) rosacea, may be associated with smoking. In a study of 400 individuals, Dr. Asli Kucukunal and colleagues from the Sisli Hamidiye Etfal Training and Research Hospital in Istanbul compared the incidence of rosacea in 200 patients with rosacea matched for age, gender and median smoking period with 200 healthy individuals. The prevalence of smoking among those with rosacea was significantly higher, as 66 percent of the patients with rosacea were active or ex-smokers, while 31 percent those without rosacea were active or former smokers. In addition, the proportion of active smokers with subtype 1 was significantly higher: 43.5 percent of subtype 1 rosacea patients actively consumed at least one pack of cigarettes per day, while only 17 percent of the control group were active smokers.

The increased rate of rosacea in smokers in this study may be related to the angiogenic effect of nicotine, which may stimulate blood vessel production to induce development of the disorder, the researchers said. However, they noted that, contrary to the findings in this study, other investigators have reported a lower prevalence of rosacea in active smokers, and suggested this may be explained by the anti-inflammatory role of nicotine. The researchers said that nicotine’s anti-inflammatory effect may also suggest a rationale for the preponderance of subtype 1 rosacea in smokers in this study, as it may protect against the progression of the inflammatory process from subtype 1 to the bumps and pimples of subtype 2 (papulopustular) rosacea. They concluded that further studies are needed to identify the mechanisms that may be behind the link between smoking and rosacea.