Electronic Cigarette’s Negative Effect on Wound Healing

Nicotine-induced vasoconstriction and the subsequent hypoxic tissue environment may be among the contributors to the possible negative affect of electronic cigarettes (e-cigarettes) on dermatologic surgery wound healing, similar to the effect of traditional cigarettes, according to systematic review findings published in the Journal of the American Academy of Dermatology.

Increased infections and impaired wound healing due to use of traditional cigarettes before dermatologic surgery is problematic. Investigators sought to determine the effect of e-cigarettes on cutaneous dermatologic surgical outcomes.

They conducted a systematic literature review of PubMed, Scopus, CINAHL, Embase, and Cochrane Library databases for studies concerning e-cigarettes and cutaneous surgical outcomes in English as of April 2021, search updated in July 2021. Exclusions included comments, directories, editorials, and notes.

They found 13 studies that met search criteria (4 animal studies, 3 case reports, and 6 studies using surrogate markers for cutaneous wound healing including various physiologic measurements such as transcutaneous oxygen tension and skin microcirculation/blood flow). The animal studies (conducted with rats) found results similar to traditional cigarettes, with significantly more tissue flap necrosis with e-cigarettes vs control patients.

A patient with significant e-cigarette usage in the 3 months before procedure had significant bilateral mastectomy tissue flap necrosis in 1 case report. Acute decreases in tissue oximeter readings of free flaps within 48 hours postoperatively were observed in the other 2 case reports, 1 of which noted a 51% drop following patient in-hospital use of an e-cigarette.

Some human studies noted decreases in transcutaneous oxygen tension and skin microcirculation/blood flow (measured with thermal imaging or laser Doppler probes) following acute e-cigarette exposure, with and without nicotine.

Investigators concluded their findings suggesting “e-cigarettes may negatively impact wound healing similar to traditional cigarettes, likely via a mechanism that is multifactorial, with nicotine induced vasoconstriction and subsequent production of a hypoxic tissue environment playing a role.” Despite review limited to animal studies and a small number of case reports and human studies using surrogate physiologic markers as proxy for cutaneous wound healing, investigators said “early evidence supports counseling for e-cigarette cessation in the immediate pre- and postoperative period, especially for graft and flap reconstructions.” They urge patient history gathering to include e-cigarette usage.