A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance. She says she dislikes "looking so much worse than all my friends." Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing. Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis. Her only medications are levothyroxine, tamoxifen, and a multivitamin. She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate. She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night. She admits to occasional marijuana usage when she was a younger adult. Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles. The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes. The skin is sallow and has variable pigmentation. The surface texture is rough in areas. There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.
The diagnosis is made. Which of the following factors is most likely to be responsible for worsening this woman's condition?

Question

A 62-year-old Caucasian woman presents to her primary care physician complaining about her facial appearance.  She says she dislikes "looking so much worse than all my friends."  Specifically, she mentions that the deep wrinkles and brown spots on her face are what she finds most disturbing.  Her past medical history is significant for breast cancer, hypothyroidism, and diverticulosis.  Her only medications are levothyroxine, tamoxifen, and a multivitamin.  She is a divorced mother of two and has recently retired from working as the supervising gardener of a large estate.  She has a forty-year history of smoking one pack of tobacco per day and consumes one or two glasses of wine each night.  She admits to occasional marijuana usage when she was a younger adult.  Examination of her facial skin is remarkable for a general leathery appearance with many deep furrows and wrinkles.  The wrinkles are especially prominent on the forehead and at the lateral corners of the eyes.  The skin is sallow and has variable pigmentation.  The surface texture is rough in areas.  There are scattered flesh-colored scaly patches with slightly irregular margins and occasional clusters of what appear to be dilated superficial capillaries and venules.
The diagnosis is made.  Which of the following factors is most likely to be responsible for worsening this woman's condition?

Quizplus · Accepted Answer

Explanation: Smoking tobacco is known to have a significant impact on the appearance of skin. Smokers have more wrinkles than nonsmokers, and are especially prone to developing coarse wrinkles prominent at the lateral corners of the eyes. It has been hypothesized that cigarette smoking may cause harmful changes in blood flow or that circulating toxins from cigarette smoke may alter production of collagen or elastin. (Choice A) Although alcohol usage has been shown to worsen rosacea, it is not associated with an amplification of photoaging. (Choice B)Photoaging occurs in both genders, though men are usually considered more likely than women to engage in prolonged outdoor activities over a period of many years. (Choice C) Hypothyroidism can cause dry, thickened, and inelastic skin independent of exposure to ultraviolet light. It is not a known risk factor for worsened photoaging. (Choice D) Heavy marijuana usage could hypothetically cause increased susceptibility to photoaging, though this has not been clearly demonstrated. Since this woman's marijuana usage is remote, it is unlikely that it played as significant a role in her appearance as does her tobacco usage. Educational Objective: Cigarette smokers have been shown to have more and deeper wrinkles than do nonsmokers.

A 62-Year-Old Caucasian Woman Presents to Her Primary Care Physician