The beneficial effect of smoking on pemphigus might be explained by its effect on the immune system. In addition, smoking has an antiestrogenic effect, while pesticides have an estrogenic effect. The lower numbers of smokers among patients, the higher exposure rates to pesticides, and the higher number of female patients who had been pregnant may point to the contribution of estrogens to the disease process. It remains to be determined whether measures, such as avoiding exposure to pesticides or metal vapor, may be beneficial in the clinical context. As the present study was a survey, more definitive studies should be conducted to validate the results.

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Although pemphigus vulgaris is still a life-threatening disease, today it can be successfully treated with a combination of immunosuppressive agents. Early diagnosis and treatment of pemphigus vulgaris allow a better prognosis with lower mortality rates.

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As the relationship between tobacco smoking and acne remains unclear, we examined the relationship between cigarette smoking and severe acne in a large cohort of young men. Trained nurses interviewed subjects upon discharge from compulsory military service, regarding family history, habits, and tobacco smoking habits. Data was correlated with severe acne status, as diagnosed and coded by board-certified dermatologists. In total, 27,083 male subjects participated in the study from 1983 to 2003, of which 237 (0.88%) had severe acne, 11,718 (43.27%) were active smokers, and 15,365 (56.73%) were nonsmokers at the time of interviews. Active smokers showed a significantly lower prevalence of severe acne (0.71%) than nonsmokers (1.01%) (P = 0.0078). An inverse dose-dependent relationship between severe acne prevalence and daily cigarette consumption became significant from 21 cigarettes a day (chi2 and trend test: P < 0.0001), odds ratio: 0.2 (95% CI: 0.06-0.63). The study did not aim to establish a temporal correlation, and passive smoking and acne treatments were not measured. Previous in vitro and clinical studies strongly support an association with nicotine. We suggest a trial with topical nicotine treatment for acne to further investigate this association.