Does Smoking Worsen SAPHO Syndrome or PPP Symptoms?

Smoking is strongly linked with palmoplantar pustulosis (PPP) and is associated with greater severity of this skin condition ^[1]. However, the evidence is much less certain regarding its direct effect on the bone and joint inflammation that characterizes SAPHO syndrome ^[2]. While quitting smoking is widely advised for general health and may help some people manage their skin symptoms, it should not be viewed as a standalone cure for SAPHO or PPP.

Smoking and Palmoplantar Pustulosis

PPP is a condition involving painful, pus-filled blisters on the palms and soles ^[3]. Research shows a strong observational connection between smoking and PPP ^[4]. In some study groups, 70% or more of people with PPP are current or former smokers ^[5][6]. Cigarette smoking is considered an environmental factor that may contribute to the condition ^[7][8].

Observational studies have found that current smokers often experience more severe skin symptoms compared to former smokers or nonsmokers ^[1]. For people who do not yet have the condition, stopping smoking is observationally associated with a lower future risk of developing PPP, although this does not prove that quitting prevents it entirely ^[9][10]. While some retrospective studies show that quitting might be followed by an improvement in existing skin lesions, the exact timeline and benefit vary greatly from person to person ^[11]. Quitting does not guarantee that the skin will clear up, and it does not replace prescribed dermatologic treatments.

Smoking and the Bone Component of SAPHO

The bone and joint (osteoarticular) manifestations of SAPHO can involve chronic pain and swelling, often in the chest wall. PPP and these bone symptoms frequently coexist ^[3]. Because PPP is common in SAPHO syndrome, smoking is also frequently reported in groups of patients studied for SAPHO ^[2].

However, current research does not clearly demonstrate that smoking independently causes or worsens the bone pain, swelling, or bone lesions of SAPHO distinct from its relationship with the skin condition ^[2][12]. Smoking and bone inflammation frequently occur together in these patients, but this co-occurrence does not prove that tobacco is driving the bone disease ^[13]. Smoking status is not part of the SAPHO diagnosis, and you should not feel blamed that smoking caused your bone condition.

Why Quitting Matters for Your Care

Even though smoking may not directly drive your bone symptoms, your care team will likely encourage you to stop smoking for several important reasons:

• Possible Skin Benefits: Because smoking is an associated risk factor for PPP, quitting might help some people manage the severity of their skin symptoms ^[7].
• Cardiovascular Health: Stopping smoking reduces cardiovascular risk ^[14]. This is particularly important because having a chronic inflammatory disease can generally put extra stress on your cardiovascular system.
• Medication Management: Stopping tobacco smoke can change how your body metabolizes certain medications. When you quit, it is important to give your clinician or pharmacist a complete medication list so they can check whether any monitoring or dose changes are needed. Quitting also reduces general surgical and healing risks.
• Overall Health: Stopping smoking is beneficial for your general health and reduces cancer risks, helping your body function better overall ^[15].

Quitting smoking is difficult, but evidence-based support is available. Using behavioral counseling combined with medications—such as nicotine replacement therapy (patches, gum, or lozenges), bupropion, or varenicline—significantly improves the chances of quitting successfully ^[16][17]. However, the safest choice depends on your medical history, kidney function, and other medications. Always discuss these options with a clinician or pharmacist to find the safest approach for you.