A recent report published in The American Journal of Cardiology regarding the relation of diagonal ear lobe crease (DELC) to coronary artery disease (CAD) raised our interest, because it addresses an important issue linked to our previous research on dermatologic indicators of coronary risk. In the study by Shmilovich et al, the observation that DELC is independently and significantly associated with the increased prevalence, extent, and severity of CAD supports the results of several investigations, including ours, that have been published in recent decades. However, because the prevalence of DELC increases with age, as does atherosclerotic diseases, other investigators have denied this association and pointed out that age is the most important influence on the appearance of DELC.

Because age is 1 of the most important cardiovascular risk factors, and advanced age is associated with an increased incidence of DELC, baldness, hair graying, and wrinkling of the skin, we hypothesized that the premature or extensive occurrence of these dermatologic signs in men aged <60 years could suggest the presence of accelerated atherosclerosis. In our hospital-based case-control study, which included 842 men aged <60 years admitted for first nonfatal myocardial infarction and 712 controls admitted with noncardiac diagnoses without clinical signs of CAD, we examined the association of the aforementioned dermatologic signs with the risk for myocardial infarction. All the signs were more common in patients compared to controls, while parietal baldness and DELC were the strongest predictors of myocardial infarction. Using highly sensitive and specific imaging methods in a large cohort of consecutive patients, Shmilovich et al confirmed our hypothesis in vivo.

In consideration of this result, other dermatologic indicators of cardiovascular risk should not be ignored. Several studies have demonstrated independent associations between parietal baldness, hair graying, and wrinkling of the skin and CAD. It seems that these dermatologic features in patients with CAD have more than aesthetic meaning. Because younger subjects with such features appear older than their age-matched pairs, perhaps these changes are an omen of premature biologic aging.

Recently published data suggest that free radical oxidative stress could be a mechanism linking dermatologic signs with cardiovascular diseases. Namely, free radical oxidative stress, a mechanism important in atherogenesis, is enhanced in the hair follicle melanocytes and leads to their selective premature aging and apoptosis. A similar mechanism could be involved in the pathogenesis of skin damage, causing its aging, wrinkling, or DELC development, by activating the metalloproteinases that break down type I collagen.

Free radical oxidative stress is 1 of the principal mechanisms in the shortening of telomeres, which represent the “biologic clock” of the cell. Telomere shortening in leukocytes may reflect the cumulative burden of oxidative stress and inflammation in circulation during an individual’s lifetime. A close relation between telomere length in leukocytes and vascular cells confirms that leukocyte telomere shortening is a useful marker of accelerated cardiovascular aging. Along the same lines, shorter leukocyte telomeres in patients with DELC than in their age-matched pairs without that sign support the appearance of DELC at an earlier age as a sign of discordance between chronologic and biologic age.

Finally, positive associations of DELC with carotid intima-media thickness and arterial stiffness, widely accepted markers of subclinical atherosclerosis, have also been demonstrated. Therefore, the presence of DELC may be an independent surrogate marker of atherosclerosis, even in patients with no traditional cardiovascular risk factors or clinically expressed cardiovascular diseases.

“A man is as old as his arteries,” said the English physician Thomas Sydenham in the 17th century. The presence of some dermatologic signs might indicate advanced arterial age regardless of the number, duration, or magnitude of traditional cardiovascular risk factors. That is why the aforementioned potential dermatologic indicators of premature biologic aging should be further investigated and could be considered together with traditional factors in assessing cardiovascular risk and diagnostic approach in some patients.