Heroin-induced chronic symmetrical skin ulcers of the forearms in a young adult

ARTICLE

ejd.2012.1681

Auteur(s) : Selma Sönmez Ergün¹ selmasonmezergun@yahoo.com, Kemalettin Yildiz¹, Emre Gönenç Baygöl¹, Özlem Su², Zeynep Işıl Uğurad³

¹ Department of Plastic, Reconstructive and Aesthetic Surgery,

² Department of Dermatology, Bezmialem Medical School Bezmialem Vakif University, Istanbul, Turkey

³ Department of Psychiatry, Istinye Hospital, Istanbul, Turkey

Withdrawal of heroin in regular abusers may occur a few hours after the last administration, therefore, they need multiple injections to avoid abstinence syndrome. Vascular access can be compromised by the repeated injection of toxic substances in intravenous drug abusers. In such cases, skin-popping, a method of drug administration by injecting under the skin through a subcutaneous or intradermal route, is practised by drug abusers to attain a “hit”. Skin-popping can result in multiple subcutaneous abscesses which may develop into chronic wounds, such as in our patient [1-3].

A 31-year old man was admitted to our hospital with chronic ulcers on the lateral sides of his forearms, present for 8 months (figure 1A). Systemic and laboratory examinations, including bacterial cultures, were unremarkable, except that HCV serology was positive. For 6 years he had regularly used heroin by intravenous routes. As vascular access in medial sides of his forearms and feet was diminished due to repeated venipunctures, he began to use veins of the lateral side of the forearms. Accidentally, drugs were injected straight into the subcutaneous tissue in these regions, which resulted in open wounds after a short period. Due to the increasing size of these open wounds, he had difficulty concealing them during social intercourse. 16 days before admission, detoxification was started in a private clinic and his open wounds were treated with systemic antibiotherapy and dressings.

Histopathology established chronic ulceration due to marked acanthosis and areas of hyalinization in the epidermis, a dense inflammatory infiltration and inflammatory granulation tissue in the dermis and subcutis. Following debridement, the open wounds were repaired with skin grafts. The patient was discharged with minor skin graft eliminations. Eliminated areas were treated with dressings. There were no problems after 2 years’ follow-up (figure 1B).

Repeated venipunctures and chemical damage arising from injected substances can cause venous trauma leading to thrombosis, scarring of the vein wall and vein collapse. In such circumstances, abusers are driven by their addiction to seek alternative body areas or alternative routes of drug delivery, as in our patient. One of the well known alternative routes of drug delivery in chronic drug abusers is skin-popping. This route is used on easily accesible sites, such as on the hand or forearm [2, 3] .

Illicit injected drugs sold on the street are usually in powder form and are then diluted with commercially available acids, such as citric or tartaric acids, which enhance the break-down of tissues at the injection site. If the injected material is microbiologically contaminated, the risks of enhancement of the tissue break down and the development of serious soft tissue infections may increase. Under these circumstances, skin-popping can result in enlarging ulcers, as in our patient. These patients use both engorged veins surrounding the ulcers and the granulation tissue itself for injection of drugs, to avoid abstinence syndrome [2-5]. Based on the findings of the clinical and histopathological examinations, the toxic effects of the acids used to dissolve the heroin powder played a major role in the formation of the ulcers in our patient.

Management of chronic, non-healing wounds ranges from conservative treatment with regular dressings to vacuum-assisted dressings and surgical intervention, which includes wound debridement, skin grafting or flap covering [6]. Chronic skin ulcers are rare in healthy young adults [6]. Although, “trace marks” represent the stigmata of drug addiction, chronic skin ulcers in healthy young adults may be also a marker for drug abuse, for that reason it should be considered in the differential diagnosis of non-healing wounds in healthy young adults.

Disclosure

Conflict of interest: none. Financial support: none

References

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6. Warner RM, Srinivasan JR: Protean manifestations of intravenous drug use. Surgeon 2004; 2: 137-40.