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Skin popping substance abuse
Other Resources UpToDate PubMed

Skin popping substance abuse

Contributors: Christine Hunt MD, Sylvia Hsu MD, Lowell A. Goldsmith MD, MPH
Other Resources UpToDate PubMed


"Skin popping" refers to the injection of drugs subcutaneously or intradermally. Drugs most commonly injected include cocaine, opiates, and barbiturates. The lesions resulting from this practice – "skin pop" scars – are depressed, irregular, and circular; they are often hyper- or hypopigmented. In some individuals, the scars may become indurated, hypertrophic, or keloidal. Skin popping scars are most commonly found on dorsal hands, digits, wrist, forearms, and lower extremities.

Many complications from skin popping can occur:
  • Barbiturate injection can cause tender, indurated, erythematous plaques that may develop into deep ulcers; infection occurs frequently.
  • Pentazocine injection can cause swollen, hard, sclerodermatous skin thickening with large and deep (may reach to muscle) ulcers that are irregularly shaped. Cutaneous sclerosis from pentazocine injections is more common in diabetic patients.
  • Tissue ischemia / infarction can result from highly vasoconstrictive drugs, such as cocaine.
  • Adulterants such as lactose, mannitol, dextrose, baking soda, flour, and quinine are used to dilute heroin and other powder drugs and can be more damaging to tissue than the drug itself. Quinine and dextrose in particular are highly sclerosing, and chronic nonpitting edema can result from repeated injection of quinine, as it is destructive to lymphatics. Levamisole mixed into cocaine has been implicated in necrosis of the ears and cheeks. "Krokodil" is a homemade injectable opioid first noted in Russia, made by mixing codeine with lighter fluid, paint thinner, and other adulterants, that causes discolored scaly skin, ulceration, and necrosis.
  • Wound botulism caused by Clostridium botulinum type A is especially associated with skin popping of black tar heroin.
  • Granulomas can form from injection of talc (magnesium silicate) or starch. They may appear many years after subcutaneous injection.
  • Fibrous myopathy, joint restriction, muscle contractures, neuropathy, ankylosis, and suppurative tenosynovitis may also occur.


L90.5 – Scar conditions and fibrosis of skin

95376002 – Injection site disorder

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Scar from trauma.
  • Skin lesions of injectional Cutaneous anthrax may appear similar to those of skin popping. Outbreaks have occurred, mainly in Europe, among Opioid use disorder.

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Updated:01/13/2019
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Skin popping substance abuse
A medical illustration showing key findings of Skin popping substance abuse : Abscess, Arm, Leg, Plaque with ulcer, Skin ulcer, Symmetric extremities distribution, Atrophic scar, Intravenous drug abuse
Clinical image of Skin popping substance abuse - imageId=2193412. Click to open in gallery.  caption: 'Crusted papules and ulcers on the arm.'
Crusted papules and ulcers on the arm.
Copyright © 2024 VisualDx®. All rights reserved.