Xylazine-induced skin ulcer
Alerts and Notices
Synopsis
Xylazine has recently emerged as a drug of concern in the United States, as its prevalence as a drug of abuse and as an adulterant in street drugs has significantly increased. Its presence in overdose deaths in the United States has increased from 0.36% of deaths in 2015 to 6.7% in 2020. Xylazine alone can be ingested, smoked, snorted, or injected, producing various effects, depending on the dose administered. It can produce energizing effects and hypertension at a minute dose, but increasing doses cause sedative effects, bradycardia, and hypotension that can progress to hemodynamic instability and respiratory arrest.
Xylazine is an increasingly common additive to street drugs such as fentanyl, heroin, and cocaine. It is thought to serve as a bulking agent to increase the supply of drug products and reportedly extends the duration of the opioid effect when combined with fentanyl and heroin. Xylazine has been detected across the United States, but Pennsylvania, Maryland, and Connecticut have the highest reported prevalence.
Chronic injection use of xylazine, either intentionally or unintentionally with adulterated drugs, has been associated with the development of abscesses and ulceration that primarily occur on the extremities. Skin ulceration is thought to occur due to direct vasoconstriction of vessels supplying the skin. The decreased perfusion of soft tissues subsequently impairs wound healing and increases the risk of infection, ulceration, and skin necrosis. Ulcerations may occur more diffusely, not limited to the drug injection site.
Without treatment, these lesions can progress to cause osteomyelitis, bacteremia, sepsis, and, in serious cases, amputation of extremities and severe disability.
Codes
ICD10CM:F19.10 – Other psychoactive substance abuse, uncomplicated
L27.1 – Localized skin eruption due to drugs and medicaments taken internally
SNOMEDCT:
110285005 – Drug-induced ulceration
200893007 – Localized skin eruption caused by drug and medicament
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Skin ulceration:- Bullous impetigo
- Ecthyma
- Bacterial abscess
- Cellulitis
- Necrotizing fasciitis
- Atypical mycobacterium infection
- Stasis ulcer
- Neurogenic ulcer
- Arterial insufficiency ulcer
- Martorell (hypertensive) ulcer
- Panniculitis with ulceration
- Leprosy
- Cutaneous tuberculosis
- Deep fungal infection
- Leishmaniasis (New World or Old World)
- Tropical ulcer
- Pyoderma gangrenosum
- Thromboangiitis obliterans
- Vasculitis
- Rheumatoid ulceration
- Necrobiosis lipoidica with ulceration
- Systemic sclerosis
- Sickle cell ulcer
- Tertiary syphilis
- Bullous pemphigoid
- Squamous cell carcinoma
- Xylazine toxidrome can resemble opioid poisoning with respiratory depression, miosis, hypotension, and bradycardia. However, it can be differentiated from opioid overdose by lack of response to naloxone.
Best Tests
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Management Pearls
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Therapy
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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.Subscription Required
References
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Last Reviewed:01/18/2023
Last Updated:02/06/2023
Last Updated:02/06/2023
Xylazine-induced skin ulcer