Xylazine-induced skin ulcers

What are xylazine-induced skin ulcers?

Xylazine-induced skin ulcers often appear on the extremities as a result of injecting xylazine, a veterinary anesthetic that is increasingly used alongside or as an alternative to narcotic recreational drugs.

As a potent alpha-2 adrenoreceptor agonist, xylazine has been identified as a street drug known as "Tranq," frequently mixed with other substances, particularly fentanyl, to enhance their euphoric effects. Injection of xylazine carries a significant risk of ulcer development and abscess formation.

Who gets xylazine-induced skin ulcers?

Xylazine-induced skin ulcers are commonly found in individuals who use injectable drugs, primarily through intradermal administration but also intravenously.

Cases have been reported mainly in the United Kingdom and the United States of America, particularly in Philadelphia and New York. Their prevalence is increasing due to the successful seizure of large quantities of opioids by the Drug Enforcement Agency, leading to xylazine use as an alternative.

What causes xylazine-induced skin ulcers?

Xylazine-induced skin ulcers result from the drug’s potent alpha-2 adrenoreceptor agonist effects, which cause profound vasoconstriction of skin vessels. This restricts blood flow to surrounding soft tissue, causing ischaemic necrosis.

Ulcers can develop at the site of infection but also in distant areas, increasing the risk for soft tissue infections, impaired healing, and recurrent infection.

What are the clinical features of xylazine-induced skin ulcers?

Xylazine-induced skin ulcers primarily develop on the extremities, particularly over extensor surfaces. Skin changes typically include:

• Bruises and blisters — early signs of tissue damage
• Black necrotic eschars — due to ischaemia and tissue necrosis
• Well-demarcated ulcers with irregular borders
• Malodorous and painful ulcers — may extend as deep as fascia, muscle and even bone
• Surrounding erythema and oedema
• Poor wound healing and chronicity — ulcers may worsen over time without intervention.

In addition to these skin changes, xylazine may cause systemic effects such as bradycardia, hypotension, and arrhythmias. There is also a risk of respiratory depression that may not respond to naloxone.

Necrotic leg ulcer due to injection of xylazine. From Malayala et al, Cureus 

What are the complications of xylazine-induced skin ulcers?

• Necrosis: Xylazine causes vasoconstriction, reducing blood flow to tissues, leading to further necrosis and worsening the ulcer.
• Infection: Necrotic tissue is highly susceptible to bacterial infections, including cellulitis, abscess formation, and necrotising fasciitis. Severe infections may lead to sepsis.
• Osteomyelitis: If the infection spreads to the bone, it can result in osteomyelitis, which may require surgical intervention or amputation.
• Chronic wounds: Wounds may become chronic, resulting in prolonged healing and an increased risk of complications such as larger wounds, deeper tissue involvement, and exposure of bone or tendons.
• Scarring and disfigurement.

How are xylazine-induced skin ulcers diagnosed?

Xylazine-induced skin ulcers may be difficult to diagnose. Xylazine has a short half-life of 25-30 minutes, making detection in blood and urine toxicology difficult. Diagnosis is therefore primarily clinical, using a thorough history and examination.

Initial evaluation should include blood and wound cultures, while ultrasound and MRI imaging may be necessary to rule out complications such as osteomyelitis and necrotising fasciitis.

What is the differential diagnosis for xylazine-induced skin ulcers?

• Venous ulcer
• Arterial ulcer
• Pressure ulcer
• Necrotising fasciitis
• Ecthyma gangrenosum
• Dermatitis artefacta
• Pyoderma gangrenosum
• Alternative drug-induced ulcers, such as those caused by cocaine or pentazocine.

What is the treatment for xylazine-induced skin ulcers?

General measures

• Cessation of drug injection
• Management of withdrawal using opioid withdrawal protocols eg, methadone
• Wound care.

Specific measures

• Intravenous antibiotic therapy, often accompanied by surgical debridement
• Referral to orthopaedic specialists if osteomyelitis is suspected
• Collaboration with drug liaison teams to manage drug use.

How do you prevent xylazine-induced skin ulcers?

Xylazine-induced skin ulcers can be prevented by:

• Avoiding xylazine drug use
• Providing public health education on the risks of drug adulteration with xylazine.

What is the outcome for xylazine-induced skin ulcers?

Xylazine-induced skin ulcers can result in a range of outcomes, from successful healing with appropriate treatment to severe complications such as chronic wounds, infections (including osteomyelitis), and potential limb amputation. Early intervention, such as with intravenous antibiotics and surgical debridement, is crucial to improve outcomes and prevent long-term disability.