Recognition and Management of Xylazine-induced Skin Wounds

Introduction: In recent years, xylazine, an alpha-adrenergic agonist, has increasingly contaminated the opioid supply in many areas of the United States.2 Used to extend the subjective effects of opioids, xylazine is implicated in difficult-to-manage drug overdoses, use disorders, and, in particular, chronic progressive skin wounds that can take on a substantial appearance.1 Given the novelty of xylazine-related skin wounds and the surge in cases seen during our local street medicine rounds, we sought and compiled the most up-to-date data on their epidemiology, pathogenesis, and practice recommendations for the recognition, triage, and management of these difficult skin wounds.Methods:To identify common themes in the clinical descriptions and treatment modalities currently employed for this problem, various resources were utilized. A review consisted of queries for PubMed articles and government websites and announcements, as well as attendance of an online street medicine webinar.Results: Though the literature base remains limited, xylazine appears to contaminate the drug supply increasingly.3 Novel pathways in the pathogenesis of these wounds have been identified, including multiple causes of local tissue ischemia.2 Though xylazine wounds can take several appearances, trends in their description include gradual worsening, location that may be local or ectopic to injection sites, and necrosis and granulation tissue formation.4 Triaging these patients requires assessing for potentially serious comorbidities as well as the need for surgical debridement. Management of xylazine wounds includes optimizing host and environmental factors for healing, treating underlying infection with tailored antibiotic coverage, gentle at-home debridement, and regimented outpatient follow-up.1,4 An emphasis should be placed on patient education and safety.Discussion: Though these wounds are a relatively new phenomenon, can have an impressive appearance, and have a recalcitrant tendency, the tools for clinical recognition and management of most xylazine wounds already exist. Nevertheless, rigorous studies are needed to assess the efficacy & safety of specific treatment approaches for these patients.References:1. Cohen K, Miller H, St. Ledger M, Williams L. Wound care in the age of xylazine: practical and ethical considerations. Project HOME Street Medicine webinar. March 13, 2024. https://nhchc.org/resource/wound-care-in-the-age- of-xylazine-practical-and-ethical-considerations-for-wound-treatment/ 2. Warp PV, Hauschild M, Serota DP, et al. A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA. Harm Reduct. J. 2024;21(1). doi:10.1186/s12954-024-00978-z 3. Bettigole C, Best A, Teixeira D. Health update: xylazine (tranq) exposure among people who use substances in Philadelphia. Philadelphia Dept of Public Health. December 8, 2022. Accessed March 22, 2024. https://hip.phila.gov/document/3154/PDPH-HAN_Update_13_Xylazine_12.08.2022.pdf/ 4. McFadden R, Wallace-Keeshen S, Petrillo Straub K, et al. Xylazine-associated wounds: clinical experience from a low-barrier wound care clinic in Philadelphia. J. Addict. Med. 2024;18(1):9-12. doi:10.1097/ADM.0000000000001245