“We’re going to review general cutaneous signs of drug abuse, and then we’re going to go over specific skin signs of drug abuse for particular illicit drugs,” explained Rebecca Vasquez, MD, at the start of her session titled “Skin Manifestations of Drug Abuse” at the Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference in Los Angeles, CA. Dr Vasquez is an assistant professor and director of the diversity and inclusion committee in the department of dermatology at UT Southwestern Medical Center and assistant chief of service of dermatology at Parkland Health and Hospital System.

Approximately 32 million people aged 12 years or older in the United States were current users of some sort of illicit drug, with the most common drug used being marijuana. Cocaine and marijuana are the most common illicit drugs associated with emergency department (ED) visits, and narcotics were the most common association for nonmedical use of pharmaceuticals. “It’s super important for us to pick up on these signs because we can provide help, we may have access to resources to get them the help that they need,” said Dr Vasquez.

The first general skin sign is track marks, which are postinflammatory hyperpigmentation spots at the injection sites. The most common site is antecubital fossa of the nondominant hand, but other sites include neck, popliteal fossa, inguinal veins, dorsal veins of the feet, and penis.

The second sign is skin popping, or deep, circular, “punched-out” atrophic scars that develop following sites of small abscesses. Skin popping is caused when the patient administers a drug intradermally, subcutaneously, or even sometimes intramuscularly.

Third, patients may present with sooting tattoos. When person who uses drugs administers the drug with a hot needle, this technique can cause an accumulation of carbon and soot in the dermis. These marks are then covered by commercial tattoos to disguise the scars.

“The concern, especially with persons who use [intravenous] drugs and also anything under the skin, is infection,” said Dr Vasquez. Skin and soft tissue infections are the most common complications and comprise the majority of ED visits. Risk factors include skin popping, nonsterile needles, speedball (cocaine and heroin combination), and booting (dirty needle used to reinject a drug). Other complications include chronic venous insufficiency, ischemic complications, pseudoaneurysms, mycotic aneurysms.

In the postlecture Q&A, an attendee asked Dr Vasquez how to ask patients about their drug use if it is suspected based on clinical appearance. “I try to spend a little bit more time with those patients and explain, ‘well goodness, looking at your labs, there’s not really a great cause, but sometimes certain medications can cause problems with itching, rashes.’ And I just ask if the patient is taking any medication or over-the-counter supplements that I don’t know about, and I’ll start that way.” Dr Vasquez then explained that the patient may not share outright in that first visit that they are using an illicit drug and providers should not seek that information or accuse during this first visit either, but it is important to establish trust and treat symptomatically. The goal is to create a safe space wherein the patient can feel comfortable sharing their use without shame to get the help that they need.

Reference
Vasquez R. Skin manifestations of drug abuse. Presented at: Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference; November 4-7, 2021; Los Angeles, CA.