The Spectrum of Bone and Soft Tissue Destruction in Deso-morphine and Xyalzine Use Disorder

: A deso-morphine derivative (fentanyl-like) that can be manufactured from codeine may develop into gangrenous skin and crocodile-scale necrosis. More recently, manufactured street fentanyl has been mixed with xylazine (traditionally a large animal veterinary tranquilizer). Xylazine leads to a different form of deep skin ulceration and distal gangrene. Methods: A retrospective chart review of a single plastic surgeons' patients from April 1, 2021 – November 30, 2023, was performed. Fifty-two patients were identified who were admitted to a hospital with complicated wounds and skin infections secondary to fentanyl-like/xylazine use. Results: Five patients were admitted with cellulitis only, nine with a sub-cutaneous abscess, 38 with wounds/ulcers, 24 patients had surgical procedures ranging from debridement to limb salvage reconstruction. Five amputations of the upper extremity were performed secondary to untreatable osteomyelitis. Anatomic distribution of wounds includes face (n=3), upper extremity (n=37) and lower extremity (n=12). Very few patients had any outpatient follow-up. Conclusion: There is a paucity of medical literature about the spectrum of wound manifestations in opioid use disorder. Deso-morphine derivative injections appear to be related to the site of injection and are most likely related to toxic agents that lead to chemical necrosis. Xylazine induced flesh rotting does not appear to be related to site specific injections and the wounds are also present in individuals with only inhalational use of xylazine. Mirror image wounds not at injection sites suggest a metabolic or autoimmune etiology. The Philadelphia geographic region is the epicenter of this soon to be nationwide dilemma.