Chronic Leg Ulcers and Skin-popping Scars from Tapentadol Abuse

Sir, A 25-year-old male undergoing treatment for tapentadol abuse presented with a 6-month history of bilateral leg ulcers. The ulcers developed at the injection sites where he had administered a self-prepared solution of crushed tapentadol mixed with normal saline. He complained of mild pain and minimal discharge from the ulcers. He was afebrile, with stable vital signs. Multiple ulcers of variable sizes, with indurated, hyperpigmented borders, and yellow slough at the center, and a few scattered atrophic scars, were found on the anteromedial aspect of both legs [Figure 1]. His complete blood count, as well as liver and renal function tests, was within the normal limits. His serological tests were negative for human immunodeficiency virus, Hepatitis B, and Hepatitis C. The pus culture from the ulcer grew methicillin-sensitive Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli. The patient was unwilling to undergo skin biopsy due to monetary constraints. Since there was a clear history of ulcer development at injection sites, which began to heal gradually after stopping tapentadol abuse, further evaluation for other general causes of leg ulcers was not done. The wound was cleaned and dressed daily and the patient was treated with intravenous antibiotics, amoxicillin-clavulanic acid, and metronidazole and was referred back to the psychiatry department for ongoing management of his addiction.Figure 1: Multiple ulcers of varying shape and size, with indurated, hyperpigmented borders and yellow slough at the center, and a few scattered atrophic scars (red arrow) seen over the anteromedial aspect of both legs. The lesions were predominantly seen over the accessible site of the legs.Drug abuse, a growing global crisis, predominantly among adolescents and young adults, can often be recognized through its associated cutaneous stigmata. The mucocutaneous manifestations vary depending on the drug, the adulterant, the route of drug administration, and the duration of drug abuse.[1] Our patient resorted to "skin popping," i.e., intradermal or subcutaneous injection of illicit drugs. Skin popping may occur accidentally in some drug users, while others prefer this route as it allows slower drug absorption and bypasses first-pass metabolism, prolonging the high, reduces the risk of overdose, and is easier to administer, particularly when the veins are sclerosed.[1] Skin and soft-tissue infections (SSTIs) such as abscesses and cellulitis are common acute complications, especially among skin poppers. While S. aureus, followed by streptococcus species, are the most commonly isolated organisms from wound cultures, other atypical pathogens such as skin or oral pathogens, anaerobic bacteria, and clostridium species may also contribute to the morbidity.[2] The SSTIs are often deep, leading to necrosis and ulceration.[1,2] These ulcers are typically confined to the accessible sites on the limbs and trunk, as observed in our patient. Many inject drugs directly into these ulcers, leading to their designation as 'shooter's patches.'[3] Toxic effect of the drug, concurrent infection, soft-tissue injury, and vascular damage from repeated injections, contributes to the chronicity of these ulcers.[2] In some cases, bacterial cultures from the wound, blood culture, and radiological imaging to detect concomitant osteomyelitis may be required. Nevertheless, these ulcers can heal with infection control, wound care, nutritional support, and addiction treatment, as observed in our patient. Timely initiation of treatment, along with adequate rehabilitation, can improve the prognosis. Other causes of leg ulcers in the context of drug abuse include venous or arterial insufficiency, thrombophlebitis, vasculitis, pyoderma gangrenosum, and nutritional deficiencies. The etiological diagnosis is based on the type of drug abused, biopsy with clinicopathological correlation, and radiological imaging. Fibrosis, dyspigmentation, and cutaneous granulomas are other chronic cutaneous complications of skin popping.[4] During the follow-up, typical round or irregular, atrophic, and punched-out scars were observed at the site of injection and healed ulcers [Figure 2].[1] Previous reports of skin popping have described a similar presentation, with cutaneous ulcers and/or atrophic scars. Most cases were associated with heroin abuse, and a complete recovery was achieved with wound care, antibiotics, and deaddiction treatment.[4–7]Figure 2: (a and b) Multiple round and irregular, atrophic, punched-out scars (red arrows) at the site of injection and healed ulcers over left legTapentadol is a relatively newer narcotic opioid analgesic, used in the management of moderate-to-severe pain. Its central pain-relieving effect is due to μ-opioid receptor agonism which contributes to dependence, and the inhibition of norepinephrine reuptake.[7] The dual mechanism of action minimizes the risk of certain opioid-related side effects and reduces the potential for abuse compared to traditional opioids. It is increasingly being used as a substitute for traditional opioids as it is less strictly controlled, less expensive, and easily procured. Although tapentadol is believed to be less addictive, use of high doses for a prolonged period, especially by a patient with a history of addiction, increases the risk of physical dependence and addiction. In conclusion, skin popping is a unique technique adopted by injection drug users for its perceived benefits. They have a higher risk of SSTIs, which can lead to ulcerations and typical atrophic scars over the accessible areas of the trunk and extremities where the drugs are injected. The reports of tapentadol abuse through skin popping of self-prepared injections are rare in the literature. In this report, we reiterate the cutaneous complications of skin popping to raise the awareness among healthcare providers. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Authors' contributions Literature search: S.H, C.J; Clinical studies: S.H, C.J; Data acquisition: S.H, C.J; Data analysis: S.H, C.J; Manuscript preparation: S.H, C.J; Manuscript editing: S.H, C.J; Manuscript review: S.H, C.J. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.