|Year : 2000 | Volume
| Issue : 4 | Page : 213-21
Chronic Leg Ulcers in Drug Abusers
RR Mittal, K Pahuja
R R Mittal
Four young males with chronic non pitting swelling of lower legs associated with multiple ulcers, scars and pigmentation after parenteral drug abuse were observed in the Dermatovenereology department during last one year. Three of them had active ulcers which healed with withdrawal of offending drug, use of systemic and topical antibiotics and B-complex. All cases were referred to the deaddiction centre. The characteristic clinical features helped in the diagnosis even before history of drug abuse was obtained.
Keywords: Drug abuse, Ulcers, Sclerosis
|How to cite this article:|
Mittal R R, Pahuja K. Chronic Leg Ulcers in Drug Abusers. Indian J Dermatol Venereol Leprol 2000;66:213
| Introduction|| |
Chronic leg ulcers, sclerosis and pigmentation of skin have been reported after pentazocine injections.  Cutaneous complications after injections of pentazocine were first observed in 1971.  Although benzodiazepines with hypnotic, sedative, anxiolytic, anticonvulsant effects enjoy a reputation of low incidence of abuse and dependence, yet the possibility of adverse complications after prolonged use cannot be overlooked.  Buprenorphine a semisynthetic, highly lipophilic opioid derivative exerts morphine-like effect and is responsible for drug abuse.  The above drugs alone or in combination when injected for long can lead to typical chronic leg ulcers.  Four such cases are being reported. Medical/ paramedical background and diabetic diathesis may be predisposing factors. 
| Case-1|| |
A 25-year-old uneducated, unskilled man taking injection buprenorphine since 6 years, developed bilateral symmetrical leg ulcers since one year. Both lower legs were swollen and had multiple, superficial, 2-5 cm diameter ulcers with purplish periphery more so on extensors. The ulcers were shallow with yellowish brown granulations and serous/ frank pus discharge. In between the ulcers skin was stretched, hyperpigmented, covered with fine scales/ crusts and was interspersed with multiple, depressed cribriform scars. Similar lesions in lesser number were seen on thighs and upper limbs.
ELISA for HIV antibodies was negative. Histopathological examination revealed pseudoepitheliomatous hyperpIasia, granulation tissue, small vessel thrombosis, perivascular mononuclear infiltrate and prominent dermal fibrosis.
| Case-2|| |
A 30-year-old illiterate man working in auto repair shop with history of addiction to s/c injection diazepam and injection buprenorphine since 4-5 years presented with bilateral symmetrical leg ulceration, woody sclerosis, hyperpigmentation of skin over the lower legs of 1 1\2 year duration. Ulcers were multiple, 1-4 cm diameter, variable in shape with nonpurulent 1bases and a characteristic hyperpigmented purplish blue halo. Histopathological, examination revealed acanthosis, proliferation of dermal vessels, perivascular (mononuclear infiltrate and iprominent dermal fibrosis.
| Case-3|| |
A27year-illiterate man with,history of addiction 'to s/c injection pentazocine for three years, presented with bilateral symme- trical swelling of legs, healed scars, pigmentation, interspersed with multiple superficial ulcers of 1-3 cm size, ariable in shape discharging serous/ frank pus and covered with crust or yellowish granulation tissue since one year. In addition multiple ellowish 1-3.5cm fibrotic plaques were seen on dorsa of feet especially around ankles. Histopathological examination evealed dilatation of dermal capillaries with thickening of vessel walls, perivascular infiltrate, dermal fibrosis and necrosis of overlying epidermis.
| Case-4|| |
A 21- year-old BAMS Doctor with three year history of addiction to s/c use of injection norphin, diazepam and pentazocine visited the OPD after discontinuing injections. He wanted complete reso- lution of non-pitting oedema, pigmentation, scars over both legs. He gave history of ulceration both legs after 1½ - 2 years of addiction. prior to getting admitted by himself for deaddiction in a hospital.
Important clinical features are summarised in the [Table - 1].
| Discussion|| |
All four patients were young males in the age range of 21-33 years with previous history of alcohol and drug abuse and negative family history of addiction in siblings and other family members. All the four patients showed sclerosis, pigmentation with nonpitting oedema of lower legs. History of medical/ paramedical background was noted in 4th case only and actual ulceration in first three of the cases. Clinical diagnosis was possible in all four cases before history of drug abuse was obtained. Case No. 2 and 3 were uneducated, poor, belonging to lower socio-economic background whereas 4th case was a BAMS Doctor; thus any strata of the society can be affected by drug abuse. Common histopathological features were pseudoepitheliomatous hyperplasia, dermal fibrosis and proliferation of dermal capillaries. No definite psychiatric illness was observed in any of the cases. Deaddiction seemed to play an important role as the 4th case never developed any active ulceration after deaddiction.
[Figure - 1], [Figure - 2]
| References|| |
|1.||Palestine RF, Milins JL, Spigel GT, et al. Skin manifestations of pentazocine abuse, J Am Acad Dermatol 1980;2;1:47-5. |
|2.||Parks DL, Perry HO, Muller SA. Cutaneous complications of pentazocine injections, Arch Dermatol 1971;104:231-235. [PUBMED] |
|3.||Theodore RW.Hypnotics and Sedatives; Ethanol, In: Goodman and Gilman's The Pharmacological basis of Therapeutics, 8th edition, edited by Gilman AG, Rall TW, Nies AS, Taylor P, Maxwell Macmillan Publishing, Singapore, 1991;1: 355. |
|4.||Jaffe JH, Marln WR. Opioid analgesics and antagonists, In: Goodman and Gilman's The Pharmacological basis of Therapeutics, 8th edition, edited by Gilman AG, Rall TW, Nies AS, Taylor P, Maxwell Macmillan Publishing, Singapore 1991;1:513. |
|5.||Singh RA. Drug abuse, Current Medical Journal of North Zone 1998;3:25. |
[Figure - 1], [Figure - 2]
[Table - 1]