Introduction

The purpose of this blog is to bring special attention to common dermatologic conditions connected with drug addiction. Although drugs are well known for their significant impact on all body organs (liver, bladder, stomach, and kidneys), various physical manifestations of drug use are often unknown or underrecognized. Many clinicians and even dermatologists fail to see the many symptoms of drug misuse in the skin. Skin lesions caused by substance use may be induced by the drug itself, an allergic reaction, the drug administration method, or any contaminants or infectious agents that may have been mixed in with the drug. It is possible to identify substance users based on the shape and pattern of their skin conditions. Clinicians can learn these signs to better help patients.¹

Why Drug Use Results in Skin Problems

Lifestyle

A substance user’s lifestyle choices are rough on the skin. People who use drugs may remain up all night, sometimes for days on end, depending on the substance used. Most of the adverse effects of substance misuse are visible on the skin. The condition of the skin and the health of the complexion may be indicators of more serious disorders. Drug misuse can leave a mark on a substance user’s skin, especially if they have been struggling with addiction for an extended period of time.²

Personal Hygiene

Given the prevalence of substance use in the unhoused community, further problems may develop for people who are unable to bathe frequently or for whom bathing is not a priority. Hygiene issues may arise in communities outside of the unhoused community, depending on personal factors such as preference and comorbid psychological conditions, such as depression.

Chronic skin disorders can result from the presence of dangerous microorganisms on the skin. Drugs also tend to cause the body to overheat and lead it to sweat more than it usually would to cool itself down. Sweat is made up of water and toxic byproducts of the substances used. This mixture’s presence on the skin results in the absorption of toxic substances through the dermis. Without being washed away, it simply sits and festers. This encourages bacterial infections and numerous skin disorders.²

Poor Nutrition

The skin, like every other part of the body, needs nourishment to function. A lack of adequate nutrition can cause skin problems. The skin will become ill if it lacks critical vitamins, minerals, and fresh drinking water, and it will let a substance user know by displaying apparent signs of illness. People who use illegal substances may be reluctant to consult a physician; therefore, they do not receive effective treatment for these issues.²

Changes in the skin related to alcohol and drug misuse may be the first clinical sign of the disorder. The symptoms of these illnesses can be distinct and clearly identifiable. Spider telangiectasias, angiomas, caput medusas, flushing, and palmar erythema are frequently linked to vascular abnormalities. By being aware of these cutaneous indicators of alcohol and drug misuse, dermatologists are often in a unique position to detect and intervene early, leading to a better therapeutic outcome for these patients and their families.

Common Drug-Induced Skin Disorders

The following are common cutaneous indications of substance use. They are not always indicative of substance use, however, so clinicians should be cautious about making assumptions.

• Skin granulomas
• Psoriasis
• Porphyria cutanea tarda
• Carcinomas of the skin
• Hyperpigmentation
• Abscesses
• Dermatillomania (skin picking disorder)
• Recurrent infections
• Rapid aging

Substances That Commonly Result in Skin Disorders

Alcohol

Alcohol is classified as a central nervous system (CNS) depressant. This indicates that alcohol impairs brain function, neural activity, and numerous important activities throughout the body. People who consume alcohol in excess are more likely to have cirrhosis, a type of acute liver disease that causes yellowish or hyperpigmented skin, as well as thinning hair and nails. Liver disease can manifest as dermatologic stigmata on the skin and may indicate alcoholism. Common rashes, dilated arterioles such as spider veins, and/or angioma may indicate moderate liver damage induced by alcohol consumption.^1,2 Other skin conditions may include:

• Puffer flusher, also called "red-face"
• Spider veins
• Angioma
• Psoriasis (flatly distributed)
• Arid skin
• Premature aging
• Jaundice

Cocaine

Cocaine use can result in a variety of skin diseases, depending on the route of administration. If a person smokes crack cocaine, they usually will experience the loss of eyelashes and eyebrows similar to madarosis. The veterinary antiparasitic drug levamisole, for example, has been found in about 70% of the illicit cocaine seized in the United States.^1,2 Common skin conditions are:

• Churg-Strauss syndrome and a perinuclear antineutrophil cytoplasmic antibody (P-ANCA)–positive Wegener granulomatosis-like syndrome
• “Crack hands” (fingers and palms blackened from exposure to extreme heat)
• Hemorrhagic blisters
• Hyperkeratosis of hands
• Raynaud phenomenon
• Scleroderma
• Urticaria
• Vasculitis and retiform purpura

Cocaine is a stimulant and can also reduce appetite, thus affecting nutrition. Depending on its source, cocaine can be mixed with other substances unbeknown to the user and therefore lead to skin conditions associated with other substances.³

Heroin

An opiate, heroin can give way to many skin conditions that depend on the substance’s administration.4 Morbilliform rash (a measles-like rash) and chronic itching of the body or genital areas commonly occur after heroin use and can linger for many days. Other difficulties are prevalent in heroin users in addition to skin disorders induced by injection drug use. It is not uncommon for people who use heroin to have lethal bacterial infections such as necrotizing fasciitis (flesh-eating disease). People who take illegal drugs are more likely to develop skin and tissue discoloration that is reddish purple, known as livedo reticularis, resulting from their accelerated aging. Substance users frequently experience skin darkening. There are even more significant complications, such as bacterial abscesses and necrosis, when heroin is injected.¹ ²

Methamphetamine

People who use methamphetamine may have pale or grayish skin with a rough texture, and they may also be more likely to sweat heavily. Smoking methamphetamine causes wrinkles that make the effects of methamphetamine usage more noticeable. Even small doses of methamphetamine can cause acne and a compromised immune system. ¹ Any stimulant such as methamphetamine can cause formication syndrome and delusions of parasitosis. In these conditions, a person hallucinates that insects are crawling beneath their skin and begins to compulsively pick at their skin, causing wounds to appear on their body. These sores, sometimes known as “meth sores” or “meth mites," have a rapid onset and spread quickly.²

Prescription Stimulants (Adderall, Ritalin, Concerta, Dexedrine)

The most common prescription stimulants are amphetamines, methylphenidates, and dextroamphetamines. Although skin problems in substance users may seem widespread, prescription medications, particularly stimulants, are known to cause skin problems and damage as well. Given the medications' similarity to methamphetamine, these stimulants are frequently used by people addicted to methamphetamine. Prescription stimulants can be injected by mixing them with a liquid and injecting them into a vein, or they can be smoked or snorted. Not everyone who uses these medications will have skin problems. That is entirely determined by genetic composition.² Common skin conditions are:

• Rash
• Hives
• Angioedema
• Stevens-Johnson syndrome
• Toxic epidermal necrolysis

Conclusion

Clinicians in all areas of medicine should be on the lookout for signs of substance use. In some instances, substance users seek therapy from their physicians but do not reveal their substance use. Providers should treat patients holistically, which includes simultaneously treating all of the patient's issues. Drug addiction has been linked to a wide array of skin abnormalities. Providers and clinicians must be familiar with the typical signs and symptoms of substance users' skin, even if these clinicians are rarely involved in the treatment of these patients. There is still an opportunity for physicians to identify substance users early by using some particular cutaneous indications and after excluding numerous other etiologic factors, thus resulting in referral to the appropriate specialist.

References

1. Areas-Holmblad L. The dermatology of addiction. Addiction Now. Drug Addiction Now. January 3, 2017. Accessed February 1, 2022. https://www.drugaddictionnow.com/2017/01/03/the-dermatology-of-addictio…
2. Skin problems for drug abusers and alcoholics: substance abuse signs. AspenRidge Recovery. April 15, 2020, Accessed February 4, 2022. https://www.aspenridgerecoverycenters.com/skin-problems-for-drug-abuser…
3. Cocaine drugfacts. National Institute on Drug Abuse. April 8, 2021. Accessed February 11, 2022. https://nida.nih.gov/publications/drugfacts/cocaine
4. Heroin drugfacts. National Institute on Drug Abuse. June 1, 2021. Accessed February 11, 2022. https://nida.nih.gov/publications/drugfacts/heroin