Introduction

Recently described as an "Emerging Threat to the United States" by the Biden Administration, the presence of the veterinary medicine xylazine is an ever-increasing additive in the United States’ illicit fentanyl supply.¹ In addition to the substance’s adverse effects on the central nervous system, xylazine use often causes severe cutaneous and necrotic wounds due to its vasoconstrictive properties.^2,3

What is Xylazine?

Xylazine, also called “tranq” or “tranq dope,” is normally used as a sedative and analgesic in veterinary medicine.¹ It is a partial alpha-2 adrenergic agonist that, when combined with opioids, can enhance feelings of euphoria and increase time before withdrawal.² Side effects of xylazine include the following:

• Localized vasoconstriction
• Decreased perfusion
• Painful skin ulceration
• Increased risk of infection

In addition to the above, its use affects the central nervous system and facilitates respiratory depression, leading to an increased risk of overdose.¹ Though recent efforts have pushed to increase availability of testing in fentanyl samples, many users are unaware of the presence of this dangerous additive. Opioid reversal agents such as naloxone do not reverse the effects of xylazine, nor are any there reversal agents approved for use in humans.³ Unawareness of the adjuvant’s presence can have dangerous implications, especially if first responders and medical personnel are unaware of the complicating factors of xylazine during the initial response and subsequent medical care.

How to Identify Xylazine-related Wounds

No classification system or wound treatment guidelines currently exist for managing xylazine-related wounds. Wounds are commonly found in injection sites like the dorsum of the hand, forearms, or lower extremities, especially when the drug is injected into soft tissue instead of intravenously.² Importantly, xylazine-related wounds are not restricted to injection sites alone; cutaneous wounds may occur in non-injection sites.³ Because these wounds do not only occur at injection sites, users may experience multiple wounds developing at one time.⁴

Wounds range from partial- to full-thickness injuries and may involve large regions of muscle necrosis, bone exposure, and/or osteomyelitis.³ Wounds quickly develop eschar, and several wounds in proximity may connect through tunneling.⁴ They have a high secondary infection rate and become necrotic very quickly, and may develop abscesses, sometimes within days of presentation.⁴

How to Treat Xylazine-related Wounds

There is a dearth of recommendations for topical wound treatment for xylazine-specific wounds. Dressing selection should focus on moist wound management principles, promoting debridement of non-viable tissue and biofilm, and antimicrobial use to reduce the risk of infection. Surgical treatment to affected areas can vary due to the severity and extent of structural involvement and may include serial debridement to remove eschar and necrotic tissue. Further surgical intervention may include skin grafting and even amputation of the affected limb.² IV antibiotics are often indicated due to the high risk of secondary infection and abscesses.⁴

Additional Considerations

Since many case studies currently published show a pattern of frequent interruptions in care and inconsistent follow-up due to patients frequently leaving the hospital during their treatment, "AMA" or "against medical advice,” dressing selection should consider these interruptions.^2,4 Dressing selection may also be influenced by affordability and availability, patient comfort, and ease of reapplication. Ultimately, the best dressings to treat these wounds are those the patient can utilize. Xylazine withdrawal involves symptoms of irritability and mood problems, and withdrawal is not effectively managed the same as opioid withdrawal alone.³

An inability to identify wounds and withdrawals complicated by xylazine use may further compound social and economic factors, resulting in further nonadherence to the medical management of these wounds. It is essential for the clinician to be aware of the prevalence of this and other drug adjuvants and be mindful of additional considerations needed to treat overdose and withdrawal in the emergent setting and, later, to treat the chronic wounds that remain.

References

1. Centers for Disease Control and Prevention. What You Should Know About Xylazine. May 4, 2023. https://www.cdc.gov/drugoverdose/deaths/other-drugs/xylazine/faq.html
2. Rengifo S, Ilyas AM, Tosti R. Upper Extremity Soft Tissue Wound Related to Xylazine-laced Fentanyl Intravenous (IV) Drug Abuse: A Case Report. SurgiColl. 2023;1(1). doi:10.58616/surgicoll.00002
3. Gupta R, DR Holtgrave, MA Ashburn. Xylazine — Medical and Public Health Imperatives. N Engl J Med. 2023; doi:10.1056/nejmp2303120.
4. K Byczek. National Alliance of State and Territorial AIDS Directors. Wound Care & Medical Triage for People Who Use Drugs and the Programs That Serve Them. 2023;66-68. https://nastad.org/sites/default/files/2023-04/PDF-Wound-Care-And-Triag…
5. SV Malayala, B Papudesi, R Bobb, A Wimbush. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022;14(8): e28160. doi:10.7759/cureus.28160

About the Author

Lauren graduated with a BSN from the University of Buffalo in Western New York, where she was born and raised. She has held various nursing jobs, but continued to work towards a goal of a career in wound care nursing after she was one of only two students who signed up for a wound care clinical during nursing school. She currently works at the Advanced Wound Healing Center in Orchard Park, NY where she once had her nursing clinicals. She became credentialed in Wound, Ostomy, and Continence Nursing in 2019 and is incorporating her knowledge and skills into her busy clinic practice. When not at work, Lauren enjoys indoor spinning, playing guitar, video games, and rooting for the Buffalo Bills NFL team.