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Cocaine Induced Full Thickness Skin Necrosis of the Upper Extremities
Ashley N. Amalfi, MD1; Erika A. Henkelman, MD2; Nicole Zook Sommer1; Reuben A. Bueno, MD1; Michael M. Neumeister, MD1
1Division of Plastic Surgery, Southern Illinois University, Springfield, IL; 2Division of Plastic Surgery, SIU School of Medicine, Springfield, IL

Introduction: We report a series of cocaine-induced full-thickness skin necrosis involving the extremities.  Wounds of 10-20% total body surface area were treated with aggressive serial debridement and split-thickness skin grafting. 

Methods: A retrospective review was performed of patients presenting with cocaine- induced skin necrosis.  IRB approval was obtained to review patient demographics and medical history.  Skin histology, serum immunology and clinical course were analyzed.   

Results: Four patients (age 37-50) with cocaine-induced skin necrosis were identified between December 2010 and June 2011.  All patients were cocaine users who experienced a prodrome of purpura, progressing to full thickness necrosis of 10-20% TBSA within 4-6 weeks.  The lesions had a predilection for the extremities, occurring most frequently on the forearms, lateral upper arms, and inner thighs.  Some patients experienced involvement of the trunk, facies and breasts as well. All patients exhibited autoantibodies, including ANA, P-ANCA, lupus anticoagulant and rheumatoid factor.  Histopathology consistently revealed cutaneous and deep thromboses in the absence of inflammation.  Wound management included serial debridement, temporary xenografting, and definitive split-thickness skin grafting of the large extremity defects.     

Conclusions: Cocaine has been used as a recreational drug for over 100 years, however, full-thickness skin necrosis secondary to its abuse has yet to be reported.  The implicated cause is not cocaine itself, but rather the adulterant levamisole.  This antihelminth, now used solely in veterinary medicine, is added to increase the volume and weight of the powder.  Levamisole is currently detected in 70% of cocaine transported into the US.   In recent reports, this adulterant has been linked to life-threatening agranulocytosis and purpura.  In all previously reported cases, lesions resolved completely with abstinence from cocaine.  We were able to identify traces of levamisole on the drug paraphernalia of a patient in our series. 

Our series represents the first report of cocaine induced skin necrosis necessitating aggressive wound management and skin grafting.  As reconstructive hand surgeons, we must maintain a heightened awareness and adhere to reconstructive principles in the management of this new entity.    

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