It Takes a Village

The Management of Extreme Sequelae of Skin Popping

C.J. Michet, BA; Courtney Whitelock, BS; Nicole Siparsky, MD, FACS


Wounds. 2021;33(1):9-19. 

In This Article


Five patients presented to Rush University Medical Center between 2017 and 2019 with lower extremity ulcers due to SP. The age range was 27 years to 51 years; 60% were male. All 5 patients were actively using nonprescription opioids at the time of presentation; 2 of the patients were concurrently receiving OUD treatment (Table 2).

All patients underwent definitive surgical intervention for infection due to necrotic lower extremity SP ulcer. In 3 cases, sharp excisional debridement was performed for source control in the setting of infected necrotic lower extremity ulcer; tissue cultures were obtained for each patient in the operating room. In 2 cases, the authors performed amputation for chronic osteomyelitis due to chronic bone exposure within the infected necrotic lower extremity ulcer; tissue culture was obtained in the operating room for 1 of the 2 patients who underwent amputation. The authors neglected to obtain a tissue culture during 1 of the amputations. Routine dressing care and medical treatment for infection was provided thereafter. For the 3 patients with open wounds, simple once-daily dressing plans were employed to optimize adherence (Table 2). Length of inpatient stay ranged from 3 days to 18 days.

In each of the 4 tissue cultures, a polymicrobial bacterial pattern was observed, including gram-positive and gram-negative bacteria (Table 3). Anaerobic bacteria were isolated in 1 case; methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 2 cases, 1 of which was associated with MRSA bacteremia. In all but 1 case, antibiotic selection reflected the authors' typical practice of broad coverage for gram-positive and gram-negative bacteria, as well as MRSA. Antibiotic regimens included vancomycin plus piperacillin-tazobactam, and vancomycin plus cefepime and metronidazole. In 1 case, an oral antibiotic regimen was needed at the time of discharge, which was tailored to the tissue culture. In 1 case, the patient received only vancomycin prior to amputation, which was felt to achieve source control; no further antibiotics were administered after surgery.

Case 1

A 27-year-old female with OUD and hepatitis C presented with a chief complaint of lower extremity pain and drainage. The patient was hypotensive; physical examination revealed a large, malodorous right necrotic lower extremity ulcer with purulent drainage and surrounding erythema. Radiographs showed no evidence of osteomyelitis. The patient underwent emergent sharp excisional debridement of the infected lower extremity ulcer into muscle (Figure 1) for source control. The operative tissue culture confirmed polymicrobial infection (Table 3), including the presence of MRSA. Treatment for MRSA bacteremia/sepsis was begun. The patient underwent twice-daily moist saline gauze dressing (MSGD) changes while receiving opioid replacement therapy (ORT) with buprenorphine-naloxone (B-N). After 3 days, significant granulation tissue was observed in the wound.

Figure 1.

Lower extremity skin-popping ulcer after debridement; fibula was exposed in the deepest aspect of the wound. Arrow is pointing to exposed fibula bone at base of wound.

The patient was transferred to a nursing facility for ongoing intravenous antibiotic therapy for bacteremia and cellulitis, OUD treatment, and daily wound care. While at the nursing facility for an 11-day stay, the patient was referred to a surgeon for skin grafting to close the wound. The surgeon advised the patient to stop B-N therapy several weeks prior to the procedure, explaining that only ibuprofen would be provided for pain management after surgery. The patient obtained a second opinion in the authors' surgery clinic, 2.5 months after her debridement, at which time she acknowledged occasional nonadherence with B-N therapy. A multidisciplinary plan was created for the patient to continue B-N therapy until the morning of the procedure, followed by postoperative admission to the intensive care unit (ICU) for multimodal pain management. On the day of surgery, the patient acknowledged snorting heroin 6 days prior to surgery. Urine drug screen was positive for benzodiazepines, opioids, and marijuana. Her procedure was cancelled. The patient discontinued ORT and resumed SP. She was lost to follow-up for 10 months; the patient became homeless during this time.

She returned to the surgery clinic for wound care; staff observed the patient displaying drug-seeking and irregular behavior on a consistent basis. The patient declined skin grafting and addiction treatment outside of a rehabilitation center. She underwent serial curettage for heavy biofilm and hypertrophic granulation associated with epibole with a good result. By 1 year, the wound was greater than 50% closed (Figure 2) through consistent wound care with serial curettage and adherence with dressing care using daily xeroform gauze, abdominal (ABD) gauze pad, and gauze wrap. At the time of the coronavirus 2019 (COVID-19) pandemic, the patient was lost to follow-up.

Figure 2.

Massive lower extremity skin-popping ulcer closing by secondary intention with wound care; pink skin represents areas of new skin.

Case 2

A 42-year-old male with a history of bipolar disorder, OUD, chronic osteomyelitis, and chronic bilateral lower extremity SP ulcers presented with worsening right lower extremity pain. The patient had undergone surgical debridement of the ulcer 1 year earlier. One day prior, he endorsed using an ulcer as a shooter's patch. Physical examination demonstrated a large lower extremity ulcer with patchy areas of necrosis, purulent drainage, and exposed bone (Figure 3). Vital signs were normal. Urine toxicology was positive for opiates. Radiographs demonstrated a fibular periosteal reaction and cortical thickening adjacent to a large soft tissue ulcer, suggesting chronic osteomyelitis. The patient was advised to undergo amputation. He began B-N ORT and piperacillin-tazobactam therapy. He underwent a guillotine below-the-knee amputation for source control; his operative tissue culture was polymicrobial (Table 2). After surgery, he was admitted to the ICU, where he received B-N, ketamine infusion, and gabapentin for pain management. He received twice-daily MSGD changes to the guillotine site. Five days later, the patient underwent closure of the guillotine amputation to a right above-knee amputation without complication. Prior to discharge to an acute rehabilitation facility, the patient completed antibiotic therapy and worked with a substance-use intervention team to facilitate continued OUD treatment upon discharge. He completed rehabilitation, remains abstinent on B-N, and follows up regularly with the addiction team.

Figure 3.

Chronic lower extremity skin-popping ulcer with exposed bone; dark purple area denotes site of recent injection (known as shooter's patch); black areas denote necrotic tissue.

Case 3

A 51-year-old homeless male with a history of OUD and SP presented to the emergency department with right lower extremity pain and malodorous ulcer for 2 weeks. The ulcer originally developed 3 years ago after the patient sustained a burn; at that time, he declined skin grafting in favor of a daily dry gauze wrap. The patient reported daily nasal heroin use; he denied SP. Physical examination demonstrated a diaphoretic patient with 2 malodorous right lower extremity ulcers with purulent drainage and small circular SP scars (Figure 4). Vital signs were normal except for intermittent tachycardia. Urine drug screen was positive for opiates. Radiographs showed no evidence of osteomyelitis. The patient received intravenous buprenorphine followed by oral buprenorphine for pain and OUD management. Intravenous vancomycin therapy was started for infected lower extremity ulcers, and the patient underwent surgical debridement. Grossly necrotic tissue was excised except in the periphery, where collagenase therapy was started for superficial enzymatic debridement. The operative tissue culture was polymicrobial (Table 3).

Figure 4.

Chronic lower extremity skin-popping ulcer with necrotic tissue and purulent, malodorous drainage.

The patient awoke from the procedural sedation with agitated delirium, swinging and attempting to bite the staff. He was immediately sedated and transferred to the ICU for acute opioid withdrawal-associated delirium, which required continued sedation for 1 day. Dressing care was continued with twice-daily collagenase and MSGD. He completed antibiotic therapy and resumed B-N for OUD before discharge from the hospital.

In the outpatient clinic, the patient was switched to extended-release buprenorphine. The patient underwent outpatient minor serial debridement of the residual scant peripheral tissue necrosis that had undergone liquefaction with collagenase therapy. The patient declined skin grafting of well-granulating wounds in favor of closure by secondary intention. His wounds were greater than 50% closed 1 year following his major surgical debridement. The patient continues to deny non-prescribed drugs; he visits the addiction medicine clinic regularly (with occasional missed visits), where he receives extended-release buprenorphine for OUD.

Case 4

A 34-year-old male with a history of OUD and SP, bipolar disorder, left above-knee amputation and left above-elbow amputation presented with right leg pain associated with a nonhealing SP ulcer extending to bone. Prior to this presentation, the patient had been evaluated on numerous occasions and advised to undergo amputation of the right lower extremity due to chronic osteomyelitis associated with exposed bone in the ulcer. At those times, he declined the procedure and left AMA. He enrolled in a methadone program but continued to use heroin with financial assistance ($800 daily) from his father. The patient lived in a hotel room with a girlfriend who also had a history of drug misuse.

On physical examination, vital signs were normal. The right lower extremity wound exhibited a necrotic ulcer extending to bone with purulent drainage. For opioid withdrawal and pain management, the patient received hydromorphone. The patient received intravenous antibiotic therapy with vancomycin, cefipime, and metronidazole. He underwent right above-the-knee amputation 1 day after admission. Postoperative pain was managed with epidural fentanyl and subsequently with intravenous hydromorphone. The patient was given the recommendation to titrate down the hydromorphone and initiate B-N, but the patient refused this plan and stated his intention to manage his pain with hydromorphone. He planned to re-enroll in a methadone program upon discharge. The patient left the hospital without narcotics AMA, and he did not follow up in the surgery clinic as directed.

The patient was readmitted to the hospital 9 months later for right lower extremity stump ulceration with malodorous, purulent drainage (Figure 5). He reported SP into the stump incision since the time of surgery. Biopsy demonstrated osteonecrosis and acute inflammation consistent with acute-on-chronic osteomyelitis. He underwent treatment of the stump infection with surgical debridement. Intravenous vancomycin and ceftriaxone were administered for stump infection and sepsis. On postoperative day 1, the patient left the hospital AMA.

Figure 5.

Infected lower extremity amputation site and chronic stump ulcer following longstanding use of surgical incision as a shooter's patch; tissue is undergoing liquefactive necrosis.

Four days later, he returned with purulent drainage from the stump wound. He appeared nontoxic. He was admitted to the hospital for suspected wound infection and acute-on-chronic osteomyelitis. Later that day, the patient admitted to using cocaine in the hospital and was subsequently found unresponsive with agonal breathing consistent with opioid overdose. An empty syringe was found. Naloxone was administered, and the patient regained consciousness. The security service searched his room per hospital policy and found several bags of white powder and drug paraphernalia among the patient's belongings. The patient left AMA.

On telephone interview performed 20 months after the patient's last visit to the treatment institution, his mother reported that he received care at an outside hospital but was suffering from infection in his right upper extremity (ie, his only remaining limb), extending into the shoulder joint due to self-administered, intra-articular SP. He left the facility AMA, continued to use drugs, and later returned to the same facility when he was found to be unresponsive at home (suspected to be due to sepsis from infected wounds). His mother reported there was a warrant out for the patient's arrest for drug-related activity. The patient has not returned to the authors' hospital in 23 months.

Case 5

A 42-year-old female with a history of OUD with SP presented because of painful bilateral lower extremity SP ulcers. The patient's history was also remarkable for total abdominal hysterectomy for ovarian cancer. On physical examination, the patient appeared nontoxic with necrotic, malodorous bilateral lower extremity ulcers. Intravenous antibiotic therapy (vancomycin and piperacillin-tazobactam) was initiated, and the patient underwent serial surgical debridement of the bilateral infected lower extremity ulcers into muscle. The operative tissue culture was polymicrobial (Table 3).

The addiction team offered B-N therapy for OUD, which the patient declined, citing side effects and poor pain control. She was not a candidate for outpatient methadone because she did not have an active identification card, which was required for the prescription of methadone. Negative pressure wound therapy was employed to facilitate granulation in the largest wound of the left lower extremity; smaller wounds were dressed with MGSD twice daily. Split-thickness skin grafting was performed on the same admission for rapid closure of the largest wound. Her postoperative pain was poorly controlled with an epidural, such that a femoral nerve catheter was placed for 4 days with concurrent methadone taper; hydromorphone and gabapentin were initiated for pain control, and lorazepam was begun for anxiety. The skin graft take in the left lower extremity wound was excellent, and daily treatment was continued with petrolatum gauze, ABD pad, and gauze wrap to protect the healing graft. She was transferred to a nursing facility for ongoing ORT and wound care (Table 2).

The patient returned to the surgery clinic as instructed and was noted to have a well-healing graft. Upon her discharge from the nursing facility, methadone was discontinued. She resumed using illicit drugs and began SP at the edge of the graft site, which she maintained as a shooter's patch. She did not return to the surgery clinic for follow-up but was readmitted to the hospital 7 months later with recurrent infection of the right lower extremity SP ulcer adjacent to the skin graft scar (Figure 6). She was admitted to the hospital monthly for serial surgical debridement at least 7 times thereafter. She has continued to decline treatment for addiction.

Figure 6.

Chronic lower extremity skin-popping (SP) ulcer at edge of recent lower extremity skin graft recipient site; the open surgical wound was used as a shooter's patch.