How should wounds potentially affected by Xylazine be managed?

Management of Xylazine-Associated Wounds

Wounds potentially affected by xylazine should be managed with surgical or enzymatic debridement, antimicrobial ointment, and nonadherent absorptive dressings, while avoiding aggressive surgical debridement that may impair healing and lead to exposure of deeper structures. 1

Recognizing Xylazine-Associated Wounds

Xylazine-associated wounds have distinct characteristics that differentiate them from typical injection drug use wounds:

• Initial presentation: Small ulcers or blisters that progress to deeper and larger necrotic wounds 1
• Location: Often on extremities (90%), particularly extensor surfaces (69%), and can appear at both injection sites and areas not associated with injection 1, 2
• Appearance: "Swiss cheese" pattern with surrounding viable tissue 1
• Progression: Wounds coalesce and deepen with progressive tissue loss 1
• Chronicity: Can persist for weeks to months, with subacute and chronic wounds more likely to be larger and have necrotic tissue 2

Wound Care Algorithm

Step 1: Assessment

• Identify wound characteristics suggestive of xylazine exposure
• Determine if wound has superficial or deep infection requiring hospitalization
• Evaluate for exposed deep structures (bone or tendon) - present in 9% of cases 2

Step 2: Outpatient Management (for wounds without deep infection)

• Debridement options:
  • Surgical debridement (conservative)
  • Enzymatic debridement
• Topical treatment:
  • Antimicrobial ointment
  • Nonadherent absorptive dressings 1
• Follow-up:
  • Regular wound care visits
  • Monitor for progression or infection

Step 3: Hospital Management (for complex wounds with infection)

• Hospitalize if:
  • Superficial or deep infection present
  • Extensive necrosis
  • Systemic symptoms
• Treatment approach:
  • Avoid aggressive surgical debridement that could expose tendon and bone 1
  • Focus on topical wound care
  • Consider antibiotics for confirmed infection
  • Delay wound closure with split thickness skin grafts until patient is stabilized in substance use treatment 1
  • Consider dermal substitutes (e.g., biodegradable temporizing matrix) which integrate rapidly into wounds 1

Important Considerations and Pitfalls

1. Avoid aggressive debridement: Unlike traditional wound care, aggressive debridement may impair healing of xylazine-associated wounds and lead to exposure of tendon and bone, chronic osteomyelitis, and potential need for amputation 1

2. Recognize barriers to care:

   • Patients may be reluctant to seek or continue in-hospital settings due to opioid withdrawal and pain 1
   • Unhoused individuals face additional challenges accessing scheduled care and supplies 1
   • Chronic open wounds may prevent entry into inpatient drug treatment centers 1

3. Address contributing factors:

   • Inadequate nutritional status
   • Limited access to personal hygiene
   • Ongoing drug injection into wound sites (increases risk of deep space infections) 1

4. Testing considerations:

   • Xylazine is not included in standard hospital testing but can be detected using advanced chromatographic technology 1
   • Xylazine is detectable in urine for less than 30-43 hours after last use 1

By following this evidence-based approach to xylazine-associated wounds, clinicians can improve outcomes while addressing the unique challenges these wounds present. The focus should be on conservative wound management, appropriate infection control, and addressing barriers to care.