What is the management for xylazine wounds?

Management of Xylazine-Associated Wounds

Xylazine-associated wounds 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

Characteristics of Xylazine Wounds

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

• Initial presentation as small ulcers or blisters that progress to deeper and larger necrotic wounds 2, 1
• Unique "Swiss cheese" pattern with surrounding viable tissue 2
• Can appear at both injection sites and areas not associated with injection (particularly on extensor surfaces of extremities) 1
• Can occur following smoking, intravenous, or intranasal use 2
• Quick progression from small lesions to large, complex, chronic wounds 3

Assessment and Diagnosis

When evaluating potential xylazine-associated wounds:

• Look for the characteristic "Swiss cheese" pattern and progression pattern
• Assess for superficial or deep infection requiring hospitalization
• Evaluate for exposed deep structures such as tendons and bone
• Consider xylazine exposure in patients with atypical wounds, especially in areas with known xylazine presence in the drug supply 4

Treatment Algorithm

1. Outpatient/Community-Based Care (for wounds without deep infection)

• Wound Debridement:

  • Use surgical or enzymatic debridement methods 2, 1
  • Avoid aggressive surgical debridement that could expose tendon and bone 2

• Topical Care:

  • Apply antimicrobial ointment 2, 1
  • Use nonadherent and absorptive dressings 2, 1
  • Maintain regular wound care schedule 3

• Hygiene Measures:

  • Emphasize importance of personal hygiene 2
  • Address barriers to care for unhoused individuals 2

2. Hospital-Based Care (for wounds with infection or complications)

• Infection Management:

  • Provide antibiotics for confirmed infection 1
  • Consider risk of polymicrobial infections including MRSA, Strep pyogenes, E. coli, and others 4

• Surgical Intervention:

  • Reserve for necessary cases but avoid aggressive debridement 2
  • Delay wound closure with split thickness skin grafts until patient is stabilized in substance use treatment 2
  • Consider dermal substitutes such as biodegradable temporizing matrix 2

• Addressing Barriers to Care:

  • Manage opioid withdrawal symptoms to prevent patients leaving against medical advice 5
  • Consider increasing medication for opioid use disorder to decrease frequency of drug use 6

Important Considerations and Pitfalls

• High Complication Rate: Surgical management has shown a 59% complication rate, primarily related to continued wound issues, infections, and graft failures 5

• Barriers to Care:

  • Patients may be reluctant to seek or continue in-hospital settings due to opioid withdrawal and pain 2
  • High rates (49%) of patients leaving against medical advice during treatment 5
  • Chronic open wounds may prevent entry into inpatient drug treatment centers 2

• Contributing Factors to Poor Wound Healing:

  • Inadequate nutritional status 2
  • Limited access to personal hygiene 2
  • Ongoing drug injection into wound sites 2
  • High rates of homelessness (40%) among affected patients 5

• Mechanism of Injury: Xylazine's vasoconstrictive effects may contribute to tissue hypoxia and impaired wound healing 2, 4

• Testing Considerations: Xylazine is not included in standard hospital testing but can be detected using advanced chromatographic technology 1

The management of xylazine-associated wounds presents unique challenges due to the distinct wound characteristics and the social context in which they occur. A conservative approach to wound management is recommended, with emphasis on regular wound care and avoiding aggressive debridement that could worsen outcomes.