Levamisole-Induced Necrosis Syndrome

Presentation and Management

Charles Fredericks, MD; James R. Yon, MD; Gillian Alex, MD; Molly Morton, MD; Thomas Messer, MD; Faran Bokhari, MD; Stathis Poulakidas, MD


Wounds. 2017;29(3):71-76. 

In This Article

Abstract and Introduction


Levamisole is an antihelminthic drug with immunomodulatory properties. Recent estimates suggest the majority of the cocaine in the United States is adulterated with levamisole. Levamisole-induced necrosis syndrome (LINES) is characterized by vasculitis, neutropenia, and purpura that progresses to skin necrosis. Diagnosis relies on physical examination findings and history of previous cocaine use. The purpose of this case series is to describe the pathophysiology, diagnosis, and management of LINES. The authors' institutional database was reviewed from 2008 to 2015, and they found 3 patients with LINES. Subsequent management and outcomes data are discussed. Patients had a variety of outcomes ranging from local wound care to necrosis and amputation of phalanges. Patients with LINES can have a wide variety of outcomes; thus, this syndrome must be aggressively managed. Psychotherapy should also be utilized to help patients with further cocaine use. Levamisole-induced necrosis syndrome incidence is expected to increase, and all providers should be aware of this patient population.


Cocaine is a recreational stimulant used by approximately 1.8% (5.65 million) of the US population in 2012.[1] Its effects are mediated by the inhibition of dopamine reuptake and lead to feelings of self-assuredness and psychic contentment, which can result in a high rate of dependence. According to the US Drug Enforcement Administration (DEA), 69% of the cocaine supply in the United States contains levamisole, a drug that is currently used to treat parasitic infections in animals, and this percentage is increasing.[2] Formerly used to treat pediatric nephrotic syndrome, rheumatoid arthritis, and colon cancer in conjunction with 5-fluorouracil, levamisole is no longer on the market due to its association with agranulocytosis and cutaneous vasculitis.[3,4] Levamisole is used as an adulterant to "cut" cocaine as it is widely available and can be reduced to a very fine powder. The increasing prevalence of levamisole in cocaine over the last decade has led to an exponential increase in the number of case reports of levamisole-induced necrosis syndrome (LINES) in cocaine users, some of which require extensive surgical debridement and skin grafting. Levamisole-induced necrosis syndrome can result in painful, retiform, purpuric lesions that can progress to full-thickness skin necrosis. Herein the authors present a series of 3 patients and their 13 admissions for levamisole-induced vasculitis as well as the subsequent surgical and wound management.