It Takes a Village

The Management of Extreme Sequelae of Skin Popping

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

Disclosures

Wounds. 2021;33(1):9-19. 

In This Article

Abstract and Introduction

Abstract

Introduction: Skin popping (SP) is a popular technique for drug misuse, for its ease of administration and longer duration of effect. Skin infection is a well-described sequela of SP, but less is known about the more extreme sequelae of this practice.

Methods: Five patients who engaged in SP requiring major surgical intervention were identified on case review to highlight extreme diseases resulting from the practice of SP. Each patient reported using heroin or tested positive for opioid on admission. Each patient admitted to practicing SP or maintained a shooter's patch. A multidisciplinary approach was employed to care for the patient. Members of the departments of medicine, surgery, nursing, addiction medicine, infectious disease, rehabilitation, and social work collaborated in the complex management of each patient.

Results: Five patients presented to Rush University Medical Center between 2017 and 2019 for complications of SP. All 5 patients were actively using nonprescription opioids; 2 were concurrently undergoing treatment for opioid use disorder. Recurrent SP led to failed surgical treatment in all but 1 patient. Surgical outcome was directly related to recidivism.

Conclusion: The successful surgical management of severe sequelae of SP depends upon the successful management of the patient's addiction. Multidisciplinary care by surgical, medical, psychiatric, addiction, nursing, rehabilitation, and social work specialists is necessary to achieve a successful outcome. Based on this experience, the author's institution no longer offers nonurgent closure procedures to patients whose addiction is not well controlled.

Introduction

Skin popping (SP) is the practice of subcutaneous injection of unsterile prescribed or recreational drugs. Skin popping is a method used by chronic drug users who have exhausted superficial venous access. It has gained popularity because it requires less accurate injection and leads to slower drug absorption. The resulting experience is less of a rush with a longer high.[1,2] However, unlike intravenous injection, SP is inexact, resulting in injection to variable depths.[1,3]

In the absence of infection, SP initiates a local inflammatory response. The result of ongoing inflammation is ischemic necrosis, ulceration, and fibrosis.[4,5] In most cases, this leads to the characteristic circular scars that are often mistaken for cigarette burns early in the course of SP.[1,6] With repetitive SP, a generalized fibrotic thickening and edema is observed, as well as nonhealing ulceration. Ulcer formation does not always compel skin-poppers to seek immediate medical attention; instead, the ulcer is maintained as a shooter's patch, which permits easy SP through an open wound.[3,7]

The practice of SP commonly results in acute infectious diseases of the skin (eg, cellulitis and abscess).[8–10] Takahashi et al,[11] observed the rate of abscess formation to be as high as 72% in people who inject drugs (PWID). In addition, SP increases the risk of more dangerous and life-threatening sequelae of drug use that require combined medical and surgical intervention for cure (eg, necrotizing fasciitis, necrotizing myositis, and acute osteomyelitis).[3,7]

When sequelae of SP occur, hospitalization and surgical intervention are necessary. This leads to complications of addiction, including drug withdrawal and nonadherence with medical advice. Following hospital admission, it is a priority to prevent acute drug withdrawal and manage symptoms that contribute to drug misuse. Up to 43% of PWID leave the hospital against medical advice (AMA) unless medications for opioid use disorder (OUD) can be promptly initiated.[12] Postoperative pain control is not easily achieved in this patient population with standard opioid regimens.

Publications on the multidisciplinary management of serious complications of SP are lacking. The sparse existing research on SP focuses on the microbiology of superficial infections and offers case reports on wound care. This case series highlights the necessity of a multidisciplinary approach in the management of the sequelae of SP. This complex approach addresses the medical, surgical, psychiatric, addiction, infection, social, and rehabilitation issues associated with the dangerous practice of SP. To the authors' knowledge, there is nothing in the literature to date that reflects this approach.

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