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Patient one:

This is a 31-year-old woman with a history of intravenous drug abuse (IVDA) with wounds on the dorsal surface of both hands. These lesions, where she previously injected heroin, progressed over several months. They began as erythema with associated pain and advanced to solitary ulcers. She denied the use of any other substances and was certain that her dealer used fiber supplements as a bulking agent. On presentation, there was marked erythema and significant tenderness around the lesions as seen in Figure 1.
The remainder of her physical exam was normal, her nails look dirty AF

Patient two:

This is a 44-year-old woman with a history of IVDA with wounds on the ventral aspects of her upper and lower extremities. These lesions, where she previously injected heroin, progressed over weeks. They began with erythema and associated pain. Over time, ulcerations developed, which began to coalesce with necrotic tissue and large alternating black and brown scales as seen in Figure 2. The remainder of her physical exam was normal.

Patient three:

This is a 31-year-old man with a history of IVDA with multiple wounds on the dorsal aspect of his bilateral upper extremities. These lesions began as erythema and pain at sites of “gray heroin” injection, which progressed to scattered ulcerations. On discovering the lesions, he attempted a home debridement with a knife and pair of scissors. At presentation, there was marked erythema around most of the ulcers and multiple, contained, black necrotic tissue as seen in Figure 3. Tissue debridement showed MRSA infection and necrosis without vasculitis. He received IV antibiotic therapy and underwent a skin grafting procedure.


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