10.5826/dpc.1204a154
Introduction: Drug abuse has been taking a great toll on the health and well-being of the community for the past few decades. Substance abuse can lead to several cutaneous manifestations both direct injury by the offending drug or the practices of drug usage causing secondary damage to the skin. The early recognition of these signs is of utmost importance to prevent long-term complications.
Objectives: To study the clinical-epidemiological profile of the skin diseases in Injecting Drug Users (IDU) attending Oral Substitution Therapy (OST) center and assess the psychological impact of skin conditions in IDUs attending oral substitution therapy center.
Methods: This cross-sectional observational study involved 100 IDUs enrolled from the OST center who were subjected to brief history taking and clinical and dermoscopic evaluation of skin lesions. Dermatological quality of life index (DLQI), Depression, Anxiety, Stress Scale (DASS), and WHO-QoL questionnaire were used to evaluate the impact of skin lesions on Psycho-social health and quality of life of IDUs.
Results: Cutaneous lesions ranged from track marks to severe ulcerations and scarring. Mucosal lesions also took a toll on several Patients. Patients had varying degrees of anxiety, depression, and mental stress.
Conclusions: Injecting Drug Abusers are prone to acquire Skin diseases due to injury caused by drugs as well as by drug practices adopted and the degree of neglect may worsen these conditions. These cutaneous lesions hamper the quality of life and cause psychosocial disturbances.
text/xml
2160-9381
1985
en
none Mankaranpreet
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
track marks
Clinico-Epidemiological Aspects of Cutaneous Lesions in Injecting Drug Users Visiting an Oral Substitution Therapy Centre: A Cross-Sectional Study  
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-08-24
2022-10-31
2022-11-29
e2022154
Dermatol Pract Concept
Introduction: Drug abuse has been taking a great toll on the health and well-being of the community for the past few decades. Substance abuse can lead to several cutaneous manifestations both direct injury by the offending drug or the practices of drug usage causing secondary damage to the skin. The early recognition of these signs is of utmost importance to prevent long-term complications.
Objectives: To study the clinical-epidemiological profile of the skin diseases in Injecting Drug Users (IDU) attending Oral Substitution Therapy (OST) center and assess the psychological impact of skin conditions in IDUs attending oral substitution therapy center.
Methods: This cross-sectional observational study involved 100 IDUs enrolled from the OST center who were subjected to brief history taking and clinical and dermoscopic evaluation of skin lesions. Dermatological quality of life index (DLQI), Depression, Anxiety, Stress Scale (DASS), and WHO-QoL questionnaire were used to evaluate the impact of skin lesions on Psycho-social health and quality of life of IDUs.
Results: Cutaneous lesions ranged from track marks to severe ulcerations and scarring. Mucosal lesions also took a toll on several Patients. Patients had varying degrees of anxiety, depression, and mental stress.
Conclusions: Injecting Drug Abusers are prone to acquire Skin diseases due to injury caused by drugs as well as by drug practices adopted and the degree of neglect may worsen these conditions. These cutaneous lesions hamper the quality of life and cause psychosocial disturbances.
none Mankaranpreet
2022/10/31
10.5826/dpc.1204a154
e2022154
Department of Psychiatary, Government Medical College, Amritsar, Punjab, India.
2160-9381
track marks
en
e2022154
Clinico-Epidemiological Aspects of Cutaneous Lesions in Injecting Drug Users Visiting an Oral Substitution Therapy Centre: A Cross-Sectional Study  
https://dpcj.org/index.php/dpc/article/download/1985/1760
       Clinico-epidemiological Aspects of Cutaneous
      Lesions in Injecting Drug Users Visiting an Oral
      Substitution Therapy Centre in Northern India:
                  A Cross-Sectional study
               Shaminder Singh Dhillon1, Tejinder Kaur1, Neeru Bala1, Mankaranpreet1


1 Department of Skin & VD, Government Medical College, Amritsar, Punjab, India
2 Deparment of Psychiatry, Government Medical College, Amritsar, Punjab, India



Key words: intravenous drug users, oral substitution therapy centers, skin manifestations, dermoscopic findings
Citation: Dhillon SS, Kaur T, Bala N, Mankaranpreet. Clinico-epidemiological aspects of cutaneous lesions in Injecting Drug Users visiting
an Oral Substitution Therapy Centre in Northern India: a cross-sectional study. Dermatol Pract Concept. 2022;12(4):e2022154.
DOI: https://doi.org/10.5826/dpc.1204a154
Accepted: March 3, 2022; Published: October 2022
Copyright: ©2022 Dhillon et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Tejinder Kaur, Professor & Head, Department of Skin & VD, Government Medical College, Amritsar, Punjab,
India. E-mail: tejinderkaurdr@gmail.com




  ABSTRACT             Introduction: Drug abuse has been taking a great toll on the health and well-being of the community
                       for the past few decades. Substance abuse can lead to several cutaneous manifestations as direct inju-
                       ries by the offending drug or the practices of drug usage cause secondary damage to the skin. The early
                       recognition of these signs is of utmost importance to prevent long-term complications.
                       Objectives: To study the clinical-epidemiological profile of the skin diseases in Injecting Drug Users
                       (IDU) attending an Oral Substitution Therapy (OST) Center in Northern India and to assess the psy-
                       chological impact of skin conditions in IDUs attending OSTs.
                       Methods: This cross-sectional observational study involved 100 IDUs enrolled from the OST center
                       who were subjected to brief history taking and clinical and dermoscopic evaluation of skin lesions.
                       Dermatological quality of life index (DLQI), Depression, Anxiety, Stress Scale (DASS), and WHO-
                       quality of life (QoL) questionnaire were used to evaluate the impact of skin lesions on psycho-social
                       health and QoL of IDUs.
                       Results: Cutaneous lesions ranged from track marks to severe ulcerations and scarring. Mucosal lesions also
                       took a toll on several patients. The patients had varying degrees of anxiety, depression, and mental stress.
                       Conclusions: Injecting Drug Abusers are prone to acquire skin diseases due to injury caused by drugs
                       as well as by drug practices adopted and the degree of neglect may worsen these conditions. These
                       cutaneous lesions hamper QoL and cause psychosocial disturbances.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022154                                                                           1
Introduction                                                     1. Injection-related effects: most commonly encountered le-
                                                                    sions in Injecting Drug Users (IDU) are the track marks
The WHO defines Drug abuse/Substance abuse as harm-                 mostly seen on the arms and especially over the ante-
ful or hazardous use of psychoactive substances, including          cubital fold [6]. These represent the sclerosed vessels re-
alcohol and illicit drugs. Psychoactive substances are the          sulting from localized thrombophlebitis due to an irritant
pharmacological agents that alter the behavioral, cognitive,        drug being abused and extravasated. The dark color at
and physiological changes in the body that, on repeated             the site is due to the post-inflammatory hyperpigmen-
use, lead to a phenomenon referred to as dependence syn-            tary changes occurring in the skin with an underlying
drome. This includes a strong desire for the drug, impulse,         affected vessel.
and repeated use despite harmful effects. A high priority is        Skin popping: Administering drugs into the skin may
given to drug use than to other activities and obligations,         result in deep punched out ulcers which heal with atro-
increased tolerance, and sometimes a physical withdrawal.           phy. These ulcers usually get secondarily affected to form
No part of the world is free of drug abuse in the current           large ulcers which heal slowly [7].
times [1]. The advent of globalization has led to several        2. Infections: skin and soft tissue infections are common
variations in the culture and economic backgrounds in In-           in IDUs due to their injection practices and weakened
dian population. Alongside positive implications, certain           immune systems. Staphylococcus aureus and streptococ-
social drawbacks like substance abuse are an important              cal species which are normal commensals over skin en-
measure to be taken care of. Several criminal acts and an-          ter the deeper tissues resulting in abscesses and cellulitis
tisocial behaviors have been associated with drug abuse             [8]. Moreover there are several impurities and adulter-
[2]. Several steps and special task forces are being gener-         ants in drugs that have deleterious effects on skin struc-
ated by the Indian government at both the national and              tures. Several uncommon pathogens such as Clostridial
state level. Despite all the measures taken by the govern-          and Eiknella which reside in the oral cavity can result
ment and society drug abuse is one of the leading causes            in superficial and deep-seated abscesses. Wound botu-
of crime in India. India is surrounded by the world's lead-         lism, necrotizing fasciitis and tetanus can occur due to
ing illicit drug-producing countries namely Thailand, Laos,         clostridial toxins usually in the skin poppers in whom
and Myanmar constituting the golden triangle on the east-           inoculation of bacilli occurs in relatively anaerobic con-
ern side. Similarly, Afghanistan, Iraq, and Pakistan which          ditions such as skin which favors their growth and toxin
constitute the golden crescent are located on the western           production [9,10]. Use of nonsterile needles poses cer-
borders of the nation. Thereby the incidence of substance           tain threats of various viral infections including Human
abuse is on the rise especially in states like Punjab which         immunodeficiency virus (HIV) and Hepatitis B and C
is has close geographic contact with the above-mentioned            viruses [11]. These infections can have various skin man-
western border [3]. Drug abuse has several implications on          ifestations ranging from acute maculopapular rash to
human health and society. These include a weak immune               chronic skin diseases [12,13].
system, increasing rates of malnutrition, and related dis-       3. Vascular complications: repeated trauma to the veins
orders due to neglect, weight, and appetite loss. The tox-          leads to vessel wall changes causing thrombophlebitis
icity of these drugs can lead to several lhepatic and heart         and venous thrombosis. This leads to venous incompe-
diseases. Neuronal damage may result in behavioural and             tence and ulcerations may ensue. Furthermore, lymphatic
cognitive disorders [4].                                            drainage may get compromised due to lymphatic damage
    Besides involving these systems, substance abuse can lead       deteriorating the picture and leading to chronic edema of
to several cutaneous manifestations as well which could be          the limb [14].
either due to direct injury by the offending drug or the prac-      Accidental intra-arterial injections may result in ischemic
tices of drug usage can cause secondary damagse to the skin      changes due to drugs or adulterants. Some of the drugs such
structure or even a presentation of medical complication due     as cocaine are vasoconstrictors that can result in vasospasms
to drug abuse visible on the skin [5]. The early recognition     and compromising the blood supply to a unit resulting in
of these signs is of utmost importance to prevent long-term      its necrosis. Drug-induced vasospasm and thrombosis may
complications like necrosis. To ease the understanding, we       result in acute pain and burning sensation in the limb and
have tried to classify the presentations.                        further leading to edema and cyanosis. Scrotal necrosis is
                                                                 seen in pudendal artery thrombosis [15]. There are reports
Classification of Skin Manifestations:                           of penile ulceration following drug administered into dorsal
a. Injection-related/local effects.                              penile vein [16]. Intravenous abuse of cocaine may result in
b. Infections: superficial, deep, viral disease transmission.    secondary Raynaud phenomenon and digital ulcerations and
c. Vascular complications.                                       infarction in organs like the liver and kidney.



2                                                                    Original Article | Dermatol Pract Concept. 2022;12(4):e2022154
    Pseudoaneurysms and mycotic aneurysms can develop             conditions. Secondly, the Depression, Anxiety, Stress Scale
following vascular injuries and infections may develop in         (DASS) questionnaire for assessing the psychological sta-
the vessel walls. A pulsatile or non-pulsatile mass may be        tus of patients on de-addiction therapy was filled. Thirdly,
seen in the distribution of a vessel which may be wrongfully      a WHO QoL index questionnaire was used to look into the
considered as an abscess and if incised may result in fatal       overall QoLof these patients visiting the OST center. At last,
outcomes [17]. These aneurysms are generally infected by          the results were tabulated and statistically analyzed.
bacteria such as staphylococcus and streptococcus species.
In some instances, Candida albicans may be the infectious
                                                                  Results
agent [18].
                                                                  In our study, we observed that the mean age of the IDUs

Objectives                                                        was 30.08 with a majority in the age group of 21-30 years.
                                                                  Among the study group, 98 were males and 2 were females.
Primary Objective                                                 Laborers accounted for the majority being 33% and 17 were
1. To study the clinical-epidemiological profile of the skin      drivers; the rest of the IDUs had several other professions.
    diseases in IDUs attending Oral Substitution Therapy          All the IDUs had heroin abuse while 8 had concomitant co-
    (OST) center in Northern India.                               caine and 3 had cannabis addiction as well. The mean dura-
                                                                  tion of drug abuse among the IDUs was 8.34 years while the
Secondary Objectives                                              maximum duration of injectables observed for the past was
1. To assess the socio-demographic profile of IDUs.               1 to 5 years. In the study group, the last dose of the abused
2. To assess the psychological impact of skin conditions in       drug taken was less than one month in 76% while others
    IDUs attending oral substitution therapy center.              had a lapse time of more than 1 month. Among the IDUs,
3. To assess the quality of life (QoL) of IDUs attending oral     99 were being managed with buprenorphine and naloxone
    substitution therapy center.                                  combination sublingual tablets and one was being given oral
                                                                  methadone. The literacy rate varied from 12/100 being illit-

Methods                                                           erate to 8/100 being graduate (with a graduation degree in
                                                                  any field) and the rest had education level between primary
A total of 100 IDUs visiting the OST center at the Govern-        to senior secondary education. Thirty-eight patients had in-
ment Medical College, Amritsar, in Northern India who met         come less than 10,000, 50 had 10,000 to 20,000 and 12 had
the inclusion criteria were randomly enrolled in the study.       more than 20,000 Indian rupees. Fifty-two IDUs were un-
Inclusion criteria:                                               married, 46 were married and 2 were divorced. A history of
                                                                  smoking was present in 57/100, while 82/100 were alcohol-
1. IDUs of both sex and aged more than 18 years.                  ics. Of the 100 IDUs, 80 were positive for hepatitis C virus
2. IDUs visiting OST centers who gave consent for the study.      (HCV) infection, 10 had HIV infection and among them, 9
                                                                  had concomitant HCV and HIV positivity. One among them
Exclusion criteria:                                               had type 1 insulin-dependent diabetes mellitus, 1 was hyper-
                                                                  tensive, 1 had chronic kidney disease (Tables 1 and 2).
1. IDUs of drug abuse employing routes other than                    In the study group, 84 patients had black-colored spots
    intravenous.                                                  and scars over their body, 34 reported a history of chronic
2. IDUs not giving consent for the study.                         itching and 6 had ulcers over various body parts. The dura-
3. IDUs with other primary dermatoses.                            tion of these complaints ranged from few months to several
4. IDUs with organic mental disorders or known significant        years. These lesions were clustered around upper limbs in
    medical conditions.                                           88% of all followed by 8% over lower limbs and 4% over
                                                                  the other body parts. Eight patients had a history of concom-
    After signing written informed consent, a brief history re-   itant joint pains. Among these patients, 38% received topi-
garding their drug abuse – duration, type of drug, and route      cal or oral treatment. The commonly used topical agent was
of administration - was enquired from patients. History of        clobetasol cream and an oral agent was an antihistamine.
any skin disease before IDU abuse was asked. A thorough           Seven patients were on Highly Active Anti Retro Viral Ther-
clinical examination was done after full body exposure. Bed-      apy (HAART) and 2 were taking Anti Hepatitis C therapy
side tests for skin diseases if required were done. Lesions       (lepidasvir and sofosfubivir).
were examined clinically and with dermoscope as well.                On examination, 92 patients had track marks, 54 had
    Questionnaires regarding the Dermatological QoL In-           hesitation marks, 53 had tattoos while small round atrophic
dex (DLQI) were filled to know about the impact of skin           scars were present in all the patients. Scabies was the most



Original Article | Dermatol Pract Concept. 2022;12(4):e2022154                                                                3
      Table 1. Socio-Demographic Profile of the         Table 2. Chronic conditions and co-morbidities
    injecting drug users visiting Oral Substitution                 in injecting drug users.
                   Therapy centers.                             Past Illness            N of cases       Percentage
         Age (Years)        N. of cases   Percentage    Chronic kidney disease                1              1.0%
< 20                             4          4.0%        Hip joint surgery                     1              1.0%
21-30                           53         53.0%        Pulmonary tuberculosis                1              1.0%
31-40                           38         38.0%        Type-1 diabetes                       1              1.0%

> 40                             5          5.0%        Urticaria                             1              1.0%

Sex                                                     Urinary tract infection               1              1.0%
                                                        None                                 94             94.0%
Female                           2          2.0%
                                                        Diabetes mellitus
Male                            98         98.0%
                                                        None                                 99             99.0%
Address (Rural/Urban)
                                                        Present                               1              1.0%
Rural                           21         21.0%
                                                        Hypertension
Urban                           79         79.0%
                                                        None                                 99             99.0%
Marital Status
                                                        Present                               1              1.0%
Divorced                         2          2.0%        HIV
Married                         46         46.0%        Negative                             90             90.0%
Unmarried                       52         52.0%        Positive                             10             10.0%
Education                                               HBsAg                          No. of cases       Percentage
Diploma                          2          2.0%        Negative                           100            100.0%
Elementary                      18         18.0%        HCV                             No. of cases      Percentage
Graduate                         8          8.0%        Negative                             20             20.0%

Illiterate                      12         12.0%        Positive                             80             80.0%

Matriculation                   23         23.0%       HBsAg = hepatitis B surface antigen; HCV = hepatitis C virus; HIV
                                                       = human immunodeficiency virus.
Primary                         24         24.0%
Senior Secondary                13         13.0%
(post matriculation)                                   common skin disease affecting 23 patients of which nine
Income (in Rupee)                                      had nodular lesions as well. Superficial dermatophytosis was
< 5000                          11         11.0%       seen in 12 patients. Six patients had facial melanosis, 4 had
                                                       intertrigo, 2 had acne vulgaris and 2 had balanitis. Other
5000-10000                      27         27.0%
                                                       skin and soft tissue ailments present were hyperhidrosis,
> 10000                         62         62.0%
                                                       urticaria, thrombophlebitis, acneiform eruptions, verrucae,
Drug Abused
                                                       and genital herpes (Table 3).
Cocaine and heroin               8          8.0%          Angular cheilitis was seen in 2 patients, 45 had pigmen-
Heroin                          89         89.0%       tation over lips and seven had depigmented patches over the
Heroin and cannabis              3          3.0%       lips. Examination of buccal mucosa revealed bluish-black
Duration of abuse (years)                              pigmentation in 77 patients and erosions in five ones. Dirty
                                                       yellowish-brown staining over teeth was present in 69 pa-
0-5.0                           29         29.0%
                                                       tients and 2 had dental caries. On examination of the gin-
6-10.0                          47         47.0%
                                                       givolabial sulcus, 33 had pigmentary changes, 24 had Sub
> 10                            24         24.0%       Mucosal Fibrosis, 8 had leukoplakia and 3 had cobble-
Treatment given                                        stone mucosa.
Buprenorphine                   99         99.0%          Hair examination revealed trichomycosis in 2 patients,
Methadone                        1          1.0%       generalized sparsity in 2 subjects, and andro-genetic alopecia
                                                       in 1. Longitudinal melanonychia was the most common nail
Smoking
                                                       abnormality observed seen in 29 IDUs. A brownish discol-
Absent                          43         43.0%
                                                       ored nail plate was seen in 4 IDUs, 3 ones had dystrophic
Present                         57         57.0%
                                                       nails, 2 had koilonychia and 1 had paronychia (Table 4).



4                                                          Original Article | Dermatol Pract Concept. 2022;12(4):e2022154
                           Table 3. Skin conditions encountered in injecting drug users.
                     Skin Lesions Description                     N of cases               Percentage
 Track Marks                                                          92                     92.0%
 Atrophic Scars                                                      100                    100.0%
 Hesitation Marks                                                     54                     54.0%
 Tattoos                                                              53                     53.0%
 Others
 Acne vulgaris                                                         2                      2.0%
 Acneiform eruptions, intertrigo                                       1                      1.0%
 Atrophic scars in groins and nodular scabies                          1                      1.0%
 Balanitis                                                             2                      2.0%
 Cholinergic urticaria                                                 1                      1.0%
 Extensive Tinea corporis                                              1                      1.0%
 Facial melanosis                                                      5                      5.0%
 Folliculitis, scabies                                                 2                      2.0%
 Herpes genitalis                                                      1                      1.0%
 Hyperhidrosis, tightness of skin                                      1                      1.0%
 Intertrigo                                                            2                      2.0%
 Intertrigo, facial melanosis                                          1                      1.0%
 Keratosis pilaris                                                     1                      1.0%
 Large atrophic scars on bilateral thighs                              1                      1.0%
 Mottled pigmentation and hyperkeratosis on palms                      1                      1.0%
 Post herpetic zosteriform scars                                       1                      1.0%
 Scabies                                                              11                     11.0%
 Scabies and acne corporis                                             1                      1.0%
 Scabies nodular                                                       8                      8.0%
 Scars in groin and pubic region                                       1                      1.0%
 Sebaceous cysts scrotum                                               1                      1.0%
 Seborrheic keratosis and facial melanosis                             1                      1.0%
 Soft tissue swelling                                                  1                      1.0%
 Thrombophlebitis                                                      1                      1.0%
 Tineacorporis Cruris and facial melanosis                             1                      1.0%
 Tineacorporis Cruris and ulcer on right palm, soft tissue             1                      1.0%
 swelling on right arm
 Tinea corp., scabies with folliculitis                                1                      1.0%
 Tineacorporis                                                         1                      1.0%
 Tineacorporis with ulcers                                             1                      1.0%
 Tineacruris                                                           1                      1.0%
 Tineacruris, facial melanosis                                         1                      1.0%
 Trichomycosis                                                         1                      1.0%
 Ulcer non-healing on left leg                                         1                      1.0%
 Ulcer on arm                                                          1                      1.0%
 Ulcer over hand and facial melanosis                                  1                      1.0%
 Ulcers on left forearm                                                1                      1.0%
 Ulcers on thighs, hands and feet, xanthelasmapalpebrum                1                      1.0%
 Warts on hands                                                        1                      1.0%
 None                                                                 37                     37.0%
 Total                                                               100                    100.0%




Original Article | Dermatol Pract Concept. 2022;12(4):e2022154                                          5
                 Table 4. Oral and skin appendageal conditions seen in injecting drug users.
                            Mucosal Lesions_Lips                             No. of cases             Percentage
 Angular cheilitis                                                                   2                     2.0%
 Depigmented patches                                                                 7                     7.0%
 Discoloration                                                                      45                    45.0%
 None                                                                               46                    46.0%
 Total                                                                            100                   100.0%
 Buccal mucosa lesions
 Erosions                                                                            1                     1.0%
 Pigmentation                                                                       77                    77.0%
 None                                                                               22                    22.0%
 Total                                                                            100                   100.0%
 Mucosal Lesions_Teeth
 Caries                                                                              2                     2.0%
 Stained                                                                            69                    69.0%
 None                                                                               29                    29.0%
 Total                                                                            100                   100.0%
 Mucosal Lesions_Gingivolabial Sulcus
 Cobblestoning                                                                       3                     3.0%
 Erosions                                                                            1                     1.0%
 Gingival ulcer, SMF and pigmentation                                                1                     1.0%
 Gum recession with gingival erosion and leukoplakia                                 1                     1.0%
 Leukoplakia                                                                         7                     7.0%
 Micro erosions over labial mucosa, recession of gums                                1                     1.0%
 Pigmentation                                                                       33                    33.0%
 Pigmentation, SMF                                                                  24                    24.0%
 SMF                                                                                 6                     6.0%
 None                                                                               23                    23.0%
 Total                                                                            100                   100.0%
                                    Hair                                     No. of cases             Percentage
 Androgenetic alopecia                                                               1                     1.0%
 Sparsity                                                                            2                     2.0%
 Trichomycosis                                                                       2                     2.0%
 None                                                                               95                    95.0%
 Total                                                                            100                   100.0%
                                    Nails                                    No. of cases             Percentage
 Clubbing                                                                            1                     1.0%
 Discolored                                                                          4                     4.0%
 Dystrophic nail                                                                     2                     2.0%
 Koilonychia                                                                         2                     2.0%
 Leukonychia                                                                         1                     1.0%
 Long. Melanonychia                                                                 29                    29.0%
 Onychomycosis                                                                       1                     1.0%
 Paronychia, longitudinal Melanonychia                                               1                     1.0%
 None                                                                               59                    59.0%
 Total                                                                            100                   100.0%

SMF = submucosal fibrosis




6                                                          Original Article | Dermatol Pract Concept. 2022;12(4):e2022154
              Table 5. Psychological aspects and quality of life Parameters of injecting drug users.
      DLQI Score (Dermatology Life Quality Index)                          N of cases                      Percentage
 0-1.0                                                                            0                             0.0%
 2-5.0                                                                            26                           26.0%
 6-10.0                                                                           54                           54.0%
 11-20.0                                                                          20                           20.0%
 21-30.0                                                                          0                             0.0%
 Depression                                                               No. of cases                      Percentage
 0                                                                                90                           90.0%
 1                                                                                5                             5.0%
 2                                                                                3                             3.0%
 3                                                                                1                             1.0%
 4                                                                                1                             1.0%
 Total                                                                        100                              100.0%
 Anxiety                                                                  No. of cases                      Percentage
 0                                                                                84                           84.0%
 1                                                                                9                             9.0%
 2                                                                                4                             4.0%
 3                                                                                2                             2.0%
 4                                                                                1                             1.0%
 Total                                                                        100                              100.0%
 Stress                                                                   No. of cases                      Percentage
 0                                                                                73                           73.0%
 1                                                                                13                           13.0%
 2                                                                                9                             9.0%
 3                                                                                3                             3.0%
 4                                                                                2                             2.0%
 Total                                                                        100                              100.0%
 WHO-QOL                                                         N     Minimum           Maximum       Mean       Std. Deviation
 Age (Years)                                                 100         19.00            60.00        30.08             6.53
 Duration of Abuse (Years)                                   100           2.00           18.00         8.34             3.77
 DLQI Score                                                  100           2.00           18.00         7.88             3.28
 WHO - QOL (BREF)_Domain 1                                   100         38.00            50.00        42.92             3.75
 WHO - QOL (BREF)_Domain 2                                   100         31.00            44.00        34.35             4.92
 WHO - QOL (BREF)_Domain 3                                   100         31.00            69.00        47.06            11.69
 WHO - QOL (BREF)_Domain 4                                   100         31.00            44.00        37.50             3.89


     DLQI revealed moderate effect (score 6-10) on QoL due           (SD) of 3.75, 4.92, 11.69, and 3.89 in Domain 1, 2, 3, and 4,
to skin affection in 54% of patients, followed by mild effect        respectively (Table 5).
(score 2-5) in 26% and very large effect (score 11-20) in 20
patients. Depression Anxiety Stress Score revealed extremely
                                                                     Conclusions
severe depression in 1, severe in 1, moderate in 3, and mild
depression in 1 IDU. Anxiety observed was extreme in 1,              Drug abuse has been taking a great toll on the health and
severe in 2, moderate in 4, and mild in 9. The stress index          well-being of the community for the past few decades. A rise
showed extreme stress in 2, severe in 3, moderate in 9, and          in injecting drug abuse has been posing threat to the indi-
mild in 13.                                                          vidual health and thus to QoL. Skin is among the neglected
     WHOQ-OL questionnaire was used which gave a mean                organs among IDUs and the tendency of neglect increases
of 42.92, 34.35, 47.06, 37.50, with a standard deviation             with the duration of abuse [19]. Track marks are linear or




Original Article | Dermatol Pract Concept. 2022;12(4):e2022154                                                                     7
closely spaced needle pricks seen as black dots on the skin                Among the infections and infestations, scabies was the
overlying veins in IDUs. (Figure 1). These are among the               most common disease encountered and the level of neglect
most common and absolute signs seen in active IDUs. There              further poses a threat to its treatment. Poor hygiene is a
can be surrounding erythema or induration which depicts                significant risk factor to acquire scabies besides deranged
inflammatory reaction either due to extravasated drug or               itch-scratch cycle, relatively immune-compromised status
infection in the intradermal or subcutaneous tissue. Throm-            are other contributory factors. The diagnosis of scabies may
bophlebitis can be associated with track marks at times and            be at times missed by psychiatrists and thought to be related
can lead to cellulitis if not taken care of. On dermoscopic            to drug abuse- delusion of parasitosis [20]. In such instances
examination, these are seen as black dots or hemorrhages,              full body exposure and site-specific examination may reveal
comedones-like or plug arranged linearly with bluish-black             burrows of mite and clinches the diagnosis. Superficial der-
to the erythematous background (Figure 2). Small rounded               matophytosis, a fungal infection, is another common infec-
atrophic scars are another hallmark of injecting drug abuse.           tion encountered among IDUs which presents as round and
These are a result of skin popping that form small ulcers              annular itchy plaques over the body (Figure 3). Other infec-
which heal with atrophy. In patients with the tendency to              tions include bacterial folliculitis and infected wounds.
keloid formation, large nodular lesions may be seen instead                Viral disease transmission is common among IDUs due
of atrophic scars.                                                     to sharing of syringes due to which there is an increased rate




    Figure 1. (A) Multiple depressed scar marks over inguinal region. (B) Skin popping marks. (C) Hesitation marks. (D) Track marks.


8                                                                           Original Article | Dermatol Pract Concept. 2022;12(4):e2022154
                                                                     of incidence of viral Hepatitis and HIV-AIDS among them
                                                                     [21]. In our study, the majority of the patients were positive
                                                                     for HCV and HIV. This draws attention to checking the be-
                                                                     havior and actions of IDUs and adopting measures prevent-
                                                                     ing them.
                                                                        The oral cavity is yet another area to be stressed upon
                                                                     in IDUs as they tend to be smokers, alcoholics, and tobacco
                                                                     abusers with poor oral hygiene and the degree of neglect
                                                                     they have may pose drastic effects such as oral malignan-
                                                                     cies [22,23]. The changes observed in our studies included
                                                                     pigmentation related to nicotine and depigmented patches
                                                                     too can be toxic reactions to the melanocytes. The gingivola-
                                                                     bial mucosa was the most exploited area in the oral cavity

Figure 2. On dermoscopic examination ( 100X. ILLUCO), black
                                                                     due to the habit of keeping the tobacco pouch undersurface
dots or hemorrhages, comedones like or plug arranged linearly with   of the lip and most patients had pigmentary changes, ero-
bluish-black and brownish to reddish white background.               sions, and submucosal fibrosis and few had leukoplakia and




  Figure 3. (A) Scabies mite burrows. (B) Extensive TineaCorporis. (C) Soft tissue swelling of arm (patient was T1 DM). (D) Herpes
  genitalis.
     Figure 4. (A) Oral cavity pigmentation with caries teeth. (B) Cobble-stoning of gingivolabial sulcus with erosions. (C) Submucosal
     fibrosis with leukoplakia. (D) Gingivolabial mucosal fibrosis with ulceration.




cobble-stoning which tend to be premalignant conditions                     The study had several limitations like the fact that the
and may lead to drastic situations if not addressed accord-             confirmatory diagnosis of the skin disorders was not estab-
ingly (Figure 4).                                                       lished due to short interaction between patient and doctor
     In the assessment of QoL related to dermatological con-            and unavailability of investigations at the OST center. The
ditions, the dermatology QoL index has proven to be a good              second bias was the neglect shown by the IDUs towards skin
tool [24]. In our study, a majority of IDUs had moderately              conditions which lead to a certain degree of concealment of
hampered life quality which means the skin conditions either            skin conditions. Thirdly, many IDUs did not consent for the
due to the direct effect of drugs or secondary involvement has          full body examination leading to missing some important
brought about changes in the daily routine of IDUs which                areas of examination like genitalia and groins which are po-
can be social, psychological, or economic encroachment.                 tential sites for infections and sexually transmitted infections
     Similarly, the mental state of the patients was assessed           as well as spots of drug injection. Lastly, it was not a case
by the Depression Anxiety Stress scale which is a crude and             control study and hence statistics could not be performed;
partially objective method of assessment of the inner horizon           moreover, the number of study patients was limited. These
of patients. It revealed a significant alteration in the mental         limitations can be overcome by bringing together the two
state of the IDUs.                                                      specialties of de-addiction and Dermatology and stressing



10                                                                           Original Article | Dermatol Pract Concept. 2022;12(4):e2022154
over the need for periodic examination of the skin of IDUs                10. Cooper JG, Spike CE, Denton M, Jamieson S. Clostridium botu-
to look for any direct or indirect effects of drug abuse.                     linum: an increasing complication of heroin misuse. Eur J Emer
                                                                              Med. 005;12:251-252. DOI: 10.1097/00063110-200510000-
    Skin conditions occurring in IDUs are a result of direct
                                                                              00011. PMID: 16175065.
injury to the skin by the offending drug or by the methods
                                                                          11. Drug use and viral infections (HIV, Hepatitis) drug facts. Na-
used to introduce drug into body. Track marks resulting                       tional Institute on drug abuse.16 Jun 2020. Available from www​
from repeated intravenous drug abuse are the commonest                        .drugabuse.gov/publications/drugfacts/druguse-viral-infections,
occurrence followed by atrophic rounded scars due to drug                     accessed on September 2020
popping into the skin. Infectious conditions of the skin are              12. Altman K, Vanness E, Westergaard PR. Cutaneous manifesta-
                                                                              tions of Human immune deficiency virus: a clinical update. Curr
common which occur either because of the contaminated
                                                                              Infect Dis Rep. 2015;17(3):464. DOI: 10.1007/s11908-015-
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                                                                              0464-y. PMID: 25821188. PMCID: PMC4447481.
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well with altered mental condition of the IDUs. Drugs and                     of viral hepatitis. Dermatol Clin. 2002;20(2):233-247, vi. DOI:
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                                                                              and injection drug use. Arch Intern Med. 2007;167(16):1807.
and psychological and physical dependence further takes its
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rate to address the healthcare needs of an IDU so that timely                 penis: a complication of heroin injection into the femoral
necessary actions can be taken.                                               vessels. J Urol. 1986;136(1):111-113. DOI: 10.1016/s0022-
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022154                                                                            11
