Table 75.1

Infections associated with drug abuse are presented in Table 75.2. A variety of cutaneous drug reactions can also develop, such as morbilliform or fixed drug eruptions, urticaria, small vessel vasculitis, and Stevens–Johnson syndrome/toxic epidermal necrolysis.

IV, intravenous; LSD, lysergic acid diethylamide; SC, subcutaneous.

Fig. 75.1 Injection sites (‘skin tracks’) in an intravenous drug user. There is overlying hyperpigmentation and scarring of veins due to inflammation from repeated nonsterile injections as well as injections of irritating drugs and adulterants. Courtesy, Mark Pittelkow, MD.

Fig. 75.2 ‘Skin popping’ scars. A–C Multiple circular depressed scars, some with rims of post-inflammatory hyperpigmentation, admixed with circular hemorrhagic crusts overlying ulcerations. Cocaine was injected into the thighs. A, Courtesy Miguel Sanchez, MD; B, C, Courtesy, Mark Pittelkow, MD.

Fig. 75.3 Retiform purpura due to levamisole-adulterated cocaine. A, B The earlobe is a common site of involvement and purpuric lesions of the earlobe had been described previously as a side effect of levamisole. At the time of writing, up to 70% of the cocaine in the United States contained levamisole, compared to <3% of the heroin. Courtesy, Jeffrey Callen, MD.

Fig. 75.4 Atrophic depressions on the thighs and extensive calcification from multiple pentazocine injections. The calcified areas are firm upon palpation. Courtesy, Mark Pittelkow, MD.

Fig. 75.7 Coma bulla. Large bulla with subsequent erosion on the medial ankle due to a prolonged coma from barbiturate overdose. Courtesy, Mark Pittelkow, MD.

Fig. 75.8 Cellulitis of the lower extremity in an intravenous drug user. Courtesy, Mark Pittelkow, MD.

Fig. 75.9 Necrotizing fasciitis of the upper extremity with extensive tissue necrosis in an intravenous drug user. Surgical debridement has been performed. Courtesy, Mark Pittelkow, MD.

Fig. 75.6 Multiple excoriations in a cocaine addict. The patient felt ‘crawling’ in his skin. Courtesy, Mark Pittelkow, MD.

Fig. 75.5 Foreign body granuloma formation leading to papules at the sites of injection of adulterated heroin. Courtesy, Mark Pittelkow, MD.

Fig. 75.10 Bruising and petechiae. A, B Bruising and petechiae of the pinna and post-auricular area in a 6-year-old boy, consistent with a hand slap by an adult. C Bruising from a belt and belt buckle on the back of an 8-year-old boy. A, B, From Hobbs CJ, Wynne JM. Physical Signs of Child Abuse. © 2001 WB Saunders; C, Courtesy, Sharon Ann Raimer, MD.

Fig. 75.11 Injuries produced by burns. A Cigarette burn. B Bullae and erosions due to dunking in hot water, with a sharp line of demarcation on the arm (arrow; ‘glove/stocking’ distribution). ‘Donut-type sparing’ on the child’s buttocks may be seen when the buttocks are held against the cooler tub while water scalds the surrounding immersed skin. Courtesy, Sharon Ann Raimer, MD.

Table 75.3

Fig. 75.12 Cutaneous disorders that may be misdiagnosed as physical or sexual abuse. A Linear hyperpigmented streaks due to phytophotodermatitis on the back of a 2-year-old girl; the mother had lime juice on her hand when she touched the child. B Genital lichen sclerosus may have associated purpura or hemorrhagic bullae. C Cutaneous Crohn’s disease can present with vulvar erythema and swelling as well as perianal ulcers. D A perianal pyramidal protrusion in the typical location, just anterior to the anus in the midline. This finding is most common in infant girls. A, Courtesy, Anthony J. Mancini, MD; B, Courtesy, Sharon Ann Raimer, MD; C, D, Courtesy, Julie V. Schaffer, MD.