Letter Regarding “Xylazine-Associated Wounds of the Upper Extremity: Evaluation and Algorithmic Surgical Strategy”

Evaluation and Algorithmic Strategy" by Tosti et al 1 with great interest.Our practice has seen a significant spike in these wounds, and our experience closely parallels that of Tosti et al 1 and Soderquist et al 2 We commend these authors for drawing attention to the rising prevalence of xylazine-associated wounds that will likely begin to emerge across the nation. 3,4he algorithm proposed by Tosti et al closely aligns with our current treatment protocol.From 2021 to 2023, our practice has managed over 100 patients with wounds associated with xylazine injections.The natural history begins with small, superficial, and scattered wounds with intervening areas of normal, at-risk skin.With continued injections, the intervening normal skin becomes necrotic and coalesces with the smaller adjacent wounds to create large, deep, confluent wounds before circumferentially encompassing the extremity.The most common location of these wounds is the dorsal aspect of the forearm, followed by the hand, wrist, and digits.Up to 20% to 30% of our patients have sensory or motor deficits, tendon ruptures, and/or contractures.Additionally, we have performed surgery on 60% of the patients presenting to our care, and 13% have received amputations.Although most patients present as interfacility transfers, reconstructive efforts are limited and prone to failure due to the lack of follow-up, leaving the hospital against medical advice, and continued drug use.The Jefferson Addiction Multidisciplinary Service was created by our hospital system to provide an inpatient team to coordinate the overall care of these patients, which is vital to successfully managing their upper extremity wounds.We applaud the efforts of Tosti et al to summarize the current understanding of xylazine-associated upper extremity wounds, but further collaborative efforts are needed to determine the optimal treatment strategy in this challenging patient population.