Xylazine-induced Skin Necrosis, Emerging Public Health Crisis and the Ethical Considerations in Surgical Reconstruction: A Case Report

Xylazine, a non-opioid veterinary sedative, is increasingly being used to adulterate illicit fentanyl. Injection into the extremities causes progressive necrotic wounds, resulting in a compromised limb and life. Managing xylazine-induced skin necrosis may require extensive surgical intervention, including serial debridements and soft tissue reconstruction. Moreover, managing these complex wounds requires a multi-disciplinary approach, including hospital medicine, infectious disease, psychiatry, addiction medicine, pain/palliative care, ethics, wound care, orthopedic surgery, and plastic surgery. A 38-year-old female with a history of intravenous drug use presented with severe bilateral dorsal forearm wounds, and despite initial non-compliance with surgical debridement, she eventually underwent successful skin grafting after extensive treatment, including antibiotics and negative pressure therapy, but was later lost to follow-up. She relapsed into fentanyl use, leading to severe bilateral lower extremity wounds requiring further debridement and skin grafting, and later returned with new forearm wounds, at which point further reconstruction was deemed inappropriate without addressing her addiction; she refused inpatient rehabilitation and ultimately being lost to follow-up again.