Surgical Management of Xylazine-Associated Wounds: A Retrospective Review and Algorithmic Approach

Xylazine is a veterinary sedative that is added to illicit fentanyl to prolong its euphoric effects. When injected subcutaneously, xylazine causes large, necrotic wounds. In 2023, the White House designated fentanyl adulterated with xylazine as an emerging US public health threat. To date, the optimal surgical management of xylazine-associated wounds is not well understood.

A total of 66 inpatient plastic and orthopedic surgery consultations for xylazine-associated wounds at an academic center in the northeast United States between 2018 and 2023 were reviewed. Following IRB exemption, charts were identified through report generation in Epic Systems. Categorical variables were compared using Fisher's exact test with significance set at P  < 0.05. A treatment algorithm was developed.

Wounds were located on the arm/forearm (54.5%), lower extremity (47.0%), hand (33.3%), neck (7.6%), chest (3.0%), and abdomen (1.5%). 69.7% presented with a chronic wound (>3 months). 20.0% presented with exposed bone. 65.2% presented with acute infection: 47.0% cellulitis, 24.2% osteomyelitis, 22.7% abscess, and 9.1% sepsis. One patient (1.5%) presented with an NSTI and was debrided urgently. Management included local wound care alone (45.5%), surgical debridement alone (22.7%), skin grafting (19.7%), skin substitute (10.6%), local tissue rearrangement (3.0%), free flap (3.0%), and amputation (9.1%). 72.7% continued to inject after initial treatment, 13.6% stopped injecting, and 13.6% were lost to follow-up. By study completion, 25.8% fully healed their wound, and 27.3% partially healed. 13.0% (3/23) of patients treated with wound care fully healed, compared to 21.4% (3/14) of those treated with debridement alone ( P  = 0.65). Among those who continued to inject, 20.4% (9/44) fully healed, compared to 75.0% (6/8) of those who stopped injecting ( P  = 0.005). Reconstructive procedures were successful in 50% (7/14).

Xylazine-associated wounds occur on all parts of the body. Substance use rehabilitation is associated with healing. Local wound care is effective for chronic, noninfected wounds. A staged reconstructive approach is preferred once the patient is optimized. An algorithm for multidisciplinary management is beneficial for standardizing care.