Beyond Necrosis: Early Recognition of Xylazine-Associated Wounds in Emergency Nursing Practice

Xylazine has emerged as a common adulterant in the illicit drug supply and is increasingly associated with severe skin and soft tissue complications. Existing literature has largely focused on advanced wound presentations characterized by extensive tissue necrosis, hospitalization, and surgical intervention. Although these presentations are clinically significant, they may not reflect the full spectrum of xylazine-associated wounds encountered in emergency nursing practice. Early-stage lesions may present as subtle findings, including superficial ulcerations, papules, pustules, bumps, or multifocal blistering, and may be identified incidentally during clinical encounters. Multiple factors may contribute to underrecognition of these early presentations, including limited clinician familiarity, competing priorities in high-acuity settings, and stigma experienced by individuals with substance use disorders. Delayed recognition may allow progression to more advanced tissue injury requiring intensive treatment. Emergency nurses are uniquely positioned to identify early wound manifestations through routine assessment, trauma-informed communication, and integration of harm reduction principles into care. Increased awareness of early wound characteristics may facilitate earlier recognition, patient education, wound management, and referral to ongoing services. This article reviews current literature on xylazine-associated wounds, highlights distinctions between early and advanced presentations, and discusses implications for emergency nursing practice.