Thu. Jul 7th, 2022

The Dermatology of Addiction

Drug addiction is a topic that tends to spark conversation about psychosocial matters, and while drugs are notorious for having profound effects on all organs of the body, a number of different physical manifestations associated with drug abuse are often not known nor discussed.

“There are so many tell-tale signs of drug abuse in the skin that a lot of dermatologists don’t pick up on,” said Dr. Navid Ezra, a dermatologist in Thousand Oaks, California. “In my training, I have seen dermatologists recognize these signs and not address it with the patient. So, really they’re doing a disservice there.”

Dr. Ezra recently conducted a research that provided an overview of crucial dermatologic indicators of different types of drug use.

His research found that some of the most common general signs of substance use come from intravenous drug administration and infectious/vascular complications, but there are other signs to look out for, as well.


The psychoactive chemical components found in cannabis may have an innocent reputation when compared to other toxic substances, but they’re also responsible for skin problems.

“Cannabis can cause vessel constriction,” Dr. Ezra said. “Vessel constriction in the fingers can cause spasms and also cause this really cold feeling in your hands, so you can develop ulcers or ischemia, which is the lack of blood to the fingertips.”

One of the most serious cannabis-related conditions is cannabis arteritis, in which necrotic lesions/ulcers don’t stop bleeding and never heal. The condition happens because cannabis widens the blood vessels, while tetrahydrocannabinol (THC) – the main mind-altering ingredient found in cannabis – is a muscle relaxer that relaxes the arteries, resulting in lower blood pressure and increased blood flow to tissues.

The first case of cannabis arteritis was reported in the 60s and the condition remains not widely known. But studies suggest that it “may prove not to be so rare if one considers consumption of cannabis besides that of tobacco.”

Cannabis arteritis can result in limb amputation. But if diagnosed early, it can be treated with balloon catheters – however, patients will likely need to maintain a lifetime medication regime.

Dr. Ezra highlighted that cannabis arteritis is often misdiagnosed as atherosclerosis or blockage of artery walls. On the other hand, his research suggested that marijuana may provide benefits to the skin and that cannabinol has been proven to have antiproliferative effects that can decrease the production of sebum, which may be useful in acne treatment.

“There are a lot of compounds in cannabis,” Ezra said. “THC is the most well-known but there are a lot of other illicit and non-illicit preservatives in cannabis, and there are a lot of cutaneous manifestations that go along with both the THC and some of the other compounds that are within cannabis.”

Stigmata of injection drug use (IDU)

Injection marks are very common indicators of intravenous drug use. ‘Track marks’ are in fact the marks of post-inflammatory hyperpigmentation that can be seen at drug injection sites, where the underlying veins were damaged.

Drugs are normally injected into veins of the non-dominant arm and injection marks left behind can be easily disguisable with clothing. Naturally, the most commonly damaged area is the antecubital fossa – the triangular cavity of the elbow. When those veins become too damaged and inaccessible, users tend to try subcutaneous or intramuscular drug administration, or ‘skin-popping,’ which normally causes bacterial tissue trauma and often results in deep, atrophic scars or keloids.

Some of the most common complications from IDU are skin and soft tissue infections (SSTIs) such as abscesses and cellulitis.

Abscesses, or boils, are painful and swollen lumps filled with pus. Cellulitis is an infection that happens when bacteria spreads through the inner layers of skin, so affected areas ache and look swollen and red.


In addition to skin complications caused by IDU, other common issues for heroin users are morbilliform (a rash that looks like measles) and chronic itching of the body or genital areas, which usually happens after heroin use, and can last several days.

Treatable conditions like acanthosis nigricans (dark, thick patches in body creases) as well as deadly bacterial infections such as necrotizing fasciitis (flesh-eating disease) have been reported among heroin users, but are especially common among black tar users.

A Brazilian Society of Dermatology study states that “in the early 1980s, a novel epidemic of pigmented tongue lesions, clinically and histologically consistent with fixed drug eruption, was described in Holland. All patients shared the habit of smoking heroin.”

The study focused on how the consumption of illicit drugs triggers premature aging, atrophic crinkling, and livedo reticularis, a condition that causes purplish, reddish discoloration of the skin and tissues.

“Skin discoloration is very common among drug abusers,” said Dr. Aline Henriques, a Rio de Janeiro-based dermatologist. “But more serious problems, such as bacterial abscesses and tissue necrosis, arise when drugs like heroin are injected.”


While heroin injection normally causes skin damage and bacterial infection, intravenous use of cocaine tends to cause skin discoloration from internal bleeding, also known as ecchymosis.

Nasal intake of cocaine can cause necrosis and perforation of the nasal septum/oral palate. Cocaine has also been linked to chronic skin tightening; hemorrhagic skin lesions that result from the leakage of red blood cells into the skin; inflammation of the blood vessels; and urticaria, a raised, itchy hive breakout that can appear in one part of the body or spread across several parts.

The U.S. Drug Enforcement Administration (DEA) estimates that about 70 percent of illicit cocaine detained in the U.S. contains a mixture of chemicals and adulterants, such as the veterinary anti-parasitic drug levamisole – consequently, levamisole-related problems including decomposing skin on ears, noses, cheeks, and other parts of the body and life-threatening skin conditions, such as hemorrhagic blisters have been more common.


Levamisole is also seen in crack cocaine. Because it’s smoked, crack cocaine often causes burns, cuts and even loss of lateral eyebrows.

Hyperkeratosis of the hands, a dermatologic condition so common among people who smoke crack that it became popularly known as ‘crack hands,’ is normally characterized by blackened palms, with linear and circular lesions.

All stimulants can lead to formication syndrome and delusions of parasitosis (DoP), which is when a person has hallucinations about insects crawling under their skin and start to compulsively pick their skin, creating wounds.


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Meth is well known for causing formication and DoP. Repetitive skin picking occurs among many chronic meth users, which results in serious wounds that start off looking like small pimples but can quickly turn into ulcers. The wounds, called meth sores or meth mites, form quick and spread fast.

Even small doses of meth are capable of prompting acne outbreaks and a weakened immune system.

Meth users may sweat more than normal and have pale or grayish skin with a rough texture. Effects of meth use are more apparent when the drug is smoked since smoking increases wrinkle formation.


Alcohol abuse can also cause

wrinkles and overall premature aging. One sign of alcohol addiction is dermatologic stigmata of liver disease, that is when diseases of the liver (often caused by excessive alcohol intake) are reflected on the skin.

Yellowish or hyperpigmented skin with thinning of body hair and nails are signs of hepatic cirrhosis, a type of acute liver disease that alcohol abusers are at increased risk for. Another indicator of severe liver disease is caput medusa or engorged veins in the abdomen.

Some conditions that are not always linked to alcohol abuse but may indicate mild liver disease caused by alcohol are common rashes, dilated arterioles such as spider veins, and/or angioma. Flatly spread psoriasis, marked by thickness in the skin’s outer layer, has also been reported among people who drink too much alcohol.

Additional dermatologic disorders linked to alcohol abuse include rosacea, nummular eczema, palmar erythema and seborrheic dermatitis.

Dr. Henriques pointed out that while many of those conditions are fairly common, they are often among the countless complications and alterations that can indicate any type of drug use or abuse.

“Dangerous drugs like heroin or methamphetamine will certainly alter the skin,” she said. “But both licit and illicit drugs can induce systemic skin disorders.”

Medical relevance

Substance abuse often goes undetected by physicians because it isn’t always self-reported.

Dr. Ezra’s research aimed to make doctors more aware of the visible signs of drug abuse and consequently give them the ability to recognize substance use disorders and provide patients with the most effective treatment.

“In every specialty of medicine physicians need to be aware of signs and symptoms of drug abuse,” Dr. Ezra said. “Sometimes patients come to physicians for ailments that are related to drug abuse, but they don’t come out and tell their physicians that they’re abusing drugs. It’s the physician’s job to take a holistic approach at treating the patient and not only treating a specific concern but all issues. Drug abuse is a very important issue now.”

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