Correspondence

An Unusual, Nonhealing Ulcer on the Forearm

N Engl J Med 2002; 347:1725-1726November 21, 2002

Article

To the Editor:

A 32-year-old woman presented to the emergency department because of a large and painful ulcer over the ulnar aspect of her left forearm. She said it had been present for more than a year but had become increasingly painful during the previous few weeks. On further questioning, she admitted to using it to inject heroin. The border of this chronic ulcer was very vascular, and injections into it produced nearly the same effect as the intravenous route.

The ulcer shown in Figure 1Figure 1Nonhealing Ulcer over the Ulnar Aspect of the Left Forearm of an Injection-Drug User. was approximately 5 cm by 9 cm with a relatively clean surface and prominent vascular granulation tissue along the border. There were rings of scar tissue around it. Radiographs of the ulna (Figure 2Figure 2Radiograph of the Forearm Showing a Marked Periosteal Reaction and Osteomyelitis of the Ulna.) showed a marked periosteal reaction, with changes consistent with a diagnosis of osteomyelitis. Cultures of the wound surface recovered methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and skin bacteria. The patient had a good response to methadone and intravenous antibiotics during 11 days in the hospital, but she did not return for follow-up after discharge.

This “shooter's patch” is an example of a nonhealing ulcer with an unusual cause. Diagnosis requires knowledge of the history of injection-drug use. Patients may describe these wounds as having mysterious origins and as very painful, as part of a quest to obtain more narcotics. Staphylococci are the dominant pathogens, but many organisms may be recovered.1 Biopsies show chronic inflammation with talc or fibrous material. Osteomyelitis is not uncommon with injection-drug use and may involve organisms from the flora of the mouth.2,3

The location of the wound in this case was a particularly convenient one, on the back of the left forearm. It provided the patient with easy, visible access to her vascular system, without forcing her to rely on scarred veins or to leave injection marks. The ulcer could be concealed easily with a long-sleeve dress or shirt. Shooter's patches have also been observed on the thighs and sometimes on the lower legs. They may start with an injury or with an injection abscess, and they vary in size depending on the duration and frequency of drug use.

Treatment should first address the opioid dependence. Antibiotic therapy should be instituted on the basis of cultures of deep aspirates or biopsy specimens, since swabs of the surface material may not reveal the true pathogens. With local care and patience, the wounds may slowly be epithelialized and close. A surgical approach may sometimes be required and should include removal of the scar tissue and foreign material embedded in the ulcer. An unusual ulcer such as this patient had is a clue to the patient's larger, life-threatening problem.

Alan D. Tice, M.D.
University of Hawaii, Honolulu, HI 96813
alantice@idlinks.com

3 References

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   Trilla A, Miro JM. Identifying high risk patients for Staphylococcus aureus infections: skin and soft tissue infections. J Chemother 1995;7:Suppl 3:37-43
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   Swisher LA, Roberts JR, Glynn MJ. Needle licker's osteomyelitis. Am J Emerg Med 1994;12:343-346
   CrossRef | Web of Science | Medline

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   Wald ER. Rick factors for osteomyelitis. Am J Med 1985;78:206-212
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Citing Articles (4)

Citing Articles

1. 1

   Srinivasan Iyer, Padmanabhan Subramanian, Amit Pabari. (2011) A devastating complication of ‘skin popping’. The Surgeon 9:5, 295-297
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2. 2

   Srinivasan Iyer, Amit Pabari, Christopher T. Khoo. (2011) A well vascularised muscle flap – Drug user’s dream. Journal of Plastic, Reconstructive & Aesthetic Surgery
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3. 3

   Richard S. Hartoch, John G. McManus, Sheri Knapp, Mark F. Buettner. (2007) Emergency Management of Chronic Wounds. Emergency Medicine Clinics of North America 25:1, 203-221
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4. 4

   P. Del Giudice. (2004) Cutaneous complications of intravenous drug abuse. British Journal of Dermatology 150:1, 1-10
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