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Dermatological With the exceptions of rashes and other skin conditions resulting from idiosyncratic or allergic reactions to drugs, most drug use complications involving skin damage result from the use of hypodermic needles or other means of drug injection that involve breaking the skin surface. There are three primary types of injection: (1) subcutaneous, also known as ''skin-popping,'' wherein the needle is injected into or directly under the skin surface; (2) intramuscular (IM), wherein the needle is injected into muscle mass, often in the shoulder or buttock; and (3) intravenous (IV), direct injection into a blood vessel. Skin damage can result from repeated injection in the same area, failure to clean the injection site, nonsterile needles, and/or impurities or insoluble materials in the substance injected. Adulterants in the drugs, liquids used to dilute the drugs and contaminated injection paraphernalia, and the surface of the injection site all provide sources of viruses, bacteria, and fungi.

The most common skin damage from repeated injection is needle-track scars. These are usually caused by unsterile injection techniques or by the injection of fibrogenic particulate matter— material often used by dealers to add bulk and weight to the drug or buffers in tablets that have been ground up and liquified for injection. Carbon deposited on needles by users who try to sterilize by heating the needle tip with a match may produce a ''tattoo'' discoloration, accompanied by a mild inflammatory reaction under the skin at the point of entry. Such scars are found mostly on the arms, but they can occur anywhere on the user's body that has been used as an injection site, including thighs, ankles, neck, and penile veins.

Needle abscesses, characterized by redness; a stinging, itching sensation; and swelling at the site, often result from repeated injection without cleaning the injection site. Such skin flora as staphylo-cocci and streptococci are driven beneath the skin surface to infect the site, often with pus formation. Forms of contact dermatitis can also result from allergic reactions, especially to fluids used to sterilize the skin at injection sites. Infections and allergic reactions increase as an individual's resistance decreases with a drug-compromised immune system.

Subcutaneous injection of SEDATIVE-HYPNOTIC drugs, such as BARBITURATES, can cause cellulitis— where the tissue becomes reddened, hot, painful, and swollen at the injection site. If not treated, the cellulitis may last for a long time. In extreme cases, the cellulitis may eventually cover most of the user's body as new needle sites are used to avoid painful areas. Superficial cellulitis, septic thrombophlebitis, and simple needle abscesses can usually be treated with local heat, incision, and drainage, followed by culture and sensitivity testing and appropriate antimicrobial therapy.

Repeated intravenous injection may produce anaerobic infections or abscesses that produce a foul-smelling discharge, sometimes gas formation, and a cellulitis that is characterized by a rapidly progressing stony or wooden-hard tenseness, often some distance from the original needle site. Although the mechanism of these infections is unclear, it is thought to involve a disruption of blood supply to the area from edema (fluid collection) resulting from the cellulitis. Treatment involves wide incision and pressure reduction in the affected area. Kaposi's Sarcoma. Kaposi's Sarcoma is a malignancy arising in the skin usually in the cells lining the blood vessels (endothelium). The lesions have a nodular or plaquelike appearance, may be localized and indolent or disseminated, and involve aggressive spreading to mucous membranes and visceral organs, especially the gastrointestinal tract.

Prior to 1980 and the advent of the human immunodeficiency virus (HIV) and AIDS, Kaposi's sarcoma was considered a rare disease and primarily limited to elderly males of Mediterranean ethnic origin. Since that time, widespread dissemination of HIV and the epidemic of AIDS accompanying it has made Kaposi's sarcoma much more common. Substance abusers who administer their drugs par-enterally (subcutaneously, intramuscularly, intravenously) are a higher risk group for Kaposi's sarcoma since many of these individuals inject drugs with unsterile needles that frequently are used in common with others. They therefore have an excellent opportunity of acquiring HIV from infected blood.

The aggressive form of Kaposi's sarcoma has occurred in at least one-third of patients with AIDS and has reached epidemic proportions in the United States and many African countries. In many AIDS patients, Kaposi sarcoma lesions may actually be the first notable manifestation of the disease. The lesions usually first appear on the upper part of the body, but rapidly spread to lymph nodes, the mucosa of the mouth and the gastrointestinal tract and other visceral organs.

Chemotherapy is the treatment of choice, either a single agent or a combination of agents. Inter-feron-a effectively slows the progression of lesions and cures others. The injection of vincristine into the lesions is also useful. The course of the disease is dictated by the level of immunosuppression that is present.

(SEE ALSO: Allergies to Alcohol and Drugs; Complications: Route of Administration)

BIBLIOGRAPHY

Cohen, S., & Gallant, D. M. (1981). Diagnosis of drug and alcohol abuse. Brooklyn: Career Teacher Center, State University of New York. Senay, E. C., & RAYNES, A. E. (1977). Treatment of the drug abusing patient for treatment staff physicians. Arlington, TX: National Drug Abuse Center. SEYMOUR, R. B., & SMITH, D. E. (1987). The physician's guide to psychoactive drugs. New York: Hayworth Press.

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