Illicit drug cutaneous outcomes- What the WOC Nurse needs to know: A Case Study

Statement of Clinical Problem: Atypical skin lesion presentations among drug users present a growing health concern. Levamisole, a veterinary antiparasitic and cocaine adulterant agent, is detected in 70%of the drug. Levamisole intensifies mood enhancement and antidepressant effects. (Hennings, C. & Miller, J., 2013; Lawrence, Jiron, Lin & Folbe, 2014).  Levamisole was withdrawn as a cancer treatment in humans in 1999 (USA) and 2003 (Canada) due to side effects. (Hou, Kronfli, Azzam & Panju, 2015). Wound Ostomy Continence nurses (WOC) are commonly consulted for these atypical presentations.

Patient Presentation: Three identified patients, ages 42-53 years, presented to the hospital with large, well demarcated purpuric/hemorrhagic plaques and rash on varied locations including legs and arms (3), ears and noses (2).  Illicit drug use included heroin, cocaine, marijuana, and PCP. All three patients were tobacco smokers. Comorbidities included Hepatitis C (3), Rheumatoid Arthritis (2), and Anemia (2). A timely wound care nurse specialist consult was initiated by the medical team. Recommendations included imaging, toxicology screen, and Dermatology consult. Pathology reports were suggestive of a diagnosis of cocaine/Levamisole-induced cutaneous vasculitis (LIV).

Description of Past Management:   As a recently recognized cutaneous reaction, no standard of optimal care has been supported in wound literature for LIV at this time.

Current Approach:  Surgical interventions with adjunctive topical management were implemented per WOC recommendations.  In all three cases, the extensive escharotic wounds evolved over the next months.

Patient Outcomes:  All three identified patients required extensive surgical debridement, two required NPWT with skin grafts and one patient required a below the knee amputation.   Known time to heal for these patients ranged from 3-8 months

Conclusions: Limited supporting evidence is available regarding optimal LIV management.  The WOC nurse’s role in early identification of Levamisole’s toxic effects is paramount to tissue viability, skin/wound care management, and community related drug awareness interventions.