Skin popping scars – a telltale sign of past and present subcutaneous drug abuse

Introduction

Illicit use of drugs has been reported to lead to adverse pregnancy outcomes such as abruptio placentae, intrauterine growth restriction, and preterm birth, and is also associated with an increased risk of sexually transmitted diseases such as HIV and hepatitis C.

Women who have used drugs before pregnancy or are using drugs during pregnancy are an elusive population, and common beliefs that substance abuse occurs only in the ethnic minority, the poor, or the young population are inaccurate. Because these women often do not openly admit to using drugs, they are often not identified by their practitioners and are thus deprived of optimal medical care.

Case

A 33-year-old primiparous pregnant woman was admitted to the hospital at 38 weeks with a history of premature rupture of membranes (PROM) about 5 h before admission. She received prenatal care from a private obstetrician from the 6^th week of pregnancy. At 34 weeks, she moved to a different city where she continued prenatal care with another private obstetrician.

She did not mention her history of drug use during her prenatal care, and physical examinations done by both obstetricians were unremarkable. On admission, her cervix was 1 cm dilated, not effaced, with the vertex at −3 station. The estimated fetal weight was 3600 g, and the fetal heart rate was reassuring. The patient initially refused oxytocin, but eventually gave informed consent for induction with oxytocin at about 15 h after PROM. Oxytocin was gradually increased until there were regular uterine contractions. Throughout labor, the patient rejected recommendations to have an epidural catheter placed. Approximately 24 h after admission, fetal tachycardia and maternal fever occurred, and the diagnosis of chorioamnionitis was made. At that time, the vertex was still at −3 station and the cervix was essentially unchanged. The delivery mode was discussed with the patient, and she gave informed consent for cesarean delivery. She was brought to the operating room and after spinal anesthesia was given, a low-segment cesarean delivery was performed through a Pfannenstiel skin incision. During the cesarean, scars on both of the patient’s arms (Figures 1–3) were detected by the nursing staff and the obstetrician who performed the surgery. The infant was of normal size and after assessment by the pediatrician was sent to the normal nursery with an uneventful course. After the conclusion of the cesarean, the patient was questioned about these scars. She initially said that she was burned as a child and is now looking for a good plastic surgeon. However, when the obstetrician pointed out to her that these scars did not look like typical burns, she immediately admitted that these were scars from prior drug use through subcuticular cocaine injections (“skin popping”). The patient said she had been drug free for many years and had rejected epidural anesthesia because she was concerned about the morphine in the epidural.

Figure 1

Right forearm with typical scars from skin popping.

Figure 2

Close-up of scars from skin popping.

Figure 3

Close-up left forearm.

Comment

There are several potential differential diagnoses for skin scarring, including keloids, chronic folliculitis, contracture scars after burns, hypertrophic scars, and acne scars. Occasionally, malignant tumors such as sarcomas and basal cell carcinomas can resemble keloid or hypertrophic scars.

In this case, the reason for the scarring was repetitive subcutaneous injections with heroin and cocaine, also known as skin popping. Skin popping is defined as the act when drugs, usually heroin or “speedballs” (heroin plus cocaine), are injected subcutaneously or intramuscularly. Skin popping is done for different reasons: some drug abusers may have difficulties injecting intravenously because of difficulties in finding a vein, while others inject subcutaneously because it results in slower drug absorption, gives less of a “rush,” may allow the drug to last longer, and can also decrease the risk of overdosing.

Opiate use in pregnancy seems to be increasing. European researchers reported an apparent increase in skin popping [3, 9] in drug users. A search on PubMed found 21 citations of skin popping, most of them related to major complications such as abscesses and cellulitis [2, 4], botulism [3, 6, 9, 13], and necrotizing fasciitis [11]. Women seem more likely than men to develop skin and soft tissue infections after skin popping [4]. A breast abscess in a woman as a complication of skin popping has been reported [1].

In addition, injecting drugs has been associated with infections such as HIV, hepatitis B and C, and also with other problems such as rhesus alloimmunization [7]. There has been no report of skin popping in a pregnant patient.

Drug and heroin use in pregnancy has been associated with many adverse effects, including higher rates of fetal acidemia and demise, lower Apgar scores, growth restriction, increase in prematurity and neonatal death, an increase in attention deficit hyperactivity disorder, and adverse neurodevelopmental outcomes [8, 12, 14, 15]. In addition to the obstetrician and the pediatrician, the anesthesiologist is also challenged by drug-dependent pregnant women with complications such as difficult intravenous access and hepatitis C exposures [5].

The common perception that substance abuse is solely a problem of poor, ethnic minority, and young individuals is inaccurate [10]. As this case demonstrates, even though the patient was repeatedly seen by several different obstetricians during her pregnancy, her past heroin use was never identified despite clear telltale signs of skin popping. One reason could be that obstetricians are not sufficiently trained to identify drug use in pregnant women who do not fit the typical stereotype of a drug user. At the first prenatal visit as well as the subsequent visits, a cursory examination of her upper extremities would have easily identified the typical scars associated with skin popping and past heroin use.

Patients with a history of drug use are at increased risks for several complications, including sexually transmitted diseases and cardiac and liver problems such as hepatitis C and HIV. When a patient presents with this history, special attention should be paid to these complications and patients should be screened for medical complications including hepatitis C and HIV. In addition, there is an increased risk of recurrent drug use during pregnancy, and this may specifically affect the newborn baby. Therefore, patients with a history of drug should be screened for drug use during pregnancy and at the time of delivery.

In conclusion, the typical physical signs of skin popping (Figures 1–3) should have alerted the patient’s physicians to her past drug use.