What causes the skin lesions?
Desomorphine itself is not likely the cause of the skin lesions. In its pure form, there is no reason to expect this compound would induce any specific changes in the skin that would lead to necrosis. In fact, similar chemical syntheses of desomorphine produced in other countries, such as in the Czech Republic and New Zealand, have not led to analogous skin lesions. Ulcerative skin damage is most likely caused by the inflammatory contaminants in Krokodil. Injection of solvents and other chemicals into the subcutaneous space lead to skin damage and provide a bed for the development of indolent infections. This mechanism is similar to that leading to epidemics, in which similar lesions have been associated with black-tar heroin injection and drug contamination with Bacillus anthracis.5,6
Some people, however, point out the severity of the skin lesions associated with the use of Krokodil compared to other injection drugs. This may be related to the need for frequent administration of Krokodil due to its short duration of action, in turn leading to repeated exposure to the impure solvents.
Treatment of associated lesions involves wound care, including debridement, topical care, and antibiotics; amputation may be required in severe cases.
Case conclusion
The patient in this case was taken to the operating room for debridement of the right arm. The pathology results of the tissue showed ulceration, abscess, acute and chronic inflamed granulation tissue, fibrosis, and necrosis. A magnetic resonance image of the arm showed no signs of osteomyelitis. A blood sample sent for analysis was negative for desomorphine. The patient was stable after the surgery, and was discharged with follow-up instructions and referral for drug abuse counseling.