Wound Care
The increasing use of xylazine as an adulterant in the fentanyl supply has given rise to a unique and severe type of wound. Xylazine-associated wounds most commonly occur at a site of injection but have been described to develop in other areas of the body, even when xylazine exposure is through means other than injection. If left untreated, these wounds can lead to extensive tissue damage and systemic complications. 
For Health Care Providers 
Health care providers play a pivotal role in addressing and managing xylazine-related wounds. This includes: 
Identification and Diagnosis 
Familiarity with the characteristic appearance of xylazine wounds—ulcerative, necrotic, found on extensor surfaces of extremities, and often resistant to healing—is essential. 
Providers should perform thorough wound assessments, evaluating the extent of tissue damage including surface area and depth, and look for signs of co-occurring infections such as cellulitis, abscess formation, or systemic involvement (e.g., sepsis). 
Management 
Treatment:
Conservative wound care management is typically recommended. Xylazine-associated wounds despite the severity retain good healing properties with regular conservative wound care and adequate nutrition.  
Wound Debridement:
Necrotic or infected tissue may require debridement. Conservative wound autolytic debridement is typically preferred over aggressive surgical debridement unless there are concerns for deep space infection. Avoiding repeated surgical debridement can prevent unnecessary tissue loss that may lead to amputation. 
Wound Dressing:
Wounds should be kept moist and covered to allow for optimal healing. Eschar (scabs) trap infection and prevent healing. Wounds should be cleaned with soap and water daily to keep bio burden to a minimum. Ointments should be applied to keep wounds moist and prevent bacterial overgrowth including silver sulfadiazine or A & D ointment. A non-adherent dressing should be utilized to avoid the dressing from drying to the surface of the wound as this will lead to painful dressing changes. An absorptive pad should be utilized for wounds with significant drainage and a cohesive or elastic wrap should be used to keep the dressing in place.  
Antibiotics:
Xylazine-associated wounds often present with significant superficial bacterial overgrowth which is typically managed with topical treatments. Systemic antibiotics are typically reserved for wounds associated with significant surrounding cellulitis or systemic signs of infection. 
Pain Management:
Patients often suffer from significant pain related to their wounds. Multimodal pain management is necessary to allow for adequate wound care. 
Referrals:
While conservative management of xylazine-associated wounds can typically take place in a primary care or addiction medicine office, severe cases may warrant referral to specialized wound care services including plastic or burn surgery. 
Education and Prevention 
It’s crucial to educate patients on properly cleaning and dressing wounds.
Harm reduction practices, such as transitioning method of use from injection to other routes, avoiding injecting into the wound, using sterile equipment, and engaging with syringe service programs are also important in preventing further wounds. 
Promoting comprehensive care that integrates treatment for substance use disorder alongside wound management is also critical. Patients can and do successfully manage day to day wound care on their own when provided with the proper resources and education. (see below) 
