Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Obervation Letter
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF
Case Report
doi: 10.4103/0378-6323.31898
PMID: 17456919

Pentazocine-induced leg ulcers and fibrous papules

Dipankar De, Sunil Dogra, Amrinder J Kanwar
 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Amrinder J Kanwar
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
How to cite this article:
De D, Dogra S, Kanwar AJ. Pentazocine-induced leg ulcers and fibrous papules. Indian J Dermatol Venereol Leprol 2007;73:112-113
Copyright: (C)2007 Indian Journal of Dermatology, Venereology, and Leprology


We herein describe a case of 55-year-old farmer, who presented with chronic non-healing ulcers over both shins of 4 years duration. Intravenous drug abuse was suspected due to inability to find any venous access and all peripheral veins being found thickened and fibrosed. There were multiple atrophic scars in linear distribution in all limbs as well as in both groins. In addition there were multiple discrete fibrous papules in linear distribution on both hands, which were more obvious on the left side. The patient denied abusing intravenous drugs. However, his relatives confirmed that he abused pentazocine for almost one year before his chronic pain in abdomen was treated by appendicectomy. With subsequent counseling, it was found that he continued to abuse pentazocine at times even after surgery leading to the non-healing of ulcers.
Keywords: Fibrous papules, Pentazocine
Well-defi ned ulcer with violaceous hue in the edge and skin colored fi brous papules along course of dorsal veins of hand in starfi sh pattern
Well-defi ned ulcer with violaceous hue in the edge and skin colored fi brous papules along course of dorsal veins of hand in starfi sh pattern


Pentazocine was introduced in 1967 as a potent ′non-narcotic, non-addicting′ analgesic. By 1969, the abuse potential of pentazocine was recognized. Since 1971, when cutaneous complications of pentazocine use / abuse were recognized, [1] various cutaneous side effects have been reported. The most prominent side effect of pentazocine use / abuse is cutaneous ulcerations. We report a case who presented with leg ulsers and have fibrous papules over hand.

Case report

A 55-year-old male farmer presented to our outpatient department with complaints of redness and swelling of the left lower limb associated with fever since three days along with painless non-healing ulcers over both the shins of four years duration. There was a history of swelling of both feet after prolonged standing. However, there was no history of dilated and tortuous veins in the lower limbs.

On cutaneous examination, there were two well defined, regular bordered, punched out ulcers of size around 5 x 5 cm with perceptible violaceous hue of the margin. The surrounding skin was hyperpigmented and indurated. In addition, there were multiple, discrete, fibrous papules in linear distribution on both hands, more obvious on the left side [Figure - 1]. No venous access was found and all veins were thickened and fibrosed. There were multiple atrophic scars in linear distribution on all limbs and in both groins.

Based on these findings, we suspected intravenous drug abuse. However, he denied any such history in the past. He had used intravenous pentazocine for his abdominal pain for almost one year before it was treated with appendicectomy. Subsequent counseling of the patient also revealed that he abused pentazocine occasionally even after surgery and the last injection was taken 6 weeks before admission under our care.

Laboratory investigations including complete blood counts, liver and renal function tests, urine examination, chest X-ray, color doppler ultrasound were all within normal limits. HIV serology, serum HBsAg, anti-HCV were also negative. A skin biopsy specimen from the margin of one of the ulcers showed changes of vasculitis with predominant neutrophilic infiltrate. Thin layer chromatography of urine specimen did not show any evidence of opioids including pentazocine.

He was treated with aseptic dressing for ulcers with platelet-derived growth factor and ultra-violet therapy. Psychiatric assessment and counseling was done. He discontinued pentazocine abuse and his ulcers almost completely healed after 3 months of treatment.


Diagnosis of pentazocine-induced ulcer is easy when the history of use of pentazocine in a given patient is forthcoming. However, this is not the case in most of the patients, as they do not admit to abuse readily for fear of social stigma, alienation by family members and losing their jobs. Therefore the diagnosis requires high index of suspicion and exclusion of other commoner causes of leg ulcers, which include venous stasis ulcers, arterial ulcers, pyoderma gangrenosum, vasculitic ulcers, malignancies etc.

Previously reported pentazocine-induced ulcers had varied range of presentation which included, irregular-shaped deep ulcers with black eschars and surrounding induration, [1],[2] halo of hyperpigmentation around the ulcer, [2] woody induration, [1],[2] needle pricks / thrombophlebitis, [3] puffy hand syndrome, [4] fibrous myopathy, [5] discomfort disproportionately less than the extent of ulcer, [2] ulcers / nodules/ scars along the superficial veins [6] and difficulty in venous access. [6] These have been observed in patients with history of chronic pain, [1],[2] iatrogenic administration of pentazocine [1],[2] and patients who have ready access to restricted medicines. [1]

There is no gold standard diagnostic test for pentazocine-induced ulcers. Histopathological examination of a skin biopsy specimen shows a mixed inflammatory infiltrate with predominance of neutrophils. If subcutaneous fat is included in the biopsy specimen, neutrophilic septal panniculitis may be observed. Pentazocine can be detected qualitatively in urine by thin layer chromatography and quantitatively by gas chromatography and gas chromatography/mass spectrometry. However, a negative result does not rule out pentazocine use / abuse, as if pentazocine has not been used in the recent past, the results may be negative. Pentazocine-induced ulcers are thought to be non-respondent to conservative therapy. Surgical excision followed by skin grafting is required for early healing of ulcers. However, spontaneous healing can occur with conservative treatment. [6]

Diagnosis in our patient was not easy. Suspicion about the acquired cause of venous fibrosis was aroused when, for blood sampling, no patent peripheral venous access was obtained. Fibrous papules in linear distribution conforming to venous arch of the dorsum of hand, more so in the left hand in a right-handed person, were obvious. Though various cutaneous signs suggestive of pentazocine abuse have been described, to the best of our knowledge, starfish shaped fibrous papules along the distribution of veins in the dorsum of hand has not been described previously.

Diagnosis of pentazocine-induced ulcers requires a high index of suspicion and any ulcer, which does not fit clinically in any common cause of ulceration, should arouse suspicion of pentazocine use/ abuse.

Schlicher JE, Zuehlke RL, Lynch PJ. Local changes at site of pentazocine injection. Arch Dermatol 1971;104:90-1.
[Google Scholar]
Parks DL, Perry HO, Muller SA. Cutaneous complications of pentazocine injections. Arch Dermatol 1971;104:231-5.
[Google Scholar]
Girolami A, Cella G. Acute superficial phlebitis in a patient with hemophilia A: Probably an iatrogenic effect. Acta Haemat 1972;48:307-11.
[Google Scholar]
Neviaser RJ, Butterfield W, Wieche DR. The puffy hand of drug addiction: A study of pathogenesis. J Bone Joint Surg Am 1972;54:629-33.
[Google Scholar]
Oh SJ, Rollins JL, Lewis I. Pentazocine induced fibrous myopathy. J Am Med Assoc 1975;231:271-3.
[Google Scholar]
Prasad HR, Khaitan BK, Ramam M, Sharma VK, Pandhi RK, Agarwal S, . Diagnostic clinical features of pentazocine-induced ulcers. Int J Dermatol 2005;44:910-5.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections