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
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
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
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
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 - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
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 in Response to Previous Publication
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
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
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
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Net letter
2012:78:4;521-521
doi: 10.4103/0378-6323.98104

Pentazocine induced ulceration of the buttocks

Sushruta Kathuria, V Ramesh, Avninder Singh
 Department of Dermatology and Venereology, and Institute of Pathology, ICMR, Safdarjung Hospital and Vardhaman Mahavir Medical College, Ansari Nagar, New Delhi, India

Correspondence Address:
Sushruta Kathuria
Department of Dermatology and Venereology, AIIMS, New Delhi - 110 029
India
How to cite this article:
Kathuria S, Ramesh V, Singh A. Pentazocine induced ulceration of the buttocks. Indian J Dermatol Venereol Leprol 2012;78:521
Copyright: (C)2012 Indian Journal of Dermatology, Venereology, and Leprology

An 18-year-old-girl presented with indurated erythematous plaques, nodules, discharging sinuses and ulcers localized to the buttocks for 2 years. On examination, discharge from the sinuses was minimal, and the nodules were better felt than seen, firm to hard on palpation and slightly tender [Figure - 1]. She also complained of recurrent abdominal pain for 3 years, refractory to oral analgesics and improved significantly only by injectable analgesics. The intramuscular injections were given on buttocks by the local practitioner once or twice daily and were continued even after occurrence of discharging sinuses. Investigations were carried out for abdominal pain such as routine blood chemistries, hemogram, ultrasound of abdomen and pelvis, and no cause could be detected for the abdominal pain. Wedge biopsy from edge of ulcer showed irregular acanthosis, mild perivascular infiltrate of lymphocytes, histiocytes with some siderophages and focal dermal fibrosis [Figure - 2]. Subcutaneous fat showed lobular panniculitis, focal macro- and microcysts, lipophages and thickened septae with fibrosis [Figure - 3]. Special stains for acid fast bacilli, fungal hyphae and spores were negative. Multiple biopsies did not show growth of any organism. A morning urine sample was tested for pentazocine by thin layer chromatography (TLC) and was found positive. Patient was diagnosed as a case of pentazocine-induced ulceration and panniculitis. The patient was admitted and counseled regarding stopping pentazocine. During 2 weeks of hospital stay, abdominal pain had paradoxically improved by 90% with paracetamol 500 mg once daily. However, no change was seen in the pentazocine ulcers.

Figure 1: Multiple nodules and discharging sinuses on buttocks
Figure 2: Fibrosis in mid and lower dermis with panniculitis. (H and E, ×10)
Figure 3: Lobular panniculitis with fatty micro- and macrocysts and septal fibrosis. (H and E, ×40)

Pentazocine is a non-narcotic, non-addicting analgesic, introduced in 1967. However, its addicting and dependence properties are known, [1] and complications due to its abuse have been reported. [2] The diagnosis of pentazocine dermopathy should be suspected in patients presenting with woody hard nodules or plaques and ulcerations with a history of chronic pain. Most patients either have direct access to pentazocine or procure from relatives, or are advised by medical practitioners. Clinical presentation can vary from irregular ulcers with surrounding induration or hyperpigmentation [2] to thrombophlebitis, [3] puffy hand syndrome, ulcers, nodules or scars along veins, [4] and fibrous papules arranged linearly. [5] Such patients unusually show less discomfort than expected even when the lesions are extensive. The ulcers often occur over sites easy for the patient to inject like thighs, arms, forearms, abdomen and most of the peripheral veins have become thrombosed due to repeated intravenous pentazocine injections. [4] When interrogated, they adamantly refuse knowledge and use of such injections. Sometimes, repeated questioning about severity of pain, treatment, occupation of the patient and family members may help in diagnosis. Admitting the patient, closely observing how the patient copes with pain and evolution of the ulcers, is often helpful as there will be no access to pentazocine.

In our case, patient repeatedly took analgesics for chronic epigastric pain of unknown cause, which gave us a clue to the diagnosis. Diagnosis was confirmed by exclusion of other diseases, demonstration of characteristic histopathology on skin biopsy and positive urine test for pentazocine. TLC on urine sample can detect pentazocine if consumed within last 72 hours, and in this patient, patient admitted to taking pentazocine a day before. Other causes of discharging sinuses with an induration include scrofuloderma, atypical mycobacterial infections, mycetoma, hidradenitis suppurativa and malakoplakia. Scrofuloderma, atypical mycobacterial infections and mycetoma were ruled out by absence of granulomas and mixed inflammatory infiltrate on biopsy. Further, no organism could be detected by special stains or culture. The characteristic sites like axillae and groin were spared, and histopathology did not show neutrophils, which ruled out hidradenitis suppurativa.

Pentazocine-induced ulcers are underrecognized cause of chronic non-healing ulcers, not only among dermatologists but also among clinicians of other specialities. The lesions increased as pentazocine was continued on an advice of local practitioner. Pentazocine is a commonly used drug for chronic pain, and this case highlights the importance of being aware of its pentazocine ulcers as the vital component of management is withdrawal of the abused drug, psychiatric counseling and alternative treatment for chronic pain.

References
1.
Sandoval RG, Wang RIH. Tolerance and dependence on pentazocine. N Engl J Med 1969;280:1391-2.
[Google Scholar]
2.
Parks DL, Perry HO, Muller SA. Cutaneous complications of pentazocine injections. Arch Dermatol 1971;104:231-5.
[Google Scholar]
3.
Girolami A, Cella G. Acute superficial phlebitis in a patient with hemophilia A: Probably an iatrogenic effect. Acta Haematol 1972;48:307-11.
[Google Scholar]
4.
Prasad HR, Khaitan BK, Ramam M, Sharma VK, Pandhi RK, Agarwal S, et al. Diagnostic clinical features of pentazocine-induced ulcers. Int J Dermatol 2005;44:910-5.
[Google Scholar]
5.
De D, Dogra S, Kanwar AJ. Pentazocine induced leg ulcers and fibrous papules. Indian J Dermatol Venereol Leprol 2007;73:112-3.
[Google Scholar]

Fulltext Views
105

PDF downloads
114
Show Sections