How Changing Skin Tells The Story Of Kashmir’s Drug Abuse Crisis

When dermatologist Dr Aaqib Aslam Shah was doing a general examination of the skin of patients who were injecting heroin, he was struck by a 22-year-old young man. The patient was an intravenous heroin abuser of over three years. With it, he had developed gangrene in the leg. 

“It was a very sad situation. It was a severe case of gangrene and his leg had to be amputated,” says Shah.

Shah says studying skin of drug abusers reveals what afflicts them and what they have been through over the years as drug users. He says early signs of drug abuse among young people can be detected from change in their skin. “Skin tells you the whole story,” he says.

In his study, titled Prevalence and Pattern of Dermatological Manifestations Among Substance Users Across Kashmir Valley in North India, Shah and his colleagues have concluded that dermatological manifestations are quite prevalent among substance users in Kashmir. He argues for the role of dermatology in drug rehabilitation as it will lead to early detection and treatment.

The study says pruritus —itchy skin, an irritating sensation that makes you want to scratch— was found to be the most common dermatological manifestation overall and was statistically significant among heroin users. The presence of itchy skin had a relation with substance use. The study says pruritus was seen most during the first few months of heroin use with 53 per cent having it in the first three months of heroin use.

The study further says track marks, tattoos, and scars at injection sites; active skin ulcers; and skin and soft tissue infections; and hyperhidrosis —excessive sweating— are among important dermatological clues for detecting substance use. Similarly, puffy hand syndrome that develops after chronic intravenous heroin use is exclusively seen among the drug abusers. The study also says oral involvement was fairly common in heroin users who would sniff or snort heroin and other drugs. Tooth decay and periodontal disease could be seen in many of these heroin users. Some of the heroin users presented with soft creamy patches in the oral cavity.

“Recognition of such signs is important in these cases for more effective diagnosis and treatment,” the study says.
Shah’s research was a cross-sectional study for 18 months carried from November 2018 to April 2020 among addicts admitted at various drug de-addiction centres (DDC) of Kashmir Valley.

The study says while 49.4 per cent patients were polysubstance users, 50.6 per cent patients used a single-substance only. Opioids were the most common substance used and among them heroin had the highest number of cases, while cannabis was found to be the second most common substance (47 per cent). Tramadol (18.9 per cent), codeine (3.7 per cent), and tapentadol (1.8 per cent) were the other opioids used by the addicts. Among heroin users, 42.3 per cent were injectable drug users (IDUs), while in the rest of the cases heroin was perpetuated through smoking (57.7 per cent).  Smoking was also the mode of substance abuse among all patients of cannabis use in Dr Shah’s study. In the case of cocaine most of the substance users would prefer snorting.

Shah says when they began the research among the substance users they were not concerned about intravenous heroin abusers. 

Shah says, “That time we were not sure what kind of substance abuse is most prevalent among the admitted patients. But during the course of the study, we realised the most common substance use among substance abusers is heroin. And a sizable number of the cases were IV injectable users. It showed us that the trend is shifting from cannabis and opioids to heroin.

“In Kashmir, drug abusers admitted at various drug de-addiction centres are generally heroin users. They start with chasing (smoking) heroin through their mouths and then resort to IV drug abuse. It is usually associated with positive hepatitis B and C serology due to needle-sharing. In these cases, they start from oral smoking and then veins of forearms, arms, legs, abdomen, and even neck. After exhausting their veins, they resort to injecting skins, muscles, resulting in atrophic scars.”

Shah says dermatologist says the patients usually come to dermatologists on their own and some are even accompanied by family.

He says, “In many cases, they are referred from various drug de-addiction centres. As a rehabilitation process, we treat them with antibiotics and then resort to other means like lasers and, in some cases, surgical correction.”
Early signs of skin diseases present among the drug abusers are presence of fungal infection called oral candidiasis, oral hairy tongue, in young people. In case of IV drug abusers, there are track marks and sooting tattoos. Later on scars can be seen.

Shah, however, says there is a ray of hope as some patients were able to leave the drug abuse due to dermatological signs. 

He says, “That was something that shocked them. I remember 16 patients who were on my treatment. They become normal after they were treated. This shows the importance and role of dermatology in drug rehabilitation and society in general apart from helping in early diagnosis and treatment.”