Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 1 Clinico-epidemiological Aspects of Cutaneous Lesions in Injecting Drug Users Visiting an Oral Substitution Therapy Centre in Northern India: A Cross-Sectional study Shaminder Singh Dhillon1, Tejinder Kaur1, Neeru Bala1, Mankaranpreet1 1 Department of Skin & VD, Government Medical College, Amritsar, Punjab, India 2 Deparment of Psychiatry, Government Medical College, Amritsar, Punjab, India Key words: intravenous drug users, oral substitution therapy centers, skin manifestations, dermoscopic findings Citation: Dhillon SS, Kaur T, Bala N, Mankaranpreet. Clinico-epidemiological aspects of cutaneous lesions in Injecting Drug Users visiting an Oral Substitution Therapy Centre in Northern India: a cross-sectional study. Dermatol Pract Concept. 2022;12(4):e2022154. DOI: https://doi.org/10.5826/dpc.1204a154 Accepted: March 3, 2022; Published: October 2022 Copyright: ©2022 Dhillon et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Tejinder Kaur, Professor & Head, Department of Skin & VD, Government Medical College, Amritsar, Punjab, India. E-mail: tejinderkaurdr@gmail.com Introduction: Drug abuse has been taking a great toll on the health and well-being of the community for the past few decades. Substance abuse can lead to several cutaneous manifestations as direct inju- ries by the offending drug or the practices of drug usage cause secondary damage to the skin. The early recognition of these signs is of utmost importance to prevent long-term complications. Objectives: To study the clinical-epidemiological profile of the skin diseases in Injecting Drug Users (IDU) attending an Oral Substitution Therapy (OST) Center in Northern India and to assess the psy- chological impact of skin conditions in IDUs attending OSTs. Methods: This cross-sectional observational study involved 100 IDUs enrolled from the OST center who were subjected to brief history taking and clinical and dermoscopic evaluation of skin lesions. Dermatological quality of life index (DLQI), Depression, Anxiety, Stress Scale (DASS), and WHO- quality of life (QoL) questionnaire were used to evaluate the impact of skin lesions on psycho-social health and QoL of IDUs. Results: Cutaneous lesions ranged from track marks to severe ulcerations and scarring. Mucosal lesions also took a toll on several patients. The patients had varying degrees of anxiety, depression, and mental stress. Conclusions: Injecting Drug Abusers are prone to acquire skin diseases due to injury caused by drugs as well as by drug practices adopted and the degree of neglect may worsen these conditions. These cutaneous lesions hamper QoL and cause psychosocial disturbances. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 Introduction The WHO defines Drug abuse/Substance abuse as harm- ful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Psychoactive substances are the pharmacological agents that alter the behavioral, cognitive, and physiological changes in the body that, on repeated use, lead to a phenomenon referred to as dependence syn- drome. This includes a strong desire for the drug, impulse, and repeated use despite harmful effects. A high priority is given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal. No part of the world is free of drug abuse in the current times [1]. The advent of globalization has led to several variations in the culture and economic backgrounds in In- dian population. Alongside positive implications, certain social drawbacks like substance abuse are an important measure to be taken care of. Several criminal acts and an- tisocial behaviors have been associated with drug abuse [2]. Several steps and special task forces are being gener- ated by the Indian government at both the national and state level. Despite all the measures taken by the govern- ment and society drug abuse is one of the leading causes of crime in India. India is surrounded by the world's lead- ing illicit drug-producing countries namely Thailand, Laos, and Myanmar constituting the golden triangle on the east- ern side. Similarly, Afghanistan, Iraq, and Pakistan which constitute the golden crescent are located on the western borders of the nation. Thereby the incidence of substance abuse is on the rise especially in states like Punjab which is has close geographic contact with the above-mentioned western border [3]. Drug abuse has several implications on human health and society. These include a weak immune system, increasing rates of malnutrition, and related dis- orders due to neglect, weight, and appetite loss. The tox- icity of these drugs can lead to several lhepatic and heart diseases. Neuronal damage may result in behavioural and cognitive disorders [4]. Besides involving these systems, substance abuse can lead to several cutaneous manifestations as well which could be either due to direct injury by the offending drug or the prac- tices of drug usage can cause secondary damagse to the skin structure or even a presentation of medical complication due to drug abuse visible on the skin [5]. The early recognition of these signs is of utmost importance to prevent long-term complications like necrosis. To ease the understanding, we have tried to classify the presentations. Classification of Skin Manifestations: a. Injection-related/local effects. b. Infections: superficial, deep, viral disease transmission. c. Vascular complications. 1. Injection-related effects: most commonly encountered le- sions in Injecting Drug Users (IDU) are the track marks mostly seen on the arms and especially over the ante- cubital fold [6]. These represent the sclerosed vessels re- sulting from localized thrombophlebitis due to an irritant drug being abused and extravasated. The dark color at the site is due to the post-inflammatory hyperpigmen- tary changes occurring in the skin with an underlying affected vessel. Skin popping: Administering drugs into the skin may result in deep punched out ulcers which heal with atro- phy. These ulcers usually get secondarily affected to form large ulcers which heal slowly [7]. 2. Infections: skin and soft tissue infections are common in IDUs due to their injection practices and weakened immune systems. Staphylococcus aureus and streptococ- cal species which are normal commensals over skin en- ter the deeper tissues resulting in abscesses and cellulitis [8]. Moreover there are several impurities and adulter- ants in drugs that have deleterious effects on skin struc- tures. Several uncommon pathogens such as Clostridial and Eiknella which reside in the oral cavity can result in superficial and deep-seated abscesses. Wound botu- lism, necrotizing fasciitis and tetanus can occur due to clostridial toxins usually in the skin poppers in whom inoculation of bacilli occurs in relatively anaerobic con- ditions such as skin which favors their growth and toxin production [9,10]. Use of nonsterile needles poses cer- tain threats of various viral infections including Human immunodeficiency virus (HIV) and Hepatitis B and C viruses [11]. These infections can have various skin man- ifestations ranging from acute maculopapular rash to chronic skin diseases [12,13]. 3. Vascular complications: repeated trauma to the veins leads to vessel wall changes causing thrombophlebitis and venous thrombosis. This leads to venous incompe- tence and ulcerations may ensue. Furthermore, lymphatic drainage may get compromised due to lymphatic damage deteriorating the picture and leading to chronic edema of the limb [14]. Accidental intra-arterial injections may result in ischemic changes due to drugs or adulterants. Some of the drugs such as cocaine are vasoconstrictors that can result in vasospasms and compromising the blood supply to a unit resulting in its necrosis. Drug-induced vasospasm and thrombosis may result in acute pain and burning sensation in the limb and further leading to edema and cyanosis. Scrotal necrosis is seen in pudendal artery thrombosis [15]. There are reports of penile ulceration following drug administered into dorsal penile vein [16]. Intravenous abuse of cocaine may result in secondary Raynaud phenomenon and digital ulcerations and infarction in organs like the liver and kidney. Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 3 Pseudoaneurysms and mycotic aneurysms can develop following vascular injuries and infections may develop in the vessel walls. A pulsatile or non-pulsatile mass may be seen in the distribution of a vessel which may be wrongfully considered as an abscess and if incised may result in fatal outcomes [17]. These aneurysms are generally infected by bacteria such as staphylococcus and streptococcus species. In some instances, Candida albicans may be the infectious agent [18]. Objectives Primary Objective 1. To study the clinical-epidemiological profile of the skin diseases in IDUs attending Oral Substitution Therapy (OST) center in Northern India. Secondary Objectives 1. To assess the socio-demographic profile of IDUs. 2. To assess the psychological impact of skin conditions in IDUs attending oral substitution therapy center. 3. To assess the quality of life (QoL) of IDUs attending oral substitution therapy center. Methods A total of 100 IDUs visiting the OST center at the Govern- ment Medical College, Amritsar, in Northern India who met the inclusion criteria were randomly enrolled in the study. Inclusion criteria: 1. IDUs of both sex and aged more than 18 years. 2. IDUs visiting OST centers who gave consent for the study. Exclusion criteria: 1. IDUs of drug abuse employing routes other than intravenous. 2. IDUs not giving consent for the study. 3. IDUs with other primary dermatoses. 4. IDUs with organic mental disorders or known significant medical conditions. After signing written informed consent, a brief history re- garding their drug abuse – duration, type of drug, and route of administration - was enquired from patients. History of any skin disease before IDU abuse was asked. A thorough clinical examination was done after full body exposure. Bed- side tests for skin diseases if required were done. Lesions were examined clinically and with dermoscope as well. Questionnaires regarding the Dermatological QoL In- dex (DLQI) were filled to know about the impact of skin conditions. Secondly, the Depression, Anxiety, Stress Scale (DASS) questionnaire for assessing the psychological sta- tus of patients on de-addiction therapy was filled. Thirdly, a WHO QoL index questionnaire was used to look into the overall QoLof these patients visiting the OST center. At last, the results were tabulated and statistically analyzed. Results In our study, we observed that the mean age of the IDUs was 30.08 with a majority in the age group of 21-30 years. Among the study group, 98 were males and 2 were females. Laborers accounted for the majority being 33% and 17 were drivers; the rest of the IDUs had several other professions. All the IDUs had heroin abuse while 8 had concomitant co- caine and 3 had cannabis addiction as well. The mean dura- tion of drug abuse among the IDUs was 8.34 years while the maximum duration of injectables observed for the past was 1 to 5 years. In the study group, the last dose of the abused drug taken was less than one month in 76% while others had a lapse time of more than 1 month. Among the IDUs, 99 were being managed with buprenorphine and naloxone combination sublingual tablets and one was being given oral methadone. The literacy rate varied from 12/100 being illit- erate to 8/100 being graduate (with a graduation degree in any field) and the rest had education level between primary to senior secondary education. Thirty-eight patients had in- come less than 10,000, 50 had 10,000 to 20,000 and 12 had more than 20,000 Indian rupees. Fifty-two IDUs were un- married, 46 were married and 2 were divorced. A history of smoking was present in 57/100, while 82/100 were alcohol- ics. Of the 100 IDUs, 80 were positive for hepatitis C virus (HCV) infection, 10 had HIV infection and among them, 9 had concomitant HCV and HIV positivity. One among them had type 1 insulin-dependent diabetes mellitus, 1 was hyper- tensive, 1 had chronic kidney disease (Tables 1 and 2). In the study group, 84 patients had black-colored spots and scars over their body, 34 reported a history of chronic itching and 6 had ulcers over various body parts. The dura- tion of these complaints ranged from few months to several years. These lesions were clustered around upper limbs in 88% of all followed by 8% over lower limbs and 4% over the other body parts. Eight patients had a history of concom- itant joint pains. Among these patients, 38% received topi- cal or oral treatment. The commonly used topical agent was clobetasol cream and an oral agent was an antihistamine. Seven patients were on Highly Active Anti Retro Viral Ther- apy (HAART) and 2 were taking Anti Hepatitis C therapy (lepidasvir and sofosfubivir). On examination, 92 patients had track marks, 54 had hesitation marks, 53 had tattoos while small round atrophic scars were present in all the patients. Scabies was the most 4 Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 Table 1. Socio-Demographic Profile of the injecting drug users visiting Oral Substitution Therapy centers. Age (Years) N. of cases Percentage < 20 4 4.0% 21-30 53 53.0% 31-40 38 38.0% > 40 5 5.0% Sex Female 2 2.0% Male 98 98.0% Address (Rural/Urban) Rural 21 21.0% Urban 79 79.0% Marital Status Divorced 2 2.0% Married 46 46.0% Unmarried 52 52.0% Education Diploma 2 2.0% Elementary 18 18.0% Graduate 8 8.0% Illiterate 12 12.0% Matriculation 23 23.0% Primary 24 24.0% Senior Secondary (post matriculation) 13 13.0% Income (in Rupee) < 5000 11 11.0% 5000-10000 27 27.0% > 10000 62 62.0% Drug Abused Cocaine and heroin 8 8.0% Heroin 89 89.0% Heroin and cannabis 3 3.0% Duration of abuse (years) 0-5.0 29 29.0% 6-10.0 47 47.0% > 10 24 24.0% Treatment given Buprenorphine 99 99.0% Methadone 1 1.0% Smoking Absent 43 43.0% Present 57 57.0% Table 2. Chronic conditions and co-morbidities in injecting drug users. Past Illness N of cases Percentage Chronic kidney disease 1 1.0% Hip joint surgery 1 1.0% Pulmonary tuberculosis 1 1.0% Type-1 diabetes 1 1.0% Urticaria 1 1.0% Urinary tract infection 1 1.0% None 94 94.0% Diabetes mellitus None 99 99.0% Present 1 1.0% Hypertension None 99 99.0% Present 1 1.0% HIV Negative 90 90.0% Positive 10 10.0% HBsAg No. of cases Percentage Negative 100 100.0% HCV No. of cases Percentage Negative 20 20.0% Positive 80 80.0% HBsAg = hepatitis B surface antigen; HCV = hepatitis C virus; HIV = human immunodeficiency virus. common skin disease affecting 23 patients of which nine had nodular lesions as well. Superficial dermatophytosis was seen in 12 patients. Six patients had facial melanosis, 4 had intertrigo, 2 had acne vulgaris and 2 had balanitis. Other skin and soft tissue ailments present were hyperhidrosis, urticaria, thrombophlebitis, acneiform eruptions, verrucae, and genital herpes (Table 3). Angular cheilitis was seen in 2 patients, 45 had pigmen- tation over lips and seven had depigmented patches over the lips. Examination of buccal mucosa revealed bluish-black pigmentation in 77 patients and erosions in five ones. Dirty yellowish-brown staining over teeth was present in 69 pa- tients and 2 had dental caries. On examination of the gin- givolabial sulcus, 33 had pigmentary changes, 24 had Sub Mucosal Fibrosis, 8 had leukoplakia and 3 had cobble- stone mucosa. Hair examination revealed trichomycosis in 2 patients, generalized sparsity in 2 subjects, and andro-genetic alopecia in 1. Longitudinal melanonychia was the most common nail abnormality observed seen in 29 IDUs. A brownish discol- ored nail plate was seen in 4 IDUs, 3 ones had dystrophic nails, 2 had koilonychia and 1 had paronychia (Table 4). Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 5 Table 3. Skin conditions encountered in injecting drug users. Skin Lesions Description N of cases Percentage Track Marks 92 92.0% Atrophic Scars 100 100.0% Hesitation Marks 54 54.0% Tattoos 53 53.0% Others Acne vulgaris 2 2.0% Acneiform eruptions, intertrigo 1 1.0% Atrophic scars in groins and nodular scabies 1 1.0% Balanitis 2 2.0% Cholinergic urticaria 1 1.0% Extensive Tinea corporis 1 1.0% Facial melanosis 5 5.0% Folliculitis, scabies 2 2.0% Herpes genitalis 1 1.0% Hyperhidrosis, tightness of skin 1 1.0% Intertrigo 2 2.0% Intertrigo, facial melanosis 1 1.0% Keratosis pilaris 1 1.0% Large atrophic scars on bilateral thighs 1 1.0% Mottled pigmentation and hyperkeratosis on palms 1 1.0% Post herpetic zosteriform scars 1 1.0% Scabies 11 11.0% Scabies and acne corporis 1 1.0% Scabies nodular 8 8.0% Scars in groin and pubic region 1 1.0% Sebaceous cysts scrotum 1 1.0% Seborrheic keratosis and facial melanosis 1 1.0% Soft tissue swelling 1 1.0% Thrombophlebitis 1 1.0% Tineacorporis Cruris and facial melanosis 1 1.0% Tineacorporis Cruris and ulcer on right palm, soft tissue swelling on right arm 1 1.0% Tinea corp., scabies with folliculitis 1 1.0% Tineacorporis 1 1.0% Tineacorporis with ulcers 1 1.0% Tineacruris 1 1.0% Tineacruris, facial melanosis 1 1.0% Trichomycosis 1 1.0% Ulcer non-healing on left leg 1 1.0% Ulcer on arm 1 1.0% Ulcer over hand and facial melanosis 1 1.0% Ulcers on left forearm 1 1.0% Ulcers on thighs, hands and feet, xanthelasmapalpebrum 1 1.0% Warts on hands 1 1.0% None 37 37.0% Total 100 100.0% 6 Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 Table 4. Oral and skin appendageal conditions seen in injecting drug users. Mucosal Lesions_Lips No. of cases Percentage Angular cheilitis 2 2.0% Depigmented patches 7 7.0% Discoloration 45 45.0% None 46 46.0% Total 100 100.0% Buccal mucosa lesions Erosions 1 1.0% Pigmentation 77 77.0% None 22 22.0% Total 100 100.0% Mucosal Lesions_Teeth Caries 2 2.0% Stained 69 69.0% None 29 29.0% Total 100 100.0% Mucosal Lesions_Gingivolabial Sulcus Cobblestoning 3 3.0% Erosions 1 1.0% Gingival ulcer, SMF and pigmentation 1 1.0% Gum recession with gingival erosion and leukoplakia 1 1.0% Leukoplakia 7 7.0% Micro erosions over labial mucosa, recession of gums 1 1.0% Pigmentation 33 33.0% Pigmentation, SMF 24 24.0% SMF 6 6.0% None 23 23.0% Total 100 100.0% Hair No. of cases Percentage Androgenetic alopecia 1 1.0% Sparsity 2 2.0% Trichomycosis 2 2.0% None 95 95.0% Total 100 100.0% Nails No. of cases Percentage Clubbing 1 1.0% Discolored 4 4.0% Dystrophic nail 2 2.0% Koilonychia 2 2.0% Leukonychia 1 1.0% Long. Melanonychia 29 29.0% Onychomycosis 1 1.0% Paronychia, longitudinal Melanonychia 1 1.0% None 59 59.0% Total 100 100.0% SMF = submucosal fibrosis Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 7 (SD) of 3.75, 4.92, 11.69, and 3.89 in Domain 1, 2, 3, and 4, respectively (Table 5). Conclusions Drug abuse has been taking a great toll on the health and well-being of the community for the past few decades. A rise in injecting drug abuse has been posing threat to the indi- vidual health and thus to QoL. Skin is among the neglected organs among IDUs and the tendency of neglect increases with the duration of abuse [19]. Track marks are linear or DLQI revealed moderate effect (score 6-10) on QoL due to skin affection in 54% of patients, followed by mild effect (score 2-5) in 26% and very large effect (score 11-20) in 20 patients. Depression Anxiety Stress Score revealed extremely severe depression in 1, severe in 1, moderate in 3, and mild depression in 1 IDU. Anxiety observed was extreme in 1, severe in 2, moderate in 4, and mild in 9. The stress index showed extreme stress in 2, severe in 3, moderate in 9, and mild in 13. WHOQ-OL questionnaire was used which gave a mean of 42.92, 34.35, 47.06, 37.50, with a standard deviation Table 5. Psychological aspects and quality of life Parameters of injecting drug users. DLQI Score (Dermatology Life Quality Index) N of cases Percentage 0-1.0 0 0.0% 2-5.0 26 26.0% 6-10.0 54 54.0% 11-20.0 20 20.0% 21-30.0 0 0.0% Depression No. of cases Percentage 0 90 90.0% 1 5 5.0% 2 3 3.0% 3 1 1.0% 4 1 1.0% Total 100 100.0% Anxiety No. of cases Percentage 0 84 84.0% 1 9 9.0% 2 4 4.0% 3 2 2.0% 4 1 1.0% Total 100 100.0% Stress No. of cases Percentage 0 73 73.0% 1 13 13.0% 2 9 9.0% 3 3 3.0% 4 2 2.0% Total 100 100.0% WHO-QOL N Minimum Maximum Mean Std. Deviation Age (Years) 100 19.00 60.00 30.08 6.53 Duration of Abuse (Years) 100 2.00 18.00 8.34 3.77 DLQI Score 100 2.00 18.00 7.88 3.28 WHO - QOL (BREF)_Domain 1 100 38.00 50.00 42.92 3.75 WHO - QOL (BREF)_Domain 2 100 31.00 44.00 34.35 4.92 WHO - QOL (BREF)_Domain 3 100 31.00 69.00 47.06 11.69 WHO - QOL (BREF)_Domain 4 100 31.00 44.00 37.50 3.89 8 Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 Among the infections and infestations, scabies was the most common disease encountered and the level of neglect further poses a threat to its treatment. Poor hygiene is a significant risk factor to acquire scabies besides deranged itch-scratch cycle, relatively immune-compromised status are other contributory factors. The diagnosis of scabies may be at times missed by psychiatrists and thought to be related to drug abuse- delusion of parasitosis [20]. In such instances full body exposure and site-specific examination may reveal burrows of mite and clinches the diagnosis. Superficial der- matophytosis, a fungal infection, is another common infec- tion encountered among IDUs which presents as round and annular itchy plaques over the body (Figure 3). Other infec- tions include bacterial folliculitis and infected wounds. Viral disease transmission is common among IDUs due to sharing of syringes due to which there is an increased rate closely spaced needle pricks seen as black dots on the skin overlying veins in IDUs. (Figure 1). These are among the most common and absolute signs seen in active IDUs. There can be surrounding erythema or induration which depicts inflammatory reaction either due to extravasated drug or infection in the intradermal or subcutaneous tissue. Throm- bophlebitis can be associated with track marks at times and can lead to cellulitis if not taken care of. On dermoscopic examination, these are seen as black dots or hemorrhages, comedones-like or plug arranged linearly with bluish-black to the erythematous background (Figure 2). Small rounded atrophic scars are another hallmark of injecting drug abuse. These are a result of skin popping that form small ulcers which heal with atrophy. In patients with the tendency to keloid formation, large nodular lesions may be seen instead of atrophic scars. Figure 1. (A) Multiple depressed scar marks over inguinal region. (B) Skin popping marks. (C) Hesitation marks. (D) Track marks. Figure 2. On dermoscopic examination ( 100X. ILLUCO), black dots or hemorrhages, comedones like or plug arranged linearly with bluish-black and brownish to reddish white background. Figure 3. (A) Scabies mite burrows. (B) Extensive TineaCorporis. (C) Soft tissue swelling of arm (patient was T1 DM). (D) Herpes genitalis. of incidence of viral Hepatitis and HIV-AIDS among them [21]. In our study, the majority of the patients were positive for HCV and HIV. This draws attention to checking the be- havior and actions of IDUs and adopting measures prevent- ing them. The oral cavity is yet another area to be stressed upon in IDUs as they tend to be smokers, alcoholics, and tobacco abusers with poor oral hygiene and the degree of neglect they have may pose drastic effects such as oral malignan- cies [22,23]. The changes observed in our studies included pigmentation related to nicotine and depigmented patches too can be toxic reactions to the melanocytes. The gingivola- bial mucosa was the most exploited area in the oral cavity due to the habit of keeping the tobacco pouch undersurface of the lip and most patients had pigmentary changes, ero- sions, and submucosal fibrosis and few had leukoplakia and 10 Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 The study had several limitations like the fact that the confirmatory diagnosis of the skin disorders was not estab- lished due to short interaction between patient and doctor and unavailability of investigations at the OST center. The second bias was the neglect shown by the IDUs towards skin conditions which lead to a certain degree of concealment of skin conditions. Thirdly, many IDUs did not consent for the full body examination leading to missing some important areas of examination like genitalia and groins which are po- tential sites for infections and sexually transmitted infections as well as spots of drug injection. Lastly, it was not a case control study and hence statistics could not be performed; moreover, the number of study patients was limited. These limitations can be overcome by bringing together the two specialties of de-addiction and Dermatology and stressing cobble-stoning which tend to be premalignant conditions and may lead to drastic situations if not addressed accord- ingly (Figure 4). In the assessment of QoL related to dermatological con- ditions, the dermatology QoL index has proven to be a good tool [24]. In our study, a majority of IDUs had moderately hampered life quality which means the skin conditions either due to the direct effect of drugs or secondary involvement has brought about changes in the daily routine of IDUs which can be social, psychological, or economic encroachment. Similarly, the mental state of the patients was assessed by the Depression Anxiety Stress scale which is a crude and partially objective method of assessment of the inner horizon of patients. It revealed a significant alteration in the mental state of the IDUs. Figure 4. (A) Oral cavity pigmentation with caries teeth. (B) Cobble-stoning of gingivolabial sulcus with erosions. (C) Submucosal fibrosis with leukoplakia. (D) Gingivolabial mucosal fibrosis with ulceration. Original Article | Dermatol Pract Concept. 2022;12(4):e2022154 11 over the need for periodic examination of the skin of IDUs to look for any direct or indirect effects of drug abuse. Skin conditions occurring in IDUs are a result of direct injury to the skin by the offending drug or by the methods used to introduce drug into body. Track marks resulting from repeated intravenous drug abuse are the commonest occurrence followed by atrophic rounded scars due to drug popping into the skin. Infectious conditions of the skin are common which occur either because of the contaminated drug or by the neglect of an IDU in receiving treatment. Hes- itation marks seen in a large number of candidates relate well with altered mental condition of the IDUs. Drugs and altered mental state form a vicious cycle such that it almost becomes impossible for IDUs to maintain a sound conscience and psychological and physical dependence further takes its toll. Thus, dermatologists and psychologists should collabo- rate to address the healthcare needs of an IDU so that timely necessary actions can be taken. References 1. Ahmed N, Bano R, Agarwal V K, Kalakoti P. Substance abuse in India. 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