Plasmapheresis and Steroid Treatment of Levamisole-Induced Vasculopathy and Associated Skin Necrosis in Crack/Cocaine Users

Background:Levamisole was removed from the market due to complications of agranulocytosis and skinnecrosis. Levamisolehas been reported in a high proportion of seized cocaine in North America and has been associated with multiple cases of skinnecrosis.Objective:We report three cases of levamisole/cocaine-induced skinnecrosis who responded to treatment with plasmapheresisand immunosuppression.Results:Three patients presented with painful necrotic skinlesions on the ears, cheeks, breasts, and buttocks. The extremities were involved in two patients and the upper respiratory tract mucosa in one patient. All had markers of immune activation, with elevated C-reactive protein, antinuclear antibody, and perinuclear antineutrophil cytoplasmic antibody. Skin biopsyin all cases revealed a mixed patternof thrombosis and vasculitis within dermal vessels, with overlying ischemic ulcerationof skinand soft tissues. One patient required extensive debridement of the skinand soft tissue of the calves and also had...