Background Up to 88% of cocaine is tainted with levamisole, an anthelmintic withdrawn from the market due to toxicity. Since 2010 levamisole-adulterated cocaine induced vasculopathy (LACIV) patients, characterised by retiform purpura, ear necrosis, multisystemic compromise and positivity for multiple autoantibodies, have been reported. Knowing the pattern and the severity of skin involvement is essential in the approach of these patients.

Objectives To describe the cutaneous manifestations of patients with LACIV and to propose a classification of skin involvement.

Methods We describe the skin compromise of 30 patients with LACIV evaluated between December 2010 and May 2017. Based on this series and the review of the literature, we propose a classification according to the distribution and severity of the lesions.

Results All patients were mestizo, median age of 31 (IQR 27–38), male:female ratio 5:1, time from symptoms to diagnosis 12 months (IQR 6–24). The most frequent clinical manifestations were skin lesions: ear necrosis (73%) and retiform purpura (83%) affecting the extensor part of the limbs, buttocks, face, and abdomen; sparing the scalp, palms and soles. Retiform purpura was classified in four grades according to distribution and severity (image). Skin biopsies revealed leukocytoclastic vasculitis (24%), pseudo-vasculitis (19%), thrombotic vasculopathy with leukocytoclastic vasculitis (19%), thrombotic vasculopathy with pseudo-vasculitis (19%), and pyoderma gangrenosum with vasculopathy (5%).

Image LACIV retiform purpura classification. A. Grade 1: livedo reticularis or racemosa with incipient purpura (individual lesions≤1 cm). B. Grade 2: More extended purpuric lesions which sometimes coalesce (individual lesions>1 cm). C. Grade 3: Purpuric lesions with haemorrhagic blisters. D. Grade 4: Deep purpuric lesions with associated ulceration.

Conclusions Given the higher consumption of cocaine and its contamination with levamisole, the report of LACIV patients is increasing. A classification of the skin involvement in LACIV is proposed, according to the frequency of affection and the stratification of purpuric lesions in four degrees of severity. Cutaneous involvement is one of the pillars for the diagnosis and properly treatment, therefore a detailed description of distribution and characteristics of the lesions are fundamental for these patients care.

References [1] Pearson T, et al. Vasculopathy related to cocaine adulterated with levamisole: A review of the literature. Dermatol Online J2012;18:1.

[2] Gillis JA, et al. Levamisole-induced vasculopathy: staging and management. J Plast Reconstr Aesthet Surg2014;67:e29–31.

Disclosure of Interest None declared