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. 2025 Aug:142:104830.
doi: 10.1016/j.drugpo.2025.104830. Epub 2025 May 8.

Tranq burn: Exploring the etiology of xylazine-related soft tissue injuries

Daniel Ciccarone  1 , George Karandinos  2 , Alex Krotulski  3 , Jeff Ondocsin  4 , Nicole Holm  4 , Fernando Montero  5 , Max Denn  3 , Christopher Moraff  6 , Sarah Mars  4
Affiliations

Tranq burn: Exploring the etiology of xylazine-related soft tissue injuries

Daniel Ciccarone et al. Int J Drug Policy. 2025 Aug.

Abstract

Introduction: 'Tranq dope' is a combination of xylazine and fentanyl that is increasingly common in the US. Frequently injected, its use appears related to severe skin and soft tissue wounds (SSTW) through an unknown mechanism. Previous research suggests that the high acidity of certain heroin source-forms contributes to vein damage and SSTW, however, the possibility of a role between the acidity of tranq dope and SSTW is understudied.

Methods: A convenience sample of persons who use drugs participated in semi-structured interviews (Philadelphia, Oct. 2023, n = 30). Observations of wounds/injection locations were made. We analyzed narrative data for perceptions of wound causation. Our partner lab analyzed the pH of 10 independently obtained samples, including tranq dope (n = 4), street opioids without xylazine (n = 2), xylazine alone (n = 2), and street stimulants (n = 2).

Results: Observed SSTW were extraordinarily severe. Several themes emerged related to wound etiology: 1) tranq dope injection caused burning sensations; 2) vein loss occurred rapidly following uptake of tranq dope; 3) vein loss resulted in increased injection attempts, the use of large central veins (e.g., jugular and femoral), as well as more frequent 'skin-popping'; and 4) wounds (called 'tranq burn') rapidly followed vein loss. The average pH of the samples was 4, with samples containing fentanyl ranging from pH 2.1-5.9; samples containing xylazine ranging from pH 3.6-5.9; and the cocaine sample with a pH of 3.

Discussion: While this study cannot confirm a causal role, our findings of reported burning sensations and moderate to high acidity of lab-tested drugs are coherent with reported rapid vein loss following initiation of tranq injection. This, in turn, lends early support to a synergistic hypothesis of tranq-related SSTW etiology: vein loss and subcutaneous injections stem from the injection of acidic drugs followed by poor tissue perfusion from vasoconstriction due to xylazine. Possible harm reduction interventions include dilution and buffering. Stigma reduction and enhanced wound care are required in harm reduction and clinical settings.

Keywords: Fentanyl; Injection; Philadelphia; Skin and soft tissue infections; Skin and soft tissue injury; Synthetic opioids; Tranq; Xylazine.

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Conflict of interest statement

Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daniel Ciccarone reports the following relevant financial relationships during the past 36 months: 1, he is a scientific advisor to Celero Systems and 2, he has been retained as an expert witness in ongoing prescription opioid litigation by Motley Rice, LLP. The remaining authors have no relevant financial or non-financial interests to disclose.

Figures

Fig. 1.
Fig. 1.
Image pimple.
Fig. 2.
Fig. 2.
Image leg wounds.
Fig. 3.
Fig. 3.
Image arm wounds.
See this image and copyright information in PMC

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