Necrotic livedo after injection of buprenorphine (Subutex®).

Introduction. Use of buprenorphine (Subutex((R))) is widely used as substitution treatment in opiate addiction although its side-effects are little known. We report a case of localised necrotic livedo subsequent to injection of Subutex((R)). Observation. A 34 year-old male drug addict on Subutex((R)) substitution treatment presented a necrotic livedo and an ulcer with clearly demarcated edges on the skin of the inner elbow. Histological analysis revealed PAS-positive particles in a hypodermic inflammatory lymphohistiocytic infiltrate that were reflective and formed a Maltese cross under polarised light and were identified as maize starch. Discussion. This clinical case describes necrotic livedo lesions induced by injection of Subutex((R)). The underlying mechanisms are associated with maize starch, an excipient used in Subutex((R)). Unauthorised subcutaneous injection of buprenorphine (Subutex((R))) is common among drug addicts but there is little description of the associated complications. In our patient, the presence in cutaneous biopsy samples of maize starch, an excipient of buprenorphine, provides evidence of intravenous administration of this drug.