Xylazine Wound Care Has Been Guessing — Two Baltimore Studies Just Asked the Patients Instead

Ask someone who injects drugs in Baltimore why their skin is breaking down in places the needle never touched, and researchers finally have an answer on record: “It start eating you from the inside out, literally.” That line comes from a Johns Hopkins Bloomberg School of Public Health interview published in the journal Addiction on March 5, 2026 — one of two linked 2026 studies that are the first real attempt to survey xylazine’s wound damage at population scale and then ask the people living with it what they think is happening.

The numbers side, published July 30 in the Journal of Addiction Medicine by Johns Hopkins epidemiologists Andrea Ponce and Danielle German, surveyed 315 people who inject drugs in Baltimore using a peer-referral method built to reach people invisible to clinic data — what researchers call respondent-driven sampling. Nearly 40% (39.4%) reported a wound history; 80% attributed at least one to xylazine, the veterinary sedative now routinely found mixed into the fentanyl supply. Among xylazine-attributed wounds, 53% had turned to dead, blackened tissue that sloughs off or needs surgical removal — necrotic eschar, in clinical shorthand — and 56% were still open at interview.

Xylazine wound care has been guessing at causation for years, and the patients living with it just handed researchers the map clinicians still aren’t trained on.

German’s companion qualitative study — 26 interviews where participants marked wound locations directly onto a body outline, a technique researchers call body mapping (69% of those interviewed were recently unhoused) — is where the “why” lives. People consistently connected worse wounds to specific, describable circumstances: missed injections landing in fatty tissue under the skin instead of the vein, and pre-existing conditions like hypertension or diabetes that were already narrowing their blood vessels before xylazine ever entered the picture. Researchers frame this as an evidence base clinicians have been missing — not a how-to for people currently using, but a map for the wound-care and syringe-service workforce that’s been debriding tissue without knowing why one wound scars clean and another eats a forearm.

Both teams land on the same recommendation: expand wound-care training for street medicine and low-barrier clinics, and build it around what patients already know instead of starting from zero. That’s a narrower ask than a xylazine antidote or a federal scheduling fight, and it’s one a county health department or an SSP can act on this budget cycle, not the next one.

The gap these studies are closing isn’t clinical mystery — it’s that nobody funded the survey until 2024, and nobody asked the follow-up question until now.