English: A man in his 40s with a history of IV drug use and HCV presented with a spreading, painful area on his right medial thigh (Fig 2). He had a longstanding history of IV cocaine and fentanyl use and last injected fentanyl 1 week prior. He believed the fentanyl contained xylazine, as the last dose of fentanyl was “more potent” than prior doses. Toxicology screen was positive for cocaine and fentanyl. Urine xylazine analysis was positive at 40,000 mg/mL. Necrotic ulcerations at previous injection sites were observed on bilateral arms, hands, legs, and feet. A broad vasculitis workup was negative. Punch biopsy showed nonspecific inflammation and subcutaneous necrosis, without vasculopathy. Tissue cultures were positive for 1 colony of streptococcus and cultibacterium, which were deemed contaminants. His clinical presentation was most suggestive of xylazine-induced skin necrosis. He received local wound care with significant improvement.