Puffy hand syndrome with histopathological evidence of a cutaneous granulomatous reaction to starch in the setting of prior intravenous drug use.

In the United States, 9.5 million people struggle with opioid misuse, of which 2.7 million meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for opioid use disorder.1 Intravenous drug use (IVDU) can lead to cutaneous reactions associated with injected drug contaminants or fillers, including sugars, talc, and starch.2 Puffy hand syndrome (PHS)—a phenomenon associated with chronic IVDU—clinically presents as intermittent, painless, erythematous, nonpitting edema of the hands and upper extremities.