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Although progress has been made in clinical and harm reduction recommendations for treating xylazine\u2010related wounds and slowing their progression, the mechanisms remain insufficiently established. This study aimed to describe wound experiences among people navigating xylazine exposure and explore their perspectives on wound etiology to inform collaborative clinical and public health approaches.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Qualitative research as part of a convergent parallel mixed methods rapid assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Baltimore, Maryland, USA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>\n                      Eligible participants were age 18 or over, Baltimore residents and reported injection drug use and xylazine and wound experience in the past year. Participants (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200926) were evenly distributed by gender and race, mostly over 40, heterosexual, recently unhoused and most frequently injected \u201cfentanyl, in combination with something\u201d or speedball.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measurements<\/jats:title>\n                    <jats:p>Semi\u2010structured qualitative interviews and participatory body mapping, verbatim transcription, iterative thematic analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>Participants classified their wounds from mild (35%) to severe (23%) and commonly reported multiple wounds with shifting severity. Some characteristics matched those typically attributed to xylazine exposure, while others had less clear origins but were still perceived as xylazine\u2010related. A spectrum from pimples, bumps, blisters to deep and blackened ulcerations were considered likely to be xylazine\u2010related and a range of vascular and systemic symptomatology were considered possibly related, as were nasal and throat wounds for those who sniffed or snorted drugs. Participant causal attribution theories related to injection preparation (dilution, contamination), point of contact (subcutaneous tissue, vascularized areas, pulse injection) and interactions with co\u2010occurring health conditions affecting vascular or immune systems (e.g. hypertension, auto\u2010immune disorders). These align with physiological pathways suggested by clinicians and other researchers and offer additional explanations generated among people who inject drugs, drawing on injection\u2010related physiological expertise and lived experience in the absence of formal clinical information. This attribution framework suggests a complex interplay between injection practices, xylazine's physiological effects and individual health conditions on wound development.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Participant causal attribution theories about their possibly xylazine\u2010related wounds align with physiological pathways suggested by clinicians and other researchers and offer additional explanations for wound etiology generated among people who inject drugs.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/add.70362","type":"journal-article","created":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T19:08:42Z","timestamp":1772996922000},"page":"1794-1807","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Theorizing causality: A qualitative study of xylazine\u2010related 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