The incidence of vascular complications due to drug addiction is increasing significantly. Intravenous heroin injection can cause arterial, venous, and lymphatic complications, affecting a multitude of vessels, whether venous, arterial, or lymphatic: arterial ischemia, arterial and venous pseudoaneurysm, septic thromboembolic disease, and puffy hand syndrome.

We report the cases of 8 patients, 6 men and 2 women, aged 28 to 44 years (average age 35.5 years), all intravenous heroin users. They presented with swollen hands. These patients had been addicted to heroin for 8 to 15 years (average 11 years). Seven of these patients were participating in a buprenorphine substitution program. The edema appeared several years after stopping heroin, from 3 to 5 years (average 3.8 years). The edema was bilateral, and the hand was swollen from the proximal segments of the fingers up to the wrist.

The duplex arterial ultrasound of the upper limbs was normal; 3 patients had sequelae of superficial venous thrombosis of the upper limb. For 5 of the patients, lymphoscintigraphy showed an abnormal lymphatic flow in the upper limbs.

The patients were treated with an intensive phase of multilayer compression, followed by maintenance with a compression garment of the hand and manual lymphatic drainage The 24-month follow-up showed a favorable clinical evolution of the upper limbs with reduced pain and moderate regression of edema in five patients.

Puffy hand syndrome is described the first time by Adeles in 1965. Typically the puffiness is bilateral and the edema appears several years after cessation the injections. The pathophysiology, still unclear and based in part on a lymphatic toxicity of heroin.

Repeated heroin injections inside or outside the veins can provoke venous thrombosis, arterial complications, infections, and fibrosis.

Fibrosis can provoke compression of lymphatic vessels. An injection outside the veins can destroy the lymphatic vessels. Puffy hand syndrome is probably a secondary lymphedema caused by heroin injection.