Pemphigus vegetans is variant of pemphigus vulgaris accounting for 5% of all patients with pemphigus disorders. We describe a case of pemphigus vegetans–Neumann type associated with intranasal heroin abuse, restricted to the modified mucous membranes. The results of routine histology and direct and indirect immunofluorescence studies confirmed the diagnosis. The patient responded to oral prednisone of 40 mg daily for 1 month, followed by reduction to a maintenance dose of 15 mg daily. A complete remission was sustained for 6 months. The relationship between intranasal heroin use and the development of pemphigus vegetans remains uncertain but appears to be an intriguing possibility in this patient. (J Am Acad Dermatol 1998;39:872-5.)