Narcotic addiction may induce systemic and local complications. Intravenous 
injections of drugs can cause venous thrombosis, and septic or embolic 
complications. The puffy hand sign is a more uncommon complication of hard-core 
injection addicts. Three long-term intravenous drug users, two males, one 
female, mean age 30.6 years (26-37) presented puffy hands. These patients had 
been drug addicts for four to twelve years (mean duration 7.3 years) and had 
stopped heroin injections for 3-5 years (mean 4.6), participating in a 
buprenorphine substitution program. The edema appeared several years after drug 
cessation (1.5-5, mean 2.3). Typically the puffiness was bilateral, the hands 
swollen from the proximal segments of the fingers to the wrist. In one patient, 
the edema was localized both in the hands and in the feet. The edema was not 
pitting and unaffected by elevation. Duplex ultrasound examination of the 
extremities was normal. Lymphangiography performed in one patient was consistent 
with deep lymphatic destruction. Puffy hand syndrome appears to be the end 
result of lymphatic obstruction. Repeated injections of drugs in or outside the 
veins destroy the lymphatics. Buprenorphine may play an important role in the 
puffy hand sign. Although it is supposed to be administered orally, many drug 
addicts use it as an i.v. solution. Because buprenorphine is poorly soluble, it 
causes lymphatic obstruction. This type of hand for which no therapy exists must 
be differentiated from deep palmar space infection with dorsal edema which 
requires incision and drainage.