Two million Americans use cocaine on a regular basis. Sixty-nine percent of cocaine in the United States is adulterated with levamisole, a veterinary antihelminthic drug. In 2008, the first cases of levamisole-induced agranulocytosis and vasculopathy associated with adulterated cocaine were reported in the southwestern United States. Since then, reports of levamisole-associated toxicity have become increasingly common. The authors present the case of a 47-year-old woman from Michigan with purpuric lesions likely secondary to levamisole-induced leukocytoclastic vasculitis.

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Outpatient VA dermatology services accomplish significant primary care and preventive services (eg, sun safety counseling, skin cancer screening, and treatment). However, the small number of dedicated dermatology services, their irregular geographic distribution, and the lack of staffing and resources may adversely affect optimal patient care. Dermatologist responses regarding the positive and negative aspects of working in the VA system may lead to improved management strategies to better retain and recruit dermatologists to provide patient care, medical education, and medical research despite dramatically lower dermatologist salaries within the VA system compared with private practice.