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Funding sources: none.

Conflicts of interest: none declared.

Dear Editor, A 33‐year‐old man with drug addiction presented immediately after buprenorphine injection in the left calf vein an intense pain with a purpura, associated with purplish, livedoid skin lesions surrounded by pale skin (a). It evolved within 5 days into a necrotic‐centre lesion (b). Nerve ischaemia due to vasospasm caused motor L5‐S1 deficiency. Histopathological examination showed capillary thrombotic occlusion and perivascular inflammation (c) with macrophages containing inorganic refringent particles (toluidine blue staining). Under topical corticosteroid and morphine, the pain and livedoid lesions resolved within 3 weeks. However, the resolution of secondary wounds took 4 month. These lesions are known as Nicolau syndrome (NS). NS complicates intramuscular, perinervous or paravascular drug administration, as well as local anaesthesia, nonsteroidal anti‐inflammatory drugs, corticosteroids, vaccines and vitamin B complex.1 The pathogenesis of NS is unknown. Hypothesis are drug‐induced vasospasm, mechanical vessel occlusion and inflammation and necrosis of the intima following injection.2

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