Aesthetic Dermatology MCQ - Peeling Related Chemical Burns

A 38-year-old woman undergoes a chemical peel with an unknown agent at a non-medical spa. She presents 24 hours later with severe pain, erythema, and blistering on her entire face. On examination, the skin has a gray-white, necrotic appearance with areas of hemorrhagic crusting. Which of the following is the most likely causative agent and the most critical immediate intervention?

A) Phenol; urgent surgical debridement and cardiac monitoring
B) Trichloroacetic acid (TCA) 50%; immediate neutralization with water
C) Salicylic acid 30%; application of topical corticosteroids
D) Glycolic acid 70%; neutralization with bicarbonate
E) Jessner's solution; oral antihistamines and emollients

Correct Answer: A) Phenol; urgent surgical debridement and cardiac monitoring

Explanation

This presentation describes a severe chemical burn, consistent with a deep peel gone wrong. The gray-white, necrotic appearance with hemorrhagic crusting indicates full-thickness injury.

Why This is a Phenol Burn:

• Phenol (Carbolic Acid): Used in deep peels (e.g., Baker-Gordon formula), phenol is a protoplasmic poison that causes rapid protein coagulation and necrosis. Its penetration is enhanced by surfactants in some formulations.

• Clinical Signs:

  • Gray-white eschar (due to intense protein denaturation)

  • Hemorrhagic crusting (from vessel damage)

  • Severe pain

• Systemic Toxicity: Phenol is absorbed through the skin and can cause:

  • Cardiotoxicity (arrhythmias, tachycardia)

  • Nephrotoxicity

  • CNS toxicity (seizures, coma)

  • This risk is especially high when large surface areas (like the full face) are treated.

Immediate Interventions:

1. Cardiac Monitoring: Essential due to risk of fatal arrhythmias. This is the most critical first step.

2. Irrigation: Copious water irrigation to dilute and remove the agent. However, note that phenol is partially hydrophobic, and irrigation may be less effective than for other acids.

3. Debridement: Surgical debridement of necrotic tissue may be required to prevent infection and assess depth.

4. Supportive Care: Pain management, fluid resuscitation, and monitoring of renal function.

Why Not the Other Options?

• (B) TCA 50%: A medium-depth agent that can cause burns if misused, but it typically causes a white frost, not gray necrosis. It is not systemically toxic. Neutralization with water is correct, but cardiac monitoring is not needed.

• (C) Salicylic acid 30%: A superficial peel. Over-application can cause irritation and superficial burns, but not full-thickness necrosis or systemic toxicity.

• (D) Glycolic acid 70%: An AHA peel. It can cause burns if not neutralized (with bicarbonate or water), but burns are typically superficial. No systemic toxicity.

• (E) Jessner's solution: A superficial peel. It may cause irritation and allergic reactions (to resorcinol), but not deep necrosis.

Long-Term Management:

• Wound care: Similar to thermal burns, with attention to infection prevention and promoting healing.

• Scar management: Pressure garments, silicone sheets, intralesional steroids for hypertrophic scarring.

• Psychological support: For potential disfigurement.

Prognosis:
Poor; full-thickness chemical burns often result in scarring, contractures, and dyspigmentation. Early intervention is crucial to minimize systemic toxicity and tissue damage.

Note: This case highlights the dangers of deep chemical peels performed by untrained practitioners. Phenol peels require in-depth knowledge, proper patient selection, and cardiac monitoring during the procedure itself. Any suspected phenol exposure requires immediate medical evaluation.