Aesthetic Dermatology MCQ - Persistent redness after peeling

A 48-year-old woman with Fitzpatrick skin type II undergoes a medium-depth 35% trichloroacetic acid (TCA) peel for photodamage. At her 3-week follow-up, she has significant persistent erythema and complains of itching and burning in the treated areas. On examination, the skin appears bright red, taut, and slightly indurated. Which of the following is the most appropriate next step to prevent progression to scarring?

A) Immediate initiation of a high-potency topical corticosteroid
B) Intralesional triamcinolone acetonide injections
C) Starting oral antihistamines for pruritus
D) Application of topical tacrolimus 0.1% ointment
E) Beginning treatment with pulsed dye laser therapy

Correct Answer: B) Intralesional triamcinolone acetonide injections

Explanation

This scenario describes a patient with persistent erythema, itching, burning, and early induration after a medium-depth chemical peel. These are classic signs of impending hypertrophic scarring, a serious complication that requires aggressive intervention to prevent permanent scarring.

Why Intralesional Corticosteroids are Critical:

• Pathophysiology: Persistent inflammation and excessive collagen deposition lead to hypertrophic scarring. The symptoms of itching and burning are often prodromal to scarring.

• Gold Standard Treatment: Intralesional triamcinolone acetonide (e.g., 10-20 mg/mL) is the first-line treatment to halt the inflammatory process and suppress fibroblast activity. It is injected directly into the indurated areas to:

  • Reduce inflammation

  • Inhibit collagen synthesis

  • Flatten the scar

  • Relieve symptoms (pruritus, pain)

• Timing: Early intervention is crucial to prevent the scar from becoming mature and refractory to treatment.

Why Not the Other Options?

• (A) High-potency topical corticosteroid: While topical steroids can reduce inflammation, their penetration is limited. They are not sufficient for established induration and impending scarring, which require intralesional delivery for deep anti-inflammatory effects.

• (C) Oral antihistamines: These may help with pruritus but do nothing to address the underlying inflammation or prevent scarring.

• (D) Topical tacrolimus: A calcineurin inhibitor used for eczema. It has no role in managing hypertrophic scarring and may even exacerbate inflammation in this context.

• (E) Pulsed dye laser (PDL): Excellent for reducing erythema in mature scars but is not first-line for early, active scarring. PDL targets vasculature but does not directly suppress collagen production like intralesional steroids. It can be used as an adjunct later.

Additional Management:

• Silicon gel sheets: Can be used adjunctively to improve scar texture and hydration.

• Pressure therapy: May be considered for larger areas.

• Close monitoring: For response to treatment and signs of infection.

Prognosis:
With prompt intralesional steroid injection, the progression to significant scarring can often be halted. Treatment may need to be repeated every 4-6 weeks until the scar flattens and softens.

Note: Persistent erythema beyond 2 weeks after a medium or deep peel is a major red flag for scarring. The combination of erythema, induration, and symptoms (itching/burning) warrants immediate intervention with intralesional corticosteroids. Topical agents are insufficient at this stage. Always rule out contact dermatitis or infection, but in this case, the clinical picture is most consistent with early scarring.