Aesthetic Dermatology MCQ - Premature peeling

A 30-year-old woman undergoes a medium-depth 35% trichloroacetic acid (TCA) peel for moderate acne scarring. On day 4 post-procedure, she manually peels off the desquamating epidermis because she is bothered by the appearance. Two days later, she presents with intense erythema, pain, and serous exudate. Which of the following is the most likely complication and the most appropriate initial management?

A) Secondary infection; perform bacterial culture and start empiric oral antibiotics
B) Contact dermatitis; apply a high-potency topical corticosteroid
C) Impending scarring; initiate intralesional triamcinolone
D) Postinflammatory hyperpigmentation; begin hydroquinone 4% cream
E) Allergic reaction; administer oral antihistamines

Correct Answer: A) Secondary infection; perform bacterial culture and start empiric oral antibiotics

Explanation

This case illustrates a common but serious error after a chemical peel: premature removal of the peeling skin, which disrupts the healing process and compromises the skin's barrier function.

Why This is a Secondary Infection:

• Disrupted Barrier: The peeling skin (desquamating epidermis) is a natural biological dressing. Removing it prematurely exposes the immature, fragile underlying epidermis, creating a portal for pathogens.

• Clinical Signs: Intense erythema, pain, and serous exudate are classic signs of a superficial wound infection (e.g., impetiginization).

• Common Pathogens: Staphylococcus aureus and Streptococcus pyogenes are most frequently implicated.

Immediate Management:

1. Bacterial Culture: Swab the exudate for culture and sensitivity to guide therapy.

2. Empiric Antibiotics: Start oral antibiotics covering common skin pathogens (e.g., cephalexin, dicloxacillin) immediately while awaiting culture results.

3. Topical Care: Gentle cleansing with saline or dilute acetic acid soaks, followed by application of a topical antibiotic ointment (e.g., mupirocin).

4. Avoid Corticosteroids: They can impair immune response and worsen infection.

Why Not the Other Options?

• (B) Contact dermatitis: Would present with pruritus and eczematous changes, not painful exudate. It is not typical after premature peeling.

• (C) Impending scarring: Scarring develops later (weeks) and presents with induration, not acute exudate. Intralesional steroids are contraindicated in active infection.

• (D) Postinflammatory hyperpigmentation (PIH): Presents as hyperpigmented macules/patches after inflammation resolves, not with acute pain and exudate.

• (E) Allergic reaction: Would cause urticaria, pruritus, or edema, not exudate.

Prevention of Premature Peeling:

• Patient Education: Crucial to instruct patients to allow natural exfoliation and not pick or peel the skin.

• Symptomatic Relief: Use cool compresses, emollients, and oral antihistamines for pruritus.

Prognosis:
With prompt antibiotic treatment, the infection should resolve. However, this complication increases the risk of prolonged healing, PIH, and scarring.

Note: Premature peeling is a behavioral complication that can undo the benefits of a peel and lead to serious sequelae. The key is patient education before the procedure. Management of infection is paramount to prevent deeper tissue involvement and scarring. Always rule out herpes simplex virus reactivation if vesicles are present.