Aesthetic Dermatology MCQ - Systemic toxicity of peels

A 55-year-old woman undergoes a full-face deep chemical peel with a phenol-based formulation for severe photodamage. During the procedure, she develops tachycardia, hypertension, and premature ventricular contractions (PVCs). Which of the following is the most likely cause and the most critical immediate action?

A) Phenol toxicity; discontinue the peel, administer IV fluids, and initiate cardiac monitoring
B) Anaphylactic reaction; administer intramuscular epinephrine
C) Vasovagal response; place the patient in Trendelenburg position
D) Local anesthetic toxicity; administer intralipid therapy
E) Alcohol intoxication; provide supportive care

Correct Answer: A) Phenol toxicity; discontinue the peel, administer IV fluids, and initiate cardiac monitoring

Explanation

This scenario describes systemic phenol toxicity, a rare but life-threatening complication of deep chemical peels using phenol-based solutions.

Key Features of Phenol Toxicity:

• Cardiac Effects: Phenol is a myocardial irritant and can cause arrhythmias (e.g., tachycardia, PVCs, ventricular tachycardia), hypertension followed by hypotension, and even cardiac arrest.

• Timing: Symptoms can occur during or immediately after phenol application, especially when large surface areas are treated rapidly.

• Other Systemic Effects: CNS depression (dizziness, seizures), respiratory distress, and renal failure due to direct toxin effects.

Pathophysiology:

• Phenol is rapidly absorbed through the skin and is a protoplasmic poison, uncoupling oxidative phosphorylation and causing cellular dysfunction.

• It has a short half-life but can cause significant damage during exposure.

Immediate Management:

1. Discontinue the peel immediately.

2. Initiate cardiac monitoring (ECG) to detect and treat arrhythmias.

3. Administer IV fluids to promote renal excretion and support blood pressure.

4. Consider urinary alkalinization (with sodium bicarbonate) to enhance phenol excretion.

5. Supportive care: Oxygen, anticonvulsants if needed, and prepare for advanced cardiac life support (ACLS) if arrhythmias worsen.

Why Not the Other Options?

• (B) Anaphylactic reaction: Would present with urticaria, angioedema, bronchospasm, or hypotension, not isolated cardiac arrhythmias like PVCs.

• (C) Vasovagal response: Causes bradycardia and hypotension, not tachycardia and hypertension.

• (D) Local anesthetic toxicity: Could cause CNS (seizures) and cardiac effects (arrhythmias), but phenol is the agent used here, not local anesthetics.

• (E) Alcohol intoxication: Some peel formulations contain ethanol, but systemic toxicity would cause CNS depression (ataxia, slurred speech), not primarily cardiac arrhythmias.

Prevention of Phenol Toxicity:

• Staggered application: Treat facial regions in 15-minute intervals to reduce peak absorption.

• Cardiac monitoring: Essential during and after full-face phenol peels.

• Adequate hydration: Before and during the procedure.

• Avoid in patients with cardiac or renal impairment.

Prognosis:
With prompt recognition and management, most patients recover. However, delayed treatment can be fatal.

Note: Phenol peels are high-risk procedures that require a controlled medical setting with resuscitation equipment available. Tachycardia and PVCs are red flags for toxicity. Always prioritize patient safety over cosmetic outcomes.