Complications

Published on 15/03/2015 by admin

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16 Complications

Kyle M. Coleman, William P. Coleman, III

Introduction

Like all medical procedures, chemical peeling has many potential side effects that should be clearly understood before beginning. Anticipating these complications can help to lessen or eliminate their occurrence. When side effects are anticipated, there is less likelihood of an event that surprises the patient or the physician. Results in peeling vary from patient to patient and so does the potential for complications. However, as always, a good physician–patient relationship and adequate understanding of the risks versus benefits of the procedure is critical.

The leading cause of complications in chemical peeling is inadequate training. Obtaining a comprehensive knowledge of the scientific literature is the obvious first step before embarking on any new procedure. After this, training at the operating table with an experienced operator is vital (in the USA this would preferably be in a formal ABMS approved residency such as Dermatology). Mistakes due to lack of training can cause huge errors in chemical peeling.

Recently, companies which market simplified chemical peel systems or ‘cookbook peel kits’ to physicians with little or no training in this procedure have targeted non-physicians. They sell chemical peel kits and weekend training to physicians willing to delegate the peels to a variety of office personnel. This inferior practice has resulted in numerous patient injuries and countless malpractice lawsuits. Only physicians who are properly trained in this technique, such as those certified by the American Board of Dermatology, should perform chemical peeling. Delegating this procedure to non-physicians is, in our opinion, dangerous, regardless of the training of the physician.

Proper storage, preparation, and handling of caustic peeling substances are absolutely necessary. Errors in formulations of the acids used for peeling can result in solutions that are much stronger than intended. Physicians must have an understanding of the different types of peeling agents and their intended uses. Additionally, the physician should be well versed in the proper application of chemical peeling solutions in order to avoid peeling deeper than intended. Although many complications of chemical peeling can be corrected, it is important to try to avoid those that are unnecessary.

Each peeling agent carries with it a unique set of possible complications; however, there are some complications that can occur no matter which solution is used. Obviously, the more aggressive the agent employed the more potential for error and side effects. Likewise, more aggressive, deeper application techniques have increased risk. Prior to beginning a peel, all of the potential dangers of the procedure should be weighed against its potential benefits in order to maximize desired results and minimize problems. See Table 16.1 and also see Box 16.1.

Table 16.1 Sequelae versus adverse reactions and complications of chemical peels

Minor sequlae	Adverse reactions	Complications
Pain Erythema Pruritus Swelling/edema Acne/milia Ecchymoses	Hypo-/Hyperpigmentation Lines of demarcation Persistent erythema Infection Herpes reactivation	Scarring Arrythmias (phenol) Toxicity (salicylic) Corneal damage

Box 16.1

Key features

• Oral corticosteroids can be used to abate severe post-procedure edema; however, steroids should not be employed preemptively as this can increase the risk of postoperative infection.

• Application of topical anesthetic cream 30 minutes before applying the acid can significantly reduce pain in medium-depth peels. However the topical anesthetic should be completely removed with soap and water prior to beginning the peel.

• Pruritus with increased erythema, or pustules that occur during the healing period, may signal a possible contact allergy to the wound care ointment being used.

• Acne prone patients will almost always flare after a medium-depth or deep peel, and they should be warned of this in advance. Oral antibiotics should be started as soon as the flare begins, usually several days post peel.

• The most consistent sign of a herpes reactivation is pain; thus all painful lesions occurring after a peel should be treated as such.

• Prophylactic antiviral medication should be started in patients who undergo medium to deep chemical peels to prevent reactivation of herpes simplex. These are typically started the day prior to peeling and continued until reepithelialization.

• Patients with a propensity for hyperpigmentation should be treated with a series of superficial peels, rather than a medium or deep peel, to avoid rebound pigmentation

• The most common areas for demarcation lines to occur are below the mandible, near the eyes and periorally.

• To create an even appearance around the eyes, peels should be applied right up to the lashes on the lower lids and to the supratarsal crease on the upper lids.

• Some early signs that scarring may be occurring are persistent erythema and pruritus.

• Be sure that the concentration of acid is what is on the label and listed in in weight/volume. Always treat only a small area of a patient’s skin when opening a new bottle of peeling agent, and watch closely to be sure there is not more frost or erythema than expected, before applying the acid over large areas.

• The most common systemic effect seen with phenol peeling is cardiotoxicity. The majority of phenol is absorbed within the first 30 minutes of its application. Thus, higher doses over a short amount of time are more likely to have systemic effects.

Complications Possible in All Types of Peel

• Swelling

Although swelling is more prominent in deeper peels, every peeling agent can cause swelling. This edema usually surfaces in 24 to 72 hours after the peel and is usually a fairly mild and expected sequelae of the procedure. In some cases, however, the edema may be severe enough to swell the eyes shut. This severe swelling may in some instances take several days to resolve. Nevertheless, this complication will be less worrisome to the patient if the possibility is raised before the procedure is done. Application of ice and proper wound care to the affected areas can serve to reduce the possibility of severe swelling. In severe cases systemic corticosteroids may be required to reduce swelling. Although some physicians routinely prescribe preoperative oral steroids for resurfacing procedures there is the possibility of impairing wound healing. It is more logical to reserve systemic steroids for the few patients who experience severe edema. See Box 16.2.

• Pain

Pain is unfortunately a very common and expected result of medium-depth and deep peels. The amount of pain experienced, of course, depends on the individual patient. Pain can range from very mild to quite severe. Medium-depth peels usually produce only a few minutes of pain, immediately after application of the peeling solution. It is rare for the medium-peel patient to require prescription strength postoperative pain medications. Topical anesthetic agents such as EMLA (2.5% lidocaine, 2.5% prilocaine) or LMX (4% lidocaine) can be used to reduce the pain of the procedure without affecting the depth of the peel penetration. Deep peels tend to involve a significantly greater amount of pain; this often crescendos several hours after the peel. Generally, the pain from deep-depth peels does not last longer than 8 to 12 hours.

• Persistent erythema

Erythema is common after all peel types. It is usually more noticeable and lasts longer in medium and deeper peels. Phenol peels usually are accompanied by erythema lasting 6 to 8 weeks before resolving. Erythema from TCA peels tends to fade in 2 to 3 weeks. Erythema is a natural response to the procedure; however, any erythema lasting longer than expected must be observed carefully for the possibility of scar formation (Figs 16.1–16.3). This ‘persistent’ erythema is best treated as soon as it is recognized with potent topical steroids. If there is no response, intralesional, oral or intramuscular steroids may be required. Resistant erythema often responds to pulsed dye lasers or intense pulsed light devices. See Boxes 16.3 and 16.4.

Figure 16.1 Persistent erythema of the neck after a 20% TCA peel

Figure 16.2 Persistent infraorbital erythema after a 35% TCA peel

Figure 16.3 Same patient as in Fig. 16.2, several weeks later, beginning to develop early hypertrophic scar in area of previous erythema

Box 16.3

Normal postpeel erythema

• Medium-depth peel (TCA): 2–3 weeks

• Deep peel (phenol): 6–8 weeks

Box 16.4

Persistent erythema

Why treat? Can herald incipient scar formation.

• Topical steroids (class I steroid bid to affected area for 1–2 weeks)

• Oral antihistamines

• Oral steroids (prednisone tapers or dose packs) or Intramuscular steroids (kenalog 40 mg IM) or Intralesional triamcinolone, gradually increasing the concentration up from 3 mg/cc, injected monthly until resolved

• Low level laser or IPL performed weekly until resolved: e.g., Vbeam (595 nm–7 mm spot, 5–7 joules, 10 msec with cooling) or IPL settings according to the specific device

• Pruritus

Pruritus is very common after medium and deep chemical peels. It occurs after reepithelialization and may last up to several weeks. Pruritus with increased erythema or pustules that occurs during the healing period may signal a possible contact allergy to the wound care ointment being used. In this case, the offending agent should be stopped and the patient given small doses of oral prednisone. The normal pruritus from healing can be disconcerting to some patients and can be treated with oral antihistamines and topical hydrocortisone creams or ointments. The fluorinated steroids should be used carefully to avoid any atrophy or telangiectasia formation.

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