Adverse Effects in Skin Disease and Care

The most notable complications include hypertrophic scarring, textural changes, and pigmentary disturbances. If hypertrophic scarring is suspected and at any sign of erythema with firmness or textural induration, the physician should be notified and the overnight application of silicone gel sheeting (Epiderm, Biodermis, Las Vegas, NV, USA) should begin, as well as weekly assessment of the patient. Early hypertrophic scarring can be successfully stopped by aggressive intervention with the silicone gel sheeting. If no improvement is seen within the first week, the area can be treated by alternating Cordran tape at bedtime with the silicone sheeting during the day. If no response is seen within 1–2 weeks of this therapy, then intralesional dilute triamcinolone acetonide 2–4 mg/ ml applications are made on an every-otherweek schedule while continuing the silicone gel sheeting and the Cordran tape at bedtime.Once the erythema has begun to subside, the Cordran tape is stopped to avoid atrophy, and the silicone gel sheeting is continued until the erythema has completely resolved [43].

Permanent pigmentary changes can occur as a complication of phenol peels. Clinically, hypopigmentation occurs when susceptible Fitzpatrick skin types III–VI undergo deep peeling. Because deep phenol peels may lead to irreversible hypopigmentation, hyperpigmentation, scarring, or keloid formation, it is not advised for dark-skinned patients with Fitzpatrick skin types IV–VI [73]. Temporary hypopigmentation is common and predictable, and the final skin color cannot be discerned until all the postpeel erythema has resolved.However, if the erythema has resolved and the hypopigmentation is still present, the pigmentary change is irreversible. Hyperpigmentation is a common postoperative sequelae in darker-skinned patients but usually resolves spontaneously with time, topical tretinoin, and hydroquinone therapy [43].


Infectious complications secondary to bacterial or viral infections and flat warts can be seen. Bacterial infections are usually the result of improper, inadequate, or infrequent cleaning. Pseudomonas aeruginosa is treated by using equal parts of water and distilled vinegar to the effected areas several times a day. Staphylococcus and Streptococcus infections are rare and must be treated with antibiotics. Toxic-shocklike syndromes have been reported following peels [74]. Viral infections secondary to HSV are treated with acyclovir, valacyclovir, or famciclovir. Flat warts (verruca plana) can occur secondary to autoinoculation. Treatment with salicylic acid, liquid nitrogen, topical tretinoin, or even re-peeling is usually successful [43].

The systemic complications of phenol peels are well documented. Phenol has extensive systemic absorption, is directly cardiotoxic [75], is inactivated by conjugation in the liver, and is 80% excreted by the kidneys [76]. Therefore, phenol peels are contraindicated in patients who have a history of cardiac, hepatic, or renal disease. The cardiotoxicity of phenol is well documented and has been shown to occur within the first 30 min of application [44]. The use of continuous cardiac monitoring, pulse oximetry, blood pressure monitoring, and intravenous hydration before and during the procedure to promote phenol excretion are mandatory and help to prevent toxicity. Additionally, the treatment of small cosmetic units with resting periods of 10–15 min between applications minimizes potential systemic complications [77, 78].

Uncommon complications include induction of pemphigus vulgaris in one patient after a phenol peel [79] and laryngeal edema, seen in three chronic smokers after phenol peels. Their respiratory symptoms resolved 48 h after inhalation therapy [80].