Severe chemical burn leaving an irredeemable scar because of unskilled chemical peel at an oriental medicine clinic

Dear Editors,

1.

Chemical peels are one of the most effective and widely used procedures in the management of acne and acne scars.1, 2 Among the various treatment modalities available for acne scars, chemical peels have the advantage of being easily performed in an office setting.3 Improper administration by non‐professionals, however, can cause excessive peeling, leading to skin burn and other serious adverse reactions.4 Nonetheless, as various peeling agents are readily accessible to the public and to non‐professionals, chemical peels are commonly performed in many oriental medicine clinics, cosmetic salons/spas, or even at home. Here, we report the case of a patient with severe burns on over 30% of his face after receiving a chemical peel with trichloroacetic acid (TCA) mixed with unknown herbal substances at an oriental medicine clinic.

A 25‐year‐old man presented to our hospital with deep second‐degree chemical burns on over 30% of his face (Figure 1B). One year prior to his visit, he had been treated with multiple sessions of acupuncture and chemical peeling at an oriental medicine clinic for his atrophic acne scars (Figure 1A). Six months prior to his visit, he received a chemical peel with 30% TCA combined with unknown herbal substances on his face. Immediately after the chemical peel, he experienced a severe burning sensation that continued until a wide ulcer developed. At the time of his visit to our hospital, most of the ulcer was covered with granulation tissue with a yellowish crust, and the periphery of the wound had already healed and begun scar formation (Figure 1B). We started a weekly treatment combination of light‐emitting diode phototherapy with hydrocolloid dressing at the site of the ulcer. For the first 6 months, the yellowish crust and exudate subsided, and reepithelialisation started from the periphery but was delayed at the sites of the most severe ulceration (Figure 1C). After 2 years of continuous treatment, complete healing was achieved, but severe atrophic scars with occasional hyper‐ and hypopigmentation remained present (Figure 1D). During his 2 years of treatment, the patient suffered physically and emotionally, and the scars on his face tremendously impacted his self‐esteem, social interactions, and even his ability to obtain employment.

Figure 1.

Clinical photographs of the patient. A, Before chemical peel. Notice rolling acne scars mixed with ice pick acne scars on both the temporal and zygomatic areas. B, Six months after the chemical peel, when the patient first visited our hospital. Severe ulcer covered with granulation tissue and yellowish crust. C, Six months after treatment at our hospital. Reepithelialisation started from the periphery but was delayed at the most severe site of ulceration that was covered with thick granulation tissue. D, Two years after treatment at our hospital. Complete removal of granulation tissue with successful reepithelialisation is seen, but severe atrophic scars with occasional hyper‐ and hypopigmentation remain

Chemical peels cause controlled destruction of the epidermis, with or without the dermis, leading to exfoliation of superficial lesions and renewal of new epidermal and dermal tissue.5 The application of chemical peels appears to be a simple and easy process, but its results can widely vary (superficial, medium‐depth, or deep peel), depending on the concentration of peeling agent and the technique used. Regarding the peeling technique, a combination of factors, such as the acid concentration, chemical reaction that can occur from other additives, number of passes, and degree of cotton gauze saturation, can affect the depth of the peel.6 Furthermore, skin colour or type, hydration, sebum content, thickness, and actinic damage should also be considered when applying chemical peels.

In addition to the peeling technique, it is crucial for physicians to be knowledgeable about the possible side effects, post‐procedure down time, and the proper management in order to optimally treat patients.7 When a chemical burn is suspected, it is important to immediately notice the possibility of the ongoing effects of the chemical agents and to apply immediate copious water lavage as it slows down the progress of tissue injury.8, 9 In our case, the patient was not informed of the possibility of chemical burns or their managing strategies. He was left untreated, and the tissue injury continued for several months, eventually resulting in a greater area of injury and scarring.

Chemical peels are one of the most commonly performed dermatological procedures. As such, it is crucial for health care providers and the public to be aware of the potential dangers and consequences of its misuse. We report this case to raise awareness of the increasing cosmetic procedures that are performed by non‐professionals and the potential resultant complications of these procedures. We would like to emphasise the importance of proper and skilled application of chemical peels by a professional clinician or under the guidance a professional clinician for safe and efficient treatment of acne scars. In addition, this case highlights the importance of early recognition and first aid in reducing the severity of chemical burns.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.