Phenol peels arrhythmias

The fear of arrhythmic complications is the main brake on the use of phenol peels today. It is therefore worthwhile studying this problem in detail. The conclusions that can be drawn from reading about these complications in medical literature help us to understand how to apply phenol with greater safety, though the possibility of arrhythmias occurring cannot be avoided. 

Truppmann and Ellenby routinely used cardiac monitoring when doing phenol peels, and detected many arrhythmias. In 1979, they published the results of a study on 48 patients treated with phenol peels. Saponified and non-saponified Baker or Litton formulas were studied. They report that 23% of patients treated with phenol showed arrhythmia, on average 17.5 minutes after the phenol was first applied. These arrhythmias were often premature ventricular (Figure 28.3) or supraventricular contractions, bigeminy, or supraventricular (Figure 28.2) or ventricular tachycardias (Figure 28.7). Tachycardia, which in extreme cases can sometimes reach 220—230 beats per minute, can turn into ventricular fibrillation and lead to cardiac arrest. 

In response to these studies. Baker claimed that, in the course of 5000 phenol peels, he never came across a case of arrhythmia. His observation was based on the following evidence ... 

Lidocaine as a preventive ( ) this point is highly debatable, since arrhythmia can be avoided simply by taking more than 1 hour to apply the phenol. Simple lidocaine used to do nerve blocks before the phenol peel should be considered a cautious technique. 

There are several articles describing the appropriate treatment for heart arrhythmias occurring in the course of a phenol peel. ... 

A phenol peel should of course not be performed after myocardial infarction or cardiac decompensation. Unstable angina also rules out a phenol peel, as the stress associated with a peel could trigger an angina attack. No clear link has ever been established between a personal medical history of a heart condition, if currently stabilized, and the incidence of cardiovascular complications during a phenol peel. Apart from arrhythmias, to the best of my knowledge there is no mention in the literature of any serious heart problems occurring as a complication of a phenol peel. ... 

Adrenaline is contraindicated in cases of diabetes, hyperthyroidism, serious heart arrhythmias and coronary insufficiency or in combination with beta-blockers or monoamine oxidase (MAO) inhibitors. Lidocaine with adrenaline has a very rapid onset of action. Its duration of action is longer than that of lidocaine without adrenaline. However, inadvertent injection of a lidocaine-adrenaline solution into the vessels located near the nerve trunks increases the heart rate (immediate sinus tachycardia at over 130 beats per minute, spontaneously reversible in around 15 minutes) and increases ventricular excitability (risk of fibrillation). It can trigger angina attacks that may lead to a heart attack. It is therefore preferable not to use adrenaline before a full-face phenol peel. 

Scarring was the second most common com-plicahon reported, with the most frequent sites being the lip, chin, and perioral areas [315]. Thirteen percent of these plastic surgeons had experienced systemic cardiac complicahons (tachycardia, arrhythmias, premature ventricular contractions (PVCs), paroxysmal atrial tachycardia (PAT), and hypertension) during phenol peeling [315]. Of these, tachycardia was the most frequent [315]. An 11-year-old boy treated with phenol for xeroderma pigmentosum developed multifocal ventricular arrhythmias with heart rates up to 220 beats/min [329]. 

Phenol peels are categorized as deep peels. Similar to TCA, phenol works through protein denaturation and coagulation. However, phenol differs from TCA in that it penetrates quickly to the level of the reticular dermis. Phenol is partially detoxified by the liver and excreted through the kidneys. Percutaneous absorption of phenol can lead to rapid elevation of serum phenol levels, resulting in systemic toxicity and cardiac arrhythmias. Therefore, all patients should be cleared from a cardiac, hepatic, and renal standpoint preoperatively. In addition, intraoperative cardiac monitoring is imperative. 

Before using hdocaine with epinephrine for any procedure, patients fill out a form which details any problems they have had [rapid heartbeat, apprehension) following dental procedures associated with lidocaine and epinephrine. Before carrying out phenolic peels we discuss the possibility of certain drugs which predispose to cardiac arrhythmias these include diuretics (hypokalemia, hypomagnesemia) which interact with epinephrine. 

Phenol is toxic when used in high doses. Phenol is metabolized in the liver and excreted by the kidneys. Although it has the potential to cause hepatorenal toxicity, this is not usually seen in chemical peels because the dose absorbed is not high enough. 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. The toxicity produces arrhythmias despite prior normal heart function. The occurrence of these arrhythmias is not... 

The most important potential complication of phenol-based peels is cardiotoxicity. Phenol is directly toxic to myocardium. Studies in rats have shown a decrease in myocardial contraction and in electrical activity following systemic exposure to phenol [i6]. Since fatal doses ranged widely in these studies, it seems that individual sensitivity of myocardium to this chemical exists. In humans neither sex/age nor previous cardiac history/blood phenol levels are accurate predictors for cardiac arrhythmia susceptibility [17]. 

Therefore, full-face phenol-based peel should always be performed under full cardiopulmonary monitoring. The average lag time for the onset of the arrhythmias was 17.5 min from the beginning of the peel, and they are usually not delayed for more than 30 min after the peel. Cardiac arrhythmias are more common while applying the solution on the thin skin of eyelids. In this area skin absorption is maximal therefore, application should be performed extremely cautiously. If arrhythmia occurs, the application of phenol should be stopped until... 

Wexler MR, Halon DA, Teitelbaum A, et al (1984) The prevention of cardiac arrhythmias produced in an animal model by topical application of a phenol preparation in common use for face peeling. Plast Recontsr Surg 73 595-598... 

Other phenol-containing products are used as chemical peels to remove skin lesions, and in the treatment of chronic pain or spasticity. These uses have occasionally been associated with adverse outcomes, like cardiac arrhythmias, that have been seen in both adults and children. 

Cardiovascular Effects. There have been several reports of cardiac arrhythmias associated with application of phenol solutions to the skin in connection with the surgical procedure of skin peeling (Gross 1984 Truppman and Ellenby 1979 Warner and Harper 1985). In this procedure, a mixture of phenol ( 50% w/v), hexachlorophene, and croton oil is applied to the skin while the patient is under anesthesia. In a series of 54 patients in which the whole face was peeled in 1 day, cardiac arrhythmias were reported in 39%, while in a series of patients in which half the face was treated on 1 day, and the second half was treated 24 hours later, cardiac arrhythmias were reported in 22% (Gross 1984). The study author also indicated that the arrhythmias were less severe in the patients treated over a longer period of time. 

Gross BG. 1984. Cardiac arrhythmias during phenol face peeling. Plastic Reconst Surg 73 590-594. 

Botta SA, Straith RE, Goodwin HH. Cardiac arrhythmias in phenol face peeling a snggested protocol for prevention. Aesthetic Plast Surg I988 I2(2) II5-I7. 

It is remarkable that no cardiovascular complications were recorded in this study. Medical publications report that when a person is exposed rapidly to a sulEcient quantity of phenol (in general, 3-4 g of phenol applied quickly to the face), abnormal heart rhythms may occur. These abnormalities appear 15-20 minutes after the beginning of the peel and are often rapidly reversible. If any arrhythmia had developed during these cases of poisoning, it would no doubt have occurred rapidly and disappeared again by the time the patient arrived at the hospital. This argues in favor of the autonomous reversibility of arrhythmias with phenol. The authors cautiously conclude The absence of serious toxicity and major chemical burns in this series does not eliminate concern with the corrosive and systemic risks of phenol poisoning . 

A study by Wexler et aft on rabbits found a correlation between the rapid onset of arrhythmia and the speed with which phenol is absorbed through the skin 70% of phenol is absorbed in 30 minutes in rabbits. Forced diuresis (intravenous furosemide) while the peel is being applied prevents cardiac arrhythmia by increasing renal elimination of free phenol, even before the conjugation and oxidation processes of detoxification could protect the organism. In addition, slow application of the solution in at least 1 hour meant that no arrhythmia was observed, as this leaves enough time for the phenol to be detoxified. 

Another study compared the toxicity of trichloroacetic acid (TGA) and phenol (Baker s solution) the conclusion was that it would appear advisable to set up a cardiac monitor during a ftill-face peel with Baker s solution, whereas TGA does not cause any type of arrhythmia. 

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