9/20/2020 A Review of Toxicity From Topical Salicylic Acid Preparations | PracticeUpdate

 FEATURED
Published in Dermatology (/explore/channel/dermatology/sp4)
Journal Scan / Review · February 13, 2014

A Review of Toxicity From Topical Salicylic Acid

Preparations
Journal of the American Academy of Dermatology
 2 Expert Comments

TAKE-HOME MESSAGE
A thorough review of the literature found 25 cases of toxicity with 4 deaths from
topical salicylic acid use. All cases occurred when salicylic acid was applied to a
large body surface area. Salicylism develops when salicylate blood concentration
is > 35 mg/dL and can cause nausea, vomiting, tinnitus, confusion, dizziness,
coma, and death.

Physicians should be aware of the potential for salicylism when prescribing topical
salicylic acid for a condition that involves a large body surface area or for patients
with an impaired skin barrier. Salicylism can occur with topical use of 6% salicylic
acid over as little as 40% body surface area.

- Sarah Churton, MD

Dermatology 

Written by Eliot N. Mostow MD, MPH (/author/eliot-mostow/77)

×
Toxicity from topical medications, while rare overall, reminds us of our role as experts in
the skin, hair, and nails. This short review is an important contribution to the medical
literature in this regard, as we should always be thinking of the implications of anything
we recommend to our patients (a thought process that should distinguish us from
colleagues with training less focused on the skin). This is why we feel comfortable
prescribing the more potent topical steroids and other medications in a thoughtful
manner considering all risks and benefits, even if our approach does not comply with
FDA recommendations.

That being said, topical steroids can lead to Cushing's syndrome, topical retinoids can
produce serum concentrations that may be relevant in pregnant women, and the

"benign" salicylic acid preparations that we use can lead to systemic toxicity in certain

https://www.practiceupdate.com/content/a-review-of-toxicity-from-topical-salicylic-acid-preparations/6584#:~:text=All cases occurred when salicyli… 1/4

9/20/2020 A Review of Toxicity From Topical Salicylic Acid Preparations | PracticeUpdate

circumstances. This should not stop us from utilizing these medications, but it should
empower us to make good decisions to simultaneously help our patients while we work
to diagnose and prevent adverse outcomes (iatrogenic problems) caused by our
treatment recommendations. In our efforts to improve patient adherence, we should not
succumb to the belief that "if a little is good, more is always better." It does not take long
to incorporate simple principles of physiology, drug absorption profiles, and toxicity
profiles to more effectively communicate risks and benefits to our patients.

Dermatology 

Written by Ashish C. Bhatia MD, FAAD (/author/ashish-bhatia/78)

This article brings to the forefront the potential danger from prescription of a well-known,
long-established topical medication used for myriad skin conditions. In the past few
months, I have heard rumblings among colleagues that there may be an FDA ban on
topical salicylic acid preparations in the US due to the dangers of toxicity. This seems a
bit extreme. Most drugs have a toxic potential if misused or over used, but that is why
they are generally used under the direction of a physician. It does bring to light that we
need to think carefully about how we ask patients to use salicylic acid preparations, and
how we train ourselves and our staff to monitor for toxicity in cases of in-office
applications such as salicylic acid peels. Even though these peels are applied to intact
skin for short periods of time, dangerous conditions may arise with application over
large body surface areas or with concomitant use of oral salicylates, and so the patients
should be observed carefully during application and treatment.

It is important to know that the danger with topical salicylic acid applications is related to
vehicle, concentration of the preparation, body surface area treated, disruption of skin
barrier through disease process, and chronicity of application. However, even when
prescribing conservatively, it may be beneficial to educate the patient to discontinue the
medication if any signs of toxicity appear and to contact the physician. It may also be
beneficial to ask the patient to avoid concomitant use of oral salicylates such as aspirin.
×

Abstract

This abstract is available on the publisher's site.

Access this abstract now  (http://dx.doi.org/10.1016/j.jaad.2013.12.005) 

https://www.practiceupdate.com/content/a-review-of-toxicity-from-topical-salicylic-acid-preparations/6584#:~:text=All cases occurred when salicyli… 2/4

9/20/2020 A Review of Toxicity From Topical Salicylic Acid Preparations | PracticeUpdate

Topical salicylic acid is often used in dermatologic conditions because of its keratolytic,
bacteriostatic, fungicidal, and photoprotective properties. The bioavailability of salicylic acid
differs depending on the vehicle used and pH of transcellular fluids. Although rare, salicylic
acid toxicity (salicylism) can occur from topical application. Physicians should be mindful of
the potential for salicylism or even death from topically applied salicylic acid.

Copyright © 2020 Elsevier Inc. All rights reserved.

Additional Info

Disclosures Article Citation

Disclosure statements are available on the authors' profiles:

Ashish Bhatia MD, FAAD (/author/ashish-bhatia/78)

Eliot Mostow MD, MPH (/author/eliot-mostow/77)

Become a PracticeUpdate member now

We Recommend
4CPS-114 Dosing of platinum
A Double-Blind, Randomized and taxanes in obese
Clinical Trial of 20% Alpha/Poly patients: a systematic review
Hydroxy Acid Cream to
Reduce Scaling of Lesions A Casas et al., Eur J Hosp Pharm
Associated With Moderate, × Sci Pract, 2019
Chronic Plaque Psoriasis
Assessing the relevance and
PracticeUpdate, 2013
uptake of core outcome sets
Pearce-ings: Why Should (an agreed minimum
Dermatologists Have All the collection of outcomes to
Fun? measure in research studies)
PracticeUpdate, 2014 in Cochrane systematic
reviews: a review
Effect of Calcipotriene Plus
Paula R Williamson et al., BMJ
Betamethasone Dipropionate Open, 2020
Topical Suspension on the 
Hypothalamic-Pituitary-Adrenal ▼Dupilumab for atopic
Axis and Calcium Homeostasis dermatitis
https://www.practiceupdate.com/content/a-review-of-toxicity-from-topical-salicylic-acid-preparations/6584#:~:text=All cases occurred when salicyli… 3/4
9/20/2020 A Review of Toxicity From Topical Salicylic Acid Preparations | PracticeUpdate

in Subjects With Extensive BMJ Publishing Group Ltd, DTB,

Psoriasis Vulgaris: An Open, 2018
Non-Controlled, 8-week Trial Use of non-steroidal anti-
PracticeUpdate, 2013 inflammatory drugs in porcine
Over-Treatment in Metastatic health management
Breast Cancer Alexandra Schoos et al., Vet Record,
2019
PracticeUpdate, 2016

OTC Topical Acne Meds Can Sequential afatinib and

Cause Severe Reactions osimertinib in patients with
PracticeUpdate, 2014
EGFR mutation-positive
NSCLC: final analysis of the
GioTag study
MJ Hochmair, et al, Future Oncology,
2020

Powered by

https://www.practiceupdate.com/content/a-review-of-toxicity-from-topical-salicylic-acid-preparations/6584#:~:text=All cases occurred when salicyli… 4/4