# Unmasking the Hidden Risk of Systemic Toxicity from Topical Salicylates

## TL;DR

This paper highlights the risk of systemic toxicity from topical salicylates and emphasizes the importance of early detection and patient education.

## Contribution

A new case of topical salicylate toxicity is presented alongside a systematic review of historical cases to better understand the risks and clinical manifestations.

## Key findings

- 44 cases of topical salicylate toxicity were identified, with tachypnea and vomiting being the most common symptoms.
- The new case involved an elderly male with altered mental status and elevated anion gap.
- The study emphasizes the need for clinicians to consider salicylate toxicity in patients with unexplained metabolic or mental changes.

## Abstract

Topical salicylates are commonly found in over-the-counter medications and are applied for pain relief or to treat dermatologic conditions. While generally considered safe, they can cause systemic toxicity under certain conditions. We conducted a systematic review of topical salicylate toxicity. This comprehensive review of previously reported cases highlights the risks, clinical presentations, and management considerations of systemic toxicity from topical salicylates.

We present a new case of topical salicylate toxicity and conducted a comprehensive systematic literature search from 1952–2024 using PubMed, Google, and Google Scholar. Our search was supplemented by cross-referencing previous studies to identify cases and reviews of topical salicylate toxicity. We then performed a descriptive analysis of the cases, summarizing key information such as clinical presentation, blood levels, and outcomes. Findings were used to contextualize the risks and clinical manifestations of topical salicylate toxicity.

A total of 44 cases of topical salicylate toxicity, including our index case, were identified and included in our analysis. Most cases involved patients > 40 years of age, but all age ranges were represented, including neonates. The most frequently reported symptoms included tachypnea (32.5%) and vomiting (25.5%). The new case was an elderly male with further altered mental status from baseline dementia and elevated anion gap.

Both the new case and the literature review emphasize the continued potential systemic risks of topical salicylates among a broad demographic. Given the variable presentations, clinicians should maintain a high index of suspicion for salicylate toxicity in patients with unexplained altered metabolic and/or mental status. Early consideration, recognition, and intervention of topical salicylates-induced toxicity is essential for good outcomes. As many of these products are heavily advertised, patient education on the appropriate use of topical salicylates may be crucial to prevent inadvertent toxicity.