A Changing Lesion and a Request to 'Freeze It'
A 58-year-old man comes in for his first facial. He has fair skin, blue eyes, and a history of blistering sunburns as a child. On his right temple you see a 9 mm pigmented macule that is asymmetric with an irregular border and two colors. He says it has been there 'forever' but has become crusty and bleeds when he shaves. He asks you to 'freeze it or scrape it off' and then give him a deep cleanse with extractions. He has no primary care provider and has not seen a dermatologist. The salon's consent form includes a section for medical referrals. You have a magnifying lamp and a Wood's lamp. Your state license permits esthetic services, not medical diagnosis or treatment.
1. What are your scope-of-practice obligations when a client asks you to freeze or scrape a lesion?
Read the worked answer
You must not freeze, scrape, shave, biopsy, or otherwise treat a suspicious lesion. Those are medical procedures outside esthetic scope, and attempting them could delay diagnosis, cause bleeding or infection, and create legal exposure. Your obligation is to recognize findings that require medical evaluation and refer, not to name a disease.
The lesion has several concerning features: asymmetry, irregular border, two colors, 9 mm size, crusting, and bleeding with shaving. Those fit the ABCDE warning signs and warrant prompt dermatologic evaluation. Do not reassure him that it is 'just sun damage' or 'nothing.' Do not use the Wood's lamp to make a diagnosis; it can be an educational tool, but it does not rule out skin cancer. State clearly that you cannot diagnose or treat the spot and that he needs a medical professional. If he has no provider, give him a written referral recommendation and suggest a dermatology clinic or his insurance's nurse line.
2. How do you communicate your concern without diagnosing?
Read the worked answer
Use plain, non-diagnostic language: 'I'm not qualified to diagnose skin lesions. This spot has features that estheticians are trained to refer-it is uneven, has more than one color, and has been bleeding and crusting. Those changes need to be checked by a doctor, preferably a dermatologist, soon.' Avoid saying 'that is cancer' or 'that is melanoma'; avoid saying 'it is fine.' Do not scare him unnecessarily, but do not minimize.
Ask whether the lesion has changed in size, shape, color, or symptoms, and document his answers. Explain that early evaluation is important and that a dermatologist can examine it properly. If he resists, repeat that you cannot safely treat it and that your concern is his health. Offer the referral information in writing. This approach respects the client's autonomy while keeping you within scope and encouraging timely care.
3. What can you safely perform today, and how do you document the referral?
Read the worked answer
You may perform a gentle facial that avoids the right temple completely. Cleanse with a mild cleanser, avoid steam or exfoliation over the lesion, do not extract near it, and do not apply masks or products to the area. You can treat the rest of the face if the skin is intact and the client consents, but keep the service calming rather than aggressive. Do not shave, pick, scrub, or apply pressure to the lesion.
Document objectively: the location, estimated size, shape, border, colors, crusting, bleeding history, and the client's statement that it has been present 'forever.' Record that you did not diagnose, that you advised prompt dermatologic evaluation, that you provided referral information, and that he declined or accepted. Note any services declined and the care instructions given. Ask him to sign the note if your salon policy allows. Good documentation shows the standard of care and protects you if the lesion is later diagnosed.