Session Four of IPL: A Photosensitising Drug, a Sunbed and a Changing Mole
A 38-year-old client attends for session four of a six-session photoepilation course on the upper lip and chin. Her skin is Fitzpatrick type III, her hair is dark brown and coarse, and the previous three sessions produced good reduction with no adverse effects. At today's consultation she reports that she started doxycycline 100 mg daily two weeks ago for acne and expects to continue for at least three months. She also used a sunbed three times last week 'to get a base' before a holiday, and her chin is visibly tanned compared with her neck. She has a 7 mm brown mole on the left upper lip that she says 'has got a bit bigger and darker since last summer'. She is keen to continue because she has a holiday in ten days and wants 'the chin done before the photos'.
1. Should you treat today? Justify your decision against each of the factors she has disclosed.
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No - do not treat today. Each factor independently would justify postponing; together they make treatment clearly unsafe.
- Doxycycline: a tetracycline antibiotic with well-documented photosensitising potential. On light-based treatment it raises the risk of exaggerated erythema, blistering and post-inflammatory hyperpigmentation or hypopigmentation. Different protocols set different washout periods, but she is two weeks into a three-month course - most services would not treat during the course at all, or only with written clearance from the prescriber.
- Sunbed use last week: recent UV exposure means there is active melanin production in the epidermis. Melanin is the competing chromophore for light targeting hair, so energy is absorbed in the skin rather than the follicle - burns, blistering and pigmentary change become much more likely, and the true skin type cannot be assessed.
- Visible tan: same problem, plus your settings were chosen for an untanned type III. Treating a tanned chin at the previous fluence is a recipe for an adverse event.
- The mole: a changing pigmented lesion is an absolute do-not-treat area and a referral trigger. It also sits within the treatment field.
The fact that the first three sessions were uneventful is irrelevant - the variables have changed since then. Her holiday in ten days is a reason to protect her skin, not a reason to treat.
2. What do you say to her, and what pathway do you put in place for the rest of the course?
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The conversation: be concrete and non-judgemental. 'The antibiotic you've started makes your skin much more sensitive to light, and the sunbed has left a tan that changes how the machine's energy is absorbed. Treating now risks a burn or a patch of darker or lighter skin on your chin - exactly what you don't want before photos.' Explain that the course is not wasted; a short delay preserves the result she has already achieved.
Pathway:
- Do not treat; reschedule the appointment.
- Ask her to speak to her GP or prescriber about the doxycycline; obtain written confirmation when the course has finished and any required washout period has passed. Many clinics will not treat until at least two weeks after stopping a photosensitising drug - confirm your own protocol and follow it.
- Require two to four weeks of no sunbed, no sunbathing and no active tan before the next session, with SPF 30+ daily; reassess the skin type and the tan at that appointment.
- Re-patch-test on the day if more than a few months have passed or anything in her medication or skin has changed.
- Adjust the plan: the course end date moves, and the remaining sessions are rebooked after the holiday, not before it.
- Document everything: the disclosure, the decision not to treat, the reasons, the advice, the medical liaison, and her response. Offer to reschedule at no penalty and confirm this in writing.
3. What are your professional obligations regarding the mole, and what do you do if she insists on treatment anyway?
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The mole: a pigmented lesion that has become larger and darker over a year needs assessment. Apply the ABCDE framework as a prompt for referral, not as a diagnosis: Asymmetry, Border irregularity, Colour variation, Diameter over about 6 mm, Evolving (change in size, shape, colour, itching or bleeding). It is not your role to say what it is. State clearly that you cannot treat over or near a changing lesion, advise her to see her GP promptly - not after the holiday - and note the advice and her response. If she declines to act on it, record that too; you cannot force a referral, but you can make sure the conversation is documented.
If she insists:
- Refuse, plainly: 'I'm not able to treat you today; it would put your skin at risk and I'd be treating over a mole that needs checking.'
- Do not be moved by pressure, by the pre-paid course, by the holiday, or by a request to 'just do a low setting'. A lower fluence does not remove the photosensitivity or tan risk.
- Offer the rescheduled appointment, a refund or credit for the unused session as per salon policy.
- If she becomes abusive or refuses to leave, end the consultation, keep the record factual, and involve your manager.
- Never treat and 'just avoid the mole': the treatment field on the upper lip overlaps it, and energy delivered near the lesion still affects it.
Document the refusal, the reason and the aftercare advice given. Professional integrity here is judged by the notes you leave, not only by the decision itself.