A pearly bleeding nodule found during a deep-cleansing facial consultation
Mrs Lindqvist, 49, books a deep-cleansing facial for 'congested, dull' skin. During skin analysis you see a 5 mm pearly, translucent nodule on the left side of her nose with fine red vessels across its surface and a rolled edge. She says it appeared about a year ago, has slowly grown, occasionally bleeds when she dries her face, and forms a crust she picks off. She assumed it was a blocked pore she could have extracted. She is Fitzpatrick II, used sunbeds in her twenties, and had a basal cell carcinoma removed from her shoulder two years ago. The rest of her face shows diffuse cheek redness, a few small papules and visible capillaries, and she wants 'strong exfoliation and plenty of steam to open the pores'. She has used tretinoin 0.05% nightly for two years and takes no medication other than the occasional antihistamine.
1. What is your main concern about the lesion, and what should you do about it during this appointment?
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Main concern: a suspected basal cell carcinoma (BCC) or other keratinocyte skin cancer.
The features that matter are: pearly and translucent appearance, a rolled edge, fine telangiectasia across the surface, slow growth over a year, bleeding with minor trauma (towel drying is enough), crusting, a sun-exposed site, Fitzpatrick II skin with sunbed use, and a personal history of BCC - which raises her risk of further lesions substantially.
What to do:
- Do not extract, squeeze, probe, exfoliate, steam directly over, massage or apply product over the lesion. It is not a blocked pore, and trauma will make it bleed and may worsen the site.
- Leave a clear margin around it and keep the rest of the treatment away from the nose.
- Do not tell her she has cancer, and do not guess at a diagnosis. Describe what you can see and explain that it is not something a facial can treat and needs a medical opinion.
- Advise a prompt GP appointment, ideally within two weeks, and suggest she mentions her previous BCC. Give written information, advise her not to pick it, and to use SPF daily.
- Record the site, size, appearance, her reported history, the advice and the referral, and that no treatment was performed on the lesion.
2. Can you carry out a facial on the rest of her face? How would you adapt the treatment plan, and why?
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Yes, with informed consent and a substantially modified plan - and only if she accepts the modifications.
Two separate issues drive the changes:
- Possible rosacea. Diffuse cheek erythema, papules and visible capillaries suggest rosacea. Heat is a classic trigger, so no steam, no hot towels and no hot-room treatment; no vigorous massage, no strong scrubs or high-strength acids, and no alcohol-based astringents. These would flush the skin, worsen redness and may provoke a flare.
- Nightly tretinoin. Her barrier is likely compromised and photosensitive. Mechanical exfoliation and waxing are inappropriate; she should stop tretinoin for about three to five days before any exfoliating or resurfacing treatment in future.
Adapted plan: gentle cream or milky cleanser, cool compresses instead of steam, light and slow massage avoiding the nose lesion, no extractions on the papules, a calming hydrating mask, and a broad-spectrum SPF 30+ to finish. Advise her on rosacea triggers (heat, alcohol, spicy food, sun) and suggest she sees her GP about the papules.
Explain the reasoning so the change does not feel like a downgrade, and if she insists on steam or strong exfoliation, negotiate or decline rather than proceed against your judgement.
3. What else in her history and presentation is relevant, and how do you document and communicate the referral?
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Relevant history and findings:
- Sunbed use in her twenties and a previous BCC - cumulative UV exposure and a personal history of skin cancer are the strongest risk pointers here.
- Fitzpatrick II skin, which burns easily.
- Nightly tretinoin - photosensitivity, irritation, and a reason to avoid exfoliation and to emphasise SPF.
- Rosacea-like redness and papules - informs today's treatment and her home-care advice.
- Occasional antihistamine - minor, but worth noting for dryness.
Documentation: exact site (left side of nose), measured size (about 5 mm), colour and texture, the telangiectasia and rolled edge, bleeding and crusting, how long it has been present and how it has changed, what she assumed it was, the advice given, the referral, the treatment actually carried out and the margin avoided, and her signature. Record observations, not a diagnosis.
Communication: be calm and specific - 'This isn't something I can treat with a facial. It has features that your GP needs to look at, ideally within two weeks, especially given your previous BCC.' Avoid alarmist language and avoid naming a condition. Give her a written note of what you saw and when, with her consent, and follow up to check she attended. If she declines the referral, record that clearly, restate the advice, and still do not treat the lesion.