A Changing Lesion on the Temple
A 38-year-old client with Fitzpatrick type III skin books a 75-minute anti-aging facial and asks the esthetician to 'take care of' a spot on her right temple. The lesion is about 8 mm across, asymmetric, with a notched border and two shades of brown; the client says it appeared last summer and has 'gotten bigger and darker' in the past three months. It occasionally bleeds when she towel-dries her face. She has no history of skin cancer, does not use sunscreen daily, and has a tan from a recent vacation. The esthetician has a magnifying lamp and a Wood's lamp, but no dermatoscope and no medical director. The client wants a glycolic peel and extractions 'around it' and says she cannot afford a dermatologist visit because her insurance deductible is $3,000. The esthetician's state license permits facial treatments, makeup, and hair removal but not diagnosis or treatment of disease.
1. Using the information given, what is the most appropriate analysis of the lesion, and what should the esthetician not do?
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Analysis. The lesion has several ABCDE warning signs: asymmetry, a notched border, two brown shades, diameter around 8 mm (larger than a pencil eraser), and evolution over three months. New bleeding with towel drying is also concerning. The esthetician cannot diagnose melanoma or any other condition, but these features raise enough concern to require prompt dermatologic evaluation.
Do not: freeze, shave, snip, extract, peel over, massage, apply acids, or use a Wood's lamp as a substitute for medical diagnosis. Do not reassure the client that it is 'just a mole' or 'age-related.' Do not take a clinical photo for the salon record without a clear policy and consent. The esthetician should not let the client's cost concern change the referral.
2. How should the facial service be modified, if at all?
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Modify or defer. The safest choice is to defer the peel and extractions until the lesion is evaluated. If the client wants a service that day, limit it to gentle cleansing, light moisturizer, and broad-spectrum sunscreen, avoiding the temple and any heat, steam, exfoliation, or massage over the area. Do not perform a 30% glycolic peel: it could irritate or bleed the lesion and obscure later evaluation. Do not extract 'around it' if that requires pressing near the lesion. Explain that the esthetician is not refusing all care; the esthetician is separating a cosmetic service from a lesion that needs medical assessment.
3. What documentation and referral language are appropriate, and how should cost concerns be handled?
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Documentation. Record the exact location, size in millimeters, colors, border, asymmetry, onset, changes, bleeding, and the client's statements. Note that no diagnosis was made and that the client was advised to see a dermatologist promptly. Record the services declined or modified and the client's response.
Referral language. Say: 'This spot has features that need a medical exam. I cannot diagnose it, and I would not feel comfortable treating over it. Please have a dermatologist look at it soon.' Provide written referral information and low-cost clinic options if available. If the client refuses, document the refusal and still offer only lesion-sparing care.
Cost concern. Acknowledge the deductible but explain that early evaluation can be simpler and less expensive than waiting. Do not bargain, diagnose, or imply that a peel is a substitute for medical care.