A Changing Cheek Lesion and a Request for a Peel
A 58-year-old man books a 'deep-cleansing facial with extractions and a light peel' three days before a reunion. He has Fitzpatrick III skin, a history of sunbathing, and a 7 mm asymmetric dark brown macule on his left cheek that he says has been changing in shape and color over the past three months. His primary care provider called it an 'age spot.' He also has flaking and erythema in the nasolabial folds consistent with seborrheic dermatitis, and he has used tretinoin 0.05% nightly for years. He wants blackhead extractions on his nose and a 30% glycolic peel. He denies cold sores, is not on antibiotics, and has no known allergies. He is taking lisinopril and aspirin 81 mg daily. The spa's peel protocol requires a patch test and stopping retinoids for five days.
1. Which findings require referral before any facial treatment?
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The changing cheek lesion is the priority. A 7 mm asymmetric macule that has changed in shape and color over three months has features that warrant prompt dermatologic evaluation. The esthetician should not diagnose skin cancer, but she also should not treat over the lesion, exfoliate it, or reassure the client that it is benign. The appropriate action is referral to a dermatologist or the client's healthcare provider.
Other findings affect treatment planning:
- Seborrheic dermatitis: active flaking and erythema mean the barrier is irritated; aggressive exfoliation, strong steam, and peeling can worsen it.
- Tretinoin nightly: retinoids increase photosensitivity and irritation, and the spa protocol requires stopping five days before a peel. He has not met that protocol.
- Aspirin 81 mg: not an absolute bar to gentle extractions, but it increases bruising risk; avoid aggressive extraction.
- 30% glycolic peel: too aggressive today given the barrier disruption, retinoid use, and untreated lesion.
2. What services, if any, can be performed today, and what adjustments are needed?
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The safest judgment is to defer the peel and extractions and offer only a very gentle, non-irritating service if the client understands the plan. A brief gentle cleanse, light moisturizer, and sunscreen away from the lesion may be acceptable, but the esthetician should avoid steam, exfoliation, massage over the lesion, and any extraction of inflamed or dermatitis-affected areas. The nose blackheads can wait; extraction near the nose is not urgent and the aspirin increases bruising risk. The 30% glycolic peel should not be performed because the retinoid washout was not completed, the seborrheic dermatitis is active, and the changing lesion needs evaluation first. The esthetician should explain that the reunion timeline does not override safety, offer a calming facial, and reschedule the peel after dermatologic clearance and protocol compliance. If the client declines the modified service, document that.
3. How should the esthetician document and phrase the referral?
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Document the lesion objectively: location, approximate size, asymmetry, color variation, the client's report of change over three months, and that the client said his primary care provider called it an age spot. Record that the esthetician did not treat the lesion, did not diagnose it, and recommended dermatologic evaluation. Use plain, non-alarming language: 'I am not able to diagnose skin lesions. Because this spot has changed, please have a dermatologist look at it before any exfoliation or peel in this area.' Note the client's response and give written aftercare: sun protection, avoid picking or scrubbing, and keep the appointment. Avoid saying 'it's probably nothing' or 'it looks like melanoma.' The note should also state that the peel was deferred and why, so the record shows a reasoned safety decision rather than an unexplained refusal.