A Changing Pigmented Lesion on the Cheek
A 52-year-old man with fair skin, blue eyes, and a history of blistering sunburns books a deep-cleansing facial with steam, extractions, and a glycolic peel for a reunion in three days. On his left cheek is an 8-mm pigmented lesion. It is asymmetric, has a notched border and mixed brown-black color, and the client says it changed last month and sometimes itches. He asks you to extract the blackheads around it and to use a drugstore freeze product on it so it will scab off before the reunion. He has not seen a dermatologist in years. The rest of his skin is oily with open comedones on the nose. He has signed a general consent form, but no medical history was taken.
1. Should you perform the requested facial and peel? Explain the clinical and scope-of-practice reasoning.
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Do not perform the full facial as requested. The lesion has several ABCDE features: asymmetry, border irregularity, color variation, and reported change. That needs medical evaluation, not esthetic treatment. Steam, heat, exfoliation, and massage can increase blood flow and irritation, and a glycolic peel could damage skin over or near a possible malignancy. Extractions around it could introduce infection or obscure later evaluation. Do not diagnose melanoma or any other condition; describe what you see and why you are declining. Offer a modified, gentle service away from the lesion only if the client understands the lesion will be untouched, or reschedule until he has seen a dermatologist. The judgment call is to protect the client and stay in scope.
2. How should you communicate your concern and document it without diagnosing?
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Use plain, non-alarming language: 'This spot has features I cannot evaluate, and it has changed. I am not able to treat over it. I would like you to have a dermatologist look at it soon.' Avoid saying it is cancer or that it is nothing. Document the location and description, the client's statement that it changed and itches, your refusal to treat over it, the referral, and his response. Give written referral information if available. Keep the record confidential. If he declines the referral, document that too. Do not let him sign a waiver to proceed; a waiver documents the conversation but does not make treatment over a suspicious lesion safe or within scope.
3. What should you say about the freeze product and the requested extractions around the lesion?
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Do not use or recommend a freeze product. That is a medical treatment, and over-the-counter freezing products are not appropriate for pigmented lesions. Do not extract around the lesion, because trauma can obscure changes and create infection risk. You may treat clearly separate comedones on the nose if the client agrees and you avoid the cheek, but even then consider postponing strong exfoliation until the lesion is evaluated. Explain that the reunion is not a reason to risk scarring or delay diagnosis. Refer promptly to a dermatologist. The esthetician's role is cosmetic care and referral, not diagnosis or destruction of lesions.