A Dark Band Under the Nail
A 58-year-old client comes for a gel manicure. She has Fitzpatrick type IV skin, smokes one pack per day, and has no history of nail trauma. On the right thumbnail she has a dark brown vertical band that begins at the cuticle and runs to the free edge. It was not present one year ago; her daughter says it has widened. The nail plate is smooth, the surrounding skin is not red or swollen, and there is no pain or drainage. The client wants a dark burgundy gel polish to cover the band for a family reunion. She says her primary care doctor "looked at it" six months ago and told her not to worry. The technician has a buffer, gel polish, and a lamp. The salon has no policy for medical referrals. The client is in a hurry and asks the technician not to "make a big deal" of it.
1. Should the technician buff the nail and apply gel polish? Explain the decision.
Read the worked answer
No. A new, widening longitudinal brown band in a 58-year-old is a red flag for longitudinal melanonychia, including subungual melanoma, even without pain or surrounding inflammation. Buffing removes evidence, and opaque gel hides the band from the client and future clinicians. The technician cannot diagnose, but she can recognize when a finding needs medical assessment. The prior primary-care comment is not a clearance for a cosmetic cover-up; the band has reportedly widened since then. The technician should decline to cover that nail, explain that this is not a diagnosis but a reason to see a dermatologist, and offer to polish the other nails or provide no polish. She should not cut, scrape, or biopsy the nail. Document the refusal and the referral.
2. How should the technician reason about subungual hematoma, fungal infection, and melanoma without diagnosing?
Read the worked answer
Use history and appearance to decide urgency, not to name a disease. Hematoma usually follows trauma, is often distal, and moves outward with nail growth; fungal change often shows yellow-white thickening, crumbling, or debris, sometimes with athlete's foot. A single-digit, painless, widening brown band that starts at the cuticle, especially with Hutchinson sign (pigment on the proximal nail fold), is more concerning for melanoma. This client has no trauma, a new band, and widening, so referral is warranted. The technician should describe objectively: color, width, location, duration, change, and surrounding skin. She should avoid words like "fungus" or "cancer" as a diagnosis and say "this needs a dermatologist's evaluation."
3. The client insists on coverage and says she cannot take time off work. What should the technician say and document?
Read the worked answer
Use a firm, respectful script: "I can finish the other nails, but I can't cover this band today. A new, widening dark band needs a dermatologist's look before I put opaque product over it. I'm not saying it is cancer, but covering it could delay care." Offer alternatives: clear strengthener on other nails, a different service, or a rebooking after evaluation. If the client still refuses, document the date, the objective finding, the referral recommendation, the client's refusal, and that no product was applied to that nail. Do not argue or diagnose. If the client becomes upset, involve the owner. The technician should not let a busy schedule or a tip override a medical red flag.