The Spot She Wants You to Work Around
A 58-year-old client, Fitzpatrick III, golfs three times a week and uses no sunscreen. During intake she points to a spot on her left nasal ala and says, "Just work around it." It measures roughly 7 mm, is asymmetric, has a notched, irregular border, and shows two shades - tan and dark brown - within the same lesion. She says it appeared about four months ago, has gotten bigger, and bleeds when she dries her face with a towel. She has booked a deep-cleansing facial with extractions plus a light chemical peel. She also mentions she has used tretinoin 0.05% nightly for the past month and had a "burn" from a peel at another salon three weeks ago.
1. How do you handle the lesion during this appointment? Include what you say, what you document, and what you must not do.
Read the worked answer
Do not treat it, do not extract near it, and refer.
Reasoning against the ABCDE framework:
- Asymmetric, Border irregular/notched, Color varied within one lesion, Diameter about 7 mm (over the 6 mm threshold), Evolving - new, growing over four months, and bleeding with minor friction. Growth plus easy bleeding on a sun-exposed site in a sun-damaged client is a referral trigger.
What to do:
- State plainly that this is outside your scope and should be seen by a physician or dermatologist, ideally within a couple of weeks. Do not name a disease and do not say "it's probably nothing."
- Do not say "just work around it" is fine and then use acids, steam, massage or extraction in the area - the tissue is friable and you have no diagnosis.
- Document: location, measured size, description of border and color, the bleeding and growth history, the date, and the referral given. Offer a written note. If she declines the referral, document that too.
- Keep your tone calm and non-alarming: "This isn't something I can treat. Things that grow and bleed need a doctor's eyes, not mine."
2. Given her barrier history, is the chemical peel appropriate today? What would you actually do, and when would you revisit the peel?
Read the worked answer
No peel today.
Three stacked reasons:
- Recent peel burn, three weeks ago - the barrier is likely still compromised. Signs to look for: persistent erythema, stinging with plain water, tightness, flaking. Exfoliating compromised skin risks post-inflammatory hyperpigmentation, prolonged redness and scarring.
- Nightly tretinoin 0.05% for one month - retinoids thin the stratum corneum and increase permeability and irritation. Standard practice is to discontinue topical retinoids roughly 5–7 days before a superficial peel (state rules and product protocols vary; follow yours).
- Undiagnosed lesion on the treatment area - another reason to keep actives well away from the nose.
Today: gentle cleanse, no steam, no extractions beyond obvious non-inflamed comedones away from the lesion, barrier-supportive hydration, and a sunscreen conversation with a specific SPF recommendation and reapplication habit. Revisit the peel in 2–4 weeks once the barrier is quiet and tretinoin has been paused, start at the lowest strength, and patch test.
3. She returns three weeks later and says the spot "hasn't changed, so it's fine." Does that change anything?
Read the worked answer
No - stability over three weeks does not clear it, and you should not let the client's reassurance override your referral.
- Many skin cancers are slow-growing; three weeks of no visible change is meaningless as a rule-out. The original features - growth over months and bleeding with towel friction - are still the relevant history.
- Re-document the current measurement and appearance, restate the recommendation, and note that the client declined or delayed. Offer the referral note again.
- Your scope does not include diagnosis or reassurance. "It's fine" is a medical conclusion you cannot supply.
- If the client pushes you to "just do the peel now," you may treat the rest of the face while strictly avoiding the lesion only if you are comfortable with the plan and have documented the referral; you are not obligated to treat at all.