The Flaky Crown, the Temple Bump, and the Numb Feet
Ray, 47, is a regular who wants a taper and a hot-lather neck shave. Today he mentions two things. First, the crown of his scalp has dry, flaky patches with a ring of redness and some short broken hairs; he's been using a medicated shampoo a friend gave him. Second, there is a 6-mm pearly, slightly raised bump on his left temple that he says 'showed up' about three months ago and bleeds when the comb catches it. He has type 2C hair, well-controlled type 2 diabetes with an A1c of 7.1, and mentions his feet have been numb lately. He swims and uses a lot of pomade. He asks you to 'just shave around it' and to recommend something for the flakes.
1. What may you do about the flaking crown, what may you not do, and how do you frame the referral?
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What you're looking at: flaking plus a ring of redness plus short broken hairs is not simple dryness. That combination is a reason to keep your hands off the scalp and send him to someone who can actually look at it. You are not deciding between seborrheic dermatitis and a fungal infection - you are recognizing that you can't, and that the difference matters.
What you may do:
- Shampoo and cut his hair as usual, gently. No scraping, no aggressive scalp massage, no trying to lift flakes off.
- Keep his own products from being shared, and clean and disinfect combs, brushes, and clippers that touch his scalp after the service. Capes and towels go to laundry.
- Tell him plainly what you noticed.
What you may not do:
- Don't apply or endorse the friend's medicated shampoo. You don't know what's in it, it wasn't prescribed for this, and some of those products are irritating on broken skin.
- Don't make treatment claims about fungus, bacteria, or 'clearing it up.' Don't name a condition.
The referral, framed plainly: 'There's redness and broken hair in that patch, which I don't treat. Have a doctor or dermatologist look at it before we do anything else up there. I'm happy to keep cutting your hair in the meantime.'
2. How does the temple bump change what you do today, and what goes in the record?
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What changes:
- No comb, clipper, trimmer, or blade touches it. Not 'shaved around' at skin level, not tapered into, not picked at.
- Adjust the taper so the hair around it is worked from a different angle, or leave that section longer. A slightly less sharp taper is a trivial cost.
- Watch it while you work. If it catches anyway and bleeds, stop, apply light pressure with clean gauze, and don't keep going over the area.
Why: a raised, bleeding lesion that appeared a few months ago is exactly the kind of thing that needs eyes on it, and repeated trauma can both make it bleed and delay that. You don't diagnose it, and you don't reassure him that it's nothing - that's a clinical judgment you aren't qualified to make, and a false reassurance can cost months.
In the record: date; location, approximate size, color, and raised appearance; that it bleeds with combing; that you did not work over it; and that you advised him to have it evaluated. Describe what you saw - don't label it. Keep the language neutral and non-alarming so it reads as a professional note and not a scare tactic.
3. Given the diabetes and the numb feet, what do you change about the neck shave?
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The reasoning: numbness in his feet tells you peripheral sensation is reduced, which means his sensation on the neck and jaw may be reduced too. Reduced sensation plus diabetes means three things at once: he may not feel a nick, he may not feel a towel that's too hot, and what he does get will heal more slowly and infect more easily.
What changes:
- Skip the straight razor. Use a trimmer or a guarded clipper for the neckline. This is not about his A1c being 'fine' - it's about the consequence of a nick being worse for him than for another client.
- Warm towel, not hot, and test it on yourself first. He is the last person who should be the thermometer. Keep the dwell time short.
- No alcohol-based astringent on freshly shaved skin. Use something bland, or nothing.
- Check the skin repeatedly rather than at the end. Look for redness, a nick he didn't mention, or a hot spot under the towel.
- Stop at the first sign of blood. Don't chase a clean line through a nick.
Say it out loud: 'Because of the diabetes I'm going to keep this off your skin and keep the towel warm rather than hot - if anything stings, tell me immediately.' Then, separately, suggest he mention the numbness to his doctor, since it's a change worth reporting and not something you can assess.