The Ring on the Cheek

Most likely: tinea corporis (ringworm of the body), a dermatophyte infection.

Supporting features:

• Annular (ring-shaped) plaque with a raised, scaly, active border and central clearing - the classic dermatophyte pattern, because the fungus is most active at the advancing edge.
• Pruritus without systemic symptoms.
• New kitten from a shelter - animal-to-human transmission is a well-recognized route.

Today's decision: no facial, no peel, no extractions.

• Fungal infection is communicable by direct skin contact, by shed scale on linens and implements, and by your hands. Steam, massage, occlusive masks, and friction all increase warmth and moisture and can worsen and spread it.
• The peel is doubly inappropriate: the barrier is compromised in an active infection, and the prepaid service should be converted to a credit, not delivered.
• Do not attempt to "clean it up" with extractions or exfoliation near the lesion.

Action: decline the service, explain what you observed, refer her to a physician or dermatologist for diagnosis and treatment, and invite her back only after the lesion has resolved and her provider has cleared skin contact (typically after a course of topical antifungal therapy). Document the location, size, description, the decline, and the referral.

Look-alikes include:

• Nummular (discoid) eczema - coin-shaped, scaly, often intensely itchy, but usually without the sharp advancing border and central clearing.
• Seborrheic dermatitis - greasy yellow scale in sebaceous areas rather than a ring with a clear center.
• Psoriasis - well-demarcated plaques with silvery scale, usually extensor surfaces and scalp.
• Granuloma annulare - a firm, non-scaly ring of papules, usually on hands and feet.
• Pityriasis rosea - a herald patch can look annular, followed by a truncal eruption.
• Discoid lupus erythematosus - annular, scarring, photosensitive plaques; a reason to be firm about referral, not a reason to treat.

Why the decision stands regardless:

1. An esthetician does not diagnose. The finding is a new, active, scaly, symptomatic lesion of two weeks' duration - that alone triggers referral.
2. If it is fungal, treating is unsafe and spreads it. If it is eczema or psoriasis, a peel plus extractions on an inflamed, barrier-damaged cheek is still a contraindication (risk of erosion, post-inflammatory hyperpigmentation, and secondary infection).
3. The differential therefore changes only how urgently you refer and what you say - it never changes "do not perform the service today." Uncertainty is a reason to refer, not a reason to proceed cautiously.

Response

• Be clear that you cannot diagnose or treat pigmented lesions, and that a device or peel aimed at a mole is outside your scope and unsafe: without a diagnosis you cannot know whether the lesion needs medical evaluation, and treating over an undiagnosed pigment lesion can mask changes or cause injury.
• Say something usable: "Flat brown spots like this are common and most are harmless, but only a physician can tell you that. Anything you want lightened should be looked at first. I can work around it, but I won't treat over it."

Record (descriptive, not diagnostic)

• Site, approximate size, color, border regularity as observed, and the client's statement that it is long-standing and unchanged.
• The advice given and the client's response, including any request you declined.
• No labels such as "benign" or "melanoma."

Do not

• Do not use cryotherapy, high-frequency "sparking," intense pulsed light, peels, or strong lightening actives over it.
• Do not tell her it is "nothing" or that it "looks fine."
• Do not photograph it for marketing or social media; if you photograph for the clinical record, get written permission and store it securely.
• Do not treat the cheek lesion either, even after she agrees to the referral - the two decisions are independent.