Three Requests From the Owner and One Lesion on the Nose

Request 1 - 35% TCA marketed as "medical-grade."

• Scope: the depth and concentration you may use are set by Washington's esthetics scope of practice, not by what a supplier will sell you. Medium-depth TCA is generally treated as a medical procedure requiring provider oversight; verify the current DOH position in writing before touching a 35% solution. If it is outside your scope, the answer is no regardless of revenue.
• Advertising: "medical-grade" has no legal definition; it is a marketing phrase. Advertising that implies a medical service, a medical result or a credential you do not hold can constitute false or misleading advertising and unprofessional conduct under RCW 18.130.180. The fix is not better wording - it is not making the claim.
• Your answer: "I'll perform what's inside my license and what I can defend in a chart. I won't advertise a service as medical-grade or run a concentration I can't support within scope."

Request 2 - supervise-by-absence.

• A license allows someone to practice; it does not certify competence in a specific high-risk procedure. Three assists is not training.
• If the peel is within esthetic scope, she may perform it within her own license - but you do not schedule a higher-risk peel for a minimally experienced practitioner on a week when the most experienced person is in another time zone.
• Your answer: "She can do a peel she's been trained and signed off on, with me on site. She can't do a 30% TCA unsupervised next week, and I won't sign off on it to cover the calendar."

Request 3 - the photos.

• A two-year-old intake line about "training purposes" does not authorize public marketing on Instagram. Training use and promotional use are different purposes, and the consent is stale.
• You need specific, current, written authorization naming the platform, the duration, and the client's right to revoke. Clients can and do withdraw permission.
• Client images are part of the client record and carry confidentiality obligations; posting without valid authorization is both a records problem and a trust problem.
• Your answer: "Nothing goes up until we have a current release signed for social media. I'll pull the existing photos down until we do."

Do not treat it, and do not improvise a destructive technique with an acid.

What the description suggests: a 7 mm pearly papule with visible telangiectasia on the nasal ala is a classic presentation for basal cell carcinoma, the most common skin cancer and one that favors sun-exposed areas like the nose. You are not diagnosing it - you are recognizing a pattern that requires a physician's eyes.

What you do:

1. Say it plainly, without alarm: "I'm not going to put acid on that spot. The way it looks - the pearly surface and those little vessels - is something a dermatologist should look at. It's very often nothing serious, and it is also very treatable when it's caught early, which is exactly why I want you seen."
2. Do not apply a peel over it, do not attempt to "freeze" or cauterize, and do not extract or microneedle near it. Acid on a suspected malignancy is both ineffective and harmful.
3. Measure and document the size, location and morphology, and take a photo with separate consent.
4. Give a written referral - the client should leave with something in hand, not a verbal suggestion.
5. Treat the rest of the face only if it is safe and only if she wants it; do not let the referral kill the appointment unnecessarily, but keep the peel well clear of the lesion.
6. Follow up at a set date to confirm she was seen.

Framing matters: this is a referral because you are protecting her, not a refusal because you are limited.

Written record for each:

Situation	Documentation
TCA scope and "medical-grade" advertising	Your written objection, the scope determination you relied on (with the DOH source and date), and the marketing claim you declined to use. Keep a personal copy - if the practice proceeds and a complaint is filed, unprofessional conduct investigations look at who knew what and when.
The unsupervised peel	The training and sign-off record for the junior esthetician: what she was actually trained on, by whom, when, and what supervision was required. Note that you declined to authorize an unsupervised 30% TCA.
The Instagram photos	The current release naming the platform and duration; the date old images were removed; the consent status of every image in the file.
The nasal lesion	Size, location, morphology, that it was not treated and why, that a written referral was provided and to whom, the date, and the follow-up reminder.

Follow-up:

• Confirm in 2 weeks that the client was seen by a dermatologist; note the outcome in the chart.
• Re-audit the photo releases and the scope question at 30 days - these are recurring process failures, not one-off events.
• If the owner proceeds with advertising or delegation you believe is outside the law, your options in Washington include declining to participate, documenting your objection, and contacting the Department of Health. Declining to perform an out-of-scope procedure is protected; performing it is not.
• Verify each specific requirement against the current RCW/WAC and DOH guidance before acting - scope and supervision rules change, and the citation you rely on should be current on the date you use it.