5.2 Contraindications, Declining or Altering Service, Medical Referral, and Patch Testing

The decision Domain 2 actually scores

PSI National Domain 2.A.2 is declining or altering service based on contraindications. Domain 2.A.3 is recommendation client seek a medical opinion. Domain 2.C adds allergic reaction (patch) test procedures, skin diseases and disorders, and signs of adverse reactions during and after product use. Georgia law supplies the hard edges those national items sit against.

Rule 240-4-.02 requires consumer signage. If the facility does not use the Board PDF, the posted wording must still include: All cosmetology services shall only be performed on intact, healthy scalp, skin, and nails. That sentence is the legal test for “may I put product or a device on this tissue today?” Cracked, weeping, blistered, bleeding, or obviously infected skin is not intact healthy skin. Asking the client to initial a release does not create authority the posted rule withholds.

O.C.G.A. § 43-10-1(8) defines the esthetician and then draws a bright line: such practices of esthetics shall not include the diagnosis, treatment, or therapy of any dermatological condition or medical aesthetics or the use of lasers. You may observe, document, stop, and recommend a medical opinion. You may not tell a Midtown client “this is basal cell carcinoma” or “I am treating your rosacea” as if you were the diagnosing clinician. Cosmetic calming care on intact skin is still cosmetic care. Therapy of a named dermatological disease is not.

Absolute versus relative

Altering is often the better professional answer when the skin is intact and the risk is timing or intensity. Declining is the only answer when the tissue is not intact, the finding is contagious in the field, the request is medical/laser, or a patch test was positive for that product.

How to decline without diagnosing

1. Describe what you see (“There is an open, crusted spot at the left corner of the mouth”).
2. Tie it to the posted rule or to injury risk (“I cannot perform a machine facial or extraction over skin that is not intact”).
3. Offer what is still allowed (a consultation only; a service on a different intact area; a later date when the tissue has closed).
4. Give a return condition that you can observe (fully closed surface, no weeping), not a disease-cure promise.
5. Do not bargain when the finding is contagious, bleeding, or out of scope.
6. Chart the observation, the decision, what you told the client, and any referral.

Recommending a medical opinion

The outline item is a recommendation, not a diagnosis. A usable script:

“I notice a dark patch near your right temple that you said has two colors and has gotten darker this year. Checking a changing spot is outside what an esthetician is licensed to diagnose or treat in Georgia. Please have a physician or dermatologist look at it before we do any exfoliation or extraction in that area.”

That script does not say melanoma, does not say “it's probably nothing,” and does not offer a spa acid “to fade it.” Refer promptly for ABCDE-type change, a sore that does not heal, spreading redness with pain or pus, a suspected eye infection, or an adverse reaction that is more than transient redness. Severe nodulocystic acne that the client wants you to “cure” is a referral, not a deeper extraction session.

Work next to injectors in a Duluth or Buckhead medical-spa suite does not expand the esthetician licence. The nurse or physician may diagnose; you still may not. Lasers remain outside § 43-10-1(8) even if the room down the hall has an IPL.

Patch (predisposition) testing

Domain 2.C.1 names allergic reaction (patch) test procedures. The tested skill is following the product-specific predisposition procedure. Georgia does not publish one universal site or clock:

1. Use the actual product that will touch the client (tint, depilatory, lash-lift chemistry, a new leave-on acid), not a random “allergy cream.”
2. Follow the manufacturer's directions for the site, amount, preparation, covering, and removal. An inner arm or post-auricular site is common for some products, but it is not a universal rule for every formula.
3. Follow the stated timing and read window. Some tint directions use a 24-to-48-hour interval; other products may specify a different procedure. A same-day smear does not replace a longer test when the label requires one.
4. Give only the care instructions printed for that test; do not improvise tape, washing, or extra products.
5. Read the site: redness, itching, swelling, vesicles, or weeping is a positive test. Do not use that product. Document. If the reaction is severe or involves breathing or widespread hives, stop playing spa nurse and send the client to urgent medical care.
6. A negative test reduces risk; it does not prove the client will never react, especially on the face or eyelid.

Perform a predisposition test before eyelash or eyebrow tint, chemical lash or brow services, depilatories, or another sensitizing product when the current manufacturer directions require it, using that product's exact method. Intake still happens. A clear patch test does not authorize tint over conjunctivitis or over broken eyelid skin.

Irritant reactions can happen on first exposure from too much heat, too much acid, or too long a contact time. Allergic (type IV) reactions often need prior sensitization and may bloom hours to days later. Either one is an adverse reaction you must recognize.

Diseases and disorders as stop signs

Chapter 4 covers lesions in depth. Domain 2.C asks you to treat them as consultation brakes:

• Viral: herpes simplex vesicles or crusts in the field — no facial, wax, or extraction over or beside them.
• Bacterial: impetigo, draining folliculitis — no service on that tissue; recommend medical care.
• Fungal or conjunctival: suspected tinea on the face, pink-eye signs — stop; do not share tools; refer.
• Inflammatory with broken skin: weeping eczema, psoriasis plaques that are open — intact-skin rule.
• Undiagnosed growths: changing moles, non-healing sores — no peel or extraction over them; medical opinion.
• Sunburn or acute dermatitis — postpone heat, wax, and acids.

You record location, appearance, and what you did. You do not write a ICD-style diagnosis to impress an inspector.

Signs during and after the service

An Augusta outdoor-worker who develops welts ten minutes into a glycolic pass does not need encouragement to “breathe through it.” That is an adverse reaction item, not a toughness item.

Georgia spa scenario: three findings, one bridal facial

A bridal party books spa facials in Savannah's historic district. The bride's intake is clean. In the chair you find: a healing but still crusted cold sore at the lip; tretinoin started nine days ago; and a 7 mm two-toned, asymmetric spot at the temple she says “got darker this year.”

• Cold sore: absolute for steam, extraction, and acid on the face near that field.
• Tretinoin: relative timing problem for peels and wax even if the cold sore were gone.
• Temple lesion: referral, not a brightening peel.

You decline the glow peel and the extractions. If you offer anything, it is a gentle cleanse and hydrating mask avoiding the perioral crust and the temple, only on intact skin, with a new consent that matches that limited service. You recommend a medical opinion on the changing spot. You chart all three findings. You do not tell her she has herpes or melanoma. You do not let the wedding timeline bully the intact-skin rule.

Traps

• Diagnosing to sound helpful.
• Treating a positive patch test as “maybe the face will be fine.”
• Substituting a quick same-day smear for a manufacturer-required predisposition procedure.
• Using a waiver to work on non-intact skin.
• Pushing through burning and hives because the appointment is prepaid.