9.3 Contraindications and When to Refer

NIC II.A is client consultation and documentation: health history, intake form, consultation chart, physician release, plus skin analysis (Fitzpatrick) and contraindications for skin services. Chapter 12 covers the full intake conversation. This section is the medical red-flag and cancer/growth stop: when you refuse, when you modify, when you demand a physician release, and when Illinois law already answered “no” before the client sat down.

A contraindication is a reason not to perform a service, or to perform only a modified in-scope service. It is not a diagnosis. “I cannot work on this lesion today; please see a physician” is the professional sentence. “You have melanoma, so I will freeze it” is the license-ending sentence.

The Decision Framework

Walk the face (and any other area you were hired to touch) through this list before steam, extraction, wax, or acid. One yes is enough to stop that procedure.

Contagious

Active herpes simplex, verruca, tinea, conjunctivitis, draining bacterial infection, lice, and scabies are refuse-and-refer presentations. Do not “work around” a cold sore with extra concealer and then steam the mouth. Chapter 4 already mapped 1175.115(b)(34)–(35). Pigment and growth services do not create an exception.

Undiagnosed Changing Lesion

A new, bleeding, crusting, or ABCDE-positive spot is not a clog. It is not a stain to peel. Stop the service that would cover, heat, extract, or exfoliate that site. Refer under 1-7.10(c). Completing Skinny on Skin trains you to listen, support, and connect to medical resources. It does not train you to name the cancer out loud as a diagnosis.

Open Wound

Cuts, unhealed extractions, open acne excoriations, and post-procedure medical wounds are not facial territory. Blood means Standard Precautions and a stop, not a “we’ll be gentle with the steamer.” If the client wants you to “help it heal faster” with a peel, that is medical-treatment advice. Refuse.

Medical-Device or Living-Layer Request

If the client — or the front desk — wants microneedling, radio frequency, microblading, medium or deep peels, Botox, collagen injections, laser, or any technique intended to affect living layers, the answer as an esthetician is no. That is the 04/06/2026 statement and 3A-1, not a shop preference. Superficial peels, surface microdermabrasion or hydrodermabrasion, and dermaplaning remain the surface lane when they are cosmetic. Depth, not the brand name, decides the question.

Isotretinoin

Isotretinoin (brand example Accutane) is a systemic acne drug prescribed by a physician. NIC contraindications still treat it as a reason to avoid waxing, aggressive chemical exfoliation, and other procedures that can scar fragile skin, during use and for at least six months after the client stops, matching long-standing manufacturer caution. You do not second-guess the dermatologist’s medical plan. You do not wax the lip “just this once.” You do not run a peel to “help the Accutane along.” If the client wants a service that the drug labeling and your training treat as contraindicated, you refuse or you obtain a physician release that specifically clears that cosmetic service — and you still stay inside Illinois surface scope. Isotretinoin is also a PIH and wound-healing warning on Fitzpatrick IV–VI skin.

Active Herpes and Sunburn

An active vesicle is an eruption. Sunburn is inflamed skin. Both fail 1175.115. Reschedule. Do not numb a burn with a gel peel. Do not extract through erythema.

Pregnancy Product Limits

Pregnancy is not a skin disease, and you are not the obstetrician. Many chemical services and electrical modalities are limited or postponed as a cosmetic caution: high-strength salicylic products, retinoids, and aggressive exfoliation are the usual exam examples of what you do not push. Gentle cleanse, hydrate, mineral SPF, and makeup are the usual in-scope path. Do not prescribe what is “safe in pregnancy.” That is medical-treatment advice. If a product or machine manufacturer contraindicates pregnancy, 1175.120 already treats use contrary to manufacturer indication as unprofessional conduct. Follow the label. When unsure, skip the active and keep the service cosmetic and superficial.

Physician Release (NIC II.A)

A physician release is written clearance from the client’s physician to receive a named esthetics service. NIC lists it with health history, intake, and the consultation chart because some medical conditions change what you may safely do on the surface: recent surgery, a managed skin disease outside an active eruption, a medication that thins skin, or a request to resume services after isotretinoin.

What a release is not:

• It is not a license to inject Botox, fire a laser, or microneedle under the 131 title.
• It is not a standing order that converts a medical spa menu into esthetics.
• It is not a substitute for 1175.115. A physician cannot require you to massage inflamed, infected skin.

If the service is otherwise in scope (superficial peel, gentle facial, cosmetic wax on intact skin) and the physician has cleared that service, you may proceed as instructed by the release and by the manufacturer. If the service is out of scope, a release does not pull it into Article IIIA.

The Illinois Prohibited List (04/06/2026)

IDFPR’s Statement on Prohibited Practices, dated 04/06/2026, restates 3A-1: no technique, product, or practice intended to affect the living layers of the skin. Listed as the practice of medicine and not within esthetician scope:

• Botox
• Chemical peels except superficial chemical peels
• Collagen injections
• Colonics
• Liposuction
• Microblading
• Microneedling
• Radio frequency

Memorize the list. The peel trap is the word except: superficial peels stay in. Medium and deep peels are medicine. Microneedling is not “advanced exfoliation.” Microblading is not “brow makeup.” Radio frequency is not “a facial machine like a steamer.” Botox is not an esthetic finishing product. A client demand, a manager demand, or a manufacturer weekend certificate does not rewrite the statement.

Physician Delegation Does Not Convert the Service Into Esthetics

The same statement addresses the medspa fact pattern. If a licensed physician delegates a listed medical procedure, all of the following must be true — and even then the work is not esthetics:

1. The person receiving services is a patient of the physician (a physician-patient relationship exists).
2. The physician examines the patient and determines the course of treatment.
3. The delegated person carries out the treatment as instructed.
4. The individual may not hold out as a cosmetologist or esthetician while performing the delegated procedure and may not indicate that the procedure is part of the practice of esthetics.

Missing any piece — no exam, a “Botox Friday” under the spa’s esthetics menu, or a business card that lists microneedling as an esthetician service — is not lawful esthetics practice. Lasers are medical devices on the same logic (IDFPR laser statement; October 30, 2025 IDFPR/IDPH medspa memo). Completing Skinny on Skin does not add lasers, needles, or injectables to profession 131.

Document the Refusal

Write what you saw, what you did not do, and that you referred. Use observational language:

• “Irregular pigmented lesion on left cheek, client declined to proceed with chemical exfoliation on that site, referred to a medical professional.”
• “Active vesicle on upper lip; service refused under 1175.115; reschedule after medical evaluation.”
• “Client requested microneedling; explained Illinois living-layer prohibition; declined to perform; not held out as esthetics.”

Do not write “diagnosed melanoma” or “treated wart.” 1-7.10 protects good-faith referral; it does not protect practicing medicine. Keep the note with the consultation chart. Full intake forms, draping, and protocol writing belong to chapter 12. Here the hours-saving move is the same on every red-flag stem: recognize, refuse, refer, record.