8.1 Primary and Secondary Skin Lesions
Key Takeaways
- Primary lesions are the first visible change: bulla, cyst, macule, nodule, papule, pustule, tubercle, tumor, vesicle, and wheal. Secondary lesions are later-stage changes: crust, excoriation, acne excoriee, fissure, keloid, scale, scar, and ulcer.
- Vesicles (herpes simplex, poison ivy) and any open lesion or ulcer are stop-and-refer findings — not extraction, steam, wax, or peel candidates.
- Mature open comedones on non-inflamed skin are the classic treatable congestion; nodules, tubercles, tumors, deep cysts, bullae, and ulcers are refer.
- 68 Ill. Adm. Code 1175.115(b)(34) forbids massaging skin that is inflamed or that shows a skin infection or eruption; gloves do not override that rule.
- 225 ILCS 410/3A-1 lets an esthetician discuss what is cosmetically appealing; it forbids diagnosing disease or rendering medical-treatment advice.
NIC Scientific Concepts I.F. tests disorders and diseases of the skin. This chapter covers three linked skills: name the lesion, recognize a gland disorder, and stop when the condition is contagious or inflamed. Illinois overlays two hard rules on every mark you see. You recognize and refuse or modify. You do not diagnose or prescribe. 225 ILCS 410/3A-1 lets you say what is cosmetically appealing. It does not let you render advice on appropriate medical treatment for diseases of the skin. 68 Ill. Adm. Code 1175.115(b)(34) forbids massaging any surface of the skin or scalp where the skin is inflamed or where a skin infection or eruption is present.
A lesion is a mark on the skin — a structural or functional change from the client’s normal surface. NIC splits lesions into two families. Primary lesions are the first visible change. Secondary lesions develop in later stages, or they are the crusts, scars, scratches, and ulcers left after a primary lesion is altered by time, picking, or healing. Exam stems will give you a size, a feel (flat versus raised, solid versus fluid), and an example. Your job is to name the lesion and then decide treat, modify, or stop.
Primary Lesions You Must Name
Memorize the name, the feel, a classic example, and the service call. Do not treat this table as medical school. Treat it as the vocabulary NIC uses to decide whether your hands stay on the face.
| Lesion | NIC-style definition | Example | Service call |
|---|---|---|---|
| Macule | Flat spot or discoloration; neither raised nor sunken | Freckle (ephelis), flat age spot | Cosmetic observation; not a disease you treat |
| Papule | Small elevation containing no fluid; may later develop pus | Early acne bump; some warts | Intact, non-inflamed papules may sit in a facial plan; inflamed papules are not digging targets |
| Pustule | Raised, inflamed papule with a white or yellow center containing pus | Acne pustule; folliculitis | Inflamed — 1175.115(b)(34) blocks massage on that surface |
| Wheal | Itchy, swollen lesion from a blow, insect bite, allergy, or sting | Hives (urticaria); mosquito bite | Do not massage or extract; refer if it lasts or spreads |
| Vesicle | Small blister or sac containing clear fluid, in or just beneath the epidermis | Herpes simplex; poison ivy or poison oak | Stop. Vesicles are the classic do-not-treat item |
| Bulla | Large blister containing watery fluid; like a vesicle but larger | Contact-dermatitis blister; second-degree burn | Stop and refer. Do not open, steam, or wax |
| Cyst | Closed, abnormally developed sac containing fluid, infection, or other matter above or below the skin | Acne cyst; sebaceous cyst | Deep or infected cysts are medical, not salon extractions |
| Nodule | Solid bump larger than 0.4 inch (1 cm) that can be easily felt | Nodular acne | Refer. Not a comedone |
| Tubercle | Abnormal rounded, solid lump larger than a papule; extends deeper into the dermis | Deeper solid lump | Refer |
| Tumor | Abnormal mass of varying size, shape, and color; not always cancer | Abnormal growth | Refer. Do not extract, tweeze, or “treat” |
Fluid versus solid, flat versus raised
Writers swap one adjective and expect you to notice.
- A macule is flat.
- A papule is raised and solid with no fluid.
- A pustule is raised with pus in the apex.
- A vesicle is a small clear-fluid blister.
- A bulla is the large version of that blister.
- A wheal is an itchy, swollen hive-type lesion.
- A nodule and a tubercle are solid and deeper than a papule.
- A tumor is an abnormal mass, not a permission slip to “just get it out.”
- A cyst is a closed sac.
If you remember only two stop signs from this list, remember vesicle and bulla. Herpes simplex and poison ivy present as vesicles. A stem that says “small blister containing clear fluid on the lip” is naming a vesicle. The service answer is refuse, not “work around the mouth,” not “dry it with high frequency and continue,” and not “the client has a wedding.” Open, weeping, or crusted herpetic lesions are also infection or eruption under 1175.115(b)(34). Gloves and Standard Precautions manage unexpected blood. They do not legalize a facial on that surface.
Papule versus pustule is the other high-frequency pair. Both are raised. Only the pustule has a visible pus apex. A non-inflamed papule is not automatically an extraction. An inflamed pustule is not a blackhead you “have to finish.” Nodule versus papule is a size-and-depth pair: if it is solid, easily felt, and larger than about 1 cm / 0.4 inch, you are in refer territory, not comedone territory.
Secondary Lesions You Must Name
Secondary lesions are later-stage changes — a crust after a vesicle, a scar after acne, a scale after inflammation, an ulcer after tissue is lost.
| Lesion | NIC-style definition | Example | Service call |
|---|---|---|---|
| Crust | Dead cells forming over a wound or blemish while it heals; sebum and pus mixed with epidermal material | Scab; healing cold sore; impetigo crust | Do not pick, steam, or exfoliate off an infectious crust |
| Excoriation | Skin sore or abrasion produced by scratching or scraping | Cuticle damage from biting; scratched insect bite | Broken skin — stop on that surface |
| Acne excoriee | Client purposely scrapes off acne lesions, causing scarring and discoloration | Picked acne | Do not join the picking; stop aggressive extraction; refer if open |
| Fissure | Crack in the skin that penetrates the dermis | Chapped lips, hands, or heels | Open depth — not a wax, peel, or extraction site |
| Keloid | Thick scar from excessive collagen | Post-surgery or piercing keloid | Cosmetic observation; do not “cut it down”; refer medical options |
| Scale | Thin plate of epidermal flakes, dry or oily; excessive shedding of dead cells | Dandruff; psoriasis flakes; oily seborrheic scale | Inflamed scale is not a peel target; contagious crust is not “just dryness” |
| Scar (cicatrix) | Raised or depressed area after healing of an injury or lesion | Acne scar; surgical scar | Makeup and texture talk only; you do not treat scars as disease |
| Ulcer | Open lesion with pus and loss of skin depth; a deep erosion | Herpes or chickenpox ulcer; pressure sore | Stop. Open lesions are never a facial, wax, or extraction site |
An ulcer should slam the service shut the same way a vesicle does. Open lesions = stop. That includes ulcers, fissures that penetrate living dermis, fresh excoriations, and any crust that is still an infectious eruption. Illinois does not write the word “ulcer” into 1175.115, but an ulcer is inflamed, infected, or erupting skin. Massage, steam, wax, and exfoliation on that surface are out.
Acne excoriee is a treatment-room trap. The client wants you to “get everything out.” Picked, open papules are excoriations. You document. You do not chase every scab. You do not diagnose a picking disorder. You may offer a calmer plan on intact comedones at a later visit when the skin is not erupting.
Keloid versus ordinary scar matters because a keloid is excess collagen, often in clients who are genetically prone to them. It is not a comedone and not a milium. Do not treat it as something to extract or “flatten” with an Illinois surface peel.
Treatable Comedones Versus Do-Not-Treat Lesions
NIC and Illinois both expect you to split ordinary congestion from disease lesions. Open comedones (blackheads) are a sebaceous finding taught in the next section, but they belong in this decision tree because they are the classic treatable bump. An open comedone is oxidized sebum in a follicle with an opening. Standard, hygienic surface extraction of a mature open comedone is ordinary esthetics. It is not treatment of a vesicle, ulcer, nodule, or tumor.
Do not treat / refer on sight:
- Vesicles and bullae (herpes, poison ivy, burns)
- Open lesions, ulcers, and penetrating fissures
- Nodules, tubercles, and tumors
- Cysts that are deep, inflamed, or would require lancing into living tissue
- Any lesion that is inflamed, infected, or erupting (Illinois massage ban)
- Lesions you cannot classify without guessing at a medical diagnosis
A macule such as a freckle is not a stop, and it is not something you “treat” as disease. A scar is not contagious. A scale may be ordinary dryness or a sign of inflammation — if the skin is red, cracked, or spreading, you modify or stop rather than grind it with an acid.
Illinois Refuse-Service Consequence
NIC wants the definition. Illinois wants the consequence. If the skin is inflamed, infected, or showing an eruption, 1175.115(b)(34) says no licensee shall be required or permitted to massage that surface. “The client drove an hour” and “I’ll just skip that cheek” are not exceptions when the presentation is an active infection or a weeping lesion covering the treatment area. 1175.115(b)(35) separately forbids working upon a person with a serious communicable disease as defined in 77 Ill. Adm. Code 690. 1175.115(b)(33) forbids an owner or manager from knowingly letting a person with such a disease work on the premises.
You still do not diagnose. “I cannot perform services on inflamed or erupting skin; please see a physician” is the lawful script. “You have herpes simplex type 1 and you should start valacyclovir” is practicing medicine and giving medical-treatment advice, which 3A-1 forbids. Document what you observed — location, open versus closed, fluid versus solid, client-reported history — and the service you declined. Failure to follow 1175.115 is unprofessional conduct and may be a Section 4-7 violation. Abnormal-growth education in the next chapter covers moles and melanoma. This section’s job is simpler: name the lesion type, decide treat versus stop, and keep Illinois law between your hands and the eruption.
A client presents with a small blister containing clear fluid on the lip. Which primary lesion is this, and what is the correct Illinois action?
Which of the following is a secondary lesion: a thick scar produced by excessive collagen?
Which finding is generally a treatable esthetics extraction rather than an automatic stop-and-refer lesion?
Under 68 Ill. Adm. Code 1175.115, a licensee is not permitted to massage a surface of the skin where: