7.3 Skin Disorders, Primary & Secondary Lesions, and Skin Cancer

Quick Answer: A lesion is a mark on the skin that may indicate injury or damage. Primary lesions appear first: macule, papule, pustule, vesicle, bulla, wheal, nodule, tubercle, tumor, cyst. Secondary lesions develop later: crust, scale, fissure, excoriation, ulcer, scar, keloid. For nail technicians, the key skin disorders are contact dermatitis, calluses (keratomas), warts, psoriasis and pigment changes. There are three skin cancers: basal cell (most common, least severe), squamous cell, and malignant melanoma (most serious). Check for melanoma with the ABCDEs and refer the client without diagnosing.

Why Lesions Matter at the Nail Table

You see more of a client's hands, wrists, ankles and feet than almost anyone else. You are not allowed to diagnose, but you must recognize what you see well enough to make two decisions:

1. Is it safe to serve this area? Kansas prohibits services on a consumer with open sores or inflamed tissue suggesting a communicable condition, fungus, lice or ringworm, unless a physician signs a statement that it is not contagious (K.A.R. 28-24-3(a); section 3.3).
2. Should I suggest a physician? Any unusual, changing or bleeding lesion deserves a gentle recommendation to see a dermatologist.

Primary Lesions

Secondary Lesions

Open lesions, including fissures that bleed, ulcers, weeping vesicles and excoriations, are broken skin. Do not soak, file, massage or apply product over them.

Skin Disorders Nail Technicians See

Inflammation and dermatitis

• Dermatitis is inflammation of the skin. Contact dermatitis comes from contact with a substance:
  • Irritant contact dermatitis is direct damage from harsh substances, such as frequent hand washing, solvents and acetone. It can appear right away.
  • Allergic contact dermatitis is an immune reaction (sensitization) after repeated, prolonged contact with an allergen. For nail professionals, the usual cause is monomer liquid, uncured gel, or adhesives touching the skin. Once you are sensitized it usually lasts, and reactions can spread beyond the contact area.
  • Prevention: never let product touch the skin (leave a small margin at the cuticle and sidewalls), don't touch your face with product on your hands, fully cure gels, clean the gel inhibition layer with a fresh surface of the wipe for each nail, wear nitrile gloves, and clean spills right away.
• Eczema is an inflammatory, itching skin disease with dry or moist lesions. Refer the client, and don't serve broken or weeping skin.
• Psoriasis shows as red patches covered with silver-white scales, and it may cause pitting in the nails. It is not contagious, but don't file or treat the patches, and avoid any broken skin.

Hypertrophies (overgrowths)

• Keratoma is a thickened patch of epidermis caused by pressure or friction. On the hands and feet this is a callus. A corn is a keratoma that grows inward. Calluses may be softened and smoothed. They are never shaved with a blade (K.A.R. 28-24-14).
• Verruca (wart) is caused by a virus (HPV) and is contagious. Plantar warts are on the soles. Don't file or cut them, and refer the client.
• Skin tags and moles (small, usually brown spots) are generally harmless. Avoid irritating them, and note any mole that changes.

Sweat gland disorders

• Hyperhidrosis is excessive sweating, common on the palms and soles. It can shorten polish and enhancement wear, so dehydrate the nails thoroughly.
• Bromhidrosis is foul-smelling perspiration, often from the feet.
• Anhidrosis is a lack of perspiration.

Pigment changes

• Hyperpigmentation: chloasma (brown patches), lentigines (freckles) and age spots.
• Hypopigmentation: vitiligo and leukoderma (white patches from loss of pigment), and albinism (no melanin).
• Stain: an abnormal brown or wine-colored discoloration, such as a birthmark.

Skin Cancer

The ABCDEs of melanoma:

• Asymmetry: the two halves don't match.
• Border: irregular, scalloped or poorly defined edges.
• Color: varies from one area to another, such as shades of brown, black, red, white or blue.
• Diameter: larger than 6 mm, about the size of a pencil eraser, although melanomas can be smaller.
• Evolving: changing in size, shape or color, or new symptoms such as itching or bleeding.

Melanoma under the nail. A new or changing dark band in a nail plate, especially a single band in an adult, a widening band, or pigment spreading onto the surrounding skin of the nail fold, can be a warning sign of subungual melanoma. Established, even bands are common and harmless in many people with darker skin tones. Your role is the same either way: don't diagnose. Mention what you notice privately and recommend a dermatologist.

How to Talk About It

Describe what you see, not a disease name: "I noticed this spot looks different from last visit." Explain that you are not able to diagnose, and suggest the client have a dermatologist take a look. If the lesion is open, weeping or inflamed, explain that Kansas rules don't allow you to perform the service on that area today (K.A.R. 28-24-3).