5.2 Declining or Altering a Service & Referring for a Medical Opinion

Declining or Altering a Service & Referring for a Medical Opinion

Quick Summary: A consultation only matters because of what you do with it. The exam outline names three consecutive actions: client intake and consent forms to determine possible contraindications, declining or altering service based on contraindications, and recommendation client seek a medical opinion. This section covers the last two — the decisions themselves.

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1. Absolute vs. Relative Contraindications

Absolute — decline or postpone

• Active herpes simplex (cold sore) in or near the treatment area. Heat, exfoliation and manipulation can spread the lesion and infect you.
• Impetigo, active bacterial folliculitis, or any contagious lesion in the field.
• Open, weeping, bleeding or unhealed wounds, including a recent biopsy site.
• Undiagnosed, changing, or ABCDE-positive pigmented lesions — no treatment over or near them, and refer.
• Active sunburn or acute thermal injury.
• Current oral isotretinoin therapy, and the manufacturer-and-prescriber-directed interval after stopping, for waxing, peels, dermaplaning and microdermabrasion.
• Uncontrolled systemic illness, fever, or acute infection.
• A positive patch test for the product in question.
• Client unable to give informed consent — intoxicated, heavily sedated, or a minor without the required parental consent.
• A request that falls outside the Michigan scope of practice — injections, lesion removal, medium or deep peels, anything past the stratum corneum.

Relative — alter and proceed

• Rosacea or reactive skin — no steam, no strong mechanical exfoliation, lukewarm water, shorter contact times, calming actives.
• Recent topical retinoid use — hold waxing and exfoliation for the manufacturer-directed interval; substitute a gentler service.
• Diabetes, especially with neuropathy — extra care with heat, extraction pressure and any risk of breaking skin.
• Pregnancy — avoid electrical modalities; check ingredient restrictions; positioning and comfort adjustments.
• Anticoagulant or antiplatelet therapy — extractions bruise more readily; lighten or omit.
• Photosensitising medication — reduce exfoliation intensity and reinforce photoprotection.
• Recent injectables, laser, or peel — respect the interval; a facial today, the exfoliation later.
• Keloid or hypertrophic scarring history — avoid anything that could wound.
• Very recent waxing or shaving in the field — reschedule the exfoliation, keep it gentle today.

Exam Note: "Altering" is the answer far more often than "declining." The 2026 outline is written around safe delivery, so the best answer is usually the one that keeps the client in the chair with a modified, gentler version — unless the finding is contagious, undiagnosed, unhealed, out of scope, or isotretinoin.

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2. How to Decline Well

Declining is a communication skill, and doing it badly is how clients end up injured elsewhere.

1. State the observation, not a diagnosis. "I can see an area on your lip that looks like an active cold sore" — not "you have herpes."
2. Explain the consequence in the client's terms. "Working over it could spread it across your face and slow the healing."
3. Say what you can do today. A gentle cleanse and hydrating mask away from the area, a product consultation, or a rebooking with the exfoliation intact.
4. Give a clear return condition. "Once it's fully healed and crusted over — usually seven to ten days — we can do the full treatment."
5. Do not negotiate on safety. A client who insists is told, once and kindly, that the answer is the same.
6. Document it.

The referral script

When a finding needs a physician, the outline item is "recommendation client seek a medical opinion." The three-part structure keeps you inside your scope:

"I've noticed [objective description — a raised, dark, irregularly bordered lesion near your hairline]. That's outside what I'm licensed to assess or treat as an esthetician. I'd recommend you have it looked at by your doctor or a dermatologist before we do any further work in that area."

What that sentence does not do: name a disease, estimate a probability, reassure ("it's probably nothing"), or alarm ("that looks like melanoma"). Both extremes are a diagnosis. In Michigan the boundary has statutory force — R 338.2179g(1)(i) bars performing services limited to a licensed health profession under article 15 of the Public Health Code absent a MCL 333.16215 delegation, and MCL 339.1210(3) confines every skin care service to the stratum corneum.

Refer promptly for: any lesion meeting ABCDE criteria; a lesion that bleeds, ulcerates, crusts or fails to heal in weeks; a rapidly changing mole; suspected infection with spreading erythema, warmth, pain or purulence; severe nodulocystic acne; sudden widespread pigment change; any adverse reaction beyond transient erythema.

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3. Documentation

Whatever you decide, the record shows:

• Date and time.
• What you observed, described objectively, with location and size.
• The decision — declined, postponed, or altered, and exactly how it was altered.
• What you told the client, including the return condition.
• The referral, if made.
• The client's acknowledgement — signature or initials on the record.

A short, specific entry protects the client, the practitioner and the establishment. A blank record does the opposite: if the service was altered and the record does not say so, the record reads as though the full-strength service was given.

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Real-World Scenario: Three Findings in One Consultation

Scenario: A new client books a dermaplane with a glycolic finish. At consultation the esthetician finds: a healing cold sore at the left oral commissure with intact crust; a note on the intake form of tretinoin 0.05% started nine days ago; and a 7 mm asymmetric, two-toned lesion near the right temple that the client says "has always been there, but got darker this year."

Analysis:

1. The cold sore. Active herpes simplex in the field is an absolute contraindication for dermaplaning and exfoliation. Even crusted, manipulation and blade work risk spread and autoinoculation.
2. The tretinoin. A relative, timing contraindication. Nine days of a topical retinoid means a thinned stratum corneum and a substantially higher risk of abrasion and post-inflammatory hyperpigmentation from both the blade and the acid.
3. The temple lesion. Asymmetry, two colours, 7 mm and a reported change. This is a referral, not a treatment decision — no exfoliation over or near it, and no opinion offered on what it is.
4. What the esthetician actually does. Declines the dermaplane and the glycolic. Delivers a gentle cleanse, a hydrating non-acid mask avoiding the perioral area and the temple, and a photoprotection consultation. Advises pausing tretinoin for the manufacturer-directed interval before rebooking, and rebooks once the cold sore is fully healed.
5. The referral. "I've noticed a lesion near your right temple that's asymmetric and has more than one colour, and you've told me it has changed. That's outside what I can assess as an esthetician — please have your doctor or a dermatologist look at it before we treat that area."
6. The record. All three findings, the decision on each, the modified service delivered, the referral, and the client's initials.

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Key Takeaways

• Absolute contraindications end the service; relative ones change it. Modification is the more common correct answer.
• Absolute list: active herpes or other contagious lesion, open wounds, undiagnosed or changing pigmented lesions, sunburn, current isotretinoin, uncontrolled illness, positive patch test, no valid consent, out-of-scope request.
• Relative list: rosacea, recent retinoid use, diabetes, pregnancy, anticoagulants, photosensitising drugs, recent injectables/laser/peel, keloid history, recent waxing.
• Refer without diagnosing: describe what you see, state that it is outside your scope, recommend a physician or dermatologist.
• In Michigan the boundary is statutory: stratum corneum only (MCL 339.1210(3)); no health-profession services absent delegation (R 338.2179g(1)(i)).
• Document the observation, the decision, the communication, the referral and the client's acknowledgement.