4.4 Skin Diseases and Disorders of the Periocular Area
Key Takeaways
- The PSI outline places Skin and Eye Diseases and Disorders inside Infection Control, so periocular skin findings are tested as a sanitation competency paired with the 16 TAC §83.102(b) refusal rule.
- 16 TAC §83.102(b) names head lice, nits, ringworm, and conjunctivitis explicitly and adds any inflamed, infected, broken, raised or swollen skin or open wound in the area to be serviced.
- Primary lesions such as macules, papules, vesicles, and pustules signal an active process, while secondary lesions such as crusts, scales, fissures, and excoriations signal a healing or chronic one.
- Impetigo, herpes simplex, molluscum contagiosum, verruca, tinea, and pediculosis are contagious and are absolute refusals; seborrheic dermatitis, eczema, psoriasis, rosacea, milia, and xanthelasma are not contagious but still bar service when the skin is broken or inflamed.
- A specialist may describe what is visible and refer to a physician, optometrist, or ophthalmologist, but naming a condition or recommending treatment falls outside the scope defined by Occupations Code §1603.0011(c).
Why Skin Sits Inside Infection Control
PSI's written outline places Skin and Eye Diseases and Disorders under Infection Control (32.5%, 13 items) — not under Consultation. That placement is a hint about how the questions are framed. Texas is not asking you to diagnose. It is asking whether a finding on the client's skin triggers a mandatory refusal and a decontamination response.
The operative rule is 16 TAC §83.102(b):
"A practitioner may not perform services on a client if the practitioner has reason to believe the client has a contagious condition such as head lice, nits, ringworm, conjunctivitis; or inflamed, infected, broken, raised or swollen skin or nail tissue; or an open wound or sore in the area to be serviced."
Read the second half carefully. Even a non-contagious condition stops the service if the skin in the treatment area is inflamed, infected, broken, raised, or swollen. A flaring eczema patch on the upper lid is not contagious, and it still bars the service.
Describing Without Diagnosing: Lesion Vocabulary
You will document what you see and refer. The vocabulary below lets you write an objective, defensible note without stepping into medical practice.
Primary lesions — the first visible change
| Lesion | Definition | Periocular example |
|---|---|---|
| Macule | A flat, discoloured spot, not raised or depressed | A freckle or post-inflammatory pigment change on the lid |
| Papule | A small, solid, raised lesion under about 1 cm, containing no fluid | An inflamed follicle at the lash base; molluscum bump |
| Pustule | A raised lesion containing pus | The yellow head of an external hordeolum |
| Vesicle | A small blister containing clear fluid | The classic herpes simplex or zoster cluster |
| Bulla | A blister larger than about 1 cm | Severe contact reaction or a burn |
| Nodule | A solid, raised lesion extending deeper into the tissue | A chalazion within the tarsal plate |
| Wheal | A transient, raised, itchy swelling | Urticarial reaction to an adhesive or gel pad |
| Tubercle | A solid lump larger than a papule, sometimes deeper | A larger benign growth on the lid |
Secondary lesions — what develops later
| Lesion | Definition | Periocular example |
|---|---|---|
| Scale | Flakes of shed, thickened epidermis | Seborrheic dermatitis or seborrheic blepharitis |
| Crust | Dried serum, blood, or pus on the surface | The honey-coloured crust of impetigo |
| Excoriation | A scratch or scrape from mechanical trauma | Damage from a client rubbing an itching lid |
| Fissure | A crack through to the dermis | A split at the outer canthus in chronic dermatitis |
| Ulcer | An open lesion with tissue loss | A deep, non-healing sore requiring urgent referral |
| Scar | Fibrous tissue after healing | Cicatricial change causing entropion or trichiasis |
| Keratosis | Thickened patch of epidermis | Chronic sun-exposed skin at the outer canthus |
How to write the note: "Visible raised, weeping lesion with yellow crust at the lateral upper lid margin; service declined; client advised to consult a physician." You have recorded the finding, the action, and the referral — and you have named nothing.
Inflammatory and Non-Contagious Skin Conditions
These are not transmissible, but §83.102(b) still bars service whenever the skin is inflamed, broken, raised, or swollen in the treatment area.
Contact dermatitis — the two types
This is the single most important skin distinction for a lash specialist, because both types are caused by the products in your own kit.
| Feature | Irritant contact dermatitis | Allergic contact dermatitis |
|---|---|---|
| Mechanism | Direct chemical damage to the skin barrier; no immune memory | Type IV delayed cell-mediated hypersensitivity; requires prior sensitisation |
| Who it affects | Anyone, on first exposure, if the dose is high enough | Only sensitised individuals |
| Onset | Minutes to a few hours | 24–48 hours after exposure |
| Sensation | Burning, stinging, rawness | Intense itching |
| Distribution | Confined to where the substance touched | Spreads beyond the contact site; usually bilateral on the lids |
| On re-exposure | Same severity | Escalates each time |
| Future services | Possible with product change and better technique | Cyanoacrylate sensitisation is a permanent contraindication |
Common periocular culprits: cyanoacrylate adhesive vapour, adhesive remover left in contact too long, gel pad preservatives and fragrance, and the acrylate chemistry in some primers.
Seborrheic dermatitis
Chronic, non-contagious inflammation in sebum-rich areas — scalp, brows, nasolabial folds, and the lid margins, where it presents as seborrheic blepharitis: soft, greasy, yellowish scales along the lash line with mild erythema. Associated with Malassezia yeast overgrowth. Extensions applied over active scaling trap debris and shorten retention dramatically; defer until the margin is clear and the client has an eyelid hygiene routine.
Atopic dermatitis (eczema)
Chronic, relapsing, intensely itchy inflammation with dryness, erythema, and lichenification. The eyelid is thin skin and a common site. Rubbing produces excoriations — broken skin, which §83.102(b) covers directly. Active flare on the lids is a defer-and-refer.
Psoriasis
Well-demarcated erythematous plaques with thick, silvery-white scale. Non-contagious. Periocular involvement is uncommon but occurs. Removing scale can produce pinpoint bleeding (Auspitz sign) — never attempt to lift or debride it. Defer while lesions are active in the treatment area.
Rosacea and ocular rosacea
Chronic facial redness with flushing, telangiectasia, papules and pustules. Ocular rosacea affects roughly half of rosacea patients and produces lid margin inflammation, recurrent chalazia, meibomian gland dysfunction, and a gritty burning sensation. Not contagious, but the inflamed margin and unstable tear film mean poor retention and a real risk of aggravating the condition. Refer for management first.
Benign growths you should recognise and never touch
| Finding | What it is | Action |
|---|---|---|
| Milia | Tiny, firm, white keratin cysts just under the epidermis; common on the lids | Do not extract — outside scope and §83.112(c) territory. Refer. |
| Syringoma | Small, skin-coloured benign sweat-duct tumours, often clustered on the lower lids | Work around them; never lash onto or through them. Refer if changing. |
| Xanthelasma | Soft yellowish plaques at the medial canthus from lipid deposition | Not contagious. Refer, as it can signal a lipid disorder. |
| Skin tag (acrochordon) | Small pedunculated skin growth | Never cut, tie off, or remove — that is not cosmetology. |
| Any new, changing, irregularly pigmented, or bleeding lesion | Unknown | Say nothing diagnostic; recommend prompt evaluation by a physician. |
Contagious Skin Conditions: Absolute Refusals
Every condition in this group is transmissible. Under §83.102(b) service is prohibited, and under §83.115 the station must be fully reprocessed afterward.
Impetigo
Superficial bacterial infection, usually Staphylococcus aureus or Streptococcus pyogenes. The classic presentation is a honey-coloured (golden) crust over a moist erosion, often around the nose, mouth, and eyelids. Highly contagious by direct contact and by fomites. Refuse, do not touch the area, and disinfect everything the client contacted.
Herpes simplex (HSV-1)
Prodromal tingling, then a cluster of clear vesicles on an erythematous base, which rupture and crust. Cold sores on the lip and periocular lesions both matter — HSV near the eye risks dendritic keratitis. Actively shedding virus while vesicles are present and until fully crusted and healed. Absolute refusal. Never apply adhesive, tape, or a gel pad over or adjacent to an active lesion.
Herpes zoster (shingles) and herpes zoster ophthalmicus
Unilateral painful vesicular eruption in a dermatome that respects the facial midline. Vesicular fluid transmits varicella to non-immune contacts. Absolute refusal and urgent referral. Hutchinson's sign — vesicles on the tip, side, or root of the nose — indicates nasociliary nerve involvement and a high risk of sight-threatening intraocular disease.
Molluscum contagiosum
A poxvirus producing small, firm, dome-shaped, flesh-coloured papules with a central umbilication (dimple). Spread by direct contact and by shared items. Lid-margin lesions can shed viral particles into the conjunctival sac and cause a chronic follicular conjunctivitis. Refuse and refer.
Verruca (viral wart)
Rough, hyperkeratotic papule caused by human papillomavirus; filiform warts occur on the lids. Contagious and autoinoculable. Refuse; removal is medical.
Tinea (ringworm) — named in the rule
A dermatophyte fungal infection producing an annular scaly plaque with a raised, advancing border and central clearing. Tinea faciei occurs on the face. §83.102(b) names "ringworm" explicitly. Contagious by direct and indirect contact; the same organisms cause tinea corporis and tinea capitis. Absolute refusal.
Pediculosis — head lice, and lashes specifically
§83.102(b) names "head lice, nits." Two presentations matter:
- Pediculosis capitis — head lice, with nits cemented to hair shafts near the scalp.
- Phthiriasis palpebrarum — pubic lice infesting the eyelashes. Presents as intense itching, marginal crusting, and small brownish specks (nits and louse faeces) adherent to the lash shafts, frequently mistaken for blepharitis. Refuse and refer; treatment is medical.
Demodex
Demodex folliculorum and D. brevis are mites, not a classic contagious disease, but the cylindrical collarettes at the lash base signal an infestation that makes extensions untenable and worsens blepharitis. Defer until treated.
The Response Protocol When You Refuse
- Stop before contact if you spot the finding at consultation. If you have already begun, stop immediately.
- Do not name a diagnosis. Describe what is visible.
- Discard everything single-use that touched the client under §83.115(e) — gloves, tissues, wipes, tape, eye pads, extensions, swabs, brushes, extension pads.
- Clean, then disinfect every implement named in §83.115(d) and everything else under §83.115(b), remembering that visible debris must come off first (§83.101(a)(1)).
- Clean and disinfect the chair or bed including the headrest under §83.115(c).
- Wash hands with soap and water under §83.115(a).
- If blood or body fluid was involved, follow §83.111: non-porous instruments cleaned and disinfected with an EPA-registered hospital grade or tuberculocidal disinfectant per label, or immersed 5 minutes in the 5,000 ppm bleach solution; porous items double-bagged and discarded.
- Document the objective finding, the refusal, and the referral, and rebook only after the client's provider confirms resolution.
A client arrives with a moist, weeping lesion covered by a honey-coloured golden crust at the outer edge of her upper eyelid. What should the Texas eyelash specialist do?
Two days after a full set, a client returns with bilateral swollen, red, intensely itchy eyelids. During the appointment she felt nothing unusual. Which reaction pattern does this match?
Which condition is named explicitly in the text of 16 TAC §83.102(b) as a reason a practitioner may not perform services?
A client asks the specialist to extract several small firm white bumps under her lower lashes before the appointment. What is the correct response?