3.6 Pigmentation, Growths & Skin Cancers

Melanin And Pigmentation Disorders

Melanin is the pigment produced by melanocytes in the stratum germinativum that gives skin, hair, and eyes their color and helps absorb damaging UV radiation. Pigmentation disorders occur when melanin production becomes uneven, excessive, or deficient.

Hyperpigmentation describes an overproduction of melanin, producing patches darker than the surrounding skin.

• Melasma (chloasma) is a hormonally influenced hyperpigmentation, often triggered by pregnancy, birth control, or hormone therapy, and worsened by sun exposure; it commonly appears as symmetrical patches on the forehead, cheeks, and upper lip.
• Lentigines (sun spots, "liver spots") are flat, brown macules caused by cumulative sun exposure over time, most common on the face, hands, and other frequently exposed areas.
• Post-inflammatory hyperpigmentation (PIH) develops after an injury, breakout, or aggressive service triggers inflammation, leaving a darker mark behind as the skin heals — the same PIH risk discussed under the Fitzpatrick scale in section 3.3.

Hypopigmentation describes an underproduction of melanin, producing lighter-than-normal or colorless patches.

• Vitiligo is an autoimmune condition in which melanocytes are destroyed, producing well-defined white patches, often symmetrical, that carry no pain but can affect a client emotionally; camouflage makeup is a common esthetics-appropriate support service.
• Albinism is a genetic condition marked by a partial or total absence of melanin production throughout the body, resulting in very pale skin, hair, and eyes and heightened sun sensitivity requiring diligent SPF use.

Common Growths

Several growths appear regularly on esthetics clients and must be correctly identified so services avoid or appropriately work around them.

• Skin tags (acrochordons) are small, soft, benign growths of skin that typically hang from a thin stalk, most common in areas of friction such as the neck and underarms.
• Seborrheic keratosis is a benign, often waxy or "stuck-on" looking growth that can be tan, brown, or black, common in older adults; it is not cancerous but should be monitored for sudden change.
• Actinic (solar) keratosis is a rough, scaly, reddish or brownish patch caused by long-term sun damage. Unlike seborrheic keratosis, actinic keratosis is considered precancerous and carries a risk of progressing to squamous cell carcinoma if left unaddressed, which makes prompt referral important rather than optional.
• Verruca (warts), introduced in the previous section as a contagious viral growth, also belongs in this category structurally, since it is a benign epidermal growth caused by HPV rather than a malignancy.

The Three Major Skin Cancers

Skin cancer recognition is one of the highest-stakes topics on the Scientific Concepts domain because a missed referral has real consequences for the client. Estheticians do not diagnose or treat cancer, but they are often the professional positioned to notice a suspicious change during a facial or body service and prompt the client to seek medical evaluation.

Basal cell carcinoma is the most frequently diagnosed skin cancer and arises from cells in the stratum germinativum; it grows slowly and rarely spreads to other parts of the body, but it can cause significant local damage if ignored for years. Squamous cell carcinoma arises from cells higher in the epidermis, often on sun-exposed skin, and carries a meaningfully higher risk of spreading to lymph nodes or other organs than basal cell carcinoma. Melanoma develops from melanocytes and is the least common of the three but by far the most dangerous, because it can spread quickly through the lymphatic and circulatory systems once it grows beyond the outer skin layers.

The ABCDE Rule

The ABCDE rule is the standard memory tool for screening a mole or pigmented lesion for melanoma warning signs.

• A — Asymmetry: one half of the mole does not match the other half.
• B — Border: edges are irregular, notched, or poorly defined rather than smooth.
• C — Color: uneven color, or the presence of multiple colors (brown, black, red, white, blue) within one lesion.
• D — Diameter: larger than about 6 millimeters (roughly the size of a pencil eraser), though melanoma can occasionally be smaller.
• E — Evolving: any change in size, shape, color, elevation, or symptoms such as itching or bleeding over time.

The Referral Rule Has No Exceptions

If a lesion meets one or more ABCDE criteria, the correct and only professional action is to recommend the client see a physician or dermatologist promptly. An esthetician must never attempt to diagnose the lesion, reassure the client that it is "probably fine," or perform any service directly on or immediately around a suspicious lesion. This referral duty exists precisely because Virginia's esthetics scope of practice under 18VAC41-70 authorizes cosmetic skin care, not the diagnosis or treatment of disease — recognizing a possible skin cancer and referring it out is itself the licensed, correct action, not a failure to help the client.