DOH Aesthetician oral exam prep

Knowledge: Glycolic acid depth depends on concentration, pH, contact time and the skin barrier, not only on the percentage. Recent tretinoin and waxing disrupt the stratum corneum, so this peel is penetrating deeper and faster than planned. Frosting is not an expected end point with glycolic acid as it can be with TCA; it signals epidermal injury. In type IV skin the main risk is post-inflammatory hyperpigmentation, which can outlast the melasma she came to treat. Blistering, infection and herpes simplex reactivation are other risks. The checklist on the day should screen for retinoids, recent hair removal, sun exposure and isotretinoin.

Management: I would stop the peel and neutralise the whole treated area, not only the frosted patch, then flush with cool water. I would apply cool compresses and stay with her. I would ask the supervising dermatologist to see her before she leaves, as the doctor may prescribe a topical steroid, antiviral or barrier repair plan. I would apply only a bland emollient and a mineral sunscreen. Written aftercare: no tretinoin, scrubs or waxing until the doctor allows, no picking, strict sun protection. With consent I would photograph the area and book review in 48 to 72 hours, sooner if blisters, pus or spreading redness appear. I would not cover it with heavy makeup or promise clear skin for her wedding on Friday.

Ethics and communication: She deserves an honest explanation, including that our screening should have caught the tretinoin and waxing. I would inform the dermatologist and complete an incident report without blaming her. Prescription advice is the doctor's role. I would record product, concentration, contact time, findings and actions.

Reference: Khunger N, IADVL Task Force, Standard guidelines of care for chemical peels (Indian J Dermatol Venereol Leprol, 2008); Tosti A, Grimes PE, De Padova MP, Color Atlas of Chemical Peels (2nd ed, 2012)

Knowledge: Boils weeks after a whirlpool pedicure, especially after leg shaving, fit furunculosis from rapidly growing mycobacteria such as Mycobacterium fortuitum, first described in a California nail salon outbreak. These organisms live in biofilm and debris behind the inlet screens of whirlpool footspas, and rinsing does not remove them. Shaving creates small skin breaks through which they enter. The infection needs culture or biopsy and often months of antibiotics chosen by a physician. Three clients in a week is a cluster to be treated as linked until proven otherwise. Disinfectant only works after cleaning has removed organic matter, and only for its full contact time.

Management: I would advise her to see a doctor today and mention the pedicure, and I would not drain the lesions. I would inform the medical director at once and contact the other two clients to advise medical review. I would take the footspas out of service immediately and leave them untouched for inspection and sampling. I would list dates, staff, footspa numbers and clients from the booking records. Once cleared, the protocol is: drain, remove and scrub the screen, clean with detergent, then disinfect with a registered disinfectant for the full contact time between clients, with an end-of-day routine and a log. I would retrain staff and advise clients not to shave their legs in the 24 hours before a pedicure.

Ethics and communication: She deserves an honest explanation that the infection may be linked to our footspas, without speculation about blame. A cluster linked to a service is a public health matter; the medical director reports it to the health authority in line with UAE law and DOH requirements, and I must not hide it. Client details go only to those who need them. If the owner pressed to reopen early, I would refuse and escalate.

Reference: Winthrop KL et al, An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon (N Engl J Med, 2002); CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

Knowledge: Isotretinoin shrinks sebaceous glands and thins the epidermis, so the skin dries, heals slowly and tears easily; cracked lips show this effect. Wax grips the stratum corneum as well as hair and on isotretinoin can lift the epidermis, leaving erosions, infection risk and, in darker skin, pigment change or scarring. Microdermabrasion carries a similar risk on fragile skin. A 2017 systematic review with consensus recommendations found little evidence for delaying several physician procedures but advised against mechanical dermabrasion, and waxing is still widely avoided during treatment. Broken skin at the mouth corners is itself a reason not to treat nearby. Pregnancy prevention on isotretinoin is the prescriber's responsibility.

Management: I would tell her kindly and clearly that I will not wax or perform microdermabrasion while she takes isotretinoin, and explain why. For the party I would offer to tidy the brows by tweezing or trimming and to trim the lip hair, and ask the supervising dermatologist whether gentle threading is acceptable. I would offer a gentle hydrating facial with no scrubs, acids or extractions, avoiding the cracked area. I would finish with a fragrance-free moisturiser, lip balm and sunscreen. I would advise her to mention the cracked lips to her prescriber and not to change her medicine herself. I would not accept a waiver, because a waiver does not make an unsafe treatment safe. I would document what I declined, why and what I offered, and flag her record.

Ethics and communication: Respecting her wishes does not oblige me to give a treatment I believe will harm her. Her medicines and acne are health information and should not be discussed where others can hear. If she is upset, I would offer the dermatologist's opinion and not criticise her prescriber.

Reference: Spring LK, Krakowski AC, Alam M et al, Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations (JAMA Dermatol, 2017); Milady Standard Esthetics: Fundamentals (12th ed)

Knowledge: This is anaphylaxis: rapid airway swelling, wheeze and poor circulation after exposure to a likely allergen. Most tints contain p-phenylenediamine or related dyes, which usually cause delayed eyelid dermatitis but can rarely cause immediate reactions. Black henna tattoos commonly sensitise people to p-phenylenediamine, so her history was a warning despite the negative test. Hoarseness means the airway is involved, and delay in giving adrenaline is the main avoidable cause of death. Intramuscular adrenaline is the first treatment; antihistamines treat only itch and rash.

Management: I would stop, call for help, and ask a colleague to call the clinic doctor and an ambulance on 998 and bring the emergency kit. I would lie her flat with legs raised, or sitting if breathing is easier, and never stand her up. The doctor, or a trained colleague under the clinic protocol, gives intramuscular adrenaline 0.5 mg (0.5 mL of 1 mg/mL) into the outer thigh, repeated after 5 minutes if needed; if I am trained and authorised, I would use the clinic auto-injector rather than wait. I would give oxygen if available, monitor her and start CPR if she stops breathing normally. Once stable, I would rinse the eyes gently with saline. She goes to hospital by ambulance even if she improves. I would hand over the exposure time, product and batch, and adrenaline doses and times. Afterwards she needs allergy referral and advice to avoid these dyes, recorded prominently on her file.

Ethics and communication: Life-saving care does not wait for formal consent; Federal Decree-Law No. 4 of 2016 recognises the emergency exception. I would document events, complete an incident report, keep the product and tell her honestly what happened. I would review whether her henna history was acted on.

Reference: Cardona V et al, World Allergy Organization Anaphylaxis Guidance 2020 (World Allergy Organ J, 2020); Resuscitation Council UK, Emergency treatment of anaphylaxis: guidelines for healthcare providers (2021)

Knowledge: A new or changing pigmented lesion over 6 mm with irregular colour and border, itching and bleeding has several melanoma warning features under the ABCDE approach. Evolution over time is the most important feature, and an aesthetician who sees the same skin regularly is well placed to notice it. Seborrhoeic keratosis, dysplastic naevus or pigmented basal cell carcinoma are alternatives, but only a doctor, usually with dermoscopy and biopsy, can tell them apart. Melanoma outcome depends mainly on thickness at diagnosis, so delay matters. Treating any undiagnosed lesion destroys tissue the pathologist needs and can hide a cancer. Removing skin tags with high-frequency current is a minor surgical procedure belonging to a physician.

Management: I would not massage, exfoliate or use a device over the lesion. I would tell him calmly that I have noticed a mark that has changed and that changing moles should be checked by a doctor without delay. With his permission I would ask the clinic doctor to see him today, or arrange an early dermatology appointment in writing. With consent I would photograph it with a ruler and record its size and position on a body chart. I would decline the skin tag treatment and explain why. I would document the observation, advice, referral and his response, and check at his next visit that he was seen. If he declined, I would restate my concern, record his decision and inform the supervising doctor.

Ethics and communication: I must not tell him it is cancer, but must not dismiss it to avoid an awkward conversation. Photographs are health information, taken with consent and stored on the clinic system, never a personal phone, consistent with Federal Law No. 2 of 2019. Declining the skin tag removal keeps me within the scope of my licence, whatever another salon did.

Reference: Abbasi NR et al, Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria (JAMA, 2004); NICE NG14 Melanoma: assessment and management (2015, updated 2022); Federal Law No. 2 of 2019 on the use of information and communications technology in health fields (UAE)

Knowledge: Unlabelled skin lightening creams are a recognised source of harm: WHO has warned about mercury in such products, and others contain undeclared potent steroids or high-strength hydroquinone. Redness, thinning and new facial hair suggest a potent steroid, while mercury can damage the kidneys and nervous system, with particular risk in pregnancy. Stopping a potent facial steroid suddenly can cause a flare, so a physician should manage withdrawal. No aesthetic treatment can promise permanent results: pigmentation recurs and natural skin colour is genetic. Words such as 'permanent' and 'guaranteed' are therefore misleading.

Management: I would not apply the cream, and would explain that its contents are unknown and her symptoms suggest a strong steroid or another harmful ingredient. I would advise her not to apply it to new areas, to keep the jar for testing, and to see the clinic dermatologist this week before stopping. I would advise her mother not to start it. I would inform the supervising physician and report the product through the clinic as facility procedure requires. I would tell the manager I cannot call the package permanent or guaranteed, and offer accurate wording such as 'a course of peels that can improve uneven pigmentation; results vary and maintenance is needed'. I would not post any photograph without the client's specific written consent for that use. If the manager insisted, I would escalate to the medical director.

Ethics and communication: Misleading claims undermine informed consent because clients choose on false promises, and health advertising must follow DOH rules. Client photographs are health data protected under Federal Law No. 2 of 2019, so consent to treatment is not consent to marketing. Pressure for fair skin often comes from family in the GCC, so I would discuss it respectfully, focusing on skin health.

Reference: WHO, Mercury in skin lightening products (2019); Federal Law No. 2 of 2019 on the use of information and communications technology in health fields (UAE)