On the Lookout

Be Clients’ First Line of Defense Against Illnesses

By John Otrompke

Bodyworkers should always watch for signs of disease in their clients. You may be the first and only person to notice symptoms that appear on a client’s skin or nails—symptoms of conditions as diverse as lupus, skin cancer, or thyroid disease.

While it’s not a massage therapist’s role to diagnose any illness, being aware of the first signs of these conditions will help you know when it’s time to suggest a doctor visit to your clients. Here is a short refresher on five of the most important signs you might see.

1. Butterfly Rash

This is a facial rash characterized by its shape: the middle part of the butterfly is on the bridge of the client’s nose, with “wings” extending onto the cheeks. “It can signify a range of diseases, from milder conditions like rosacea, significant acne, eczema, and psoriasis, all the way to serious autoimmune connective-tissue disorders such as lupus,” says Joseph Jorizzo, MD, professor and founding chair of the dermatology department at Wake Forest University School of Medicine in Salem, North Carolina.

2. Infections

“Bodyworkers should look for any sign of infection, such as a cold sore, which is characterized by a painful bump or blister on the face or nose,” says Jill Weinstein, MD, instructor of clinical dermatology at Northwestern University in Chicago. “This may be caused by herpes simplex.”

Both viral and bacterial infections may appear as pustules or tender lesions. They can sometimes look like acne, but may also be bigger or more isolated than a pimple, Weinstein says. While a doctor referral is not always required for these conditions, you should avoid touching the areas in question so the infection is not spread to other parts of the client’s body, to yourself, or to other clients.

3. Patchy Hair

MTs should be alert for round, patchy areas of hair loss that can be a sign of an autoimmune disease called alopecia areata, Jorizzo says. 

“Alopecia is associated with thyroid disease, but it can also be upsetting to the client in and of itself,” Jorizzo explains. “The prognosis is very good if there is just one little circle, but if clients lose their eyebrows or eyelashes, or if it goes around the bottom of the scalp, the condition is more likely to be chronic.”

4. Symptoms on the Nails

A client’s nails may also offer evidence of a medical condition to the alert bodyworker. “Signs on the nails include a condition called clubbing, where there’s body under the cuticle that changes the angle of the nail, so that it’s like an upside down V,” Jorizzo says. Clubbing is sometimes accompanied by edema, and the cuticle area may feel wet. It can be a symptom of several lung conditions, ranging from chronic bronchitis to lung cancer.

Pits in the nails can be a sign of arthritis or psoriasis. Pits resemble a mere dent, perhaps 1 millimeter across. Jorizzo explains, “In psoriasis, the outer layers of skin turn over very quickly, and when they come from under the cuticle, little patches fall off, so you get a pit.”

Finally, a single dark black streak in the nail that comes up on to the cuticle can be a sign of melanoma.

5. Skin Cancer

The most common cause of skin cancer deaths is melanoma, which may be identified using the ABCDE criteria (see Spotting Melanoma—ABCDE Danger Signs, above), but the most common form of skin cancer is basal cell carcinoma. There are also some less common varieties that have different symptoms.

 “Basal cell carcinoma often presents in the form of shiny or pearly bumps, which patients think are pimples,” says Elizabeth Quigley, MD, a physician in the dermatology service at Memorial Sloan-Kettering Cancer Center in New Jersey. If the lesion has been there for six months, and sometimes bleeds, that’s a warning sign that it is not a pimple.

Merkel cell carcinoma is typically seen in the elderly, or those who have problems with their immune system. “It often looks like a big red bump, usually greater than 5 millimeters, and usually rapidly grows over a period as short as a few weeks,” Quigley says.

Atypical fibroxanthoma is another skin cancer found primarily in older individuals. “There are bumps, and the skin is colored redder than your normal skin,” Quigley says. “The tumor is rapidly growing, with bleeding and persistent symptoms.”

Squamous cell carcinoma, responsible for about 20 percent of all skin cancer deaths, has symptoms that are quite different from those of melanoma. “Squamous cell carcinoma can present as firm bumps, scaly patches, or ulcers that don’t get better. The skin is red and the scale is the kind that doesn’t go away with moisturizer,” Quigley says. “It’s different from just dry skin, and the scale is usually thicker.” She says squamous cells don’t rub off like normal dry skin, and the scaly patch may bleed if it is removed by pulling or picking.

Health-care team

Bodyworkers are often the first line of defense when it comes to the well-being of clients and their skin. Being familiar with the appearance of these early signs of disease makes you a valuable part of your clients’ health-care team. 

 John Otrompke is a health-care writer
and consultant. He can be reached at


Raising the Red Flag

When you see something suspicious on a client’s skin, how do you bring it up? “I usually phrase it like, ‘I see this mole has an irregular shape. Have you noticed that?’” says Kirsten Kayser, a licensed esthetician and massage therapist in Denver, Colorado. “They may say yes or no. Then I say, ‘Do you have a dermatologist that you like to see?’ If not, then I say, ‘Because I’m not a physician, I can’t make a diagnosis, so I’m going to give you the name of a dermatologist who can check this for you, just to be safe.’ I’ve had clients who were diagnosed with skin cancer after I referred them to a dermatologist. If I hadn’t referred them, it could have been life-threatening.”

It’s natural for a client to ask what you think the problem is, but avoid answering that question. “I tell them, ‘Usually it’s nothing to worry about, but it’s better to have it checked out,’” Kayser says. “Dermatologists can be booked months in advance, so I let the client know that they should call within the next couple of days to set up an appointment. It’s also important to make a note in their file about what you found and who you referred them to.”

What about those delicate situations where you need to refuse service because the client has an infection or otherwise problematic skin condition? Susanne Schmaling, a licensed esthetician and director of education for Associated Skin Care Professionals, says, “I never get specific about the disease, but describe the characteristics of what I see. If I have to refuse service due to open lesions, irritation, infection, or other unusual appearance of the skin, my statement is, ‘I am concerned that I will cause this infection (or rash, or whatever) to get worse if I work on this area today.’ You can also suggest an alternative if possible, such as a relaxation massage avoiding that part of the body.”


Spotting Melanoma—ABCDE Danger Signs

Remember this list of danger signs for moles. Any of these symptoms could be indicative of skin cancer.

Asymmetry. The mole is an unusual shape, not round.

Border irregularity. The edges of the mole may be jagged, scalloped, or wavy, or very sharp in one area.

Color. The mole shows variation in color from one area to another. There may be multiple shades of black, blue, brown, red, tan, or white. 

Diameter. The mole is more than 6 millimeters in diameter.

Evolving. The mole is new, or an existing mole has changed in size,
shape, or color.

A more informal method of spotting a suspicious mole is called the Ugly Duckling test: when a mole just seems to catch your attention for some reason. “The classic example is when a client has one thing on her that just doesn’t look like any other spot on her body,” explains Elizabeth Quigley, MD. “Let’s say she has many black moles, but one brown mole. Or most of the client’s moles are round and small, but one is big and a different shape. That is a client who should be evaluated by a physician.”

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