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Advanced Clinical Pathology: Diseases of the Skin (2 CE Hours)

This course is approved for 2 hours of Continuing Education for Massage Therapists by the Texas Department of State Health Services: Approved Provider: MARK SCOTT URIDEL CE0009. Mark S. Uridel is approved by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) as a continuing education provider.

Learning Objectives: After reading this course, you will...

  1. be able to explain the importance of identifying skin disorders in massage.
  2. be able to identify and describe the different diseases of the skin most often seen during massage practice.
  3. be able to differentiate between contagious and non-contagious skin disease.
  4. be able to identify neoplastic skin conditions and list the ABCDE's of melanoma.
  5. be able to identify common injuries to the skin and describe the massage implications.


Because Massage Therapists  and other bodyworkers provide hands-on care, it is important that these practitioners are aware of and understand conditions and diseases affecting the skin.  The knowledge of skin disorders and their associated contraindications to hands-on therapy is crucial information for the therapist to be able to provide safe and effective care.  Often therapists that provide touch-centered care are the first to notice skin lesions and blemishes that the client or patient is not aware of.  It is important for the therapist to be able to recognize and differentiate common skin conditions and to recommend to the client to alert their doctor as appropriate.  Many skin conditions contraindicate massage therapy due to their contagious nature, ability to spread or potential to create infection in the client.  Any open or broken skin, scabbing skin or lesions on the skin should raise a red flag for therapist to avoid the area and notify the client in case they are unaware of it.  Any wound or break in the skin is an automatic local contraindication to massage due to the risk of infection.  We will begin our study of skin disorders by looking at those conditions that are contagious.

Contagious Skin Conditions

Boils, also known as furuncles, are staphylococcus bacterial infections of the skin, primarily S. Aureus.  The bacteria infect the sebaceous glands (oil glands) and aggressively attack the surrounding tissue.  Boils are typically large and painful infections that can be one large lesion or several smaller lesions connected under the skin (called a carbuncle).  They start out as small hard red lesions and can grow to the size of a golf ball.  They will usually soften in the center and accumulate purulent exudate or pus.  As long as the infection stays localized, boils are not dangerous infections.  However, if the infection spreads to deeper tissues, it can become serious quickly.  Treatment for boils involves hot compresses, which will help the boil come to a head and burst.  You should never try to force a boil to burst because it could push the infection into deeper tissues.  Since a boil is a localized infection, massage or manual therapy on or around the lesion is contraindicated.  This is a highly contagious, virulent and hardy bacteria (some strains are resistant to antibiotics) and if the therapist comes in contact with the lesion, immediately disinfect the skin.  Linens used with a client or patient with a boil should be isolated and washed separately with extra bleach to disinfect the linens. 

Erysipelas is a streptococcal infection of the skin that is characterized by red patches caused by the bacterial enzymes that irritate and break down the skin.  Strep bacteria infect cuts and scrapes or some other break in the skin.  Once under the skin, the bacteria can spread into the lymphatic and/or circulatory systems.  The infection starts as a red tender swollen area, usually on the face or leg with distinct edges.  As the infection spreads, it will have red streaks running toward the nearest lymph nodes.  If the infection spreads to the lymphatic or circulatory system, it is then “systemic” and can cause fever, chills and other systemic symptoms.  If left untreated (usually by antibiotics), the bacteria can cause septicemia (aka sepsis).  Like staphylococcus, streptococcus has morphed into strains that are antibiotic resistant, which makes it that much more important to identify this infection early and treat it promptly.  Massage is strictly contraindicated during any streptococcal infection due to the highly contagious nature of this bacteria and potential for systemic infection.  Avoid all contact with the infected area and use sterile gloves and techniques when handling linens, clothing and bandages.  If you suspect erysipelas in a client or patient, you should notify their doctor or healthcare practitioner immediately.

Dermatophytosis, fungal infections, also known as mycoses, may involve several types of fungi, aka dermatophytes.  The lesions associated with fungal infections are called tinea and can refer to several types of fungal infections.  The most common forms of tinea are listed below:

  • Tinea corporis, or body ringworm, is relatively common and very contagious.  It begins as a small round, red, scaly and itchy patch of skin and can spread to larger and larger red rings.
  • Tinea capitis inhabits the head and scalp and presents as scaly, red itchy patches that are just as contagious as tinea corpus.
  • Tinea pedis, aka athlete’s foot, is found on the feet and toes and presents as dry, scaly itchy lesions.  Since 20% of the population is infected with tinea pedis, it is important to wash your hands thoroughly and/or apply disinfectant to your hands after doing any massage or manual therapy on a client’s feet.  If you notice a tinea pedis infection, it is contraindicated to perform massage on the area due to the possibility of spreading the infection.
  • Tinea cruris, or jock itch, is the least contagious, but can spread to the upper thigh and buttocks.
  • Tinea manus, hand ringworm, presents as scaly itchy patches on the hand and between the fingers.  Tinea barbae affects the face, tinea versicolor creates a pigmented area of skin, and tinea unguium is found under the fingernails and toenails.  All fungal infections should be avoided and it is contraindicated to massage over these areas due to the high potential of spreading the infection. They are considered a localized caution, as long as the therapist uses sterile techniques.  If contact is made, it is important to wash your hands and use hand sanitizer.  Linens should be isolated, sterilized with extra bleach to kill the fungus and dried thoroughly.

 Herpes Simplex is one of the most common herpes viruses.  Oral herpes causes cold sores or fever blisters around the mouth and lips and genital herpes causes painful blisters around the genitals, thighs and buttocks.  Originally, oral herpes was considered a different virus strain from genital herpes, but now medical scientists have seen crossover between the two and there is no real delineation.  It is estimated that up to 60% of sexually active adults have genital herpes and even a higher percentage of people have oral herpes.  Herpes is transmitted by skin to skin contact or contact with mucous secretions.  The herpes virus cannot be eradicated from the body.  It goes through phases of hiding and reactivating, called recurrent outbreaks that are brought on by stress, a sunburn, a fever, an infection, a menstrual period or some other factor that puts stress on the body.  The herpes virus is highly contagious and can remain active outside the host for hours.  Also, no sore or break in the skin is necessary to transmit the virus.  So if a client with oral herpes touches the face pad with their mouth, the virus could lay dormant on the face pad and be spread to the next client.  Therefore, it is essential to sterilize the face pad between clients.  All linens should be isolated in a closed container and either professionally sterilized or washed with extra bleach to insure sterilization.  Handling of linens should be done with gloves to avoid contact with the virus.  Acute outbreaks of herpes contraindicate massage and even when the blisters are scabbed over, therapists should consider them at least a local contraindication.  Therapists that have herpes need to practice sterile techniques to avoid spreading herpes to their clients.  This includes hand washing between clients, using hand sanitizer and avoiding touching or scratching blisters inadvertently during a massage. 

Impetigo is a bacterial infection, common in children, that appears as lesions around the nose, mouth or ears.  It is caused by both staphylococcus and streptococcus bacteria.  It begins as a rash with small blisters that have a clear or milky fluid.  If the blisters open, a honey-colored crust forms around the open blister.  Mild cases of impetigo are treated with a topical antibiotic while systemic infections may be treated with oral antibiotics.  Impetigo is highly contagious and the blisters are itchy, which if scratched can spread the infection.  If infected, children should stay home from school and avoid contact with other children until the sores have cleared up.  This highly contagious infection involves virulent bacterial pathogens that may be resistant to antibiotics and systemically contraindicates massage until the lesions have completely healed.  As with other bacterial infections, linens exposed to people with impetigo should be isolated and washed separately with extra bleach to kill the bacteria.

Mites, Sarcoptes scabies, are parasites that live on the body, burrowing under the skin in moist places like the axillae, groin and between the fingers.  Mites are too small to see with the naked eye, but they create skin lesions called scabies, which appear as reddish or gray lines with blisters that arise from the skin’s allergic reaction.  Scabies are itchy, especially at night, and are hard to diagnose because the bugs are small and burrow under the skin.  Like other parasitic infestations, mites are treated by bathing in pesticidal soap.  Massage is contraindicated on anyone with scabies until the parasite has been eradicated from the body and all symptoms are gone.  It can take 4 weeks or more for symptoms to appear after an initial infestation of mites and during that time, the person is able to pass on the parasite to other people.  If a therapist contracts mites, they should consider that they may have passed on the parasite to anyone they have had contact with over the past month and half.  Linens are considered “hot” and should be isolated and washed separately with extra bleach to kill the parasites.

Lice, are parasites that live in the head hair (head lice) or pubic hair (pubic lice).  These two lice are different species and have distinctly different appearances.  Unlike mites, lice are visible to the naked eye, which makes them easy to diagnose.  Pediculosis, the condition of having a lice infestation, may not be obvious because the lice are small and very mobile.  They also jump into hats or clothes and so body contact is not necessary to spread them.  Head lice lay their eggs at the base of hair shafts and these sticky white “nits” are one way to diagnose an infestation.  Pubic lice, called crabs because they look like little white crabs, are less discerning about where they live.  They usually inhabit the pubic hair, but may also live in armpit hair, body hair, eyebrows or eyelashes.  Pubic lice are usually spread through sexual contact, but as with head lice, do not need body contact to be spread.  Treatment consists of using medicated pesticidal shampoo.  Massage is contraindicated for anyone who has lice and if the therapist believes they have come in contact with lice, immediate precautions should be taken.  All linens and clothing should be isolated and washed in 130 degree water and dried on high heat for at least 20 minutes.  Any items, like soft toys or hats, that may have come in contact with the person needs to be isolated and dry cleaned.  If the therapist has a parasitic infestation, they need to respectfully inform clients so that the infestation can be controlled and not spread to other people.

Warts are benign neoplasms caused by slow-acting viruses, usually the human papilloma virus (HPV), which arise from the keratinocytes in the epidermis.  Warts can be contagious through contact with the localized shedding skin cells or local blood.  Warts usually go away on their own, but that might take a year or more.  They are usually just a nuisance, but plantar warts on the feet can grow inward and be painful when stepped on.  It is common medical practice to freeze warts off, but if any of the virus remains, the warts will recur.  Warts are considered a local contraindication to massage and normal sterilizing techniques (hand washing, hand sanitizer, washing linens with bleach) are indicated.

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