Massage therapists typically see more of a client’s skin than the client does. That fact alone carries with it a responsibility to be educated about some common and not-so-common skin conditions. A well-trained massage therapist will know what creams or lotions might best soothe a rash or what conditions to avoid touching altogether. You could even be the sentinel who discovers and alerts a client to a potentially life-threatening illness.

Here are 10 things every massage therapist should know about skin conditions.

It’s just called that because its typical symptom is a circular lesion. It’s actually a fungal infection, not too different from athlete’s foot. So relax, there’s no icky creature crawling around inside a person’s body. But take care, because ringworm is contagious and is spread by skin-to-skin contact with an infected person. Ditto for warts, impetigo, and shingles. All those conditions are incredibly inconvenient, but they’re not usually life-threatening.

The infection (Methicillin-resistant Staphylococcus aureus) is caused by a strain of staph bacteria that has become resistant to antibiotics. While most MRSA infections occur in people who have been hospitalized, some occur in healthy people. This latter kind often begins as a painful skin boil, and it spreads on contact.
“It’s really time for us to pay a lot more attention to drug-resistant forms of staph,” warns Ruth Werner, author of A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2008).

“They may look aggressive and intimidating, but they’re not contagious,” says Natalie Pergar, international trainer coordinator for Eminence Organic Skin Care in Vancouver, British Columbia. “So massage away. You won’t catch it. In no way do [these conditions] put massage therapists in a position where they have to stop the treatment.”

In fact, since eczema and psoriasis are often stress-related, a massage could be an excellent treatment option for someone suffering from either condition.

Now widely associated with the late pop star Michael Jackson, vitiligo is a skin condition where there’s a loss of pigment from areas of the skin, resulting in irregular white patches. It’s not contagious and there’s no reason to avoid massaging the de-pigmented patches.

“One of my clients went to a spa in Arizona with some friends, and they all went in for a massage,” says Morag Currin, president of Touch for Cancer Online, which provides training in skin care for oncology patients. “But she had developed vitiligo, and the massage therapist had never seen that before. He didn’t know what it was and refused to give her a massage. She was humiliated.”

“Unfortunately, there are many,” says Dr. Marc Ronert, plastic surgeon, medical director, and director of product development for Image Skin Care of West Palm Beach, Florida. “To name a few more common: open lesions, warts, dermatitis, pemphigus vulgaris where massage clients develop bulbous bubbles from touch, as well as lipomatosis (which means benign fat tumors below the skin surface). They should not be massaged before a tumor is excluded from the diagnosis.”

Be wary of massaging any area of cracked or fragile skin, particularly if your client is undergoing chemotherapy or has any sort of compromised immune system. “If there are any open wounds, any creams or oils you apply could get into the body, so you have to be very careful with what products you’re using,” Currin warns.

People receiving chemotherapy sometimes develop a condition commonly known as hand-foot syndrome (HFS), which causes redness, dry skin, and extreme pain. “Heat and friction must absolutely be avoided,” Currin says, “yet their skin is so dry it needs some moisturizing.” In such cases—or with elderly clients whose skin has become paper-thin and tears easily—don’t rub, just pat as gently as possible.

“Sometimes, you can’t even touch the area,” Currin says. If that’s the case, energy treatments such as reiki, that rely less on touching the body, could be helpful, she says.

Nail cuticles can become cracked and dry for the same reasons other parts of the skin become cracked and dry. It can be a reaction to stress, or a side effect of chemotherapy or of some medications. Whatever the cause, it can be painful.

“Every massage therapist should be massaging those cuticles,” Currin says. “Find a nice nail balm and always massage the whole cuticle area, because if they [clients] start ripping and scratching, it can lead to infection.”

“Anything unexplained requires at least a question,” Werner says. “When skin lesions don’t hurt, they’re alarming. It’s the things that don’t hurt that are most dangerous, because they’re sneaky. If we find something on a client’s skin—whether a carcinoma or a diabetic ulcer or something else—if the client doesn’t know it’s there, it’s important to bring it to their attention.”

As for moles, make note of anything that looks unusual: maybe its color is deeper, or it’s oddly shaped.

“It would be interesting to gather data about how many clients have found skin cancer at an early, treatable stage because a massage therapist has seen something,” Werner says. “It may be on the top of the scalp or the back of the neck—places people don’t think to check themselves.”

“Chances are excellent it’s nothing,” Werner says. It’s an unusual client who has perfect skin. Everyone has stuff happening. “So don’t say, ‘This might be cancer.’ You can think it, but don’t say it. Use carefully non-alarmist language. Say, ‘You have a raised red area here. Can you tell me what’s going on?’ It’s descriptive, but not scary. Whether you proceed depends on their answer. If they feel they have a pretty good idea of what’s going on, you can make the judgment call about whether to proceed.”

And don’t make a diagnosis, even if you think you know what you’re looking at. “As therapists, we don’t have the ability to diagnose,” Pergar emphasizes. “All we have the ability to do is recognize and recommend.”

Hand dermatitis—in which hands become red, dry, cracked, and inflamed—is a huge issue among massage therapists. One 2004 study involving 350 massage therapists living in and around Philadelphia found that 23 percent had hand dermatitis during a 12-month period, while the rate for the general population was just 2–10 percent. The researchers speculated that massage therapists’ frequent hand washing and contact with fragrances, dyes, detergents, and allergens found in massage oils—particularly aromatherapy products—may account for the bulk of the problem.

One possible response is to temporarily back away from using scented products and try jojoba oil, which mimics the sebum in the skin.