Skin Deep

 By Matt Alderton, February 1, 2022

In every sense of the word, skin is sensational. The body’s largest organ, it encompasses some 300 million cells that occupy approximately 21 square feet of space. In every square inch are 20 feet of blood vessels, 100 oil glands, 650 sweat glands and more than 1,000 nerve endings, each of which can sense touch, temperature, pain and pressure.

But it’s not only its physical properties that make skin remarkable. Just as impressive are its functional attributes. Skin heals itself from injury, for example; protects underlying muscle and bone; keeps germs, dirt and moisture at bay; and helps the body regulate its temperature.

For these and many other reasons, skin is an important barometer for human health and wellness—not to mention a centerpiece of massage therapy.

Indeed, skin for massage therapists is an inescapable waypoint on the road to touch-hungry muscle and tissue. To reach the latter, they must assuage the former. When the skin is healthy and happy, that’s easy to do. Understanding the difference between healthy skin and when a client might be experiencing skin issues that require more delicate massage or further assessment to tease out contraindications is a critical part of providing safe and effective massage.

According to dermatologists and massage therapists who are familiar with common skin ailments, when it comes to acute and chronic skin conditions, massage therapists should proceed with caution.

Stressed-Out Skin

There are two categories of skin conditions that massage therapists will encounter in their practices, according to Daniel Grabell, MD, a dermatologist at Princeton Dermatology in Princeton, New Jersey: communicable skin conditions, which are contagious, and noncommunicable skin conditions, which are not. Communicable skin conditions include ringworm, scabies and warts. Noncommunicable skin conditions, meanwhile, include common ailments like eczema, psoriasis, rosacea and acne.

“Massage should be avoided when the client has a communicable disease,” cautions Grabell, who says contraindications are for the good of both the client and the practitioner. “For example, clients with athlete’s foot can have the fungus spread to other areas of the body, as well as to the therapist. Other examples include viral illnesses caused by the herpes virus—chicken pox, shingles or cold sores—or bacterial infections … However, if the client has a skin condition that is not communicable, then massage can proceed.”

With only a few exceptions—people with the obscure skin-thickening conditions morphea and scleroderma, for example, for whom massage can help soften the skin and thereby increase range of motion—there’s no evidence of direct dermatological benefits from massage therapy, according to Grabell. For people with chronic noncommunicable skin conditions, however, the indirect benefits are clear, he says.

“Stress is a trigger in many skin conditions, including acne and psoriasis, and sometimes eczema,” Grabell explains. “So managing stress through massage therapy can help patients manage their symptoms.”

Take psoriasis, for example. In a 2018 literature review that appeared in the International Journal of Dermatology, researchers concluded that up to 88 percent of patients cite stress as a trigger for their psoriasis.¹

“There was also a reported higher incidence of psoriasis in subjects who had a stressful event the previous year, suggesting that stress may have a role in triggering the disease in predisposed individuals,” the researchers observed. “Understanding the role of stress makes it appropriate to target stress when proposing treatment to patients with psoriasis.”

Meanwhile, numerous studies have documented the positive impacts of massage on stress. Among the most recent, for example, is a 2020 study in the journal Scientific Reports. Conducted by psychologists at Germany’s University of Konstanz, it found that just 10 minutes of massage can activate the body’s physiological defenses against stress.²

“It’s pretty clear that with many skin conditions, stress makes things worse,” says Juliette Soihl, ND, LMT, a naturopathic doctor and massage therapist whose Portland, Oregon-based practice, Renewed Health, specializes in holistic dermatology. “So anything that reduces stress is going to help, and massage for many people is stress-reducing. I definitely get that feedback from many of my patients and clients; their skin is worse when they’re under stress and better when they do things to reduce stress.”

Handle With Care

Because of the distinction between communicable and noncommunicable skin conditions, one of the most important tools for dermis-conscious massage therapists is the intake form, according to massage therapist and retired dermatology physician assistant Annie Morien, PhD, PA-C, LMT, a teacher at The Florida School of Massage in Gainesville, Florida.

“The therapist’s intake is very important and should include questions related to past and current skin conditions,” Morien says. “Questions related to skin conditions can include duration of the skin condition, signs and symptoms, and treatment.”

Sometimes, clients have undiagnosed skin conditions. If they haven’t been to the dermatologist, for example, someone might mistake eczema for dry skin or dandruff. Likewise, someone with a fungal infection might assume they have an innocuous rash or bug bite. Those people won’t check boxes on an intake form, but might nevertheless have symptoms. Therefore, it can be a good idea to follow up a written intake with a verbal one, according to massage therapist and esthetician Terrance Bonner, LMT, LE, owner of The Glam Station and Spa in Columbus, Mississippi.

“I have come to find out over the years that when you ask questions verbally, people tend to go into more detail,” Bonner says.

In addition to basics—what conditions they have, how long they’ve had them and whether they’re receiving treatment—there are a few things that are especially helpful to learn from written and verbal intakes:

1. Are there open wounds?

Open wounds generally should be avoided, according to Grabell. In the case of communicable conditions, he says, open wounds may be sources of transmission. And in the case of noncommunicable conditions, contact with open wounds can cause pain and irritation, and may further aggravate the condition.

While blood is an obvious sign of open wounds, broken skin doesn’t always bleed. “Watch out for skin that looks wet,” Grabell says. “You’ll typically see serosanguineous discharge, which might be blood, but could also be a yellow-brown fluid. It might look oily or goopy, and there might be dried blood or a crust over it. That is broken skin, and I would avoid touching that.”

Among other things, broken skin may manifest in people with shingles, extreme cases of eczema and psoriasis, and even acne.

“Physical contact with the acne … may exacerbate the condition. Open wounds—popped, scratched, or bleeding pimples and cysts—are contraindications to massage,” explains Morien, who says massage also is contraindicated for skin that’s red, swollen or hot—although therapists have discretion to define for themselves what “contraindication” means. “The therapist may approach the client’s skin condition as a local or general contraindication.”

Which is to say: You can massage around injured skin if you’re comfortable with a client’s condition, or avoid a massage altogether if you aren’t. If you’re somewhere in between, you might consider wearing gloves, according to Bonner. “If you’re going to wear gloves, I recommend using nitrile gloves because some people are allergic to latex,” he says. “Also, make sure you keep your hands lubricated so you don’t cause a burn.”

2. What triggers symptoms?

Along with stress, there are myriad triggers that can precipitate or exacerbate symptoms for people with chronic skin conditions—several of which clients might encounter on the massage table. Among the possible triggers for eczema and psoriasis, for example, are itchy or synthetic fabrics, like wool or nylon; heat, including hot water; certain foods, including peanuts and milk; and harsh chemicals, including detergents, dyes and fragrances.

If a client is triggered by fabrics or fragrances, you might need to use cotton sheets that are laundered in fragrance-free detergent, sans fabric softener. And if heat is a trigger, you’ll need to be mindful of the temperature in the room and avoid treatments that use heating pads, hot water bottles or other heat sources.

Mostly, though, you need to be selective about oils, according to Soihl. “A lot of eczema patients have allergies, so I would avoid using nut oils like peanut oil, almond oil or sesame oil,” she says. “I have found fractionated coconut oil to be very well tolerated by most people with skin conditions. It’s hypoallergenic and non-comedogenic, which is what I look for. Or you could ask your clients to bring in their own oil if there’s a certain oil that they prefer.”

Because clients might not be aware of all their triggers, verbal feedback during and after sessions is important. “Ask them, ‘How is your skin feeling?’ If it’s itchy, stinging or burning, you might want to modify what you’re using,” Soihl advises. “And next time you see them, you should ask how their skin did afterward. Because sometimes they won’t know until a little bit later that it was irritating.”

3. Is touch uncomfortable?

Massage can be irritating if you use the wrong topicals or techniques. Even if you do everything right, however, massage can still be uncomfortable for people with skin conditions—mentally if not physically. 

“The biggest thing for me when I’m working with clients who have skin conditions is education,” Bonner says. “A lot of people with skin conditions feel ashamed or embarrassed about their symptoms, so coming in to get a massage is a big deal. It’s important to have a conversation to let them know that skin issues are very common, and to reassure them that it’s OK for them to have a massage. Let them know that you’re experienced, that you’re not going to do anything to make their symptoms worse and that massage might actually help them with their symptoms by reducing their stress. It’s all about making the client comfortable so they don’t feel tense on the table.”

4. Are you undergoing treatment for your condition?

Common treatments for chronic skin conditions include topical steroids, which may thin the skin, and ultraviolet light therapy, which might cause mild sunburn. As long as topical medications are washed off prior to treatments, and the client doesn’t complain of discomfort, neither is a contraindication for massage, according to Grabell. If you’re not sure, he says, you can always ask clients for a doctor’s note confirming that massage is OK.

What About Skin Cancer?

Along with skin conditions that clients know they have, massage therapists have to navigate skin conditions of which their clients aren’t yet aware—like skin cancer, which a massage therapist might be the first to notice.

“It is beyond our scope of practice to diagnose, but it is within our scope of practice to bring awareness to an unusual skin spot that the client may not be able to see,” Morien says. “We should encourage the client to seek medical assistance for any unusual skin condition.”

Bonner agrees and sees unusual skin symptoms through an ethical lens. Although massage therapists cannot and should not diagnose skin problems, he sees it as his responsibility to say something when he notices something suspicious. “Especially if it’s a repeat client you’ve been seeing for months or years, you’re going to notice something that’s not normal,” Bonner says. “In that case, I just say something like, ‘Hey, there’s a peculiar mark or mole here that I wanted to bring your attention to. It could be nothing, but I recommend going to the doctor to have it checked out.”

Indeed, Grabell says massage therapists have found many skin cancers for him. If you’re unsure what warrants a referral to a dermatologist, remember the acronym ABCDE. “When it comes to moles,” Grabell says, “you want to ask yourself: Are they asymmetric? Do they have irregular borders? Are they changing colors? Do they have a diameter larger than a pencil eraser? And if you see this client regularly, are they evolving over time? If the answer to any of these questions is yes, then I recommend they see a dermatologist.”

It’s an important reminder: Although skin is tough stuff, what’s extremely resilient can also be extremely sensitive. Knowing how to best work with clients who come to you with skin conditions, whether acute or chronic, can help you show them the real benefits massage has to offer.

A Helping Hand: How to Heal Hand Eczema

As a massage therapist, your most valuable asset is your hands. Unfortunately, a therapist’s hands are as vulnerable as they are vital, according to massage therapist and retired dermatology physician assistant Annie Morien, PhD, PA-C, LMT, a teacher at The Florida School of Massage in Gainesville, Florida.

“Because of the nature of our work, we are constantly handwashing,” Morien says. “Repeated handwashing causes loss of natural oils, and the skin becomes compromised.”

For many massage therapists, compromised skin leads to recurrent hand eczema, otherwise known as hand dermatitis, symptoms of which can include dry, chapped skin; itchy blisters; deep, painful cracks; and even bleeding or weeping skin.

If you suffer from chronic hand eczema, there are simple things you can do to help your hands heal.

First and foremost, you should moisturize regularly—especially after you wash your hands, Morien suggests. “To decrease the negative effects of constant handwashing, I suggest applying a non-irritating emollient to the hands immediately after handwashing,” she says. “This helps lock in the moisture and helps maintain the skin barrier.”

The best moisturizers are those with ceramides in them, according to Daniel Grabell, MD, a dermatologist at Princeton Dermatology in Princeton, New Jersey. When the skin breaks down, he says, it’s often because the skin barrier has been worn away. When you moisturize with ceramides, you’re replacing the lost lipids that constitute that barrier, thereby restoring the skin’s natural protection.

If your hand eczema persists, try moisturizing before bed and wearing cotton dermatology gloves overnight. “When you put it on, moisturizer just sits on the surface of the skin,” Grabell explains. “When you wear gloves, it helps it get actually absorbed into the body.”

If all else fails, it’s a good idea to see a dermatologist.

 

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