3.4 Contraindications and contra-actions

You’ve now got a firm grasp on the anatomy and physiology of nails, arms, hands, legs, and feet. Well done! While this level of knowledge is a prerequisite for your progression within this course, it is worth mentioning that (unfortunately!) many nail technicians will lack this critical knowledge due to sub-standard training courses and programs, and so you are likely already better educated than many of your soon-to-be competitors.

The final important component of your foundational biological knowledge is to gain an appreciation for the more common adverse conditions, irritations and reactions associated with the arms, hands, nails, legs and feet.

Contra what?

If you have ever received a beauty or cosmetic treatment, or visited the website of a responsible provider of these, you may have heard or seen the words contraindications and contra-actions before. But what do these actually mean? We’re glad you asked!

Contraindications

The term contraindication originated in the medical field. When broken down into its components, it is defined as:

• contra – against, opposite to;
• indication – a symptom that suggests a certain medical treatment is necessary.

When combined, the term contraindication is thus defined as a condition or factor that serves as a reason to refuse treatment due to the potential harm that treatment may cause to you or your client.

Key phrase | Contraindication: a condition or factor that serves as a reason to refuse treatment due to the potential harm that treatment may cause to you or your client.

While the term contraindication originated in medicine, it is now widely used across many facets of beauty, health, and personal services industries. In simple terms, it is any condition under which you should either refuse treatment to someone altogether or only proceed with treatment after additional safety measures are carried out.

The best way to get your head around contraindications is to learn what they are, and why they prevent treatment.

Common non-contagious hand, foot, or nail disorders that you will as a nail technician include, but are not limited to:

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As you can see, there are numerous non-contagious hand, foot and nail disorders that you will encounter, and there are many more that are not listed. To learn more about each, download the resource provided:

Now that you have a better understanding of non-contagious hand, foot and nail disorders, we must now look at contraindications that prevent treatment or require referral to health practitioners. While it can be a bit awkward refusing treatment, you must always put the clients’ health first. Continuing to do a manicure or pedicure when there are serious contraindications present can cause serious harm to clients and may increase the spread of infection, bacteria and/or parasites to healthy clients.

Contraindications that prevent treatment or require referral to health practitioners and relationship to manicure and pedicure services include:

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• Abnormal skin around the nail
• Allergic reactions
• Bacterial, fungal, parasitic and viral infections (pseudomonas)
• Bruising or swelling around the nail
• Contraindications of products used in combination or with other services
• Damaged natural nails
• Dermatophytes Fungus
• People with diabetes who have ulcers, lacerations, or inflamed skin
• Onycholysis (severe or fungal)
• Recent fractures or sprains
• Recent operations
• Subungual Melanoma

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As you can see, there is a vast range of contraindications to be aware of, and there are many more that we haven’t covered! To read more about each contraindication that will prevent treatment, download the resource provided:

You are not expected to know and remember all hand, foot and nail disorders, nor is it your role to diagnose any conditions. This website has over 100 contraindications for manicures and pedicures, so you may like to do more research if you come across a contraindication you are unsure of: Contraindications A-Z.

Most contraindications will be identified by the client during the client consultation, and for some, you will be able to identify them upon visual inspection. If you are ever unsure, always consider the potential risks. If proceeding with the service could harm your client, then refuse service. It is too big of a risk for your business to proceed if contraindications are present, and not only will you harm your client, but it will also harm your reputation.

The table below outlines medical professionals that your client may need to visit before you can provide a service if contraindications are present:

Profession	Overview
Podiatrist	Podiatrists are medical specialists who help with problems that affect your feet or lower legs. They can treat injuries as well as complications from ongoing health issues like diabetes.
Dermatologist	A Dermatologist is a doctor who specialises in diagnosing and treating diseases or infections affecting skin, hair, nails, sweat and oil glands, and mucus membranes.
Orthopaedic doctor	An orthopaedic doctor is a medical professional who specialises in diagnosing, treating, preventing and rehabilitating musculoskeletal injuries and diseases, both surgically and non-surgically, in people of all ages. The musculoskeletal system includes bones, joints, ligaments, tendons, muscles and nerves.
General practitioners (GPs)	GPs treat all common medical conditions and refer patients to hospitals and other medical services for urgent and specialist treatment. They focus on the health of the whole person combining physical, psychological and social aspects of care.

Further to referring clients to medical professionals if needed, you need to stress the importance and consequence of not stating contraindications to your clients. This is generally discussed with your client during the consultation process but must also be documented. A good tip to remember is ‘ if it isn’t written down, it never happened’. If for any reason legal action was taken as a consequence of a reaction to a service you have provided, you will want to ensure that you have documented evidence that a client did not indicate any contraindications and that they were fully aware of any contra-actions.

Key phrase | Contra-action: an undesirable reaction that can occur during or after a nail service.

The best way to remember the difference between contraindications and contra-actions is to think about contraindications being the ‘indicator’ of a potential issue and contra-actions being a reaction. 99.9% of the time, clients will have minimal reactions to nail services, but on rare occasions, clients will show some type of reaction that can range in severity. This is something that is out of your control, and despite your best efforts to prevent contra-actions, they may occur from time to time and symptoms to look out for will include redness, itching, swelling, sensitivity, burning or stinging. For gel applications and acrylic applications, there are specific contra-actions that may occur.

Adverse effects of gel products	Adverse effects of acrylic products
– Allergy to products – Exothermic reactions – Injury to natural nail due to poor removal technique – Natural nail separation – Peeling of product – Pseudomonas (bacterial infection)	– Allergy to product – Damage to natural nail due to poor application or removal technique – Product discolouration – Natural nail separation – Product peeling – Product reaction to temperature – Pseudomonas (bacterial infection)

If any contra-actions occur during the treatment, stop immediately and assess the situation. How the contra-action is managed will all depend on what the contra-action is and the severity. Let’s take a look at each contra-action in more detail.

Allergy to products and patch tests

If your client has an allergy to a product, like a cream or a cleanser, it will usually result in a red and itchy rash. If you notice this during a service, remove the product and apply a cold compress. Stop the service and advise the client to contact their GP or another medical practitioner if there is no improvement in 24 hours.

When you are selecting products, you must also be aware of the ingredients. HEMA is a common ingredient found in beauty products, and it is said to be the number one allergen product in nail products and cosmetics. Commonly known as 2-hydroxyethyl methacrylate or hydroxyethyl methacrylate, these are monomers that are used to polymerise UV gels. Although HEMA is mostly found in some Acrylic Monomers, gels do contain small amounts of HEMA too.

A clear indicator of over-exposure to chemicals is skin irritation. This is not an immediate sign that you are allergic to a chemical, rather a warning that if over-exposure continues, the person may become permanently sensitised or allergic to that chemical. The picture below shows an allergic reaction to a monomer liquid:

To prevent over-exposure in your control, ensure that you:

• Follow manufacturers product notes and guidelines
• Avoid touching your clients’ hands with the brush as much as you can
• After placing the bead of acrylic, wipe any excess liquid monomer from the brush before working with the bead
• Do not use acrylic monomer (liquid) without polymer (powder).
• Change your UV bulb lamp for a modern UV LED lamp
• Change table towels between clients

To determine whether or not your products contain HEMA, you need to read the product descriptions, and you may also need to access the Safety Data Sheet (SDS). We will look at SDS in the keeping you and your clients’ safe module. Not everyone will have a reaction to HEMA, but it is better to be on the safe side and select products without it. In addition to HEMA, there are a range of ingredients that can be potential allergens for clients. The table below outlines common nail enamel components and potential allergens:

Nail enamel component	Chemical/potential allergen	Use
Film former	Nitrocellulose	Used in topcoats to enhance gloss and minimize abrasion
Resins	Tosylamide formaldehyde resin, alkyd resins, acrylates, vinyl, polyesters	High amounts used in base coats to improve adhesion to the nail surface
Plasticisers	Camphor, dibutyl phthalate, dioctyl phthalate, tricresyl phosphate	Used in topcoats to enhance gloss and create a flexible film after drying
Solvents	Alcohol, toluene, ethyl acetate, butyl acetate	The diluent used to dissolve nail enamel components
Colourants	e.g. D&C Red No. 7	Provide the desired colour
Pearlisers	Guanine, bismuth oxychloride	Used to create colour tones and hues, e.g. sparkling effect

One of the best ways to pre-empt and prevent contra-actions related to allergies is to conduct a patch test. Patch testing for nail technicians is not as common as in other beauty therapies, but if you have a client who is concerned or if a client advises you they have sensitive skin or are prone to allergies, then it can be useful.

The purpose of the patch test is to test products to ensure there are no reactions to any of the ingredients. Even natural ingredients can cause sensitivity, so patch testing is a way of ensuring a client won’t have issues with your products.

To perform a patch test, follow these steps:

1. Apply a small amount of the intended products you wish to use with a cotton bud to the inner crease of the elbow, behind the ear, inside of the wrist, or inside the leg (not as obvious location!).
2. Leave for 24 to 48 hours.
3. If any contra-actions occur such as redness, swelling, inflammation or itching, avoid using the product, as this is a positive reaction for sensitivity.

If no reaction occurs with any of the products you plan on using, then it is fine to proceed with nail services. It will also help for your own peace of mind if you document your patch tests in your client files or on your client consultation cards. You should always ensure that you record the date the client was tested, which products were used and where you conducted the patch test/s. Always ensure you include the date and a client signature on this paperwork to ensure you are covered.

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To learn more about patch tests, access the resources linked:

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Damage to natural nail due to poor application or removal technique

Effective applications and removals are key to ensuring that damage to the natural nail does not occur. Despite your best efforts, when starting out as a nail technician, there may be instances where nail lifting happens. Common reasons for nail lifting include, but are not limited to:

• Overfilling the nail
• Failing to prepare the nail properly
• Overusing or underusing primer
• Applying acrylic or gel too close to the cuticle

Nail lifting can occur with any nail coating but is more common with acrylic and gel enhancements. As the name suggests, nail lifting is where the nail lifts away from the nail plate and is a clear indicator of a service breakdown. The images show what nail lifting looks like:

Lifting can occur near the cuticle and also in the centre of an enhancement. Lifting in the centre is known as ‘pocket lifting’ and is usually caused by infill and maintenance procedures that aren’t performed correctly or when damage occurs. Clients can expect to experience a minimal amount of lifting over the weeks due to wear and tear and growth, but if your client is experiencing regular or substantial lifting, this must be investigated further and must be addressed.

In addition to improper application damaging a clients nails, incorrect removal can cause just as much damage. When removing nails, we need to take great care and use the most appropriate methods depending on the state of the nail and the nail type.

Some nail technicians opt to remove lifting nails using nippers or tools to rip away the lifting from the nail – this is careless and will likely cause damage to the natural nail. Nipping and pulling nails off the nail plate will only cause more trauma, so it may also cause onycholysis. As you learned earlier in this lesson, onycholysis is the separation of a fingernail or toenail from its pink nail bed. The separation occurs gradually and is painless. The most common cause of onycholysis is trauma, although skin diseases and infections can also cause this condition. Remember, it can take up to 6 months for our fingernails to grow and 12 to 18 months for toenails, so you do not want to be the cause of a timely recovery for clients simply because you were careless in the application or removal process. You will learn more about correct applications and removals later in this module.

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In the meantime, to learn more about minimising nail lifting, watch the videos linked:

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Natural nail separation

Clients may come to you with natural nail separation (onycholysis) prior to any sort of treatment. You will usually be able to see this as the nail itself may appear healthy; however, sections that are separated will be white in colour. The extent of onycholysis will determine what treatment you can perform. If the onycholysis is caused by a medical condition, the product should not be applied, and the client should seek advice from a medical practitioner. If the nail is growing out, it is possible to trim the nail if the lifting is nearer to the free edge of the nail.

Remember, onycholysis can also be caused by a fungal infection, so it can be possible to pass this on to other clients if correct sanitation is not followed. The best course of action for clients with onycholysis is to have clean, trimmed nails without product. Patience is key with this condition because causing further trauma may worsen the problem.

Exothermic reactions (heat spikes)

Excessive heat spikes are caused whenever unusually rapid polymerization or hardening occurs. When polymerization occurs too quickly, excessive heat will be released in a short time period, and that will create a heat spike. Some likely reasons for heat spikes are:

• the use of an incorrect mix ratio when applying acrylic products
• the use of an incorrect lamp to cure the gels
• the incorrect timing into the lamp

To prevent these, always use products according to the Manufacturer’s instructions. Additionally, ensure that you are never over-filling the nail or filing off too much of the nail. Prior to starting a treatment epically for gel nails, ask your client if they have had them before and ask if they have ever had a heat spike. If they have, apply the gel thinly and ensure that if there is too much heat, they remove their hand from the lamp temporarily.

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To learn more about minimising heat spikes, watch the videos linked:

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Peeling of product and/or nails

Much like nail lifting, the peeling product can be caused by general wear and tear or incorrect application techniques. If a clients gel nail polish is peeling, it is important that they do not remove this themselves as they can damage the nail plate. If peeling product is not removed correctly, it can lead to:

• Cracked and brittle nails
• Irregular surfaces and textures
• Weakened nail plate

If the clients’ nails are naturally oily, this could be a culprit of peeling products as well. If you remember back to the lesson on pH levels, a pH balancing product might be useful as part of the fixing process.

Product discolouration and nail discolouration

Discolouration can occur after some nail services as a contra-action, largely due to staining the natural nail. A way to prevent staining the natural nail is by applying a high-quality base coat which acts as a barrier and prevents staining. Discolouration from nail polish often has a yellow tinge and is a common side effect of darker nail polishes. The yellow tinge can usually be significantly reduced using an acetone nail polish remover, and usually, the stain will fade out over time.

As a nail technician, you might be the first person to identify a change in the colour of your clients’ nails which could be contraindications. Given that you work with nails every day, you will be able to easily spot abnormalities that may be a cause of concern for your client. If your client has discoloured nails that are not a result of nail polish staining, this could definitely indicate an issue that will need to be dealt with prior to any services. The table below outlines common colours to look out for with an overview of what these colours can indicate:

Colour	Potential issues
Yellow	– Fungal infection – A respiratory problem, like chronic bronchitis – Chronic sinus infections – Smoking – Nail polish stain
Green	– A bacterial infection such as pseudomonas – Fungal infection
Blue	– B12 deficiency – Lung problem – A side effect of medications – Smokers – The dark blue line may indicate skin cancer
Red	– Blood due to recent trauma – Very red/purple can indicate poor circulation or even heart failure – Brown/red spots can signal a nutritional deficiency in folic acid, protein or vitamin C – Nail polish stain
White	– An all-white nail is called leukonychia, a congenital condition – White spots are usually a result of small trauma – May indicate some malnutrition
Black/ dark brown	– A single black or dark brown longitudinal band under the nail can signify melanoma – Excessive fluoride can cause brown-black discolouration of the nails – Brown on only the upper half of the nail can signal kidney disease

If you notice any abnormal discolouration on your clients’ nails, do not apply any products until there is a confirmed cause.

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If you are interested in learning more about what nail colours can indicate, watch the videos linked:

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Pseudomonas (bacterial infection)

As you learned earlier, pseudomonas, or as they are more commonly known, greenies, are a bacterial infection that can be found in moist environments such as under nail enhancements that have lifted. If you have not correctly disinfected or sanitised your equipment, you could be the cause of your client getting greenies! Much like onycholysis, greenies can take up to six months to heal, and no products should be applied during this time.  Greenies can be avoided by ensuring both you and the client have washed and sanitised your hands, all bacteria are removed prior to the service, and all your equipment has been correctly disinfected or disposed.

Other contra-actions

If a client develops any sort of severe reaction in the days following the treatment, ensure that you do not offer any medical advice and suggest that they visit their doctor (GP). If a person has had an allergic reaction previously but wants to try a nail service again, unfortunately, refusal of future appointments is the most appropriate option. Usually, allergic reactions will worsen in severity rather than get better, so it is not worth the risk! Alternatively, you can do a patch test if your client persists in wanting to try again with different products.

All products will usually have a safety data sheet (SDS) which will outline the actions to be taken in such circumstances. We will cover SDS in more detail in a later module, but if in doubt, seek emergency medical attention – it is better to be safe than sorry! To prevent any reactions, it is so important to take notice of the product quality and ingredients (as you learned about earlier) and ensure you know as much as possible about your products, including how they are made and where the ingredients are sourced (if possible). Always have SDS to prove any supplier claims and to have on hand in the event of an emergency.

Did you know…
– Onychomycosis accounts for up to 30% of all skin infections
– Nail fungal infections affect 5% of the general population, 20% of people over 60, and 50% of individuals over 70
– Men contract toenail fungus more often than women
– Risk factors for nail infections include age, poor circulation, thickening of nails, diabetes, psoriasis, immune system disorders, and excessive perspiration

There has been extensive information in this lesson regarding all the types of contraindications and contra-actions that you will encounter as a nail technician. While it can be a bit tricky at first, as you develop your skills and service a wide variety of clients, you will become more familiar with the range of hand, foot and nail conditions. Always remember that if doing a service is likely to impact your clients’ health, your own health, or the health of others – refuse service. As you become more comfortable with non-contagious nail conditions, you may decide to provide services when mild conditions are present. Be sure always to ensure that your client knows exactly what the condition is before you provide any services that will cover up any contraindications.