Toughness Is More Than Skin-Deep: Who Cries and Who Doesn’t in a Dermatology Clinic

Toughness: What does it mean? Does it mean you’re a muscular man who can crack open a beer bottle with just your eyes? Does it mean you’re like Chuck Norris, making onions cry when slicing them? The answer from a dermatologist’s perspective is none of the above. The answer may come as a surprise.

Image Credit: © SHOTPRIME STUDIO (girl); Ljupco Smokovski (man) - stock.adobe.com

Someone may see a tattooed motorcyclist and think, “That is one tough guy.” What they may not know is that, in my experience, this patient demographic is more often the one upset during minor procedures. This type of patient sometimes needs more support and reassurance, which I am happy to provide—no patient shaming here.

Nonetheless, toughness appears to be more than skin-deep. Perhaps the tough exterior of these patients is nothing but a protective shell around a sensitive, empathetic being that has been hardened by societal pressures and experiences—the world may never know.

The toughest patients in the eyes of this dermatologist are, to the surprise of some, preteen and teenage girls. As opposed to their pubescent male counterparts, young female patients typically shed a single brave tear during the freezing of a wart or the injection of dilute steroid into their angry acne cysts.

Why is this? There are many theories I have conjured, as well as some gathered via colleagues and medical literature. Some believe this patient demographic to be more empathetic and emotionally mature, facilitating better coping mechanisms for external stressors. I would love to take a deep dive into that theory, but I cut off my ponytail after medical school, which is a not-so-subtle psychiatry joke for those keen on inside medical specialty references.

Like many medical specialties, dermatology experiences overlap with others, addressing psychiatric illnesses directly or indirectly by treating related skin conditions. In sharing some case stories that exemplify “toughness,” I apologize for not having a significant P value on toughness or randomizing for confounding metaphorical skin-depth statistics.

Recently, “Verruca,” a 10-year-old girl, came in for a wart on her middle finger. She had eyeglass lenses as thick as hockey pucks, pigtails with pink bows, a Taylor Swift T-shirt, and pink Crocs with innumerable Jibbitz charms (Crocs shoe flair pieces). This young lady knew the liquid nitrogen/freezing spray was coming, and no amount of squirming, screaming, or pleading with her parents to go home was on the horizon. In anticipation of the procedure, this model patient reached her outstretched arm to me like God reaching out to Adam in the famous Michelangelo painting. As Adam in this religiously artistic metaphor, I reached my hand out to stabilize her finger.

After the freeze, a small tear was shed from the corner of Verruca’s left eye. She was promptly given a lollipop with her mother’s permission and a Spider-Man sticker—the only sticker in my mostly adult medical dermatology clinic—upon leaving the office. No exam room furniture or medical assistants were harmed during this encounter, and no soul-piercing shrieks were heard across the great state of Ohio. It was a good day.

Case 2 is that of 50-year-old male biker with innumerable tattoos. “Harley” checked every box of the quintessential macho man. Harley stood at a monumental 6-foot-plus stature—at least, he appeared this tall due to my height of 5-foot-7 by comparison.

Harley had biceps the size of an NFL lineman’s, neck tattoos of ex-girlfriends and his favorite horror movie character (Chucky from Child’s Play), and a leather jacket with more patches than an overachieving Girl Scout. He had several precancerous growths on his sun-kissed, non–sunscreen-applied, bald scalp, which had seen many decades of majestic open road direct UV radiation.

During the examination, Harley said to me in a seemingly brave and masculine voice, “Doc, do what you gotta do.”

So, I did what I had to do. I got the freezing spray, and as soon as my cold-washed hands grasped the liquid nitrogen canister, Harley started sweating profusely, experienced some jerky movements, went limp, dilated his pupils, and fainted. In medical terms, he had a vasovagal episode. He omitted this tendency in his medical history, and after the fact, it turns out he routinely faints at all his blood draws and whenever he sees a needle. Luckily for Harley, this wasn’t my first rodeo, and after an apple juice box, recumbent position, and a few minutes of reassurance, he was back to being himself again.

Before freezing, Harley apprehensively inquired, “Doc, is this gonna hurt?” To which I responded, “Just a little cold burn.” Upon a small press and ejection of liquid nitrogen, a symphony of screams erupted, which an outside observer may have confused with a wartime interrogation situation. Unfortunately for him, I did not offer Harley a lollipop or sticker but a reassuring pat on the shoulder.

Hershel Dobkin, MD, FAAD

In the end, I have learned not to judge a patient’s toughness by the exterior or assume toughness based on age, size, or demeanor. Well, a caveat: Young female patients are the reigning champs of toughness until I am proven otherwise—no offense to bikers, who are always reliable for intriguing stories of the open road.