SAN DIEGO — When faced with a difficult patient, Los Angeles dermatologist H. Ray Jalian, MD, urged aesthetic specialist colleagues to remember that they’re not required to treat everyone who comes in the door. 

Saying “no” is a treatment decision, Jalian said in a presentation on “when not to treat” at the 2026 Masters of Aesthetics Symposium.

At the meeting, Jalian described several types of patients who can be especially challenging to treat:

• Dreamers: “We have a saying in our practice: Satisfaction equals expectations minus reality. If somebody’s expectations far exceed their reality, no matter how good a result you get them, they’re going to be dissatisfied.”
• Doctor shoppers: “They’ve seen four other people in town, and you’re number 5 on the list.”
• Fibbers: “People are squirrely,” Jalian said, and they may deny having a cosmetic procedure history despite clearly having received filler treatments, for example. This is a sign of potential noncompliance with pre- and post-procedure instructions, he said.
• ‘Dr Google’ afficionados: “The over-researched patient nowadays is becoming more and more common.” In an interview, he elaborated that “the problem lies with the individual who thinks their research and AI searches supersede your 10-plus years of clinical experience.”

When a patient insists on a specific treatment strategy, Jalian said, “I often use analogies to shine light on the situation.” For example, in the case of a patient who comes in requesting treatment with a specific device, “I tell them that’s like going into a restaurant and demanding they cook your meal in a specific brand of pan,” he said. “At the end of the day, you just want a good meal, and good restaurants can provide that to you. It’s the same with device-based treatments: the brand of the device is not as important as the technique and experience of the person delivering the treatment.”

As for patients fixated on flaws that are not readily visible, he said, “I always tell them, ‘I can’t see this clearly. My laser can’t see it either.’ That really helps dial that home for people.”

Jalian pointed out that in aesthetic dermatology, “you are under no legal obligation to perform a cosmetic procedure,” as opposed to a person with a medical emergency, for example.

And to dismiss or “fire” a patient in nonaesthetic cases, he said, “There are obligations and documentation you have to go through to move this patient on to another practice. But when you’re doing an aesthetic, voluntary cosmetic procedure, there’s no obligation.”

In some cases, the best approach “is to turn the patient down,” he said.

In an interview, Jalian elaborated on how to say “no” to a patient: “This can be tricky. You want people to feel heard and not feel dismissed. I often use lines like ‘I know this is not the answer you want to hear, but it’s what my clinical experience has led me to believe is the truth,’” and that “it’s in their best medical interest to not pursue treatment for this particular matter.”

Consider Noncosmetic Diagnoses

Jalian also cautioned colleagues not to automatically assume that a patient who comes in for a cosmetic procedure actually has a cosmetic problem, citing the importance of a skin exam and recognizing “medical conditions before you treat them as aesthetic procedures.”

He highlighted a 2011 report that described four cases of cutaneous vascular lesions that were presented for evaluation at a cosmetic laser center and turned out to be cases of serious diseases:

• A 38-year-old male sought cosmetic evaluation of a “bright red rash” and appeared with numerous 1-3 mm petechiae over much of his body. Blood work showed a low platelet count of 9000/µL. The patient was ultimately diagnosed with idiopathic thrombocytopenic purpura.
• A 52-year-old male presented for a repeat laser treatment of nasal telangiectasias and had prominent rashes on the backs of both hands. He received a presumptive diagnosis of amyopathic dermatomyositis.
• A 43-year-old male presented for treatment of nasal telangiectasias. An examination revealed a 5 mm pearly papule, and a biopsy showed it was a nodular basal cell carcinoma.
• A 60-year-old male was referred for an apparent angiokeratoma on his left posterior calf. An examination showed a 9 mm × 7 mm dark blue plaque, and a biopsy revealed a 2.2 mm nonulcerated nodular melanoma.

All patients were successfully treated for the diseases that were discovered during examination.

Jalian also highlighted a 2012 case series of three patients who presented at a cosmetic center for cosmetic treatment of solar lentigines. One was referred by a dermatologist, one by a physician family member, and one was self-referred. All three were diagnosed with melanoma.

The lesson, Jalian said, is this: “Diagnose before you treat.”

Jalian reported having no relevant disclosures.