DENVER — Adaptation is key to treating patients with personality disorders, a dermatologist told colleagues here, making it crucial to understand their conditions and react accordingly.

“We have to adjust our behaviors to the patient’s unique experiences and make educated predictions about which comments and interventions will be best received,” said Mio Nakamura, MD, MS, assistant professor of dermatology at the University of Michigan Medical School, Ann Arbor, Michigan, in a presentation at the American Academy of Dermatology (AAD) 2026 Annual Meeting.

As she noted, “personality can determine how a patient presents with and manages his or her illness, relates to the clinician, and responds to treatments and procedures.” And she said, personality traits can be exacerbated due to the stress of illness.

“As doctors, we could potentially be seeing the worst of a patient’s personality,” she said. And you can’t change a patient’s personality…. Don’t take it personally. It’s not you.”

Nakamura offered tips about how to deploy a trio of strategies — reassurance, routine, and respect — to treat patients with the following three types of personality disorders:

Borderline Personality Disorder: Reassurance

Imagine this scenario: A patient walks into the examination room with a complaint of an allergic rash. “When you enter the room, she’s visibly upset, and she says that all the nursing staff are incompetent,” Nakamura said.

But she is very happy to see you. “You’re the only doctor she’s ever seen who ever understood her. You just met, but she loves you already.”

Still, no rash is visible on exam, and the patient erupts when you decline to order allergy testing because it’s not needed. “She becomes very upset, and she says that you’re incompetent, just like everybody else.”

This represents the “all-or-nothing” thinking of someone with borderline personality disorder, Nakamura said. “Everything is black and white. You’re either the best or you’re the worst.”

These patients have “an instability in interpersonal relationships, self-image, and emotions. Their emotions are often irrational and very, very intense, and this comes from a fear of abandonment.”

Maintain calm with these patients, she advised, and set up regular visits. “You may not like seeing this patient, but you actually want to see them more frequently to avoid the drama.”

This is a better approach than saying, “just come back if you need me,” Nakamura said. “Because then they’ll call you tomorrow.”

It’s also helpful to reject patient demands in a careful way that makes the patient feel supported: “I don’t want to just send you for allergy testing. That’s a really extensive process. It could be expensive. I really want to make sure I have the right diagnosis. I want you to call me when you have the rash.”

With this strategy, Nakamura said, “you’re not straight up saying, no, they’re not feeling abandoned. And then you can just say, ‘Hey, let’s see you in 4 weeks, just to check on things.’ Usually they’re happy with that.”

Obsessive Compulsive Personality Disorder: Routine

A patient with obsessive compulsive disorder may come in with irritant eczema due to frequent handwashing, reflecting an “inflexible focus on orderliness, perfectionism, and control,” Nakamura said.

“They really like a kind of structured, back-and-forth, very intelligent kind of conversation. You can also praise them: ‘Wow, you’re really good at taking care of your skin. But let’s do this instead.’”

Then give them specific, step-by-step instructions. “You can even tell them, ‘Hey, make this list. Check it off every day, bring it back at your next visit. Let’s make sure you did all these things.’ And they will do it.”

Narcissistic Personality Disorder: Respect

A narcissistic patient may demand urgent attention for a day-old rash, invoke his or her academic degrees, and ask for antibiotics before the examination is complete, Nakamura said.

Patients with narcissistic personality disorder have “this grandiose sense of self-importance,” she noted. “They believe they’re very special, unique, and superior. There’s complete lack of empathy toward others and a constant need for admiration.”

The best approach is to meet their needs instead of pushing back, Nakamura said. “Give them a sense of uniqueness. Engage with the patient at the level you might with a colleague.” These patients, she said, “respond better to respect rather than concern or gentle [tender loving care].”

It can also be helpful to let these patients make decisions such as choosing between two equivalent topical steroids. “Do you want clobetasol or halobetasol? Cream or ointment? Follow-up in 4 weeks or 6 weeks?”

Nakamura’s advice: “Let them choose. They like that a lot better than you telling them what to do.”

Nakamura disclosed having relationships with Amgen, Argenx, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Galderma, Janssen, MoonLake, Pfizer, Regeneron, Sol-Gel Technologies, and Takeda.