You have a big eyebrow!

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.