BACKGROUND: Since during the COVID-19 pandemic nail psoriasis was evaluated exclusively with teledermatology, dermatologists started to face the difficulty in rating it concurrent with other onycopathies (i.e., onychotillomania and onychophagy). Thus, we aimed to improve the existing severity scores and verify the value in different clinical settings (i.e., in person vs. teledermatology (video or picture)).
METHODS: This multicenter prospective observational study evaluated patients with nail psoriasis and screened them for onychophagy or onychotillomania in telemedicine from May 2020 to January 2021. For therapeutic purposes patients with nail psoriasis were followed and rated with the Nijmegen-Nail psoriasis Activity Index tooL (N-NAIL) for 9 months; at the same time, N-NAIL and a new dedicated index that monitor also the changes in nail dimension (Galeazzi-(G) N-NAIL) were tested for accuracy. We assessed inter- and intraobserver agreement for the three different settings (in person, video, and pictures).
RESULTS: In our cohort of 382 patients with nail psoriasis after a clinical and dermatoscopic assessment we found 20 (5.24%) patients with onychophagy and 17 (4.45%) patients with onychotillomania. Analysis of the impact of nail psoriasis on patients revealed that onycholysis and crumbing, followed by subungual hyperkeratosis, were the clinical signs that prevalently bothered patients. N-NAIL score displayed moderate intra- and interobserver agreement. Over the 9 months follow-up, N-NAIL vs. GN-NAIL displayed a solid correlation at all the examined time points, i.e., baseline and after 3, 6, and 9 months.
CONCLUSIONS: We created a new tool, the GN-NAIL capable of efficiently scoring nail psoriasis severity in complex cases, such as patients with onychotillomania and onychophagy, and monitor response to treatment during the COVID-19 pandemic.

Onychotillomania is characterized by an irresistible urge to pick or pull at one\'s nails, resulting in significant damage to the nail and surrounding tissue. In severe cases, it can cause onychodystrophy, which leads to abnormal changes in nail shape, color, texture, and growth. Managing onychotillomania can be challenging due to the lack of standard treatment and concurrent behavioral disorders. Pharmacotherapy and behavioral therapy have shown some positive outcomes from reported cases. The treatment for onychodystrophy varies depending on the underlying cause and may entail the application of topical, systemic, or laser therapies. Nevertheless, there is currently no consensus on the most effective treatment approach. This report presents a case of onychodystrophy caused by onychotillomania successfully treated using a pulsed dye laser 595 nm. The treatment was administered four times, with a two-week interval between sessions. Significant improvement was seen within four weeks of starting the treatment, and by the end of the eight-week program, the dystrophic thumbnails had almost completely resolved. After a thorough ten-month follow-up, it has been determined that the dystrophic nails have not reappeared. Moreover, there has been a significant decrease in the patient\'s tendency to pull her nails.

Self-induced nail disorders are a broad group of different clinical manifestations that share the common trait of being caused more or less voluntarily by the patient. These are distinct conditions within the clinical spectrum of onychotillomania. Most patients diagnosed with these disorders have psychiatric co-morbidities, and a multidisciplinary approach is thus highly recommended. The purpose of this review is to describe the most common clinical features encountered during daily nail consultations and to provide useful diagnostic tools and therapeutic tips for the best approach to these conditions.

BACKGROUND: Obsessive-compulsive disorder is a condition in which patients experience an obsession and/or a compulsion. It has a high impact on the quality of life, and is associated with an increased prevalence of psychiatric comorbidities in patients. Onychotillomania is an underestimated psychodermatosis caused by repeated self-inflicted damage to the nail unit. In patients, it is characterized by an obsessive or irrepressible impulse to repeatedly damage their own nails, resulting in their destruction. It is a chronic condition that is difficult to manage, largely because of its psychocutaneous character, as well as its high tendency to interact with underlying neuropsychiatric diseases or other behavioral disorders. Only a few studies have reported an association between obsessive-compulsive disorder and onychotillomania, which typically presents with therapeutic challenges. Cognitive behavioral therapy, physical-barrier approaches, and pharmaceutical treatments have been reported to be beneficial in the management of onychotillomania; however, no major clinical studies have investigated the effectiveness of these therapies. Onychotillomania remains a clinical and therapeutic issue owing to the lack of evidence-based treatment techniques.
METHODS: We report a case of an 18-year-old, middle-eastern female patient who developed onychotillomania when she was being treated with paroxetine for obsessive-compulsive disorder and was showing partial improvement. The patient developed side effects from paroxetine, and was switched to fluoxetine. Thereafter, improvement in her obsessive-compulsive disorder was observed, which relapsed when treatment was discontinued. However, the onychotillomania symptoms did not reemerge.
CONCLUSIONS: Onychotillomania typically presents both diagnostic and therapeutic challenges. Fluoxetine plays an important role in the treatment of onychotillomania and other psychiatric disorders. However, large-scale studies should be conducted before these outcomes can be generalized.

Artificial nails are an essential component of nail cosmetics. The artificial nails are either preformed and glued onto the existing nail plate or they are custom made by applying a polymerizing mixture to the existing nail plate and overlying the template with a paintbrush that is subsequently allowed to harden into an acrylic nail. Artificial nails require regular maintenance. Onychotillomania is a body-focused repetitive disorder in which the person is usually aware that they are picking at their nail and/or the surrounding soft tissue. A woman with onychotillomania affecting her artificial nails is described; although this may be a relatively common occurrence, additional reports of artificial nail-associated onychotillomania were not able to be retrieved from the medical literature. The woman was not only aware that she picked at her artificial nails, but also realized that the action might result in adverse events to her natural nails and the corresponding digits. She desired no interventions for her nail-associated repetitive behavior and continued to regularly visit the nail salon for the application of new artificial custom acrylic nails. The acronym ANASON is introduced to define the condition of artificial nail-associated onychotillomania.

Trichotillomania (TTM), excoriation disorder, onychophagia, and onychotillomania are categorized as body focused repetitive behavior (BFRB) disorders, causing damage to the skin, hair, and/or nails with clinically significant psychosocial consequences. Currently, there are no standardized treatments for these compulsive, self-induced disorders. Studies on treatment of these disorders using psychotropic drugs (i.e., selective serotonin reuptake inhibitors, tricyclic antidepressants, anticonvulsants) have shown variable efficacy. Recently, there is a growing interest in N-acetylcysteine (NAC) for treating BFRBs. NAC is a glutamate modulator that has shown promise in successfully reducing the compulsive behaviors in BFRB disorders. This article provides an updated review of the literature on the use of NAC in TTM, excoriation disorder, onychophagia, and onychotillomania.
Relevant articles were searched in the PubMed/MEDLINE database.
Twenty-four clinical trials, retrospective cohort studies, and case reports assessing the efficacy of NAC in TTM, excoriation disorder, and onychophagia were included. No studies for onychotillomania were found in our search.
Although NAC has proven successful for treatment of BFRB disorders, data is derived from few clinical trials and case reports assessing small numbers of patients. Larger studies with longer durations are needed to fully establish the efficacy of NAC in these disorders.

Onychotillomania is a psychodermatosis that involves repetitive, self-induced trauma to the nail and sometimes the periungual skin. It is generally seen as an overlapping psychiatric and dermatologic disorder, although there have not been any statistically significant associations with psychiatric illness. Some studies have noted an association with obsessive-compulsive disorder (OCD). Due to the relative lack of empirical data on this condition, treatments are often not evidence-based. As a result, there is no standardized method of treating onychotillomania, and patients suffering from this disease are susceptible to relapse. This report presents the case of a 32-year-old male experiencing homelessness and suffering from major depressive disorder and methamphetamine use disorder who developed onychotillomania two months after becoming homeless. He regularly used various instruments such as nail cutters, tweezers, and nail files to constantly pick at his nails, a few of which were noted to be bleeding with signs of infection. He was evaluated jointly by dermatology and psychiatry providers who confirmed the diagnosis. By thorough examination of the patient\'s history, he was provided tactile sensory equipment to reduce his repetitive picking behavior. A direct referral for substance use counseling was also provided. At follow-up, he was noted to have a subjective improvement in his picking symptoms, although there was no significant difference in the size of his nails. This case represents the twofold challenge of managing a difficult condition, onychotillomania, in the setting of the severe socio-personal stressor of homelessness.

Habit-tic nail deformity, onychophagia (also referred to as nail biting) and onychotillomania (also referred to as nail picking) are body-focused repetitive behaviors that can involve the nails and periungual skin. Patients with habit-tic nail deformity are typically unaware that repeatedly using their nail, often the adjacent index finger, to rub the proximal nail fold and its underlying matrix - usually of one or both of their thumbnails - is the cause of the longitudinal depressed groove that extends along the entire the nail plate. Nail biters usually bite multiple nails - most commonly on the digits of the hands - and the patient is cognizant of their behavior. However, the term onychophagia is a misnomer and onychodaxia would be a more appropriate nomenclature. Nail pickers also often realize that their dystrophic nail results from using other nails or tools to pick, pull, or excessively manicure the affected nail. Individuals with habit-tic nail deformity or onychophagia or onychotillomania may concurrently have other repetitive behaviors involving the skin or the hair or both. Three patients with a nail-associated body-focused repetitive behavior are described who not only presented with dystrophy of their nails but also abnormalities of the adjacent nail apparatus: a 36-year-old woman with habit-tic nail deformity and dermatodaxia, a 64-year-old man with biting of both the nails and the skin, and a 63-year-old man with nail picking and skin picking. The nail dystrophy and concurrent skin biting or skin picking were not the issues that prompted the reported patients to seek evaluation by a physician; the body-focused repetitive behaviors of the nails and skin were incidental findings during their cutaneous examination. The management of nail-associated body-focused repetitive behavior may include non-pharmacologic treatments (such as physical modalities and behavior modifications) and/or pharmacologic agents. The reported woman with habit-tic nail deformity was willing to consider an attempt to modify her repetitive behavior by using paper tape as a physical modality to cover the area on her thumbs that she would unconsciously rub. However, similar to the men in this report with onychophagia and onychotillomania, many of the patients with nail-focused repetitive behaviors do not want to initiate any interventions that might decrease or eliminate their nail condition.

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

Onychotillomania is a psychodermatosis that results from self-induced repeated trauma to the nail unit. It is characterized by the neurotic and irresistible urge to pick at, pull out, or harmfully bite or injure the nail(s). Multiple psychological factors can be involved. It can be difficult to diagnose, as patients mostly deny the self-destructive behavior, and the clinical features may mimic other inflammatory conditions of the nail apparatus. It presents with typical, usually bizarre morphologies of the nail plate. There is no evidence-based treatment for the condition, and it can be highly resistant to both dermatological and psychological interventions. Based on history and classical nail changes, a case of onychotillomania in a 19-year-old woman successfully treated with local steroid injection plus topical calcipotriol/betamethasone dipropionate combination is presented. An injection of a local steroid (0.2 mL of 5 mg/mL triamcinolone acetonide) was given monthly for 3 months and was then decreased to a bimonthly interval. In addition, topical calcipotriol/betamethasone dipropionate combination was applied daily for 3 months and was then decreased to every other day. Clinical improvement was noted after the third month, while complete resolution of the condition was achieved after 8 months. This treatment regimen can be advocated for similar nail dystrophies after excluding infective etiology.