CONTINUING MEDICAL EDUCATION

Onychotillomania: 2 Case Reports

Marc Inglese, BS; Heather R. Haley, MD; Boni E. Elewski, MD

GOAL To gain a complete understanding of

OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Understand the clinical presentation of onychotillomania. 2. Describe the psychopathology associated with onychotillomania. 3. Explain the treatment for onychotillomania.

CME Test on page 194.

This article has been peer reviewed and is accredited by the ACCME to provide continuing approved by Michael Fisher, MD, Professor of medical education for physicians. Medicine, Albert Einstein College of Medicine. Albert Einstein College of Medicine designates Review date: February 2004. this educational activity for a maximum of 1 This activity has been planned and implemented category 1 credit toward the AMA Physician’s in accordance with the Essential Areas and Policies Recognition Award. Each physician should claim of the Accreditation Council for Continuing Medical only that hour of credit that he/she actually spent Education through the joint sponsorship of Albert in the activity. Einstein College of Medicine and Quadrant This activity has been planned and produced in HealthCom, Inc. Albert Einstein College of Medicine accordance with ACCME Essentials.

Mr. Inglese and Dr. Haley report no conflict of interest. The authors report no discussion of off-label use. Dr. Fisher reports no conflict of interest.

Onychotillomania is an uncommon condition We report 2 cases of onychotillomania with dif- characterized by self-destruction of the finger- fering presentations in a young man and in an nails and/or toenails by compulsive manipulation. older man. Onychotillomania may be a form of obsessive-compulsive disorder (OCD), and we discuss the psychologic factors and current Accepted for publication January 16, 2004. treatments for this condition. Mr. Inglese is a fourth-year medical student at the University of Cutis. 2004;73:171-174. Florida, Gainesville. Dr. Haley is Chief Resident of dermatology and Dr. Elewski is Professor of Dermatology, both at the University of Alabama at Birmingham. Reprints: Boni E. Elewski, MD, Department of Dermatology, motional and psychologic factors have the 2000 6th Ave S, Birmingham, AL 35233-0271 (e-mail: ability to influence the underlying disease [email protected]). E process in at least 33% of patients with a VOLUME 73, MARCH 2004 171 Onychotillomania

dermatologic condition.1 In some cases, such as osteomyelitis were negative. Attempts to use onychotillomania, a psychiatric condition can be occlusive dressings were made, but the patient the underlining cause. Onychotillomania, a condi- refused to keep the nails covered because he was tion whose true incidence is unknown, is character- unable to manipulate the remaining nails or ized by the compulsive or irresistible urge in beds. Also, referral for psychiatric evaluation was patients to pick at, pull off, or harmfully bite or vehemently refused. The patient did not return for chew their nails. This urge may be conscious or follow-up. unconscious. The word onychotillomania is derived Patient 2—A 22-year-old white man presented from the Greek onycho, nail; tillo, to pull; and to the dermatology clinic with a several-month , madness or frenzy. In , onycho- history of pain in his toenails. On physical exam- tillomania has been classified as an impulse control ination, he was missing all nails on his right foot. disorder that includes conditions such as compul- He had blood on and under all the remaining toe- sive gambling, , , habit-tic nails, blood on all nail beds, and blood under deformity, and obsessive-compulsive disorder most of his fingernails and on his fingertips. On (OCD). The more well-documented trichotillo- questioning, the patient adamantly denied mania, or pulling of the hair, is estimated to occur pulling his nails, even after confronted with the in up to 1 in 200 individuals.2 The incidence of blood evidence on his fingers and fingernails. onychotillomania is thought to be much lower and His mother reported that he constantly picked at widely underreported. However, the incidence may his toenails. surpass that of when , Due to our suspicion of onychotillomania with nail chewing, or habit-tic deformity is included, secondary , the patient was treated ini- though this thought is controversial. In this report, tially with oral cephalexin followed by placement we document 2 patients with slightly different pre- of an Unna boot on the involved foot with modifi- sentations of onychotillomania and the approaches cations to cover the entire foot and digits. This was to their therapy. changed once weekly. After one month, new healthy nail was noted, but the patient refused our Case Reports recommendation for psychiatric evaluation and did Patient 1—A 72-year-old white man was referred not follow-up with us as recommended. to the dermatology clinic with an 8-month history of fingernail loss and pain. On physical examina- Comment tion, he was missing 2 nails on the left hand. In both of our cases, the diagnosis of onychotilloma- Prominent longitudinal ridging was observed on nia was made by the obvious physical signs on exam- the remaining nails, which were thick and yellow ination, as well as by self-admission in patient 1. and showed some loss of the distal nail plate. All Although we believed a psychiatric evaluation was nails on the right hand were normal. Results of a necessary for proper treatment, it was refused by biopsy showed epithelial necrosis with no evi- both patients. dence of lichen planus or inflammation. Fungal Psychodermatologic problems can be grouped culture results were negative. into 3 categories. Psychophysiologic disorders are The patient was confrontational during the exacerbated by emotional and include visit, protesting the nail examination. He continu- atopic dermatitis and psoriasis.3 Primary psychi- ally drew back in protest, not wanting his nails atric disorders (anxiety, , delusion, and examined. His wife reported the same, stating that OCD) may present as delusions of parasitosis, he would slap her hands away anytime she tried to neurotic excoriations, trichotillomania, and ony- look at his nails. He also reported that there was a chotillomania. In secondary psychiatric disorders, “clear goo” under his nails that he thought was patients endure psychologic or emotional distress necessary to remove by picking. Past medical his- as a result of physical or visual deformity caused tory was significant for essential tremors, chronic by primary skin disorders such as , leprosy, obstructive pulmonary disease, and congestive psoriasis, and vitiligo.4 heart failure. Medications included primidone and The term onychotillomania previously has been gabapentin for essential tremor and alprazolam at used to include nail biting in addition to physical night for . deformities caused by self-induced damage to the Based on examination findings and the nails or periungual tissues by picking or pulling. patient’s own admission, the diagnosis of ony- However, it is generally reserved for the manual chotillomania was made. Results of plain film removal of the nail plate. Examination of individ- radiographs that were obtained to rule out uals with onychotillomania may show periungual

172 CUTIS® Onychotillomania

erosions and crusts associated with nail-plate Fluoxetine hydrochloride also has been found surface abnormalities.5 The damage simply may helpful, specifically in the treatment of onychotil- be diminished or missing nails. The matrix lomania.12 In addition, pimozide has been used melanocytes can be stimulated by chronic trauma, specifically to treat onychotillomania.8 Topical which may result in longitudinal melanonychia.6 treatments also have been approached using dis- Onychotillomania has been classified as a habit- tasteful preparations applied to the nails to dis- tic deformity that may occur after psychological courage nail biting and chewing.5 The physical and emotional stress or as a form of OCD.7 How- barrier method appeared to work quite well in our ever, the habit-tic deformity may not fit the true younger patient, though it was not effective in the definition of onychotillomania, though pharmaco- treatment of our older patient. logic treatment is similar. Paranoid delusions and Onychotillomania has been cited in the liter- psychoses also have been associated with onychotil- ature to include both nail pulling and nail bit- lomania,8 as has Smith-Magenis syndrome. This ing, but our 2 patients exhibited the most classic congenital anomaly associated with mental retarda- form of onychotillomania of picking and pulling tion is estimated to occur in 1 in 25,000 individu- of the nails, as the term was originally coined. als. Self-mutilatory behavior is seen in 70% of Neither of our patients had what would be clas- patients and includes onychotillomania.9 The dif- sified as habit-tic deformity. We speculate that ferential diagnosis also should include Lesch- onychotillomania can be divided into a nail- Nyhan syndrome. pulling/picking group, a nail-biting group, and a Treatment of the underlying psychologic disor- combination of the 2. In any case, it is advisable ders should be considered in those with onychotil- to explore etiologies other than self-inflicted lomania. In addition to onychotillomania, the trauma, such as mechanical or friction trauma, more common manifestations of OCD in dermatol- fungal infection, or another form of nail dystro- ogy include trichotillomania, onychophagia, acne phy. However, when the diagnosis of onychotil- excoriee, and neurotic excoriations.10 OCD most lomania is reached, in addition to occlusion to frequently is manifested in childhood, though prevent the self-induced damage, referral to and behavior such as obsessive hand washing, AIDS treatment by a psychiatrist is warranted because , and other psychosomatic dermatoses can of the strong association with underlying psychi- be observed in all age groups. atric conditions, namely, OCD. However, not every patient with onychotillo- mania has OCD as the underlying psychopathol- ogy. Before coming to a conclusion that a patient REFERENCES with onychotillomania has OCD, one must rule 1. Koo JY, Pham CT. Psychodermatology. practical guide- out other psychiatric diagnostic possibilities, lines on pharmacotherapy. Arch Dermatol. mainly delusion and simple habit disorder (habit- 1992;128:381-388. tic deformity). The key distinction between obses- 2. Tynes LL, Winstead DK. Behavioral aspects of trichotil- sion and delusion is the presence or absence of lomania. J La State Med Soc. 1992;144:459-463. insight on the part of the patient. Obsessive 3. Krueger G, Koo J, Lebwohl M, et al. The impact of psori- patients have more insight than delusional patients asis on quality of life: results of a 1998 National Psoriasis do. Often, patients with OCD are apologetic for Foundation patient-membership survey. Arch Dermatol. their behavior.10 Patients with habit-tic deformity 2001;137:280-284. may be differentiated from true onychotillomania 4. Alam M, Moossavi M, Ginsburg I, et al. A psychomet- in that they may only rub their nails unconsciously ric study of patients with nail dystrophies. J Am Acad and not actually pick off their nails. Dermatol. 2001;45:851-856. It is important for the underlying psychiatric 5. Tosti A, Piraccini BM. Treatment of common nail disor- disorder to be defined by psychiatric evaluation ders. Dermatol Clin. 2000;18:339-348. and subsequent treatment with psychoactive medi- 6. Baran R. Nail biting and picking as a possible cause of lon- cations.11 Common treatments for OCD include gitudinal melanonychia. a study of 6 cases. Dermatologica. individual psychotherapy and behavioral therapy. 1990;181:126-128. In addition, there are 3 oral medications com- 7. Vittorio CC, Phillips K. Treatment of habit-tic deformity monly used for their anti–obsessive-compulsive with fluoxetine. Arch Dermatol. 1997;133:1203-1204. effect, namely, clomipramine, fluoxetine, and flu- 8. Hamann K. Onychotillomania treated with pimozide voxamine.9 Paroxetine, sertraline, the mixed (Orap). Acta Derm Venereol. 1982;62:364-366. uptake inhibitor venlafaxine, and citalopram are 9. Moldavsky M, Lev D, Lerman-Sagie T. Behavioral the latest additions for the treatment of OCD.12 phenotypes of genetic syndromes: a reference guide for

VOLUME 73, MARCH 2004 173 Onychotillomania

psychiatrists. J Am Acad Child Adolesc Psychiatry. 11. Koo JYM, Smith LL. Obsessive-compulsive disorders in the pedi- 2001;40:749-761. atric dermatology practice. Pediatr Dermatol. 1991;8:107-113. 10. Koo JYM, Gambla C. Psychopharmacology for dermato- 12. Swerdlow NR. Obsessive-compulsive disorder and tic syn- logic patients. Dermatol Clin. 1996;14:509-523. dromes. Med Clin North Am. 2001;85:735-755.

DISCLAIMER The opinions expressed herein are those of the authors and do not necessarily represent the views of the sponsor or its publisher. Please review complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

FACULTY DISCLOSURE The Faculty Disclosure Policy of the Albert Einstein College of Medicine requires that faculty participating in a CME activity disclose to the audience any relationship with a pharmaceutical or equipment company that might pose a potential, apparent, or real conflict of interest with regard to their contribution to the activity. Any discussions of unlabeled or investigational use of any commercial product or device not yet approved by the US Food and Drug Administration must be disclosed.

174 CUTIS®