Onychotillomania: clinicopathologic correlations

Abstract

Onychotillomania represents an unusual dermatosis affecting the nail unit. The term refers to 'neurotic picking at a nail until it is permanently altered'. It can be difficult for dermatologists to diagnose, as typically patients will deny the self-destructive behavior and the clinical features may mimic other inflammatory conditions affecting the nail unit. Aside from the difficulty in establishing the diagnosis clinically, the histopathologic features of onychotillomania are nonspecific. With this limited knowledge, dermatopathologists could have difficulty in correlating the clinical and histopathologic features and determining the correct diagnosis. Establishing the diagnosis is critical, as onychotillomania is sometimes associated with major depression and obsessive-compulsive disorder, and can be a clue to uncovering these debilitating psychiatric disorders. Here we present two cases of onychotillomania and emphasize the clinical-pathological confrontation necessary to secure the diagnosis.

Onychotillomania: A Chameleon-Like Disorder: Case Report and Review of Literature

“…This habitual disorder may lead to profound shortening, distortion, and, in severe cases, complete extraction of the nail plate as well as onychoatrophy, due to permanent damage of the nail matrix. The majority of nail pickers use their own fingers/nails to manipulate other digits, albeit sharp instruments, from scissors to knives or toothpicks, can be employed for excessive grooming [1][2][3].…”

“…To further complicate matters, both periungual and digit cutaneous tissues may be involved. This protean phenotype renders onychotillomania a dermatological masquerader able to mimic, both clinically and histologically, various nail disease entities and may comprise a major obstacle to differential diagnostic procedure for both dermatologists and dermatopathologists [2,3]. All these evidences prompted Reese et al [3] in 2013 to maintain that "onychotillomania could be considered a unique variant of lichen simplex chronicus/prurigo nodularis situated at the nail unit."…”

“…It is specifically delineated by recurrent and overwhelming picking and manicuring of the nail unit, with the fingers or tools, resulting in notable onychodystrophy and, in severe cases, onychoatrophy. It may also be complicated by infections and/or paronychia [1][2][3]. This nail picking pattern has been classified among the field of psychocutaneous ailments, owing to its high predisposition to concomitantly manifest with neuropsychiatric comorbidities or other behavioral disorders [4][5][6][7].…”

“…Taken together, all these parameters may entail underrecognition, misdiagnosis, and inadequate therapeutic approach of onychotillomania, hence highlighting the pivotal role of clinicopathological confrontation towards establishment of a solid differentiation and diagnosis [2,3].…”

The Habit Tic: Onychotillomania

“…1 The deformity is the result of repetitive nail bed trauma from the conscious or unconscious manipulation of the cuticle. The characteristic findings include a midline furrow in the nail plate, often yellow in color, running the length of the nail, with a series of transverse ridges.…”