Onychotillomania in the Setting of Homelessness

Abstract

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.

Nailing the Diagnosis: Onychotillomania in Patients With Artificial Nails—An Underrecognized Phenomenon?

“…Two months after becoming homeless, he developed the nail picking behavior that involved both his fingernails and toenails; he presented with short painful nails, nail fold erosions, and paronychia. In addition to using his fingernails, he also used a nail file, tweezers, and a nail cutter to pick, pull, and cut his nails [ 19 ].…”

“…Cognitive behavioral therapy, habit-removal therapy, stimulus control procedures, and occlusive barriers are non-pharmacologic therapeutic interventions [ 11 - 13 , 20 ]. For example, onychotillomania treatment for the 32-year-old homeless man was multifactorial; he not only received counseling and distracting tools so that he would avoid nail picking but also was provided with resources to treat his substance use disorder [ 19 ].…”