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  • A nail-picking disorder that can lead to trauma and drastic changes to all nail constituents.

  • The disorder can be associated with psychological comorbidities.


  • Inspect fingernails and toenails thoroughly, utilize a dermatoscope. Specific clues include hemorrhages and crusts, partial or complete absence of the nail plate, melanonychia, and loss of cuticle.

  • Ask patients if they use instruments to clean their nails; they often admit their habit.

  • Inquire about the patient’s psychiatric history.


  • Nail occlusives such as cyanoacrylate glue or bandages can be utilized as mechanical barriers to reduce nail damage.

  • Psychotherapy such as cognitive-behavioral therapy or habit-reversal therapy may be incorporated within the treatment plan.

  • Psychiatric medications like selective serotonin reuptake inhibitors and N-acetylcysteine.


  • It is important to inquire about the patient’s mental health to identify and ameliorate any underlying causes or behavioral triggers. A formal psychiatric consultation may be useful.


  • Onychotillomania can be confused for other disorders including lichen planus, psoriasis, nail tumors, and onychomycosis. Maintaining a broad differential, having a high index of suspicion, and utilizing a multi-system approach to narrowing diagnoses is essential to avoid misdiagnoses.

  • Patients may not be consciously aware of their nail-picking behaviors, may be sensitive about psychiatric referral, or have delusions regarding their behavior that make diagnosis and treatment challenging.


  • Consider this diagnosis in any nail showing absence of cuticle, periungual hemorrhages and crusts and macrolunula.

  • Dermatoscopy clues: wavy lines in the nail plate or nail bed, nail bed hemorrhages with oblique wavy pattern.


  • Onychotillomania is a nail-picking disorder that leads to self-inflicted damage of the nail.

  • Preventative measures exist to minimize nail trauma; however, long-term resolution requires assessing and treating the underlying triggers for this behavior.


Onychotillomania is a nail-picking disorder. Nail injury may result from manipulation of the nail using one’s own fingers or utilization of sharp instruments including scissors or knives.2 These behaviors lead to abnormal nail plate morphology, damage to the nail bed and periungual skin, as well as generalized nail dystrophy.3

Compared to other nail disorders, onychotillomania is especially associated with underlying psychiatric comorbidities.2 These can include depression, fixed hypochondriacal delusions, and obsessive-compulsive disorder.2 Onychotillomania is one of many disorders falling within the emerging field of psycho-dermatology, representing the nexus between psychiatry and dermatology. Thus, treatment of onychotillomania requires care for the mental and physical well-being of patients.

In the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), onychotillomania falls under the subcategory of “other specified obsessive-compulsive and related disorders,” which is classified under “body-focused repetitive disorders” (BFRD).4 BFRDs are compulsive behaviors that cause unintentional physical damage to the body and alter appearance.5 Onychotillomania is also listed in the International Classification of ...

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