Onychophagia and onychotillomania can be effectively managed

Onychophagia and onychotillomania can be effectively managed To the Editor: We greatly appreciate the commentary by Lipner and Scher.1 We agree that our patients would benefit from prompt treatment to reduce shame and prevent irreversible nail damage. Herein, we present our clinical pearls using pharmacotherapy, stimulus control, habit-reversal training (HRT), and cognitive behavioral and aversion therapy. We often combine psychotherapies such as HRT and stimulus control. Six or more sessions are typically required. We have treated several cases of onychophagia and onychotillomania with N-acetylcysteine 1200-2400 mg/day. The safety profile of N-acetylcysteine is superior to that of alternative pharmacotherapies, such as antidepressants. Stimulus control procedures involve 3 steps: reducing environmental cues (eg, being in a car, working on the computer) and triggers (eg, mirrors, bright lighting, splintered cuticles), making picking and biting more difficult, and removing positive reinforcements.2 The pulling and biting behavior can be made more difficult by placing a barrier between the mouth and fingers (eg, gloves or bandages on the fingers, chewing gum or toothpicks in the mouth). The enjoyable aspects of picking and biting also can be attenuated by some strategies, such as putting bitter-tasting polish on the nails, which makes placing fingers in the mouth less pleasurable. HRT includes 3 components: awareness training (bringing the habit into consciousness), competing response training (engaging in an opposing behavior that makes it physically impossible to pick or bite until the urge subsides), and social support.2 In awareness training, the patient describes the act of biting and picking focusing on triggers (‘‘I get anxious when I have to study, and it helps me cope’’) and negative consequences (eg, infections, embarrassment). Patients are strongly encouraged to keep journals. Once patients are made aware, they are taught competing response behaviors (knitting, making a fist, or playing with the ever-so-popular fidget-spinner). Social support entails getting loved ones or an accountability partner (a friend who is also trying to break a bad habit) to gently advise the patient to stop picking and biting and offer encouragement when the patient engages in competing responses. Cognitive behavioral therapy helps patients understand that their beliefs about the behavior might be distorted or inaccurate. Patients who rationalize that the behavior is helpful might need to be challenged with the several hours of shame that J AM ACAD DERMATOL

follow it, counteracting the initial soothing effects. In aversion therapy, patients are simultaneously subjected to discomfort (distasteful lacquer applied to the nails) when engaging in onychophagia. Mild aversion improved nail length more than competing response,3 but competing response was more beneficial than mild aversion regarding self-monitoring.4 A nonremovable reminder of behavior modification, such as a wristband, was as effective as mild aversion.5 We strongly recommend weekly manicuring, which serves as a nonremovable reminder, acts as a barrier, and eliminates the trigger of splintered cuticles. For the toughest of patients, we recommend putting a daily bandage on the small finger for 2 weeks. Patients might become more motivated after seeing the evidence on just one unharmed nail. We also recommend that patients reward themselves (eg, go out for a celebration dinner) when they reach a milestone, such as no picking for 2 weeks. Michelle Magid, MD,a,b,c Constance Mennella, DO,d Helena Kuhn, MD,e Caroline StamuO’Brien, MD,f and George Kroumpouzos, MD, PhDe,g,h From the Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, Texasa; Department of Psychiatry, University of Texas Medical Branch at Galveston, Galveston, Texasb; Department of Psychiatry, Texas A&M Health Science Center, Round Rock, Texasc; Department of Pediatrics, Mount Sinai Hospital, New York, New Yorkd; Department of Dermatology, Alpert Medical School of Brown University, Providence, Rhode Islande; Department of Psychiatry, New York University Medical School, New York, New Yorkf; Department of Dermatology, Medical School of Jundia
ı, S~ ao Paulo, Brazilg; and GK Dermatology, PC, South Weymouth, Massachusettsh Funding sources: None. Conflicts of interest: None declared. Correspondence to: George Kroumpouzos, MD, PhD, 593 Eddy St, APC 10, Providence, RI 02903 E-mail: [email protected] REFERENCES 1. Lipner S, Scher R. Psychocutaneous disease: clinical perspectives. J Am Acad Dermatol. 2017;77:e141-e142. 2. Abramowitz JS, Jacoby RJ. Pickers, pokers, and pullers: obsessive-compulsive and related disorders in dermatology. In: Bewley A, Taylor RE, Reichenberg J, Magid M, eds. Practical Psychodermatology. Oxford, UK: Wiley-Blackwell; 2014:134-141.

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3. Allen KW. Chronic nailbiting: a controlled comparison of competing response and mild aversion treatments. Behav Res Ther. 1996;34:269-272. 4. Silber KP, Haynes CE. Treating nailbiting: a comparative analysis of mild aversion and competing response therapist. Behav Res Ther. 1992;30:15-22.

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5. Koritzky G, Yechiam E. On the value of nonremovable reminders for behavior modification: an application to nail-biting (onychophagia). Behav Modif. 2011;35: 511-530. http://dx.doi.org/10.1016/j.jaad.2017.06.154