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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_141_библиотеки_им_акад_М_И_Перельмана
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Onychotillomania
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https://t.me/med1917
46
I’m worried because my son, who has intellectual developmental disabilities and emotional instability, has torn
off all his nails (Fig.46.1).
A 35-year-old male, K, has been suffering from LennoxGastaut syndrome with epilepsy since childhood and is currently taking anticonvulsants. However, due to severe
intellectual disability and emotional instability, he always
tears or pulls his nails, causing damage. He came to the clinic
with his father for treatment (Fig.46.2).
Onychotillomania is a rare psychocutaneous disease that
causes damage to one’s own nails. Since it was rst reported
in 1934, it has been associated with obsessive-compulsive
disorder, depressive neurosis, hypochondria, and other psychological factors, but there have also been cases without a
clear psychiatric diagnosis, and it can also occur in patients
with intellectual disabilities. The condition to be differentiated, onychophagia, is difcult to dene as a psychiatric dis-
order because the incidence of biting nails among psychiatric
ward patients is similar to that of a control group of students
of the same age. However, onychotillomania patients differ
from onychophagia in that they use instruments such as scissors, bite the proximal part of the nail plate, and are indifferent to the consequences of the behavior. And unlike excessive
trimming of nails, this behavior clearly falls into the pathological category. Patients diagnosed with onychotillomania
may be accompanied by trichotillomania, onychophagia,
neurotic excoriation, etc. Clinically, due to the act of tearing
or pulling out the nail, erosion or scab around the nail can be
observed, abnormalities in the nail plate are found, and part
or all of the nail has been removed. The histological ndings
show hyperkeratosis of the nail matrix, and there may be proliferation of melanocytes in the nail matrix due to chronic
damage (Figs.46.3, 46.4, 46.5 and 46.6).
Fig. 46.1 Nail lesions of a patient with onychotillomania
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_46
Fig. 46.2 Nail lesions of onychotillomania
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Figs. 46.3 and 46.4 Onychotillomania
46 Onychotillomania
Fig. 46.5 Deformed nails due to nail biting, which needs to be differentiated from onychotillomania
The treatment of onychotillomania should focus on the
treatment of the underlying psychiatric condition. If the act
of damaging the nails is stopped by psychiatric supportive
therapy and medication, the lesion will improve. However,
Fig. 46.6 Onychoatrophy caused by onychotillomania
since his father does not want to receive psychiatric treatment, I am unable to provide any help other than treatment
for Mr. K’s damaged nails and wounds, which is very
unfortunate.
Onychophagia: Nail Biting
https://t.me/med1917
47
My child has had a habit of biting his ngernails since he
was 5years old, and now he even bites his toenails with
his teeth. Would it be okay to just leave it at that?
(Fig.47.1)
The mother of 11-year-old M, who is being treated for
chronic urticaria with antihistamines, brought her child today
and asked, “He has had a habit of biting his ngernails since
he was 5 years old, and he still can’t break the habit. Now he
even bites his toenails with his teeth. Is this okay?” Upon
closer inspection, the ends of the toenails are not smooth and
show signs of being bitten by teeth (Figs.47.2 and 47.3).
The skin can be an easy target for compulsive self-harm
behaviors to relieve psychological tension. Self-biting, a
behavioral disorder that invades the skin as an expression of
anger and dissatisfaction, appears in the form of nail biting,
skin biting on the arms, hands, ngers, and lip biting.
Onychophagia (nail biting) refers to the habitual biting of
nails, which can lead to deformities of the nail plate, such as
transverse grooves or washboard nails, or the trimming of
nails by biting. Among these, when the nail is cut using teeth,
no deformation occurs on the surface of the nail plate, so it is
difcult to diagnose without careful observation. Parents
often believe that their child’s nails are not growing, and the
color and thickness of the nails are normal, only the ends of
the nails are not smooth. If this continues for a long time, the
length of the nail plate will shorten, and the size will decrease.
It can occur at any age, but it usually occurs around the age
of 5, with similar rates in boys and girls, and the prevalence
is reported to be about 5%. Even normal children can bite
their nails due to stress, and it can be accompanied by enuresis or stuttering. Tension and rejection can also be the cause.
In psychoanalysis, it is seen as an oral xation habit, and it is
also explained as a narcissistic mechanism like nger sucking, and it is classied within the stereotypic movement disorder. Since nail biting is observed in a signicant number of
children, people tend to look down on it, thinking that it is
just a bad habit and that all they need to do is get rid of this
bad habit, so most children continue to bite their nails without the knowledge of people around them. However, without
proper treatment, nail biting can cause serious problems such
as inammation and deformation of the nails and damage to
the gums and teeth. Clinically, changes in the nails can
Fig. 47.1 An 11-year-old boy who trims his toenails with his teeth
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_47
Fig. 47.2 Toenails that are not smooth at the ends due to being trimmed
with teeth
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47 Onychophagia: Nail Biting
Fig. 47.3 The ends of the ngernails are not smooth due to being
trimmed with teeth
Fig. 47.4 Cases where all nails are deformed due to nail biting
reduce the size of the nail plate, partial loss of the nails,
transverse grooves, washboard nails, chronic paronychia,
secondary bacterial infections can be induced, and it can
even cause damage to the nail matrix, resulting in pterygium
unguis (Figs.47.4, 47.5, 47.6, 47.7, 47.8 and 47.9).
In cases where deformities such as washboard nails are
caused by nail biting, the most important thing in treatment
is to make patients with nail biting aware that this habit can
lead to permanent deformation of the nails. If the patient is
taught to stop biting his or her nails, normal nails can usually
be expected to grow. However, treatment is difcult if the
child denies nail biting. In cases associated with obsessivecompulsive disorder, there have been reports of good therapeutic effects with serotonin reuptake inhibitors, and in cases
where severe deformation is shown due to nail biting, psychiatric consultation is necessary and if problems are found,
Fig. 47.5 Deformation of the thumbnail including Beau’s lines due to
nail biting
Fig. 47.6 Nails deformed by nail biting
Fig. 47.7 Onychophagia observed in adults
47 Onychophagia: Nail Biting
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Fig. 47.8 Washboard nails due to nail biting
191
concurrent treatment is effective. It was explained to M that
if he does not break these habits, his nails may permanently
shorten or deform, and it was agreed to regularly observe the
condition of his nails to ensure he keeps his promise, which
made him very embarrassed.
Fig. 47.9 Brachyonychia caused by nail biting
Subungual Hematoma: Subungual
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Hemorrhage
48
My nger got stuck in the door gap and there’s a bruise
under my nail. It hurts so much (Fig.48.1).
Yesterday morning on my way to work, my nger got
stuck in the door gap. My nger is swollen and there’s blood
pooled under my nail. It hurts so much, says Mr. M in his
20s. I’ve experienced it too, and when blood pools under the
nail, it throbs and hurts unbearably.
The nail bed is a tissue with rich blood ow, and when
damaged, subungual hemorrhage easily occurs. Subungual
hematoma is caused by blood pooling under the nail plate
due to trauma to the nail plate, causing immediate bleeding
and pain. It immediately causes severe throbbing pain and
swelling in the nger and later causes cosmetic problems due
to discoloration of the nail area, and in cases where there is a
lot of blood, it can lead to separation and loss of the nail
plate. For treatment, it is rst necessary to conrm the presence of a fracture with an X-ray examination (Figs. 48.2,
48.3, 48.4 and 48.5).
The most traditional and effective treatment method to
drain the blood pooled under the nail, which causes unbearable pain due to acute trauma, is to heat the end of a paper
clip (or steel wire) with an alcohol lamp and pierce the nail
(Fig.48.6).
In addition, there are many treatment methods including
using sharp knife tips, dental burrs, hot needles, toothpicks,
23G, 21G, and 18G needles, using biopsy punches, using
insulin syringe needles, and using CO2 lasers. Among these,
when using a CO2 laser, the hematoma is removed by melting the nail in the center of the colored area. When the laser
is focused on the outside of the nail lunula with a super pulse
or ultra pulse CO2 laser without local anesthesia, blood is
discharged immediately. And the pain disappears. Using a
hand drill, dental burr, or sharp-ended scalpel can cause pain
due to the pressure applied to pierce the nails, and considering the patient’s fear, it is recommended to use a CO2 laser.
However, it must be considered whether there is a fracture or
whether bleeding continues due to laceration in the nail bed
that extends to the nail matrix. Mr. M said it was amazing
that the hematoma and pain disappeared with such a simple
method using a CO2 laser (Figs. 48.7–48.10).
Fig. 48.1 Subungual hematoma
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_48
Fig. 48.2 Subungual hemorrhage caused by trauma
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Fig. 48.3 A severe case of subungual hematoma in a 9-year-old boy
caused by his nger getting stuck in a door gap, accompanied by a
fracture
48 Subungual Hematoma: Subungual Hemorrhage
Fig. 48.6 The classic method of using a paper clip heated on an alcohol lamp for the treatment of subungual hematoma
Figs. 48.4 and 48.5 Treatment of subungual hematoma using a CO2 laser
48 Subungual Hematoma: Subungual Hemorrhage
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Figs. 48.7–48.10 CO2 laser treatment for subungual hematoma on the toenail
Onycholysis
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49
Half of our child’s ngernail has turned white. Did dad’s
toenail fungus spread? No.
The mother of an 11-year-old girl, M, said, “Two of our
child’s ngernails have turned white. My husband has toenail fungus, has it spread? What should we do if it’s contagious?” But after carefully examining the ngernails, I said,
“This is not the nail fungus. It didn’t spread from her dad!”
(Figs.49.1 and 49.2).
Onycholysis refers to a state where the nail plate is painlessly separated from the nail bed. One or more nails are
involved, and it usually progresses unevenly from the distal
or lateral side of the nail plate toward the proximal side. The
nail itself is smooth and hard and does not show an inammatory reaction. The separated part of the nail often appears
opaque or white, but it can be discolored by bacteria (commonly Pseudomonas) or yeast (commonly Candida). Color
changes can show green due to Pseudomonas because it is
pyocyanin, and yellow tones imply secondary Candida
infection, but it can also show a similar form in psoriasis or
tinea unguium. Onycholysis is commonly seen in women,
and it is thought to be an important factor next to trauma. It
is common in patients with hand dermatitis. Keratinization
of the distal nail bed, chronic exposure to irritants, untreated
dermatitis, and secondary infection by Candida albicans are
strong reasons why detached nails do not reattach. Systemic
causes include hyperthyroidism and hypothyroidism, pregnancy, iron-deciency anemia, porphyria, pellagra, syphilis,
Kawasaki disease, etc. Atopic dermatitis, eczema, lichen planus, congenital nail abnormalities, nail trauma including
improper nail care, and foreign body intrusion can also be
causes. It can also occur due to fungal infections, suppuration, and viral infections. In women, it is necessary to check
for vaginal candidiasis, as it can be a source of opportunistic
infections that cause or exacerbate onycholysis. Chemical
causes include solvents, nail polish, base coats, formalin
derivatives in nail hardeners, articial nails, and allergies or
irritant contact dermatitis caused by their use. Rarely, photoonycholysis can occur when exposed to sunlight during or
after treatment with tetracycline derivatives, psoralen, uoroquinolones, and chloramphenicol. Anticancer chemotherapy and systemic retinoids also cause onycholysis. In Korea,
there have been reports of subungual abscess and onycholysis caused by the administration of taxane. Although very
Figs. 49.1 and 49.2 Onycholysis observed in a child’s ngernails
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_49
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49 Onycholysis
rare, it can be a sign of metastasis or a known form of autosomal dominant inheritance.
The nail itself is smooth and hard and shows no signs of
inammation, and the nail plate is separated from the nail
bed, and the separated part of the nail is opaque or shows a
white hue, so it can be easily diagnosed. In ambiguous
cases, a fungal test may be needed to differentiate from onychomycosis (Figs.49.3, 49.4, 49.5, 49.6, 49.7, 49.8–49.10,
49.11, 49.12, 49.13, 49.14, 49.15, 49.16, 49.17, 49.18 and
49.19).
Figs. 49.3 and 49.4 Onycholysis observed in eight nails
Fig. 49.7 Progression of onycholysis
Figs. 49.5 and 49.6 Early stage of onycholysis
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