Onychotillomania as manifestation for underlying depressive disorder

Sir,

Onychotillomania is characterized by the compulsive or irresistible urge in patients to pick at, pull off, or harmfully bite or chew their nails, not to be confused with onychophagia which is self-induced damage to nails caused by nail biting. In International Classification of Diseases-10 (ICD-10), onychotillomania may be classified among the other impulse control disorders not explained by any other mental disorder along with other impulse control disorders such as trichotillomania, seen in 1 in 200 individuals,[1] whereas the incidence of onychotillomania is thought to be much lower and widely underreported. It is not included as a separate diagnosis in Diagnostic and Statistical Manual-5 but can be classified as a body-focused repetitive behavior disorder under the category of other specified obsessive-compulsive and related disorder. Here, we report case of a 15-year-old girl who presented to dermatology outpatient unit with black discoloration and destruction of all the fingers nails of both hands and all the toe nails for the past 4 months along with bleeding and pain, which had started with the middle finger of the right hand. General examination and systemic examination were found to be uneventful. On dermatological examination, hemorrhagic red colored crusts over all fingertips with varied destruction of nail plates of hands and 4 toes of right foot were observed; remaining nail plates were thinned and irregular. Multiple fissures and cuts were present over fingertips. Oral mucosa had small, round to oval, well-defined ulcers with yellowish base and red colored areola present over the undersurface of lower lip and buccal mucosa. Her hemogram revealed white blood cell: 10,700/mm³, neutrophil: 76%, lymphocyte: 23%, eosinophil: 01%, hydroxide mount: No fungal element seen, and her antinuclear antibody: Negative at dilution 1:100. Her drug history, past medical and surgical history did not reveal any significant findings. A psychiatric evaluation was sought which revealed depressed mood, sleep and appetite disturbances, lack of interest, fatigability, and suicidal ideation for the past 1 month. The patient was diagnosed with severe depressive episode as per ICD-10 criteria. In detailed psychological evaluation on neurosis scale, the patient was under distress, on R. I.B.T. She had poor conventional thought, impulsivity, emotional dominance, and low capacity for logical thinking had conflict and poor experience type organization. T.A.T findings were consistent with an affective disorder with manifest neurotic tendencies. Since the first case of onychotillomania was first described in 1934,[2,3] our knowledge about this problem is still based only on a few case reports. Incidentally, these patients tend to first take a dermatological opinion for their problem. In our case, it was a big problem to convince even the family members, of the self-mutilating behavior of the patient, who both vehemently refused psychiatric opinion initially. The published case reports[3,4,5] of onychotillomania confirm that thorough examination including the mental state examination is essential for the comprehensive assessment of the patient's problems and allow recognizing underlying mental disorder, often misdiagnosed previously. Likewise, in patients with diagnosis of mental disorders comprehensive examination enables identification of not only serious medical conditions but also comorbid psychodermatological problems that may cause pain or discomfort.

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