Signs of Psychological Anxiety in Nails

Nail Biting and Picking: More Than Just Skin Deep

Onychophagia

Many patients have their own ways of dealing with stress: from twirling their hair to biting their nails. Onychophagia, or nail biting, is a common disorder with increased frequency from childhood to adolescence and decreased frequency in adulthood.¹ Those who tend to bite their nails in stressful situations have described the action as a “tension-reducer.”² Other studies have noted that nail biting is more commonly due to boredom or working through a difficult problem rather than anxiety itself.¹ Regardless of the cause, these habits themselves can affect quality of life as nail biters may feel embarrassed due to the disfiguring appearance of their nails.² Additionally, this habit may result in the child or young adult being stigmatized or teased by others and therefore affect the individual’s self-esteem.¹

Onychotillomania

While onychophagia involves trauma of the nail itself, onychotillomania involves picking the skin around the nail.³ For humans, nail biting and picking the skin around the nails can be a similar repetitive behavior caused by a stressful experience but also continue after the situation has passed.³

Nail and Skin Damage

Nail biting and picking can increase the risk of tissue damage to the nails as well as nail infections.¹ If untreated, the nail damage can lead to nail thickening, ridging, and discoloration.⁴ Nail biting can damage the mouth and gums leading to dental problems such as temporomandibular dysfunction and alveolar destruction as well as infections of the oral cavity due to transfer of fomites from the digits.⁵ It can even cause stomach inflammation.⁶

Treatment Approaches

Nail biting can be a challenging habit for patients to break and while it can be uncomfortable, talking with your patients about treatment options can help.⁷

Stress reducing habits

Some approaches include bringing more self-awareness to the habit, finding other ways to reduce stress, and cognitive behavioral therapies to reduce stress.⁸ Additionally, care teams strongly recommended weekly manicuring and taking care of your nails to help reduce the splintered cuticle triggers.⁸ Even with these approaches, onychophagia is a difficult disorder to treat.

Pharmacotherapy

Fluoxetine

There have been no double blind, randomized controlled studies evaluating a possible pharmacologic option for the treatment of nail biting, though fluoxetine is the treatment of choice for other similar behaviors such as skin picking and chewing of digits.¹ Nevertheless, fluoxetine has been associated with increased impulsivity which could worsen the condition, not to mention its side effect profile.¹

N-acetylcysteine

There have been reports of successful treatment with N-acetylcysteine 1200-2400 mg/day.⁸

Mechanical appliance

There has also been one report of successful treatment with one month of a permanent dental appliance preventing the chisel-shaped teeth from meeting in an edge-to-edge bite and thereby physically preventing nail biting.⁵

Positive reinforcement

Though a lot is uncertain regarding the treatment of onychophagia, what is known for certain is that punishment is not an effective treatment for onychophagia and it is important that those who suffer from this condition feel supported rather than shamed.¹

Practical Tips for People With Nail Biting Anxiety

1. Keeping the nails short with weekly manicuring. If there is nothing to bite, it won’t be as satisfying.
2. Use unpleasant-tasting nail polish. There are many available brands of nail polish that make poor-tasting nail polish for this very purpose.
3. Wear gloves or Band-Aids. Physically prevent the patient from being able to bite their nails.
4. Pay attention to triggers. Noticing when the patient bites their nails and why is an important first step to avoid that nail-biting drive.

Keep hands or mouth busy. Patients can try stress balls, clicking a pen, and chewing gum instead.