Ragged Nails and Repetitive Picking: A Case of Onychotillomania

Abstract

Onychotillomania is an uncommon and often underrecognized self-induced nail disorder within the body-focused repetitive behaviour spectrum, caused by recurrent picking or manipulation of the nail unit and resulting in chronic traumatic nail dystrophy. We report a 25-year-old software engineer who presented with a one-year history of progressively shortened, ragged fingernails associated with marked social embarrassment. He described compulsive nail picking during periods of occupational stress, particularly around work deadlines, often without full awareness until bleeding occurred. Examination showed multiple uniformly shortened, jagged fingernails with irregular free margins, mild periungual erythema and maceration, and minor cuticular tears, without pitting, Beau’s lines, subungual debris, onycholysis, or secondary infection. Dermoscopy demonstrated splinter haemorrhages, irregular nail plate scaling, loss of proximal nail fold shine, and periungual telangiectasias, supporting chronic mechanical trauma rather than fungal or inflammatory nail disease. Potassium hydroxide mount and fungal culture were negative, and nail clipping histopathology showed parakeratosis without spongiosis or dermatophytes. Psychiatric evaluation based on DSM-5 criteria was consistent with a body-focused repetitive behaviour disorder, and the Hamilton Anxiety Rating Scale score was 18/56, indicating moderate anxiety. A diagnosis of onychotillomania was made. The patient was managed with habit reversal training, oral N-acetylcysteine 1200 mg daily, bitter nail lacquer, emollients, and psychiatric referral for cognitive behavioural therapy. At 8 weeks, approximately 60% nail regrowth with improved behavioural control was observed.