key: cord-1023991-qf1pdm8i authors: Baghchechi, Mohsen; Pelletier, Janice L.; Jacob, Sharon E. title: Art of Prevention: The importance of tackling the nail biting habit date: 2020-09-17 journal: Int J Womens Dermatol DOI: 10.1016/j.ijwd.2020.09.008 sha: 0eb69a0a696bcdfd9f5a66c31a04efd451c1b119 doc_id: 1023991 cord_uid: qf1pdm8i Onychophagia, commonly referred to as nailbiting is a chronic condition that is repetitive and compulsive in nature, and generally seen in both children and young adults. Multiple factors play a role in the development of nailbiting, ranging from genetic components, to underlying psychiatric conditions. Complications of chronic, compulsive nail-biting range from obvious distortion of the nail bed unit, to ungual and oral infection. Dental hygiene is, typically, less well-maintained in patients with nail-biting disorders: teeth may become chipped or notched, and gums many become inflamed. Treatment of nailbiting involves a multidisciplinary team that provides social, psychiatric, dermatologic, and dental care. Treatment ranges from psychotherapy modalities, to medication trials of selective serotonin reuptake inhibitors and N-acetylcysteine. Proper nail hygiene remains a mainstay in the prevention of the complications of chronic nail-biting. Additional supportive measures include the support of self-motivational novels and television episodes that help children learn coping mechanisms. Onychophagia, commonly referred to as nailbiting, is a chronic condition that is 50 repetitive and compulsive in nature. Though commonly seen in both children and young adults, 51 there is a paucity of related epidemiologic studies. A review of the literature demonstrates that 52 multiple stressors can cause an exacerbation of "impulsive" nail biting, ranging from school 53 stress to family dysfunction (Halteh et al., 2017) . This can be explained by underlying anxiety 54 creating a feed-forward impulsive behavior which helps soothe the patient. Other researchers 55 suggest nailbiting is a form of attention seeking in children and adolescents (Illingworth, 1964 Another therapeutic approach is done by utilizing cognitive behavioral therapy (CBT) to 179 address the intrusive behavior. CBT is based on both the behavior and cognitive model, and 180 mechanistically works to limit maladaptive coping behaviors (Rothbaum et al., 2000) . 181 Historically, a limited number of case reports describe the use of aversive hypnosis to effectively 182 reduce chronic nailbiting (Leshan, 1942 Token economy is used to encourage positive behaviors 185 through reinforcement with rewards This type of 188 therapy evaluates specific environments and situations that may be the stimulus for repetitive 189 behavior such as nailbiting. For example, a researcher may evaluate a patient in multiple 190 environments to determine frequency of nailbiting (e.g. conversation discussing nailbiting versus 191 conversation void of nailbiting). Dufrene et al. showed that functional analysis data may be used 192 to formulate a targeted treatment aimed at behavior reduction and eventual extinction HRT includes three components: awareness 197 training, competing response training (e.g. gum chewing rather than nail biting), and a social 198 support system Aversive therapy under the guidance of a professional may provide nailbiting relief as It is 204 important that this modality be correctly used, as shaming and punishment for nailbiting is 205 associated with adverse outcome and potentiates the compulsion and is not recommended as a 206 treatment service line Pharmacotherapy is a second line treatment for nailbiting in children and adolescents Under the basis that chronic nailbiting is within the 214 OCD umbrella, specifically body focused repetitive behavior, SSRIs are proven to attenuate 215 compulsions. Clinicians should be careful with prescribing other drugs within the SSRI family as 216 studies show this class of drug can exacerbate impulse related disorders The antioxidant and glutamate modulator N-acetylcysteine has shown positive 219 outcomes in the treatment of repetitive disorders including onychophagia Annual dentist 229 visits are also encouraged to evaluate for gingival and dental pathologies and initiate early 230 intervention. Dermatologists should remain involved in the care of patients suffering from 231 persistent peri-ungual infections and nail dystrophy Proper nail hygiene is essential and includes keeping the nails trimmed and filed Interestingly, allowing girls to have professionally manicured nails may keep the adolescent 239 engaged in not biting their nails secondary to positive cosmetic appeal Gum chewing may be an effective alternative to curb the compulsion in socially stressful 245 situations for an older child, when other coping mechanisms cannot be utilized. This results in 246 better oral hygiene and less irritating for the gingiva and teeth What to do when bad habits 252 take hold" by Dr. Dawn Huebner. This book creates a unique and fun self-exploration in 253 identifying bad habits such as nailbiting to bring self-awareness, followed by tips and tricks to 254 curb the habit. For children who prefer a more visual approach, an episode of the Bernstein Bears 255 creatively addresses nailbiting in a comfortable and enlightening episode Creating a sticker chart 260 for children and adding a sticker each day the child keeps nails free from biting damage keeps 261 children motivated, knowing that a prize is available after multiple 'good days Bringing awareness to the habit can help create self-awareness and search for socially 267 acceptable ways to cope with stress and anxiety. Cognitive therapy suggests that persons engage 268 in alternative behavior to distract from the intrusive impulsions, such as arts and crafts, sports, 269 and musical instruments in order to improve confidence and focus, and to reduce distress 270 Nailbiting can be a chronic and debilitating habit that may continue into adulthood. It can 278 be both a source and a transmitter of disease. While related to stress, this habit also can 279 contribute to severe psychosocial distress itself. Knowing the appropriate preventative steps and 280 treatment plans for children and adolescents can help prevent habit permanence. 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