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Habit Tic Deformity

 

We live in a hand-held world today, where we are always tapping away on our devices and our hands end up being front and center in everything we do. Thus, the appearance of our nails is a central part of our image and nail habits can be a major concern for many. The effective treatment of nail-related habits requires a combination of correct diagnosis and treatment. Both behavioral modification and the correct therapeutic approach are therefore essential. Such is the case with habit tic.

Habit tic deformity occurs when a person repetitively picks or pushes back her cuticle. An acquired condition that usually occurs in adulthood, habit tic is associated with a very distinct appearance, although, as with most conditions in medicine, variations are also often seen. Classically, the nail (or nails) has a longitudinal defect that is usually several millimeters in width and extends along the midline of the nail plate beginning at the cuticle and ending at the free edge. Along the longitudinal defect are a series of parallel, transverse depressions often in a “washboard” configuration. Sometimes the depressions are at an angle and appear to be more of a “fir tree” pattern. Other typical features include a macro-lunula — an enlarged half-moon area at the base of the nail. The cuticles are always compromised and often they are completely absent, with associated redness and swelling along the proximal nail fold (the skin behind the cuticle).

Habit tic is most often a result of onychotillomania, the compulsive and repetitive habit of picking at the nails specifically at the cuticle area. Patients may or may not be aware that they are picking. Most often, the index finger is used to pick or repetitively push back the cuticles of the thumbnail. There are exceptions and habit tic deformities can occur in other fingernails as well, however it isn’t normally seen on toenails as it is not typical for people to have access to their toenails throughout the day.

It’s important to note that any repetitive trauma to the cuticle can ultimately result in the abnormal outgrowth of the nail because the cuticle directly overlies the nail matrix and the nail matrix is the anatomical structure that becomes the actual nail plate. Therefore, overly aggressive cuticle removal or even pushing back of the cuticle can, when repetitive, impact and deform the cosmetic appearance of the nail. The cuticle is an amazing biological structure; it’s the nail’s natural protective seal, preventing moisture and infection from entering the nail unit. Once this barrier is compromised, the new nail will grow in a very abnormal environment and if the issue persists, the nail itself will begin to grow abnormally.

Approaches to Treatment

Effective treatment of habit tic requires an individualized approach. The first step is to determine whether the habit is a conscious behavior. Most people with habit tics are aware of their actions, but simply don’t know how to break the habit. As with any habit, you need to be motivated to stop the behavior. The next step is honing in on when the tic is most often occurring. It’s often during a lull in activity during the day, such as sitting in traffic, attending a meeting, sitting at the computer, or watching television. Keeping a diary for a few days to establish a personal pattern can be very helpful. Once you have a good sense of the times when they are tempted, you need a plan to divert the behavior.

Everyone’s method for diversion differs. Wearing a rubber band around the wrist and playing with the band during tempting picking times can be effective for many. Some use squeezy balls or cover their nails with Band-aids. Keeping a photo close by of someone who motivates you can also be very effective. These methods are all part of the behavioral modification aspect of conquering the habit, but treatment is also required.

In 2012, a case report was published in The Archives of Dermatology entitled “Inexpensive Solution for Habit Tic Deformity.” The article showed incredible treatment success by having the patient apply super glue (cyanoacrylate) to the cuticle twice weekly for three to six months. This method makes a lot of sense, as one of the biggest issues with habit tics is compromise to the cuticle.

By applying the glue, you are essentially recreating the cuticle artificially. The glue also serves as a reminder to not engage in the habit. At times, if there is also very significant swelling and bogginess (a spongy texture) at the proximal nail fold (skin behind the cuticle), a prescription anti-yeast cream and steroid or injection of a small amount of steroid into the nail fold will also be helpful. Many patients improve dramatically with a combination of behavioral modification and super glue alone.