Images in Clinical Rheumatology
Arthritis and Onychophagia: A Confounding Factor
Artritis y onicofagia: un factor de confusión
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Even with nail psoriasis being one of the most common onychodystrophies, it is important to recognize other common causes, such as nail biting, self-induced or traumatic causes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 48-year-old woman, smoker of 20 packs/year, with a family history of psoriasis (mother and brother). She had carpal arthritis which had lasted for 9 months, with no history of inflammatory back pain, along with major onychodystrophy of the hands and a normal skin examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Analytical studies were normal or negative, including acute phase reactants, rheumatoid factor, anti-CCP and antinuclear antibodies and HLAB27. Radiographs of hands and pelvis showed no abnormalities. Treatment was started with methotrexate and a dermatologist was consulted for suspected psoriasis with nail involvement in psoriatic arthropathy. The diagnosis was “traumatic dystrophy due to onychophagia”. The patient stopped biting her nail for 6 months (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The response to methotrexate has been good and she has not presented arthritis. After 4 years of follow-up, the case remains an undifferentiated arthritis, with negative CASPAR criteria for psoriatic arthropathy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">In all, 12% of patients with psoriasis have nail involvement, although the reported prevalence varies, being greater if there is joint involvement.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The manifestations of nail psoriasis are multiple.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most common form is subungual hyperkeratosis, and nail pitting is the characteristic sign, although not pathognomonic, but oil spots under the nail bed can be considered very specific.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It may be clinically indistinguishable from onychomycosis and differential diagnosis must also be made with other processes, including self-induced nail dystrophy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Onychophagia can be explained as a compulsive habit that causes the destruction of the nails. It is a common behavior among children and young adults, although underestimated, which has received little attention in the psychiatric and dermatologic literature, but can be related to obsessive-compulsive disorders.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Complications include superinfection, paronychia and dental problems, and phalanx osteomyelitis may occur exceptionally.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Most patients admit onychophagia, so in nail deformities it should be one of the first direct questions we ask to exclude the diagnosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our patient, because of the arthropathy, it was very important to diagnose the cause of onychopathy. If the source had been psoriasis, she would have been diagnosed with psoriatic arthropathy based on the CASPAR<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> criteria. However, we showed that with willpower she could stop nail-biting for 6 months. This confirms once again the importance of the history and multidisciplinary collaboration.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Responsibilities</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of people and animals</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments have been performed on humans or animals.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Data confidentiality</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace regarding the publication of data from patients and that all patients included in the study have received sufficient information and have given their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have obtained informed consent from patients and/or subjects referred to in the article. This document is in the possession of the corresponding author.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Case" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pantoja Zarza L, Díez Morrondo C, Manjón Haces JA. Artritis y onicofagia: un factor de confusión. Reumatol Clin. 2014;10:260–261.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 871 "Tamanyo" => 259947 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nail disorders by onychophagia: absence of the distal end of the nail, subungual ecchymosis, callus type mechanical injury, deformity of the paronychium and characteristic grooves in the nail, indicative of chronic trauma of the nail bed.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1200 "Ancho" => 790 "Tamanyo" => 205978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fingernails with no alterations after 6 months.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Color \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Onycholysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Punctuate depressions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Transverse grooves \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fungal infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Often yellow or brown: part of the nail or the entire nail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal or yellow or brown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presents and fine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rare \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic paronychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Black or brown discoloration of the edge of the nail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usually absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Uncommon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequently \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Onychophagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal with subungual hemorrhages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">On the tip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Missing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Present \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab520494.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis Between the 4 most Common Diseases of the Nails.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 5 | 14 |
| 2024 October | 96 | 54 | 150 |
| 2024 September | 117 | 44 | 161 |
| 2024 August | 95 | 67 | 162 |
| 2024 July | 132 | 61 | 193 |
| 2024 June | 114 | 56 | 170 |
| 2024 May | 104 | 55 | 159 |
| 2024 April | 118 | 36 | 154 |
| 2024 March | 93 | 54 | 147 |
| 2024 February | 82 | 48 | 130 |
| 2024 January | 72 | 54 | 126 |
| 2023 December | 65 | 46 | 111 |
| 2023 November | 65 | 52 | 117 |
| 2023 October | 81 | 62 | 143 |
| 2023 September | 52 | 54 | 106 |
| 2023 August | 81 | 38 | 119 |
| 2023 July | 66 | 48 | 114 |
| 2023 June | 53 | 42 | 95 |
| 2023 May | 75 | 50 | 125 |
| 2023 April | 53 | 19 | 72 |
| 2023 March | 82 | 42 | 124 |
| 2023 February | 74 | 41 | 115 |
| 2023 January | 59 | 27 | 86 |
| 2022 December | 78 | 52 | 130 |
| 2022 November | 76 | 39 | 115 |
| 2022 October | 72 | 35 | 107 |
| 2022 September | 81 | 33 | 114 |
| 2022 August | 67 | 61 | 128 |
| 2022 July | 65 | 62 | 127 |
| 2022 June | 69 | 51 | 120 |
| 2022 May | 58 | 72 | 130 |
| 2022 April | 82 | 58 | 140 |
| 2022 March | 124 | 53 | 177 |
| 2022 February | 93 | 34 | 127 |
| 2022 January | 67 | 39 | 106 |
| 2021 December | 50 | 43 | 93 |
| 2021 November | 56 | 54 | 110 |
| 2021 October | 127 | 50 | 177 |
| 2021 September | 47 | 32 | 79 |
| 2021 August | 52 | 44 | 96 |
| 2021 July | 31 | 29 | 60 |
| 2021 June | 54 | 46 | 100 |
| 2021 May | 70 | 39 | 109 |
| 2021 April | 158 | 92 | 250 |
| 2021 March | 66 | 27 | 93 |
| 2021 February | 62 | 44 | 106 |
| 2021 January | 32 | 19 | 51 |
| 2020 December | 44 | 25 | 69 |
| 2020 November | 36 | 21 | 57 |
| 2020 October | 31 | 10 | 41 |
| 2020 September | 32 | 27 | 59 |
| 2020 August | 35 | 20 | 55 |
| 2020 July | 17 | 18 | 35 |
| 2020 June | 34 | 14 | 48 |
| 2020 May | 38 | 16 | 54 |
| 2020 April | 24 | 11 | 35 |
| 2020 March | 13 | 4 | 17 |
| 2020 January | 1 | 0 | 1 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 8 | 0 | 8 |
| 2018 December | 2 | 0 | 2 |
| 2018 May | 8 | 0 | 8 |
| 2018 April | 90 | 7 | 97 |
| 2018 March | 109 | 21 | 130 |
| 2018 February | 92 | 6 | 98 |
| 2018 January | 100 | 8 | 108 |
| 2017 December | 45 | 7 | 52 |
| 2017 November | 35 | 8 | 43 |
| 2017 October | 35 | 8 | 43 |
| 2017 September | 36 | 12 | 48 |
| 2017 August | 45 | 31 | 76 |
| 2017 July | 28 | 30 | 58 |
| 2017 June | 65 | 6 | 71 |
| 2017 May | 54 | 9 | 63 |
| 2017 April | 43 | 8 | 51 |
| 2017 March | 34 | 18 | 52 |
| 2017 February | 22 | 16 | 38 |
| 2017 January | 33 | 9 | 42 |
| 2016 December | 68 | 17 | 85 |
| 2016 November | 57 | 9 | 66 |
| 2016 October | 76 | 11 | 87 |
| 2016 September | 87 | 11 | 98 |
| 2016 August | 63 | 9 | 72 |
| 2016 July | 35 | 10 | 45 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 40 | 8 | 48 |
| 2015 June | 32 | 8 | 40 |
| 2015 May | 47 | 8 | 55 |
| 2015 April | 32 | 7 | 39 |
| 2015 March | 29 | 10 | 39 |
| 2015 February | 44 | 3 | 47 |
| 2015 January | 72 | 11 | 83 |
| 2014 December | 40 | 8 | 48 |
| 2014 November | 35 | 13 | 48 |
| 2014 October | 40 | 5 | 45 |
| 2014 September | 38 | 13 | 51 |
| 2014 August | 54 | 21 | 75 |
| 2014 July | 45 | 25 | 70 |
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