Telemedicine Tool Developed for Nail Psoriasis, Concurrent Onychophagia and Onychotillomania

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The tool’s development for scoring severity among complex nail psoriasis cases and monitoring response to treatment may allow for improved outcomes among patients.

A new index for monitoring nail psoriasis impacts was developed known as Galeazzi-(G) N-NAIL, which correlates with the Nijmegen-Nail psoriasis Activity Index tooL (N-NAIL) and is efficient in monitoring treatment response and scoring severity among those with complex cases, according to new findings.1

This new research was led by Alessia Pacifico, of the Gallicano Dermatological Institute’s clinical dermatology department in Rome. Pacifico et al. noted that both onychophagy and onychotillomania are known to be somewhat common among those with nail psoriasis, adding that they are underdiagnosed perhaps due to their being a well-known trigger of nail psoriasis.2

“Actually, poor evidence is present for teledermatological assessment of patients with nail psoriasis, so we aimed to evaluate different teledermatological strategies to monitor and characterize nail psoriasis in difficult subsets, such as patients with concurrent onychophagy and/or onychotillomania,” Pacifico and colleagues wrote.

Background and Methods

The research team’s work was conducted from May 2020 - January 2021 out of multiple primary referral centers in Italy and involved subjects with psoriasis and nail psoriasis who were given systemic treatment. They focused on assessment of adults with onychophagy and onychotillomania, confirming such conditions through detailed phone interviews.

The team utilized a visual analogue scale (VAS) bother score to assess participants’ views of various nail psoriasis manifestations. They also implemented N-NAIL to evaluate nail psoriasis severity in these individuals and assessed the reliability of the tool by measuring intra- and interobserver agreement among dermatologists through in-picture, in-person, and in-video evaluations.

Their research also included follow-up assessments at specific intervals with the aim of tracking nail psoriasis severity changes over time. Various assessment methods were implemented depending on the preferences of subjects and hospital policies.

The research team’s new dedicated index, designed to monitor nail dimension changes (G N-NAIL), was also tested for accuracy.

The investigators looked into cutaneous severity by utilizing the Psoriasis Area Severity Index (PASI), with psoriatic arthritis being screened and diagnosed with the Psoriasis Epidemiology Screening Tool (PEST), the Classification Criteria for Psoriatic Arthritis (CASPAR), and the Disease Activity Index for Psoriatic Arthritis (DAPSA). The research team’s decision to use N-NAIL over other indices such as NAPSI was based upon the tool’s practicality in daily clinical use, accuracy, and general efficiency.


The study involved assessment of 382 subjects with nail psoriasis, and the investigators identified 5.24% who exhibited onychophagy and 4.45% who exhibited onychotillomania. They noted that onycholysis and nail crumbling were shown to be the most frequently reported clinical concerns, followed by subungual hyperkeratosis.

The N-NAIL score had been evaluated for its reliability, and the investigators found that there was a moderate level of agreement between observers.

Importantly, over the course of the 9-month follow-up period, the team noted there was a consistent correlation between the scores of the N-NAIL and GN-NAIL tools across all of their assessment time points. These included baseline as well as subsequent assessments performed at the 3, 6, and 9-month time points.

“Obviously, the onychophagy and onychotillomania prevalence needs to be further investigated in different age groups to better orient therapeutic efforts and multidisciplinary strategies,” they wrote. “Although onychophagy and onychotillomania are psychiatric disorders, their implications are multiple…so patients with onychophagy and onychotillomania should be strictly monitored with dedicated tools, such as GN-NAIL, and pictured every visit.”


  1. Pacifico, A., Iorizzo, M., Pasch, M. et al. Telemedicine in Nail Psoriasis: Validation of a New Tool to Monitor (In-Person, In-Picture, and In-Video) Nail Psoriasis Severity in Patients with Concurrent Onychophagia and Onychotillomania. Dermatol Ther (Heidelb) (2024).
  2. Cohen PR. Nail-associated body-focused repetitive behaviors: habit-tic nail deformity, onychophagia, and onychotillomania. Cureus. 2022;14(3):e22818.