Onychophagia and onychotillomania can be effectively managed

To the Editor: We greatly appreciate the commentary by Lipner and Scher.1 We agree that our patients would benefit from prompt treatment to reduce shame and prevent irreversible nail damage. Herein, we present our clinical pearls using pharmacotherapy, stimulus control, habit-reversal training (HRT), and cognitive behavioral and aversion therapy. We often combine psychotherapies such as HRT and stimulus control. Six or more sessions are typically required. We have treated several cases of onychophagia and onychotillomania with N-acetylcysteine 1200-2400 mg/day.