Have you seen people who are fond of biting their nails? Nail biting is quite common, especially if you are under a great deal of stress. However, some people tend to bite their nails out of a habit. Worst, they result in not only biting their nails but chewing them including the surrounding skin.

For people who have this habit, they are actually suffering from a condition called dermatophagia, which belongs to the obsessive-compulsive disorder. In layman’s term, those who have a morbid habit of biting their nails are called wolf biters.

These people bite their nails even if they are not in a stressful situation. They bite their nails and the skin surrounding it causing severe bleeding and damage. This simply goes to show that what seems to be a habit is actually a disorder.

From a medical standpoint, dermatophagia belongs to the body-focused repetitive behavior. Other habits that actually belong to this type of disorder are the habit of pulling the hair, picking the skin, tongue chewing, chronic biting of the lips, and hair eating. ^{(1, 2, 3, 4)}

Image 1: Nails are extremely short and the surrounding skin has reddish discoloration with dried blood stains all around – a classic manifestation of dermatophagia.
Picture Source: upload.wikimedia.org

Photo 2: The skin surrounding the nails are distorted secondary to nail biting and chewing of the skin.
Image Source: i.imgur.com

What is the cause?

Dermatophagia is an excessive compulsive disorder, a mental condition wherein a person has the habit of doing things repetitively to the point of causing more harm than good.

There is some research suggesting that dermatophagia has something to do with the genetic makeup of the person. Other possible causes include extreme stress, traumatic childhood, and just plainly out of boredom. ^{(3, 4)}

Who are at risk for dermatophagia?

According to statistics, dermatophagia is more common in women than men. Environment, exposure to stress, and temperament can all contribute to the onset of dermatophagia.

Clinical Manifestations

Picture 3: A severely distorted fingernails and skin caused by excessive biting of the nails.
Photo Source: img-s3.onedio.com

Dermatophagia symptoms are pronounced that you can easily identify someone who has it. Signs and symptoms include the following:

• Frequent biting of the nails and the surrounding skin.
• The skin surrounding the nails are red and sometimes bleed.
• You will notice discoloration, calluses, and scarring around the fingernails.
• The person is uneasy and uncomfortable when he/she can’t bite her nails. ^{(4, 5, 6)}

What are the possible complications?

Dermatophagia, although may sound like a simple condition can actually affect a person’s physical and mental health. Some of the possible complications include:

1. Risk for infection – An intact skin is the body’s first line of defense. Frequent biting of the nails and the skin surrounding it leads to open wound in which bacteria can enter through the broken skin. Signs of infection include pain, tenderness, swelling around the nails, fever with or without chills, and purulent discharge, especially when the infection is in the advanced stage.
2. Social withdrawal – There are instances when a person is actually ashamed of the nail-biting behavior, especially when other people start to notice it. Chances are they tend to isolate themselves from the public. Eventually, their self-esteem and self-confidence will be affected. There is also a possibility of depression. ^{(6, 7, 8)}

Diagnosis

Diagnosing dermatophagia is all about differentiating a simple habit from a disease condition. Is dermatophagia a mental disorder? The truth is that body-focused repetitive behavior like dermatophagia is included in the Diagnostic and Statistical Manual of Mental Disorder under the other forms of obsessive-compulsive disorder.

There should be a significant damage or distress to the patient before it can be classified as DSM-V. ^{(7, 9)}

Dermatophagia Treatment

There are various treatment modalities used for dermatophagia. They are divided into the following categories:

Therapy

• Behavior modification therapy – There are various ways psychologist used to discourage nail biting behavior such as polishing the nail with a foul-smelling substance. Some use artificial nails, something made of gel or acrylic which will discourage the patient from biting the nails.
• Cognitive behavioral therapy – The patient’s root cause of dermatophagia is addressed, especially if the behavior is brought by stress and other emotional triggers. The psychologist, patient, and immediate family work hand in hand to address emotional triggers. It may take some time but is actually effective, especially if the triggering factors are identified and addressed. ^{(1, 7, 9, 10)}

Dermatophagia medication

Aside from the behavior and cognitive approach, there are medications that can help address the nail-biting behavior. Depending on the assessment of the patient, the doctor might require the use of antidepressants.

However, antidepressants should be used carefully and should only be given under the supervision of a mental health professional. As you know, antidepressants have an addicting effect. It is prone to misuse and abuse.

Medications prescribed are selective serotonin reuptake inhibitors such as paroxetine, sertraline, escitalopram, and fluoxetine. A dermatophagia cream can be given to the patient too in order to improve the condition and integrity of the skin. There are also instances when an antibacterial cream is prescribed to treat infection particularly on the skin that surrounds the nails. If the skin surrounding the nails are open, it should be cleaned regularly and covered with a sterile bandage to prevent infection. ^{(3, 9, 10)}

Natural remedies for dermatophagia

The symptoms of dermatophagia can be gradually reduced with the help of these natural remedies. They are acupuncture, massage, engaging in relaxing activities that will help lessen stress such as exercise, joining sports, and even simple breathing exercises. Nail biting can also be reduced to a great extent if the patient chews gums.

If you or someone you know might have dermatophagia, then the best thing to do is to consult a mental health professional. Just because you are consulting a mental health professional does not necessarily mean that you are crazy. This notion is wrong. Seeing a mental health expert simply means that there is a certain aspect of your mental and psychological health that you want to address. ^{(3, 7, 10)}

References:

1. https://en.wikipedia.org/wiki/Dermatophagia
2. https://www.epainassist.com/mental-health/what-causes-dermatophagia-and-how-is-it-treated
3. https://www.healthline.com/health/dermatophagia
4. https://www.doctorshealthpress.com/brain-function-articles/dermatophagia/
5. https://ehealthwall.com/dermatophagia-treatment-pictures-causes-symptoms/
6. https://putthatcheeseburgerdown.com/2018/01/06/mental-health-5-signs-that-you-suffer-from-dermatophagia/
7. https://onedio.co/content/the-scary-disorder-that-makes-you-eat-yourself-dermatophagia-12663
8. https://www.bfrb.org/learn-about-bfrbs/treatment/self-help/170-living-with-dermatillomania-and-dermatophagia
9. http://www.mylifeinlimbo.com/self-care/dermatophagia-tips/
10. https://www.skinpick.com/node/3713

A total parenteral nutrition (TPN) is a way of delivering nutrition to the body through the veins. It literally bypasses the gastrointestinal tract. The dripping solution is introduced directly into the vein, which is beneficial to patients who cannot be fed by mouth. ^{(1, 2)}

Image 1: A solution used for total parenteral nutrition.
Picture Source: www.enasco.com

Picture 2: A female patient who has a total parenteral nutrition line.
Photo Source: 78.media.tumblr.com

Photo 3: A total parenteral nutrition can also be given to children.
Image Source: netdna-ssl.com

Total parenteral nutrition indications

It should be given to people who cannot get the nutrition needed by the body through eating such as in the case of:

• Intestinal obstruction
• The small intestine has problems absorbing nutrients properly
• Gastrointestinal fistula/abnormal connection
• The bowel needs to rest for a while such as in the case of pancreatitis, Crohn’s disease, and ulcerative colitis.
• Severe burns
• Severely malnourished person
• Multiple fractures
• Individuals who are to undergo major surgery, radiation treatment, and chemotherapy
• Acquired immune deficiency syndrome (AIDS)
• Sepsis (widespread infection) ^{(1, 2, 3, 4)}

Total parenteral nutrition procedure

Image 4: A cartographic image of the total parenteral nutrition site.
Picture Source: www.infusionsolutionsinc.com

Total parenteral nutrition is introduced to the body through the large central vein. A sterile catheter is inserted into the vein located in the chest under a local anesthesia. After a successful placement of the catheter, a chest x-ray is performed to see to it that the placement is correct. The procedure of inserting catheter for TPN is usually performed in the hospital setting. However, there are instances when the procedure is performed in the home setting but with the supervision of a private nurse or experienced caregiver. ^{(3, 4, 5)}

Total parenteral nutrition guidelines

The content of TPN is mixed on a day to day basis to make sure that everything is fresh and sterile. The content of the TPN solution is determined based on the patient’s age, height and weight, and medical condition. A TPN solution contains:

• Sugar (dextrose)
• Protein (amino acid)
• Fats (lipids)
• Electrolytes like sodium, potassium, magnesium, calcium, phosphate, zinc, manganese, copper, chromium, and chloride
• Vitamins
• Insulin ^{(5, 6)}

What to keep in mind?

An adult patient would need about two liters of TPN solution on a day to day basis. Although the exact amount varies depending on the patient’s overall health condition. While the patient is on TPN, his weight should be thoroughly monitored including health parameters like the urine output, blood count, and blood sugar level.

The condition of the liver and kidneys should be monitored too. Ideally, TPN should be given to the patient for a short period of time. Once the patient is allowed to eat through the mouth, the catheter should be removed right away. ^{(5, 6, 7)}

Total parenteral nutrition complications

1. Mechanical complications pertain to the manner the central venous catheter is inserted in the veins. If there is problem in the placement of the catheter, there is a possibility that the patient could suffer from pneumothorax, cardiac arrhythmia, and brachial plexus.
2. Venous thrombosis is one of the TPN complications that could lead to death. Signs and symptoms of venous thrombosis include neck vein distention, swelling of the face, as well as ipsilateral arm. The possibility of venous thrombosis is high in people with malignancy, dehydration, sepsis, and venous stasis. ^{(5, 7, 8)}
3. There is also a greater risk for infection. The harmful microorganisms can grow in areas where the catheter is inserted such as the catheter tip. It is important to strictly adhere to the safety measures and aseptic procedure so as to prevent infection.
4. Metabolic complications can arise too. It can arise in the beginning of the feeding or at the end of the feeling. Metabolic complications can be avoided by a strict monitoring and adjusting the intake based on the patient’s response to TPN. As with the late metabolic complications, they could be caused by pre-existing abnormalities and failure to monitor the feeding process. Hence, it is of utmost importance to thoroughly monitor the patient while on total parenteral nutrition to notice any abnormalities the soonest time possible.
5. There is also a risk for fluid and electrolyte imbalance. Managing the level of electrolyte is quite difficult, especially if the patient is in total parenteral nutrition. Most of the time, the level of electrolyte is outside the normal range and the TPN alone is not the one responsible for it. The primary reason is the patient’s underlying medical condition. To somehow keep the level of electrolyte within the normal range, you need to make an incremental dose adjustment while the root cause of electrolyte imbalance is addressed.
6. There is a possibility of refeeding syndrome, which is common in severely malnourished patients. These patients have a severely low level of minerals such as phosphate, magnesium, and potassium. In the case of refeeding syndrome, there is a possibility that various organs of the body will be affected, especially the heart. If not addressed properly, it could lead to paralysis, cardiac dysrhythmias, acute respiratory failure, liver dysfunction, nephropathy, and heart failure. ^{(5, 8, 9, 10)}

What is the difference between Enteral and Parenteral nutrition?

Many are confused between enteral and parenteral nutrition. They thought that the two are the same, but they are not. What is enteral nutrition? It is a feeding method that uses the gastrointestinal tract to deliver nutrients to the body. It can be in the form of liquid supplements or the usual oral diet. In other words, an enteral nutrition is a tube feeding.

On the other hand, parenteral nutrition pertains to the delivery of nutrients through the vein and is given to the patient who has a problem in their gastrointestinal systems such as short bowel syndrome, bowel obstruction, ulcerative colitis, and the likes. Both deliver nutrients to the body but the route is different. The solution is also different. The parenteral nutrition route is more complicated than the enteral nutrition. ^{(2, 5, 8)}

References:

1. https://en.wikipedia.org/wiki/Parenteral_nutrition
2. https://www.msdmanuals.com/professional/nutritional-disorders/nutritional-support/total-parenteral-nutrition-tpn
3. https://www.g-pact.org/gastroparesis/nutrition/intravenous-nutrition/tpn
4. http://www.nutritioncare.org/about_clinical_nutrition/what_is_parenteral_nutrition/
5. https://medlineplus.gov/ency/article/007239.htm
6. https://www.inmo.ie/article/printarticle/4377
7. https://healthosphere.com/total-parenteral-nutrition/
8. https://lifeinthefastlane.com/ccc/total-parenteral-nutrition-tpn/
9. https://www.healthline.com/health/parenteral-nutrition
10. https://www.oncologynurseadvisor.com/palliative-care/benefits-and-risks-of-parenteral-nutrition-in-patients-with-cancer/article/209090/

The elbow is one of the body parts that need special attention. Women, in particular, do everything to keep their elbows smooth and bump free. Unfortunately, some people notice bumps on their elbows along with other impurities.

In this article, we are going to discuss the different kinds of elbow bumps and the possible causes. ^{(1, 2)}

Image 1: Itchy small bumps on the elbows.
Picture Source: healthh.com

Picture 2: Itchy reddish bumps on the elbows of what seem to be filled with fluid.
Photo Source: treatmd.org

Bumps on elbows of viral origin

If you are infected with a virus, chances are you will have a fever and inflammatory responses, which are usually in the forms of rashes, bumps, and blisters. They can be found in different parts of the body including the elbows. Bumps on the elbows of viral original go away on their own in a few days. ^{(1, 2, 3)}

White bumps on the elbows

Had you noticed white bumps on your elbows? If yes, then there are reasons why such as shingles, a viral disease that belongs to the same strand that causes chickenpox. If the shingles subside, there are instances when a bit of the strain of virus remains in the body leading to non-itchy white bumps on the elbows and other parts of the body. ^{(3, 4)}

Rashes on the elbows

What causes a rash on elbows? There are many reasons why rashes could appear on your elbows and the common reasons are the following:

• Psoriasis – dry skin accumulates in different parts of the body including the elbows. Classic manifestations include bumps on the elbows and red scaly patches. If you have psoriasis, you have to do everything to keep your skin moisturized. Apply a moisturizer several times a day.
• Atopic dermatitis – it is a hereditary skin condition commonly seen in children. It is linked to a certain type of allergies such as food allergy, cosmetics, detergents, and the likes. ^{(3, 4, 5, 6)}

Bumps on the elbows (non-itchy)

Photo 3: Olecranon bursitis on the elbow.
Image Source: upload.wikimedia.org

Image 4: A Lyme disease on the patient’s elbow.
Picture Source: www.lymedisease.org

You could notice a bump on your elbow that is not itchy and you might be wondering what could be the possible cause. Depending on the characteristics of the bump, the following could be the culprit:

• Cyst – If you notice a sac-like growth on your elbow, then that might be a cyst. It could contain a gaseous substances, a liquid, or a semi-solid substance. The size varies too. It could be a tiny cyst to a large cyst. In most instances, the cyst is nothing to worry about but it has to be drained and surgically removed.
• Granuloma annulare/necrotic papulosis – If you notice a circular-shaped ring and a reddish non-itchy bump on your elbows, then that might be a granuloma annulare. It commonly affects children and young adults, although, the prevalence is higher in girls than boys. The exact cause is unknown and treatment is not really required as the bumps go away on its own for a few weeks to months.
• Lyme disease – It is caused by a tick bite. Once you are bitten by a tick, you will notice small red bumps after a few hours or day. As time passes by, the bump gets bigger and resembles a bull’s eye pattern. There is a possibility that the infection will spread to the surrounding areas, which is why it is important to take antibiotics to get rid of the infection the soonest time possible. ^{(4, 5, 6, 7, 8)}

Bumps on the elbows (itchy)

• Dermatitis herpetiformis – it is one of the common reasons for itchy bumps on the elbows. Typical characteristics include fluid-filled bumps and blisters. It has extremely itchy that it has to be treated with anti-pruritic and anti-inflammatory cream.
• Scabies – It is a severely itchy skin condition caused by tiny mites. It burrows itself in your skin and the next thing you notice, you have rashes on your skin. You need to be extremely careful when dealing with people with scabies as it is a highly contagious skin condition.
• Allergic reaction – Itchy bumps on the elbows and other parts of the body could be an indication that you are experiencing an allergic reaction. It could be triggered by exposure to poison ivy, poison sumac, or oak plant. The severity of the bumps and itching vary depending on the level of exposure to the plant. It is treated with anti-itch medication and anti-histamine.
• Olecranon bursitis/Popeye elbow – It is the inflammation of the tiny fluid sac at the back of the elbow. It is caused by a sudden blow to the elbow such as in the case of injury. It can be mildly itchy, especially when infection takes place.
• Boils – A deep skin infection found on a certain spot of the body, which causes pain and mild itching. It is also unsightly and usually cause by bacteria. It should go away in just a few days. However, if the boil grows out of control, then you need to see your doctor.
• Insect bites – A bite of an insect such as mosquitoes causes bump on the skin, especially if you have a sensitive skin. Insect bites usually go away on its own but if the bite has been around for several days and does not seem to improve, then you need to consult your doctor. ^{(7, 8, 9, 10)}

Getting rid of bumps on the elbows

To get rid of the bumps on the elbows, the root cause should be determined first. If it is just dryness of the skin, then the best remedy is to keep the skin moisturized. Choose an organic-based moisturizer, especially if you have sensitive skin.

If it is caused by a virus, then there is nothing you can do about it but to wait for the virus to take its course. Just make sure you keep your body healthy so that it will take its natural course of getting rid of the virus. If it is caused by bacteria, then it has to be treated with antibiotics. ^{(2, 4, 5)}

References:

1. https://healthh.com/bumps-on-elbows/
2. https://www.wowremedies.com/bumps-on-elbows/
3. http://www.healtreatcure.org/bumps/bumps-on-elbows-small-raised-white-itchy-get-rid-fast/
4. https://www.hopkinsmedicine.org/healthlibrary/conditions/dermatology/dermatitis_herpetiformis_85,P00276
5. https://www.medhelp.org/posts/Dermatology/Tiny-bumps-on-elbow/show/1368299
6. https://www.healthyandnaturalworld.com/bumps-on-elbows/
7. https://www.healthline.com/health/dermatitis-herpetiformis
8. https://www.livestrong.com/article/303871-small-red-bumps-on-my-elbows/
9. https://iytmed.com/small-raised-bumps-elbows/
10. https://www.dailyhealthcures.com/skin-care/bumps-on-elbows-causes-treatment/