Limited treatment information on brittle nail syndrome on TikTok™ and only a minority of videos are posted by board‐certified dermatologists: A cross‐sectional study

To the Editor, Almost 60% of the world's population used an online digital platform as of January 2023.1 There has been an upward trend in the number of individuals using social media for online health information.2 TikTok is the world's fastest growing social media platform, reaching large audiences using algorithms based on user engagement.2 Brittle nail syndrome (BNS), defined as nail plate fragility resulting in soft nails that split, flake, or crumble, is a common nail condition affecting up to 20% of the population.3 In this study, we sought to characterize TikTok video creators and content on BNS. TikTok was queried on January 25, 2023, for the top 125 most viewed videos with the “brittle nails” search term. NonEnglish videos were excluded. Videos were categorized by creator and content type. Treatment posts included recommendations of specific nail products, medications/vitamins/supplements, nail regimens, and alternative remedies. Educational posts included videos explaining BNS etiology and pathology. Personal posts involved creators sharing BNS experiences. Treatment videos were evaluated for accuracy using consensus 2020 guidelines for optimal management published by a nail expert group.3 A total of 28 899 480 views and 1 925 915 likes were associated with the top 125 BNS videos. The top 3 creator types included patients (30.4%), health/wellness “gurus” (16%), and nail artists (15.2%). Only 11 (8.8%) videos were posted by boardcertified dermatologists (BCDs), with 10 BCDs practicing in the United States and 1 practicing in the Philippines (Table 1). The most common content category was treatment (49%), with 52/61 (85%) of videos mentioning at least one recommendation following BNS treatment guidelines,3 5 (8.2%) mentioning 2 recommendations, and 3 (4.9%) mentioning 3 recommendations, with no video addressing more than 3 options (Table 2). Only 18/61 (29.5%) videos mentioned nail strengtheners/hardeners/builders, and only 2 (3.2%) mentioned avoiding wet work. A total of 25/61 (40.9%) videos discussed nail moisturizers, 15/61 (24.6%) discussed treatment with biotin, and 11/61 (18%) discussed other supplements, such as calcium, keratin, collagen, and vitamins C, D, and B12. Only one video, which was posted by a BCD, discussed the Food and Drug Administration (FDA) warning on biotin. Overall, 48/125 (38.4%) of videos mentioned that BNS is secondary to other diseases, including hypothyroidism, low iron, and perimenopause/ menopause/low estrogen. Our study demonstrated that BCDs represented <10% of creator groups and that discussion of BNS treatment options was extremely limited. Therefore, viewers of TikTok BNS videos might come away with the incorrect impression that failing the recommended treatments means that they are out of options. Similarly, in another study characterizing 171 dermatologyrelated TikTok videos, only 25.8% were posted by BCDs and BCDposted educational videos had a 50.1% greater probability of following American Academy of Dermatology guidelines compared to videos posted by all other sources (p < 0.00001).4 Therefore, there is a need for a greater presence of BCDs both individually and communally on platforms such as TikTok to post accurate information


Limited treatment information on brittle nail syndrome on TikTok™ and only a minority of videos are posted by boardcertified dermatologists: A cross-sectional study
To the Editor, Almost 60% of the world's population used an online digital platform as of January 2023. 1 There has been an upward trend in the number of individuals using social media for online health information. 2kTok is the world's fastest growing social media platform, reaching large audiences using algorithms based on user engagement. 2 Brittle nail syndrome (BNS), defined as nail plate fragility resulting in soft nails that split, flake, or crumble, is a common nail condition affecting up to 20% of the population. 3In this study, we sought to characterize TikTok video creators and content on BNS.TikTok was queried on January 25, 2023, for the top 125 most viewed videos with the "brittle nails" search term.Non-English videos were excluded.Videos were categorized by creator and content type.Treatment posts included recommendations of specific nail products, medications/vitamins/supplements, nail regimens, and alternative remedies.Educational posts included videos explaining BNS etiology and pathology.Personal posts involved creators sharing BNS experiences.Treatment videos were evaluated for accuracy using consensus 2020 guidelines for optimal management published by a nail expert group. 3total of 28 899 480 views and 1 925 915 likes were associated with the top 125 BNS videos.The top 3 creator types included patients (30.4%), health/wellness "gurus" (16%), and nail artists (15.2%).
Only 11 (8.8%) videos were posted by board-certified dermatologists (BCDs), with 10 BCDs practicing in the United States and 1 practicing in the Philippines (Table 1).The most common content category was treatment (49%), with 52/61 (85%) of videos mentioning at least one recommendation following BNS treatment guidelines, 3 5 (8.2%) mentioning 2 recommendations, and 3 (4.9%)mentioning 3 recommendations, with no video addressing more than 3 options (Table 2).on social media, educate the public, and combat spread of false information.
Despite lack of evidence for biotin in treating BNS, especially in patients with normal biotin levels, 5 24.6% of videos mentioned biotin as a treatment option.The FDA issued two separate warnings of biotin supplementation significantly interfering with laboratory test results, in some cases leading to death. 6Since information on TikTok is unregulated, BCDs must take action to post accurate information on BNS.
The search was performed on a single date, and our search term may have missed relevant posts, limiting our analysis.Numbers were too small to perform meaningful statistical analysis.
TikTok creators have large impact and influence on their followers.Therefore, it is imperative that medical information being posted is accurate and evidence based.Encouraging BCDs and other dermatology organizations to increase their presence on social media platforms such as TikTok would likely improve dissemination of reliable medical information to larger audiences.

FU N D I N G I N FO R M ATI O N
There is no funding for this study.

CO N FLI C T O F I NTER E S T S TATEM ENT
Ms. Conway has no conflicts of interest.Dr. Lipner has served a consultant for Ortho-Dermatologics, Hoth Therapeutics, Moberg Pharmaceuticals, and BelleTorus Corporation.

I R B S TAT E M E N T
Not applicable.

D ECL A R ATI O N S
This work has not been previously presented and is not under consideration at any other journal.
Only 18/61 (29.5%) videos mentioned nail strengtheners/hardeners/builders, and only 2 (3.2%) mentioned avoiding wet work.A total of 25/61 (40.9%) videos discussed nail moisturizers, 15/61 (24.6%) discussed treatment with biotin, and 11/61 (18%) discussed other supplements, such as calcium, keratin, collagen, and vitamins C, D, and B12.Only one video, which was posted by a BCD, discussed the Food and Drug Administration (FDA) warning on biotin.Overall, 48/125 (38.4%) of videos mentioned that BNS is secondary to other diseases, including hypothyroidism, low iron, and perimenopause/ menopause/low estrogen.Our study demonstrated that BCDs represented <10% of creator groups and that discussion of BNS treatment options was extremely limited.Therefore, viewers of TikTok BNS videos might come away with the incorrect impression that failing the recommended treatments means that they are out of options.Similarly, in another study characterizing 171 dermatology-related TikTok videos, only 25.8% were posted by BCDs and BCD-posted educational videos had a 50.1% greater probability of following American Academy of Dermatology guidelines compared to videos posted by all other sources (p < 0.00001). 4Therefore, there is a need for a greater presence of BCDs both individually and communally on platforms such as TikTok to post accurate information This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2023 The Authors.Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.TA B L E 1 Source and content type of top 125 brittle nail videos on TikTok.

a 3 TA B L E 2
Guideline-based treatment recommendations included avoidance of traumas and allergens/ irritants, limiting contact with water/detergents and wearing gloves, regular use of nail moisturizers, and use of nail strengtheners/hardeners/builders.Treatment recommendation analysis by source and reliability based on nail expert published guidelines.a