Normal Capillaroscopic Pattern Research Articles

Common mistakes in capillaroscopy

Nail fold capillaroscopy (NFC) is a non-invasive examination and the "gold standard" in rheumatology practice to evaluate the microcirculation and distinguish primary from secondary Raynaud's phenomenon (RP). Alternatives to videocapillaroscopy are USB microscopy, dermatoscopy and ophthalmoscopy. Before the capillaroscopy examination, a detailed general history (including concomitant diseases) and occupational history (including a history of recent trauma to the fingers or onychophagia), a history regarding the patient's hobbies, practicing sports and physical activity, history of taking medications (beta-blockers, vasodilators, anticoagulants, antihypertensives), as well as the use of other vasoactive substances (tobacco, caffeine, cannabis, cocaine, amphetamines) should be taken. A detailed history regarding discoloration of the fingers is necessary to confirm the diagnosis of Raynaud's phenomenon (RP). Capillaroscopic examination should be carried out under certain conditions (not during an attack of RP, after acclimatization, in a certain position of the patient, without consumption of coffee and smoking before the examination, without manicure procedures in the last 15-30 days, examination of all 8 fingers, excluding those with recent trauma and/or infection). Correctly following all these steps will avoid technical errors that can change the interpretation of the result. It is necessary for the examiner to have a good knowledge of the normal capillaroscopic pattern, the variations of the norm in adults, the differences that might be found between children and adults, as well as the different pathological findings and specific patterns ("scleroderma" and "scleroderma-like" type) in diseases occurring with secondary RP. While in rheumatology practice there are defined criteria for "scleroderma" and "scleroderma-like" capillaroscopic finding, the changes in some paraneoplastic, socially significant (AH and DM), occupational (VD) and infectious diseases (Covid-19) occurring with microangiopathy, which can lead to misinterpretation of the finding. The “scleroderma-like” pattern also differs in different rheumatic diseases and the findings can also be misleading. The results of the study must be carefully interpreted with a view to the correct assessment of the patients' condition.

Characterization of patients with idiopathic interstitial pulmonary disease and capillary and laboratory findings in two health institutions in Medellín, Colombia: A descriptive study

IntroductionInterstitial lung disease (ILD) usually has a poor therapeutic response and prognosis. One of the methods that could help in the diagnosis and optimize the management of these patients is capillaroscopy. The study aimed to determine the clinical and capillaroscopic characteristics of patients with ILD and the frequency of findings suggestive of autoimmune disease. Materials and methodsA descriptive observational study that evaluated patients with ILD treated between 2010 and 2019 without a previous diagnosis of autoimmune disease. An interview, capillaroscopy, and laboratory tests were performed. Results28 patients were evaluated, 16 (57.1%) were women and 17 (60.7%) had hypertension. Three patients (10.7%) reported morning stiffness for more than 60 minutes and there was one unexplained digital edema. There were no telangiectasias, Raynaud’s phenomenon, mechanic’s hands, sclerodactyly or Gottron’s sign, or ANAS titres greater than 1:80. The rest of the laboratory tests were negative in 100% of the patients. In the capillaroscopies, 13 (46.4%) patients had a normal capillaroscopic pattern, and 15 (53.6%) had capillaroscopic abnormalities of undetermined significance. There were none with a pattern of systemic sclerosis or similar. ConclusionsNo laboratory or capillaroscopy findings were found that suggested interstitial disease with autoimmune features, possibly due to the low prevalence of the disease, its high mortality, and underdiagnosis. These findings reinforce the concept of capillaroscopic normality in patients with non-autoimmune ILD and call for an active search for ILD with autoimmune features for prognostic purposes.

Capillaroscopic findings in undifferentiated connective tissue disease with Raynaud’s phenomenon

Background: Undifferentiated connective tissue disease (UCTD) is characterized with presence of clinical signs and immunological findings suggestive of connective autoimmune disease, but the criteria for a definite rheumatic disease are not fulfilled. Raynaud’s phenomenon (RP) could be found in approximately 50% of cases with UCTD and about half of patients with UCTD and RP exhibit “scleroderma-like” pattern.
 The aim of the study: To assess the characteristics of capillaroscopic changes in early UCTD.
 Patients and methods: Inclusion criterion for the study was newly diagnosed by rheumatologist, early UCTD in patients with RP. 26 patients were included in the study – 24 females and 2 males, mean age 38±14 years (range 19 – 66 years). Capillaroscopic examination was performed in all patients using USB microscope Dino-Lite. Follow-up was perfomed for a period between 1 and 3.5 years.
 Results and discussion: At the time of the initial diagnosis, “scleroderma-like” pattern, “early” phase (giant capillaries, presence of hemorrhages in some cases, preserved distribution, normal capillary density) was found in 17 patients (65%). More advanced capillaroscopic changes including devascularization and derangement were not observed. In 4 patients nonspecific capillaroscopic findings were present (dilated capillaries, hemorrhages, increased tortuousity, elongated capillaries,) and in 5 cases – normal capillaroscopic picture was found. During the follow-up in one patient the diagnosis was revised to systemic lupus erythematous due to newly appeared clinical, laboratory and immunological findings. The normal capillaroscopic pattern was changed to nonspecific findings in this case. Two patients fulfilled the criteria for prescleroderma during the follow-up without skin and visceral involvement. In the rest patients clinical diagnosis and capillaroscopic findings remained unchanged.
 Conclusion: In conclusion, “scleroderma” type microangiopathy, “early” phase is a common finding in UCTD with RP, while more advanced microvascular pathology is not usually observed. Stable capillaroscopic pattern during the follow-up correlates with the stable clinical course. Capillaroscopy is a key technique for assessment of RP patients in rheumatology and for early diagnosis of UCTD with peripheral vascular syndrome.

Caracterización de pacientes con enfermedad pulmonar intersticial idiopática y hallazgos capilaroscópicos y de laboratorio en dos instituciones de salud en Medellín, Colombia: estudio descriptivo

IntroductionInterstitial lung disease (ILD) usually has a poor therapeutic response and prognosis. One of the methods that could help in the diagnosis and optimize the management of these patients is capillaroscopy. The study aimed to determine the clinical and capillaroscopic characteristics of patients with ILD and the frequency of findings suggestive of autoimmune disease. MethodsA descriptive observational study that evaluated patients with ILD treated between 2010 and 2019 without a previous diagnosis of autoimmune disease. An interview, capillaroscopy, and a laboratory tests were performed. Results28 patients were evaluated, 16 (57.1%) were women and 17 (60.7%) had hypertension. Three patients (10.7%) reported morning stiffness for more than 60minutes and there was one unexplained digital oedema. There were no telangiectasias, Raynaud's phenomenon, mechanic's hands, sclerodactyly or Gottron's sign, or ANAs titres greater than 1:80. The rest of the laboratory tests were negative in 100% of the patients. In the capillaroscopies, 13 (46.4%) patients had a normal capillaroscopic pattern and 15 (53.6%) had capillaroscopic abnormalities of undetermined significance. There were none with a pattern of systemic sclerosis or similar. ConclusionsNo laboratory or capillaroscopy findings were found that suggested interstitial disease with autoimmune features, possibly due to the low prevalence of the disease, its high mortality, and underdiagnosis. These findings reinforce the concept of capillaroscopic normality in patients with non-autoimmune ILD and call for an active search for ILD with autoimmune features for prognostic purposes.

Capillaroscopy: A Valuable Diagnostic Tool

Capillaroscopy produces in vivo images of skin microcirculation. It is a simple, noninvasive tool for analyzing microvascular abnormalities and, as such, can be used in both adults and children. Capillaroscopy has proven to be useful in many diseases, but it is of particular value in Raynaud phenomenon and other autoimmune diseases.The test is used to analyze capillaroscopic patterns in the nailfold bed of the second to fifth fingers of each hand. A normal capillaroscopic pattern is characterized by the presence of 7 to 11 capillaries in a hairpin shape. Pathologic patterns are characterized by morphologic and structural alterations, such as ectasias, giant capillaries, pathologic hemorrhages, avascular areas, and neoangiogenesis.In this article, we review the fundamentals of capillaroscopy, with an emphasis on the technique and its indications, diagnostic value, and use as a prognostic tool for rheumatologic disorders.

Particularities of nailfold capillaroscopy in children – literature review

Nailfold capillaroscopy is a simple, non-invasive and low-cost method, that is extremely important in the assessment of adults and children with definite or suspected connective tissue diseases. Peripheral microvascular changes found in nailfold capillaroscopy examination can provide useful information in differential diagnosis and therapy monitoring in majority of connective tissue diseases. Although in adult rheumatology this method has had an incredibly growing interest in the last decades, studies in paediatric population are fewer and generally, the capillaroscopic data used in children are extrapolated from adults. The normal capillaroscopic pattern in the paediatric population has some differences which must be known when performing nailfold capillaroscopy in children.

Capilaroscopia: una herramienta diagnóstica valiosa

Capillaroscopy produces in vivo images of skin microcirculation. It is a simple, noninvasive tool for analyzing microvascular abnormalities and, as such, can be used in both adults and children. Capillaroscopy has proven useful in many diseases, but it is of particular value in Raynaud phenomenon and other autoimmune diseases.The test is used to analyze capillaroscopic patterns in the nailfold bed of the second to fifth fingers of each hand. A normal capillaroscopic pattern is characterized by the presence of 7 to 11 capillaries in a hairpin shape. Pathologic patterns are characterized by morphologic and structural alterations, such as ectasias, giant capillaries, pathologic hemorrhages, avascular areas, and neoangiogenesis.In this article, we review the fundamentals of capillaroscopy, with an emphasis on the technique and its indications, diagnostic value, and use as a prognostic tool for rheumatologic disorders.

La capillaroscopie péri-unguéale en dermatologie

Nail-fold capillaroscopy is a non-invasive tool to study the microcirculation and is increasingly being used in dermatology, angiology and rheumatology. More recently, the use of video-capillaroscopy has allowed computer storage of capillaroscopic images (video-capillaroscopy), enabling evaluation of changes in capillaroscopic abnormalities during the follow-up of patients with systemic sclerosis or mixed connective tissue disease. Qualitative and quantitative assessment of the nail-fold dermal capillaries and of their organization can readily distinguish between a normal capillaroscopic pattern in primary Raynaud phenomenon and a specific sclerodermic pattern in secondary Raynaud phenomenon carrying a very high risk of systemic sclerosis. Apart from its important role as a diagnostic tool for distinguishing between primary and secondary Raynaud phenomenon, capillaroscopy is now used to predict the risk of development of digital ulcers and of future visceral complications in patients with systemic sclerosis. Moreover, nail-fold capillaroscopy is essential for differential diagnosis between connective tissue diseases, for the etiologic diagnosis of digital necrosis and diffuse interstitial lung disease, and in sclerodermiform syndromes.

SP0171 How to Differentiate Normal from Abnormal Capillaroscopic Patterns and Its Role in Distinguishing between Primary and Secondary Rp

Medical doctors frequently get patients with Raynaud's phenomenon (RP), a frequent symptom in the general population, referred. The importance of distinguishing normal capillaroscopic findings from (pathognomonic) abnormal (pathological) findings, lies...

SAT0187 Capillaroscopy: A Useful Tool for Identifying Primary Raynaud

BackgroundIdentifying individuals with primary Raynaud who are likely to develop scleroderma or other connective tissue diseases is very important for early control and therapeutic management of the disease and has...

SP0113 How to Differentiate Normal from Abnormal Capillaroscopic Patterns and Its Role in Distinguishing between Primary and Secondary Rp

Medical doctors frequently get patients with Raynaud's phenomenon (RP), a frequent symptom in the general population, referred. The importance of distinguishing normal capillaroscopic findings from (pathognomonic) abnormal (pathological) findings, lies...

AB1017 What Are the Distinct Capillaroscopic Features in Connective Tissue Disease as Compared with Diseases of Social Importance – Arterial Hypertension and Diabetes Mellitus?

BackgroundThe diseases of social importance such as arterial hypertension (AH) and diabetes mellitus (DM) are frequent concomitant pathology in patients with rheumatic diseases. At present, the capillaroscopic findings in these...

FRI0474 Association of serum vascular endothelial growth factor and angiopoietin-2 levels with clinical manifestations and nailfold capillaroscopic changes in patients with raynaud’s phenomenon

BackgroundRaynaud’s phenomenon (RP) is an exaggerated vasospastic response to cold and emotion, which can be primary (idiopathic) or secondary to a number of different conditions, including rheumatological diseases. Functional and/or...

SP0043 How to Distinguish Normal from Pathological Capillaroscopic Patterns

The importance of distinguishing normal capillaroscopy findings form (pathognomonic) abnormal (pathological) findings, lies in the fact that this distinction allows the differentiation between a primary Raynaud’s phenomenon characterized by normal...

Clinical and Capillaroscopic Modifications of the Psoriatic Plaque during Therapy: Observations with Oral Acitretin

Psoriasis is considered to be an inflammatory autoimmune disease, where angiogenesis plays an undefined pathogenetic role. The well-known changes of the superficial microvasculature in the psoriatic plaque can be easily assessed in vivo by videocapillaroscopy. In the last years, several studies reported the clinical and capillaroscopic response of the psoriatic plaque during different topical and systemic treatments. In the present work we evaluated the effects of acitretin (0.8 mg/kg/day) on videocapillaroscopic alterations and the clinical response in 11 patients affected by plaque psoriasis at the baseline (T0) and after 4 (T1), 8 (T2), and 12 (T3) weeks. A clinical improvement during the treatment with a complete clinical healing of the plaque in 7 of the 11 patients was observed. The typical “basket-weave” capillaries of the psoriatic lesions showed a reduction of 65.4% in diameter at the end of the study; only 3 patients returned to a normal capillaroscopic pattern. As observed during previous our studies, we found a discrepancy between clinical and capillaroscopic results, with a far greater improvement in the first than in the second. This finding could be in agreement with a secondary role of blood vessels in the pathogenesis and persistence of psoriatic lesions.

Capillaroscopic pattern in systemic lupus erythematosus and undifferentiated connective tissue disease: What we still have to learn?

In rheumatology, specific is the capillaroscopic pattern in systemic sclerosis (SSc), the so-called "scleroderma type". Capillaroscopic pattern in systemic lupus erythematosus (SLE) is less specific and includes a wide range of microvascular changes-"SLE-type" capillaroscopic pattern, non-specific findings and in a small percentage "scleroderma-like" pattern. The latter finding is currently associated with a potential subclinical overlap with SSc. Various microvascular changes have been observed in a different proportion of patients with undifferentiated connective tissue disease (UCTD). The aim of the study was to evaluate the capillaroscopic changes in SLE and UCTD. Patients from the following groups were included in the study: 30 female patients with SLE (mean age, 49 ± 15.4 years), 31 patients with UCTD (mean age, 50 ± 17 years; 30 females and 1 male); 34 age- and sex-matched healthy volunteers were examined as a control group. Nailfold capillaroscopy was performed using videocapillaroscope Videocap 3.0 (DS Medica). Capillaroscopic findings were compared with clinical and laboratory data of the patients. At capillaroscopic examination, the most frequent capillaroscopic changes in SLE patients were the presence of elongated capillaries in 43 % (13/30), an increased tortuosity in 70 % (21/30) and a prominent subpapillary plexus in 60 % (18/30) of the cases. In 80 % (24/30) of the patients, dilated capillaries were found; in 6.6 % (2/30), giant capillary loops; and in 16.6 % (5/30), haemorrhages. In 50 % of the patients, an "SLE-type" capillaroscopic pattern was found. In 30 % (9/30) of the cases the capillaroscopic examination revealed "non-specific changes", in 6.6 % (2/30) of the patients it was found a normal capillaroscopic pattern and in 13.3 % (4/30) a "scleroderma-like" pattern. Positive tests for ANA were detected in 73.3 % (11/15) of the patients with "SLE-type" capillaroscopic pattern. In all the patients with "scleroderma-like" capillaroscopic finding, positive autoantibodies with a high titre were found, without signs for overlap with other connective tissue disease (CTD). In two out of four patients with such capillaroscopic findings, a vasculitis of peripheral vessels was evident and in the other two secondary RP and high immunologic activity. A "scleroderma-like" pattern was found in 38 % (12/31) of the patients with UCTD. In 51 % (16/31) of the patients from this group, "non-specific" capillaroscopic findings were observed. For the evaluation of the predictive value of capillaroscopic pattern for the development of a distinct rheumatic disorder in patients with UCTD, a longer period of follow-up is necessary. In SLE patients, it has been found that capillaroscopic examination reveals microvascular changes also in the absence of RP. Here, the results from the study illustrate the correlation between capillaroscopic changes and immunological profile. "Scleroderma-like" capillaroscopic pattern may be observed in the context of active vasculitis of peripheral vessels as well as in patients with secondary RP and high immunologic activity. It does not have an obligatory association with an overlap syndrome with other CTD. Capillaroscopic findings in UCTD are heterogeneous. The potential of capillaroscopic examination in UCTD for evaluating the prognosis of the disease needs to be revealed through long-term follow-up.

Clinical significance of nailfold capillaroscopy in systemic lupus erythematosus: correlation with endothelial cell activation markers and disease activity

Objective: To evaluate whether nailfold capillaroscopy (NC) changes are associated with the main serum endothelial cell activation markers and the disease activity of systemic lupus erythematosus (SLE).Methods: Serum levels of vascular endothelial growth factor (VEGF), endothelin‐1 (ET‐1), soluble E‐selectin (sE‐selectin), and soluble thrombomodulin (sTM) were determined by an enzyme‐linked immunosorbent assay (ELISA) in 80 SLE patients and 33 healthy controls.Results: Nailfold capillary abnormalities were seen in 74 out of 80 (92.5%) SLE patients. A normal capillaroscopic pattern or mild changes were found in 33 (41.25%) and moderate/severe abnormalities in 47 (58.75%) of all SLE patients. In SLE patients a capillaroscopic score >1 was more frequently associated with the presence of internal organ involvement (p<0.001) as well as with immunosuppressive therapy (p<0.01). Significant differences were found in VEGF (p<0.001), ET‐1 (p<0.001), sE‐selectin (p<0.01), and sTM (p<0.001) serum concentrations between SLE patients with a capillaroscopic score >1 and controls. SLE patients with severe/moderate capillaroscopic abnormalities showed significantly higher VEGF serum levels than patients with mild changes (p<0.001). Moreover, there was a significant positive correlation between the severity of capillaroscopic changes and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) (p<0.005) as well as between capillaroscopic score and VEGF serum levels (p<0.001).Conclusions: Our findings confirm the usefulness of NC as a non‐invasive technique for the evaluation of microvascular involvement in SLE patients. A relationship between changes in NC, endothelial cell activation markers and clinical features of SLE suggest an important role for microvascular abnormalities in clinical manifestation of the disease.

Assessment of nailfold capillaroscopy by נ30 digital epiluminescence (dermoscopy) in patients with Raynaud phenomenon

Dermoscopy is a useful tool for dermatologists to study melanocytic lesions. Its possible usefulness in the assessment of capillary nailfold morphological changes (capillaroscopy) has recently been advocated. To assess the practical utility of digital epiluminescence microscopy as a capillaroscopic instrument in patients with Raynaud phenomenon (RP). To compare the sensitivity and specificity rates obtained by epiluminescence microscopy with those previously reported with conventional capillaroscopic devices. Fifty-six consecutive patients with primary RP (PRP; n = 5) or secondary RP (SRP; n = 51) (11 men and 45 women in total) were included in the study. A control group of 10 healthy subjects was also evaluated. Twenty-six patients (46%) had systemic sclerosis (SS), 12 (21%) presystemic sclerosis (pre-SS), one (2%) dermatopolymyositis-SS, one (2%) mixed connective tissue disease, two (4%) Sjögren syndrome, two (4%) an overlap syndrome, one (2%) rheumatoid arthritis and six (11%) other connective tissue diseases. Capillary nailfold changes were studied using a nonportable digital epiluminescence device (magnification x 30). Following a systematized protocol, capillary nailfold morphology, density and distribution were evaluated. Several capillaroscopic patterns were identified (normal, sclerodermic, nonspecific, nondiagnostic) as previously defined. A possible relationship between capillary nailfold changes and the intensity of RP or the presence of associated autoimmune diseases was assessed. The sclerodermic pattern showed a sensitivity of 76.9% and a specificity of 90.9% in SS. A typical capillaroscopic SS pattern was observed in 73% of cases of limited SS and in 82% of cases of diffuse SS. Patients with Sjögren syndrome and dermatopolymyositis-SS showed a nonspecific capillaroscopic pattern. All patients with PRP presented a normal capillaroscopic pattern. A normal capillaroscopic pattern was also observed in 11 of 12 patients with pre-SS. In one of two patients presenting severe sclerodactyly and in all patients showing hand oedema (three of 56), capillaroscopic changes could not be evaluated. Avascular areas correlated significantly with severe RP (P < 0.002), bone resorption (P < 0.007) and diffuse SS (P < 0.008). Digital epiluminescence seems to be a useful and reliable technique in the evaluation of capillary nailfold morphological changes. This technical variation allows the identification of specific capillaroscopic patterns associated with connective tissue diseases. It also permits us to differentiate PRP from SRP. The results obtained with this technique are similar to those previously reported using standard capillaroscopy devices.

Cutaneous Vascular Alterations in Psoriatic Patients Treated with Cyclosporine

Videocapillaroscopy can be used to assess cutaneous microcirculation modifications in vivo, and therefore allows assessment of variations in the microvascular architecture in psoriatic subjects during treatment. The aim of this study was to observe and quantify the modifications of the superficial capillary bed in psoriatic plaques during treatment with cyclosporin A. Twelve patients with psoriasis vulgaris were treated with an initial dose of 4 mg/kg/day cyclosporin A over a period of 3 months with periodic clinical and capillaroscopic assessments. Clinical resolution of the lesions and a reduction in microcirculatory alterations was observed in 70% of patients, although none returned to a normal capillaroscopic pattern.

Nailfold capillaroscopy is useful for the diagnosis and follow-up of autoimmune rheumatic diseases. A future tool for the analysis of microvascular heart involvement?

Raynaud's phenomenon (RP) represents the most frequent clinical aspect of cardio/microvascular involvement and is a key feature of several autoimmune rheumatic diseases. Moreover, RP is associated in a statistically significant manner with many coronary diseases. In normal conditions or in primary RP (excluding during the cold-exposure test), the normal nailfold capillaroscopic pattern shows a regular disposition of the capillary loops along with the nailbed. On the contrary, in subjects suffering from secondary RP, one or more alterations of the capillaroscopic findings should alert the physician of the possibility of a connective tissue disease not yet detected. Nailfold capillaroscopy (NV) represents the best method to analyse microvascular abnormalities in autoimmune rheumatic diseases. Architectural disorganization, giant capillaries, haemorrhages, loss of capillaries, angiogenesis and avascular areas characterize >95% of patients with overt scleroderma (SSc). The term 'SSc pattern' includes, all together, these sequential capillaroscopic changes typical to the microvascular involvement in SSc. The capillaroscopic aspects observed in dermatomyositis and in the undifferentiated connective tissue disease are generally reported as 'SSc-like pattern'. Effectively, and early in the disease, the peripheral microangiopathy may be well recognized and studied by nailfold capillaroscopy, or better with nailfold video capillaroscopy (NVC). The early differential diagnosis between primary and secondary RP is the best advantage NVC may offer. In addition, interesting capillaroscopic changes have been observed in systemic lupus erythematosus, anti-phospholipid syndrome and Sjogren's syndrome. Further epidemiological and clinical studies are needed to better standardize the NCV patterns. In future, the evaluation of nailfold capillaroscopy in autoimmune rheumatic diseases might represent a tool for the prediction of microvascular heart involvement by considering the systemic microvascular derangement at the capillary nailfold.