9Capillaroscopy
Section snippets
Capillaroscopy and classification criteria for systemic sclerosis
In 1980, the American College of Rheumatology (ACR, formerly American Rheumatism Association) proposed classification criteria for systemic sclerosis (SSc) with the aim of establishing ‘a standard for definite disease in order to permit comparison of groups of patients from different centers’ and not for diagnostic purposes.1 However, these criteria have been used by clinicians for more than two decades as diagnostic criteria.2, 3
In 1988, SSc was classified into subsets by LeRoy et al.4 Limited
Brief history of capillaroscopy
Italian physician Giovanni Rasori (1766–1837) first noted the close relationship between conjunctival inflammation and the presence of an ‘inextricable knot of capillary loops’ using a magnifying glass.10 Following these descriptions (obtained in the mid-19th Century), at the beginning of the 20th Century, Hutchinson was able to differentiate RP into a primary phenomenon and a phenomenon secondary to different diseases by detecting microvascular changes.11 Following these observations,
How to perform videocapillaroscopy in the nail bed
Morphological evaluation of skin capillaries is generally performed at the nail fold because this area is easily accessible for examination, and the major axis of the capillaries is parallel to the skin surface (in other areas, it has a perpendicular status) (Figure 1).14
Each subject must remain in the test room for a minimum of 15 min before the nailfold analysis, and the room temperature should be maintained at 20–22 °C. The nail folds usually at least 8 fingers should be examined (out first
Most important capillaroscopic changes in secondary RP
In normal conditions or in primary RP (excluding during the cold-exposure test), the normal nailfold capillaroscopic pattern shows regular disposition of the capillary loops along the nailbed (Figure 2).
However, in patients suffering from secondary RP, one or more abnormal capillaroscopic findings should alert the physician to the possibility of a previously undetected connective auto-immune disease.
Scleroderma pattern
The peripheral microvascular damage in SSc is characterized by progressive alterations of the capillaries with a decrease in their density. Blood flow is also reduced.18, 19
Studies have partially graded the capillaroscopic aspects of vascular damage in SSc into two major patterns: active and slow.20
More recently, new classifications in relation to selected characteristics of disease progression have been proposed in order to improve the diagnostic and prognostic power of capillaroscopic
Scoring the SSc capillaroscopic patterns
In order to quantify the microvascular changes, a semiquantitative rating scale was recently adopted to score each capillary abnormality observed during NVC (0, no changes; 1, <33% of capillary alterations/reduction; 2, 33–66% of capillary alterations/reduction; 3, >66% of capillary alterations/reduction per linear millimetre) according to previous studies.22 The mean score for each capillaroscopic parameter was calculated from the analysis of four consecutive fields (each of 1 linear
Transition from primary to secondary RP: the role of NVC
Specific microvascular alterations are found by capillaroscopic analysis in several different connective tissue diseases [i.e. dermatomyositis, mixed connective tissue disease (MCTD) and systemic lupus erythaematosus (SLE)].14 In addition, distinct morphological patterns on NVC and a significant and gradual increase in these microvascular abnormalities are observed during the progression of SSc, and seem to reflect the evolution of the pathophysiological process.21
In a recent investigation, 20%
Clinical applications of NVC
NVC has a predictive value. In a recent large study, NVC was performed in 1024 consecutive patients for RP.28 Follow-up was undertaken with observation of the pathological features of nailfold capillaroscopy in all patients who had neither clinical nor serological signs of a connective tissue disease (CTD) at the time of NVC.
Of 308 patients with neither serological nor clinical signs of CTD but with RP and pathological features on NVC suspicious for CTD, follow-up data were available for 133
Patterns in other CTDS
A well-defined pattern has been reported in patients affected by dermatomyositis.31 This pattern, often associated with aspects of the scleroderma pattern, includes the presence of two or more of the following findings in at least two fingers: twisted enlarged capillaries and capillary haemorrhages, enlargement of capillary loops, loss of capillaries, disorganization of the normal distribution of capillaries, and budding (bushy) capillaries.
The typical SLE pattern includes morphological
Conclusions
The increasing interest in capillary microscopy and its clear diagnostic usefulness in SSc and other CTDs is now a reality.42, 43 Few diagnostic techniques can combine all the positive features typical of capillaroscopy with such low cost, uninvasiveness, repeatability, high sensitivity, good specificity and easy interpretation of results.44 The third EULAR course on capillaroscopy in rheumatic diseases (held in 2008) supported the augmented request for its application as the standard
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Capillaroscopy
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Updating the American College of Rheumatology preliminary classification criteria for systemic sclerosis: addition of severe nailfold capillaroscopy abnormalities markedly increases the sensitivity for limited scleroderma
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Systemic sclerosis – diagnosis and classification
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(2006)
Nailfold capillaroscopy and classification criteria for systemic sclerosis
Clinical and Experimental Rheumatology
Raynaud's phenomenon and the role of capillaroscopy
Arthritis and Rheumatism
Raynaud's phenomenon
La Presse médicale
Patterns of finger capillary abnormalities in connective tissue disease by ‘wide-field’ microscopy
Arthritis and Rheumatism
Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis
The Journal of Rheumatology
The contribution of capillaroscopy to the differential diagnosis of connective autoimmune diseases
Best Practice & Research. Clinical Rheumatology
Nailfold capillaroscopy is useful for the diagnosis and follow-up of autoimmune rheumatic diseases. A future tool for the analysis of microvascular heart involvement?
Rheumatology (Oxford, England)
Vascular disease in diabetes. Pathophysiological mechanisms and therapy
Archiv für innere Medizin
Diagnostic significance of nailfold capillary patterns in patients with RP: an analysis of patterns discriminating patients with and without connective tissue disease
The Journal of Rheumatology
The microcirculation in systemic sclerosis
Clinical and Experimental Rheumatology
Capillaroscopy and rheumatic diseases: state of the art
Zeitschrift für Rheumatologie
Diagnostic potential of in vivo capillary microscopy in scleroderma and related disorders
Arthritis and Rheumatism
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