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Capillaroscopy

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Raynaud's phenomenon (RP) is the most common and significant clinical condition with an indication for a microvascular analysis to be carried out as soon as possible. Microvascular involvement is a key feature of RP and several rheumatic diseases are characterised by the presence of RP. Nailfold capillary microscopy shows an impressive cost/effectiveness ratio: it is simple, non-invasive and inexpensive. Well recognised nailfold videocapillaroscopic patterns (NVC) have been described mainly in systemic sclerosis (SSc) patients with secondary RP. The peripheral microvascular damage in SSc is characterised by increasing structural alterations of the capillaries (giant capillaries and microhaemorrhagies) with a progressive decrease in their density. The detection of the scleroderma NVC pattern allows an early distinction between the primary RP (functional, not disease associated) and the secondary RP (disease associated). Other major NVC patterns have been described in the field of rheumatic diseases. Interestingly, correlations are evident between the NVC and the clinical symptoms, severity of the disease and the laboratory findings.

Section snippets

The history of capillaroscopy

The history of capillaroscopy started about 200 years ago (for a review, see Cutolo et al1). An Italian physician, Giovanni Rasori (1766–1837), described the close relationship between conjunctival inflammation and the presence of an ‘inextricable knot of capillary loops’ visible through a magnifying glass. He also stressed that ‘the parts where this phenomenon is developing become abnormally reddish’.

After this description in the mid-19th century, at the beginning of the 20th century

How to perform a capillaroscopy

‘In vivo’ morphological evaluation of skin capillaries is generally performed at the nailfold because that area is easily accessible for examination and here the major axis of the capillaries is parallel to the skin surface, while in other areas it appears to be perpendicular.

Each subject must be kept inside the procedure room for a minimum of 15 minutes before the nailfold analysis can be performed, to adapt to the room temperature of 20–22 °C. The nailfolds of all 10 fingers should be examined

Raynaud's phenomenon

Microvascular involvement is a key feature of RP and several rheumatic diseases are characterised by its presence (Figure 2). The best technique currently available for studying such an involvement is surprisingly the oldest: nailfold capillaroscopy.

According to population-based surveys of various ethnic groups, the prevalence of RP is approximately 3–5% and geographical variations in prevalence reflect differences in climate.6, 7

Clinical criteria have been suggested for distinguishing between

The ‘scleroderma-pattern’: the reference pattern

The peripheral microvascular damage in SSc is mainly characterised by increasing structural alterations of the capillaries with a progressive decrease in their density. Blood flow is also altered, with an average slowing of flow and increased periods of stasis.22, 23

Effectively and early in the disease, the peripheral microangiopathy can be well recognised and studied using nailfold capillaroscopy or even better using NVC, a non-invasive and safe technique, which is reported to have both

Scleroderma and scleroderma-like

The presence of megacapillaries and a decreased capillary density are the hallmarks of the scleroderma capillary pattern, which can be detected using nailfold capillaroscopy. In a large recent study, 186 patients with RP, 65 with UCTD, 47 with systemic lupus erythematosus (SLE), 26 with dermato/polymyositis, 14 with rheumatoid arthritis (RA), seven with primary Sjogren's syndrome and 102 patients with SSc were investigated.37

Of the 16 patients with diffuse cutaneous SSc and the 86 cases with

Conclusions

Videocapillaroscopy of the microvessels combined, eventually, with measurement of microvascular blood flow using laser Doppler imaging, seems to represent the best technique for examining disease progression over time and responsiveness to vasoactive treatment, thus also facilitating clinical trials. Recent studies and reviews seem to support such stimulating perspectives.1, 50, 51

Considering the relatively short period of time that is required for training, the majority of rheumatologists

Summary

The history of capillaroscopy started about 200 years ago. Today, nailfold capillary microscopy shows an impressive cost/effectiveness ratio: it is simple, non-invasive and inexpensive. Raynaud's phenomenon (RP) is the most common and significant clinical condition with an indication for a microvascular analysis to be carried out as soon as possible. Microvascular involvement is a key feature of RP and several rheumatic diseases are characterised by the presence of RP. In normal conditions or

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