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Nailfold Capillaroscopy: A Basic Screening Tool in Raynaud’s Phenomenon
The term “Raynaud’s phenomenon” refers to a defined triphasic colour change pattern (white, blue, red) of the skin of the fingers. The initial pallor, which may lead to cyanosis (blue coloration) of the digits, is followed by reactive hyperemia and can be accompanied by numbness, paresthesias and pain. Raynaud’s is triggered by exposure to cold, emotional stress and specific drugs. Pathophysiologically it is characterized by an excessive vasoconstrictive response (dominance of vasoconstrisctive over vasodilatory factors) of the small arterioles and the digital arteries.Etiologically it can be classified as primary or secondary, mainly either to systemic sclerosis and related diseases, or to the thoracic outlet syndrome. As such, Raynaud’s phenomenon represents an important clinical manifestation of microvascular involvement. Rare cases of paraneoplastic Raynaud’s have been described, the pathogenesis of which remains unclarified, has however been most likely attributed to neuroendocrine substances secreted by the tumor.Despite the evolution of the technology involved over the decades, nailfold capillaroscopy remains very simple in principle. The term refers to the non-invasive observation of the nailfold capillary bed. Nailfold capillaroscopy can be performed with basic equipment such as a magnifying lens, an ophthalmoscope, a dermatoscope/ stereomicroscope or a conventional wide field microscope; the nailfold video capillaroscope, however, is the gold standard tool, and provides the technology for the visualization and analysis both of morphological as well as rheological parameters of the skin microvasculature. Qualitative and quantitative microangiopathic parameters that can be recorded and analyzed include, among others, microhemorrhages, plexus morphology, capillary density, and morphologic anomalies of the end row loops. In normal conditions, or in primary Raynaud’s, the normal nailfold capillaroscopic pattern shows a regular disposition of the capillary loops along with the nailbed. In subjects suffering from secondary Raynaud’s phenomenon, alterations of the capillaroscopic findings should alert the physician of the possibility of a connective tissue disease or other conditions not yet detected.This review aims to outline the major characteristics of the normal nailfold microvascular network and the healthy variations that may be encountered in relation to age, race, employment etc, and highlight its applicability not only as a powerful tool in the screening of a variety of vascular disorders, in particular of autoimmune origin, but also as a potent tool in the follow-up of patients with established microvascular disorders in response to treatment.As microcirculation involvement is attracting increasing interest in chronic vascular diseases such as diabetes mellitus or hypertension, as a prognostic marker for macrovascular disease and target organ involvement, the acquaintance with and application of techniques assessing microvascular compromise gains particular significance. The advantages of capillaroscopy (low cost, uninvasiveness, repeatability, high sensitivity, good specificity and easy interpretation of the results) render this technique a valuable asset for the clinician.
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Nailfold Capillaroscopy for Diagnosis of Secondary Raynaud
Nailfold capillaroscopy can determine whether or not Raynaud’s is secondary to an illness such as scleroderma. Raynaud’s is often the first symptom of scleroderma, and may precede the onset of Scleroderma and other scleroderma symptoms by years or by months.
Only 5% to 20% of people with Raynaud’s phenomenon subsequently develop scleroderma, but about 90% of scleroderma patients experience this extreme cold sensitivity with red/blue flashes in their hands and feet as a primary manifestation of their disease. What Causes Raynaud’s? National Heart Lung and Blood Institute. NIH.
Low Risk for Developing Systemic Sclerosis
Some people with positive ANA and Raynaud’s never go on to develop a defined connective tissue disease (CTD).
A 2006 study presented at the American College of Rheumatology meeting showed that there is a subset of patients with positive ANA and Raynaud’s who never go on to develop systemic scleroderma.
High Risk Factors for Systemic Sclerosis
Raynaud’s + SSc Antibodies + Abnormal Nailfold = 60x Higher Risk of Systemic Sclerosis
Difficulties in diagnosis of systemic sclerosis-related interstitial lung disease (SSc-ILD). The diagnosis of SSc-ILD could maybe be made sooner if a capillaroscopy was performed earlier, according to the current criteria of early SSc. PMC, Respirol Case Rep, 2015 Sep; 3(3): 99–101.
Nailfold Capillaroscopy and Other Diseases
Nailfold Capillaroscopy and Other Diseases. Capillaroscopy can also be useful for the diagnosis of secondary Raynaud’s due to diseases other than scleroderma, including glaucoma, graft vs. host disease, rheumatoid arthritis, and vascular diseases.
Research on Nailfold Patterns in Systemic Sclerosis
Nailfold capillary abnormalities in erectile dysfunction (ED) of systemic sclerosis (SSc). Neither the presence or absence of abnormal capillaroscopy findings nor the subdivision into early, active and late patterns is associated with coexistent ED in SSc. PubMed,Rheumatology. (Also see Erectile Dysfunction and Scleroderma)
Nailfold capillaroscopy (NFC) abnormalities as predictors of mortality in patients with systemic sclerosis (SSc). Avascular scores higher than 1.5 at NFC was an independent predictor of death in SSc, suggesting that NFC can be useful for predicting SSc outcome. PubMed, Clin Exp Rheumatol.
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