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ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 4  |  Page : 215-219

Nail fold capillary patterns in patients with systemic sclerosis using a hand-held dermoscope – A prospective study from a tertiary center in South India


1 Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission14-Mar-2022
Date of Decision11-May-2022
Date of Acceptance03-Jun-2022
Date of Web Publication17-Oct-2022

Correspondence Address:
Dr. C V Dincy Peter
Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_30_22

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  Abstract 


Introduction: Nail fold dermoscopy is a noninvasive technique which aids in the diagnosis of systemic sclerosis. It also helps in predicting the extent and stage of microvascular damage. There are only a few studies describing the pattern of nail fold capillaries in systemic sclerosis in the Indian population. Objectives: To study the patterns of nail fold capillaries using a hand-held dermoscope and to correlate these findings with cutaneous and systemic manifestations in patients with systemic sclerosis. Methods: Thirty-five patients were recruited in the study period between February 2014 and September 2015. All patients with systemic sclerosis were examined for cutaneous manifestations and dermoscopy of the nail fold capillaries was performed using Heine delta 20 dermoscope. Results: Our study had a female preponderance with the diffuse type of disease in 91% of patients. The most common abnormal nail fold dermoscopic pattern was dilated capillaries (91%). Scleroderma pattern was seen in 77% of our patients with the most common being active pattern. Early, active, and late type of the capillary pattern were associated with increased duration of disease but was not statistically significant. There was no significant association between capillary pattern and systemic manifestations. Conclusions: Majority (77%) of our patients had scleroderma patterns of which the active scleroderma pattern was the most common. There was no significant association between capillary pattern and systemic manifestations.

Keywords: Capillary hemorrhage, dermoscopy, dilated capillaries, drop out, scleroderma


How to cite this article:
Kuryan PS, Dincy Peter C V, Pulimood SA, George L, Mathew J. Nail fold capillary patterns in patients with systemic sclerosis using a hand-held dermoscope – A prospective study from a tertiary center in South India. Curr Med Issues 2022;20:215-9

How to cite this URL:
Kuryan PS, Dincy Peter C V, Pulimood SA, George L, Mathew J. Nail fold capillary patterns in patients with systemic sclerosis using a hand-held dermoscope – A prospective study from a tertiary center in South India. Curr Med Issues [serial online] 2022 [cited 2022 Dec 1];20:215-9. Available from: https://www.cmijournal.org/text.asp?2022/20/4/215/358639




  Introduction Top


Systemic sclerosis is an autoimmune condition of unknown etiology which can affect the skin, blood vessels, and internal organs.[1] Nail fold dermoscopy is a noninvasive technique which aids in the diagnosis of systemic sclerosis. Abnormal nail fold capillaries forms a part of the EULAR diagnostic criteria for systemic sclerosis and carries a score of 2. It also aids in predicting the extent and stage of microvascular damage.[2] There are very few studies from India that have described the nail fold capillary pattern in systemic sclerosis.[3]

Objectives

Our study aimed to describe the patterns of nail fold capillaries using a hand-held dermoscope and to correlate these findings with cutaneous and systemic manifestations in patients with systemic sclerosis.


  Methods Top


Study design and setting

A prospective study was conducted in the department of Dermatology in a tertiary care center in south India between February 2014 and September 2015 after Institutional Review Board (IRB Min. No 8594 (OBSERVE) dated 04/12/2013).

Inclusion criteria

Patients with diffuse and limited systemic sclerosis who were more than 16 years of age were included.

Exclusion criteria

Patients with overlap connective tissue disease with systemic sclerosis were excluded.

The diagnosis of the diffuse type of systemic sclerosis was based on the American College of Rheumatology criteria and, the criteria by LeRoy et al. which is skin involvement restricted to the hands, face, forearm, and feet and positivity for anti-CENP antibodies was used in the diagnosis of limited type of disease.[4]

After obtaining an informed written consent, dermoscopy of the nail fold capillaries was performed by examining all the fingernail folds after immersion with ultrasound gel using a Heine DELTA 20 dermatoscope. The photographs were taken using Sony Cybershot DSC-H55 camera.

The combinations of abnormal findings seen in nail folds were noted. The abnormal capillary findings looked for included dilated capillaries, capillary dropouts, avascular patterns, giant capillaries, and capillary hemorrhages. Capillary dilatation is defined as width more than two times the surrounding capillaries. Capillary dropout is defined as focal areas of capillary loss. Avascular areas are defined as multifocal or diffuse loss of capillaries. Capillary hemorrhages is defined as dotted or lined microhemorrhage, located at the periphery of capillaries.[5],[6] Giant capillaries are defined as the width of the capillaries of more than five times the normal. The capillary findings were classified based on the classification devised by Cutolo et al. and Maricq et al. into normal pattern, scleroderma pattern, and nonspecific type.[7],[8]

  1. Normal pattern – homogeneous capillary distribution without capillary loss in the nail plexus
  2. Scleroderma pattern – It is defined as the presence of two or more abnormalities such as dilated capillaries, drop out, avascular pattern, giant capillaries, and capillary hemorrhage.


  3. It is divided into three types based on classification by Maricq et al. and Bergman et al.[8],[9]

    1. Early pattern – The early pattern has relatively preserved capillary architecture with no obvious capillary loss. There are few enlarged or giant capillaries with few capillary hemorrhages.
    2. Active pattern – There is moderate capillary loss with frequent giant capillaries and capillary hemorrhages.
    3. Late pattern – There is severe capillary disorganization with severe loss of capillaries with large avascular areas. There are frequent ramified or bushy capillaries.


  4. Nonspecific type – The capillary changes do not have the complete scleroderma pattern


The prevalence was expressed in terms of percentages along with a 95% confidence interval. The association of nail fold capillary pattern with various clinical manifestations was evaluated using χ2 tests.


  Results Top


Thirty-five consecutive patients who fulfilled our inclusion criteria were enrolled in our study. The male-to-female ratio was 1:6. The age of our patients ranged from 17 to 62 years with a mean age of 36.29 ± 12 years. The mean duration of disease was 43.31 ± 31.8 months. Diffuse type of systemic sclerosis was seen in 91% of the patients and only 9% had limited disease. The most common dermoscopy pattern was dilated capillaries (91%), followed by dropouts (63%). In limited disease, the most common pattern was dilated capillaries seen in all patients (n = 3) which was similar to diffuse type of disease (n = 29, 90.6%), followed by giant capillaries (n = 1) and capillary hemorrhage (n = 1). There were no dropouts or avascular areas seen in a limited type of disease. [Table 1] demonstrates the distribution of abnormal capillary patterns. The most common finding was two abnormal patterns seen in 11 patients with the most common being capillary dilatation with dropouts. Only two patients had all five abnormal findings. Based on the classification by Cutolo et al., an abnormal dermoscopic nail fold pattern was seen in all patients, of which scleroderma pattern was present in 77% (n = 27) and nonspecific pattern was present in 23% (n = 8). Among the patients with scleroderma pattern, 5 (14%) had the early pattern, 15 (43%) had active pattern, and 7 (20%) had late pattern, as shown in [Figure 1], [Figure 2], [Figure 3]. The mean duration of illness was less in patients with early scleroderma pattern (32.4 ± 23.8 months) as compared to active (44.80 ± 30.4 months) and late pattern (46.29 ± 29.2 months).
Table 1: Abnormal nail fold dermoscopy patterns in patients of systemic sclerosis (n=35)

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Figure 1: Early scleroderma pattern: dilated capillaries (blue arrow) with normal capillary configuration (original) (×10, nonpolarized, Heine delta 20 dermoscope).

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Figure 2: Active scleroderma pattern: giant capillaries (orange arrow), dilated capillaries (blue arrow), dropout (yellow arrow), capillary hemorrhage (black arrow) (original) (×10, nonpolarized, Heine delta 20 dermoscope).

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Figure 3: Late scleroderma pattern: Avascular areas (green arrow) with dilated capillaries (blue arrow) (original) (×10, nonpolarised, Heine delta 20 dermoscope).

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The capillary patterns were analyzed with telangiectasia (n = 10), digital scars (n = 18), and modified Rodnan skin score. The most common pattern associated with telangiectasia was nonspecific pattern (n = 4, 40%), followed by late scleroderma pattern (n = 3, 30%) and active scleroderma pattern (n = 3, 30%) with no significant association (P = 0.169). The most common pattern associated with digital pitted scars was active scleroderma pattern (n = 9, 50%), followed by late scleroderma pattern (n = 4, 22.2%), but there was no statistically significant association (P = 0.41). There was no statistically significant association between modified Rodnan skin score and capillary pattern (P = 0.68). The capillary patterns were not analyzed with digital ulcers as it was present in only one patient.

The most common systemic manifestation was interstitial lung disease in 78% of the patients. The gastrointestinal system was the second-most common system involved with esophageal reflux in 47%, followed by esophageal dysmotility in 28%. The cardiac involvement included ventricular premature complexes, mitral and tricuspid regurgitation, and anterior wall myocardial infarction and was seen in 15.6% of the patients. Myositis was present in 13% of the patients. Renal involvement and pulmonary artery hypertension were seen in only one patient each and hence their association with nail fold capillary patterns was not analyzed. Patients with limited scleroderma had no systemic manifestations.

[Table 2] demonstrates the frequency of abnormal nail fold dermoscopic patterns and its association with systemic manifestations. The most common capillary pattern associated with interstitial lung disease was active scleroderma pattern (n = 13, 52%), followed by late scleroderma pattern (n = 5, 20%). The most common capillary pattern associated with esophageal dysmotility and reflux was active scleroderma pattern. There was no significant association between abnormal dermoscopic findings (dilated capillaries, capillary hemorrhage, giant capillaries, capillary dropouts, and avascular areas) and the nail fold capillary pattern (early, active, and late scleroderma pattern) with systemic manifestations.
Table 2: Association of nail fold dermoscopic patterns and systemic manifestations in patients of systemic sclerosis (n=35)

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  Discussion Top


Systemic vasculopathy in systemic sclerosis affects the nail fold capillary configuration which leads to capillary hemorrhage and loss. Hence, nail fold capillary examination may help in predicting the stage and extent of microvascular damage. Giant capillaries are representative of abnormal angiogenic response to peripheral ischemia. Capillary hemorrhages are representative of Raynaud's phenomenon and multiple are more in favor of scleroderma.

The results of our study were compared to a similar study by Dogan et al.[10] Scleroderma pattern was seen in 77% of our patients as compared to 83% by Dogan et al. The most common capillary pattern noted in both the studies was dilated capillaries which also was the most common type noted in both diffuse and limited disease. Our study had a higher prevalence of dilated capillaries as compared to the other study (91% vs. 49%). All our patients had abnormal capillary configuration, while Dogan et al. observed 17% with normal capillary configuration. Nonspecific pattern was noted in 23% of our patients. Our study demonstrated 14% of patients with early, 43% with active, and 20% with late scleroderma patterns. Digital pitted scars were most commonly associated with an active scleroderma pattern which was comparable to the study by Shenavandeh et al. Telangiectasia was commonly associated with nonspecific patterns in our study as compared to active patterns in the study by Shenavandeh et al.[11] None of the systemic manifestations showed a positive association with nail fold capillary patterns which was similar to a study by Theunuo et al. and Dogan et al.[10],[12] The most common pattern noted in all systemic manifestations was the active pattern. The most common finding was two abnormal findings which were seen in 11 patients. Further studies are required to study the association of the type of nail fold capillary pattern and systemic manifestations.

Limitation

The sample size was too small to delineate the association between nail fold capillary patterns with the type of disease and systemic manifestations.


  Conclusion Top


This study throws light on the nail fold capillary patterns seen in an Indian population.

The most common abnormal nail fold finding seen was dilated capillaries. Majority (77%) of our patients had scleroderma patterns of which the active scleroderma pattern was the most common. Early, late, and active pattern scleroderma patterns were associated with the increasing trend of disease duration, but this was not of statistical significance. There was no statistically significant correlation between nail fold capillary pattern and cutaneous or systemic manifestations.

Research quality and ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board/Ethics Committee review, and hence prior approval was obtained IRB Min. No 8594 (OBSERVE) dated 04/12/2013. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Connolly MK. Systemic sclerosis (scleroderma) and related disorders. In: Jean B, editor. Bolognia Textbook of Dermatology. 3rd ed. China: Elsevier Limited; 2012. p. 643-56.  Back to cited text no. 1
    
2.
Hasegawa M. Dermoscopy findings of nail fold capillaries in connective tissue diseases. J Dermatol 2010;38:66-70.  Back to cited text no. 2
    
3.
Ankad B, Jaju P. Nailfold capillaries in connective tissue diseases in skin of color: A dermoscopic view. Clin Dermatol Rev 2019;3:115.  Back to cited text no. 3
  [Full text]  
4.
LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger TA Jr., et al. Scleroderma (systemic sclerosis): Classification, subsets and pathogenesis. J Rheumatol 1988;15:202-5.  Back to cited text no. 4
    
5.
Jung P, Trautinger F. Capillaroscopy. J Deutsch Dermatol Ges 2013;11:731-6.  Back to cited text no. 5
    
6.
Jakhar D, Grover C, Singal A. Nailfold capillaroscopy with USB dermatoscope: A cross-sectional study in healthy adults. Indian J Dermatol Venereol Leprol 2020;86:33-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Cutolo M, Pizzorni C, Tuccio M, Burroni A, Craviotto C, Basso M, et al. Nailfold videocapillaroscopic patterns and serum autoantibodies in systemic sclerosis. Rheumatology (Oxford) 2004;43:719-26.  Back to cited text no. 7
    
8.
Maricq HR, LeRoy EC, D'Angelo WA, Medsger TA Jr., Rodnan GP, Sharp GC, et al. Diagnostic potential of in vivo capillary microscopy in scleroderma and related disorders. Arthritis Rheum 1980;23:183-9.  Back to cited text no. 8
    
9.
Beltrán E, Toll A, Pros A, Carbonell J, Pujol RM. Assessment of nailfold capillaroscopy byx30 digital epiluminescence (dermoscopy) in patients with Raynaud phenomenon. Br J Dermatol 2007;156:892-8.  Back to cited text no. 9
    
10.
Dogan S, Akdogan A, Sahin S. Can end organ damage in scleroderma be predicted based on nail fold dermatoscopy findings? J Dermatol 2012;39:416-8.  Back to cited text no. 10
    
11.
Shenavandeh S, Haghighi MY, Nazarinia MA. Nailfold digital capillaroscopic findings in patients with diffuse and limited cutaneous systemic sclerosis. Reumatologia 2017;55:15-23.  Back to cited text no. 11
    
12.
Theunuo R, Sasidharanpillai S, Manikath N, Devi K, Samad KA, Derapi J, et al. Relation between nailfold capillaroscopic pattern (assessed using a dermoscope) and organ involvement in systemic sclerosis. J Skin Sex Transm Dis 2021;4:68-75.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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