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Ghannem A, Zaouak A, Aydi Z, Somai M, Hammami H, Boussema F, Fenniche S. Nail involvement in connective tissue diseases: an epidemiological, clinical, and dermoscopic study. Int J Dermatol 2024. [PMID: 38426318 DOI: 10.1111/ijd.17113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD. METHODS A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM). RESULTS Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern. CONCLUSION Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool.
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Affiliation(s)
- Azza Ghannem
- Department of Dermatology, Habib Thameur Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Anissa Zaouak
- Department of Dermatology, Habib Thameur Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Zohra Aydi
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Internal Medicine, Habib Thameur Hospital, Tunis, Tunisia
| | - Mehdi Somai
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Internal Medicine, Habib Thameur Hospital, Tunis, Tunisia
| | - Houda Hammami
- Department of Dermatology, Habib Thameur Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Fatma Boussema
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Internal Medicine, Habib Thameur Hospital, Tunis, Tunisia
| | - Samy Fenniche
- Department of Dermatology, Habib Thameur Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
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Lutze S, Westphal T, Jünger M, Arnold A. Mikrozirkulationsstörungen der Haut: Microcirculation disorders of the skin. J Dtsch Dermatol Ges 2024; 22:236-266. [PMID: 38361200 DOI: 10.1111/ddg.15242_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/06/2023] [Indexed: 02/17/2024]
Abstract
ZusammenfassungVeränderungen in der Mikrozirkulation der Haut sind ein häufig beobachtetes Begleitphänomen vieler Erkrankungen, weit über das Spektrum dermatologischer Krankheiten hinausreichend. Nicht alle dieser Veränderungen haben einen Krankheitswert, viele treten temporär auf, ohne schwerwiegende Folgen zu verursachen. Dies trifft für viele inflammatorische Erkrankungen wie die Psoriasis vulgaris oder das atopische Ekzem zu.Daneben gibt es aber auch Erkrankungen, bei denen funktionell und morphologisch erkennbare Mikroangiopathien zu schwerwiegenden Krankheitsfolgen führen. Eine der wichtigsten Erkrankungen in diesem Zusammenhang ist die systemische Sklerose, eine autoimmune Systemerkrankung mit multiplen Organmanifestationen. Hier sind die Untersuchungen der kutanen Mikrozirkulation sowohl in der Erstdiagnose als auch in der Prognose‐ und Verlaufsbeurteilung von weitreichender Bedeutung.Auch bei Erkrankungen der peripheren Hämodynamik wie der peripheren arteriellen Verschlusskrankheit (pAVK) und der chronisch venösen Insuffizienz (CVI) spielt das Verständnis von Mikrozirkulationsstörungen eine wichtige Rolle für die Therapie und die Erfolgskontrolle therapeutischer Interventionen.
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Affiliation(s)
- Stine Lutze
- Klinik- und Poliklinik für Haut- und Geschlechtskrankheiten, Universitätsmedizin Greifswald
| | - Thea Westphal
- Klinik- und Poliklinik für Haut- und Geschlechtskrankheiten, Universitätsmedizin Greifswald
| | - Michael Jünger
- Klinik- und Poliklinik für Haut- und Geschlechtskrankheiten, Universitätsmedizin Greifswald
| | - Andreas Arnold
- Klinik- und Poliklinik für Haut- und Geschlechtskrankheiten, Universitätsmedizin Greifswald
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Lutze S, Westphal T, Jünger M, Arnold A. Microcirculation disorders of the skin. J Dtsch Dermatol Ges 2024; 22:236-264. [PMID: 38229208 DOI: 10.1111/ddg.15242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/06/2023] [Indexed: 01/18/2024]
Abstract
Changes in the microcirculation of the skin are a frequently observed accompanying phenomenon of many diseases, far beyond the spectrum of dermatological diseases. Not all of these changes are pathological, many are transient and have no serious consequences. This is true for many inflammatory diseases such as psoriasis vulgaris or atopic eczema. However, there are also diseases in which functionally and morphologically recognizable microangiopathies lead to severe disease consequences. One of the most important diseases in this context is systemic sclerosis, an autoimmune systemic disease with multiple organ manifestations. Investigations of the cutaneous microcirculation are of great importance for the initial diagnosis as well as for prognosis and assessment of disease progression. In peripheral hemodynamic disorders such as peripheral arterial disease (PAD) and chronic venous insufficiency (CVI), understanding microcirculatory disturbances also plays an important role in therapy and in monitoring the success of therapeutic interventions.
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Affiliation(s)
- Stine Lutze
- Clinic and Polyclinic for Skin and Venereal Diseases, University Hospital Greifswald, Greifswald, Germany
| | - Thea Westphal
- Clinic and Polyclinic for Skin and Venereal Diseases, University Hospital Greifswald, Greifswald, Germany
| | - Michael Jünger
- Clinic and Polyclinic for Skin and Venereal Diseases, University Hospital Greifswald, Greifswald, Germany
| | - Andreas Arnold
- Clinic and Polyclinic for Skin and Venereal Diseases, University Hospital Greifswald, Greifswald, Germany
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Monfort JB, Klejtman T, Lazareth I, Kottler D, Blaise S, Imbert B, Chaby G, Lok C, Maillard H, Beneton N, Journet-Tollhupp J, Goujon E, Jacquin A, Tella E, Mboup B, Vicaut E, Senet P. Nailfold dermoscopy predicts the absence of a capillaroscopy sclerodermic pattern: The multicentre, prospective VASCUL-R trial. J Eur Acad Dermatol Venereol 2024. [PMID: 38251814 DOI: 10.1111/jdv.19803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 11/28/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Nailfold capillaroscopy is recommended to diagnose primary or secondary Raynaud's phenomenon (RP). Capillaroscopy is normal in primary RP, which is the most frequent. Screening for RP capillary anomalies with nailfold dermoscopy has been promising. OBJECTIVE To determine whether normal nailfold dermoscopy-based on the absence of five criteria that define a sclerodermic pattern-is able to predict normal capillaroscopy with good positive-predictive value (PPV). METHODS Prospective, 2-phase (monocentre and multicentre) study on patients at first consultation for RP undergoing nailfold video capillaroscopy (NVC) and nailfold dermoscopy by two different 'blinded' trained observers, respectively, a vascular specialist and a dermatologist, not familiar with capillaroscopy. The five criteria noted were as follows: disorganization, megacapillaries, low capillary density, avascular areas and haemorrhages. RESULTS Based on 105 patients, the dermoscopy PPV for a normal NVC was 100% (p = 0.015), with 37.9% sensitivity, when no criterion was observed. Excluding haemorrhages, the PPV remained 100% (p < 0.0001), with sensitivity rising to 73.7% and 100% specificity. CONCLUSION Normal nailfold dermoscopy with the absence of four easy-to-observe criteria predicts normal NVC with an excellent PPV.
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Affiliation(s)
- Jean-Benoît Monfort
- Service de Dermatologie et Médecine Vasculaire, Faculté de Médecine, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Tiffany Klejtman
- Service de Médecine Vasculaire, Institut de la Cicatrisation Jean-Paul-Belmondo, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Isabelle Lazareth
- Service de Médecine Vasculaire, Institut de la Cicatrisation Jean-Paul-Belmondo, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Diane Kottler
- Service de Dermatologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Sophie Blaise
- Department of Vascular Medicine, Grenoble Alpes University Hospital, Grenoble, France
| | - Bernard Imbert
- Department of Vascular Medicine, Grenoble Alpes University Hospital, Grenoble, France
| | - Guillaume Chaby
- Service de Dermatologie, Centre Hospitalier Amiens, Amiens, France
| | - Catherine Lok
- Service de Dermatologie, Centre Hospitalier Amiens, Amiens, France
| | - Hervé Maillard
- Service de Dermatologie, Centre Hospitalier Le Mans, Le Mans, France
| | - Nathalie Beneton
- Service de Dermatologie, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Elisa Goujon
- Service de Dermatologie, Centre Hospitalier Chalon-sur-Saône, Chalon-sur-Saône, France
| | - Aurélien Jacquin
- Service de Dermatologie et Médecine Vasculaire, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Emilie Tella
- Service de Dermatologie et Médecine Vasculaire, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Bassirou Mboup
- Unité de Recherche Clinique, Hôpital Fernand-Widal, Paris, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Hôpital Fernand-Widal, Paris, France
| | - Patricia Senet
- Service de Dermatologie et Médecine Vasculaire, Faculté de Médecine, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, Paris, France
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Ma Z, Mulder DJ, Gniadecki R, Cohen Tervaert JW, Osman M. Methods of Assessing Nailfold Capillaroscopy Compared to Video Capillaroscopy in Patients with Systemic Sclerosis-A Critical Review of the Literature. Diagnostics (Basel) 2023; 13:2204. [PMID: 37443598 DOI: 10.3390/diagnostics13132204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Nailfolds of patients with systemic sclerosis (SSc) provide an opportunity to directly visualize microvascular remodeling in SSc. Nailfold video capillaroscopy (NVC) remains the gold standard for assessing nailfold capillaroscopy (NFC). However, access to NVC is limited by expense and expertise. This review aims to synthesize current research on other NFC devices compared to NVC. METHODS The literature search included the primary research of adult patients with SSc as defined by the 2013 ACR/EULAR criteria. Methods of assessing NFC included stereomicroscopy/wide-field microscopy, ophthalmoscopy, dermatoscopy, smartphone devices, and digital USB microscopy. Primary outcomes included both qualitative (normal vs. abnormal nailfolds, overall pattern recognition, presence/absence of giant capillaries, hemorrhages, and abnormal morphology) and quantitative (capillary density and dimension) measures. RESULTS The search yielded 471 studies, of which 9 were included. Five studies compared NVC to dermatoscopy, two compared it to widefield/stereomicroscopy, one to smartphone attachments, and one to USB microscopy. In dermatoscopy studies, NVC had a higher percentage of images that were interpretable (63-77% vs. 100%), classifiable (70% vs. 84%), or gradable (70% vs. 79.3%) across three studies. Dermatoscopy had a lower sensitivity (60.2% vs. 81.6%) and higher specificity (92.5% vs. 84.6%) compared to NVC. One stereomicroscopy study found a significant difference between methods in capillary density in limited cutaneous SSc, while another found correlations in all parameters between stereomicroscopy and NVC. One smartphone lens had good agreement with NVC on abnormal capillary morphology and density. USB microscopy was able to differentiate between SSc and healthy controls using mean capillary width but not by capillary density. DISCUSSION A dermatoscope may serve as a more portable and affordable screening tool to identify a normal "scleroderma pattern", and images that need further corroboration by NVC. NFC parameters reported are heterogenous and the standardization of these parameters is important, especially in non-gold-standard devices.
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Affiliation(s)
- Zechen Ma
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Douwe Johannes Mulder
- Division of Vascular Medicine, Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Robert Gniadecki
- Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Mohammed Osman
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R7, Canada
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Smith V, Ickinger C, Hysa E, Snow M, Frech T, Sulli A, Cutolo M. Nailfold capillaroscopy. Best Pract Res Clin Rheumatol 2023; 37:101849. [PMID: 37419757 DOI: 10.1016/j.berh.2023.101849] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 07/09/2023]
Abstract
Nailfold capillaroscopy is a safe and well-established method for the assessment of structural alterations of the microcirculation. It is a crucial tool in the investigation and monitoring of patients presenting with Raynaud's phenomenon. Detection of the characteristic "scleroderma pattern" on capillaroscopy may indicate an underlying rheumatic disease, particularly systemic sclerosis (SSc). Herein, we highlight the practical aspects of videocapillaroscopy, including image acquisition and analysis, with mention of dermoscopy. Special emphasis is placed on standardized use of terminology to describe capillary characteristics. Systematic evaluation of images in discerning the normal from the abnormal using the validated European Alliance of Associations for Rheumatology (EULAR) Study Group consensus reporting framework is paramount. In addition to the relevance of capillaroscopy in the (very) early diagnosis of SSc, its emerging predictive value (especially capillary loss) for new organ involvement and disease progression is underscored. We further provide capillaroscopic findings in selected other rheumatic diseases.
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Affiliation(s)
- Vanessa Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Department of Rheumatology, Ghent University Hospital, Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium.
| | - Claudia Ickinger
- Division of Rheumatology, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Marcus Snow
- Department of Internal Medicine, Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tracy Frech
- Internal Medicine, Vanderbilt University Medical Center and Tennessee Valley Healthcare System Nashville, TN, USA
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
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Miziołek B, Pieczyrak R, Polak K, Frątczak A, Jedlecka A, Grosicka A, Bergler-Czop B. Role of short courses on nailfold capillaroscopy in obtaining abilities for the identification of microvasculopathy in patients with Raynaud's phenomenon. Skin Res Technol 2023; 29:e13223. [PMID: 36385255 PMCID: PMC9838766 DOI: 10.1111/srt.13223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION An early distinction between "normal" and "abnormal" capillaroscopic pattern during the first visit to a dermatologist has a crucial significance for a diagnostic management of Raynaud's phenomenon (RP). There exists a question about the level of expertise sufficient to evaluate the microcirculation. AIM To evaluate the utility of short courses on NFC among dermatologists and medical students in obtaining sufficient abilities for the identification of microvasculopathy in patients with RP using videocapillaroscope and handheld dermoscope. METHODS Both groups participated in 1-h course on NFC. Before the course, participants were asked to classify 20 videocapillaroscopic and 10 dermoscopic capillaroscopic pictures into "normal" or "abnormal" pattern. Each picture was displayed on a separate slide MS PowerPoint for 10 s. The evaluation was repeated soon after the course. RESULTS A total of 36 dermatologists and 49 medical students were enrolled. The rate of properly classified dermoscopic and videodermoscopic pictures increased after the course in both groups, but students improved the accuracy of classification on dermoscopic pictures to the greater extent than dermatologists. The rate of correctly recognized pictures with "abnormal" pattern was significantly greater than ones with "normal" pattern at the baseline and after the course, independently of imagining tool. CONCLUSIONS Short courses on NFC may improve the classification of capillaroscopic images, even in medical staff with no previous experience in NFC. The recognition of capillaroscopic abnormalities seems to be easier than obtaining the confidence that evaluated picture has "normal pattern."
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Affiliation(s)
- Bartosz Miziołek
- Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Robert Pieczyrak
- Department of Internal Medicine, Rheumatology and Clinical Immunology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Karina Polak
- Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aleksandra Frątczak
- Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aleksandra Jedlecka
- Students' Scientific Association at the Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anida Grosicka
- Department of Internal Medicine, Rheumatology and Clinical Immunology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Beata Bergler-Czop
- Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Eden M, Wilkinson S, Murray A, Bharathi PG, Vail A, Taylor CJ, Payne K, Herrick AL. Nailfold capillaroscopy: a survey of current UK practice and 'next steps' to increase uptake among rheumatologists. Rheumatology (Oxford) 2022; 62:335-340. [PMID: 35640131 PMCID: PMC9788809 DOI: 10.1093/rheumatology/keac320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To identify barriers to the use of nailfold capillaroscopy as a diagnostic tool for patients presenting with Raynaud's phenomenon in UK rheumatology centres and to obtain rheumatologists' views on a proposed internet-based standardized system for clinical reporting of nailfold capillaroscopy images. METHODS An online survey was developed using expert opinion from clinicians, scientists and health service researchers. The survey was piloted and sent to UK-based rheumatologists using established electronic mailing lists between October 2020 and March 2021. Survey data were analysed using descriptive statistics. RESULTS A total of 104 rheumatologists representing rheumatology centres across the UK responded to the survey. Wide variations in terms of workloads and practices were described. Thirty-four (33%) respondents reported using nailfold capillaroscopy only at their own centre, 33 (32%) referred to other centres, 9 (9%) did both and 28 (27%) did not use capillaroscopy at all. Of the 43 respondents using capillaroscopy on site, 25 (58%) used either a dermatoscope or universal serial bus microscope and 9 (21%) used videocapillaroscopy. Among the 61 respondents not undertaking capillaroscopy on site, barriers included lack of equipment (85%), lack of experience in acquiring images (69%) and lack of expertise in interpreting images (67%). Sixty-six respondents (63%) expressed interest in an internet-based, standardized automated system for reporting images. CONCLUSION Most UK rheumatologists currently do not perform nailfold capillaroscopy on site. An internet-based nailfold capillaroscopy system for use with low-cost microscopes as well as with videocapillaroscopy could help increase uptake of capillaroscopy and thereby facilitate early diagnosis of SSc across the UK.
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Affiliation(s)
| | - Sarah Wilkinson
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre
| | | | - Andy Vail
- Centre for Biostatistics, The University of Manchester, Manchester, UK
| | | | | | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre
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Detection of microvascular changes in systemic sclerosis and other rheumatic diseases. Nat Rev Rheumatol 2021; 17:665-677. [PMID: 34561652 DOI: 10.1038/s41584-021-00685-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 02/08/2023]
Abstract
Morphological and functional analysis of the microcirculation are objective outcome measures that are recommended for use in the presence of clinical signs of altered peripheral blood flow (such as Raynaud phenomenon), which can occur in systemic sclerosis (SSc) and other autoimmune rheumatic diseases. Several advanced non-invasive tools are available for monitoring the microcirculation, including nailfold videocapillaroscopy, which is the best-studied and most commonly used method for distinguishing and quantifying microvascular morphological alterations in SSc. Nailfold videocapillaroscopy can also be used alongside laser Doppler techniques to assist in the early diagnosis and follow-up of patients with dermatomyositis or mixed connective tissue disease. Power Doppler ultrasonography, which has been used for many years to evaluate the vascularity of synovial tissue in rheumatoid arthritis, is another promising tool for the analysis of skin and nailbed capillary perfusion in other autoimmune rheumatic diseases. Other emerging methods include raster-scanning optoacoustic mesoscopy, which offers non-invasive high-resolution 3D visualization of capillaries and has been tested in psoriatic arthritis and SSc. The principle functions and operative characteristics of several non-invasive tools for analysing microvascular changes are outlined in this Review, and the clinical roles of validated or tested imaging methods are discussed for autoimmune rheumatic diseases.
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Berks M, Dinsdale G, Marjanovic E, Murray A, Taylor C, Herrick AL. Comparison between low cost USB nailfold capillaroscopy and videocapillaroscopy: a pilot study. Rheumatology (Oxford) 2021; 60:3862-3867. [PMID: 33232464 PMCID: PMC8328506 DOI: 10.1093/rheumatology/keaa723] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/24/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Universal serial bus (USB) microscopy (capillaroscopy) could provide all rheumatologists with an easy-to-use, low-cost tool to examine the nailfold capillaries to facilitate early diagnosis of SSc. The objectives of this pilot study were to examine the feasibility of acquiring and analysing images using USB microscopy and to compare results to videocapillaroscopy. METHODS Videocapillaroscopy and USB microscope images were obtained from the right and left ring fingers of 20 patients with SSc and 20 healthy control subjects. In addition to generating panoramic capillary mosaics from across the whole nailbed, custom software made fully automated measurements of vessel structure including capillary width and density. The area under the receiver operating characteristic curve (AZ) was used to measure separation between the SSc and healthy control groups. RESULTS High quality images could be generated from the USB microscope, with reconstructed USB images comparing very favourably with those obtained using videocapillaroscopy. Using USB microscope images, the receiver operating characteristic curve AZ for group separation based on mean width was 0.81 (standard error 0.120) compared with 0.81 (standard error 0.095) for the (gold standard) videocapillaroscopy. The receiver operating characteristic curve AZ for group separation using capillary density was 0.48 (standard error 0.16) for USB microscope images, compared with 0.70 (standard error 0.10) for videocapillaroscopy. CONCLUSION In this pilot study, USB capillaroscopy was able to discriminate between patients with SSc and controls as well as videocapillaroscopy on the basis of capillary width. This finding, together with the high-quality images obtained, highlights the potential of USB capillaroscopy as a low-cost, easily accessible clinical and research tool.
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Affiliation(s)
- Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Graham Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth Marjanovic
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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11
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Herrick AL, Berks M, Taylor CJ. Quantitative nailfold capillaroscopy-update and possible next steps. Rheumatology (Oxford) 2021; 60:2054-2065. [PMID: 33493310 DOI: 10.1093/rheumatology/keab006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 11/14/2022] Open
Abstract
We review the exciting potential (and challenges) of quantitative nailfold capillaroscopy, focusing on its role in systemic sclerosis. Quantifying abnormality, including automated analysis of nailfold images, overcomes the subjectivity of qualitative/descriptive image interpretation. First we consider the rationale for quantitative analysis, including the potential for precise discrimination between normal and abnormal capillaries and for reliable measurement of disease progression and treatment response. We discuss nailfold image acquisition and interpretation, and describe how early work on semi-quantitative and quantitative analysis paved the way for semi-automated and automated analysis. Measurement of red blood cell velocity is described briefly. Finally we give a personal view on 'next steps'. From a clinical perspective, increased uptake of nailfold capillaroscopy by general rheumatologists could be achieved via low-cost hand-held devices with cloud-based automated analysis. From a research perspective, automated analysis could facilitate large-scale prospective studies using capillaroscopic parameters as possible biomarkers of systemic sclerosis-spectrum disorders.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Chris J Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
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ELMAS ÖF, OKÇU M, DEMİRBAŞ A, AKDENİZ N. Handheld dermatoscopy as an easy-to-use capillaroscopic instrument in rheumatoid arthritis: a cross-sectional study. Turk J Med Sci 2020; 50:1540-1545. [PMID: 32718130 PMCID: PMC7605092 DOI: 10.3906/sag-2006-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Background/aim Nailfold video capillaroscopy is considered as a reliable method for evaluating peripheral microangiopathy in rheumatologic diseases. In this study, we aimed to demonstrate the utility of handheld dermatoscopy as an easy-to-use nailfold capillaroscopic instrument in patients with rheumatoid arthritis. Materials and methods This cross-sectional study included patients with rheumatoid arthritis and healthy subjects. A handheld dermatoscopic examination of proximal nail fold was performed in each subject. The possible correlation of capillaroscopic findings with disease activity was evaluated using the disease activity score 28 (DAS28). Results A total of 59 patients with rheumatoid arthritis and 60 healthy subjects were enrolled in the study. The presence of capillaryenlargement, avascular areas, capillary deformities, and capillary vascular anomalies in the group of patients showed a statistically significant difference when compared with the healthy subjects. No correlation was found between the nail fold capillaroscopic findings and DAS28 score. Conclusion Hand-held dermatoscopy seems to be a useful technique in the evaluation of nail fold capillary changes. We suggest that in patients with rheumatoid arthritis, when capillaroscopic examination is needed, it can be evaluated using handheld dermatoscopy. Selected patients who showed findings using this method can be further examined with classical capillaroscopy to obtain more quantitative data.
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Affiliation(s)
- Ömer Faruk ELMAS
- Department of Dermatology and Veneorology, Faculty of Medicine, Ahi Evran University, KırşehirTurkey
| | - Mehmet OKÇU
- Department of Physical Therapy and Rehabilitation, Faculty of Medicine Ahi Evran University, KırşehirTurkey
| | - Abdullah DEMİRBAŞ
- Department of Dermatology and Veneorology, Konya Numune State Hospital, KonyaTurkey
| | - Necmettin AKDENİZ
- Department of Dermatology and Veneorology, Faculty of Medicine, İstanbul Medeniyet University, İstanbulTurkey
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Herrick AL, Dinsdale G, Murray A. New perspectives in the imaging of Raynaud's phenomenon. Eur J Rheumatol 2020; 7:S212-S221. [PMID: 33164735 PMCID: PMC7647685 DOI: 10.5152/eurjrheum.2020.19124] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
The last 10-20 years have seen huge strides in imaging science. The aim of this review article is to share with the reader the key recent advances in non-invasive imaging of the digital (finger) vasculature in patients with Raynaud's phenomenon (RP), including in systemic sclerosis (SSc)-related digital vasculopathy. For the rheumatologist, seeing a patient with RP is an opportunity for early diagnosis of an underlying SSc-spectrum disorder or (conversely) for reassuring the patient with primary (idiopathic) RP. Non-invasive imaging techniques can help to provide diagnostic certainty. In addition, they can provide new insights into pathophysiology and have the potential to facilitate the development of much needed effective treatments by providing primary and secondary endpoints for randomized controlled trials: validation studies are ongoing. This review article focuses on nailfold capillaroscopy, thermography, and laser Doppler methods but also discusses (briefly) other technologies, including optical coherence tomography, multispectral imaging, and photoacoustic imaging. Key recent advances are the increasing use/availability of nailfold capillaroscopy (and better understanding of the role of low-cost hand-held devices), increased accessibility of thermography (including mobile phone thermography), and increased application of laser Doppler methods to the study of RP/digital vasculopathy (in particular of laser Doppler imaging and laser speckle contrast imaging, both of which measure blood flow over an area rather than at a single site). In an era of precision medicine, non-invasive imaging techniques can help stratify risk of (a) SSc in the patient with RP and (b) digital vascular disease progression in the patient with an SSc-spectrum disorder.
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Affiliation(s)
- Ariane L. Herrick
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Graham Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
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Abstract
Raynaud's phenomenon (RP) is common, affecting approximately 5% of the population, and is important to the rheumatologist because it is often the presenting symptom of connective tissue disease, especially of systemic sclerosis (SSc)-spectrum disorders. RP therefore provides a window of opportunity for early diagnosis. When RP is associated with SSc it is particularly challenging to treat. This review begins with a discussion of some of the recent advances in our understanding of the pathogenesis of RP: it is through increased understanding of the complex pathophysiology of RP that we are most likely to develop new therapies. The following questions are then addressed (with three clinical scenarios demonstrating key principles of assessment and management): 1. How can we predict underlying connective tissue disease in the patient presenting with Raynaud's? 2. How can we measure severity of Raynaud's? 3. What are the latest advances in treatment of connective tissue disease-related digital vasculopathy?
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Fredrick M Wigley
- Department of Medicine, Division of Rheumatology, Johns Hopkins School of Medicine, Baltimore, USA.
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Nolan E, Manning J, Heal C, Moore T, Herrick AL. Impact and associates of digital pitting in patients with systemic sclerosis: a pilot study. Scand J Rheumatol 2020; 49:239-243. [PMID: 31928291 DOI: 10.1080/03009742.2019.1683888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Despite being a cardinal clinical sign of systemic sclerosis (SSc), digital pitting has been little studied. Our objective was to test, in a pilot study, the hypothesis that pitting is painful and associated with digital vascular disease severity.Method: Fifty patients with SSc were recruited: 25 with and 25 without digital pitting. Fingertip pain was assessed on a 0-10 scale. Thermography of both hands assessed surface temperature, allowing calculation of the distal-dorsal difference (temperature gradient) for each finger. Nailfold capillaroscopy was performed in each finger using a dermatoscope, and graded on a 0-3 scale (0 = normal; 3 = grossly abnormal).Results: In the 25 patients with digital pitting, 65 fingers in total were affected (mainly the index and middle fingers). Pain scores were higher in 'pitting' patients [median 4 (interquartile range 3-8) vs 0 (0-2), p < 0.001], and pitting patients reported that pitting impacted on activities of everyday living. Temperature gradients along the fingers did not differ significantly between patients with and without pitting (p = 0.248). Pitting patients were more likely to have 'grossly abnormal' capillaries than those without pitting, and less likely to have 'no/mild' nailfold capillary changes.Conclusions: Digital pitting is painful and impacts on hand function. Capillaroscopy findings provide further support for an association between pitting and severity of digital vascular change. Larger, more comprehensive studies are required to examine the pathophysiology of pitting and to pave the way to therapeutic intervention, ideally including preventive strategies.
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Affiliation(s)
- E Nolan
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - J Manning
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - C Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - T Moore
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Karbalaie A, Emrani Z, Fatemi A, Etehadtavakol M, Erlandsson BE. Practical issues in assessing nailfold capillaroscopic images: a summary. Clin Rheumatol 2019; 38:2343-2354. [PMID: 31278512 DOI: 10.1007/s10067-019-04644-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 11/30/2022]
Abstract
Nailfold capillaroscopy (NC) is a highly sensitive, safe, and non-invasive technique to assess involvement rate of microvascularity in dermatomyositis and systemic sclerosis. A large number of studies have focused on NC pattern description, classification, and scoring system validation, but minimal information has been published on the accuracy and precision of the measurement. The objective of this review article is to identify different factors affecting the reliability and validity of the assessment in NC. Several factors can affect the reliability of the examination, e.g., physiological artifacts, the nailfold imaging instrument, human factors, and the assessment rules and standards. It is impossible to avoid all artifacts, e.g., skin transparency, physically injured fingers, and skin pigmentation. However, minimization of the impact of some of these artifacts by considering some protocols before the examination and by using specialized tools, training, guidelines, and software can help to reduce errors in the measurement and assessment of NC images. Establishing guidelines and instructions for automatic characterization and measurement based on machine learning techniques also may reduce ambiguities and the assessment time.
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Affiliation(s)
- Abdolamir Karbalaie
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Zahra Emrani
- Medical Image and Signal Processing Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Alimohammad Fatemi
- Rheumatology Section, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Etehadtavakol
- Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Björn-Erik Erlandsson
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
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Herrick AL. Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:89-101. [PMID: 35382391 PMCID: PMC8922643 DOI: 10.1177/2397198319826467] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/27/2018] [Indexed: 09/05/2023]
Abstract
Raynaud's phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud's phenomenon is very common, affecting approximately 3%-5% of the general population. Although much rarer, systemic sclerosis-related Raynaud's phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud's phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis-related Raynaud's phenomenon (which is the most researched form of Raynaud's phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from 'isolated' to systemic sclerosis-related Raynaud's phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both 'uncomplicated' and 'complicated' Raynaud's phenomena (i.e. Raynaud's phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5-10 years are highlighted.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
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