Vol. 47, No.

4
Prinfed in U.S.A.

THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

Copyright

1966 by The Williams & Wilkins Co.

NAIL FOLD CAPILLAROSCOPYA USEFUL AID IN THE

DIAGNOSIS OF COLLAGEN VASCULAR DISEASES*
J. B. ROSS, M.B., B.S., F.R.C.P.(O)., D.OB5T.R.C.O.G.

The appearances of the nail fold capillaries

in systemic lupus erythematosus, dermatomyositis and systemic sclerosis are sufficiently distinctive to be of use in the differential diagnosis
of these conditions.

Whilst capillaries may be studied in the

2. Evidence of capillary hemorrhage, bulbous

tips of the loops and pericapillary 'halo'.

3. Frequency and degree of efferent limb

distension.

4. Relationship of vessels to adjacent skin

disease.

conjunctiva, the gums and smooth skin of the

body, the nail fold affords two advantages for
study. It is easily accessible for routine clinical
and photographic examination, and is the only
site in which it is possible to see a length of the
capillary ioop obliquely, in contrast to all other
sites in which only the tip of the loop capillary

5. The presence of pericapillary structures in

the halo space around the capillaries.

The present study was undertaken to confirm the appearances of the nail fold capillaries
described by previous authors in three so-called
collagen diseases and to obtain suitable photographic illustrations.

is visible.
MATERIALS AND METHODS

Gilje, O'Leary and Baldes (1) have recounted

the history of the subject and quote Kollhaus

Ten patients with collagen vascular diseases
as being the first observer of the nail folds in were studied:
No. of patients
1663. In 1897 Karl Hueber studied the capil-

laries of the lip and at the same time lJnna Systemic lupus erythematosus
applied oil as a clearing agent. Recently Gibson,
Bosley and Griffiths (2) have outlined ten basic Dermatomyositis

morphological patterns to be found in normal Systemic sclerosis

individuals. Zimmer and Demis (3) have investigated the numbers of capillaries in forearm and

nail fold skin. They found no sexual variation

4
2
4 (including one patient
with calcinosis cutis)

The finger was held in a moulded block of acrylic

plastic material. A drop of immersion oil was

and quote six loops per mm with a range of placed on the nail fold and this was covered with
eight per mm in the most distal row of nail fold a standard coverslip. The capillary appearances
then observed with a Watson stereoscopic
capillaries as being a normal figure. Davis and were
microscope equipped with X 5 and X 10 eyepieces
Lawler (4) determined that the ratio of the and using X 2.5 and X 5 objectives. Illumination

lumen of the afferent and efferent limbs was was by a Watson focussing spot lamp. (Fig. 1).
1:1.5.
For photography, a medium dark green filter
There is no agreement on the appearance of was used being attached to the spot lamp in a
filter-holder. The camera was a Leitz Mikas
the normal and abnormal capillary loops in paper
camera attachment with a Leica camera body.
disease states. Griffith (5) felt that neurasthenics H.P. 3 film was used and light meter readings were

had a distinctly abnormal pattern. Similar re-

taken with a Weston light meter from the free

ports have been made relating to multiple

eyepiece of the microscope.

sclerosis, schizophrenia and manic-depressive

OBSERVATIONS
psychosis. Callander (6) has recommended that
at least 25 to 30 loops be examined. Bosley (7)
Lupus Erythematosus
gave five criteria relating to pathological states,
The
appearances
of "thick clumsy crops runi.e.:
fling in horizontal and oblique directions" as re1. Deviation from the distribution of the nor- ported by Gilje (1) are seen. An occasional corkmal basic patterns.
screw form is present. Fig. 2 (x 12.5) illustrates
Author's address now8, Campbell Ave., St. the nail fold capillaries in this condition. Though
John's, Nfid. Canada.
the terminal capillaries are not as thickened as
Received for publication November 20, 1965.
* From the Department of Dermatology, Uni- is commonly found, the disorderly arrangement

of capillaries behind the most distal row is

versity of Newcastle upon Tyne, England.

282

283

NAIL FOLD CAPILLAROSCOPY

Ftc. 1. Stereoscopic microscope with equipment

noted. The capillaries arc fewer in number than in systemic lupus erythematosus, dermatomyonormal. Hemorrhage into the center of the cuti- sitis and systemic sclerosis are usually distinccle has occurred. The dark markings at the tive enough to be useful evidence in differential
sides of the cuticle are artefaets.
diagnosis. Occasionally these appearances may
afford the essential clue to the diagnosis, parDermatomyositis
ticularly in the case of dermatomyositis.
Fig. 3 (x 12.5) shows the characteristic pallisading of the terminal capillaries of the nail fold.
Lupus Erythematosus
The dilated capillaries in dermatomyositis are

not abnormal in form but are increased in

Whilst the disorder of the vessels in lupus

crythematosus may resemble the findings of
systemic sclerosis, the wide dilatation present
in many of the loops in that condition is not
found. The capillary changes may be found in
Systemic Sclerosis
both systemic lupus erythematosus and in the
Fig. 4 (x 25) shows that the capillary lines discoid form, when widespread. Lawler and
are irregular and many arc obliterated. The Lumpkin (5) found the terminal capillaries of
individual capillaries vary much in shape and the unaffected skin of the forearm reduced in
number above the normal figure given by Zimmer and Demis (3). Hemorrhage into the cuticle has occurred.

size, and are generally dilated. Some are tortu-

number by 50% in 17 patients examined, 13 of

ous and wide at the tip but are not markedly whom had discoid L.E. and four of whom had
curled. The circulation is greatly slowed and systemic L.E.
occasionally extravasated blood pigment can be
seen surrounding the capillaries. Fig. 5 (x 25)
shows the capillaries of a patient with calcinosis

Dermatomyositis

In its most advanced form the capillaries of

cutis and Raynaud's disease (? systemic sclerosis). Cuticular hemorrhage has occurred, and dermatomyositis can be seen clinically as a
a charactistic dimple at the apex of a dilated blush proximal to the cuticle, though often a
lens may be needed to bring out the feature.
capillary tip is seen.
Ingram (9) has drawn attention to this differDiscussIoN
ence between dermatomyositis and systemic
Though not absolute and invariable, the ap- lupus erythematosus, and Vickers (10) has conpearances of capillaries observed in the nail fold firmed these findings in a series of 32 patients.

284

THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

'1

4.

a
I

Fie. 2. Nail fold capillaries in systemic lupus erythematosus

Ftc. 3. Nail fold capillaries in dermatomyositis
FIG. 4. Nail fold capillaries in systemic sclerosis

Ftc. 5. Nail fold capillaries of patient with calcinosis cutis and Raynaud's disease (?

systemic sclerosis).

Systemic Sclerosis

Gilje et ol (1) found that in general seleroderma without Raynaud's phenomenon (? universal morphea) the nail fold capillaries were
normal, but in aereselerosis the changes of systemic sclerosis were seen. Jablonska et al (11)
have drawn attention to these changes, and in

clinical practice, the observer should be f amiliar with the appearances under the stereoscopic microscope. Such findings should be fol-

lowed by careful thermometry to investigate

particular to the dilated tip which is often

underlying digital vascular function (12).

The finding of euticular hemorrhage would
seem to be of pathognomonic significance in the
three described collageneses, and grossly abnor-

dimpled at its apex.

mal capillaries are usually found intimately

In order to appreciate the subtle differences related to the areas of bleeding. However euticwhen observing the nail fold with a loupe in ular hemorrhage without associated capillary

285

NAIL FOLD CAPILLAROSCOPY

abnormality does not necessarily indicate disease and may result from many forms of local

con he observed with a lens, and are of use in

dfferentiating these conditions.

trauma, including nail biting.

No importance should be attached to finding

a single or even a few abnormal capillaries. Following Callander's recommendations (6) at least
5 mm of nail fold should be studied; and the ex-

perience of this study and that of capillary

examination in a wide variety of dermatoses
suggests that at least 50% of the vessels in the
examined area be abnormal to be significant. One

REFERENCES

1. Odje, 0., O'Leary, P. A. and Blades, E. J.:

Capillary microscopic (xamination in skin

discase. Arch. Derm. (Chicago), 68: 136, 1953.

2. Cibson, W. C.. Bosley, P. 0. 1. 3. and Cnffiths,
R. S.: Photn microscnpic studios nn thc nail-

bcd capillary nctwcrks in the human control

subiects. J. Nerv. Mont. Dis., 219: 123, 1956.

3. Zimmer, J. C. and Demis, J.: Studies of the

micro-circulation of the skin in disease. 3.
Invest. Derm., 39: 501, 1962.

or several nail folds may present a normal appearance in the three conditions described, but
positive findings in at least one nail fold would

4. Davis, M. J. and Lawler, 3. C.: The capillary

be of diagnostic significance. Perniosis and idio-

5. Criffith, J. Q.: Frequent occurence of abnormal

cutaneous capillaries in constitutional neurasthenic states. Amer. J. Med. Sci., 183: 180,

pathic Raynaud's phenomenon may cause a

distortion of the capillaries and cause cuticular
hemorrhage. These observations should be taken
into account in assessing the validity of abnor-

mal appearances, particularly with regard to

lupus erythematosus.
The technic of examining the nail folds with

a loupe is easily acquired, and the procedure

circulation of the skin; some normal and

some pathological findings. Arch. Dorm.
(Chicago), 77: 690, 1958.

1932.

6. Caliandcr, C. L.: Photomicrographic studies of

morphology of surfaco capillaries in health
and disease. 1. The anatomy of normal surface capillaries and a photographic method
of their observation and recordings. J.A.M.A.,
84: 352, 1925.

7. Bosley, P. 0. H. J.: A consideration of pathological niorphology in the nailbed capillary

takes little time. The information obtained may

network of human subjects. Bibl. Anat.

be of great value in the differentiation of thc

8. Lawler, J. C. and Lumpkin, L. R.: Cutaneous

capillary changes in lupus erythematosus.

so-called collagen vascular diseases.

SUMMARY

(Basel),1: 229, 1961.

Arch. Derm. (Chicago), 83: 636, 1961.

9. Ingram, J. T.: Sequeira's Diseases of the Skin.

6th Edition, p. 349. London, Churchill, 1957.

A technic is described for observing and

10. Vickers, C. F.: Society Report Discussion.

photographing capillaries of the nail folds. The

appearances of these capillaries in lupus erythematosus, dermatomyositis and systemic sclerosis are described and illustrated. The changes

11. Jablonska, S., Bubnow, B. and Lukasiak, B.:

Raynaud's syndrome; aeroselerosis sclero-

Arch. Dorm. (Chicago), 88: 97, 1963.

derma. Brit. J. Dorm., 70: 37, 1958.

12. Holti, C.: Vascular phenomena diagnostic of

latent psoriasis. Brit. J. Dorm., 76: 503, 1964.