Panoramic Nailfold Capillaroscopy: A New Reading Method and Normal Range By Luis Eduardo Coelho Andrade, Alexandre Gabriel, Jr, Rozeane Lupino Assad, Antonio Jose Lopes Ferrari, and Edgard Atra Current interpretation of nailfold capillaros- copy is largely based on qualitative and subjec- tive parameters. These parameters make the accurate assessment of the extent of the nail- fold microangiopathy difficult. The authors present a comprehensive method in which sev- eral quantitative or semiquantitative parame- ters are used to assess the main microangio- pathic features, such as microhemorrhage. plexus visibility, devascularization. and morpho- logic anomalies of the end row loops. The method is checked for reproducibility and ap- plied to a sample of 800 healthy people to establish the normal range. The influences of extrinsic variables, such as gender, ethnicity, age, and local nailfold conditions are also in- cluded. o 1990 by W.B. Saunders Company. INDEX WORDS: Capillaroscopy; microcircula- tion; reference values; microangiopathy. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA C APILLARY MICROSCOPY is a useful tool that allows direct access to viewing the microvasculature in living beings. Several meth- ods have been applied to capillaroscopy in the past. Johan Christophorous Kolhaus described small blood vessels around the nail with a primi- tive microscope in 1663. Subsequent reports used magnifying optical systems for visualization of capillaries at different body sites, such as the ocular conjunctivae, lips, malleoli, nailfolds, and fingertips in humans, as well as mesentery and earlobes in mice. I_5 The nailfold has been exam- ined most often because of accessibility and optimal capillary visualization. On most of the integument, the dermal papillae are perpendicu- lar to the skin surface (Fig 1). Each papilla shelters one capillary loop, which appears at capillaroscopy as a tiny red point corresponding to the top of the loop. In contrast, on the dorsal surface of the distal phalange, the papillae bend progressively as they approach the nail so that those papillae close to the nailfold are oriented parallel to the skin surface. The same occurs to the capillary loops that are longitudinally visual- ized at the nailfold edge. In the early 20th century, many investigators described the use of nailfold capillaroscopy (NFC) in the study of several diseases.6-8 They used microscopes with 100 to 300 times magnifi- cation power, which could provide detailed im- ages of a few loops in a narrow microscopic field. Information of the whole assemblage of capillar- ies was lost.“” Due to the great morphological variability of individual capillary loops, the nar- row field approach was highly subjective and yielded a plethora of capillaroscopic descriptions attributed to a myriad of pathologic conditions (Table 1). Moreover, many of the studies did not include healthy controls, so that results were not repro- ducible, causing NFC to become unpopuiar. In 1955, Wertheimer and Wertheimer” intro- duced capillaroscopy with smaller magnification (25x to 50x). However, it was Maricq12 who recognized and established the advantages of the panoramic approach, in which some morphologi- cal details of individual loops are lost but much information is gained about the assemblage of the capillaries. This turns the observer’s atten- tion away from the great and subtle morphologi- cal variability of individual loops, allowing the recognition of the microvascular landscape. Maricq also applied the panoramic technique to the study of several rheumatic diseases.13-” Her results were reproduced by other investiga- tors.‘6-‘9 Presently NFC has attained considerable pop- ularity as a valuable diagnostic tool and is now From the Rheumatology Division, Escola Paul&a de Medicina. Sao Paulo, Brazil. Luis Eduardo Coelho Andrade, MD, PhD: Assistant Professor of Rheumatology; Alexandre Gabriel Jr, MD, PhD: Assistant Professor of Rheumatology: Rozeane Lu- pino Assad, MD: Associate Professor of Rheumatology; Antonio Jose Lopes Ferrari, MD: Associate Professor of Rheumatology; Edgard Atra, MD, PhD: Chairman of Rheu- matology Division. Address reprint requests to: Luis Eduardo Coelho An- drade. MD, PhD: Escola Paul&a de Medicina, Reumatolo gia, Rua Botucatu 740, Sao Paula, SP. 04023, Brazil. 0 1990 by W.B. Saunders Company. 0049-0172/90/2001-0002%5.00/0 Seminars in Arthritis and Rheumatism, Vol 20, No zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 1 (August), 1990: pp 2 l-3 1 21