Dermatoscopic Assessment of Nailfold Capillary Structures in Connective Tissue Diseases

doi:10.21203/rs.3.rs-4824658/v1

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Dermatoscopic Assessment of Nailfold Capillary Structures in Connective Tissue Diseases

https://doi.org/10.21203/rs.3.rs-4824658/v1

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This study aimed to evaluate nailfold capillary abnormalities in patients with connective tissue diseases (CTDs) using a videodermatoscope and compare the findings with healthy controls.

Seventy-two patients diagnosed with CTDs, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), primary Sjögren’s syndrome (SS), undifferentiated connective tissue disease (UCTD), and thirty-three healthy controls, were included. Capillary abnormalities such as enlarged capillaries, avascular areas, tortuous-twisted capillaries, ramified-bushy capillaries, and hemorrhages were assessed at magnifications of ×20, ×30, and ×40. The scleroderma pattern (SScP) was defined by the presence of two or more abnormalities in at least two nailfolds, with a revised SScP excluding tortuous-twisted capillaries.

The standard SScP exhibited a sensitivity of 78.57% and a specificity of 96.97%. SScP was observed in 25% of rheumatoid arthritis (RA) cases, 42.9% of primary Sjögren's syndrome (SS) cases, and 57.1% of undifferentiated connective tissue disease (UCTD) cases, but none in primary RP or systemic lupus erythematosus (SLE) cases. The revised SScP showed a sensitivity of 64.29% and a specificity of 100%. It was found in 28.6% of primary SS cases and 42.9% of UCTD cases, but none in primary RP, SLE, or RA cases. One (3%) of healthy controls exhibited SScP, but none showed the revised SScP. There was no statistically significant difference in detecting tortuous-twisted capillaries between patients and healthy controls (p > 0.05). However, there was a significant difference in identifying the other four parameters (p < 0.05). Comparison of magnifications showed no significant difference between ×30 and ×40 (p > 0.05), but a significant difference between ×20 and ×40 in detecting tortuous-twisted capillaries (p < 0.05). No significant correlation was found between disease duration and capillaroscopic abnormalities.

Videodermatoscopy is a reliable tool for evaluating nailfold capillaries in connective tissue disease (CTD) patients, with magnifications of ×30 and above providing the most detailed assessments. It effectively differentiates primary and secondary Raynaud's phenomenon and highlights the diagnostic value of capillaroscopy in identifying CTD-specific abnormalities, particularly in systemic sclerosis (SSc).

nailfold capillaroscopy

capillaroscopy

connective tissue disease

videodermatoscope

Connective tissue diseases(CTDs) are inflammatory autoimmune diseases that are common in the population. This group includes systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), primary Sjögren’s syndrome (SS), and undifferentiated connective tissue disease (UCTD). Their etiology is not known exactly and microvascular involvement is present in the majority of them. This involvement causes local vascular changes in the skin, which can be evaluated through capillaroscopic examination of the nail fold [1].

Nailfold capillaroscopy is a non-invasive and in vivo method used to assess nailfold microcirculation. Studies with dermatoscopy have also shown that it can be used effectively for capillaroscopic examination.The most prominent and significant changes detected in the capillary structure are enlarged capillaries, hemorrhages, tortuous capillaries, ramified/bushy capillaries, avascular areas, and disruption of normal capillary structure [1,2,3,4,5]. Enlarged capillaries are thought to compensate for changes in the microcirculation by increasing the endothelial exchange surface and capillary permeability. Enlarged capillaries are especially observed in diseases within the spectrum of SSc [2]. Haemorrhages are caused by damage to the capillaries and are frequently observed in SLE and SSc [3,6]. Tortuous capillary is a common finding in healthy individuals and should not be considered as a feature of microangiopathy [2]. Ramified/bushy-like capillaries are a marker of neoangiogenesis and are thought to be formed to compensate for capillary loss [2]. Avascular areas can be described as a decrease in the number of capillaries per millimeter or loss of two or more consecutive capillaries [2]. Disruption of the normal capillary structure occurs due to the combination of many abnormalities such as morphological abnormalities in the microvascular vascular network, neoangiogenesis, capillary loss, and impaired capillary alignment [2].

The use of nail capillaroscopy has increased with the description of capillaroscopic patterns in connective tissue diseases [2]. Maricq et al. described the scleroderma pattern (SScP) which includes differing proportions of enlarged capillaries, capillary loss, disrupted capillary structure, tortuous capillaries, and ramified capillaries [5]. In 2003, Bergman et al. revised Maricq's pattern, defining SScP as the presence of at least two of the following in at least two nailfolds: enlarged capillaries, avascular areas, tortuous-twisted capillaries, ramified-bushy capillaries, and hemorrhages [1]. Improved characterisation of these patterns could help in the diagnosis of connective tissue diseases and in determining the stage of the disease.

This study aims to examine the nailfold capillary structures in patients with different CTDs using dermatoscopy and compare the findings with those of healthy individuals. The identification of specific capillary patterns in different CTDs will increase the diagnostic value of this technique and may further improve the management of these diseases.

This study included patients with connective tissue diseases (CTDs) who visited the Dermatology and Venereology Outpatient Clinic of Selcuk University Faculty of Medicine between April 1, 2015, and July 31, 2015. Additionally, healthy, non-smoking controls with no known diseases were included. CTDs include primary Raynaud’s Phenomenon (RP), Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), Systemic Sclerosis (SSc), primary Sjögren’s Syndrome (SS), and Undifferentiated Connective Tissue Disease (UCTD). The diagnosis of primary RP was based on the criteria defined by LeRoy and Medsger [7], UCTD was diagnosed according to the criteria defined by Mosca et al. [8], and other connective tissue diseases were diagnosed according to the American College of Rheumatology (ACR) criteria.

Exclusion criteria included individuals under the age of 18, those who had undergone a manicure in the past three weeks, those with a habit of nail-biting, individuals with nailfold trauma, and those with nailfold staining due to nail polish or henna. Patients undergoing chemotherapy or those with alcohol or substance dependence were also excluded.

All participants provided both verbal and written informed consent after being informed about the study and the procedures involved. Ethical approval for the study was obtained from the Non-Interventional Clinical Research Ethics Committee of Selcuk University Faculty of Medicine on March 31, 2015 (Approval No: 2015/127).

Participants were evaluated for age, occupation, duration of symptoms, and duration of diagnosis. Symptoms such as Raynaud's Phenomenon, malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, dry mouth, and dry eyes were documented. Dermatological examinations for swelling and edema in fingers, skin thickening and hardening in hands, telangiectasia, digital ulcers, and pitting scars were performed. Secondary involvement of connective tissue in renal, pulmonary, cardiac, and neurological systems was assessed through hospital records. Additional diseases such as hypertension, diabetes mellitus, and hypothyroidism were also recorded. Laboratory data, including hemogram, ANA, extractable nuclear antigen (ENA) antibodies, RF, ACPA, CRP, ESR, complement C3, and C4 levels, were reviewed and recorded.

Capillaroscopic examination was performed in a room with a temperature of 20–24 ̊C, after the volunteers rested for 15 minutes and adapted to the environment. During the procedure, participants' hands were kept at heart level. Ultrasound gel was applied to the nailfolds to prevent light reflection and obtain clearer images. Care was taken to avoid applying pressure to the nailfolds, which could distort the images. The examination was conducted on eight fingers, excluding the thumbs of both hands. A FotoFinder dermoscope (FotoFinder Systems GmbH, Bad Birnbach, Germany) equipped with a FotoFinder medicam 500 video camera capable of ×10-×70 magnification was used.

Images of the eight fingers were taken at ×20, ×30, and ×40 magnifications, with at least one image per finger recorded in the computer-based dermatoscope system. Images were evaluated both during recording and at a later time by the same researcher.

Capillaroscopic examination focused on assessing the nailfold for five parameters; enlarged capillaries, avascular areas, twisted capillaries, ramified/bushy capillaries, and hemorrhages. Examples of normal capillaroscopic images and the parameters evaluated are provided in Figs. 1–5. The criteria defined by Bergman et al. were used to determine the five parameters [1]. Avascular areas were defined as the loss of at least two consecutive capillary loops. All forms of capillary tortuosity, such as crossing, glomerular-like loops, etc., were included in the twisted capillary category, with even a single instance of crossing being sufficient for inclusion. Excessively twisted, branching, bush-like, or brush-like capillaries were classified under the ramified/bushy capillaries group. Additionally, the presence of at least two of these five parameters in at least two nailfolds excluding the twisted capillaries was used to define revised systemic sclerosis pattern (SScP) as described by Bergman et al [1]. We also assessed a revised SScP, described in this study, which excludes tortuous-twisted capillaries and is defined by the presence of at least two out of four parameters in at least two nailfolds.

Statistical analyses were performed using IBM SPSS Statistics 20 software. Descriptive methods and comparative analyses such as Pearson Chi-Square, Fisher's exact test, Spearman's correlation, Mann-Whitney U test and Student's t-test were used to evaluate the study data. Statistically significant difference was defined as p < 0.05.

A total of 72 patients and 33 healthy controls were included in the study. Statistical analysis showed no significant difference in age and gender distribution between the patient and control groups (p > 0.05). Demographic findings of the patients and healthy controls included in the study are given in Table 1 and Table 2.

Table 1

Age and Gender Distribution of Participants
Group	Number	Female	Male	Youngest Age	Mean Age	Oldest Age
Patients	72	65	7	18	40.85	69
Healthy Controls	33	28	5	18	40	71

Table 2

Diagnosis Distribution of Patients
Diagnosis	Number	Percentage
Primary Raynaud's Phenomenon	18	25%
Systemic Lupus Erythematosus (SLE)	14	19.4%
Rheumatoid Arthritis (RA)	12	16.7%
Systemic Sclerosis (SSc)	14	19.4%
Primary Sjögren's Syndrome (SS)	7	9.7%
Undifferentiated Connective Tissue Disease (UCTD)	7	9.7%

The average duration of symptoms in patients was 8.85 years, and the average time since diagnosis was 3.75 years. The average time from symptom onset to diagnosis was 5.04 years. Among the 18 patients with primary Raynaud's phenomenon (RP), 16 were newly diagnosed, and 2 had a long-standing diagnosis. Similarly, among the 7 patients with undifferentiated connective tissue disease (UCTD), 6 were newly diagnosed, and 1 had a long-standing diagnosis. In contrast, most patients in other groups had long-standing diagnoses. RP was present in 61 patients, with 18 having primary RP and 43 having secondary RP. Secondary RP was observed in 71.4% of SLE, 58.3% of RA, 92.9% of SSc, 85.7% of primary SS, and 100% of UCTD patients. No RP was found in the control group.

Joint pain and/or arthritis were observed in 48 patients. All patients with rheumatoid arthritis (RA) experienced joint pain and/or arthritis, whereas none of the patients with primary Raynaud's phenomenon (RP) had these symptoms. Among patients with other connective tissue diseases, 85.7% reported joint pain and/or arthritis. In contrast, none of the healthy control subjects reported experiencing joint pain and/or arthritis. Photosensitivity was significantly higher in the patient group (30 patients) compared to controls (5 patients) (p < 0.05). Malar rash was observed in 5 patients, and discoid rash in 2 patients, all diagnosed with SLE. Recurrent oral ulcers were observed in 11 patients, with at least one patient affected in each subgroup except for those with undifferentiated connective tissue disease (UCTD). Only one control subject had recurrent oral ulcers. Dry eyes were reported by 37.5% of patients and dry mouth by 12.5% of patients. All patients with primary Sjögren’s syndrome (SS) experienced dry eyes, and 57.1% of them reported having a dry mouth. None of the control subjects reported having dry eyes or dry mouth. Finger swelling and edema, skin thickening and hardening, telangiectasia, digital ulcers, and pitting scars were observed in patients, particularly those with systemic sclerosis (SSc), but not in any of the control subjects. Renal disease was diagnosed in 5 patients: 4 with systemic lupus erythematosus (SLE) and 1 rheumatoid arthritis (RA) patient with chronic renal failure. Interstitial lung disease was identified in 10 patients, including 8 with SSc, 1 with SLE, and 1 with Sjögren’s syndrome (SS). Central nervous system involvement, such as psychosis and seizures, was observed in 3 patients: 2 with SLE and 1 RA patient with a history of schizophrenia. Additionally, 5 patients had diabetes mellitus, 12 had hypertension, and 8 had hypothyroidism.

Antinuclear antibody (ANA) and extractable nuclear antigen (ENA) values were available for 68 and 65 patients, respectively. The most common ENA antibodies identified were anti-dsDNA in patients with systemic lupus erythematosus (SLE), Scl-70 in patients with systemic sclerosis (SSc), anti-SSA and anti-Ro52 in patients with Sjögren’s syndrome (SS), and anticentromere antibodies (ACA) in patients with undifferentiated connective tissue disease (UCTD). Among the 61 patients with Raynaud's phenomenon (RP), ANA values were available for 57 patients. All 18 patients with primary RP tested negative for ANA. Secondary RP patients had 6 ANA-negative and 33 ANA-positive results (Table 3).

Table 3

Positive (P) and Negative (N) Results of ANA, ENA, RF, ACPA, CRP, ESR, Complement C3, and C4 among patients
Marker	Status	Primary RP	SLE	RA	SSc	Primary SS	UCTD
ANA	N	18	0	8	0	0	0
	P	0	13	4	12	6	7
AMA M2	N	18	12	11	9	6	5
	P	0	0	0	2	0	2
Histones	N	18	11	11	11	6	7
	P	0	1	0	0	0	0
Nucleosomes	N	18	10	11	11	6	7
	P	0	2	0	0	0	0
dsDNA	N	18	5	11	11	6	7
	P	0	7	0	0	0	0
ACA	N	18	10	11	9	6	3
	P	0	2	0	2	0	4
Scl 70	N	18	12	11	7	6	7
	P	0	0	0	4	0	0
SS B	N	18	12	11	10	2	7
	P	0	0	0	1	4	0
Ro 52	N	18	11	11	10	0	5
	P	0	1	0	1	6	2
SS A	N	18	9	11	11	0	6
	P	0	3	0	0	6	1
Sm	N	18	12	11	11	6	7
	P	0	0	0	0	0	0
nRNP Sm	N	18	12	11	10	6	4
	P	0	0	0	1	0	3
Primary RP:Primary Raynaud's Phenomenon, SLE:Systemic Lupus Erythematosus, RA:Rheumatoid Arthritis, SSc:Systemic Sclerosis (SSc),Primary SS:Primary Sjögren's Syndrome, UCTD:Undifferentiated Connective Tissue Disease

Capillaroscopic examination showed that the most clearly observed fingers were the 4th and 5th fingers on both hands. Enlarged capillaries, avascular areas, twisted capillaries, ramified capillaries, and hemorrhages were significantly more common in patients than controls (p < 0.05). These findings were most frequent in SSc patients.

However, when examining primary Raynaud's phenomenon (RP) and systemic lupus erythematosus (SLE) patients individually and comparing them to the control group, the differences in the occurrence of these parameters were not statistically significant. In rheumatoid arthritis (RA) patients, only the difference in the proportion of ramified-bushy capillaries was significant compared to controls (p < 0.05). For systemic sclerosis (SSc) patients, significant differences were found in all parameters except tortuous-twisted capillaries when compared to controls (p < 0.05). Significant differences were also found between undifferentiated connective tissue disease (UCTD) patients and controls regarding the proportions of enlarged capillaries, avascular areas, and hemorrhages (p < 0.05).

When comparing the five parameters at magnifications of ×30 and ×40, no statistically significant differences were observed. However, a significant difference was found when comparing magnifications of ×20 and ×40 for tortuous-twisted capillaries (p < 0.001).

The specific pattern (SScP) defined by at least two positive parameters in at least two nailfolds was observed in 29.2% of patients and 3% of controls, with the highest prevalence in SSc patients. Revised-SScP pattern was seen in 19.4% of patients and none of the controls, with the highest prevalence in SSc patients (Table 4). The sensitivity and specificity of SScP were 78.57% and 96.97% respectively when comparing SSc patients with controls, and 78.57% and 82.76% respectively in the overall patient group.

Table 4

Percentages of Capillaroscopic Changes and Average Percentage of Finger Involvement
Condition	Enlarged Capillaries	Avascular Areas	Tortuous-Twisted Capillaries	Ramified-Bushy Capillaries	Hemorrhages
Primary RP	-	-	77.8 (2.94)	5.6 (0.05)	22.2 (0.33)
SLE	-	7 (0.07)	78.6 (3)	21.4 (0.28)	21.4 (0.28)
RA	8.3 (0.08)	-	75 (3.08)	33.3 (0.41)	50 (1)
SSc	71.4 (2.85)	85.7 (5)	71.4 (1.78)	42.9 (1.92)	64.3 (2.14)
Primary SS	42.9 (1.71)	14.3 (0.28)	85.7 (4)	14.3 (0.14)	57.1 (1.28)
UCTD	57.1 (1.71)	28.6 (1.57)	100 (2.14)	28.6 (0.42)	71.4 (2.14)
Control Group	-	-	84.8 (2.24)	3 (0.03)	27.3 (0.45)
Primary RP:Primary Raynaud's Phenomenon, SLE:Systemic Lupus Erythematosus, RA:Rheumatoid Arthritis, SSc:Systemic Sclerosis (SSc),Primary SS:Primary Sjögren's Syndrome, UCTD:Undifferentiated Connective Tissue Disease

The revised SScP, defined by the presence of at least two of the four parameters excluding tortuous-twisted capillaries, was observed in 19.4% of patients and none of the controls. This pattern was not observed in any primary RP, SLE, or RA patients. It was found in 64.3% of SSc patients, 28.6% of primary SS patients (2 patients), and 42.9% of UCTD patients (3 patients). The sensitivity and specificity of the revised SScP were 64.29% and 100% respectively when comparing SSc patients with controls, and 64.29% and 91.38% respectively in the overall patient group. A statistically significant difference was found between the results of SScP and revised SScP patterns (p < 0.05).

Statistical analysis showed significant differences between patients and controls in the frequency of enlarged capillaries, avascular areas, and ramified capillaries. No significant differences were found in twisted capillaries between groups. Additionally, SScP and revised-SScP patterns were significantly associated with secondary RP and not with primary RP. There was no significant correlation between the duration of symptoms and the presence of these capillaroscopic parameters.

The study includes 72 patients and 33 healthy controls. Both groups have similar ages and genders, allowing for balanced comparisons. The average duration of symptoms (8.85 years) and time since diagnosis (3.75 years) in the patient group highlight the chronic nature of connective tissue diseases (CTDs), with the exception of the newly diagnosed patients in primary Raynaud's phenomenon (RP) and undifferentiated connective tissue disease (UCTD).

Our study observed that clinical factors such as joint pain and/or arthritis were common in particularly RA and other CTDs, but absent in primary RP and healthy controls. Photosensitivity was significantly higher in patients.Malar rash and discoid rash were seen in SLE patients, and recurrent oral ulcers were reported in most subgroups. Dry eyes and mouth were prevalent in primary SS. Systemic complications like renal disease and interstitial lung disease were mostly seen in SLE and RA patients. The distribution of ENA antibodies supports their diagnostic use in connective tissue diseases.

In connective tissue diseases, local vascular changes can be observed in various skin areas, and these changes can be evaluated using nailfold capillaroscopy [1,9].

In our study capillaroscopic examination revealed significantly higher frequencies of enlarged capillaries, avascular areas, twisted capillaries, ramified capillaries, and hemorrhages in patients compared to controls. These abnormalities, indicative of microvascular changes commonly associated with systemic sclerosis (SSc) and other connective tissue diseases, align with the known capillary pathology of SSc and can be observed through capillaroscopic examination in scleroderma spectrum diseases [6,10]. We found that the 4th and 5th fingers on both hands provided the clearest images, with the left 4th finger being the most clear overall. We examined eight fingers, excluding thumbs, similar to recent studies [3,9].

Our study is one of the few to use high-resolution computerized dermatoscopes for capillaroscopic examination in connective tissue diseases. Unlike other studies, which used different devices, we evaluated and recorded findings at 20x, 30x, and 40x magnifications using the same device [10,11,12]. We found no significant difference in the detection of enlarged capillaries, avascular areas, twisted capillaries, ramified capillaries, and hemorrhages between 30x and 40x magnifications. However, fewer twisted capillaries were detected at 20x magnification than 40x magnification, and this difference was statistically significant. The examiner noted that 20x magnification required more careful and prolonged examination and that distal twists could be mistaken for dilated capillaries by inexperienced users. Therefore our study suggests that magnifications of 30x or higher are preferable for more accurate capillaroscopic evaluations.

Capillaroscopic examination in connective tissue diseases has been effectively used since Maricq and LeRoy described capillaroscopic patterns in 1973. These patterns, especially the SSc pattern (SScP), include enlarged capillaries, avascular areas, and disorganized capillaries [13]. Subsequent studies by Cutolo et al. and Bergman et al. have further refined these patterns [1,14]. In 2000, Cutolo et al. described the SSc pattern (SScP) in their study with 97 patients, categorizing it into early, active, and late stages [14]. Later in 2003, Bergman et al. revised Maricq's pattern, defining SScP as the presence of at least two out of five parameters (enlarged capillaries, avascular areas, tortuous-twisted capillaries, ramified-bushy capillaries, and hemorrhages) in at least two nailfolds [1]. The definition of tortuous capillaries is controversial in the literature [15]. In our study, we defined tortuous-twisted capillaries as those with increased coiling, excluding ramified-bushy capillaries. This included capillaries with one or more crossings, those resembling a loop key, and glomeruloid capillaries.In this study, we utilized the SScP pattern as described by Bergman et al. Additionally, due to the lack of clarity in the definition of tortuous capillaries, their occurrence in healthy individuals, and their absence in the SScP pattern defined by Cutolo, we defined a revised SScP pattern by excluding this finding, and this revised pattern was also evaluated.

Systemic sclerosis (SSc) is the primary disease where capillaroscopic examination is performed, and the sensitivity and specificity of this pattern are widely used in literature for differentiating between SSc patients and healthy controls [1,4,9]. In our study, the SScP pattern had a sensitivity of 78.57% and a specificity of 96.97%, while the revised SScP (excluding twisted capillaries) showed slightly lower sensitivity but higher specificity. Therefore, the usability of the revised SScP pattern should be evaluated, especially as it provides higher accuracy in excluding healthy individuals; however, it should be kept in mind that the classical SScP pattern should also be considered in cases with high suspicion of disease.

Some studies have explored the correlation between capillaroscopic findings and disease duration in SSc, with mixed results [15]. Our study found no significant correlation between disease duration and capillaroscopic patterns.

Raynaud's phenomenon (RP) is a primary indication for capillaroscopic examination [6,15]. Studies indicate that capillaroscopy can effectively distinguish between primary and secondary RP, with a positive predictive value of 47% [16]. Our study found similar results, with primary RP patients showing normal capillaroscopic findings, while secondary RP patients displayed significant differences, including higher rates of enlarged capillaries and avascular areas.

In systemic lupus erythematosus (SLE) patients, capillaroscopic findings can vary significantly [13,17].Our study found that SLE patients had a higher prevalence of avascular areas, twisted capillaries, and hemorrhages compared to controls, but no specific SLE pattern was identified.

Rheumatoid arthritis (RA) patients can show non-specific capillaroscopic changes, similar to those in healthy individuals. However, hemorrhages are more common in RA patients [18].Our findings indicated that RA patients had similar capillaroscopic changes to healthy controls, with only ramified capillaries showing a statistically significant difference.

Primary Sjögren's syndrome (SS) does not have a specific capillaroscopic pattern, but findings can range from normal to SScP [18,19]. Our study found higher rates of twisted capillaries in primary SS patients, consistent with previous studies.

In undifferentiated connective tissue disease (UCTD) patients, capillaroscopy is useful for detecting progression to a defined connective tissue disease [20]. Our study found that 57.1% of UCTD patients had SScP, compared to 38% reported by Lambova and Müller-Ladner [21]. The higher rates of SScP and revised-SScP in our study may be due to the presence of ANA positivity in all UCTD patients and the use of more parameters in defining patterns.

The study has several limitations, including a small sample size and the lack of evaluation of capillary changes over time and their relationship with disease progression. Additionally, while the study provides valuable clinical data on symptoms such as photosensitivity, rashes, and oral ulcers and immunological markers (ANA and ENA), it did not directly compare these findings with capillaroscopic results. This absence of comparison limits the ability to understand how specific symptoms and antibody profiles correlate with capillaroscopic patterns.

In conclusion, a computerized dermatoscope can be effectively used for capillaroscopic examination, differentiation of primary and secondary Raynaud's phenomenon, and in the diagnosis of connective tissue diseases. For the most accurate examination, 30x or higher magnification is recommended. Future research should aim to integrate clinical symptoms, immunological markers, and capillaroscopic findings to enhance diagnostic accuracy and better understand the relationship between these factors.

Author Contribution

M.D. H.C.A S.Y.A.D. E.D. wrote the main manuscript text. All authors reviewed the manuscript.

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No competing interests reported.

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Dermatoscopic Assessment of Nailfold Capillary Structures in Connective Tissue Diseases

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