Clin Rheumatol (2015) 34:279–284 DOI 10.1007/s10067-014-2795-8


Nailfold capillaroscopic changes in dermatomyositis and polymyositis A. Manfredi & M. Sebastiani & G. Cassone & N. Pipitone & D. Giuggioli & M. Colaci & C. Salvarani & C. Ferri

Received: 15 July 2014 / Revised: 13 September 2014 / Accepted: 5 October 2014 / Published online: 17 October 2014 # International League of Associations for Rheumatology (ILAR) 2014

Abstract Inflammatory myopathies (IM) are a group of muscle diseases occurring both in children and adults. Nailfold videocapillaroscopy (NVC) alterations are described in IM, but available data are discordant, including differences between polymyositis (PM) and dermatomyositis (DM). The aim of this study was to describe the capillaroscopic differences between PM and DM patients and possible correlation with clinical and serological features. We analyzed 52 unselected patients with IM in a cross-sectional study in a 6-month period. NVC findings of 29 DM and 23 PM patients were compared with those of 52 patients with primary Raynaud’s phenomenon. Tortuosities, capillary loss, enlarged and giant capillaries, microhemorrhages, and ramified capillaries were scored by a semiquantitative rating; disorganization of the vascular array, avascular areas, and scleroderma pattern were scored as presence/absence. Sex, mean age, and mean disease duration were similar in both groups. Disorganization of the vascular array, enlarged and giant capillaries, capillary loss, and scleroderma-like pattern were observed almost only in IM patients. Significant differences were observed between PM and DM with higher frequency and mean score of NVC changes in DM. In DM patients with disease duration ≤6 months (14/29 patients), capillary density was significantly reduced (P=0.039) and giant capillaries more frequent (P= 0.027), compared with patients with longer disease duration, while a scleroderma pattern tended to be more frequent in patients with a disease duration of less than 6 months. On the A. Manfredi (*) : M. Sebastiani : G. Cassone : D. Giuggioli : M. Colaci : C. Ferri Rheumatology Unit, University of Modena and Reggio Emilia, Via del Pozzo, 71, 41121 Modena, Italy e-mail: [email protected] N. Pipitone : C. Salvarani Rheumatology Unit, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy

contrary, no differences were observed for ramified capillaries with regard to disease duration. Capillaroscopic alterations are identified only in DM patients as expression of diffuse microangiopathy; surprisingly, more severe changes were associated with shorter disease duration, while persistence of ramified capillaries with long-standing disease. Keywords Dermatomyositis . Polymyositis . Videocapillaroscopy

Introduction Inflammatory myopathies (IM) are a group of acquired muscle diseases with heterogeneous features occurring both in children and adults [1, 2]. A common manifestation of IM is muscle inflammation leading to weakness. However, differences in clinic, immunopathology, histology, and prognosis allow to distinguish among polymyositis (PM), dermatomyositis (DM), and inclusion body myositis (IBM) [3–5]. DM is considered a complement-mediated microangiopathy, clinically characterized by cutaneous manifestations, including heliotrope rash, an erythematous rash on the face and neck, Gottron papules, and muscle weakness. In contrast, PM is thought to be mediated by cytotoxic T cells, clinically occurring as sub-acute myopathy with variable grade of muscle weakness [6]. Extra-muscular clinical manifestations are described both in PM and DM, such as interstitial lung disease and the association with malignancies, in particular for DM [6–11]. Nailfold capillaroscopy is an imaging technique for the in vivo study of microcirculation, with a well-defined predicting value in identifying patients with Raynaud’s phenomenon at risk of evolving into a scleroderma spectrum disorder, especially systemic sclerosis (SSc) [12–15]. The use of modern videocapillaroscopies allows a real-time


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control of images and the possibility to save several pictures for repeated and subsequent qualitative, but also semiquantitative and quantitative examinations [13, 16–22]. Capillaries’ alterations have been described in patients with IM, but their frequency, typical features, and possible correlation with clinical and serological data are not well defined, such as the differences between PM and DM patients [23–26]. The aims of this study were to describe the differences in capillaroscopic features between PM or DM patients and to look for possible correlations with clinical and serological features.

Patients and methods Fifty-two unselected, consecutive patients affected by IM (23 PM and 29 DM), all satisfying the Bohan and Peter criteria [27], were evaluated in a 6-month cross-sectional study (June 2013 to December 2013). No patients met the criteria for other rheumatic diseases. Clinical, laboratory, histological, and imaging data at diagnosis were retrieved from the clinical records, while data related to the time of capillaroscopic evaluation were recorded in the same visit. The main features of the patients’ population are summarized in Table 1. Capillaroscopic findings of DM and PM patients were compared with those of 52 controls (42 females, 10 males; mean age 53.7±9.4 years), represented by patients with primary Raynaud’s phenomenon from the same geographic area, matched by gender and age. Table 1 Clinical and serological features of 52 patients with chronic inflammatory myopathies

Mean age (years±SD) Male/female ratio Mean disease duration (months±SD) Dysphagia (%) Dyspnea (%) Raynaud’ s phenomenon (%) Skin involvement (%) Arthritis basal (%) Interstitial lung disease (%) ESR basal (mmh) CRP basal (g/L) CK basal (U/L) LDH basal (U/L) Antinuclear antibodies (%)

Polymyositis (23 patients)

Dermatomyositis (29 patients)

49.4±16.3 4.7/1 42.6±42.2 21.4 50 21.4 0 6.7 64.3 35.1±25.5 0.8±1.01 930.4±1475.2 693.2±299.9 65.0

52.9±16.8 3.8/1 47.4±102.2 25 15 25 66.7 20 18.2 20.4±25.2 2.9±4.1 382.7±549.7 609.8±193.3 81.5

ESR erythrosedimentation rate, CRP C-reactive protein, CK creatinekinases, LDH lactate dehydrogenase

Collection of nailfold videocapillaroscopy images Nailfold videocapillaroscopy (NVC) was performed using a videocapillaroscope (VideCcap software 3.0; DS Medica, Milan, Italy) equipped with a ×200 optical probe, after a permanence of all patients in a comfortable temperature of 22–25 °C for 20 min. A drop of immersion oil was applied to the nailfold to maximize the translucency of the keratin layer, and the second through the fifth fingers of both hands were examined. At least two images of the middle of nailfold were saved per finger and captured, coded, stored, and independently analyzed by an expert operator (MS) blinded to the clinical data of the patients. According to previous definitions [13–16, 18, 20], the following capillaroscopic parameters were evaluated: tortuosities (single or multiple crossovers), enlarged loops (irregular or homogeneous increase of capillary diameter ≥20 and 500 μm). Moreover, a scleroderma pattern, defined as an alteration of the nailfold microvascular network, characterized by enlarged and giant loops, microhemorrhages, capillary loss, neovascularization, and architectural disorganization, [13–16, 18, 20], was recorded as present or absent. Total number of capillaries, enlarged and giant capillaries, microhemorrhages, and ramified capillaries were each scored by a semiquantitative rating scale (0=no changes, 1=less than 33 % of capillary alterations/reduction, 2=33–66 % of capillary alterations/reduction, 3=more than 66 % of capillary alterations/reduction, per linear millimeter), obtaining a mean score value for each capillaroscopic parameter; the disorganization of the vascular array and the avascular areas were scored as presence/absence [19]. Finally, the capillary loss was scored as 0 (≥7 capillaries/mm), 1 (4–6 capillaries/mm), or 2 (≤3 capillaries/mm).

Statistical analysis Data were expressed as mean±standard deviation (SD) unless otherwise noted. Categorical variables were analyzed by chisquare test or Fisher’s exact test as appropriate, while differences between the means were determined using Mann-

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Whitney U test for unpaired samples. P values ≤0.05 were considered statistically significant [28].

Results The clinical, serological, and demographic features of the 52 patients with IM (23 PM and 29 DM) are reported in Table 1. No significant differences were observed with regard to sex, mean age, and mean disease duration between patients with PM and DM, while higher values of creatine-kinase (CK) and erythrocyte sedimentation rate (ESR) were recorded in PM compared to DM patients. NVC alterations were more frequent in patients with IM than controls. In patients with Raynaud’s phenomenon, the main capillaroscopic feature was represented by tortuosities, observed in 86.8 % of patients, with a mean score of 1.47. Conversely, major capillaroscopic alterations, namely disorganization of the vascular array, enlarged and giant capillaries, and capillary loss, were observed in IM patients. Moreover, a scleroderma-like pattern was detected in 39.6 % of patients with IM. Significant differences were observed between patients with DM and PM (see Table 2). DM patients showed more frequently, and with higher score, capillary enlargement than PM patients (69 vs. 17.4 % of patients, with a mean score of 0.83±0.71 vs. 0.17±0.39 for DM and PM, respectively; P≤0.001). Similarly, a reduction in the number of capillaries was observed in patients with DM (75.9 % of DM patients vs. only 4.2 % of PM and no control

patients; P≤0.001 in both cases). Moreover, giant capillaries and avascular areas were exclusively observed in DM patients, but not in PM and control patients (P≤0.001; see Table 2). Microhemorrhages were more frequent (P=0.02) and with significantly higher score (P≤0.001) in DM patients compared to PM. Ramified capillaries were recorded in almost 60 % of DM, with a significant higher mean score compared with PM (0.93 vs. 0.09, respectively; P≤0.001). The disorganization of the vascular array, a marker of microangiopathy severity, was observed in 72.4 % of DM, but only in 1 PM patients (4.3 %; P≤0.001). Significant differences were recorded between DM and control patients for ramified, enlarged, and giant capillaries and for the presence of disorganization of the microvascular array, while no differences were observed between PM and controls for these parameters. Finally, a scleroderma-like pattern was observed only in DM patients, but not in PM and controls (P≤0.001 in both cases) (Table 2). In DM patients with disease duration ≤6 months (14/29 patients), capillary density was significantly reduced (P=0.039) and giant capillaries more frequent (P=0.027), compared with patients with longer disease duration, while a scleroderma pattern tended to be more frequent in patients with a disease duration of less than 6 months, although no statistical significance was reached (P=0.063). No difference was observed for ramified capillaries (Table 3). Finally, NVC findings of DM and PM patients were comparable with regard to clinical and serologic features, namely Raynaud’s phenomenon, skin manifestations, muscle weakness, interstitial lung disease, CK, ANA, and ESR.

Table 2 Comparison of capillaroscopic features in patients with inflammatory chronic diseases and controls Dermatomyositis (n=29)

Polymyositis (n=23)

Controls (n=52)

DM vs. C

PM vs C

DM vs. PM

Mean score (0–3) Tortuosities Enlarged capillaries Giant capillaries Ramified capillaries Hemorrhages Capillary loss

0.79 0.83 1.31 0.93 0.41 0.96

0.83 0.17 0.00 0.09 0.13 0.04

1.47 0.19 0 0.09 0.23 0

P 0.001 ≤0.001 ≤0.001 ≤0.001 ≤0.001 ≤0.001

P 0.003 ns ns ns ns ns

P ns ≤0.001 ≤0.001 ≤0.001 ≤0.001 ≤0.001

Frequency (%) Tortuosities Enlarged capillaries Giant capillaries Ramified capillaries Hemorrhages Disorganization of vascular array Avascular areas Scleroderma pattern

% 58.6 69 65.5 58.6 37.9 72.4 31 69

% 52.2 17.4 0 8.7 8.7 4.3 0 0

% 86.8 17 0 9.4 22.6 0 0 0

P 0.001 ≤0.001 ≤0.001 ≤0.001 ns ≤0.001 ≤0.001 ≤0.001

P 0.001 ns ns ns ns ns ns ns

P ns ≤0.001 ≤0.001 ≤0.001 0.02 ≤0.001 ≤0.001 ≤0.001

DM dermatomyositis, PM polymyositis, C controls, ns not significant


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Table 3 Capillaroscopic features of dermatomyositis patients according to disease duration ≤6 months (n=14) >6 months (n=15)

1.0 0.73 0.8

P ns ns 0.02

1.07 0.5 1.14 % 42.9 85.7 85.7 64.3 42.9 85.7

0.8 0.33 0.8 % 73.3 53.3 46.7 53.3 33.3 60.0

ns ns 0.039 P ns ns 0.027 ns ns ns




Scleroderma pattern 85.7



Mean score (0–3) Tortuosities 0.57 Enlarged capillaries 0.93 Giant capillaries 1.86 Ramified capillaries Hemorrhages Capillary loss Frequency (%) Tortuosities Enlarged capillaries Giant capillaries Ramified capillaries Hemorrhages Disorganization of vascular array Avascular areas

ns not significant

Discussion In this study, we analyzed NVC changes in 24 PM and 29 DM patients and graded them with a semiquantitative score. In line with published data [23–26, 29–33], major capillaroscopic alterations were detected in IM patients, but not in controls. The most frequent capillaroscopic findings were represented by capillary loss, enlarged and giant capillaries, ramified capillaries, and disarray of vascular architecture. Moreover, for the first time, we provided evidence of significant differences between DM and PM patients, with more severe NVC alterations being observed only in DM patients. In fact, the capillaroscopic alterations detected in PM patients were generally minor and similar to those described for healthy subjects. These data are only partially in agreement with those reported in previous studies, which described NVC alterations both in PM than in DM, with some conflicting results [23, 26, 31, 32, 34, 35]. Following the first observations by Hildegard Maricq [36], the presence of capillaroscopic changes in patients with IM were investigated in 1988 by Ganczarczyc et al. [35], who described capillaroscopic alterations in 19 DM patients and 16 PM patients. Using a stereomicroscope at ×20 magnification, the authors detected more frequently enlarged capillary loops and avascular areas in DM than in PM patients. Moreover, Raynaud’s phenomenon, arthritis, and pulmonary involvement were associated with a higher number of enlarged capillary loops and more severe avascular lesions.

A microangiopathy, with or without enlarged capillary loops, was observed in 14/17 DM compared to 7/15 PM patients, but enlarged capillary loops were not found in PM [32]. In a Spanish study, 53 IM patients (29 DM, 14 PM, 1 overlap syndrome, 6 cancer-associated myositis, and 3 IBM) were assessed by stereomicroscope capillaroscopy, and capillary changes were graded using a semiquantitative rating scale. IM patients had a higher prevalence of abnormal capillaroscopy features than controls. In particular microhemorrhages and capillary enlargement were prevalent in patients with DM, while ramifications and tortuosities were present in both diseases. No relationship was found between capillaroscopic abnormalities and specific auto-antibodies, while a higher capillary score was associated with interstitial lung disease [23]. In 24 patients with IM (14 PM, 6 DM, 4 DM/PM/connective tissue diseases overlap), Mercer et al. found a higher frequency of ramified capillaries, avascular areas, enlarged capillaries, and capillary loss compared to controls; capillary abnormalities were more frequent in the DM subgroup, while a lower capillary density was found in anti-Jo1-positive patients [24]. Another study assessed capillaroscopic changes in 50 DM patients, graded with a semiquantitative scale; an association was found between the presence of scleroderma pattern and elevated serum CK levels and more severe muscle disease activity. Capillary loss was significantly associated with muscle and global disease activity; hemorrhages were significantly associated with cutaneous disease activity, while no parameters were associated with pulmonary disease activity. Irregularly enlarged capillaries, hemorrhages, and capillary loss decreased or disappeared in parallel with a decrease in disease activity [25]. Altogether, these studies showed a higher prevalence of major capillaroscopic alterations in DM patients compared to those with PM. In contrast, in our study, capillaroscopic abnormalities appeared to be virtually confined to patients with DM. A number of methodological differences could explain some discordances among studies reporting on capillaroscopy findings in adults with IM. For example, the choice of magnification (varying from ×20 to ×300) could influence the different results obtained; also, the selection of the nailfold area to evaluate is a key parameter; some authors used 1 linear mm per finger [23, 25], but the criteria to select the image are not clear, while others evaluated the dominant ring only [24]. To avoid “sampling error,” we evaluated a wide nailfold surface and selected two 1-mm images of the middle of nailfold per each finger of both hands, as previously suggested by capillaroscopy studies on scleroderma patients [15, 16, 19, 30]. Following the different pathogenesis of DM and PM, our study suggests that capillaroscopic alterations (mainly

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capillary loss, enlarged and giant capillaries, and bushy and ramified capillaries) are clearly identifiable only in DM pat i e n t s , w h i c h m a y p r o b a b l y r e f l e c t t h e d i ff u s e microangiopathy. Interestingly, more severe changes, in particular capillary loss, were associated with shorter disease duration, while persistence of ramified capillaries was also detected in patients with longstanding disease; therefore, ramified and bushy capillaries could represent the real hallmark of microangiopathy in DM. We cannot exclude that the presence of more severe abnormalities in patients with short disease duration could be related to the presence of more active disease, which is frequent in the first months of the disease. Longitudinal studies on IM patients, particularly in DM, are required to investigate possible correlations of capillaroscopic changes with disease activity. Consistently, the presence of typical scleroderma pattern only in DM suggests some pathogenetic similarities between DM and systemic sclerosis [37]. However, the overlapping capillaroscopic pattern among DM and systemic sclerosis should be confirmed on comparative studies as well as in longitudinal prospective studies.

Conflict of interest The authors declares declare that they don’t do not have any financial support or other benefits from commercial sources or any other financial interests which could create a potential conflict of interest.

References 1. Bohan A, Peter JB (1975) Polymyositis and dermatomyositis (first of two parts). N Engl J Med 292:344–348 2. Bohan A, Peter JB (1975) Polymyositis and dermatomyositis (second of two parts). N Engl J Med 292:403–407 3. Dalakas MC (2010) Inflammatory muscle diseases: a critical review on pathogenesis and therapies. Curr Opin Pharmacol 10:346–352 4. Dalakas MC (2011) Review: an update on inflammatory and autoimmune myopathies. Neuropathol Appl Neurobiol 37:226–242 5. Dalakas MC (2012) Pathogenesis and therapies of immune-mediated myopathies. Autoimmun Rev 11:203–206 6. Dalakas MC, Hohlfeld R (2003) Polymyositis and dermatomyositis. Lancet 362:971–982 7. Marie I, Guillevin L, Menard JF, Hatron PY, Cherin P, Amoura Z et al (2012) Hematological malignancy associated with polymyositis and dermatomyositis. Autoimmun Rev 11:615–620 8. Zahr ZA, Baer AN (2011) Malignancy in myositis. Curr Rheumatol Rep 13:208–215 9. Wang J, Guo G, Chen G, Wu B, Lu L, Bao L (2013) Meta-analysis of the association of dermatomyositis and polymyositis with cancer. Br J Dermatol 169(Suppl 4):838–847 10. Maddison P (2001) Cancer types in dermatomyositis and polymyositis. Lancet 357:1443 11. Sigurgeirsson B, Lindelöf B, Edhag O, Allander E (1992) Risk of cancer in patients with dermatomyositis or polymyositis. A population-based study. N Engl J Med 326:363–367

283 12. Koenig M, Joyal F, Fritzler MJ, Roussin A, Abrahamowicz M, Boire G et al (2008) Autoantibodies and microvascular damage are independent predictive factors for the progression of Raynaud’s phenomenon to systemic sclerosis: a twenty-year prospective study of 586 patients, with validation of proposed criteria for early systemic sclerosis. Arthritis Rheum 58:3902–3912 13. Maricq HR, Spencer-Green G, LeRoy EC (1976) Skin capillary abnormalities as indicators of organ involvement in scleroderma (systemic sclerosis), Raynaud’s syndrome and dermatomyositis. Am J Med 61:862–870 14. Grassi W, De Angelis R (2007) Capillaroscopy: questions and answers. Clin Rheumatol 26:2009–2016 15. Ingegnoli F, Ardoino I, Boracchi P, Cutolo M, EUSTAR co-authors (2013) Nailfold capillaroscopy in systemic sclerosis: data from the EULAR scleroderma trials and research (EUSTAR) database. Microvasc Res 89:122–128 16. Cutolo M, Sulli A, Pizzorni C, Accardo S (2000) Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis. J Rheumatol 27:155–160 17. Lambova SN, Hermann W, Müller-Ladner U (2012) Comparison of qualitative and quantitative analysis of capillaroscopic findings in patients with rheumatic diseases. Rheumatol Int 32:3729– 3735 18. Lee P, Leung FYK, Alderdice C, Armstrong SK (1983) Nailfold capillary microscopy in the connective tissue diseases: a semiquantitative assessment. J Rheumatol 10:930–938 19. Sulli A, Secchi ME, Pizzorni C, Cutolo M (2008) Scoring the nailfold microvascular changes during the capillaroscopic analysis in systemic sclerosis patients. Ann Rheum Dis 67:885–887 20. Andrade LE, Gabriel Júnior A, Assad RL, Ferrari AJ, Atra E (1990) Panoramic nailfold capillaroscopy: a new reading method and normal range. Semin Arthritis Rheum 20:21–31 21. Smith V, Pizzorni C, De Keyser F, Decuman S, Van Praet JT, Deschepper E et al (2010) Reliability of the qualitative and semiquantitative nailfold videocapillaroscopy assessment in a systemic sclerosis cohort: a two-centre study. Ann Rheum Dis 69:1092–1096 22. Ingegnoli F, Gualtierotti R, Lubatti C, Zahalkova L, Meani L, Boracchi P et al (2009) Feasibility of different capillaroscopic measures for identifying nailfold microvascular alterations. Semin Arthritis Rheum 38:289–295 23. Selva-O’Callaghan A, Fonollosa-Pla V, Trallero-Araguás E, Martínez-Gómez X, Simeon-Aznar CP, Labrador-Horrillo M et al (2010) Nailfold capillary microscopy in adults with inflammatory myopathy. Semin Arthritis Rheum 39:398–404 24. Mercer LK, Moore TL, Chinoy H, Murray AK, Vail A, Cooper RG et al (2010) Quantitative nailfold video capillaroscopy in patients with idiopathic inflammatory myopathy. Rheumatology 49:1699– 1705 25. Mugii N, Hasegawa M, Matsushita T, Hamaguchi Y, Horie S, Yahata T et al (2011) Association between nail-fold capillary findings and disease activity in dermatomyositis. Rheumatology 50:1091–1098 26. Szabo N, Csiki Z, Szanto A, Danko K, Szodoray P, Zeher M (2008) Functional and morphological evaluation of hand microcirculation with nailfold capillaroscopy and laser Doppler imaging in Raynaud’s and Sjogren’s syndrome and poly/ dermatomyositis. Scand J Rheumatol 37:23–29 27. Cox S, Limaye V, Hill C, Blumbergs P, Roberts-Thomson P (2010) Idiopathic inflammatory myopathies: diagnostic criteria, classification and epidemiological features. Int J Rheum Dis 13:117–124 28. Altman DG (1991) Practical statistic for medical research. Chapman et al., London 29. Leu AJ, Yanar A, Geiger M, Franzeck UK, Bollinger A (1991) Dermatomyositis: diagnostic value of capillary microscopy. [Article in German]. Schweiz Med Wochenschr 121:363–367 30. De Angelis R, Cutolo M, Gutierrez M, Bertolazzi C, Salaffi F, Grassi W (2012) Different microvascular involvement in dermatomyositis

284 and systemic sclerosis. a preliminary study by a tight videocapillaroscopic assessment. Clin Exp Rheumatol 30:67–70 31. Klyscz T, Bogenschütz O, Jünger M, Rassner G (1996) Microangiopathic changes and functional disorders of nail fold capillaries in dermatomyositis. [Article in German]. Hautarzt 47: 289–293 32. Leteurtre E, Hachulla E, Janin A, Hatron PY, Brouillard M, Devulder B (1994) Vascular manifestations of dermatomyositis and polymyositis. clinical, capillaroscopic and histological aspects. [Article in French]. Rev Med Interne 15:800–807 33. Lukasiak B, Vnorowski J (1972) Capillaroscopy studies in dermatomyositis and lupus erythematosus. Z Haut Geschlechtskr [Article in German] 47:509–515

Clin Rheumatol (2015) 34:279–284 34. Riccieri V, Vasile R, Macri V, Sciarra I, Stefanantoni K, De Luca N et al (2010) Successful immunosuppressive treatment of dermatomyositis: a nailfold capillaroscopy survey. J Rheumatol 37:443–445 35. Ganczarczyk ML, Lee P, Armstrong SK (1988) Nailfold capillary microscopy in polymyositis and dermatomyositis. Arthritis Rheum 31:116–119 36. Maricq HR, LeRoy EC, D’Angelo WA, Medsger TA Jr, Rodnan GP, Sharp GC et al (1980) Diagnostic potential of in vivo capillary microscopy in scleroderma and related disorders. Arthritis Rheum 23:183–189 37. Chiricozzi A, Zhang S, Dattola A, Cannizzaro MV, Gabellini M, Chimenti S et al (2012) New insights into the pathogenesis of cutaneous autoimmune disorders. J Biol Regul Homeost Agents 26: 165–170

Nailfold capillaroscopic changes in dermatomyositis and polymyositis.

Inflammatory myopathies (IM) are a group of muscle diseases occurring both in children and adults. Nailfold videocapillaroscopy (NVC) alterations are ...
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