Nailfold Capillary Changes in Adult Bangladeshi Patients with Systemic Lupus Erythematosus: Correlation with Disease Activity

Background: Peripheral microangiopathy is an important feature in systemic lupus erythematosus (SLE). Nailfold capillary (NFC) changes observed by nailfold videocapillaroscopy (NVC) may play a role in the early detection of microangiopathy and assessment of disease activity in SLE.

Objectives: This study aimed to evaluate nailfold capillary alterations and their diagnostic precision in Bangladeshi patients with Systemic Lupus Erythematosus (SLE) compared to healthy individuals. Additionally, it sought to establish the correlation between these capillary changes and SLE disease activity.

Methods: A cross-sectional study with a comparison group was conducted at Chittagong Medical College Hospital (CMCH) in Chattogram, Bangladesh. The study included 27 Bangladeshi SLE patients diagnosed according to the ACR 1997 revised criteria and 27 age- and sex-matched healthy subjects. Participants underwent thorough history taking, clinical examinations, laboratory tests, and nailfold video capillaroscopy (NVC) examinations. SLE disease activity was measured using the SLE Disease Activity Index (SLEDAI), and nailfold capillary changes were evaluated based on NVC patterns.

Results: The average age of the SLE patient group was 31.2 (±7.8) years, with a female-to-male ratio of approximately 6:1. Among the patients, 23 out of 27 (85.2%) exhibited multiple phenotypes, and 18 (66.6%) had high or very high disease activity. The sub-papillary venous plexus (SPVP) was more prominently visible in SLE patients, and capillary density was lower compared to healthy controls. Nailfold capillary changes were observed in 26 out of 27 (96.3%) patients. Major and scleroderma patterns were identified in 51.9% and 11.1% of the SLE patients, respectively. Common abnormal morphological changes included crossed capillaries (66.7%), tortuous capillaries (63%), and meandering capillaries (37%). There was a significant positive correlation between SLE disease activity and NVC-pattern changes (r = 0.443, p = 0.021).

Conclusion: Abnormal nailfold capillary changes are prevalent among SLE patients and are positively correlated with disease activity in SLE.

Introduction

Systemic lupus erythematosus (SLE) presents a significant challenge for physicians due to its diverse clinical manifestations. A study characterized SLE as a multisystem autoimmune disorder caused by immune system-induced tissue damage [1]. According to the literature, SLE is a chronic autoimmune disease affecting multiple organs and presenting with diverse clinical phenotypes. It is characterized by a systemic loss of self-tolerance, resulting in the activation of autoreactive T and B cells. This activation leads to the production of pathogenic autoantibodies and extensive organ damage [2]–[4]. A study indicates that SLE is a quintessential systemic autoimmune disorder [5]. Another study highlights that the incidence, prevalence, age of onset, clinical manifestations, and mortality rates of SLE are significantly impacted by race and ethnicity [6]. Literature suggests that the global prevalence of SLE varies between 20 and 150 cases per 100,000 individuals [2], [7], [8]. The reported prevalence of SLE in Asia varies from 3.2 to 70.4 cases per 100,000 people [9]. A study reveals that the male-to-female ratio for SLE increases from 1:2 in pre-pubertal children to 1:4.5 during adolescence and further to between 1:8 and 1:12 in adult-onset SLE patients [10]. A study indicates that SLE encompasses a broad spectrum of severity, from relatively mild symptoms to life-threatening complications, such as lupus nephritis and neuropsychiatric disorders [11]. Vascular lesions mediated by immune complexes in blood vessels of various organs are commonly observed in SLE [12]. The significance of vascular lesions in SLE was first noted by Osler in 1904 [13]. A study suggests that immunologically mediated activation of vascular endothelial cells is considered a pathogenic factor contributing to systemic organ damage in SLE. The microcirculation in SLE patients has been extensively researched [14]. The significant role of microcirculatory events in SLE is validated by numerous publications on this subject [15]. Nailfold capillaroscopy (NFC) is a non-invasive clinical technique that allows for direct observation and analysis of nailfold capillary morphology and microcirculation through intact skin [16]. It is recognized as a highly sensitive and repeatable method for assessing microvascular abnormalities in various rheumatic diseases. One study posited that evaluating nailfold capillaries in autoimmune rheumatic diseases might serve as a predictive tool for microvascular heart involvement by examining systemic microvascular abnormalities observed in nailfold capillaries [17]. The literature indicates that nailfold capillaroscopy can predict disease activity and organ-specific complications. One study reported that the following capillaroscopic parameters are both reliable and specific for diagnosing Connective Tissue Diseases (CTDs): avascularity (specificity 86%; PPV 67%; NPV 77%), hemorrhage (specificity 92%; PPV 44%; NPV 69%), and capillary disorganization (specificity 70%; PPV 42%; NPV 69%) [18]. This technique is emerging as a valuable and sensitive clinical tool in the management of connective tissue diseases and can aid in improving survival outcomes [19]. These findings highlight the significant role of microvascular involvement in the clinical manifestations of these diseases. However, there is no consensus on a specific SLE pattern in nailfold capillaroscopic findings due to inconsistent reporting and the heterogeneity of the disease [20]. The mode of organ involvement and the severity of outcomes differ based on location, race, and ethnicity. To date, no published data have compared nailfold capillary changes in Bangladeshi SLE patients with those in healthy controls. Thus, conducting an NVC study on SLE patients in our setting was essential to evaluate its role in disease diagnosis, early detection of microangiopathy, and assessment of disease activity.

Objectives

The objective was to assess the utility of nailfold capillary changes in diagnosing and evaluating disease activity in adult Bangladeshi patients with SLE.

Materials and Method

Study Design

This cross-sectional study with a comparison group was conducted at Chittagong Medical College Hospital (CMCH), Chattogram, from April 2020 to March 2021. Adult Bangladeshi patients diagnosed with SLE, from both sexes, attending the Medicine, Nephrology, Neurology, Rheumatology, and Dermatology and Venereology clinics at CMCH were selected as study participants based on specific inclusion and exclusion criteria using purposive sampling. A total of 27 SLE patients and 27 age- and sex-matched healthy controls were enrolled during the study period.

Inclusion and Exclusion Criteria

Participants included adult Bangladeshi individuals diagnosed with systemic lupus erythematosus (SLE) according to the ACR-1997 revised criteria, aged between 18 to 49 years, and with disease onset after age 12. Each participant had at least eight evaluable nailfolds (excluding thumbs) for the nailfold capillaroscopy (NVC) examination. Exclusion criteria encompassed severely ill individuals, occupational exposure to vibrating tools or pneumatic drills, smokers, and those with overlap syndrome, Buerger’s disease, Takayasu arteritis, Carpal tunnel syndrome, Behcet’s disease, or thoracic outlet syndrome. Additionally, participants with hypertension (SBP ≥ 140 mmHg, DBP ≥ 90 mmHg) unrelated to lupus nephritis or diabetes were excluded from the study.

Procedure for Data Collection

Approval for the study was obtained from the ethical review committee of Chittagong Medical College prior to initiation. Using purposive (judgment) sampling, adult Bangladeshi SLE patients of various ethnic backgrounds were recruited from the Rheumatology, Medicine, Nephrology, Neurology, Dermatology, and Venereology departments at CMCH. Patients who expressed interest after initial counseling were screened by the study physician for age, occupation, smoking history, diabetes, blood pressure, vascular medication history, and nailfold capillary status. Following informed written consent, participants meeting selection criteria underwent a detailed history, physical examination, and relevant laboratory tests, including screening for diabetes, complete blood count, hemoglobin, packed cell volume, and chest radiography if indicated. SLE disease activity was assessed using the SELENA modification of the SLE Disease Activity Index (SLEDAI). Nailfold capillary changes were evaluated using NVC and categorized based on pattern changes. NVC procedures were performed according to established protocols. Age- and sex-matched healthy volunteers who consented after initial counseling were selected as a comparison group using the same screening criteria. NVC procedures for healthy subjects were conducted following protocol requirements. Captured images from both SLE cases and healthy controls were analyzed by the study physician. Data collection involved face-to-face interviews and recorded information in a pre-designed semi-structured case record form, encompassing socio-demographic details, SLE clinical phenotypes, disease duration, SELENA-SLEDAI scores, medication information, comorbidities, physical examination findings, NVC results, and laboratory investigations.

Nailfold Videocapillaroscopy (NVC) Procedure

Before commencing the procedure, several prerequisites needed to be fulfilled. Initial inquiries regarding these prerequisites were documented using a semi-structured interviewer-administered questionnaire. Subjects were instructed to abstain from consuming coffee for a minimum of 6 hours prior to the examination. To ensure subjects were comfortable and relaxed before the test, they were instructed to wait for 15–20 minutes in the examination room maintained at a temperature of 22–25 °C, which was determined as optimal according to recommendations by Ingegnoli et al. [21], [22].

The preferable time was 9–12 am. Subjects’ hands were positioned at their heart level [22]. Too much or too little oil placement was avoided as it may decrease image resolution. Nail polish had to be removed before starting the NVC procedure if present. Subjects who had manicured within the last 2 weeks were not examined until two weeks had elapsed. A computer-based Dino-Lite videocapillaroscope AF4115N2UT220x equipped with Dinocapture 2.0 Windows software and a digital video camera was employed as the primary instrument for measuring and assessing capillaroscopic parameters. The optical probes were set at a magnification power of 200X. During the examination, the second, third, fourth, and fifth fingers of both hands were scrutinized according to the established practice in nailfold capillaroscopy, which typically involves evaluating eight fingers while excluding the thumbs. This approach acknowledges the challenges in visualizing thumb capillaries, which are often affected by irregularities due to repetitive daily activities [23], [24]. Special attention was directed towards the fourth and fifth fingers of both hands due to their superior transparency, enabling a more detailed morphological assessment during the examination process. This focus aimed to achieve a more precise evaluation of capillary morphology in these specific digits [25], [26]. The videocapillaroscope probe was positioned on the subjects’ nailfold region at an approximate 45° angle, as recommended for optimal probe placement by Smith and Pizzorni [27]. Each subject underwent an examination for a duration of 20–30 minutes. Using the videocapillaroscope set at 200X magnification, eight consecutive images were captured from the distal nailfold of participants. Olive oil was applied to the nailfold to enhance image quality. Images were taken sequentially from left to right on the left hand and from right to left on the right hand. Acquired images were processed and analyzed using videocapillaroscopy software integrated with an image digitizer board by the study physician. Digital filters such as grey scale and top hat filters were applied to enhance visibility and isolate relevant areas from the image background. The study assessed capillaroscopic parameters such as distribution, shape, dimensions (width and length) of capillary loops, density, presence of avascular areas, micro-hemorrhages, and neoangiogenesis. Semi-quantitative scores were assigned for micro-hemorrhages, capillary disorganization, sub-papillary venous plexus visualization, overall nailfold capillary changes, and specific capillaroscopic patterns. Measurements were conducted using Dinocapture 2.0 Windows software for parameters including capillary loop diameter, width, length, limb diameter, inter-capillary distance, and density. Results were recorded for each finger’s nailfold, with averages calculated across all parameters. Nailfold capillary changes were evaluated using NFC-pattern analysis.

Laboratory Investigations

Blood samples of 10 mL were collected using proper aseptic techniques from all SLE patients participating in the study. Additionally, clean catch midstream urine samples were obtained to assess for RBCs, pus cells, and casts, along with spot urine samples for PCR analysis. These samples were sent to the clinical laboratory for a range of serological and biochemical tests, including serum anti-dsDNA levels, serum complement C3 and C4 levels, ESR, blood platelet and leukocyte counts, hemoglobin levels, and urine analyses. ECG and chest radiography were conducted for all enrolled SLE patients. Additional diagnostic tests such as echocardiography, joint radiology, ultrasonography, brain imaging, serum CPK, CRP, anti scl-70, direct Coombs test, aldolase, serum electrolytes, blood urea, serum creatinine, and OGTT were performed as needed. For the healthy comparison group, CBC, RBS, serum creatinine, ECG, ANA, and bedside urine dipstick tests were conducted if deemed necessary. All biochemical and serological investigations were carried out at CMCH laboratory facilities, with any unavailable tests conducted at accredited external laboratories.

Data Analysis

After data collection, all collected information was entered into Microsoft Excel to compile a master sheet, which was later imported into SPSS v23 for Windows for thorough processing and analysis. Continuous variables were presented as mean values with corresponding standard deviations (SD), while categorical variables were reported as percentages or proportions. Categorical data underwent analysis using the Chi-square test or Fisher’s exact test as appropriate, whereas continuous variables were compared between groups using the unpaired Student’s t-test. The correlation between NFC pattern of changes, disease duration, and SLEDAI score was evaluated using Spearman’s rank correlation coefficient. Diagnostic accuracy metrics, including sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio, were computed. Statistical significance was defined as a P value < 0.05.

Ethical Considerations

Before commencement, this study received approval from the ethical review committee of Chittagong Medical College. All participants provided informed consent, fully understanding the study’s objectives, procedures, and possible risks involved. Strict confidentiality of participant data was upheld, and all measures were taken to safeguard participant welfare and minimize any potential harm. Participants retained the right to withdraw from the study at any time without repercussions. The study adhered to ethical principles, including non-maleficence, beneficence, and justice, ensuring equitable and respectful treatment of all participants throughout the research process.

Results

The study enrolled 27 SLE patients and an equal number of age- and sex-matched healthy controls. Nailfold capillaroscopy (NVC) was conducted for all participants, and the disease characteristics and severity of SLE patients were assessed. The findings and outcomes are detailed in the subsequent tables and graphs.

Data were presented as frequency (%) unless specified otherwise. P values were obtained from an independent sample t-test or Chi-square test. Table I indicates that the mean age of SLE patients was 31.2 (±7.8) years, ranging from 18 to 49 years, with a female-to-male ratio of approximately 6:1. Controls were matched to SLE patients based on age and sex distribution, as shown in Table I.

Table I. Demographic Characteristics of the Participants Stratified by Study Groups

Variables	SEL patients (n = 27)	Control (n = 27)	P value
Age (years)
Mean ± SD	31.2 ± 7.8	31.3 ± 7.8	0.945*
Range	18–49	19–48
Sex
Female	23 (85.2)	23 (85.2)	1.0†
Male	4 (14.8)	4 (14.8)

Table II presents the clinical characteristics of the SLE patients. It illustrates that the disease duration ranged from 0.5 years to 12 years, with a mean duration of 4 years among the studied SLE patients. The majority of patients exhibited high disease activity (37%), followed by very high disease activity (29.6%).

Table II. Clinical Characteristics of the SLE Patients (n = 27)

Characteristic	Value
Duration of disease, years
Mean ± SD	4.46 ± 3.26
Range	0.5–12.0
Diseases phenotype, frequency (percentage)
Constitutional	4 (14.8)
Mucocutaneous	23 (85.2)
Cutaneous	4 (14.8)
Musculoskeletal	22 (81.5)
Renal	17 (63.0)
Cardiovascular	6 (22.2)
Neuropsychiatric	6 (22.2)
Pulmonary	3 (11.1)
Lymphadenopathy	1 (3.7)
Hematological	4 (14.8)
Polyserositis	5 (18.5)
Secondary-APS	3 (11.1)
Disease activity category
Multiple	23 (85.2)
No activity	1 (3.7)
Mild activity	4 (14.8)
Moderate activity	4 (17.8)
High activity	10 (37.0)
Very high activity	8 (29.6)

Table III highlights that SPVP was notably visible in 51.9% of SLE patients compared to 7.4% in healthy controls, with a statistically significant difference (p < 0.001). NFC distribution appeared irregular and disarranged in 37% of SLE patients, contrasting with no irregularities observed in the healthy control group (p < 0.001). Additionally, a low mean capillary density was significantly more common in SLE patients than in healthy controls (p = 0.005).

Table III. Comparison of NVC Variables in SLE Patients and Healthy Controls

Variables	SLE patients (n = 27)	Controls (n = 27)	P value
Prominently visible SPVP NFC distribution	14 (51.9)	2 (7.4)	<0.001
Homogenous & parallel	17 (63.0)	27 (100.0)	<0.001
Irregular & disarranged	10 (37.0)	0 (0)
Mean capillary density <6 mean="" capillary="" number="" td="">6	7 (25.9)	0 (0)	0.0056
Normal	20 (74.1)	27 (100.0)	0.005
Decreased	7 (25.9)	0 (0)
Mean capillary length >500 µm	3 (11.1)	0 (0)	0.075

In Fig. 1, the mean capillary density in the control group was 8.3 ± 1.6 per linear mm, while in SLE patients, it was 7.2 ± 1.9 per linear mm. The difference in mean capillary density between the two groups was statistically significant (P = 0.024), indicating that mean capillary density was notably lower in SLE patients compared to healthy controls.

Fig. 1. Comparison of mean capillary density between SLE patients and healthy subjects. Error bars represent standard deviation.

As Table IV demonstrates, the abnormal NVC characteristics such as dilated capillaries, widened capillaries, enlarged capillaries, and elongated capillaries were more frequently observed in SLE patients compared to healthy controls. However, statistical significance was reached only for dilated capillaries (p = 0.009), widened capillaries (p = 0.026), and enlarged capillaries (p = 0.038).

Table IV. Comparison of Nailfold Capillary Dimension Changes in SLE Patients and Healthy Controls

Dimensions	SLE patients (n = 27)	Controls (n = 27)	P value
Dilated capillaries	10 (37.0)	2 (7.4)	0.009
Widen capillaries	10 (37.0)	3 (11.1)	0.026
Enlarged capillaries	4 (14.8)	0 (0)	0.038
Giant capillaries	3 (11.1)	0 (0)	0.075
Elongated capillaries	6 (22.2)	2 (7.4)	0.125

As demonstrated by Table V, in SLE patients, the prevalence of abnormal morphological patterns included tortuous capillaries in 63% of patients, crossed capillaries in 66.7%, meandering capillaries in 37%, and bizarre capillaries in 3.7%. Capillary micro-hemorrhage was observed in 18.5% of SLE patients. These abnormal morphological patterns were significantly less common in healthy controls. Bushy capillaries were more frequently observed in healthy individuals compared to SLE patients (7.4% versus 3.7%), but this difference did not reach statistical significance (p = 0.552).

Table V. Comparison of Nailfold Capillary Morphological Abnormalities, Micro-Hemorrhage, and Avascular Area in SLE Patients and Healthy Controls

Morphological type	SLE patients (n = 27)	Controls (n = 27)	P-value
Crossed capillaries	18 (66.7)	5 (18.5)	<0.001
Tortuous capillaries	17 (63.0)	4 (14.8)	<0.001
Meandering capillaries	10 (37.0)	2 (7.4)	0.009
Bushy capillaries	1 (3.7)	2 (7.4)	0.552
Bizarre capillaries	1 (3.7)	0 (0)	0.313
Micro-hemorrhage	5 (18.5)	0 (0)	0.019
Avascular area	3 (11.1)	0 (0)	0.075

Table VI presents the diagnostic performance of different nailfold capillary changes for diagnosing SLE. It reveals that these changes generally exhibited low sensitivity ranging from 3.7% to 66.67% but demonstrated relatively high specificity ranging from 81.48% to 100%. Despite varied sensitivity, nailfold capillary changes showed diagnostic utility for SLE.

Table VI. Diagnostic Utility of Various Nailfold Capillary Changes for Diagnosis of SLE

Parameters	Sensitivity	Specificity	PPV	NPV	PLR	NLR
Dilated capillaries	37.04%	92.59%	83.33%	59.52%	5.00	0.68
Widen capillaries	37.04%	88.89%	76.92%	58.54%	3.33	0.71
Enlarged capillaries	14.81%	100.00%	100.00%	54.00%	–	0.85
Giant capillaries	11.11%	100.00%	100.00%	52.94%	–	0.89
Elongated capillaries	22.22%	92.59%	75.00%	54.35%	3.00	0.84
Tortuous capillaries	58.62%	85.19%	80.95%	65.71%	3.96	0.49
Crossed capillaries	66.67%	81.48%	78.26%	70.97%	3.60	0.41
Meandering capillaries	37.40%	92.59%	83.33%	59.52%	5.00	0.68
Bushy capillaries	3.70%	92.59%	33.33%	49.02%	0.50	1.04
Bizarre capillaries	3.70%	100.00%	100.00%	50.94%	–	0.96
Microhemorrhage	18.52%	100.00%	100.00%	55.10%	–	0.81

The findings plotted in Fig. 2 show that capillaroscopic abnormalities were significantly more prevalent in the SLE patients compared to the control group (P < 0.001). Among healthy controls, 63% exhibited a normal NFC pattern, while 37% displayed minor changes. In contrast, over half of the SLE patients (51.9%) showed major NFC changes, with only 3.7% presenting no NFC changes. A specific scleroderma pattern of NFC changes (severe changes) was identified in 11.1% of the SLE patients.

Fig. 2. The overall NFC pattern of changes observed in the study participants categorized by study groups.

The results plotted in Fig. 3 show a statistically significant positive correlation (r = 0.443, p = 0.021) between the SLEDAI score and NFC pattern of changes, indicating that as disease activity increases (as measured by the SLEDAI score), there is a corresponding increase in the severity of nailfold capillary abnormalities observed through NFC.

Fig. 3. Correlation between SLEDAI score and NFC pattern of changes among SLE patients (n = 27).

Discussion

NVC is a valuable technique for visualizing nailfold capillaries, known for its non-invasive nature, painlessness, and high reproducibility [28]. This study aimed to identify nailfold capillary abnormalities in a group of SLE patients compared to age and sex-matched healthy controls. The researcher conducted NVC examinations on 27 adult SLE patients and 27 healthy controls. The findings demonstrated that various abnormal nailfold capillary changes are prevalent among adult Bangladeshi SLE patients, highlighting NVC’s effectiveness in assessing these changes. These results align with previous studies that have shown a significant correlation between capillaroscopic abnormalities and disease activity in SLE patients [15], [29], [30]. In this study, a significantly higher proportion of SLE patients exhibited a prominently visible sub-papillary venous plexus compared to healthy controls (51.9% versus 7.4%, p <0.001). The control group also demonstrated a statistically significant higher mean capillary density of 8.3 ± 1.6 compared to 7.2 ± 1.9 in the SLE group (P = 0.024). Consistent with these findings, previous research has also indicated a lower mean capillary density at the nailfold in SLE patients compared to healthy individuals [31]–[33]. However, the mean length of capillaries did not show any statistically significant difference between the control group (323.8 ± 70.3 µm) and the SLE group (340.6 ± 108.1 µm) (p = 0.502).

In this study, the normal range for mean capillary length was defined as 200 to 500 µm. Three SLE patients (11.1%) exceeded this limit with abnormal capillary lengths (>500 µm), while none in the control group did. Similarly, another study noted a significantly higher frequency of abnormal mean capillary lengths among SLE patients compared to controls [25]. In our study, the majority of SLE patients exhibited high or very high disease activity. In contrast, other studies have predominantly included patients with low-intensity inflammatory processes, potentially indicating undetectable tissue perfusion damage by NVC [34], [35].

In our study, the observed morphological abnormalities among SLE patients included tortuous capillaries, crossed capillaries, meandering capillaries, bizarre capillaries, and bushy capillaries. Corkscrew capillaries and ramified capillaries were not identified in this series. In contrast, other studies have reported a range of capillary morphological abnormalities in SLE patients, such as meandering capillaries, tortuous capillaries, corkscrew capillaries, bushy capillaries, and capillary hemorrhage [20].

The disparity between their findings and our study may stem from differences in the ethnic compositions of the cohorts. Tortuous capillaries, followed by crossed capillaries, were the second most common morphological abnormalities observed in our current study, found in 63% of SLE patients compared to 14.8% in the control group, a difference that was highly statistically significant (p < 0.001). In our study, 26 out of 27 SLE patients (96.3%) exhibited nailfold capillary changes, whereas some abnormalities were also noted in the control group, albeit less frequently. Specifically, 63% of controls had a normal NFC pattern, while 37% showed minor changes. In contrast, more than half of the SLE patients (51.9%) displayed major changes, with an additional 11.1% exhibiting severe changes (scleroderma pattern of capillaroscopy), totaling 63% with major to severe NFC changes. This difference between the two groups reached statistical significance (p < 0.001). A study documenting nailfold capillary morphological changes in SLE reported minor changes in 30.6% and major changes in 63.9% of cases, figures comparable to our findings. Meanwhile, studies conducted in the Egyptian population reported lower prevalence rates of nailfold capillary abnormalities among SLE patients, at 76.7% and 75%, respectively, which contrasts with the higher prevalence observed in our study [30], [34], [35].

In a separate study, no statistically significant correlations were found among various nailfold capillaroscopic findings, age, disease duration, treatment regimens, or specific clinical manifestations such as cutaneous, renal, or neurological involvement in their cohort [36]. In our current study, meandering capillaries were observed in 10 out of 27 SLE patients (37.04%), all of whom also exhibited renal involvement. However, no definitive conclusions could be drawn as these patients also presented with other phenotypes, including mucocutaneous, musculoskeletal, cardiovascular, and hematological manifestations. Since our study did not include follow-up assessments for capillary changes post-treatment, future investigations involving regular capillaroscopy examinations over long-term follow-ups could reveal dynamic changes in nailfold capillary morphology during disease activity and remission phases. Such studies may elucidate correlations between the timing or pattern of capillary changes and the subsequent clinical outcomes in SLE patients with capillary abnormalities.

Conclusion

This study highlights the significantly higher prevalence of nailfold capillary changes in SLE patients compared to healthy individuals. Furthermore, it establishes a notable positive correlation between nailfold capillary changes and SLEDAI scores. These findings underscore the diagnostic utility of nailfold capillaroscopy in SLE.

Limitations

The study’s sample size was relatively small, and participants were recruited solely from a single tertiary-level government hospital.

Recommendations

Nailfold capillary changes could serve as a valuable adjunct for diagnosing and assessing disease activity in SLE patients. There is a pressing need for increased education and training among internists and rheumatologists in nailfold capillaroscopy. Future longitudinal studies with larger sample sizes are warranted to further elucidate the role of nailfold capillary changes in managing SLE within our healthcare setting.