Nail/Skin Diagnostics 😀

[kafie]

Hey everybody! I recently ran across some interesting information that may help some of you guys. I know some of you suspect your Dysautonomia is connected to an autoimmune process and some have family members diagnosed with catch-all categories for their autoimmune illnesses.

I couldn't remember who exactly I had talked to about wanting to differentiate psoriasis from fungus and other inflammatory conditions.

I found a cool technique called Dermoscopy (looking at the skin/nails/blood vessels under a microscope). You can purchase a cheep microscope (about $10-$20 for a handheld, lighted microscope, $30-$40 for a USB microscope... You will need at least 10x magnification, preferably 50x... And 100-200xs minimum of you want to look at capilaries.

This technique can aid in the diagnosis of: Dermatomyositis, Systemic Sclerosis, Sjogren's, Raynaud's (in differentiating primary from secondary), Systemic Lupus, Psoriasis (and PsA), RA (to a lesser extent, the pattern isn't super definitive from what I can tell... there seems to be two patterns that show up)... as well as show changes from diabetes, heart disease, and schizophrenia. It call also help to differentiate fungal infections from inflammatory skin conditions (like eczema and psoriasis but also lichen planus, rosasea, ect).... And a ton of other skin and nail conditions. Considering it's so inexpensive and takes about 1-5 minutes to perform... I'm surprised it's not used more often (especially since many of the signs are both very specific and sensitive (seen often in the condition and only seen in the condition)).

Prep: acclimate yourself to room temp for 20-30 minutes. Nothing strenuous before, no smoking, no stimulants, ect, within that time (provided you want to look at the capilaries). Clean areas you intend to examine. For wet examination use coconut oil, petroleum (vaseline or mineral oil), or plain lube (like KY - which seems to be what they use in research studies)... Basically, clear, preferably unpigmented oil as an interface (this makes capilaries more visible but reduces the view of scales).

 

Skin (Dermoscopy)

I'd start at 50x magnification if you can. Look at spots with obvious involvement first (they may show up in spaces that don't appear effected to the naked eye, I had scales everywhere I have joint involvement). Look for scales, red and pink areas, and red dots. Pink areas are likely spots of inflammation or vessel dilation. Tiny red spots are blood vessels under the skin. In psoriasis they will be equally spaced, possibly in circles, lines, or rings. In eczema they are randomly arranged and usually in circles/globs. Scales in psoriasis are sparkly and white to creamy colored on pink or red skin (possibly with microhemorrhages/bright red to brown spots). In eczema they are likely yellow. Fungal infection will not show up with sparkly scales (these are caused by the scales sticking to each other and trapping air - the appearance is called "micaceous").

Nails (Onychoscopy)

Note: some of this a regular magnifying glass may suffice... or the highest magnification available to your cell phone, some of it needs at minimum 20-50x.

Eczema, and psoriasis can all cause nail changes, amongst other conditions. Look for color and pattern (same as scales). Lifting will show as light/whitish-creamy spots near the end of the nail, in psoriasis this will be bordered by red/pink (inflammation). Bordering lifted or thickened spots may also be yellow/orange/salmon roundish areas (these are called salmon/oil spots). Look for ridges (ps can cause both vertical and horizontal ridges, ra can cause vertical ridges, some of which may not be visible to the naked eye). Fungal will appear with verticle stripes, they look like spikes and can be any color from a light yellow to brown to green (also may have areas that look like mushroom clouds - these are large areas of fungus - spikes show the direction that the fungus has spread). Bleeding may also be visible as red, brown, or purple spots. Thickened spots from PS usually have more flat or rounded boarders but they may look like spikes at lower magnification (especially if they have hemorrhages in them), so increasing magnification to 200x can help differentiate them. You may also see microbleeds around the nails (not just under) or on the cuticles (I found them ALL OVER the affected areas... Kinda freaked me out a little honestly). Pitting can also be seen in a variety of inflammatory skin conditions (they look like little tiny dents... they may fill with interface cream that's been applied or dye if used... They may also appear yellow in the center). Fungus also usually shows a "ruin appearance" which causes the thickened bit under the nail to look torn or like there's little caves (note: under lower magnification psoriasis may look like this but greater magnification will likely show brown and red spots (which are hemorrhages)... With the thickned bit being relatively uniform (there may be cracks though)). There's a bunch of other findings that are very, very specific. A look at the wet nail will make it near impossible to see scaling but can help you see bleeds and things like salmon patches... It may also make micropits show up more clearly.

Veins/Blood Vessels/Ect (Capillaroscopy)

This test you'll need to do wet. In my experience vaseline can be a pain to work with... It likes to be irregularly thick which can hide or blur things. If you have a thinner oil (like lube or mineral oil), this works very well. It can still be a pain in the butt on areas where there's skin involvement because it can make bumpy and scaly skin very shiney but it's easier to work with.

The areas to look are: involved skin, above the cuticles ("proximal nail fold") and in the nails themselves ("nail bed").

Capilaries are usually very uniform - they should be nearly the same spacing, size, shape, length, and relatively straight (a little curving can be normal but they should not go sideways, curl, twist, have missing pieces, or have splotches (the later may actually be a bleed)... they should look kinda like a hairpin with a loop at the top (upside u). Abnormalities show up in a variety of things, but some types are specific to certain conditions. I believe 3 coiled capilaries and 1 other abnormality is normal, but they shouldn't show up on more than 1-2 fingers nor be widespread on a finger (I had several fingers with long rows of coiled/twisting capilaries and several microhemorrhages and avascular areas throughout...). Skin capilaries will usually look like little dots, coiling or capilaries that look like rings may signify a health issue (like psoriasis) - but may not be visible in those without a related health issue. Widespread abnormalities are suggestive of a health issue, especially autoimmune. These changes may show up before the illness becomes apparent on blood tests of with overt signs you can see with the naked eye. Psoriasis shows up with coiled capilaries commonly, amongst other findings. Things like dermatomyositis and Raynaud's will show up with a wide variety of abnormalities (generally a "systemic Sclerosis pattern"). Avascular areas (where there's no capilaries) and microhemorrhages (spots of bleeding) are highly suggestive of a connective tissue (autoimmune) condition. There is also something called angiogenesis which is a sign that new capilaries are growing after they've been destroyed (these look really... really wild)... areas with this sign may have microhemorrhages in the cuticle and up where the capilaries are. There's way too many for me to list them all though. Also, some nail changes may show up with similar capillary changes in the nail bed as the proximal nail fold.

I found Capillaroscopy to be a giant pain in the butt but it was super interesting and also kinda scary (my capilaries are super screwed up).

There's other techniques that use different types of light and the likes. If you are curious enough to do this technique, I'd suggest at least looking up photos from journals or studies to compare. There is a blog called "Who Needs Doctors" that has a very good run down of different capilary changes. There are a lot of changes that basically need a computer program to identify (like abnormal spacing).

I did this test on my husband and found a single microbleed and abnormal capillary. The difference between his and mine was pretty overt.

I just thought I'd share because it was kinda fun and very diagnostically relevant but some places don't have docs that perform it or don't even think to do it. A dermatologist is the best bet there. For systemic Sclerosis and dermatomyositis the capilaries changes are directly connected to disease activity (not necessarily in anything else).

If you don't want to sort through all the diagnostics but are curious you can do it then bring the findings to your doctor. If you're curious enough to want to know what they mean there are plenty of websites with that info (obviously I'd still suggest bringing the findings to your doctor if you find something concerning).

If you have any questions, I'd be happy to help but please know what I'm not a medical professional in any way (I have training in medical coding, which gives me the bare minimum of basic knowledge... mostly enough to read studies and understand them and feed my curiosity, lol).