Patterns are tools
The end-goal is not to force a label. The end-goal is a clinically useful interpretation that can be integrated with Raynaud history, examination, autoantibodies, organ screening, and follow-up.
Capillaroscopic Patterns
A practical guide to normal, non-specific, and Cutolo systemic sclerosis capillaroscopy patterns.
Pattern Language, Used Carefully
In daily capillaroscopy, pattern recognition is a starting language, not the final answer. A useful report still has to describe image quality, capillary density, morphology, hemorrhages, avascular areas, distribution across fingers, and clinical context.
The simplest practical distinction is normal pattern, non-specific pattern, and a systemic-sclerosis-type microangiopathy. The Cutolo early-active-late scheme remains the classic way to describe scleroderma-pattern evolution in systemic sclerosis, but it is visual and partly observer-dependent.
Before Naming a Pattern
Describe before concluding
A pattern label should be backed by visible findings: density, giant capillaries, hemorrhages, avascular areas, abnormal shapes, and whether changes repeat across several evaluable fingers.
Visual categories vary between observers
Cutolo patterns are useful, but they are not completely objective. Borderline studies, poor image quality, mixed features, and isolated abnormalities can be interpreted differently by different readers.
Three Practical Buckets
Baseline
Normal Pattern
A normal pattern has an ordered distal row, preserved density, predominantly hairpin or U-shaped loops, and no coherent microangiopathic pattern.
- No repeated giant capillaries.
- No diffuse capillary loss or broad avascular areas.
- No repeated non-traumatic hemorrhages forming a pattern.
- Minor tortuosities or occasional variants may still be compatible with normality.
Grey zone
Non-Specific Pattern
A non-specific pattern contains abnormalities, but not enough structure to call it scleroderma-pattern microangiopathy.
- Examples include mild tortuosity, isolated dilations, sparse hemorrhages, or borderline density reduction.
- Common causes include technical artefact, trauma, cosmetics, vascular risk factors, and non-SSc inflammatory disease.
- The correct output is often a cautious description rather than a disease label.
SSc-type
Scleroderma Pattern
A scleroderma pattern is a coherent combination of giant capillaries, hemorrhages, capillary loss, avascular areas, disorganization, and neoangiogenesis.
- It has high clinical value in Raynaud assessment when the clinical and serological context fits systemic sclerosis.
- It can also appear as a scleroderma-like pattern in other diseases, especially inflammatory myopathies.
- Cutolo early, active, and late patterns describe the dominant stage of this microangiopathy.
Cutolo Patterns in Systemic Sclerosis
The Cutolo scheme is best understood as a practical description of dominant microvascular damage, not as a rigid biological sequence that every patient must follow.
Early
Few giant capillaries and few microhemorrhages, with relatively preserved capillary distribution.
- Giant capillaries are present but not numerous.
- Hemorrhages may be visible but remain limited.
- Capillary loss is absent or minimal.
Do not overcall early SSc from a single enlarged loop or one traumatic hemorrhage.
Active
Frequent giant capillaries and hemorrhages, with moderate capillary loss and early architectural disorganization.
- Giant capillaries and hemorrhages are prominent.
- Density begins to fall in a repeated way.
- The distal row becomes less regular.
The active label should come from the overall field and several fingers, not from one striking capillary.
Late
Severe capillary loss, avascular areas, disorganization, and neoangiogenesis, often with fewer typical giant capillaries.
- Avascular areas and capillary rarefaction dominate.
- Ramified, bushy, or highly abnormal capillaries become more visible.
- Classic giant capillaries may be less evident despite more advanced damage.
A late pattern may look less 'giant-capillary rich' while still representing more severe microvascular damage.
Representative Pattern Cases
These complete capillaroscopy studies show how normal, non-specific, and Cutolo SSc patterns appear across multiple fields. They help calibrate pattern recognition while keeping the pattern label as only one part of the capillaroscopy interpretation.
Normal Pattern: Representative Case
Normal Capillaroscopy
Normal Pattern
Mild
Complete capillaroscopy study with preserved density, regular morphology, and no scleroderma-pattern features.
Author: Miguel Antonio Mesa Navas
Clinical context: A normal reference study is useful for comparing density, loop morphology, and distal-row organization before judging abnormal patterns.
Capillaroscopy: The complete image set shows a regular distal row, preserved density, absent giant capillaries, and no avascular areas.
Key Capillaroscopic Findings:
- • Preserved capillary density across the study
- • No giant capillaries or avascular areas
- • Regular architecture without scleroderma pattern
normal pattern
reference case
nailfold capillaroscopy
Non-Specific Pattern: Representative Case
Non-Specific Microangiopathy
Non-Specific Pattern
Mild
Complete capillaroscopy study with preserved density, mild morphologic changes, and hemorrhages without giant capillaries.
Author: Miguel Martín Cascón
Clinical context: This example highlights how hemorrhages or mild morphologic variation can be abnormal without forming a reproducible scleroderma pattern.
Capillaroscopy: The study shows preserved density, around 8.8 capillaries/mm, scattered dilated or tortuous loops, and hemorrhages around 0.46/mm, with no giant capillaries and no Cutolo SSc pattern.
Key Capillaroscopic Findings:
- • Preserved capillary density, around 8.8/mm
- • Hemorrhages are present, around 0.46/mm
- • No giant capillaries; mild dilation and tortuosity without SSc pattern
non-specific pattern
microangiopathy
differential pattern
Early SSc Cutolo Pattern: Representative Case
Systemic Sclerosis
Early Cutolo SSc Pattern
Moderate
Complete capillaroscopy study illustrating early scleroderma-pattern microangiopathy with preserved density.
Author: Borja Gracia Tello
Clinical context: In early Cutolo SSc, the descriptive label should be integrated with Raynaud history, autoantibodies, and the broader clinical assessment.
Capillaroscopy: The study shows scattered giant capillaries and limited hemorrhages while capillary density and overall architecture remain relatively preserved.
Key Capillaroscopic Findings:
- • Few giant capillaries on a preserved-density background
- • Limited hemorrhages
- • No established avascular areas or major disorganization
systemic sclerosis
early cutolo pattern
giant capillaries
Active SSc Cutolo Pattern: Representative Case
Systemic Sclerosis
Active Cutolo SSc Pattern
Moderate to Severe
Complete capillaroscopy study with prominent giant capillaries, hemorrhages, and moderate capillary loss.
Author: Borja Gracia Tello
Clinical context: In active Cutolo SSc, pattern reading depends on the balance of giant capillaries, hemorrhages, density loss, and early disorganization across several fields.
Capillaroscopy: The study shows frequent giant capillaries and hemorrhages with reduced density and early architectural disorganization.
Key Capillaroscopic Findings:
- • Frequent giant capillaries
- • Hemorrhages with capillary density reduction
- • Beginning architectural disorganization
systemic sclerosis
active cutolo pattern
hemorrhages
Late SSc Cutolo Pattern: Representative Case
Systemic Sclerosis
Late Cutolo SSc Pattern
Severe
Complete capillaroscopy study dominated by capillary loss, architectural disorganization, and abnormal neoangiogenic shapes.
Author: Gema María Lledó Ibáñez
Clinical context: In late Cutolo SSc, fewer classic giant capillaries may coexist with more advanced microvascular damage and remodeling.
Capillaroscopy: The study shows severe capillary rarefaction, avascular areas, disorganization, and ramified or highly abnormal capillaries.
Key Capillaroscopic Findings:
- • Severe capillary loss and avascular areas
- • Marked architectural disorganization
- • Ramified or abnormal neoangiogenic capillaries
systemic sclerosis
late cutolo pattern
capillary loss
Key References
- Cutolo M, Sulli A, Pizzorni C, Accardo S. Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis. J Rheumatol. 2000;27(1):155-160. PMID 10648032 .
- Cutolo M, Pizzorni C, Tuccio M, Burroni A, Craviotto C, Basso M, et al. Nailfold videocapillaroscopic patterns and serum autoantibodies in systemic sclerosis. Rheumatology (Oxford). 2004;43(6):719-726. doi:10.1093/rheumatology/keh156 . PMID 15026581 .
- Sulli A, Secchi ME, Pizzorni C, Cutolo M. Scoring the nailfold microvascular changes during the capillaroscopic analysis in systemic sclerosis patients. Ann Rheum Dis. 2008;67(6):885-887. doi:10.1136/ard.2007.079756 . PMID 18037628 .
- Cutolo M, Melsens K, Herrick AL, Foeldvari I, Deschepper E, Iagnocco A, et al. Reliability of simple capillaroscopic definitions in describing capillary morphology in rheumatic diseases. Rheumatology (Oxford). 2018;57(4):757-759. doi:10.1093/rheumatology/kex460 . PMID 29361155 .
- Smith V, Vanhaecke A, Herrick AL, Distler O, Guerra MG, Denton CP, et al. Fast track algorithm: How to differentiate a "scleroderma pattern" from a "non-scleroderma pattern". Autoimmun Rev. 2019;18(11):102394. doi:10.1016/j.autrev.2019.102394 . PMID 31520797 .
- Gracia Tello BDC, Sáez Comet L, Lledó G, Freire Dapena M, Mesa MA, Martín-Cascón M, et al. Capi-score: a quantitative algorithm for identifying disease patterns in nailfold videocapillaroscopy. Rheumatology (Oxford). 2024;63(12):3315-3321. doi:10.1093/rheumatology/keae197 . PMID 38530791 .
- Lledó-Ibáñez GM, Sáez Comet L, Freire Dapena M, Mesa Navas M, Martín Cascón M, Guillén Del Castillo A, et al. CAPI-Detect: machine learning in capillaroscopy reveals new variables influencing diagnosis. Rheumatology (Oxford). 2025;64(6):3667-3675. doi:10.1093/rheumatology/keaf073 . PMID 39918978 .