Review Article

Capillaroscopy and videocapillaroscopy assessment of skin

microcirculation: dermatologic and cosmetic approaches
Blackwell Publishing, Ltd.

Philippe Humbert, Jean-Marie Sainthillier, Sophie Mac-Mary, Adeline Petitjean, Pierre Creidi
& Franois Aubin
1

Cutaneous Engineering and Biology Laboratory, Saint Jacques University Hospital, Besanon, France

Summary

Background Different noninvasive bioengineering techniques exist to study the microvasculature of the skin and the dynamics of the microcirculation. The goal of these
techniques is to visualize the skin capillary circulation easily and directly. Indeed, this
information is irreplaceable to study the physiology and physiopathology of the skin
capillary circulation efficiently.
Aims Capillaroscopy and video-capillaroscopy techniques are presented with different
methods to study the capillary structure of the skin.
Methods The methods presented in this work include image processing analysis combining morphology, statistics, geometry, and neural network detection designed to quantify
the microcirculation and to follow its evolution. To illustrate the combination of these
techniques and methods, different examples of their application are described, in dermatology (hypertension, venous insufficiency, age-related changes) as well as in cosmetology
(rosacea and erythrosis assessment).
Conclusion The determination of structural or dynamic changes in the cutaneous microcirculation belongs to the noninvasive techniques of the biometrological domain. Thus,
every capillary modification resulting from topical cosmetic products, or chemical agents
can be observed. In pathology, numerous conditions can be better examined with this
system. Associated with the potential of numerical image analysis, capillaroscopy techniques
will probably extend their application fields to the assessment of the influence of arterial
and venous diseases on the skin nutritional circulation.
Keywords: capillaroscopy, image processing, microcirculation, morphology, videocapillaroscopy

Introduction
Many methods are now available for studying skin
microcirculation, and are set in motion in cosmetology
and pathology. Microcirculation may be defined as the

Correspondence: Philippe Humbert, MD, Dermatology, Saint Jacques

University Hospital, Besanon, France, 25000,
E-mail: dermatologie-1@chu-besancon.fr
Accepted for publication June 25, 2005

2005 Blackwell Publishing Journal of Cosmetic Dermatology, 4, 153162

blood circulation in arterioles (< 300 m), capillaries,

and venules.1 Studies of capillary function in man are
difficult because of limited access to the vascular bed.
However, skin capillaries can readily be studied by the
technique of capillaroscopy, which is the most useful
method to directly visualize the skin capillary circulation
and to assess density and blood flow velocity. Therefore,
both morphology and blood flow can be investigated.
The straightforward morphological analysis of the
superficial dermal capillary network provides a precise
and nontraumatic assessment of various microangiopathies;

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Table 1 Different architectural frameworks of skin capillary network.4

Parallel arrangement and
regular meshes network
Forehead
Cheekbone region
Cheek
Chin
Internal surface of arms

Parallel arrangement with

irregular meshes network
Trunk (anterior and)
posterior aspects
Breast
Arms (external surface)
Legs (internal and external surfaces)

Perpendicular arrangement
and regular dot line
Fingertip
Eminentia tenar
Eminencia hipotenar
Tip of toes

at present it should therefore be the most widely used

technique to study microcirculation in human clinics.

Anatomy of the skin microcirculation

The skin microcirculation is organized into two
horizontal plexus, one located 11.5 mm below the skin
surface, and the other at the dermal-subcutaneous junction
that comprises collecting veins. It consists of arterioles,
which may divide into many capillary loops in the papillary
layer of the skin. Indeed, arterial capillaries give rise to
form the dermal papillary loops at this level.1,2 Capillaries
then converge into collecting systems of the venous plexus.
The vascular network of the skin varies considerably from
one area to another.3,4
In most body areas, the vascular morphology shows
differences (Table 1). Line and network forms dominate
on the forehead and crows feet at the eyes, the dot and
comma ruled on the dorsum of the hand5 while both
types occurred equally on the inner forearm.
The normal architectural framework, which can be
vizualized by videocapillaroscopy (see paragraph below),
shows two main patterns, a parallel and a perpendicular
arrangement of capillary loops with respect to the
skin surface (Fig. 1a). Capillary loops with a parallel
arrangement form a vascular network with meshes,
which may or may not be regular. In most areas6,7 capillaries are perpendicular to the skin surface so that only
the summit can be seen (Fig. 1b). It looks like a point
or a comma. The calibre of capillaries varies from 15 to
20 m in regions with parallel arrangement of capillary
loops. The capillary density ranges from 14 to 30 capillary
loops per mm2 in skin regions where capillary loops are
arranged perpendicularly to the skin surface.4

Apparatus
Capillaroscopy

Among the different techniques available5 to study skin

microcirculation (Table 2), human skin capillaroscopy, a

154

Perpendicular arrangement
and irregular dot line
Palm of hands
Back of the hand
and the foot
Nipple

Special pattern with

parallel arrangement
Fingernail fold
Labial mucosa

specialized form of intravital microscopy, is the only

method that allows direct visualization of the capillary
network in vivo. Its principle is simple. After a drop of
oil is added to enhance skin transparency, an optical
magnifying system is used to visualize its vascular
network directly through the skin.
Peringual capillaroscopy (Fig. 2) is usually performed
in order to look for capillary deformations, which characterize the presence of a pathological situation.8,9 In this
area, capillaries lie in a horizontal plane, so that a large
part of their loops can be observed. Their aspect is distinct:
they look like hairpins with a diameter of 815 m,
are parallel, and are orientated to the extremity of the
finger (Fig. 3a).
Some distinctive aspects of the capillary loops allow
systemic conditions such as progressive systemic sclerosis or lupus erythematosus (Fig. 3b) to be detected.
Nailfold capillaroscopy has a good sensitivity and a good
specificity. Therefore, morphological abnormalities must
systematically be looked for in all accessible fingers.
Videocapillaroscopy

Videocapillaroscopy devices (Fig. 4) tend to replace the

more conventional capillaroscopy instruments. Contact
videomicroscopy systems appeared recently in the industry
for nondestructive control processes. They require epiillumination of the skin surface10 and image transmission
to a video camera via the optics of a microscope. The
sensor located at one end of a flexible cord easily allows
investigation on the whole tegument. Optical fibers convey
illuminating light provided by the handheld probe. The
images are visualized on a monitor then digitalized. Image
numerization can be done directly during the examination,
and data quality is therefore controlled instantly.
The video imaging systems (Scopeman, FORT,
Microvision, Microwatcher) consist of a video signal
control unit and a mini CCD (charged-coupled device)
camera. A manually adjusted focusing system coupled
with the camera head allows a sharp image of the capillary network to be obtained. Magnification ranges from

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Figure 1A Simplified cross-section of the skin. (a) Capillary loops, perpendicular to skin surface; (b) Horizontal capillary network; (c) deep

dermal vascular plexus; (d) hypodermis vascular plexus.

Figure 1B Vascular morphology examples in different skin body areas. (a) Scalp; (b) forehead; (c) cheek; (d) forearm. Dark red dots are the

tops of papillary loops. Below them, out of focus, the superficial part of the subepidermal vascular plexus. (magnification 200 = 1.73 mm2)

2005 Blackwell Publishing Journal of Cosmetic Dermatology, 4, 153162

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Table 2 Noninvasive bioengineering techniques used to study skin

microcirculation.
Skin temperature measurements
Capillaroscopy
Dynamic capillaroscopy
Dynamic capillaroscopy with dye
Laser Doppler flowmetry
Isotope techniques (133Xenon)
Transcutaneous measurement of partial oxygen pressure
Capillary pressure
Photopulse plethysmography
Infrared thermography
Colorimetry

Figure 2 Capillaroscopy equipment for the nailfold area analysis.

100 to 1000 . A magnification higher than 600

enables blood cells inside the capillary to be visualized. Venous
congestion increases the number of capillaries detected.
Capillaries detection
Videocapillaroscopy is mainly used for the morphological
information it provides, and it is different from indirect
techniques (laser-Doppler, transcutaneous PO2) also
because it is free from interpretation artifacts, a considerable
advantage in a field as complex as microcirculation.
However, because of the absence of quantification
and the subjective and operator-dependent character
of capillaroscopy, it has its limits.

156

Quantitative capillaroscopy is now possible because

computerized systems and a series of advanced image
processing methods have been developed.
Finding capillary loops automatically in an image is a
difficult yet important first step in achieving microcirculation analysis. An automatic counting of capillaries
is now available11,12 with a detection rate of 82%. This
detection system was based on principal component
analysis (PCA), and was associated with a retinally
connected neural network. This filter system is capable of
real-time processing, recognition of capillaries anywhere
in an image, and successful operation under a wide range
of lighting and noisy conditions.
It is assumed that the study of microcirculation must
include all dynamic and cooperative processes between
the capillaries. Indeed, the geometric complexity of the
capillary structure can lead to heterogeneities in oxygen
delivery. If a finite tissue element is not within the proximity
of a capillary site, necrosis could develop in that tissue area.
Geometrical capillary network analysis
For characterizing capillary ensembles, the statistical
and geometrical properties of the network need to be
explored.13 In fact this network forms a map, which is
based on the adjacent relationship among the capillaries.
These relationships14,15 can be quantified by a distance
parameter (distance between one capillary and all its
neighbors) and a surface parameter (an influence area
corresponding to a surface around the capillary).
Zhong et al.13 described for the first time a method to
construct the capillary network by using image processing with Delaunay triangulation and Vorono diagram.
Delaunay triangulation16 was implemented to obtain
the nearest neighbor for each capillary (Fig. 5a). This
representation can calculate the minimal, the maximal,
or the mean distance between capillaries. Vorono diagram17
was used to determine a surface parameter which could
be considered as an oxygen diffusion area (Figure 5b).
For each parameter, the distribution (thresholding or
normalization) was analyzed in order to eliminate extreme
values, which correspond to artifacts.18 We noticed
that without these values, the proximity parameters
distribution was normal.
These algorithms have been implemented in a software
platform (Capilab Toolbox) providing functions and
interactive tools for analyzing pictures of the skin. This
graphical environment integrates complete statistical
and geometrical computing, visualization, and image
enhancement algorithms.
The analysis could be improved by taking into account
the morphological parameters (shape, roundness) of each
capillary (Fig. 6). Indeed, we do not know whether a

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Figure 3 Nailfold capillaroscopy images. (a) Normal aspect; (b) dilated capillaries with heterogenous distribution in lupus erythematosus.

detected capillary is physiologically active or not, and if

an interaction exists between patterns with different
shapes or sizes. The mathematical morphology could
be a means to focus the analysis on a specific group of
capillaries, with the same properties, or to construct a
network with shape-based relations.

Applications

Figure 4 Contact videocapillaroscopy with monitoring on TV set.

Videomicroscope Optican high definition system (FORT).
Videotape recorder: SVO 9500 MDP (Sony). Monitor: PVM
1440 (Sony). The objective 200 examines a 1.73 mm2
area.

2005 Blackwell Publishing Journal of Cosmetic Dermatology, 4, 153162

The availability of videomicroscopes together with advances

in our knowledge about the importance of microcirculation
in the pathogenesis of trophic complications of arterial
and venous insufficiencies explain the present development
of capillaroscopy on the skin.
The determination of morphological or dynamic changes
in the microcirculation belongs to the noninvasive
techniques of the biometrological domain.
Some conditions such as peripheral arterial obliterative
disorders and venous disorders such as venous insufficiency
(Table 3) are candidates for microcirculatory evaluation.
Thus, videocapillaroscopy was used to assess microcirculation in hypertension, venous insufficiency,

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Peripheral arterial obliterative disorders19

Venous insufficiency20
Diabetes mellitus21
Hypertension22
Psoriasis23
Aging24
Effects of topical cosmetics or chemical agents

Specific morphological changes

Rarefaction and dilatation of the capillary loops
Tortuous and dilated capillaries
Capillary rarefaction
Grossly dilated and tortuous capillaries
Many more perfused capillaries
Reduced dermal papillary loops
Miscellaneous

Table 3 Pathological or cosmetical usefulness

of videocapillaroscopy.

video microscopy allowed a 15% to 20% reduction in the

capillary density of the nailfold skin to be discovered.
Intravital fluorescein angiography showed a 20% reduction
in capillary density in the forearm skin of hypertensive
subjects compared with normotensive subjects.25
Venous insufficiency

Videocapillaroscopy is mainly performed on the instep in

venous insufficiency, and on the back of the foot (first
intermetatarsian space and toes) in arterial insufficiency.
Venous insufficiency is characterized by the decrease
of the capillaries density, the widening of the dermal papilla
(the size of which becomes heterogeneous), and the contours
marked by the hemosiderine deposits of ochre dermatitis. The
decrease of the capillaries density is partially compensated
by their increased length, inducing an increased number
of meanders, which can even take the shape of a glomerular
cluster in the most severe forms (lipodermatosclerosis,
white atrophy). As soon as the first trophic troubles occur,
the venules are no longer visible.26 28
Fagrell has described three classes of increasing severity,
and validated their discriminating value for the local
trophic prognosis29,30: (i) capillary dilatation, (ii) edema
impairing capillary visualization, (iii) absence of visible
capillary (prenecrosis stage).
Age-related changes of the cutaneous microcirculation
Figure 5 Delaunay triangulation (a) and Vorono diagrams (b). 67
capillaries, on the scalp. 200 = 1.73 mm2.

age-related changes, couperosa (Fig. 7a), or psoriasis

(Fig. 7b).
Hypertension

Capillary network analysis on the volar aspect of

the forearm or on the fingers could be of interest in
hypertension. Indeed, it was suggested that microvascular rarefaction represents an important mechanism
in primary hypertension. The introduction of intravital

158

A significant decrease of cutaneous capillary loop density

is observed with age (Table 4). The microvasculature
is regularly formed in young skin, with many orderly
arranged capillary loops (dots) and some horizontal
vessels (lines) (Fig. 8a).31 It becomes thicker, twisted,
and irregular in older skins (Fig. 8b), with horizontal
vessels which appear tortuous, elongated, disorganized,
and dilated (personal data). Thus, the parallel vasculature
can be more easily observed with aging. This result
accords with that of biopsy specimens observed by light or
electron microscope. As the epidermis becomes thinner,
the transparency of the skin increases, facilitating the
observation of the papillary vascular plexus. And as

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Figure 6 Intermediate images showing the morphological image processing technique. (a) Original 24-bit RGB image; (b) automatic neural
detection of each capillary loop (78 loops detected); (c) gray-scale image after preprocessing; (d) binary image with the finally identified
capillaries and their shapes.

Table 4 Number of capillary loops in five

age groups on different examined sites
(n = 20).

Sites

Group 1

Group 2

Group 3

Group 4

Group 5

Age range (years)

(Mean age)
Hand
Arm
Postauricular

2029
(25.3)
48.5
23.3
12.6

30 39
(34.5)
41.4
23.1
16.5

40 49
(44.6)
49
26.8
13.3

50 59
(53.5)
38
26.8
15.5

60 69
(64.4)
28.5
20.1
2.6

Assessment of cutaneous microvasculature in aging and photoaging: a videocapillaroscopic

study in caucasian women, personal data, 2002.

the vasculature expands and thickens, some of the

microvasculature (usually difficult to observe) and the
deeper vasculature can also be examined. The results also
indicate that photodamaged vessels correspond to an
increased formation of new vessels.32

2005 Blackwell Publishing Journal of Cosmetic Dermatology, 4, 153162

Rosacea and erythrosis assessment

Rosacea is a frequent disease that occurs mostly in

women. Rosacea is heralded, around the age of 20 years,
by intermittent facial erythema, and by the gradual

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Figure 7 Peripheral arterial obliterative disorders. (a) Rosacea

( 50 = 27 mm2), calculated surface parameter = 8.2 %.

(b) Psoriasis with dilated and tortuous capillaries
( 200 = 1.73 mm2), total of 67 loops detected, including 26
tortuous loops detected.

development of permanent erythema (erythrosis) with

telangiectasia (rosacea).
Image processing techniques based on neural network
algorithms can be used again to detect and to quantify by
a surface parameter of the erythema in the pictures. A
color neural networkbased method was developed,
based on an RGB (red, green, blue) and a L*a*b* code
(System of the Commission Internationale de lEclairage),
that is capable of real-time processing, increases the
quality of videocapillaroscope images, and minimizes
the disturbance of artifacts.33 This system can selectively
recognize regions where the rosacea is heavy or light.
The algorithms (implemented in Capilab Toolbox)
can process any kind of color images of the skin
(Fig. 9).

160

Figure 8 Capillary patterns observed by videocapillaroscopy on the

hand of young (a) and elderly subjects (b).

Discussion
The determination used of morphological or dynamic
changes in the cutaneous microcirculation belongs to the
noninvasive techniques of the biometrological domain. In
pathology and cosmetology, numerous conditions can be
better examined with this system.
Capillaroscopy is now used routinely in different hospitals
and companies. Although it requires some experience,
this technique brings direct information on the capillary
network morphology. It differs from the indirect methods
used to explore microcirculation, such as laser Doppler or
transcutaneous partial oxygen.
The techniques used to visualize skin capillaries enable an
irreplaceable approach of the physiology and physiopathology
of the skin capillary circulation to be obtained. Compared
to other heavy research methods, traditional capillaroscopy
techniques, which are much simpler and cheaper, have
shown their usefulness in the detection of connectivite
microangiopathies and vascular acrosyndromes. Combined

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Capillaroscopy assessment of skin microcirculation P Humbert et al.

Figure 9 Examples of rosacea image processing. First row: original image at time T0 (a) and its neural filter (b) calculated surface
parameter = 21.4%. Second row: original image at time T2 (c) after 2 months of treatment, and its neural filter (d). Calculated surface
parameter = 8.5%. Arrows show the pattern used for repositioning.

with the potential of numerical image analysis, they will

probably extend their application fields to the assessment
of the influence of arterial and venous diseases on the skin
nutritional circulation.

Conclusions
Direct visualization of the skin capillaries is of the utmost
interest to the study of microcirculation and associated
diseases. Capillaroscopy and especially videocapillaroscopy,
combined with image processing, can be used widely in
dermatology. Their application can be easily adapted for
use in pharmacological and cosmetical research.

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Appendix
Capiflow, Capiflow AB, Kista, Sweden
FORT Imaging Systems, Curno BG, Italia
Scopeman Moritex, P.M. Industries Ltd, Cambridge, UK
Microvision MV 2100, Finlay Microvision Co. Ltd,
Warwickshire, UK
Microwatcher Model VS-10, Mitsubishi Kasei Corp.,
Tokyo, Japan
Capilab Toolbox, Cutaneous Engineering and Biology
Laboratory (LIBC), Besanon, France

2005 Blackwell Publishing Journal of Cosmetic Dermatology, 4, 15 3 162