A Simple Instrument Designed to Provide Consistent Digital Facial Images in Dermatology

Photography has proven to be a valuable tool in the field of dermatology. The major reason for poor photographs is the inability to produce comparable images in the subsequent follow ups. Combining digital photography with image processing software analysis brings consistency in tracking serial images. Digital photographs were taken with the aid of an instrument which we designed in our workshop to ensure that photographs were taken with identical patient positioning, camera angles and distance. It is of paramount importance in aesthetic dermatology to appreciate even subtle changes after each treatment session which can be achieved by taking consistent digital images.     

Better understanding of digital photography for skin color measurement: With a special emphasis on light characteristics

Background/Aim: Digital photography can be used to measure skin color colorimetrically when combined with proper techniques. To better understand the settings of digital photography for the evaluation and measurement of skin colors, we used a tungsten lamp with filters and the custom white balance (WB) function of a digital camera. Materials and methods: All colored squares on a color chart were photographed with each original and filtered light, analyzed into CIELAB coordinates to produce the calibration method for each given light setting, and compared statistically with reference coordinates obtained using a reflectance spectrophotometer. They were summarized as to the typical color groups, such as skin colors. We compared these results according to the fixed vs. custom WB of a digital camera. Results: The accuracy of color measurement was improved when using light with a proper color temperature conversion filter. The skin colors from color charts could be measured more accurately using a fixed WB. In vivo measurement of skin color was easy and possible with our method and settings. Conclusion: The color temperature conversion filter that produced daylight‐like light from the tungsten lamp was the best choice when combined with fixed WB for the measurement of colors and acceptable photographs.     

Digital imaging in clinical dermatology across the UK in the year 2001

Colour photography is an important tool in the daily practice of dermatologists. Digital photography promises quicker acquisition and handling of clinical images. Despite increasing availability and falling costs, dermatologists have been slow in adopting this new technique. To establish to what degree digital photography has found its way into routine practice in dermatology departments in the UK during the year 2001, we conducted a postal survey of all dermatology departments in the UK about usage of digital cameras. A total of 65.4% of the questionnaires were returned. The responses indicated that 71% of departments in teaching hospitals vs. 56% of departments in district general hospitals (DGH) had access to a digital camera. Reasons for not having a digital camera were satisfaction with conventional photography and lack of resources. In 48% of the departments of teaching hospitals or DGH with access to a digital camera, less than 10% of all photos were taken digitally. However, 24% of departments in DGH and 22% in teaching hospitals took more than 80% of their clinical photos digitally, indicating that in many departments digital photography is still in an early phase and only occasionally used, whilst in others a change from conventional photography towards digital photography as the mainly used technique has already taken place. Overall, the main drawbacks of digital photography were poorer resolution in comparison with conventional photography, problems with storage and filing images and time required for downloading and storing images.     

Radio‐guided surgery: advantages of a new portable γ‐camera (Sentinella®) for intraoperative real time imaging and detection of sentinel lymph nodes in cutaneous malignancies

Background The histological status of the sentinel lymph node (SLN) is one of the most relevant prognostic factors for the overall survival of patients with cutaneous malignancies, independent of tumour depth of the primary tumour. Objectives Our study seeks to evaluate the reliability and medical benefit of SLN excision (SLNE) performed with a portable γ‐camera for intraoperative real time imaging of SLN. Methods Therefore our study compares the visualization of SLN performed with preoperative lymphoscintigraphy and preoperative SPECT/CT with the intraoperative real time imaging of SLN performed with a new portable γ‐camera (Sentinella^®) in 60 patients who were treated with a SLNE for early stage melanoma (n = 38), high risk cutaneous squamous cell carcinoma (n = 16), Merkel cell carcinoma (n = 4), sebaceous gland carcinoma (n = 1), and sweat glands carcinoma or porocarcinoma (n = 1). Results Sixty patients were enrolled in this study. The portable γ‐camera visualized all 126 preoperatively identified SLN. 23 additional SLN (15.4%) in 15 patients were only identified using the portable γ‐camera. Two of these additional SLN showed metastatic involvement. Conclusion The portable γ‐camera is an innovative imaging technique, reliable and providing additional information in the detection of SLN. Therefore SLNE with intraoperative γ‐camera use is an attractive option to improve the detection of SLN in cutaneous malignancies and could help to reduce false negative SLN results.     

Inexpensive digital photography in clinical dermatology and dermatologic surgery

Digital photography can be used to follow clinical improvement in a variety of dermatoses, document pre and postoperative results, and document histologic findings from skin biopsies. Images may be printed as part of text documents and can be filed in conventional medical charts. Images can be transmitted via electronic mail rapidly and to any location. We have found digital photography to be relatively inexpensive and a powerful tool to enhance dermatologic practice.     

Safety Evaluation of Stamp Type Digital Microneedle Devices in Hairless Mice

Background

Microneedles provide a minimally invasive means to transport molecules into the skin. A number of specific strategies have been employed to use microneedles for transdermal delivery.

Objective

The purpose of this study was to investigate the safety of two new digital microneedle devices (Digital Hand® and Digital Pro®; Bomtech Electronics Co., Ltd., Seoul, Korea) for the perforation of skin in skin-hairless-1 mice. This device replaces conventional needles and is designed specifically for intradermal delivery.

Methods

We used two newly developed digital microneedle devices to perforate the skin of skin-hairless-1 mice. We conducted a comparative study of the two digital microneedle devices and DTS® (Disk type-microneedle Therapy System; DTS lab., Seoul, Korea). To evaluate skin stability, we performed visual and dermatoscopic inspections, measurements of transepidermal water loss, and biopsies.

Results

The two novel digital microneedle devices did not induce significant abnormalities of the skin on visual or dermatoscopic inspection, regardless of needle size (0.25~2.0 mm). No significant histopathological changes, such as inflammatory cell infiltration, desquamation of the stratum corneum, or disruption of the basal layer, were observed. The digital microneedle devices and microneedle therapy system produced similar results on measures of skin stability.

Conclusion

These two novel digital microneedle devices are safe transdermal drug delivery systems.     

TREATMENT OF SUPERFICIAL MYCOSES IN THE TROPICS: WHITFIELD'S OINTMENT VERSUS CLOTRIMAZOLE

Background. In tropical primary health care, essential drugs should be safe, effective, and as inexpensive as possible. To treat the very common dermatophyte infections of the skin, one may use inexpensive Whitfield's preparations, more expensive topical imidazole derivatives, or extremely expensive oral antifungals. Because a cream base is felt to be more appropriate than an ointment in tropical conditions, we wanted to compare the effectiveness of Whitfield's cream and a topical imidazole derivative in field conditions in the tropics. Methods. A double-blind trial was performed involving 153 patients with a dermatophyte infection of the skin in Karonga District, Northern Malawi, including 25 patients who were Hiv-i-seropositive, comparing Whitfieid's cream with clotrimazole cream. Results. 75 patients were treated with Whitfield's cream and 78 with clotrimazole cream for a period of 6 weeks. Cure rates ranged from 80% to over 90% depending on the definition of cure. If positive cultures after treatment were used as criterion for treatment failure, six were found in each treatment group. One in each treatment failure group was an mv-i-seropositive patient. Conclusions. The great majority of patients in the tropics with a dermatophyte infection of the skin can be cured with a topical antimycotic preparation and do not need expensive oral therapy. This also proved to be valid for HIV-I-seropositive patients. Whitfield's cream and clotrimazole cream are both very effective. The lower cost makes Whitfield's cream the treatment of choice in dermatophyte infections of the skin in tropical primary health care.     

Digital camera images obtained using a light-emitting diode illuminator and their dermatological applications

BACKGROUND/PURPOSE: Although digital cameras have powerful macrocapabilities, flash macrophotographs are often unsatisfactory. The aim of this study was to develop a light-emitting diode (LED) illuminator for macro digital photography that allows colorimetric investigations of the skin. METHODS: We devised an LED illuminator suitable for acquiring super-macro digital images of the skin. Reference CIELAB color chart values were compared statistically with computed values from digital images in order to obtain equations for real CIELAB values. Using these, we acquired and analyzed images of various dermatological conditions using an LED illuminator. RESULTS: The images obtained with the devised LED illuminator were more reproducible than flash-assisted photographs. With proper camera settings, the devised LED illuminator and the color analysis method developed during this study provided digital skin images containing colorimetric information. CONCLUSION: A digital camera equipped with an LED illuminator is a useful tool for dermatological research and clinical practice.     

Polarized light photography enhances visualization of inflammatory lesions of acne vulgaris

Background: Polarized light photography has been used to selectively differentiate surface from subsurface features of photoaged skin.Objective: Our purpose was to compare acne assessments obtained from clinical evaluations with assessments from photographs obtained with flash photography and with perpendicular polarized light photography.Methods: Assessments of acne with the Cunliffe scale were made of 32 subjects. Retrospective evaluations of standard and perpendicular polarized light photographs were made in a blinded fashion by a panel of evaluators.Results: Visualization of inflammatory acne lesions was enhanced with perpendicular polarized light photography, with clear delineation of erythematous borders. Acne assessments with the use of a Cunliffe scale were significantly higher (p = 0.001) from perpendicular polarized light photographs than for clinical evaluations.Conclusion: Polarized light photography enhances visualization of inflammatory acne lesions in a manner not possible with conventional flash photographs, permitting accurate evaluation of the extent of disease and the effectiveness of therapy. (J Am Acad Dermatol 1997;37:948-52.)     

A novel ultraviolet photography technique for assessing photodamage

Photography is critical to accurately capturing clinical results in cosmetic dermatology.  However, this shift from film to digital photography has made the capture of true ultraviolet (UV) images more difficult. Film cameras were developed that used special lighting and film to create true UV images, but this technology has not translated into the digital realm. At present, commercial digital photography systems use computer processing to generate UV-like images from visible light photography. This research developed a technique to obtain UV images with a UV pass glass filter placed in front of the camera lens. The UV filter was opaque to visible light (400–750 nm) with a peak transmission at 360 nm. In addition, a glass infrared (IR) block filter was also placed in front of the UV filter during photography. This research resulted in the development of an affordable digital camera system that was able to capture true UV light photographs.  This technique can be used by research and clinical dermatologists to obtain photographs demonstrating changes in photodamage as a result of therapeutic intervention.     

Fluorescence digital photography of acne using a light-emitting diode illuminator

BACKGROUND/PURPOSE: The fluorescence findings of several dermatological diseases, such as erythrasma, tinea versicolor, and acne are helpful for diagnosis and follow-up. However, many experience difficulty taking photographic images of fluorescence. The aim of this study was to develop a 405 nm light-emitting diode (LED) system for fluorescence digital photography of acne and to determine whether such a diode can be used to evaluate acne. METHODS: Eight healthy acne patients were compared with controls by fluorescence digital photography using a digital camera equipped with a 405 nm LED illuminator. Digital photographs were taken by two different ways of exposure, i.e. appropriate exposure level and longer exposure. One side of the nose, cheek, and glabella was compared. The numbers and extents of fluorescence dots were counted and measured. As normal controls, seven individuals with apparent oiliness and no acne were enrolled. RESULTS: Red fluorescent facial dots were observed and photographed digitally using the 405 nm LED illuminator. These were more numerous and extensive on the glabella and cheeks of acne patients. CONCLUSION: Fluorescence digital photography of acne was successfully performed using a 405 nm LED illuminator. This illuminator could be used for acne evaluations.     

Split‐face study of melasma patients treated with non‐ablative fractionated photothermolysis (1540 nm)

Background Melasma treatment remains challenging despite various laser systems available, because of potential side‐effects and high recurrence rates. Objective Non‐ablative fractionated photothermolysis (FP) is a promising therapeutic method, long‐time results comparing treated vs. non‐treated site are lacking. Methods A total of 14 patients were treated with FP in a split‐face mode with standardized adjustments in three sessions (weeks 0, 3–4, 6–8, follow‐up: 26–28). At each consultation, improvement was evaluated by patients and physicians. Objective assessment was performed using digital photographs and the pigment imaging tool SIAscope^®. Results Melasma improvement was registered in 83% and 75% of the cases 26–28 weeks after the first treatment based on two evaluations: by patient and by physician, respectively. Digital photography and SIAscope^® revealed improvement in 54% and 85% after the first, 61% and 85% after the second, 41% and 58% after the third treatment, accordingly, mostly due to reduction of the outline sharpness. Patients with lighter skin complexions revealed significant improvement ranged from slight to moderate (P = 0.03). Postinflammatory hyperpigmentation occurred in two cases with skin types III and IV. Conclusion Non‐ablative FP can be considered as a valuable treatment option with short‐term improvement in terms of mild reduction and softening the edges of melasma in patients with skin types I/II, if prior topical therapies failed. Treatment of patients with skin types III+ should be critically questioned.     

Surgical scar remodelling after photodynamic therapy using aminolaevulinic acid or its methylester: a retrospective, blinded study of patients with field cancerization

Summary Background Photodynamic therapy (PDT) is a nonsurgical alternative to conventional tumour excision for nonmelanoma skin cancers (NMSCs). Objectives We evaluated whether patients with field cancerization (multiple NMSCs) treated with aminolaevulinic acid (ALA) or its methylester (MAL) for that indication had PDT‐induced changes in surgical scars in the treatment field. Methods Six adult patients with multiple NMSCs and a total of 21 scars from previous excisions were studied in a retrospective blinded evaluation from clinical photographs of scar response to ALA/MAL‐PDT. After a 3‐h application of topical 20% ALA or 16·8% MAL under occlusion, each field was irradiated with 635‐nm light‐emitting diode light at the fluence of 200 J cm^?2. Patients underwent one to three PDT sessions per field at ～1 month intervals, to fields that included scars on the back, thigh, arms and neck. Pre‐ and post‐treatment digital photographs of scars were combined into 92 pairs that were independently and blindly evaluated by three board‐certified dermatologists. This study was performed at our academic practice at the Massachusetts General Hospital. Results PDT produced a statistically significant improvement in scar appearance. The degree of improvement correlated with the number of treatment sessions (two or three treatments; P < 0·05). Improvement after a single treatment was not statistically different from baseline ratings (P = 0·99). Conclusions Surgical scar remodelling and clinical improvement may be accomplished via ALA/MAL‐PDT, but may require repeated treatment sessions. Larger, prospective studies are necessary to confirm the effectiveness of PDT for this indication.     

The clinical features of late onset acne compared with early onset acne in women

Background Little is known about the clinical characteristics of acne based on the age of onset. Objectives The aim of this study was to investigate the clinical characteristics of patients according to the age of onset of acne and evaluate whether the findings were related to regional differences in the density of Propionibacterium acnes or the levels of sebum secretion. Methods A total of 89 women were recruited. The acne lesions were assessed by counting the lesions using standard digital photographs. Digital fluorescent photography for the evaluation of the density of P. acnes were taken and quantitative measurements of facial sebum secretion were performed. Results In women with acne, the age of onset was negatively correlated with the number of comedones and the proportion of comedones. By comparing the number of comedones and the proportion of comedones, onset of acne after 21 years of age was defined as late onset acne. In the patients with late onset acne, the number of comedones, the total number of acne lesions and the proportions of comedones were significantly less than in the patients with early onset acne. However, there were no significant differences in the fluorescence density of P. acnes or the level of sebum secretion between the two groups. Conclusions The results of this study, using objective evaluation tools, suggest that late onset acne has different clinical characteristics. Other possible factors might explain the clinical differences in late onset acne.     

Quantitative evaluation of patch test reactions: a comparison between visual grading and erythema index image analysis

Background/aims: The interpretation of patch test reactions may vary between examiners. As test results are graded, an issue also arises when differing degrees of erythema are placed in the same grade. The purpose of this study was to quantitatively evaluate the degree of erythema in patch tests using image analysis and to study the usefulness of this method by comparing it with visual grading. Methods: A total of 121 Japanese patients were patch tested with various materials. At 48 h, digital photographs of the patch test areas were taken, in addition to a visual evaluation by dermatologists. Digital images of the areas were converted to erythema index (EI) images using image processing and both EI and ΔEI (the difference between the patch test site and adjacent normal skin) values of the patch test sites were compared with the corresponding visual grades. Results: An excellent linear correlation (r=0.95) was found between ΔEI and visual grades, although EI also significantly correlated with visual grades. There were significant differences (P<0.0001–0.05) between the mean ΔEI values of any two adjacent visual grades. Conclusion: ΔEI values derived from image processing appear to be suitable for the quantitative evaluation of erythema in patch tests. This method may be helpful in overcoming the subjectiveness of visual evaluation and for training non‐experts in patch testing.     

High-resolution ultrasound reflex transmission imaging and digital photography: potential tools for the quantitative assessment of pigmented lesions

BACKGROUND/AIMS: High-resolution ultrasound (HRU) is a relatively cheap imaging method that shows small quantitative differences between benign naevi and melanoma. Previous studies using B-mode display suggest that these arise from their differing attenuating properties. Attenuation characteristics, however, are better evaluated using reflex transmission imaging (RTI). White light clinical (WLC) photography is an even cheaper imaging method that is routinely used for monitoring but less frequently in everyday diagnosis. As features from each method may have an independent origin, two such modalities may be of greater diagnostic value than either method alone. However, although quantitative analysis of digital photographs is being developed to aid tumour diagnosis, in vivo RTI for the evaluation of pigmented skin lesions has not previously been described. This paper presents the feasibility of performing RTI in vivo and evaluates the reliability of the objective features used. The potential of the combination of quantitative RTI and white light (WL) digital photography data for the classification of pigmented lesions was assessed. METHODS: Randomly selected patients were recruited via a skin cancer screening clinic. RTI data were acquired from each index lesion with a 20 MHz single-element scanner. WL images were taken using a high-resolution (2.8 Mpixels) digital camera. Quantitative features calculated from both images were used to derive a discriminant rule. This equation was then applied to reclassify each case based on its quantitative criteria. The resultant classification was compared with histological diagnosis. RESULTS: Twenty-four lesions (10 melanoma and 14 naevi) were studied. On RTI, no subjective differences were observed between benign naevi and melanoma. Many lesions were either not visible on RTI or lacked clearly definable borders. Consequently, the WL photographs were used to draw lesion boundaries on RT images for feature calculation. Melanoma were less attenuating than naevi on RTI (P=0.026) and had greater red colour variegation on WL imaging (P=0.016). The combination of quantitative parameters (two from RTI and four from photographs) improved sensitivity for this sample without compromising the specificity of 100% compared with either modality alone. The procedure is highly reproducible (r=0.85 between two operators). CONCLUSIONS: Pigmented skin lesions can be quantitatively defined from RTI data acquired in vivo and a significant difference in attenuation is shown. However, accurate registration of the RT image with a corresponding photograph was crucial for this purpose and only possible when corresponding points could be reliably identified on both images. Combination of features from ultrasound and optical images may synergistically improve diagnostic accuracy and a larger study is warranted to investigate this.     

Digital photography for patient counseling in dermatology – a study

Objectives To evaluate the use of digital photography in dermatology as an aid to patient counseling and follow‐up. Materials and methods Two hundred patients attending the dermatology Out‐Patient Department at our centre over a 1‐year period were included. Half the group, randomly assigned (G1), had their clinical photographs taken and were counseled using basic imaging software, their images and other relevant images regarding their disease and possible treatment outcomes. The control group (G0) was counseled without using any kind of imaging. Patient satisfaction was scored in both groups after the initial counseling session and then after 2 months. Results The test group (G1) gave statistically significant higher scores at both readings compared with the control group (G0). Conclusion Digital imaging can be a very effective tool for the dermatologist for patient counseling.     

Availability of digital dermoscopy in daily practice dramatically reduces the number of excised melanocytic lesions: results from an observational study

Background Digital dermoscopy has been shown to permit an earlier detection of melanoma. However, few studies have investigated its added value in reducing unnecessary excisions in everyday clinical practice. Objectives To compare, in daily practice, the efficiency of three dermoscopy methods: dermoscopy alone with little training, dermoscopy alone with adequate training and dermoscopy with adequate training and access to digital dermoscopy, and to confirm the safety of this latter approach. Methods Thirty‐six dermatologists working without digital dermoscopy were divided into two groups according to their training in dermoscopy. The third group constituted of two dermatologists working in a pigmented lesion clinic with access to the digital dermoscopy technique and eight additional dermato‐logists working in the same dermatology department. These 46 dermatologists included all presumed melanocytic lesions excised over a period of 1 year. The primary endpoint was the melanoma/nonmelanoma ratio (M/NM‐R); secondary endpoints were the ratio of ‘problem’ naevi to common naevi (PN/CN‐R), specificity and sensitivity for the diagnosis of melanoma, in situ/invasive melanoma ratio, and the mean Breslow thickness. Results In total, 1865 excised lesions, including 231 melanomas, were included. In the digital dermoscopy availability group (DD‐G) the M/NM‐R was significantly better (1/2·43), as was the PN/CN‐R (1/1·48) (P < 0·001 in both cases). The specificity was significantly higher in the DD‐G and significantly higher for trained examiners as compared with examiners with little training. More that one‐third of all melanomas discovered by digital dermoscopy were in situ, and the mean Breslow thickness was 0·32 mm for the invasive ones. Conclusions The reduction of unnecessary excisions when using digital dermoscopy compared with dermoscopy alone in our study suggests that access to digital dermoscopy offers a better management of pigmented lesions in daily practice. The high number of early lesions diagnosed by this technique confirms that its use is safe.     

Digital image analysis of facial erythema over time in persons with varied skin pigmentation

Background/purpose: Selected chemotherapeutic agents used for the treatment of cancer are known to cause skin toxicities. One group of agents, epidermal growth factor receptor (EGFR) inhibitors, characteristically precipitates an acneform rash. Currently, no standard of care exists for the management of the rash resulting from EGFR inhibitors. In order to objectively evaluate any management strategy, a method to quantify the rash is required. The purpose of this paper is to describe a method to quantify the erythema of a facial rash through the use of digital photography and image analysis. Methods: A Canfield OMNIA System using a Canon PowerShot Pro1 camera was used to obtain high‐resolution digital images of facial rashes. Digital images were recorded in Joint Photographic Experts Group format, corrected for brightness and white balance and color. A method was developed to analyze digital images of erythema independent of the range of skin pigmentation. Results: Two examples are given to illustrate the method developed and its utility. Conclusion: An inexpensive and portable method is described for objectively monitoring the development of facial erythema in subjects of the full range of skin pigmentation. This method can be used clinically to examine the development and resolution of facial rash erythema in response to treatment.