Digital Imaging in Dermatology

Sandy Campbell is a Denver-based freelance writer who specializes in healthcare technology.

For dermatologists, high-quality care depends on detailed visualization that allows comprehensive examination and accurate diagnosis. Accordingly, digital photography is becoming an essential tool in dermatology care delivery.

"I use digital imaging every day in my office," says Ashish Bhatia, MD, a dermatologist with the DuPage Medical Group in Naperville, Ill., and a clinical professor of dermatology at Northwestern University. "And I use [the technology] in different ways for different patients."

For example, Bhatia uses digital photography for Mohs surgery. In a process that spares as much normal tissue as possible, he conservatively removes malignant tissue, then takes a photograph. If the magnified digital image shows residual malignancy, he removes more tissue and takes another photograph. Bhatia also uses photos to track subtle changes, like those that occur with laser treatments for acne scarring.

At Skin & Cancer Associates in Miami, Harold Rabinovitz, MD, uses digital images to evaluate patients at high risk of melanoma. A professional photographer takes standardized full-body photographs, which Rabinovitz uses as a baseline for further examinations. "When you have a patient with many moles of different sizes, shapes, and colors, it's difficult to see if they have a new mole or if an old mole has changed," he says.

Rabinovitz also uses digital images for education. As a volunteer professor of dermatology at the University of Miami, he says, "It's easier to carry a memory stick than six trays of slides."

It's also easier to e-mail image files to other specialists for consultation and evaluation. "When a patient has a mole or pigmented lesion, sometimes the pathologist is aided by a photo. When reviewing the pathology, he has an image to help him with decision-making," Rabinovitz says.

Bhatia's staff even send him photos when he's out of the office. For example, if a physician assistant (PA) removes sutures and is concerned about the condition of a wound, the PA e-mails a photo to the dermatologist for evaluation. "I can even look at them on my phone. It's kind of cool," says Bhatia.

Digital or standard?

Industry estimates indicate that two-thirds to three-fourths of dermatology offices currently use some type of digital photography. Although the goal of both digital and standard photography is to take clear images of lesions to ultimately improve condition tracking and outcomes, the primary reasons for the migration to digital imaging are cost and simplicity.

Robert Brodell, MD, a dermatologist in Warren, Ohio, and associate professor at Case Western Reserve University, used to spend at least several thousand dollars annually on film and processing. Then he decided to go digital. After an initial investment in cameras, accessories, and related computer hardware and software, Brodell's ongoing photography costs have dropped to almost zero.

Digital photography also saves time. Photos for patient records are available immediately. Instead of waiting days for slides for presentations, Brodell now imports digital images directly into his software in minutes.

The future

Several emerging technologies are close to becoming standard tools, according to Rabinovitz:

• Digital dermoscopy — A Sydney, Australia-based company, Polartechnics, has developed a digital dermoscopy camera called SolarScan, which captures and analyzes images of pigmented skin lesions and presents information for clinical evaluation.
• Machine vision — The MelaFind machine vision system from Electro-Optical Sciences in Irvington, N.Y., is a hand-held device that emits multiple wavelengths of light to capture images of suspicious pigmented lesions. The extracted data are analyzed against the company's proprietary database of melanomas and benign lesions using algorithms to provide information and treatment recommendations. The system is slated for FDA evaluation.
• Confocal microscopy — Confocal laser scanning microscopy sends a near-infrared laser beam into human skin; the beam is backscattered to a detector that generates a digital image. The FDA-approved VivaScope 1500 from Lucid, Inc., in Rochester, N.Y., provides cellular-level images — what the manufacturer calls an "optical biopsy."

Drawbacks

Like most technologies, digital photography is not without flaws. The most common complaint, according to Bhatia, regards the use of image manipulation software. Many dermatologists edit images to show patients how they might look after a procedure. If a result doesn't look like the photo, patients may get upset.

"Be careful about controlling expectations," Bhatia says. "You should have a written disclaimer that says actual results may vary."

Basic components

Once the basic components listed below are in place, monitoring patients' skin conditions with an eye toward improving outcomes will be a snap.

• Digital camera — The foundation of your system. Units vary widely in price and features, but most now deliver clinical-quality images. Cameras with higher resolution are better for large images, such as full-body shots.
• Camera accessories — Lights, lenses, filters, flashes, and tripods can be used to improve the quality of digital photography. Specialty accessories are also available for dermatologists, mounts for facial photography and attachments for dermoscopy and microscopy.
• Power source — Most cameras use regular batteries, rechargeable batteries, or rechargeable battery packs. Most also come with AC adapters for recharging.
• Removable storage media — Most digital cameras use some kind of removable, reusable memory stick. Memory sticks with greater storage capacity can hold more images or the same number of images at higher resolution.
• Image transfer device — Most digital cameras allow transfer of images directly from the camera or removable storage media. Some cameras have docking stations that connect them directly to a computer for image downloading; others allow connection to the camera via USB cable. Other transfer devices include adapters for memory sticks or PC cards for slots commonly found on laptop computers.
• Image cataloging and editing software — Software packages that facilitate database storage, retrieval, and modification of images.
• Computer — The computer used for image viewing should be equipped with a high-resolution video card, sufficient disk space, and at least a 17-inch high-resolution monitor.
• Mass storage/backup device — Optical disc and tape drives are the most common storage devices. Compact discs provide more rapid access to individual files, but tapes store more data at a lower cost per megabyte.
• Printer — Liquid inkjet printers on photo-quality paper produce photo-quality prints at the lowest cost. Dye sublimation printers produce higher quality prints, but the cost per page is higher. Color laser printers, solid inkjet printers, and thermal wax transfer printers are not suitable for photo printing.

Tips for improved digital photographs

Before completing medical school, Bhatia was a digital imaging consultant for nearly a decade. He offers these tips for improved digital photographs — and improved condition management:

• Use a standard background — Bhatia recommends a black background — either a square painted on a wall or a pull-down shade.
• Take photographs in a windowless room — This allows control over lighting without having to account for various types of daylight (e.g., sunny, hazy) that enter through a window.
• Make sure camera and subject are always in the same place — Place marks on the floor to ensure image consistency. This is especially important for images of a single patient taken over time.
• Have patients remove all makeup and jewelry — These can cover skin problems or create reflections that compromise image quality.

Set up a dedicated studio if office space permits. This allows practices to set up special, permanent lighting to highlight subtle textural skin changes.

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Disclaimer: The material above has been prepared by Physicians Practice. It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.