Dermatology, more than many other medical specialties, relies on a visual clinical impression when assessing a skin lesion or dermatosis. As such one would think that photography and digital imaging in particular would be the current standard of care in every dermatology practice. We recently published the results of a study in the Journal of the American Academy of Dermatology that found 18% of board-certified US dermatologists do not use this technology at all citing cost and complexity as the major deterrents.1
In this digital age, introducing digital imaging to a practice need not be complex, costly or time consuming. In this article, we share our methods and provide straightforward advice that should help any practitioner immediately incorporate digital photography into their practice. If you own a digital camera or camera phone and can create a folder on your computer, you already possess all the equipment and knowledge necessary to add digital imaging to your practice.
Related: Are you using digital photography in your dermatology practice? Take this month's poll here.
Over the past 10 years, our 3-provider office has used inexpensive compact cameras and a simple and time efficient method for cataloging clinical photos. Although our system will work with any clinical scenario, we primarily utilize photography to record the size and location of lesions; however, it could be just as easily utilized to assess response to treatment in an acne or rosacea patient. In our clinic, all lesions are photographed prior to biopsy.
Our method requires an address label with the patient’s name and account number. Our practice management software permits us to print a full sheet of labels for each new patient, however, this information could be handwritten as well. We then date stamp the label and place this sticker next to the lesion being photographed. Lesions are circled in black ink and assigned a letter also drawn with ink. (Figures 1-3).
Figures 1-3. Our method requires an address label with the patient’s name and account number. We then date stamp the label and place this sticker next to the lesion being photographed. Lesions are circled in black ink and assigned a letter also drawn with ink.
We always include anatomical landmark(s), mark the midline as appropriate and highlight old surgical scars. We sometimes include a ruler, which can be used not only to document lesion size but also the distance between the lesion and a nearby landmark. Should a close-up photo be desired, a second photo can be taken to record lesion morphology. The same sticker is then applied to the biopsy bottle so there is no duplication of effort.
At the end of the day, the pictures are transferred to our computer using a card reader and Windows XP picture wizard. During the import process, the wizard will ask for a destination for the pictures. Our filing system is by date, so we create a folder within the “My Pictures” folder and name it “yyyymmdd.”
On any given day, several dozen photos may be taken and they all go into the same dated folder. When we want to verify a lesion location on the day of surgery, we open that folder, which corresponds to the biopsy date, and quickly scan the pictures in thumbnail view to find the one we want. If we are doing the surgery, the medical assistants do this ahead of time and print a wallet-sized photo for the chart, otherwise, the photo can be e-mailed to the Moh’s surgeon or radiation oncologist, as appropriate. Before the surgical procedure, the photo is reviewed with the patient further decreasing the risk of wrong site surgery.2
For your practice, we recommend to purchase and label a compact consumer camera for each treatment room. Excellent cameras may be purchased for under $200, so it makes little sense to leave the treatment room to go look for one. Purchase the same brand and model and consider purchasing a few spares because inevitably one will get dropped or otherwise fail. By choosing one brand, even as you replace cameras, the controls and menus will remain familiar.
The camera you choose should not be fully automatic. Fully automatic cameras, or cameras which are set to the automatic shooting mode indicated by a green rectangle, will not let you make the critical adjustments necessary to record the best clinical images. Choose a camera that offers a “Programmed” shooting mode symbolized by the letter “P” on the shooting mode dial or menu. In order to obtain a properly oriented image your medical assistants may sometimes need to lean over a patient blocking some of the ambient room lighting. We have found that the Program setting best compensates for this.
In this mode, the camera will choose both the aperture and shutter speed and permit you to make the other necessary adjustments.
Do not be tempted to choose a camera based solely on megapixels. Megapixel capacity is not synonymous with quality and for our purposes any camera rated at least 2 megapixels will be adequate. However, there are other camera features that we would recommend to enhance both ease of use and productivity. There are websites that will enable the consumer to compare cameras side by side by price, brand and features (www.dpreview.com). The best camera for your practice will combine the largest number of desirable features within your price range. Excluding one or more features (ie, an articulating display screen) will increase the number of cameras for consideration. Having used cameras with a variety of features, we would recommend that special consideration be given to the following:
As time goes on and you replace cameras, you may accumulate an assortment of proprietary batteries and chargers specific for each new camera model. We have found that limiting our camera choices to those that utilize only AA batteries is both more efficient and over time more economical. Our cameras all take 2 AA batteries.
We use rechargeable nickel metal hydride (NiMH) batteries and have a trickle charger in each treatment room. We always have 2 batteries in the camera and 2 in the charger and when they run low, we quickly swap them out without leaving the room. Label rechargeable batteries and use them in pairs, they will last longer. Alternatively, AA alkaline batteries can be used, however; we would recommend choosing 1 battery system exclusively. There is a risk of explosion if alkaline batteries are mistakenly inserted into a charger.
Look for cameras with “image stabilization,” also called “vibration reduction” by some manufacturers. This technology effectively compensates for slight camera movements enabling sharper pictures. This is especially important because all photographs are taken with ambient room lighting only without flash.
A macro setting, indicated by a “tulip” icon, is nearly a universal feature on consumer cameras. All clinical photographs taken within a few feet of the patient should be recorded in macro mode.
Larger LCD display screens will make it easier to determine if an image is properly exposed and in focus. Articulating display screens will enable assistants to view the display from the side while pointing the camera lens down onto the patient.
Dials, Buttons And Menus
Cameras with hard buttons or dials for choosing shooting mode, setting macro and disabling flash are more convenient than accessing these features through an on-screen menu.
It’s not part of the camera, but it’s an important added piece of equipment. There are several advantages for utilizing a USB memory card reader to transfer images from the camera to the computer. The card reader requires no external power and often transfers the images faster than connecting the camera directly. Furthermore, if the camera loses battery power during transfer the image files may become corrupted.
After the pictures have been transferred, format the memory card in the camera and not on the computer. As time goes on, consolidate day folders into parent folders (ie, 2010Jan-Jun, 2010July-Dec).
Camera Set Up
The new cameras will all need adjustments prior to use. Ambient lighting may vary among treatment rooms. Overhead lights, even if they are the same type, might not be placed identically and some treatment rooms may have a window. For this reason, label each camera with the name of a treatment room and use it exclusively in that room. Next, add your batteries and follow the simple menu instructions for setting date and time. Set the shooting mode to “Program” and disable the flash (lightening bolt icon) and enable the macro setting (tulip icon). We take our photographs without flash using normal room lighting. The next setting to choose is white balance. Automatic white balance may work satisfactorily. If your rooms have fluorescent lighting and the skin tones on your images are not natural, try setting the white balance to fluorescent.
The ISO setting of choice may be different for each room depending on the ambient light. Experiment a bit and choose the lowest ISO setting that yields consistently sharp, well-exposed images. We have found an ISO of 800 works well in our windowless treatment rooms. Set file numbering to “continuous” so each image will be given a new file number up to 9,999 rather than starting from 1 each time you format the memory card. Next, shoot some dummy photos so that each camera is starting its file numbering from a point different than all your other cameras. This is important because as you import the images from all the cameras into a single folder, the computer will interpret images with the same file name as duplicates and will ask if you would like to overwrite the existing file. It is important to realize that over time some of your cameras may coincidently overlap in file number sequence. Whenever the import dialog asks if you want to overwrite an existing file, always opt for NO and the computer will import with new file names. Utilizing our system, individual file names are unimportant.
Next, choose image size and quality. Consumer cameras save images in a compressed format called jpeg. You can set both the image size and quality within the camera menu settings. Large, high-quality images create larger file sizes, however, for our purposes smaller medium quality images work well. By choosing medium size and quality, you can conserve hard disk space and still generate image sizes of approximately 500-800 kilobytes. This size is more than adequate for e-mail and will enable you to print satisfactory images up to 4x6 inches. If you anticipate printing larger and higher quality prints, choose the largest and highest quality settings.
Start each day with a blank formatted memory card in each camera. Prior to photographing lesions, circle them in ink, even if you feel the lesion is obvious, and be sure to draw a corresponding letter as well. When it is time to photograph a lesion on a patient, the following techniques will prove helpful.
Lesions located within the lateral canthal lines should be photographed straight on with the nose midline in the center of the field. If the patient is reclined, ask them to turn their head toward you. By doing this you will have no difficulty determining whether the lesion falls medial or lateral to the mid-pupillary line.
For lesions lateral to the lateral canthal line and those located on the side of the nose, shoot an exact profile by holding the camera at 90 degrees to the face. By convention, we always place the nose at the top of the field. For those lesions that are in the transition zone, we take 2 photographs and will most often use an adhesive ruler as well as delineating the distance from an anatomical landmark. Before taking 2 views, write “2 views” on the patient label so that when photos are retrieved you will always know that there is a second photograph.
For lesions located elsewhere on the body, take a photo that will identify the region then a close-up photo if necessary to more precisely identify the lesion. The second photo should always maintain the same orientation as the first. The regional photo is extremely important when photographing lesions on the extremities because the close-up may not capture the hand or foot. The regional photo will tell you whether a lesion close to the nipple is on the right or left side. Similarly, whether a peri-umbilical lesion is caudal or cephalad. Again taking photos along the mid-sagittal lines and even marking and labeling the midline with ink is helpful. If the lesion is small or located within a field of severe sun damage or scarring, it is helpful to mark nearby scars with ink and even write notes directly on the skin.
Review unsatisfactory images with your staff showing them why an image does not accurately define a lesion location and you will make them better photographers.
At the end of the day have one staff member collect all the cameras and transfer the images to the computer. It does not matter in which order the cards are read. File names are unimportant because each photo is labeled with the patient’s information. After transfer, return the card to the camera and format the card in camera before returning the camera to the treatment room. Even on a busy day, we generally have only recorded several dozen lesions and can find them quite easily by scrolling through the thumbnails in the corresponding “My Pictures” folder.
We have networked all the PC’s in the office and have created a shortcut on the task bar of each computer. This shortcut will link to the “My Pictures” folder on the computer where the photos are stored. This is useful because you can access any image from any computer by simply knowing the date of the patient’s visit. The routine is simple and can be performed by your medical assistants. Because there is no file renaming and no elaborate catalog system, this method is fast requiring only a few minutes at the end of each day.
All hard drives eventually fail so a daily backup is strongly advised. We use an external hard drive that came bundled with backup software. We leave this PC running and backup takes place each day after hours. Alternatively, you could backup to a small office server or to one of the “cloud” services. Periodically, older files are transferred to optical or flash media and stored off site.
The principal advantages of this system:
• Ease of use, no special software, minimal staff training and both inputting and retrieving images is fast.
• No dedicated space required for equipment or for capturing images.
• No expensive or sophisticated photography equipment.
The principal disadvantages are:
• This system will not aggregate images either by patient name or diagnosis.
• Images are retrieved by manual, not automatic search.
• Cannot be used for patient recall or a statistical analysis.
Some of the shortcomings of this system are also its strong point. Filing images by name or account number requires either renaming the images or the use of dedicated catalog software or an electronic health record. In all cases, images need to be manipulated or moved after transfer to the computer.
We have provided step-by-step illustrated instructions at www.dermphotosite.com for both Windows XP and Macintosh.
Although we consider these images to be a part of the medical record, we do have patients sign a broad photo consent permitting us to use the photos for teaching purposes. Likewise, office computers are password protected to comply with Health Insurance Portability and Accountability Act regulations.
Dr. Accetta is associate clinical professor of dermatology at SUNY Buffalo in New York.
Ms. Accetta is a student at The George Washington University in Washington, DC.
Mr. Kostecki is senior manager, survey research with the American Academy of Dermatology.
Disclosure: The authors have no conflict of interest to report.
1. Accetta P, Accetta J, Kostecki J. The use of digital cameras by US dermatologists. J Am Acad Dermatol. 2013;69(5):837-838.
2. Starling J 3rd, Coldiron B. Outcome of 6 years of protocol use for preventing wrong site office surgery. J Am Acad Dermatol. 2011;65(4):807-810.