A three-dimensional photography system for dermatologic diagnosis

Journal of the American Academy of Dermatology

Duke

4. StMing GS: Pimozide as a replacement for maintenance therapy in chronic schizophrenia. Curt Med Res Opin 6:331-337, 1979. 5. Garton D, Silverstone T: Pimozide in acute schizophrenia: A pilot study. Curr Med Res Opin 5:799-806, 1979. 6. Avnstrop C, Hamann K, Jepsen PW: Parasifforrykthed behandlet med pimozid (Orap). Ugeskr Laeger 142: 2191-2192, 1980. (Dan; Eng. Abst.) 7. Corbin A, Upton GV: Effect of dopaminergic blocking agents in plasma luteinizing hormone activity in hypophysectomized rats. Experientia 29:1552-1553, 1973.

8. Corbin A, Upton GV, Mabry CG, et al: Diencephalic involvement in generalized lipodystrophy: Rationale and treatment with the neuroleptic agent, pimozide. Acta Endocrinol (Kbh) 77:209-220, 1974. 9. Taub RN, Baker M_A:Treatment of metastatic malignant melanoma with pimozide. Lancet 1:605, 1979. (Letter to Editor.) 10. Watt DC: Maintenance drugs for schizophrenia. Lancet 2:1045-1046, 1978. (Letter to Editor.)

A three-dimensional photography system for dermatologic diagnosis H. Irving Katz, M . D . , * Ngo T. Hien, M . D . , * Steven E. Prawer, M . D . , * Robert W . Goltz, M . D . , * * Kenneth P. Manick, M.D.,** Mark V. Dahl, M . D . , * * and Marie E. Briden, M.D.**

Fridley and Minneapolis, MN Dermatology is a visual specialty, Three-dimensional photography was used in our study to capture significant morphologic detail not present in ordinary two-dimensional photographs. Using three-dimensional photographs, texture and depth assessment are readily apparent, Three-dimensional photography enhances the real life morphologic changes of dermatologic patients. This can greatly assist in the confidence and accuracy in diagnosing of dermatologic conditions at a distance. (J AM ACAD DERMATOL8:850-856, 1983.)

Dermatology is a visual specialty. In both diagnosis and teaching, recognition of the characteristic morphologic features of a skin disorder is of foremost importance. ~ History and laboratory studies are often simply confirmatory or supplementary to clinical diagnosis. Attempts to use photographs of a patient's skin disorder as an extension of dermatologic acumen have been limited by significant technical difficulties. 2 Standard photographs, even though in color, are two-dimensional, while skin

From the Officesof Diseases of the Skin Clinic* and the Department of Dermatology, Universityof Minnesota.** Accepted for publicationOct. 15, 1982. Reprintrequeststo: Dr. HarryIrvingKatz,Diseasesofthe SkinClinic, P.A., 500 Osborne Rd., Fridley, MN 55432/612-786-6200. 850

lesions usually have three dimensions. We report our study of a three-dimensional photographic system as an aid in the remote diagnosis of dermatologic diseases. A high degree of concordance between the opinion of the examining dermatologist (clinician) and other dermatologists (the reviewers), who reviewed three-dimensional photographs of the problem and a short history, was found. METHODS The study was conducted between Aug. 1 and Sept. 15, 1981. All patients were seen in the Dermatology Clinic or were participants in the weekly Dermatology Grand Rounds at the University of Minnesota. Routine history and physical examinations were carried out and a diagnosis made in the usual fashion (R. W. G.),

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Photography systemfor dermatologic diagnosis 851

T a b l e I, List of cases and diagnoses made directly by the university dermatologist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51.

Pyogenic granuloma Trichofolliculoma Epidermal cyst Undiagnosed lesion Lichen amyloidosis, macular amyloidosis R/O psoriasis, verruca, eczema, Bowen's disease, basal cell carcinoma Confluent and reticulated papillomatosis of Gougerot and Carteaud Vitiligo Psoriasis Pyogenic granuloma, dermatofibroma Seborrheic keratosis Basal cell carcinoma Mycosis fungoides Necrobiosis lipoidica Miescher's granulomatosis disciformis, necrobiosis lipoidica, sarcoidosis Linear morphea with facial hemiatrophy Aftereffect of mucocutaneous candidiasis following ketoconazole therapy for 7 months Pitted keratolysis of soles Tinea rubrum of great toe, razorback toenail of second toe Leg ulcers, vasculitis with widespread allergic contact dermatitis Leg ulcers, multiple vasculitic, atrophie blanche Discoid lupus erythematosus Linear epidermal nevi Discoid lupus erythematosus Venous stasis leg ulcer Alopecia arcata Excoriated acne Alopecia areata Morphea and linear scleroderma Psoriasis of palms and soles R/O Hansen's disease, granuloma annulare, lupus erythematosus, other granulomatous disease, lymphocytoma cutis Chronic erythroderma with acute flare Darier's disease Cutaneous vasculitis Fibroma of tongue Undiagnosed R/O acute dermatitis, collagen vascular disease, porphyria, phototoxic/photoallergic reaction Tinea versicolor Angiosarcoma Scleroderma Psoriatic nails Atrophie blanche Syringomas of infraorbital region bilaterally Multicentric, basal cell carcinoma Verrucae with excoriations on back Actinic keratosis with possible malignant change to squamous cell caminoma Keratoacanthoma Schamberg's disease Acne rosacea with rhinophyma, perforating folliculitis Localized herpes simplex infection, allergic contact dermatitis, impetigo, prurigo, acute flare of atopic dermatitis Periungual warts

R/O: Rule out. continued

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T a b l e I. Cont'd 52. Mosaic wart of right plantar surface 53. R / O segmental vitiligo, nevus depigmentosus, tinea versicolor, zosteriform idiopathic guttate hypomelanosis, nevus achromicans 54. Mycosis fungoides 55. Tinea faciale, R / O sensitization R to miconazole nitrate (MicaTin), seborrheic dermatitis 56. Atopic eczema 57. Blue nevus 58. Atopic dermatitis, contact dermatitis 59. Sebaceous cyst 60. Epithelioid nevus 61. Recurrent infections of nose, pyoderma, impetigo 62. Actinic elastosis 63. Pruritus with chronic lymphatic leukemia and fungal infection, onychomycosis 64. Ichthyosis vulgaris 65. Median canaliform dystrophy 66. Contact dermatitis 67. Telangiectasias of malar prominence 68. Discoid lupus erythematosus 69. Linear lichen planus of scalp 70. Lichen planus 71. Nevoid unilateral telangiectasia 72. Calcinosis of finger 73. Nevus pigmentosus 74. Herpes gestationis, R/O erythema multiforme, PUPPP, Spangler's disease 75. Dysplastic mole syndrome with multiple junctional nevi 76. Discoid lupus erythematosus 77. Actinic keratosis 78. Pressure blisters vs burn 79. Acne rosaeea 80. Lichen nitidus, sarcoidosis 81. Dysplastic mole syndrome 82. Dermatitis herpetiformis 83. Eczema-- nummular 84. Disseminated lichen planus 85. Multicentric basal cell carcinoma 86. Psoriasis -- guttate 87. Factitious lesion 88. Discoid lupus erythematosus 89. Molluscum contag[osum 90. Scabies 91. Multiple nevi pigmentosa 92. Dyshidrotic eczema 93. Subcomeal pustular dermatosis 94. Tinea versicolor vs pityriasis alba vs hypopigmenting dermatitis 95. Erythema nodosum 96. Scabies 97. Verrucous actinic keratosis 98. Keratoacanthoma vs squamous cell carcinoma 99. Eczema 100, Dyshidrosis of palms 101. Psoriasis 102. Insect bites 103. Keratosis pilaris, R / O folliculitis, Darier's disease vs keratosis, Lichen's spinulosus 104. Acne vulgaris

Volume 8 Number 6 June, 1983 Consenting patients were asked to fill out a brief history form, and photographs were taken. If a scraping for fungi was made, this material was included in the material sent to the reviewers. The examining dermatologist recorded his diagnosis, or list of differential diagnoses, but these were not available to the reviewers until the end of the study. Distant and close-up photographs of the patient were t~en (M. E. B.). An experimental camera with equal duplicate lenses and lighting factors was used to obtain simultaneous stereoscopically paired photographs on a single instant photographic film (Figs. 1 to 6). The fiat print images were fused into a three-dimensional picture, using a special stereoscopic viewer. The two-dimensional image analysis was achieved by covering one-half side of the print with an opaque material and showing only one of the two images of the same photograph to the observer (M. V. D.). The reviewing dermatologists had available photographs, the brief history, and any skin scrapings (H. I. K., S. E. P., and N. T. H.). The diagnoses of clinicians and reviewers were collated by yet another dermatologist (K. P. M.). Concordance was defined as essential agreement in diagnosis or differential diagnosis. Discordance was felt to be present if diagnoses or differential diagnoses were materially different between clinician and reviewers. A comparative study of morphologic and diagnostic detail, using two- and threedimensional photographs, was done by an independent dermatologist (M. V. D.). Two- and three-dimensional close-up color photographs from identical areas were reviewed without the benefit of either the site of origin or the history. The independent dermatologist recorded the morphology, diagnosis, and degree of confidence he had in his interpretation. RESULTS The 104 cases examined, photographed, and r e v i e w e d are listed in Table I. Two cases were excluded from the study (Cases 4 and 36) because a diagnosis was not made by the clinician. Of the remaining 102 cases, there was concordance between the diagnosis based on direct examination and indirect examination by patient's history and photograph in ninety-eight cases (Table II). In four cases, there was discordance (Table III). An attempt was made by the reviewers to assess the relative importance of the photographic, historical, and laboratory data in reaching the correct diagnosis. Results are shown in Table IV. Threedimensional photographs were thought to be the

Photography system for dermatologic diagnosis 853

Table II. Comparison of the diagnoses by the two groups of dermatologists Number of cases with no diagnosis made by the University of Minnesota Number of cases with concordance between the two groups Number of cases with discordance between the two groups Total number of cases

2 98 4 104

most important source of information leading to accurate diagnosis in seventy-five cases, c o m bined photographic, historical, and/or laboratory data in twenty-three. The results of the two-versus three-dimensional photographic analysis revealed that in fourteen of the seventy-five cases, the stereoscopic interpretation was needed. The two-dimensional photography failed to demonstrate the morphologic detail to the degree necessary in these fourteen cases to make the correct assessment. In two-dimensional photographic analysis, thirty-six of seventy-five cases were judged to be of high confidence in their interpretation. Threedimensional photographic interpretation had a high confidence rating in sixty-three o f the s a m e seventy-five cases. DISCUSSION Several studies comparing results of direct examination of patients compared to that of various forms of photographic images have been published. ''2 Results range from approximately 5 0 % to 96% correct for common dermatoses. The fact that two-dimensional photographs possess inherent distortion may account for some of this e r r o r ) [t has been stated that the addition of history may materially increase the percentage of correct responses. 1'3 Sufficient information was available from the three-dimensional color photographs alone to permit accurate diagnosis in seventy-five of ninety-eight cases studied. In only twenty-three did addition of history and laboratory data help much. Miller et al4 estimated that a standard two-dimensional 3x 3-inch black and white photographic print can be divided into 22,500 separate information squares. Each square can register twenty different levels of light density. If it is a colored photograph, then there would also be

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Journal of the American Academyof Dermatology

Katz et al

Figs. 1-6. For legends, see opposite page.

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Table I I I . Cases in which there was discordance No.

32

I

University of Minnesota

Indirect data diagnosis

Chronic erythroderma with acute flare-up

Pruritus with excoriations, R/O dermatitis, pruritus secondary to diabetes, infestation, or id reaction; recommend more history, pictures, and laboratory studies Localized ichthyotic skin vs postinflammatory hyperpigmentation vs acanthosis nigricans; more history and biopsy needed Neurodermatitis vs discoid lupus erythematosus; suggest biopsy

60

Epithelioid nevus

69

Linear lichen planus of the scalp Subcorneal pustular dermatosis vs questionable fungus infection

93

Psoriasifoml dermatitis, R/O superficial fungus infections; mycosis fungoides, treated psoriasis or parapsoriasis; recommend fungal studies and biopsy

R/O: Rule out.

twenty separate density levels for each of the primary colors. If we now add the additional information available using three-dimensional analysis, even more realism is achieved. In this study, the patient population is skewed by the fact that all patients were in attendance at the Dermatology Clinic of the University of Minnesota or by being presented at the weekly dermatology grand rounds. In either case, they may have been unusual or diagnostically difficult cases. Only a few examples of the two most common skin diseases listed in Mendenhall et al's ~ study are represented in our series (Table V). A disproportionate number of collagen vascular disease cases were included. Of our cases, 38.2% fall into the "dermatologic, other" classification of Mendenhall et al, 5 representing the less mundane. The diagnoses ranged from the relatively infre-

quent to extremely rare conditions. Presumably, however, it is exactly such cases which would most need a consultant's opinion, or would be of greatest teaching value. All of the cases included under the discordance results were found in the "rare or dermatologic, o t h e r " classification (see Table III). The efficacy of three-dimensional photography in the more common dermatoses was 100% concordance. It is difficult to compare results of our study with those of others. Murphy et al, 2 in a study to determine the accuracy of dermatologic diagnosis by television, found that a dermatology professor was correct 85% of the time, while another dermatologist scored 68% on the same cases. This publication mentioned that absence of a third dimension on the photographs presented a technical limitation. Results of our study indicate that the

The Polaroid SX70 photographs shown in Figs. 1 to 6 can be visually fused and viewed stereoscopically with a specially built transposing viewer; however, stereoscopic (threedimensional) visualization can also be achieved by intensely observing an individual print at arm's distance, allowing one's eyes to accommodate and then to slightly cross. An illusion of a picture will appear between the pairs of photographs on the prints. This free vision illusionary picture in the middle will have three-dimensional features of texture and depth which may only be inferred when viewing a two-dimensional or flat photograph. Fig. 1. Photograph of a nodule diagnosed as basal cell carcinoma. Fig. 2. Photograph of a pore on the surface of a cyst diagnosed as an epidermal cyst. Fig. 3. Photograph of an eroded nodule diagnosed as a pyogenic granuloma. Fig. 4. Photograph of an ulcer. Fig. 5. Photograph of an atrophic, dry, desquamating yellow-orange plaque diagnosed as necrobiosis lipoidica. Fig. 6. Photograph of a plaque with raised borders and central clearing diagnosed as a granuloma.

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Table IV. Analysis of factors leading to concordance diagnoses Stereophotographis data alone Photographic + historical data Photographic + historical + laboratory data

75 cases 21 cases 2 cases

Table V. Relative frequency o f diseases Disease

I Mendenhall et al's~ study (%)

Acne Warts Eczematous, other Psoriasis Actinic keratosis Basal cell carcinoma Contact dermatitis Fungal infection Atopic dermatitis Benign neoplasm, other Seborrheic dermatitis Seborrheic keratosis Bacterial infection Pigmented nevus Viral infection Alopecia Dyshidrosis Malignant neoplasm, other Lichen simplex chronicus Parasitic Urticaria Drug eruption Collagen vascular disease Pityriasis rosea Venereal disease Dermatologic, other Nondermatologic

27.4 6.7 4.8 4.8 4.6 4.5 4.3 3.5 3.1 2.9 2.5 2.4 1.7 1.7 1.6 1.5 1.4 1.4 1.3 1.0 1.0 0.9 0.7 0.6 0.3 11.2 2.2

I

Our study (%) 2 2 3.9 6 2.9 2.9 1 3.9 2.9 6.9 0 1 1 4.5 1 2 3.9 2.9 0 2 0 0 7.8 0 0 38.2 0

enhanced reality and confidence achieved by three-dimensional photography significantly improve diagnostic capability. Three-dimensional color photography captures morphologic detail not present in two-dimensional photographs. A skin lesion m a y be elevated, depressed, or level with the skin. With three-dimensional photography, " d e p t h " is easily appreciated. We believe that three-dimensional photography can significantly enhance diagnosis at a distance, and that it can contribute greatly to effective teaching o f dermatology to students, primary care physicians, and those in specialty training. William Gentry, M.D., Corwin Vance, M.D., and a number of Minneapolis and St. Paul private dermatologists have contributed patients to our study at the dermatology clinic and the weekly dermatology grand rounds held at the University of Minnesota. John Rupkalvis, Stereo Photographic Engineer, designed and produced the specialized camera and viewing materials used in this study. We acknowledge David Whiting and Drew Webb, of the Polaroid Corporation, who generously provided the film used in this study. REFERENCES 1. Ramsay DL, Benifmoff A: The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol 117:620-622, 1981. 2. Murphy RLH, Fitzpatrick TB, Haynes HA, et al: Accuracy of dermatologic diagnosis by television. Arch Dermatol 105:833-835, 1972. 3. Weary PE: The cost effectiveness of primary care. Arch Dermatol 117:609-610, 1981. (Editorial.) 4. Miller D, Taube J, Miller R, et al: A system for slit-Iamp polaroid photography. Ophthalmic Surg 12:328-331,1981. 5. Mendenhall RC, Ramsay DL, Girard RA, et al: A study of the practice of dermatology in the United States: Initial findings. Arch Dermatol 114:1456-1462, 1978.