Hello, my name is Iltifat Hamzavi, and along with Mohsin Mukhtari, a medical student at the William Beaumont Oakland University Medical School, we put together a clinical trials general photography tips presentation. I hope you find it helpful. So here are some general photography tips for individuals doing clinical trials. So consider using a standard camera device, and there's a list on the slide reviewing the type of options. You can use a smartphone or a tablet nowadays. The quality of the resolution has improved dramatically, but sometimes the lens quality can be improved by using a DSLR. One of the key points behind any clinical trials photography is patient positioning. You have to minimize distractions such as jewelry, clothing, and tattoos, and you have to position the camera lens perpendicular to the area of interest. In addition, note that any identifying tattoo or jewelry can affect your ability to publish pictures. So be aware that not only is this important for clinical trials, but it's also important for the publication of any of these images. When you're orienting the image, you want to orient the body region vertically or horizontally within the frame of view and not at an angle. Shadows can cause a lot of problems in reproducibility of images. You also want to obtain one image of the area of interest from such a distance as to prevent identification of that body region. If you can't tell this is an arm, you can't tell the arm is left or right, or leg is left or right, then it's again going to be hard to evaluate this in a reproducible fashion. Lastly, obtain a closer image of the area of interest once you've identified the regional location that accounts for 50-75 percent of the field of view. So if more than half of the field of view is the lesion, you're at the right positioning. But don't forget, you have to have regional view so you know what area you're looking at. So let's walk through an example of one disease state for vitiligo. We'll use some of the general recommendations we made earlier. But for vitiligo, you want to remove all the clothings while providing some minimal coverage for the respect of the patient. You want to remove makeup or sunscreens. Sunscreens are important because you might be using a UV imaging system. You also want to remove any accessories for the general exam and the reasons we stated earlier. The background is important because it affects the actual contrast that we'll be able to pick up, and it shifts sometimes between skin of color populations and lighter skin populations. So you want to have a uniform black, dark blue, or green, and you also may want to consider a brown color if you have predominantly skin of color population, but generally black, dark blue, or green is going to work. Then you want to have a background that is even and reflects light in a consistent fashion. Lastly, you want to have a reference scale, because when you're trying to determine the size of the deep pigment patches, the adhesive sticker will allow future imaging technologies to measure the surface area. A commercial gray card or a color chart with a known size is an alternative to that. Then in the diagram we've listed, we summarize the distance that is recommended. That can apply to any clinical trials study, but specifically for vitiligo. In some of the presentations and publications in the references of this presentation, there's a recommendation for imaging for vitiligo trials. In those recommendations, there's a core set of 10 photographs, which we'll cover in the next few minutes. For each disease state, the different photographs might be different, but the overall goals have been listed before this, and then you can apply the number of photographs, the locations, the orientation of the patients, the positioning of the patient based on the disease state. Continuing on with vitiligo, we've got the positioning of the patients. You want to be able to image the common areas of deep pigmentation which are going to be the face, the hands, the feet, but also the axilla are common areas that sometimes are a little more challenging to image. Here are the 10 different views that we discussed earlier. You want the arms and hands fully extended, stretched out, and you want one image where you have the hands at the side of the patient, one image where the arms are above the shoulders of the patient, which is specifically image 5 in the figure that we presented in the slide. The face has to focus on the eyes, and then with the mouth lightly closed, and ensure that the hair is held back. Lighting is critical for vitiligo imaging. You have to ensure that you minimize shadows, so fixed position lights on either side of the patient. Use of an ambient light with a light-sensitive camera can also help, and then position the camera perpendicular to the area of interest. When you're selecting the cameras, ensure that the low light sensitivity, the digital single lens reflux cameras, those are options for you to use to try to minimize a situation where there's low light or you get shadows because the contrast is critical. Then ultimately, you need that minimum set of 15 photographs for research with the different positions that have been listed in this particular diagram. Jumping over to hydroadenized separativa, the shadowing impact is not as critical as it is in vitiligo, but positioning becomes even more important. It also requires a little bit of counseling because these positions are invasive and they can really affect the patient's well-being and state of mind. Showing them pictures such as the one developed by the Mayo Clinic in this slide set is a good way of addressing what positions you will ask the patient to take. In addition, in a clinical examination, you may not look at all these areas such as behind the ears unless you go through this checklist. Lastly, when you prepare the patient for this type of imaging, such as evaluation, the intergluteal fold, it allows them to prepare their minds as well as yourself on how to orient them. The positioning of the skin folds should be done in a flat orientation with the camera about 50 centimeters from the individual's body part, and then the equipment has to have the appropriate lighting. There requires a little bit of education of the subject. You also have to ensure that the lighting is important and you also have to have clarity in the positioning. You don't want to keep asking individuals to go through this positioning again and again, so you want to get it right the first time. Atopic dermatitis is another condition that has some unique variations in its imaging. There's a guide that we provided here for sending pictures using a smartphone of children at home. It's sometimes hard to get children to position themselves effectively, and being comfortable at home sometimes will help. Oftentimes, we'll ask parents to use a smartphone to take a picture of the child from the front, child from the back, and then move in to the areas of concern. All the same recommendations we made for general photography apply here, but educating parents on how to do the imaging sometimes is more effective than doing it yourselves in clinic. Now, atopic dermatitis imaging of an adult can often be done inside the clinic using the same parameters we talked about earlier. But those images where you have the regional view and the close-up view are important because it allows for comparison. In multiple studies, when you do effective imaging, it allows for photographic assessments done by people who were not in the room for the examination. There's a significant concordance between the in-person and the photographic exam if the pictures are taken. Again, I want to emphasize, watch out for your shadows, making sure that you take the appropriate distance for these images, and making sure that you cover all the body parts that are commonly affected by atopic dermatitis. Now, atopic dermatitis shares certain features with acne, especially when you're imaging the face. Erythema is something that is used to assess severity. In order to assess that in all skin types, it's really important to consider using a cross-polarized lens. If we're going to look at erythema as a marker of severity in both atopic dermatitis and acne, those cross-polarized images allow us to see erythema in darker skin types. In addition, you can also use specialized systems that are very good at quantifying erythema such as the Vizia system, which captures images under white light, UV light, and polarized light, and allows for software analysis to discriminate between the erythema and the normally pigmented skin. It also can auto-classify images to identify the inflammatory, non-inflammatory acne counts. These automated systems are very helpful, and then using appropriate lenses can be helpful in these two areas, atopic dermatitis and acne, in order to assess erythema. Going on to another disease state, psoriasis has been studied for many years, and many of us have seen the images presented using some of the innovations that have been developed in the past 15, 20 years. Generally, there's nine standard photographs for patients with plaque psoriasis. Just like with HS, patient positioning is important, and you follow some of the same guidelines that we laid out earlier. In psoriasis, there's those nine standardized photographs that were listed in the slide prior to this one. In those slides, if you can do it properly, where you take the regional view and the close-up view, the photographic assessment, the clinical assessment match up very closely with the deviation of one point difference, and it was about 90 percent concordance between the photographic assessment and the clinical examination. These images, when they're done properly, really improve the reproducibility of the assessments within psoriasis. Take the nine standardized photographs, ensure that you follow some of the general recommendations, and then also take the close-up views, and we can really improve the clinical trials results and the reproducibility. Here's a nice advance that will be coming up for all diseases within dermatology, where we can add computer-based quantification of disease states using erythema, scale, and other targets, and in psoriasis, this is advancing quickly as documented in this particular image. I also wanted to add another component of photography, which is the different shades of our populations vary, and we made lots of progress in imaging and assessing skin-to-color individuals now. Couple of recommendations. One is trying to do both natural light as well as artificial light in the same visit can be helpful, in which the front of the window or the outside of the window is present and is facing the patient. There's a particular image where the light is falling on the left side of the patient's body, and then the clinician is imaging at the same direction as where the light source is. So not behind the light source, not in front, but to the side. Be aware that indirect light can be reflected on the subject, and you want the light to be located behind and on both sides of the subject so that you have a uniform distribution, especially in artificial areas. You want to minimize brightly colored or patterned backgrounds, and you want to ensure that the hair is separate from the cutaneous examination. And then I cannot emphasize enough how important cross-polarization is for skin-to-color populations because it's very hard to assess pigmentation and erythema in those populations without using that. And like all individuals who get imaging using these guidelines, please ensure that you have the consent from the patient. That's important for all these different categories we discussed, and we've listed clinical photography tips and best practices in this particular slide. Thank you for taking the time to learn how to image our patients more effectively using these devices. It has really dramatically improved the quality of literature as well as the ability to quantify the impact of interventions on various disease states. If you take your time to learn these general principles and apply them to the different disease states, hopefully you can pick the appropriate camera, pick the appropriate position, pick the appropriate lighting, and then we can eventually add some of the other tools to improve the consistency and quality of our clinical images. Those images ultimately are the basis of our specialty and have allowed us to dramatically improve the quality of lives for so many patients. But the details matter, and I do hope that this slide set has been helpful for you. Thank you again.

clinical photography

standardized imaging

cross-polarized lenses

patient consent

disease documentation