Skin Imaging

By Dr Anita Sturnham / 11 May 2016

Dr Anita Sturnham discusses the benefits of incorporating surface imaging technology in a clinic for help with medical assessments and treatment plans

During my journey as a skin specialist and general practitioner over the last 12 years, I have practised evidence-based medicine, always believing that assessing and monitoring a patient’s progress throughout their treatment plan is an essential and important part of any medical practitioner’s role.

I have always followed an analytical approach in my medical practice, with the use of blood tests, scans and x-rays to follow a patient’s journey. However, in my previous skin clinics, both in the NHS and in private settings, my ability to diagnose and monitor skin conditions had been limited by a lack of diagnostic equipment and technology, preventing me from accurately recording, assessing and following-up my patients. When launching my clinic, Nuriss Skincare and Wellness Centre, I wanted to create an advanced skincare and wellness centre that reflects this same methodology, using cutting-edge technology to aid diagnosis and patient care. I wanted to introduce a reliable imaging system, which would allow me to monitor a patient’s baseline skin condition and, in turn, use this data to assess progress throughout their treatment course. Many of my peers in the UK were not using imaging devices in their practice, but from my time spent researching in the US, it seemed to be common place, as well as beneficial, to have this technology in-house.

Using surface imaging

Surface imaging enables the possibility to capture high quality, consistent and repeatable facial images and provides an insight into your patient’s skin. The images provide information that routine examination alone would not be able to establish (Figure 1).

Figure 1: Standard photography imaging positions for skin assessment, showing frontal, left and right sided facial views4

When a patient comes to see me for their initial skin consultation, after taking a full medical history and assessing their diet and lifestyle factors, all patients have a skin scan. The process is quick, taking a matter of minutes to complete. The results provide me with the information needed to design a tailor-made home-care and clinic treatment programme, to suit their specific skin needs. The system I use utilises a patented comparison for analysis (Figure 2).4 By inputting your patient’s age, sex and skin type details into the system, their results are compared to the world’s largest skin database. This allows me to grade my patient’s skin relative to others of the same age and skin type and therefore enables me to establish their skin strengths and weaknesses. My patients love this personal and bespoke approach. The process also allows me to really engage with my patients, and provides the opportunity for me to educate and empower them, so that when they leave my clinic, they are armed with the information they need to understand their skin better and look after it appropriately moving forwards. There are several features of surface imaging that I use regularly and find extremely helpful. These include the skin scanner, skin analyser feature, the simulator mode, and the personalised information printout, which are features only found in the particular device I chose to incorporate in my clinic.

Figure 2: Discussion of scan results in a skin consultation

The skin scanner My philosophy at Nuriss focuses on the importance of feeding the body and the skin with the right nutrients it needs to be healthy. Our skincare plays an important role in the appearance of our skin. As part of my treatment plans, I therefore design a ‘day’ and ‘night’ skincare regimen for my patients, which targets their skin concerns and the issues identified in their scan.7 The skin scan also gives the opportunity to assess a patient’s progress at various stages of their treatment plan, allowing adjustments in their programme if the desired improvements haven’t been noted. The system enables me to take identical images at return visits, resulting in a reliable assessment tool that can provide ‘side-by-side’ results comparing past with present.

The skin analyser

The skin analyser enables me to assess the following parameters of skin health (Figure 3):

  • Spots: assesses superficial brown and red lesions, including acne scars, hyperpigmentation and vascular lesions.
  • Wrinkles: assesses folds or wrinkles in the skin, assessing fine and deeper lines.
  • Texture: assesses the ‘smoothness’ of the skin.
  • Pores: the circular surface openings of the sweat glands.
  • UV: assesses UV damage.
  • Brown pigment: assesses hyperpigmentation, freckles, lentigines and melasma.
  • Red pigment: assesses a variety of conditions such as acne, rosacea, telangiectasia and inflammation.
  • Porphyins: assesses bacterial excretions that can be causative factors of conditions such as acne. 

Figure 3: Example of parameters assessed during the surface imaging assessment4

The simulator

The simulator mode enables me to calculate an individual’s ageing process, creating a predicted image of the patient five to seven years on. This predicts the changes one may expect to see with their pigmentation and wrinkles, assuming no additional skin intervention. I find this module particularly useful. It highlights the ‘problem areas’ and helps both the clinician and the patient to focus their efforts on treating the key areas of concern. I find it a great tool to boost a patient compliance with a treatment programme. 

Personalised reports

At the end of the consultation, patients receive a personalised and informative printout of their results. I have programmed my analysis system so that all of our skincare products are placed into the built-in skincare catalogue. Once I have established a patient’s skin strengths and weaknesses, I can then select the appropriate products, highlighting key active ingredients that may be beneficial for them to use as part of their daily skincare regimen. I have found this to be a great upselling tool. In my opinion, patients don’t just want to be told what their problems are, they also want to know how they can improve things.

Another benefit of using surface imaging is that it acts as a motivational tool and often helps to support my product and clinic treatment recommendations. A new patient may be reluctant to stop using his/her current skincare products, despite the scan results suggesting that they are potentially doing more harm than good. The scan is also a good way of documenting a patient’s skin health for medico-legal reasons before starting a skin programme, to ensure accurate comparisons pre and post treatments. Case Studies 1 and 2 are studies that I have worked on which illustrates how to make use of a skin surface imaging device in a clinic.

Case Study 1: Patient A

  • 45-year-old female
  • Fitzpatrick 1
  • Concerns: rosacea and sensitive skin
  • Onset: gradual worsening over the past five years
  • Skincare: a well-known high street brand. Products included a foaming cleanser, alcohol-based toner, oil-based day cream and facial oil, which was used at night
  • Non-smoker, occasional alcohol, minimal caffeine intake
  • Medical history: nil else of significance
  • Surface imaging results: significant redness and pigmentation, increased pores and porphyrin load

The results of the surfacing imaging made me feel that Patient A’s daily skincare products were exacerbating her problems. Sometimes, simply altering a patient’s skincare regimen can improve their skin condition, without the need for moving on to more advanced clinic treatments, such as laser. Foaming cleansers, containing sodium laurel sulphate and the alcohol-based toners are common culprits for skin redness and inflammation. My strategy with rosacea and sensitive skin sufferers is to remove any harsh products and common skin irritants and to follow the ‘less is more’ approach. I advised her to stop using her high street brands and switch to using a gentle wheat germ cleanser, a water-based toner and non-comedogenic day cream, containing mineral SPF zinc oxide. It is important to remember that the pathophysiology of rosacea often stems from the pilosebaceous unit, with an overgrowth of the demodex mite seen in the pores.8 I therefore recommended removing any comedogenic, oil-based products and I introduced a gentle retinol and hyaluronic acid formulation to use at night time. Her skin scans were taken at the initial consult and then repeated eight weeks later. Making a simple change to the skincare regimen resulted in a significant reduction in redness as well as reducing the appearance of fine lines and wrinkles. Having the opportunity to reassess the skin in this way, and to show improvement in such a short period of time, fuelled this patient’s motivation to continue her efforts to use the new products. It also enabled me the opportunity to discuss other clinic treatments that could be of benefit. When a patient sees improvements, this cements their trust in my recommendations and they are more likely to return for further treatments. 

Case Study 2: Patient B

  • 34-year-old female
  • Fitzpatrick 3
  • Concerns: post-inflammatory hyperpigmentation, secondary to acne lesions
  • Treatments tried: been to various clinics and had chemical peels, with worsening of the pigmentation
  • Skincare regimen: simple skincare wipes, argan oil at night
  • No medication, no other significant health problems

During my assessment, I established that Patient B’s pigmentation was likely to be secondary to the inflammation triggered by her acne breakouts. My first strategy was to establish the cause for her breakouts and to treat these. Her visual imaging scan provided useful information including an excessive pore count and porphyrin load. I therefore suggested a strategy to target these areas identified: a salicylic acid based cleanser, topical benzoyl peroxide and clindamycin cream, and advised her to stop all facial oils. Her skin analysis also identified both superficial and deep brown pigmentation, allowing me to identify an appropriate strategy to target the different depths of pigment. I designed a homecare skin regimen, which used a twice-daily alpha arbutin treatment to stabilise the melanocytes and a retinol night cream. Retinol provides additional pigment-stabilising properties. To target the deeper pigmentation, we performed a number of laser treatments using a 1064nm laser, every two weeks. After six sessions, I performed two glycolic peels over a two-month period, to target the superficial pigmentation. Her results at this stage are encouraging, with more than 50% reduction in pigmentation shown in the visual imaging scan results. We will repeat her scan in six weeks’ time. 

Types of imaging devices 

Various skin imaging devices have been developed to enable photography and assessment of the skin.1

Standard photography imaging systems This uses a camera to deliver visible light to the skin by direct or diffuse illumination.1 Angled lighting is used to generate a gradient of the illuminating field on the skin in order to assess fine lines and wrinkles.5

Polarised light photography This allows assessment of surface and subsurface features of the skin.1 A polarising filter is placed both in front of the flash unit, and in front of the camera. When the polarising filters are in the same orientation with each other, surface features of the skin such as texture, pores, fine lines and wrinkles are visually enhanced.2 When the polarising filters are aligned perpendicular to each other, subsurface features of the skin such as inflammation, red and brown pigmentation and blood vessels are visually enhanced.5

Ultraviolet photography This allows for assessment of pigmentation and bacteria, Propionibacterium acnes. The flash unit is filtered to produce ultraviolet A light and the camera is filtered so that only visible light enters the lens. There are variations of UV photography devices available; some also record the reflected UV light to assess distribution of pigment.2

Choosing a device

Looking at the case studies, it should be evident that there is a benefit of incorporating this type of technology into a clinic. Once you have decided to introduce a surface imaging device, you must be aware of the different types of devices available. When choosing a surface imaging device, careful research must be conducted to determine which one is best for you. You need to identify the parameters you wish to assess. For example, if you are only interested in assessing UV damage, then a UV Imaging device will suffice. If you are looking to assess epidermal and sub-epidermal factors, you will need a more advanced polarised and UV imaging system. When choosing my device, I decided I wanted to use it for all new skin consultations to ensure uniform assessment of my patients and to allow the opportunity to design tailor-made skin treatment plans to suit an individual’s skin needs. Skin scans also provide an excellent way of monitoring a patient’s progress throughout their treatment programme. My choice was based on many factors, including peer reviews and my own testing of various devices on the market. I selected the The Visia analysis system, which combines both polarised light photography and UV photography, to photograph, analyse and document parameters relating to the skin’s health.4 This system also comes with a selection of advanced 3D visual tools, eyelash analysis, side-by-side comparisons, skin simulation and a ‘Tru skin age’ module,4 which estimates the approximate age of the patient’s skin, based on their results. In my opinion, this provides a revolutionary new metric to guide the selection of skincare products and treatment options.4 Other popular devices on the market include Beauvisage and Image Pro.6

When choosing my device, I decided I wanted to use it for all new skin consultations to ensure uniform assessment of my patients and to allow the opportunity to design tailor-made skin treatment plans to suit an individual’s skin needs

A place for surfacing imaging in aesthetic clinics

I believe surface imaging systems to be a useful adjunct to any dermatology or medical aesthetics clinic. Not only does surface imaging allow me to carefully assess and document a new patient’s skin health, it allows me to formulate tailor-made treatment programmes to target key problem areas. It also enables me to monitor patients’ progress throughout their treatment programme. In addition, I find the scan results to be a great motivational tool for my patients. My advice to any clinician considering the introduction of a skin analysis system into their clinic, is to do your research, invite sales representatives to visit your clinic and trial a few devices before purchase. 

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