Clinical Photography in Pediatric Dermatology : Indian Journal of Paediatric Dermatology

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Clinical Photography in Pediatric Dermatology

Ashique, Karalikkattil T.; Kaliyadan, Feroze1; Jayasree, Puravoor2

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Indian Journal of Paediatric Dermatology: Oct–Dec 2022 - Volume 23 - Issue 4 - p 335-338
doi: 10.4103/ijpd.ijpd_62_22
  • Open

Dermatology being a visual specialty, clinical photography, and documentation has a crucial role to play in our day-to-day practice even more so in pediatric dermatology. Taking pictures of children in the office is no child’s play! It needs a lot of perseverance, tactics, and often a bit of luck to get good clinical images of children. Keeping the child subject idle for clinical photography is very important. The general principles of clinical photography apply for imaging of pediatric dermatology cases too. A good understanding of the basics of photography like camera settings, background, lighting, and photograph framing is essential.[1]

There are quite a few reasons why photographing children is more difficult as compared to adults. It could be an overzealous child who wants the smiling face to be photographed even when the area of interest is patch on the back or a crying and irritable child with staphylococcal scalded skin syndrome who is not cooperative at all. The clinician who is also the photographer may have to wear more than one hat (role) to keep the ambience comfortable for the subject and the parents. Various distraction techniques such as use of keychains, rattles, and colorful toys may have to be put to use to gain the child’s attention and easy photography. The parent can be asked to stay with the child during the session, so that the child feels comfortable and is more cooperative.

Gear

Even though an SLR camera or a dedicated photobooth is a good thing to have for clinical photography, we would suggest that a good mobile phone camera can do the job equally well if not better. One of the biggest advantages of using a mobile phone for pediatric clinical photography is that it is a familiar gadget unlike the SLR camera and the overhead flash which may seem scary. Any mobile phone with a camera resolution of more than 4 MP and preferably with options for image stabilizing and multiburst is good enough for clinical photography.[2]

Image Format

RAW file is the most common file format for uncompressed images captured by digital cameras and scanners. These files have images stored exactly as captured by the camera sensors. They preserve the maximum details of the subject. They can be edited any number of times without losing the quality in the post processing stage. These files are heavy and take up more space on the storage drives and requires some amount of knowledge on photo editing software like the Adobe Photoshop™.[3] RAW images cannot be opened by all the software and cannot be printed directly. The popular and readily usable file format is JPEG (Joint Photographic Expert Group). This can be opened by any software and editing is quite easy. For a clinical photography point of view, this would be an ideal format to save the files. On the DSLR camera and most of the mobile phones, there are options to choose the file format before saving the images.

Background

Clear and distraction-free background is crucial for any clinical image. Appropriate background is important for visual appeal and for the purpose of submitting for scientific publication.[3] Having a dedicated photography area is the ideal situation but if often not feasible.[4] Some of the easier and economical alternatives are using a black or green cloth as a background the shooting the image with the child standing in front of it [Figure 1]. Even an ordinary white paper held properly can serve as an excellent background for taking clinical images if there are other colours aren’t available. However, chances of shadows being evident are high in a white or grey background [Figure 2].

F1
Figure 1:
(a) A Child with toilet seat dermatitis. (b) An immunocompromised child with extensive warts. The images are shot with a black cloth held as a back ground to enhance the visual appeal
F2
Figure 2:
Image of child with onychomadesis secondary to hand, foot, and mouth disease. (a) A sheet of paper is kept under the foot as shown and image is shot with mobile phone camera (b) The lesion is well appreciable when the background is clear

Lighting and Flash

The correct lighting is an important element of clinical photography. If available, natural lighting is the best source of light. The next best option would be a studio light which can deliver a shadow-free image. Forced flash [photograph taken with the flash on] is best not used for clinical photography. Auto flash can also give a decent image for documentation [Figure 3]. If shot in a professional mode in the mobile phone or an SLR camera, a shutter speed of 1/125 and Aperture 5.6 and ISO200 should be sufficient for a decent clinical image.

F3
Figure 3:
Hand, foot, and mouth disease lesions in a child’s palm. (a) Natural light no flash. (b) Auto flash mode where the flash did not fire because of the available light and the camera adjusted the exposure by itself. (c) Forced flash where the flash worked by default. (d) Studio light image

Framing and Focusing

The subject or the area of interest has to be kept preferably in the center of the frame to attract attention of the readers. The multiburst mode can help decrease the chances of errors, especially when the children are not very cooperative. Shoot many, choose the best. It is very easy with the mobile phone cameras these days. Make it a point to take multiple images. The angle of the photography is very crucial and this is preferably done with the patient in the anatomical position and the camera held parallel to the area being photographed. It is important to retain a uniformity in the clinical photography to compare serial images and follow-up of the patients.

Scales and Measurements

In conditions where periodic monitoring of the size and shape of the lesions need to be done, it is ideal to have a ruler placed next to the lesion when the image is shot. Including a standard object like an adult thumb or a pen tip can also help in conveying an idea of the size of the lesion, to the readers [Figure 4].

F4
Figure 4:
A child with hemangioma on the day of presentation prior to initiating topical propranolol. (a) Normal view where the size of the lesion cannot be appreciated or compared. (b) An adult thumb placed next to the lesion gives a relative idea of the size. (c) A ruler placed adjacent to the lesion gives the correct size and extend of the lesion. This is very important in serial photography for assessing prognosis to treatment

Image Manipulation

We can edit the complete image to some extent or some areas of the image to enhance the features for the purpose of scientific publications.[5] This should be done keeping in mind that the manipulation should not result in tampering the look of the clinical condition [Figure 5]. In the pediatric age group, this may have to be undertaken very often as the subjects are often uncooperative.

F5
Figure 5:
(a) Child with alopecia areata is held by the mother while photographing the scalp lesion. (b) The image has been edited to remove the distractions and only the area of interest is visible

Consent and Ethical Aspects

With the advent of newer and simpler gadgets for doing photography in the clinic, it is very important that the clinician be aware of how much is too much and how well it can be done taking in to account the medico legal and ethical standards keeping in mind that the patient consent, confidentiality, and privacy are preserved.[6] In this era of internet, email, and social media, the chances of images being misused or misquoted are very high and the clinician should be aware of this too.

A prior written informed consent in the patient’s own language signed by the parent or legal guardian is needed prior to photographing a child’s clinical condition. It is ideal to use an explicit consent even if the face is not being shown in the photograph.[7] Consent should always include why the photo is being taken and who may have access to the photographs.[8]

Never barge into the privacy of the patient in the zeal to get a good image of the clinical condition. If the child is not cooperating to be photographed, sick or irritable one has to refrain from bothering the child further in the attempt to take the clinical image however interesting the clinical scenario is and even if the parents have given the consent to photograph. Imagining oneself in the patient’s or the relatives’ shoes will make the clinician more careful about the basic manners and ethics of clinical photography.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Akhtar S, Chen V, Benjamin L, Mayoral F Photodocumentation in skin of color Pediatr Dermatol 2021 38 Suppl 2 86 9
2. Ashique KT, Kaliyadan F, Aurangabadkar SJ Clinical photography in dermatology using smartphones:An overview Indian Dermatol Online J 2015 6 158 63
3. Available from:https://www.adobe.com/in/creativecloud/file-types/image/raw.html Last accessed on 2022 Jul 31
4. Ramam M Awards, images, instructions Indian J Dermatol Venereol Leprol 2015 81 1 3
5. Ashique K, Kaliyadan F Clinical photography for trichology practice:Tips and tricks Int J Trichology 2011 3 7 13
6. Kaliyadan F Image manipulation and image plagiarism –What's fine and what's not? Indian J Dermatol Venereol Leprol 2017 83 519 21
7. So N, Waldman R, Waldman S Professionalism of clinical photography in the pediatric setting Curr Probl Pediatr Adolesc Health Care 2019 49 74 8
8. Kaliyadan F Image quality for publication Indian J Dermatol Venereol Leprol 2016 82 367 70
9. Van der Rijt R, Hoffman S Ethical considerations of clinical photography in an area of emerging technology and smartphones J Med Ethics 2014 40 211 2
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