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Automatic Quantitative Analysis of

Healing Skin Wounds using Colour


Digital Image Processing
William Paul Berriss B.Sc, M.Sc, AMIEE,
wpberriss@iee.org Abstract,
Stephen John Sangwine, Senior Member IEEE Introduction
Colour image processing
S.J.Sangwine@reading.ac.uk Image acquisition, digitisation and calibration
Department of Engineering, University of Reading, Reading, England Conclusion
Publishing Details: References
Submitted: 26th April, 1997 Acknowledgement,
Published: 19th September, 1997 Useful resources.
Edition 1.1
Includes hyperlinks to online abstracts where available.
Previous edition 1.0 (14 July 1997) also available.

Abstract

This article reviews the recently published research of image processing laboratories
involved in colour image processing applied to skin wounds and lesions. The lack of non-
invasive methods to evaluate wound repair is a major obstacle in acquiring quantitative
data in clinical trials. The role of colour image processing as the most acceptable
automatic method of objectively and reproducibly analysing skin lesions and wounds is
explored. Image acquisition, digitisation and the use of various image processing
algorithms in the analysis of wounds and lesions have been studied in this review. In
conclusion, there is considerable scope for further research and development in this field.

Introduction

Colour image processing has many advantages over human assessment of wounds and
skin lessions; digital image processing techniques are objective and reproducible. Colour
image processing has significant potential, since the analysis and comparison of colour
images is a task which humans find particularly difficult. With the current technological
trends in computer hardware and scanners, computerised systems are becoming
increasingly affordable.

There are two main applications of colour image processing in the field of skin imaging.
They are the assessment of the healing of skin wounds or ulcers, and the diagnosis of
pigmented skin lesions such as melanomas. The analysis of lesions involves more
traditional image processing techniques such as edge detection and object identification,
followed by an analysis of the size, shape, irregularity and colour of the segmented
lesion. However, in wound analysis, although it is necessary to detect the wound border
and to calculate its area, analysis of the colours within the wound site is often more
important. In short, wounds generally have a non-uniform mixture of yellow slough, red
granulation tissue and black necrotic tissue, and the proportions of each are an
important determining factor in the healing state of the wound.

In the case of assessing skin lesions in the clinic, clinicians have to decide whether or not
a skin lesion should be tested further, and analysis using colour image processing could
provide additional information to aid such decisions. A very general review on digital
imaging has been written by Perednia et al. [1] . Their review covers the basics of image
analysis, transmission and storage on computer. One problem of storage is that image
files can be very large. However this can be reduced to some extent by use of data
compression techniques without significantly reducing the information content or quality
of an image. One of the groups reviewed found that dermatologists were able to
diagnose lesions with compressed digital images without significant change from their
performance with the original digital image.

Colour Image Processing


There are relatively few research groups around the world involved in colour image
processing of wounds or lesions. Fewer still have experimented with techniques for
assessing skin wounds using colour image processing. Herbin et al. [2] [3] at the
Department de Biostatistiques et Informatique Medicale, Hopital Cochin, Paris, France
analysed RGB colour images digitised from Kodachrome colour slides of wounds, in order
to quantitatively assess wound healing kinetics. They studied artificially created blister
wounds on the forearms of eight volunteers over twelve days. The wounds were
photographed with a 2mm white paper disk placed adjacent to the wound site, which
served as both a colour and geometric reference. Each digitised slide image was
corrected, using the white reference patch. They evaluated a simple colour index of
healing for these uniformly coloured wounds and used an automated approach to
determine the wound area. Although they have tackled the problem of automating
wound analysis, their method was not as complex as would be necessary for the analysis
of natural wounds which have a highly variegated colouring. Another group, Arnqvist et
al.[4] at the Department of Scientific Computing, University of Uppsala, Sweden,
experimented with a method for the semi-automatic classification of secondary healing
ulcers. Color photographs were acquired with a 35mm still camera with ring flash. The
photographs were then digitised into a 24-bit RGB image. Photographs were taken at an
optimal angle of thirty degrees to the wound plane normal in order to reduce reflections
from the flash. In each scene they placed a scale, calibrated in millimeters, to enable
estimation of the wound area. The wound tissue types were divided into black necrotic
eschar, yellow necrosis/fibrin (or slough), red granulation tissue, and a fourth class
which contained the undesired reflections from glossy parts of the wound which were
almost entirely white. Their method was only semi-automatic because a skilled operator
had to use a mouse to track around the wound boundaries to define the region of
interest (ROI). The operator then chose one wound classifier from a database of 16
which had been created using hundreds of photographs of different wounds taken under
various lighting conditions. An algorithm then segmented the wound image into the three
tissue types, the segmentation depending on the classifier chosen. Each classifier related
to a type of wound. Finally, the operator-defined binary image and the segmentation
performed by the classifier were combined to give an overall wound classification. Finally
the areas of each of the three tissue type zones and the total wound area were computed
using the scale.

At the University of Glamorgan, Wales, Jones and Plassmann [5] [6], of the Department
of Computer Studies have developed an instrument, known as MAVIS (Measurement of
Area and Volume InStrument), to measure the dimensions of skin wounds. It involves
capturing two images of the wound in quick succession whilst the wound is illuminated
with colour-coded structured light. This enabled phvolume measurements to be made. A
colour CCD video camera with a 250 W tungsten halogen bulb was used for imaging the
skin directly. MAVIS is capable of measuring the area phand volume of deep three-
dimensional wounds. For each acquisition, a magnesium oxide chip, placed alongside the
wound, was used as a white standard. The group have experimented with algorithms
that use colour to segment an image into one of three tissue types: healthy skin, wound
tissue and epithelialisation tissue. They found that epithelialisation tissue is often a
darkened band around the wound, separating skin from wound. In all, they tried six
measurement parameters: the R, G, and B intensities; Hue; Saturation; and gray-level
intensity. The R, G and B intensities were only examined in isolation and they concluded
that, `It is clear from inspection of Red, Green and Blue plane intensity-level histograms
for the different tissue types that straightforward thresholding of these planes cannot
produce a good segmentation which distinguishes between wound and skin or wound and
surrounding connected tissue'. They conclude that in looking at such 1D histograms,
segmentation is only partially achievable, but using a 3D RGB histogram space, volume
clusters may be more widely separated.

One group has made some progress with such a 3D RGB colour histogram clustering
technique. Mekkes et al.[7] at the Department of Dermatology, University of Amsterdam,
The Netherlands, have been using colour images to assess the healing of wounds. They
recognized that many of the enormous number of wound care materials that have been
introduced into the market have not been properly tested in randomized, double-blind
clinical trials. They pointed out that such trials are desperately needed to supply
clinicians with information to guide them in their choice of wound care products. They
compared a debriding product (Intrasite Gel) with an old form of treatment using saline
soaked gauzes [8]. They found that for a proper evaluation of the cleansing effect of
both treatments, colour aspects were more important than wound size. Their technique
measured the shift from black to yellow necrotic tissue to red granulation tissue. Their
aim is to create an automatic computerised method which can be used as a reference
standard or `gold-standard' for colour wound analysis. In their system, images were
acquired directly with an RGB video camera and framegrabber. They used two polarised
filters to reduce unwanted reflections. A clinicians knowledge of the colours in secondary
healing ulcers was used for calibration of the system. The computer had to be instructed
in advance as to which colours can be encountered in the granulation region and which in
the necrotic region of a wound. They found that clusters in RGB space for a given tissue
type formed an irregularly shaped 3D cloud, and so simple thresholding along the R, G
and B axes would not help to segment the image into these three tissue types. For this
reason, large classification tables, of the colours present in each tissue type, were
created semi-automatically by the computer with the aid of a clinician. One problem
discovered was that although digital image analysis could detect the wound margins
automatically, the colour differences between granulation tissue, surrounding skin and
the thin partly transparent layer of newly formed epithelium were too small to allow
automatic detection.

Finally, there are a few other groups that have done some work in colour image
processing of wounds. El Gammal et al. [9] at the Dermatological clinic of Ruhr
University, Germany, wrote a very short paper on the use of the black-yellow-red
classification scheme to evaluate the debridement activity of wounds. Solomon et al.
[10] at the University of Otago Medical School, New Zealand developed a simple and
rapid technique to measure the size of skin wounds and ulceration using two-dimensional
colour video images of ulcers. The images were stored on video cassette, thus rendering
low image quality. The work did not involve the development of colour image processing
algorithms, but a novel method to correct for limb convexity was presented. Smith et al.
[11] at the University of Akron, Ohio, USA, evaluated wound repair in humans and
animals using video images. Images were stored on VHS video tape, and only basic
colour image processing techniques were applied to the digitised images.

Image Acquisition, Digitisation and Calibration

Some groups used photography to capture the original wound image, others decided to
use a video camera and framegrabber for direct image capture and digitisation. If
photography is used, then the type of film used will affect the image quality. Once the
film has been processed then the slides need to be digitised and for this a colour slide
scanner can give a very high spatial resolution, up to 2,700 dots per inch. Such a
scanner can capture 95% of the information in a high resolution colour slide. For 35mm
film, this means that a resolution of over 3000 pixels across the image is possible.
Standard 35mm still cameras have the added advantage that they are highly portable,
and can easily be used outside the laboratory or clinic, in the patient's home for instance.
Care must be taken with the exposure setting on the camera. In considering just
greyscale images, Hall et al. [12] discovered that different exposures of the film have a
significant effect on the histogram of the image. This has many repercussions in image
processing since histogram analysis is a major tool of the image processor.

Framegrabbers, the digitiser boards in computers that connect to the video camera, do
not have such high resolution. Typically framegrabbers digitise images to only 512 pixels
by 512 pixels, and resolution does not meet up to the standards of photography or
colour slide scanners. Colour resolution is also inferior for framegrabbers, typically a
colour framegrabber has a colour resolution of 24-bits, corresponding to 16 million
colours. Their advantage is that digitisation of the images takes place as they are
acquired, and consequently no photographic processing time is incurred. However,
although video cameras can be as compact as a still camera, and use of a laptop
computer allows the system to be portable, such a system tends to be less versatile than
using a 35mm still camera. This renders imaging outside the laboratory less suitable. The
best solution would be to use a phdigital still camera, but these are still fairly new on the
market and rather expensive. Still, costs are gradually falling and so they are becoming a
viable option. They are quick, as no photographic processing is needed, digitisation
occurs immediately, and they render high resolution images, comparable with slide
scanners.

Calibration is a very important step and often overlooked by programmers since they
often aim to improve results by writing more complex algorithms rather than aim to
improve the quality of the original input image. By considering the nature of non-
uniformities in an image acquisition system due to the non-linear response of electronic
devices and non-uniform lighting, methods can be devised to measure these non-
uniformities to enable corrections to be made at the pre-processing stage. The use of a
pure white reference object in each scene, or better still a uniform greyscale, can be of
great benefit in correcting for non-linearities between the red, green and blue channels
as well as correcting for the non-linear reproduction of intensity by the system. In fact,
Hall et al. [12] found that It is not sufficient to simply have a reference white and black
in the image for calibration purposes, as this would assume a linear relationship for all
shades of grey in between'. Such greyscale non-linearities are inherent in all imaging
systems. Calibration can also be taken further, to ensure the correct reproduction of
colour as well as intensity. Frey and Palus [13]. Others considered the measurement of a
colour in a digital image processing system and explained a method for calibrating such a
system. In particular, they state that greyscale linearisation of each of the three
channels, R, G and B, is not enough to allow the system to reproduce colours or hues
correctly. A further step of linearisation must be performed over the three channels
together. This ensures that a pure red object which is twice as bright as another object
of the exact same red hue, is represented as being twice as bright in the red channel
only, rather than becoming marginally brighter in the red, green and blue channels for
example. For this stage, a colour look-up table (LUT) must be created and used for each
digitisation.

Conclusion

In conclusion it is found that for wound imaging in particular, the image processing
functions and algorithms needed are not simple compared with the functions provided by
the majority of image processing packages used by research laboratories and industry.
Wound imaging requires the use of colour; effective results cannot be achieved with
grey-scale images. This is not so true for lesion imaging though, and the use of greyscale
processing algorithms is sometimes sufficient. Industry has yet to catch up with the
latest colour image processing algorithms currently being developed by researchers. A lot
of commercial image processing software packages have colour image processing
operations/algorithms that are simply greyscale algorithms applied to the Red, Green
and Blue signals separately. However, it is important to treat a colour pixel as a whole,
and not to separate it into its three constituent components, in order to make full use of
all the information available in a colour image resulting in a more successful algorithm.

Acknowledgement

The authors gratefully acknowledge the supply of the wound images by, and helpful
discussions with, P.J.Phillips and Dr S.Thomas of the Surgical Materials Testing
Laboratory, Bridgend General Hospital, Wales.

References

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Journal of the American Academy of Dermatology, vol. 25, no. 1, pp. 89-108,
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G Strauch, Assessment of healing kinetics through true color image processing,
IEEE Transactions on Medical Imaging, vol. 12, no. 1, pp. 39-43, March 1993.
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image processing in skin, IEEE Transactions on Medical Imaging, vol. 9, no. 3,
pp. 262-269, 1990.
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secondary healing ulcers in multispectral images, in Proceedings of 9th
International Conference on Pattern Recognition, Rome, November 1988, pp.
459-461.
5. B F Jones and P Plassman, An instrument to measure the dimensions of
skin wounds, IEEE Transactions on Biomedical Engineering, vol. 42, no. 5, pp.
464-470, 1995.
6. T D Jones, Semi-automatic segmentation algorithms for measuring the
area of skin wounds, University of Glamorgan, Department of Computer Studies,
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Useful resources

http://www.elec.rdg.ac.uk/~strberis/wound_images.html was Will Berriss' image


analyses Web page, including details of his research into this area. It is no longer
available, but we hope to install his pages on t he SMTL server soon.