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Background: Once-daily topical oxymetazoline cream 1·0% significantly reduced persistent facial erythema of rosacea in trials requiring live, static patient assessments., Objectives: To evaluate critically the methodology of clinical trials that require live, static patient assessments by determining whether assessment of erythema is different when reference to the baseline photograph is allowed., Methods: In two identically designed, randomized, phase III trials, adults with persistent facial erythema of rosacea applied oxymetazoline or vehicle once daily. This phase IV study evaluated standardized digital facial photographs from the phase III trials to record ≥ 1-grade Clinician Erythema Assessment (CEA) improvement at 1, 3, 6, 9 and 12 h postdose., Results: Among 835 patients (oxymetazoline n = 415, vehicle n = 420), significantly greater proportions of patients treated with oxymetazoline vs. vehicle achieved ≥ 1-grade CEA improvement. For the comparison between phase IV study results and the original phase III analysis, when reference to baseline photographs was allowed while evaluating post-treatment photographs, the results for oxymetazoline were similar to results of the phase III trials (up to 85.7%), but a significantly lower proportion of vehicle recipients achieved ≥ 1-grade CEA improvement (up to 29.7% [phase 4] vs. 52.3% [phase 3]; P<0.001). In the phase IV study, up to 80·2% of patients treated with oxymetazoline achieved at least moderate erythema improvement vs. up to 22·9% of patients treated with vehicle. The association between patients' satisfaction with facial skin redness and percentage of erythema improvement was statistically significant., Conclusions: Assessment of study photographs, with comparison to baseline, confirmed significant erythema reduction with oxymetazoline on the first day of application. Compared with the phase III trial results, significantly fewer vehicle recipients attained ≥ 1-grade CEA improvement, suggesting a mitigated vehicle effect. This methodology may improve the accuracy of clinical trials evaluating erythema severity., (© 2018 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery.

Background: Photographic severity scales depicting facial wrinkling are used extensively to assess the severity of skin ageing features, but they have been poorly investigated for their reproducibility., Objectives: To investigate the reproducibility of ordinal scales depicting four skin ageing features illustrated by reference photographs., Methods: A set of 253 images of caucasian women's faces was evaluated independently by four dermatologists using four different skin ageing severity scales: Larnier's overall photodamage, expression lines, glabellar frown lines, and wrinkles under the eyes. For each pair of dermatologists, degree of agreement was estimated using the weighted kappa statistic and degrees of distinguishability between adjacent categories along these scales were estimated using a recently developed log-linear method., Results: The kappa statistic highlighted substantial degrees of agreement between dermatologists for the glabellar frown lines scale, and the log-linear method did not evidence any scale defect. For the three other scales, only fair to moderate degrees of agreement were observed between dermatologists. In addition, difficulties in distinguishing between some adjacent categories were evidenced., Conclusions: The glabellar frown lines scale is a reproducible tool for assessment of the severity of facial wrinkling. The other scales should be redefined to improve their reproducibility, and therefore their quality, in future studies.

Background: The severity of hand eczema is of interest in epidemiological studies. Ideally, as no validated methods of self-assessment exist, a dermatologist should examine all subjects. However, this is very resource intensive., Objectives: To examine if severity grading performed by patients with hand eczema using a self-administered photographic guide was in agreement with the assessment performed by a trained dermatologist. Furthermore, to measure the correlation between the severity of hand eczema expressed on a visual analogue scale (VAS) and the clinical severity assessment, using the photographic guide., Methods: Fifty-three consecutive outpatients with hand eczema were included, a number based on a prestudy statistical calculation. The patients were asked to grade current severity of their hand eczema by choosing one of four groups of photographs representing differing severities of hand eczema. On the same day all patients were examined by an experienced dermatologist, who graded the severity using the same photographic guide. The photographic guide was a modified version of a validated guide for use by physicians. In addition, the patients rated the severity of their hand eczema on a VAS., Results: Fifty-one of the respondents completed the full questionnaire. For 37 of the 51 patients (73%) the clinical severity assessments of patient and dermatologist were identical. The measure of agreement, Cohen's kappa coefficient, was 0.61, indicating good inter-rater agreement. The correlation between the dermatologist-rated severity and the corresponding score by the patients on the VAS was only moderate (Spearman's rank correlation coefficient rho = 0.52)., Conclusions: The photographic guide for the self-assessment of hand eczema is an easy instrument to use, and for research purposes can be a reliable tool for patients with hand eczema to grade severity. A VAS can only be considered as a mediocre tool for estimation of the dermatologist-rated clinical severity, but should be validated as an independent instrument to assess severity of hand eczema.

Background: Focal injections of botulinum toxin A are used successfully for the treatment of hyperkinetic facial wrinkles. Efficacy can be measured by several methods. However, so far none has been investigated for its reproducibility. Objectives To investigate the reproducibility of a clinical 0-3 score for glabellar frown lines., Methods: In the first part of the study, a standardized photographic documentation of glabellar frown lines was produced. Based on the results of this phase, a consensus atlas of glabellar frown lines was developed and participants were trained using this atlas. In the main study, 50 standardized photographs were shown on two consecutive days to 28 dermatologists. The reproducibility of the score was investigated by conventional kappa statistics., Results: In the main study, we found an unweighted kappa according to Fleiss of 0.62 for interobserver reproducibility. Intraobserver reproducibility showed an unweighted kappa according to Cohen of between 0.57 and 0.91 for each observer, and a weighted kappa according to Cicchetti and Allison of between 0.68 and 0.94., Conclusions: The clinical 0-3 score for glabellar frown lines shows a good inter- and intraobserver reproducibility.

This three-part study investigated the reproducibility of natural head posture (NHP) using radiographs and photographs. In part 1, reproducibility of cephalograms 1 year after the introduction of NHP was investigated and found to be less favourable (Dahlberg coefficient of 2.99 degrees) than most other previous investigations. In order to minimize radiation exposure of patients, reproducibility of photographs and method agreement between photographs and cephalograms were investigated in part 2. Reproducibility of the two photographs was poor (2.71 degrees). However, method agreement between cephalograms and the photographs taken at the same time was good (1.39 degrees). Replacement of the radiographic method with the photographic method for assessing NHP reproducibility appeared justified. Changing the protocol for achieving NHP in part 3 of the study improved reproducibility substantially (1.41 degrees). Various statistical methods were used to assess reproducibility and method agreement. Bland and Altman's graphical representation was found to be the most appropriate for method agreement. The Dahlberg coefficient, commonly used to assess NHP repeatability/reproducibility, does not provide an extreme enough interval to allow a sufficient clinical assessment of a method to be undertaken, compared with the reproducibility coefficient. That is, the latter provides a 95 per cent range, compared with 52 per cent with Dahlberg.

Background and Purpose: The purposes of this study were to compare test-retest reliability of measurements obtained by the use of a photographic method and those obtained by the use of a transparency method and to compare wound surface area (WSA) measurements obtained by these two methods., Subjects: Twenty inpatients (18 male, 2 female), aged 31 +/- 16 years (mean +/- SD), participated in the study., Methods: Tracings of ulcer borders generated by the photographic and transparency methods were digitized to obtain WSA measurements. To assess intrarater reliability for each method, 5 ulcers were measured on two occasions. The magnitude of WSA measurements obtained by the photographic and transparency methods was compared in 22 ulcers measured on one occasion and in 16 ulcers measured at 5-day intervals for 20 days., Results: Intraclass correlation coefficients (ICCs) were high (ICC = .99) for each method, indicating reliability of measurements. The WSA measurements did not differ between photographic and transparency methods, either at one occasion or over a 20-day period., Conclusion and Discussion: We concluded that the photographic and transparency methods, as applied in this study of ulcers, provided equivalently reliable measurements and that WSA measurements obtained by the two methods were equivalent. The transparency method was more economical than the photographic method in terms of time and equipment requirements.

The Baltimore Eye Survey was a population-based survey conducted from January 1985 to November 1988 among residents of east Baltimore, Maryland, who were 40 years of age or older. A total of 5,308 black subjects and white subjects received a comprehensive screening examination for glaucoma including tonometry, visual fields, stereoscopic fundus photography, and a detailed medical and ophthalmic history. Based on a definitive examination, a diagnosis of glaucoma of any type was made for 196 persons. Tonometry, cup:disc ratio, and narrowest neuroretinal rim width were evaluated for their ability to correctly classify subjects into diseased or nondiseased states. There were no cutoff values at which these variables provided a reasonable balance of sensitivity and specificity, separately or in combination. Logistic regression models were fit that included demographic and other risk factors. Sensitivities and specificities were calculated for varying cutoff levels on the distribution of predicted probabilities. There was no cutoff for which reasonable sensitivity and specificity were obtained. The authors conclude that the effectiveness of current techniques for glaucoma screening is limited.