The importance of good photography in clinical trials and in the clinic

Abstract

In this issue of the BJD, Eichenfield and his colleagues have highlighted the utility of comparative photography in clinical trials where a global evaluation of improvement is required. They have convincingly demonstrated that a clinical evaluation of erythema without the ability to validate the outcomes with photography can be inaccurate especially when judging a vehicle’s effect. There was an excellent correlation between the face-to-face examination in patients receiving the active agent with photographs taken at these visits. However, there was a significant difference in the outcome when an evaluation of the vehicle effects at the visit were documented without the benefit of a view of baseline photography. It appears that there is some degree of evaluator bias at follow-up visits when a clinical effect might be expected. Clinical photography has become much more sophisticated over the past few years. The system used in this trial, VISIACR (Cannfield Scientific, Parsippany, NJ, U.S.A.), places the patient’s face in a self-contained small facial booth that finely controls lighting and comes with a number of filters that can be used to evaluate several parameters. These instruments are easy to use and only require simple positioning to achieve a consistent digital photograph. As the system is self-contained there is no need to worry about difference in lighting that might confound an accurate evaluation. A version of this system can also count open and closed comedones, giving us another tool to validate lesion counting in acne trials. With the availability and the ease of use of these systems, it might be time for journals that publish clinical trials and governmental agencies that approve drugs to consider requiring this type of controlled clinical photography to complement the onsite clinical evaluation. In many instances it would permit an independent validation of the outcomes and give us all much more confidence in results. This study also prompts us to reflect on a number of clinical drug trials that failed where the vehicle’s effect was not confirmed by photography and might have been overstated. There are some limitations to using photographs when comparing them with patients who are in the clinic for an evaluation. There are significant challenges attempting an accurate comparison of a lightingand position-controlled digital photograph with a live patient in a room where the environment can be highly variable. Comparing digital photographs as done in this study is a much more accurate methodology. There is a practical application for this type of photography when demonstrating an improvement or change to a patient who has had a device or filler treatment. In our facility we routinely use the before and after photographs taken with the VISIA-CR to demonstrate improvement as well as a record of the treatment results. It is a vast improvement from the evaluations that were made with the patients using a hand mirror and attempting to correlate any change with a picture on a monitor or from their memory. It is time for controlled digital photography to have a proper place in certain clinical studies where an investigatorclinical assessment is required and also in the clinic where comparative photography is important.