Imaging of skin birefringence for human scar assessment using polarization-sensitive optical coherence tomography aided by vascular masking

Feasibility of deep learning-based polarization-sensitive optical coherence tomography angiography for imaging cutaneous microvasculature

Polarization-sensitive optical coherence tomography (PS-OCT) measures the polarization states of the backscattered light from tissue that can improve angiography based on conventional optical coherence tomography (OCT). We present a feasibility study on PS-OCT integrated with deep learning for PS-OCT angiography (PS-OCTA) imaging of human cutaneous microvasculature. Two neural networks were assessed for PS-OCTA, including the residual dense network (RDN), which previously showed superior performance for angiography with conventional OCT and the upgraded grouped RDN (GRDN). We also investigated different protocols to process the multiple signal channels provided by the Jones matrices from the PS-OCT system to achieve optimal PS-OCTA performance. The training and testing of the deep learning-based PS-OCTA were performed using PS-OCT scans collected from 18 skin locations comprising 16,600 B-scan pairs. The results demonstrated a moderately improved performance of GRDN over RDN, and of the use of the combined signal from the Jones matrix elements over the separate use of the elements, as well as a similar image quality to that provided by speckle decorrelation angiography. GRDN-based PS-OCTA also showed ∼2-3 times faster processing and improved mitigation of tissue motion as compared to speckle decorrelation angiography, and enabled fully automatic processing. Deep learning-based PS-OCTA can be used for imaging cutaneous microvasculature, which may enable easy adoption of PS-OCTA for preclinical and clinical applications.

Viewing life without labels under optical microscopes

Optical microscopes today have pushed the limits of speed, quality, and observable space in biological specimens revolutionizing how we view life today. Further, specific labeling of samples for imaging has provided insight into how life functions. This enabled label-based microscopy to percolate and integrate into mainstream life science research. However, the use of labelfree microscopy has been mostly limited, resulting in testing for bio-application but not bio-integration. To enable bio-integration, such microscopes need to be evaluated for their timeliness to answer biological questions uniquely and establish a long-term growth prospect. The article presents key label-free optical microscopes and discusses their integrative potential in life science research for the unperturbed analysis of biological samples.

Molecular Contrast Optical Coherence Tomography and Its Applications in Medicine

The growing need to understand the molecular mechanisms of diseases has prompted the revolution in molecular imaging techniques along with nanomedicine development. Conventional optical coherence tomography (OCT) is a low-cost in vivo imaging modality that provides unique high spatial and temporal resolution anatomic images but little molecular information. However, given the widespread adoption of OCT in research and clinical practice, its robust molecular imaging extensions are strongly desired to combine with anatomical images. A range of relevant approaches has been reported already. In this article, we review the recent advances of molecular contrast OCT imaging techniques, the corresponding contrast agents, especially the nanoparticle-based ones, and their applications. We also summarize the properties, design criteria, merit, and demerit of those contrast agents. In the end, the prospects and challenges for further research and development in this field are outlined.

Evaluation of Mannitol Intervention Effects on Ischemic Cerebral Edema in Mice Using Swept Source Optical Coherence Tomography

Cerebral edema is a serious complication of ischemic cerebrovascular disease and mannitol is a commonly used dehydrating agent for relieving cerebral edema. However, the edema state and surrounding vascular perfusion level during mannitol treatment remains unclear, which affects the clinical application of the medicine. In this paper, we demonstrated the role of swept-source optical coherence tomography (OCT) in the evaluation of mannitol efficacy using mouse models. The OCT-based angiography and attenuation imaging technology were used to obtain the cerebral vascular perfusion level and cerebral edema state at different times. Vascular parameters and edema parameters were quantified and compared. Experimental results show that mannitol can significantly reduce the water content in the central region of edema, effectively inhibiting the rapid growth of the edema area, and restoring cerebral blood flow. On average, the edema area decreased by 33% after 2 h, and the vascular perfusion density increased by 12% after 5 h. This work helps to provide a valuable theoretical basis and research ideas for the clinical treatment of cerebral edema.

Birefringent tissue-mimicking phantom for polarization-sensitive optical coherence tomography imaging

SIGNIFICANCE

Tissue birefringence is an important parameter to consider when designing realistic, tissue-mimicking phantoms. Options for suitable birefringent materials that can be used to accurately represent tissue scattering are limited.

AIM

To introduce a method of fabricating birefringent tissue phantoms with a commonly used material-polydimethylsiloxane (PDMS)-for imaging with polarization-sensitive optical coherence tomography (PS-OCT).

APPROACH

Stretch-induced birefringence was characterized in PDMS phantoms made with varying curing ratios, and the resulting phantom birefringence values were compared with those of biological tissues.

RESULTS

We showed that, with induced birefringence levels up to 2.1  ×  10  -  4, PDMS can be used to resemble the birefringence levels in weakly birefringent tissues. We demonstrated the use of PDMS in the development of phantoms to mimic the normal and diseased bladder wall layers, which can be differentiated by their birefringence levels.

CONCLUSIONS

PDMS allows accurate control of tissue scattering and thickness, and it exhibits controllable birefringent properties. The use of PDMS as a birefringent phantom material can be extended to other birefringence imaging systems beyond PS-OCT and to mimic other organs.

Imaging striae distensae: a comparison between PS-OCT and digital dermoscopy

Stretch marks or striae distensae (SD) cause emotional distress and negatively affect the psychological well-being of patients. We investigate and compare two methods for quantifying the severity of SD: visual scoring of images captured using a clinical visible-light dermatological camera (C-Cube, Pixience Inc) and measuring the local birefringence of skin using polarization-sensitive optical coherence tomography (PS-OCT). Data on skin visually affected by SD and visually normal skin were collected from 19 human volunteers. Our results show a weak correlation between visual scores of the C-Cube images and the birefringence values obtained from the PS-OCT system. SD datasets have a significantly larger birefringence values compared to visually normal datasets.

Attenuation corrected-optical coherence tomography for quantitative assessment of skin wound healing and scar morphology

Imaging the structural modifications of underlying tissues is vital to monitor wound healing. Optical coherence tomography (OCT) images high-resolution sub-surface information, but suffers a loss of intensity with depth, limiting quantification. Hence correcting the attenuation loss is important. We performed swept source-OCT of full-thickness excision wounds for 300 days in mice skin. We used single-scatter attenuation models to determine and correct the attenuation loss in the images. The phantom studies established the correspondence of corrected-OCT intensity (reflectivity) with matrix density and hydration. We histologically validated the corrected-OCT and measured the wound healing rate. We noted two distinct phases of healing-rapid and steady-state. We also detected two compartments in normal scars using corrected OCT that otherwise were not visible in the OCT scans. The OCT reflectivity in the scar compartments corresponded to distinct cell populations, mechanical properties and composition. OCT reflectivity has potential applications in evaluating the therapeutic efficacy of healing and characterizing scars.

Polarization sensitive optical coherence tomography for imaging microvascular information within living tissue without polarization-induced artifacts

When imaging birefringent samples using optical coherence tomography angiography (OCTA), the phase retardation may appear opposite to the phase change due to the blood flow in the orthogonal signals, for which a cancellation effect can occur when deriving OCTA signals. This effect can diminish the ability of OCTA to detect vascular information, leading to an erroneous interpretation of the final OCTA images. To mitigate this issue, we demonstrate polarization-sensitive optical coherence tomography (PS-OCT) to image microvascular information within a living sample without polarization induced artifacts. The system is furnished with a swept source OCT (SS-OCT) that incorporates two imaging modes: OCTA imaging and polarization-sensitive imaging. PS-OCT is used to provide birefringent contrast where the color-encoded Stokes parameters are used to obtain high contrast polarization-state images. OCTA is used to acquire high-resolution images of functional microvascular networks permeating the scanned tissue volume. Taking the advantages of the dual-channel PS-OCT configuration, the polarization induced artifacts are eliminated from OCTA vascular imaging. The proposed PS-OCTA system is employed to visualize the birefringent components and the vascular networks of the human skin in vivo. It is expected that the proposed system setup would have useful and practical applications in the investigations of the vasculature in the birefringent tissue samples both pre-clinically and clinically.

Jones matrix-based speckle-decorrelation angiography using polarization-sensitive optical coherence tomography

We show that polarization-sensitive optical coherence tomography angiography (PS-OCTA) based on full Jones matrix assessment of speckle decorrelation offers improved contrast and depth of vessel imaging over conventional OCTA. We determine how best to combine the individual Jones matrix elements and compare the resulting image quality to that of a conventional OCT scanner by co-locating and imaging the same skin locations with closely matched scanning setups. Vessel projection images from finger and forearm skin demonstrate the benefits of Jones matrix-based PS-OCTA. Our study provides a promising starting point and a useful reference for future pre-clinical and clinical applications of Jones matrix-based PS-OCTA.

In vivo imaging of the depth-resolved optic axis of birefringence in human skin

Recent progress has enabled the reconstruction of the local (i.e., depth-resolved) optic axis (OAx) of biological tissue from measurements made with polarization-sensitive optical coherence tomography (PS-OCT). Here we demonstrate local OAx imaging in healthy human skin in vivo. The images reveal dense, weaving patterns that are imperceptible in OCT intensity tomograms or conventional PS-OCT metrics and that suggest a mesh-like tissue organization, consistent with the morphology of dermal collagen. Using co-registered polarization-sensitive optical coherence microscopy, we furthermore investigated the impact of spatial resolution on the recovered OAx patterns and confirmed their consistency. OAx orientation as a contrast mechanism merits further exploration for applications in dermatology.

Polarimetric imaging in backscattering for the structural characterization of strongly scattering birefringent fibrous media

Interpreting the polarimetric data from fiber-like macromolecules constitutive of tissue can be difficult due to strong scattering. In this study, we probed the superficial layers of fibrous tissue models (membranes consisting of nanofibers) displaying varying degrees of alignment. To better understand the manifestation of membranes' degree of alignment in polarimetry, we analyzed the spatial variations of the backscattered light's Stokes vectors as a function of the orientation of the probing beam's linear polarization. The degree of linear polarization reflects the uniaxially birefringent behavior of the membranes. The rotational (a-)symmetry of the backscattered light's degree of linear polarization provides a measure of the membranes' degree of alignment.

Parametric imaging of attenuation by optical coherence tomography: review of models, methods, and clinical translation

SIGNIFICANCE

Optical coherence tomography (OCT) provides cross-sectional and volumetric images of backscattering from biological tissue that reveal the tissue morphology. The strength of the scattering, characterized by an attenuation coefficient, represents an alternative and complementary tissue optical property, which can be characterized by parametric imaging of the OCT attenuation coefficient. Over the last 15 years, a multitude of studies have been reported seeking to advance methods to determine the OCT attenuation coefficient and developing them toward clinical applications.

AIM

Our review provides an overview of the main models and methods, their assumptions and applicability, together with a survey of preclinical and clinical demonstrations and their translation potential.

RESULTS

The use of the attenuation coefficient, particularly when presented in the form of parametric en face images, is shown to be applicable in various medical fields. Most studies show the promise of the OCT attenuation coefficient in differentiating between tissues of clinical interest but vary widely in approach.

CONCLUSIONS

As a future step, a consensus on the model and method used for the determination of the attenuation coefficient is an important precursor to large-scale studies. With our review, we hope to provide a basis for discussion toward establishing this consensus.

Assessing the progression of systemic sclerosis by monitoring the tissue optic axis using PS-OCT

The clinical assessment of fibrosis is critical to the diagnosis and management of patients with systemic sclerosis. Current clinical standards for patient assessment is to use skin fibrosis as an indicator of organ involvement, though this approach is highly subjective and relies on manual palpation. The development of a new method for accurately quantifying collagen content may therefore significantly improve the accuracy of the traditional skin score in patients with systemic sclerosis and may additionally aid in the monitoring of anti-fibrotic therapies in clinical practice. Polarization-sensitive optical coherence tomography (PS-OCT) is a high-speed volumetric imaging modality that can be used to assess birefringent tissues including collagen. In this work we demonstrate a novel computational approach using PS-OCT for the assessment of fibrosis. This approach, based on the measured distribution of optic axis values associated with a given volume of collagen orientation, characterizes fibrotic changes independently from the depth of the region of interest in the tissue. This approach has the potential to accurately quantify collagen content and orientation faster and more robustly compared to traditional PS-OCT metrics. We investigate the viability of this approach for assessing the development of fibrosis in a bleomycin induced skin fibrosis mouse model.

Buffered polarization diverse detection for single-camera polarization-sensitive optical coherence tomography

Herein we propose a method to mitigate a position mismatch problem for a spectral-domain polarization-sensitive optical coherence tomography (SD-PS-OCT) system that uses a single line-scan detection scheme. A single detector-based PS-OCT detects two orthogonal polarization components as two adjacent A-scan signals in turns. Thus, two adjacent A-scan signals are not scattered at a fixed point in time (position mismatch problem), resulting in uncorrelated signals between them. To achieve sequential detection of simultaneously scattered light, a buffering single-mode fiber was connected to one of the two ports coming out of the optical switch, provided a proper time delay. A single-mode optical fiber of 2.69 km in length was used to buffer, and its length was determined by a frame rate of the spectrometer used as a detector. With the proposed SD-PS-OCT scheme, the PS-OCT system with a simple configuration, and the minimized position mismatch problem between two polarization components can be set.

Robust reconstruction of local optic axis orientation with fiber-based polarization-sensitive optical coherence tomography

It is challenging to recover local optic axis orientation from samples probed with fiber-based polarization-sensitive optical coherence tomography (PS-OCT). In addition to the effect of preceding tissue layers, the transmission through fiber and system elements, and imperfect system alignment, need to be compensated. Here, we present a method to retrieve the required correction factors from measurements with depth-multiplexed PS-OCT, which accurately measures the full Jones matrix. The correction considers both retardation and diattenuation and is applied in the wavenumber domain, preserving the axial resolution of the system. The robustness of the method is validated by measuring a birefringence phantom with a misaligned system. Imaging ex-vivo lamb trachea and human bronchus demonstrates the utility of reconstructing the local optic axis orientation to assess smooth muscle, which is expected to be useful in the assessment of airway smooth muscle thickness in asthma, amongst other fiber-based applications.

Label-free volumetric imaging of conjunctival collecting lymphatics ex vivo by optical coherence tomography lymphangiography

We employ optical coherence tomography (OCT) and optical coherence microscopy (OCM) to study conjunctival lymphatics in porcine eyes ex vivo. This study is a precursor to the development of in vivo imaging of the collecting lymphatics for potentially guiding and monitoring glaucoma filtration surgery. OCT scans at 1300 nm and higher-resolution OCM scans at 785 nm reveal the lymphatic vessels via their optical transparency. Equivalent signal characteristics are also observed from blood vessels largely free of blood (and devoid of flow) in the ex vivo conjunctiva. In our lymphangiography, vessel networks were segmented by compensating the depth attenuation in the volumetric OCT/OCM signal, projecting the minimum intensity in two dimensions and thresholding to generate a three-dimensional vessel volume. Vessel segmentation from multiple locations of a range of porcine eyes (n = 21) enables visualization of the vessel networks and indicates the varying spatial distribution of patent lymphatics. Such visualization provides a new tool to investigate conjunctival vessels in tissue ex vivo without need for histological tissue processing and a valuable reference on vessel morphology for the in vivo label-free imaging studies of lymphatics to follow.

In vivo polarization-sensitive optical coherence tomography of human burn scars: birefringence quantification and correspondence with histologically determined collagen density

Obtaining adequate information on scar characteristics is important for monitoring their evolution and the effectiveness of clinical treatment. The aberrant type of collagen in scars may give rise to specific birefringent properties, which can be determined using polarization-sensitive optical coherence tomography (PS-OCT). The aim of this pilot study was to evaluate a method to quantify the birefringence of the scanned volume and correlate it with the collagen density as measured from histological slides. Five human burn scars were measured in vivo using a handheld probe and custom-made PS-OCT system. The local retardation caused by the tissue birefringence was extracted using the Jones formalism. To compare the samples, histograms of birefringence values of each volume were produced. After imaging, punch biopsies were harvested from the scar area of interest and sent in for histological evaluation using Herovici polychrome staining. Two-dimensional en face maps showed higher birefringence in scars compared to healthy skin. The Pearson's correlation coefficient for the collagen density as measured by histology versus the measured birefringence was calculated at r=0.80 (p=0.105). In conclusion, the custom-made PS-OCT system was capable of in vivo imaging and quantifying the birefringence of human burn scars, and a nonsignificant correlation between PS-OCT birefringence and histological collagen density was found.

In vivo imaging of human oral hard and soft tissues by polarization-sensitive optical coherence tomography

Since optical coherence tomography (OCT) provides three-dimensional high-resolution images of biological tissue, the benefit of polarization contrast in the field of dentistry is highlighted in this study. Polarization-sensitive OCT (PS OCT) with phase-sensitive recording is used for imaging dental and mucosal tissues in the human oral cavity in vivo. An enhanced polarization contrast of oral structures is reached by analyzing the signals of the co- and crosspolarized channels of the swept source PS OCT system quantitatively with respect to reflectivity, retardation, optic axis orientation, and depolarization. The calculation of these polarization parameters enables a high tissue-specific contrast imaging for the detailed physical interpretation of human oral hard and soft tissues. For the proof-of-principle, imaging of composite restorations and mineralization defects at premolars as well as gingival, lingual, and labial oral mucosa was performed in vivo within the anterior oral cavity. The achieved contrast-enhanced results of the investigated human oral tissues by means of polarization-sensitive imaging are evaluated by the comparison with conventional intensity-based OCT.

Multifunctional in vivo imaging for monitoring wound healing using swept-source polarization-sensitive optical coherence tomography

BACKGROUND AND OBJECTIVE

Wound healing involves a complex and dynamic biological process in response to tissue injury. Monitoring of the cascade of cellular events is useful for wound management and treatment. The aim of this study is to demonstrate the potential of multifunctional polarization-sensitive optical coherence tomography (PS-OCT) to longitudinally monitor the self-healing process in a murine cutaneous wound model.

MATERIALS AND METHODS

A multi-functional PS-OCT system based on swept source OCT configuration (1,310 nm central wavelength) was designed to obtain simultaneously microstructural, blood perfusion, and birefringent information of a biological tissue in vivo. A 1-mm-diameter wound was generated in a mouse pinna with a complete biopsy punch. Afterwards, the self-healing process of the injured tissue was observed every week over 6-week period using the multifunctional system to measure changes in the tissue birefringence. Further OCT angiography (OCTA) was used in post data processing to obtain blood perfusion information over the injured tissue.

RESULTS

Three complementary images indicating the changes in anatomical, vascular, and birefringent information of tissue around wound were simultaneously provided from a 3-dimensional (3-D) PS-OCT data set during the wound repair over 1 month. Specifically, inflammatory and proliferative phases of wound healing were characterized by thickened epidermal tissue (from OCT images) and angiogenesis (from OCT angiography images) around wound. Also, it was observed that the regenerating tissues had highly realigned birefringent structures (from PS-OCT images).

CONCLUSION

This preliminary study suggests that the proposed multi-functional imaging modality has a great potential to improve the understanding of wound healing through non-invasive, serial monitoring of vascular and tissue responses to injury. Lasers Surg. Med. 50:213-221, 2018. © 2017 Wiley Periodicals, Inc.

In vivo volumetric quantitative micro-elastography of human skin

In this paper, we demonstrate in vivo volumetric quantitative micro-elastography of human skin. Elasticity is estimated at each point in the captured volume by combining local axial strain measured in the skin with local axial stress estimated at the skin surface. This is achieved by utilizing phase-sensitive detection to measure axial displacements resulting from compressive loading of the skin and an overlying, compliant, transparent layer with known stress/strain behavior. We use an imaging probe head that provides optical coherence tomography imaging and compression from the same direction. We demonstrate our technique on a tissue phantom containing a rigid inclusion, and present in vivo elastograms acquired from locations on the hand, wrist, forearm and leg of human volunteers.

Investigation of optical attenuation imaging using optical coherence tomography for monitoring of scars undergoing fractional laser treatment

We demonstrate the use of the near-infrared attenuation coefficient, measured using optical coherence tomography (OCT), in longitudinal assessment of hypertrophic burn scars undergoing fractional laser treatment. The measurement method incorporates blood vessel detection by speckle decorrelation and masking, and a robust regression estimator to produce 2D en face parametric images of the attenuation coefficient of the dermis. Through reliable co-location of the field of view across pre- and post-treatment imaging sessions, the study was able to quantify changes in the attenuation coefficient of the dermis over a period of ∼20 weeks in seven patients. Minimal variation was observed in the mean attenuation coefficient of normal skin and control (untreated) mature scars, as expected. However, a significant decrease (13 ± 5%, mean ± standard deviation) was observed in the treated mature scars, resulting in a greater distinction from normal skin in response to localized damage from the laser treatment. By contrast, we observed an increase in the mean attenuation coefficient of treated (31 ± 27%) and control (27 ± 20%) immature scars, with numerical values incrementally approaching normal skin as the healing progressed. This pilot study supports conducting a more extensive investigation of OCT attenuation imaging for quantitative longitudinal monitoring of scars. En face 2D OCT attenuation coefficient map of a treated immature scar derived from the pre-treatment (top) and the post-treatment (bottom) scans. (Vasculature (black) is masked out.) The scale bars are 0.5 mm.

Imaging Blood Vessel Morphology in Skin: Dynamic Optical Coherence Tomography as a Novel Potential Diagnostic Tool in Dermatology

Conventional optical coherence tomography (OCT) enables the visualization of morphological changes of skin cancer. The use of OCT in the diagnostic investigation and in the therapy decision of non-melanoma skin cancer and other skin changes is already established, and has found its way into routine practice. With the development of speckle-variance OCT, also named dynamic OCT (D-OCT), the vascular architecture and the blood flow of the skin can be displayed in vivo and in 3D. This novel angiographic variant of OCT offers the ability to visualize and measure vessel morphology providing a new insight into healthy, inflammatory and neoplastic skin lesions such as malignant melanoma. This review focuses on the possibilities of using D-OCT on healthy and diseased skin. We suggest and illustrate key diagnostic characteristics by analyzing the initial publications and preliminary unpublished data on vessel morphology and distribution. The potential of D-OCT as a diagnostic tool in dermatology is examined and may give rise to future studies on D-OCT, which are needed to confirm the aforementioned features.

Polarization sensitive optical coherence tomography - a review [Invited]

Optical coherence tomography (OCT) is now a well-established modality for high-resolution cross-sectional and three-dimensional imaging of transparent and translucent samples and tissues. Conventional, intensity based OCT, however, does not provide a tissue-specific contrast, causing an ambiguity with image interpretation in several cases. Polarization sensitive (PS) OCT draws advantage from the fact that several materials and tissues can change the light's polarization state, adding an additional contrast channel and providing quantitative information. In this paper, we review basic and advanced methods of PS-OCT and demonstrate its use in selected biomedical applications.

Review of near-infrared methods for wound assessment

Wound management is a challenging and costly problem that is growing in importance as people are living longer. Instrumental methods are increasingly being relied upon to provide objective measures of wound assessment to help guide management. Technologies that employ near-infrared (NIR) light form a prominent contingent among the existing and emerging technologies. We review some of these technologies. Some are already established, such as indocyanine green fluorescence angiography, while we also speculate on others that have the potential to be clinically relevant to wound monitoring and assessment. These various NIR-based technologies address clinical wound management needs along the entire healing trajectory of a wound.

Optical coherence tomography for longitudinal monitoring of vasculature in scars treated with laser fractionation

This study presents the first in vivo longitudinal assessment of scar vasculature in ablative fractional laser treatment using optical coherence tomography (OCT). A method based on OCT speckle decorrelation was developed to visualize and quantify the scar vasculature over the treatment period. Through reliable co-location of the imaging field of view across multiple imaging sessions, and compensation for motion artifact, the study was able to track the same scar tissue over a period of several months, and quantify changes in the vasculature area density. The results show incidences of occlusion of individual vessels 3 days after the first treatment. The subsequent responses ˜20 weeks after the initial treatment show differences between immature and mature scars. Image analysis showed a distinct decrease (25 ± 13%, mean ± standard deviation) and increase (19 ± 5%) of vasculature area density for the immature and mature scars, respectively. This study establishes the feasibility of OCT imaging for quantitative longitudinal monitoring of vasculature in scar treatment. En face optical coherence tomography vasculature images pre-treatment (top) and ˜20 weeks after the first laser treatment (bottom) of a mature burn scar. Arrows mark the same vessel pattern.

A systematic review of objective burn scar measurements

BACKGROUND

Problematic scarring remains a challenging aspect to address in the treatment of burns and can significantly affect the quality of life of the burn survivor. At present, there are few treatments available in the clinic to control adverse scarring, but experimental pharmacological anti-scarring strategies are now beginning to emerge. Their comparative success must be based on objective measurements of scarring, yet currently the clinical assessment of scars is not carried out systematically and is mostly based on subjective review of patients. However, several techniques and devices are being introduced that allow objective analysis of the burn scar. The aim of this article is to evaluate various objective measurement tools currently available and recommend a useful panel that is suitable for use in clinical trials of anti-scarring therapies.

METHODS

A systematic literature search was done using the Web of Science, PubMed and Cochrane databases. The identified devices were then classified and grouped according to the parameters they measured. The tools were then compared and assessed in terms of inter- and intra-rater reproducibility, ease of use and cost.

RESULTS

After duplicates were removed, 5062 articles were obtained in the search. After further screening, 157 articles which utilised objective burn scar measurement systems or tools were obtained. The scar measurement devices can be broadly classified into those measuring colour, metric variables, texture, biomechanical properties and pathophysiological disturbances.

CONCLUSIONS

Objective scar measurement tools allow the accurate and reproducible evaluation of scars, which is important for both clinical and scientific use. However, studies to evaluate their relative performance and merits of these tools are scarce, and there remain factors, such as itch and pain, which cannot be measured objectively. On reviewing the available evidence, a panel of devices for objective scar measurement is recommended consisting of the 3D cameras (Eykona/Lifeviz/Vectra H1) for surface area and volume, DSM II colorimeter for colour, Dermascan high-frequency ultrasound for scar thickness and Cutometer for skin elasticity and pliability.