Wound Assessment by 3-Dimensional Laser Scanning sources of measurement error for manual tracings, and in general, DIA provides a technology that can at least partially overcome these problems. Finally, it is important to note that DIA provides information beyond the quantitative evaluation of traditional manual tracings. Because DIA involves digital photog- raphy, it provides an image and thus a basis for objec- tive evaluation of other end points such as infection, lesion thickness, granulation status, surrounding edema, and lesion progression over time, if used at sequential time points. Overall, additional studies are needed to further assess the uses of DIA in quantita- tive evaluation of other cutaneous lesions and beyond. Correspondence: Dr Chen, Department of Dermatol- ogy, Emory University School of Medicine, 101 Woo- druff Cir, Atlanta, GA 30322 (schen2@emory.edu). Financial Disclosure: None reported. Funding/Support: This project was supported in part by an unrestricted educational grant from Otsuka Pharma- ceuticals; National Institutes of Health (NIH) grant NHLBI R01-47345 and the Veterans Administration Merit Re- view Board (Dr Sumpio); and Mentored Patient Ori- ented Career Development Award K23AR02185-01A1 from the National Institute on Arthritis and Musculo- skeletal and Skin Disease, NIH, and the American Skin Association David Martin Carter Research Scholar Award (Dr Chen). 1. Sumpio BE, Chen SC, Moran E, et al. Adjuvant pharmacological therapy in the management of ischemic foot ulcers: results of the HEALing of Ischemic Foot Ulcers With Cilostazol Trial (HEAL-IT). Int J Angiol. 2006;15(2):76-82. Wound Assessment by 3-Dimensional Laser Scanning R ecent advances in our understanding of the biol-ogy of cutaneous tissue repair have influencedcurrent therapeutic strategies for chronic wound management and will continue to influence chronic wound management strategies into the future.1 An effective and accurate monitoring of skin lesions should be performed by measuring in an objective, pre- cise, and reproducible way the complete status and evo- lution of the wound.2 The main goal of current research projects is to design an easy-to-use technological sys- tem that can monitor the qualitative and quantitative evo- lution of a skin lesion. This level of monitoring can be achieved by using 3-di- mensional scanners: in particular, systems based on ac- tive optical approaches.3 There are 2 different areas of potential applications of such types of devices: in medi- cal treatment (to improve the efficacy of therapeutic regi- mens)4 and pharmacologic scientific research (to assess the quality and effectiveness of new chemicals or clini- cal procedures).5 Methods. We prospectively examined 15 patients with venous leg ulcers. The patients who underwent sequen- tial imaging of chronic wounds for this study all at- tended the leg ulcer clinic of the Wound Healing Re- search Unit at the University of Pisa, Pisa, Italy. Our sequential imaging system is equipped with a Vivid 900 laser scanner (Minolta, Osaka, Japan), which is used for digitizing or scanning the wound shape. With regard to the calculation of the “external” surface and volume of a wound, it is necessary to assess its original shape to de- termine the missing volume virtually. At the time of pa- tient presentation, information on the shape of the skin be- fore the wound occurred is missing, and the technique for virtual reconstruction of the original wound surface must be as easy and user-friendly as possible. The system, rely- ing on an analysis of the shape of the surface immediately outside the wound perimeter, creates an interpolating vir- tual surface that is continuously connected to the existing surface outside the wound and to that covering it. The parameters we studied were the mean wound area (measured in square centimeters) and mean volume (cu- bic centimeters). To assess interrater reproducibility, scans were evaluated by 2 independent investigators. For as- sessment of intrarater reproducibility, a single investi- gator performed 2 consecutive measurements 5 min- utes apart. Immediately after the first wound assessment of the first observer, a second observer, blinded to the findings of the first analysis, measured the same wound. The means and standard deviations of duplicate de- terminations for each wound were used for analysis. The reproducibility of measurements was evaluated by means of an intraclass correlation coefficient (ICC) and its 95% confidence interval (CI). Results. The measured total areas and volumes for inde- pendent raters and for subsequent measures of 1 rater are Figure 2. Procedure for using the Image Pro Express (Media Cybernetics, Silver Spring, Maryland) digital image analysis (DIA) software: (1) position target lesion toward camera at a set distance and toward a light source for standardization; (2) place ruler for calibration (present scale is in millimeters); (3) take digital photograph; (4) download image into computer running DIA software; (5) trace target, as demonstrated in this image; and (6) query DIA software to perform diameter and area calculations. Zakiya M. Pressley, MD Jovonne K. Foster, MS Paul Kolm, PhD Liping Zhao, MS Felicia Warren, BA William Weintraub, MD Bauer E. Sumpio, MD, PhD Suephy C. Chen, MD, MS (REPRINTED) ARCH DERMATOL/ VOL 143 (NO. 10), OCT 2007 WWW.ARCHDERMATOL.COM 1333 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 reported in Table 1. No statistically significant differences were found between scans evaluated by the 2 investiga- tors about wound area and volume. The relative errors and the intraclass correlation coefficients are reported in Table 2. The ICC values were excellent for both intrarater and interrater reproducibility with a very low relative er- ror value. The mean ± SD time for a full scan acquisition on the wound area and volume was 3.6 ± 1.4 minutes. Comment. The laser scanner system used in this study enables users to accurately acquire 3-dimensional digi- tal models of various types of skin wounds. Since the fi- nal users will be physicians and not computer experts, a user-friendly system is believed to be a fundamental pa- rameter for its success. The accuracy of scanning systems has improved in the past few years, and prices have also decreased, making these devices affordable for a wider community of po- tential users.6 The integration into a single system of ca- pabilities that can capture the shape and surface reflec- tion characteristics makes 3-dimensional scanning an invaluable resource in all those applications where it is necessary to sample both surface attributes. Correspondence: Dr Romanelli, Wound Healing Re- search Unit, Department of Dermatology, University of Pisa, Via Roma, 67, 56126 Pisa, Italy (m.romanelli@med .unipi.it). Financial Disclosure: None reported. 1. Schultz G, Mozingo D, Romanelli M, Claxton K. Wound healing and time: new concepts and scientific applications. Wound Repair Regen. 2005;13(4) (suppl):S1-S11. 2. Romanelli M, Gaggio G, Coluccia M, Rizzello F, Piaggesi A. Technological advances in wound bed measurements Wounds. 2002;14:58-66. 3. Chen F, Brown GM, Song M. Overview of three-dimensional shape measure- ment using optical methods Opt Eng. 2000;39:10-14. 4. Kantor J, Margolis DJ. A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br J Dermatol. 2000; 142(5):960-964. 5. Moore K, McCallion R, Searle RJ, Stacey MC, Harding KG. Prediction and monitoring the therapeutic response of chronic dermal wounds. Int Wound J. 2006;3(2):89-96. 6. Mani R. Science of measurements in wound healing. Wound Repair Regen. 1999; 7(5):330-334. The Diagnostic Yield of Histopathologic Sampling Techniques in PAN-Associated Cutaneous Ulcers P olyarteritis nodosa (PAN), a medium-sized ves-sel (MSV) vasculitis, may result in cutaneousulcers.1 There is no specific serologic abnormal- ity associated with PAN; therefore, the mainstay diag- nosis consists of histologic evidence of MSV vasculitis in the context of pertinent clinical findings.2 Several fac- tors may contribute to the potential low diagnostic yield of tissue biopsy specimens from MSV-vasculitic ulcers. The present study evaluates the role of tissue sampling in the histologic evaluation of PAN-associated cutane- ous ulcers. Methods. Retrospective analysis of de-identified archi- val biopsy specimens taken from skin ulcers and sural nerves of 29 patients with histologically proven PAN- associated MSV vasculitis. Patients met the classifica- Table 1. The Total Areas and Volumes of the Different Wounds Measured by the 2 Independent Raters and the 2 Measurements Made by the Single Rater a Wound Parameter Rater 1 Rater 2Measurement 1 Measurement 2 Area, cm2 52.36 ± 8.5 51.26 ± 3.6 53.36 ± 8.4 Volume, cm3 18.3 ± 2.6 18.6 ± 3.7 19.4 ± 4.6 a All data are reported as mean ± SD. Table 2. Percentage Relative Error in the Measurements of Total Areas and Volumes and ICC of the Different Scans Between 2 Independent Raters and Within a Single Rater a Wound Parameter Intrarater ICC Interrater ICC Area, cm2 1.06 ± 0.66 0.9976 0.54 ± 0.39 0.9936 Volume, cm3 1.96 ± 1.33 0.9832 1.44 ± 0.91 0.9714 Abbreviation: ICC, intraclass correlation coefficient. a Unless otherwise indicated, data are reported as mean ± SD percentage relative error. Total cases of PAN-associated cutaneous ulcers 29 Diagnosis on first skin biopsy Diagnosis on second skin biopsy Negative (40%)12 Positive specimens contained subcutis and peripheral and nearby central areas of the ulcer (60%) 17 Specimens lacked subcutis and nearby central areas of ulcer (17%) 2 Specimens contained subcutis but lacked nearby central areas of ulcer (83%) 10 Positive specimens contained subcutis and peripheral and nearby central areas of the ulcer (75%) 9 Negative (25%)3 Biopsy speciman contained subcutis, peripheral, and nearby central areas of ulcer (33%). Diagnosis was confirmed with sural nerve biopsy 1 Specimens contained subcutis but lacked nearby central areas of ulcer (66%) 2 Figure 1. Evaluation of the role of sampling technique and site of polyarteritis nodosa (PAN)-associated cutaneous ulcer in the yield of the histopathologic diagnosis. Marco Romanelli, MD, PhD Valentina Dini, MD Tommaso Bianchi, MD Paolo Romanelli, MD (REPRINTED) ARCH DERMATOL/ VOL 143 (NO. 10), OCT 2007 WWW.ARCHDERMATOL.COM 1334 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021