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A new guide to digital photography for dermatologists goes well beyond the basics, addressing everything from consent, patient comfort, and room setup to lenses, lighting, and clinical workflows, with special emphasis on skin of color (SOC). Having high-quality photos of patients of all skin types will improve not only clinical care, authors said, but also representation of diverse populations in dermatology research and education and access to care through teledermatology.

“As the US population rapidly diversifies, it is important to increase awareness of photography techniques that can better portray dermatologic processes in diverse skin types,” wrote the authors, led by Nada Elbuluk, MD, MSc, director of the Skin of Color and Pigmentary Disorders Program at the University of Southern California, Los Angeles. Beyond supporting clinical decision-making and patient counseling, they said, improving dermatologists’ SOC resources will boost clinicians’ diagnostic confidence while reducing delays, disparities, and misdiagnoses for patients with darker skin. The article was published online on April 16 in JAMA Dermatology. 

Consent Concerns, Lighting Tips

Before snapping any shots, Elbuluk and colleagues wrote, a thorough, culturally conscious approach can help put patients at ease. For example, informed consent requires ensuring that patients understand why photos are needed, how they will be stored, and who will have access to them — all of which assume greater importance with members of marginalized communities who may mistrust physicians and medical photography. 

“Lighting is perhaps the most important factor to consider in creating high-quality, representative dermatologic photography,” they noted. Accordingly, they recommended using light-emitting diodes (for soft, uniform lighting with reduced glare), choosing neutral and white tones (to avoid blue or yellow hues from cool and warm lighting tones, respectively), and positioning two sources — one behind the photographer, another aimed at the area of interest.

Because pigmentary changes may be harder to appreciate in photographs of darker skin, the authors wrote, choosing the optimal background also carries greater importance with such patients. The paper noted that according to an article published in the Journal of the American Academy of Dermatology in 2022, royal blue may offer increased contrast against dark skin while minimizing aberrant hues. Conversely, white and gray backgrounds may be helpful for Fitzpatrick types IV-VI because such backgrounds enhance contrast and maximize light reflection onto the patient. And using retractable pull-down background screens can streamline room setup.

Smart Technology

Additional suggestions in the paper addressed shutter speeds, filters, settings, and editing applications available on smart phones. Smart digital devices’ photographic capabilities have grown, the authors said. However, they added, technologies such as Google’s Real Tone, a software designed to avoid washing out darker skin colors, are needed to address remaining issues regarding lighting and color balance in photographing skin of color. 

Teledermatology Tips

“Challenges with photographs may emerge when captured outside of the standard clinical setting,” the authors added. Photography tips for teledermatology consultations range from using oblique views and multiple angles to taking complementary images — of the feet, for instance, if the hands are involved — for comparison purposes.

Timely Gems

“One of the real gems of this paper is how specific it is, and the tools it provides for both in-clinic use and communication with primary care colleagues or patients about how dermatologists would like to receive images, and the considerations for different skin tones,” Mya L. Roberson, MSPH, PhD, told Medscape Dermatology. She is an assistant professor of health policy and management at Gillings School of Global Public Health, University of North Carolina at Chapel Hill, and was not involved with the paper.

Overall, added Andrew Alexis, MD, MPH, professor of clinical dermatology and vice-chair for diversity and inclusion, at Weill Cornell Medicine in New York City, the document provides a timely, useful reference for dermatologists in clinical practice, research settings, and academia — the vast majority of whom rely on digital photography to a large degree. He was not involved with the article but was asked to comment.

“We’ve all seen examples in practice where a clinical photo is suboptimal,” Alexis said, “and that makes follow-up assessment of the baseline characteristics, anatomic location, and improvement from baseline difficult.” 

Historically, Roberson added, lack of awareness regarding key considerations for photographing patients with skin of color in different clinical contexts has created major gaps in medical education, clinical care, and journal submissions.

Rather than a guideline or official position, she said, the JAMA Dermatology paper provides best practices, additional context, and resources. “It provides tangible solutions and skills so that dermatologists and other folks working in dermatology clinics can take high-quality images in all skin types and can think about the unique attributes to consider when photographing darker skin tones.”

If a photographic background does not provide proper contrast, Roberson said, “some people mistakenly use flash to try to artificially create that contrast, which can result in a lower quality image, particularly for skin of color.” Both she and Alexis said that the depth and detail with which the guide addresses such issues makes it unique.

Authors acknowledged the contribution of Rick Guidotti, a New York-based professional photographer, to the manuscript. Study authors reported no funding sources. Elbuluk reported receiving stock options and personal fees from VisualDx, and personal fees, grants, and royalties from more than a dozen pharmaceutical and publishing companies including Medscape Medical News. She is also current president of the Skin of Color Society, which had no involvement with the publication. Alexis had served as a consultant for Canfield and VisualDx and had received honoraria as a speaker for Medscape Medical News. Roberson reported no relevant financial relationships.

John Jesitus is a Denver-based freelance medical writer and editor.