Pattern Recognition Letters 28 (2007) 1012–1018

www.elsevier.com/locate/patrec

Automatic change detection and quantification of

dermatological diseases with an application to psoriasis images
David Delgado Gomez a,*, Constantine Butakoff a, Bjarne Ersbøll b,
Jens Michael Carstensen b
a
Computational Imaging Lab, Department of Technology, Universitat Pompeu Fabra, Pg. de Circumval.lacio 8, Barcelona 08003, Spain
b
Informatics and Mathematical Modelling, Technical University of Denmark, Denmark

Received 7 April 2005; received in revised form 17 July 2006

Available online 31 January 2007

Communicated by C.-F. Westin

Abstract

Change monitoring in skin lesion analysis has proven to be a useful adjunct in their assessment. This article presents a comparative
study of the available change detection techniques applied to change visualization and quantification in bi-temporal psoriasis images.
The chosen methods are evaluated on a time series of psoriasis images and results are compared with dermatologists’ scores.
 2007 Elsevier B.V. All rights reserved.

Keywords: Change detection; Skin lesion; Psoriasis; Image analysis

1. Introduction
During many years, melanoma analysis has monopo-
lized the research effort in dermatological imaging. The
conducted studies aimed at obtaining a fast classification
of melanoma images as malign or benign to support physi-
cians’ diagnoses. The first developed works that aimed at
evaluating the lesion severity were based on analysis of sim-
ple features such as areas obtained from gray-scale images
(Engstrom et al., 1990). The advances in medical image
acquisition methods and equipment (Marszalec and Pieti-
kainen, 1994; Haeghen et al., 2000) allowed obtaining bet-
ter characterization of skin lesions using new features
based on color or lesion variation. Perhaps the most popu-
lar of these methods is the ABCD rule (Stolz et al., 1993)
which relies on asymmetry, borders, color and differenti-
*
Corresponding author. Tel.: +45 45253407; fax: +45 45881397.
E-mail addresses: david.delgado@upf.edu (D. Delgado Gomez),
constantine.butakoff@upf.edu (C. Butakoff), be@imm.dtu.dk (B. Ersbøll),
jmc@imm.dtu.dk (J.M. Carstensen).
ated structures of the lesion. This and other proposed mea-
sures (Day, 2000; Day and Barbour, 2000) were initially
developed in the analysis of melanoma images.
However, the amount of money and resources invested
in the field allowed to gradually extend the research to
other dermatological diseases. One of such diseases is pso-
riasis (Taur et al., 2006). According to statistics, 1–2% of
the population of the United States and United Kingdom
is affected by the disease, and about three million people
receive treatment every year (Camisa, 1998). The total
annual expenditure on psoriasis research and treatment in
these two countries is over $1.5 billion.
The analysis of psoriasis has also extended the objec-
tives. Unlike melanoma, where a fast analysis is required,
the treatment of psoriasis takes longer time. Therefore,
apart from evaluating the current condition of the lesion,
much importance is given to evaluating its change, which
aids the correct diagnosis and treatment. The importance
of change monitoring has been investigated by many
researchers (Maglogiannis, 2003; Menzies et al., 2001;
Del Mar and Green, 1995). However, nowadays, within

0167-8655/$ - see front matter  2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.patrec.2006.12.020
 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018
the dermatology field there are no objective methods to
accomplish it automatically. The change is evaluated
merely by visual inspection. As a rule, physicians score
each lesion using a five point scale, and make notes in
the patient’s file. These notes, and sometimes a number
of photographs, are presently the only mean of monitoring
the evolution of psoriasis. The scoring system and the lack
of images for each stage of lesion evolution introduce a cer-
tain dependency on the doctor and an imprecision in the
history of the disease, both of which can cause an incorrect
diagnosis especially if the patient has to be treated by dif-
ferent doctors. As a consequence, there is a need for an
automatic algorithm, based on a set of objective measures,
to characterize and quantify the changes in dermatological
lesions.
As opposed to the skin lesion monitoring, more research
on change detection has been done in geo-informatics.
Coppin et al. (2004) has recently described the main avail-
able change detection techniques and their applicability for
ecosystem monitoring. In this paper we present a study of
the applicability of these techniques to detect and quantify
changes in the evolution of psoriasis. The chosen methods
are the simple image subtraction, difference analysis in the
Principal Component Analysis (PCA) space, post-classifi-
cation comparison and the MAD transform (Nielsen
et al., 1998). The evaluation is performed on sets of bi-tem-
poral psoriasis images.
The structure of the paper is the following. Section 2
describes the equipment used for image acquisition and
the necessary image preprocessing. The change detection
techniques are presented in Section 3. Finally, Section 4
demonstrates how the change detection methods can be
utilized to find and quantify the areas of maximum change
in a set of bi-temporal psoriasis images.
2. Equipment and image preparation
It has been shown in a number of studies that usual
cameras are inadequate for skin lesion monitoring (English
et al., 2003; Humzah, 2003). These studies have shown that
with serial photography it is difficult to obtain a standard-
ized image. The ambient lighting and other external factors
change the view of the skin lesion, hampering thus objec-
tive comparisons.
Partly to solve that problem a number of radiometric
normalization (image standardization) techniques have
been proposed. Radiometric normalization serves to ensure
that color changes of small magnitude can be detected and
measured, and that the changes are not consequences of
differences in the illumination or sensor calibration. Since
in dermatology it is feasible to physically interact with
the imaging system, it is possible to conduct a normaliza-
tion process before the device is used. This normalization
is carried out by camera calibration algorithms (Marszalec
and Pietikainen, 1994; Folm-Hansen, 1999). These algo-
rithms in their turn have given rise to different imaging sys-
tems (Haeghen et al., 2000; Maglogiannis, 2004).
1013
Considering the above factors we decided to use special-
ized equipment for our experiments. The images were col-
lected using VideometerLab equipment,1 (see Fig. 1)
developed specifically to capture standardized dermatolog-
ical RGB images. The system is made up of an integrating
intensity sphere illumination together with a high resolu-
tion 3CCD camera. The lesion is introduced into the open-
ing in the frontal hemisphere. The camera is mounted on
the rear hemisphere. Three light sources are positioned
inside the sphere in a triangular configuration. They are
external and shielded from the camera to reduce thermal
noise. To guarantee uniform acquisition conditions, the
device is brought to thermal equilibrium by being turned
on three hours in advance to capturing the images. Such
a design allows to minimize the influence of shadows and
specular reflections and it has been demonstrated that it
guarantees the reproducibility of the collected images (Del-
gado et al., 2003, 2004c).
After the images are normalized it is critical that they
are registered correctly in order to perform any change
analysis. Registration is required to obtain a correspon-
dence between points. A number of algorithms have been
developed to accomplish these goals in dermatological
imaging. A number of registration methods can be found
in (Maglogiannis, 2003), and a number of older methods
requiring human intervention in (Roning and Riech,
1998). In this work we decided to use the recently intro-
duced SHARP registration algorithm, which was shown
to give superior results for psoriasis images in terms of
average correlations (Delgado et al., 2004a). This algo-
rithm is made up of two stages. In the first stage, the algo-
rithm segments the lesion in all the images and creates a set
of corresponding binary images with 1 and 0 standing for
lesion and normal skin. The segmentation is performed
under an assumption that under a suitable linear combina-
tion of the color bands the distribution of values obtained
by this combination can be represented as a mixture of two
Gaussians. The parameters of these Gaussians are esti-
mated (Taxt et al., 1991) and used to separate the two clas-
ses (skin from lesion) via quadratic discriminant analysis.
The second stage applies a rigid registration by moments
to the obtained binary images to align them (Gramkov,
1996). Specifically, let I be a binary digital image of dimen-
sions n1 · n2 and let IðxÞ be the intensity of the pixel
x ¼ ½x1 ; x2 . The first and second order moments of the
image I are calculated by
P
IðxÞx
EI ¼ P ; ð1Þ
IðxÞ
P
IðxÞðx  EI Þðx  EI ÞT
DI ¼ P ð2Þ
IðxÞ
where summations are performed over all the pixels.
Let PI be the orthogonal matrix whose columns are
the eigenvectors of DI and KI the diagonal matrix of
1
http://www.videometer.com
1014 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018
Fig. 1. The imaging system used for lesion acquisition.
eigenvalues such that DI ¼ P I KI P TI . Then if J ð
uÞ is another
image characterized by the moments EJ and DJ with eigen-
vector matrix PJ and eigenvalue matrix KJ, the rigid
motion  u ¼ R  x þ t, where R ¼ P J P 1
I and t ¼ EJ ðuÞ
R  EI ðxÞ transforms the first order moment of the image I
to that of the image J and aligns the first principal compo-
nents of the images.
The rotation R and translation t are then used to register
the original images. In order to check that the eigenvectors
are not flipped, the correlation between the aligned images
is verified to be positive. If not, R is rotated 180.
3. Change detection techniques
In this section, four methods, frequently used in remote
sensing to detect changes in bi-temporal standardized reg-
istered images, are described. These methods, originally
described by Singh (1989) are presented in the order of
increasing complexity, emphasizing their advantages and
disadvantages.
3.1. Image subtraction
This technique is one of the simplest methods to obtain
a change from one image to another. It is performed by
subtracting pixels of the same spectral band of two regis-
tered standardized images acquired at two different time
instants. Let I1(x, y, n) and I2(x, y, n) be the n-th spectral
band of two registered multispectral images. The change
is defined, for a fixed n and all x, y by
DIðx; y; nÞ ¼ I 2 ðx; y; nÞ  I 1 ðx; y; nÞ
The characteristic of this function is that in the areas of
no change, the value of the difference DI, will be very small,
while areas of significant changes will have higher corre-
sponding values. One disadvantage of this method is that
for a multispectral image there is a data representation
problem. It means that one band has to be chosen for
change evaluation. Alternatively, the method can be
applied to all the bands, but then the obtained information
about the change must be fused usually in a nontrivial way.
Another problem is the choice of the threshold to separate
significant changes from insignificant.
3.2. Principal Component Analysis
Principal Component Analysis (PCA) (Jolliffe, 2002) is a
procedure which transforms the data such that new ortho-
normal axes are aligned with the directions of maximum
variability in the data. Essentially, a set of correlated vari-
ables are transformed into a set of uncorrelated variables
(principal components) which are ordered by decreasing
variability. By keeping lower-order principal components
and ignoring higher-order ones, PCA can be used for
dimensionality reduction in a dataset while retaining those
characteristics of the latter that contribute most to its var-
iance. Such low-order components often contain the ‘‘most
important’’ aspects of the data. But this is not necessarily
the case, depending on the application.
Given two multispectral images, the idea of the method
is to compute their difference and apply PCA to a matrix of
values taken from all the bands of the difference image.
Then by reconstructing the difference image using only
the first PCA component it is assumed that the result will
exhibit the most significant global changes. In contrast to
that, the reconstruction using only high-order components
is expected to exhibit minor local changes.
The advantage of this method is that by applying PCA
to all the bands of multispectral images the data represen-
tation problem is automatically solved. However the
threshold, to separate significant changes from insignifi-
cant, still remains to be estimated.
3.3. The MAD transform
ð3Þ
The Multivariate Alteration Detection (MAD) transfor-
mation was proposed by Nielsen et al. (1998) to find
changes in multi-temporal images. This approach solves
both the problem of data representation and the threshold
selection.
Given two multispectral images with k bands X =
[X1, . . . , Xk] and Y = [Y1, . . . , Yk], the MAD transform
looks for coefficients a = (a1, . . . , ak)T and b = (b1, . . . , bk)T
such that Var(Xa  Yb) is maximized, subject to the con-
straints Var(Xa) = Var(Yb) = 1. In other words, this crite-
rion looks for combinations of image bands that maximize
difference between them. This problem is solved by the
 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018
standard canonical correlation analysis, representing the
change in the images by a number of components, called
MAD components.
The MAD components have a property that i-th compo-
nent exhibits maximum variance under the constraint that
it is uncorrelated to the previous components. Therefore,
high-order MAD components complement the difference
information of thePlow-order ones. Furthermore, it is
worth to note that Ni¼1 ðMADi =rMADi Þ2 approximately fol-
lows the v2 distribution with N degrees of freedom (Canty
and Nielsen, 2004). This property allows a statistical choice
of the threshold. The threshold t can be chosen as
t ¼ v2N ;P ¼0:95 where P is the probability of difference being
less or equal than t.
3.4. Post-classification comparison
Given a bi-temporal set I1 and I2, a classification of the
different structures within the images is performed. As a
result, corresponding images IC1 and IC2 are obtained.
The difference of the IC1 and IC2 corresponds to direct
changes in the lesion. The problem of this method is that
misclassification in each of the images hampers the locali-
zation of the areas of changes. If two images have a correct
classification rate of a 70%, they could have only
70% Æ 70% = 49% of correct joint classification rate, which
is disastrous for change analysis. Moreover the classifica-
tion might require training, while the previous three
approaches do not.
4. Experimental results
In this section, an automatic detection of the areas of
maximum change in bi-temporal psoriasis images is evalu-
ated. The compared methods are subtraction, PCA and
MAD. The post-classification comparison is rather a
framework than a specific method and the results will
depend on the classifier employed. Due to the multitude
of different classification algorithms the latter is not
included into the comparison. Nevertheless, it will be used
to quantify the changes later on.
In order to evaluate the three techniques, an evaluation
set composed of six temporal series of psoriasis images was
acquired in collaboration with the dermatological depart-
ment of the Gentofte Hospital in Denmark. Each series is
composed of four images collected with a one week inter-
val.2 The whole collected series can be seen in Fig. 2. The
change detection was performed on every pair of consecu-
tive images, i.e., between Session 1 and Session 2, Session 2
and Session 3 and so on for each patient. In total there are
17 such pairs.
Before applying any change detection technique, all the
pairs (bi-temporal sets) were registered. As it was already
2
Due to the unavailability of one patient during the last acquisition
week, his fourth temporal image could not be collected.
1015
mentioned earlier the registration is performed by the
SHARP algorithm. Once the lesions were registered, the
image subtracting, PCA and the MAD transform were
applied. The thresholds were chosen as to keep the pixels
that correspond to a difference higher than 95% of the max-
imum difference. An example of change detection can be
seen in Fig. 3 where changes between the Sessions 1 and
2 were detected in the images of the first series (the first col-
umn in Fig. 2). Similar results were obtained with the other
bi-temporal sets. It was observed that all the techniques
identify the scaling as the areas of the most significant
change. This result corresponds to the common point of
view of dermatologists that the major changes in psoriasis
happen inside of the lesion and not in its shape. Although
the three techniques give very similar results, those
obtained by the image subtracting technique depend on
the chosen color band and it is not clear which band is bet-
ter (see Fig. 3c–e). This leads us to an assumption that the
MAD and PCA are more suitable to visualize the areas of
maximum change, because they statistically determine how
the information from the bands has to be combined. It can
also be noted that the MAD transform detects many pixels
in the healthy area around the lesion, while PCA exhibits
significantly clearer results.
To quantify the efficiency of change detection between
two images, the pixels corresponding to the detected
changes were removed and Mahalanobis distance between
the images was computed, which being small signifies that
the precision of change detection is high. The Mahalanobis
similarity measure between images X and Y is defined as
follows:
DðX ; Y Þ ¼ ðX  Y ÞT R1 ðX  Y Þ ð4Þ
" #
1 XN
T
XN
T
R¼ ðX i  X ÞðX i  X Þ þ ðY i  Y ÞðY i  Y Þ
N  1 i¼1 i¼1
ð5Þ
where Xi and Yi are the pixel intensities of the two images,
X and Y are the mean pixel intensities and N is the number
of pixels. According to the Mahalanobis distance and vi-
sual inspection, the PCA seems to provide the best means
(in comparison with the subtraction and MAD) to visualize
changes in psoriasis. An example of change detection using
the PCA approach on six consecutive bi-temporal sets se-
lected randomly, one per series, are shown in Fig. 4. It is
worth to note that the changes detected correspond quite
well to the psoriasis scales.
Although the considered techniques prove to be useful
in change visualization, they provide no quantitative
assessment. In order measure the change, we propose to
use the post-classification framework. To achieve this, a
team of dermatologists was asked to score the severity of
each lesion using a five-point scale, ranging from the least
to most severe. The ground-truth change at two different
time instants was calculated by subtracting the correspond-
ing dermatologist’s scores.
1016 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018

Fig. 2. Psoriasis dataset used in the experiments. Each column corresponds to one series and each row to a different week.

Fig. 3. Changes detected in the images of the first series (the first column in Fig. 2) from the Session 1 to Session 2 by: (a) PCA; (b) MAD; (c)–(e) difference
in red, green and the blue channels respectively.

Fig. 4. Change areas detected by the PCA technique on the different bi-temporal sets.

The fact that the above change detection techniques are
not appropriate for segmentation and detect changes out-
side the lesion, the algorithm proposed by Delgado et al.
(2004b) was used. Briefly, the appropriate combination of
the image bands was obtained as the first component of
the Independent Histogram Pursuit (Delgado et al., in
press). The combined bands were post-processed by the
mean shift (Cheng, 1995; Comaniciu and Meer, 2002) algo-
rithm to make the image more homogeneous. Then, to
extract the scales inside the lesion, the image was threshol-
ded using the highest threshold value such that the area of
the largest region (detected to have changes) does not con-
tain more than 150 pixels (the value was obtained empiri-
cally). A demonstration of the segmentation can be seen
in Fig. 5, where black blobs represent the scales inside
the gray lesion.
 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018 1017

Fig. 5. Segmentation results of the different psoriasis images. The lesion is gray and the scales are black (cf. Fig. 2).

Table 1
Relations between the ratios provides by the developed system and
dermatologists’s scores
# Ratio Score # Ratio Score
1 0.1428 1 10 0.0007 1
2 0.1362 1 11 0.0024 0
3 0.0402 1 12 0.0103 0
4 0.0376 1 13 0.0116 0
5 0.0307 1 14 0.1150 +1
6 0.0053 1 15 0.0130 +1
7 0.0035 0 16 0.0344 +1
8 0.0031 1 17 0.1239 +1
9 0.0028 1

To characterize the change in the lesion we have chosen
the ratio of the difference in the number of pixels classified
as scales to the area of the lesion. These ratios together
with the corresponding dermatologist’s rankings are dis-
played for all 17 image pairs in Table 1 and plotted in
Fig. 6. It can be seen from the figure, that the sign of the
ratio is in most cases consistent with the ground-truth,
except for the differences 7, 11, 12 and 13, corresponding
to the absence of psoriasis severity change. On the other
hand it can be noted that by applying a function
8
< 1; if x < 0
>
f ðxÞ ¼ 0; if 0 6 x < 0:012 ð6Þ
>
: rithm can be performed in an unsupervised manner,
þ1; if x P 0:012
to the ratios, the results will match the doctors scores ex-
actly except for the difference #7.
5. Conclusions
In this work, several geo-informatics techniques were
applied to detect and quantify changes in psoriasis images.
It has been shown that the PCA transform is a good tool
for displaying changes in the structure of the psoriasis.
Fig. 6. Relationship between the doctor rankings (represented by bars)
and the ratios (plotted behind the bars). Absence of a bar means that the
corresponding score is zero.
On the other hand an algorithm to quantify changes was
introduced which gives promising results. The values pro-
vided by that algorithm are continuous and are based on
the proportion of pixels detected as scales, which might
make the change quantification more precise (provided
that the scales were detected correctly) than doctors’ five-
point system.
Since both PCA and the change quantification algo-
together with the image acquisition equipment and image
registration algorithm, they can constitute an image-based
system to aid physicians in evaluation of the psoriasis
evolution.
Acknowledgements
The authors would like to thank the SITE Project
funded by a grant from the Danish Technical Research
Foundation (Project Number STVF 56-00-0123) for
1018 D. Delgado Gomez et al. / Pattern Recognition Letters 28 (2007) 1012–1018
supporting the present work. The authors would also like
to thank the dermatologists Lone Skov and Bo Bang of
Gentofte Hospital of Denmark and the anonymous pa-
tients, for their collaboration during the image acquisition
sessions.
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