Objective Erythema Assessment of Psoriasis
Lesions for Psoriasis Area and Severity Index
(PASI) Evaluation
Simona Banu, Gheorghe Toacse, Gabriel Danciu
Department of Electronics and Computers
Faculty of Electrical Engineering and Computer Science, “Transilvania” University of Brasov
Brasov, Romania
Abstract—Psoriasis severity assessment is usually performed
based on the computation of the Psoriasis Area and Severity
Index (PASI). Physicians subjectively classify the erythema
parameter into several grades of severity. To support the decision
and the evaluation of the psoriasis lesions' evolution in time, this
study proposes an approach for the objective assessment of
erythema degree. There were processed seventeen images
depicting psoriasis lesions from mild to severe and the erythema
parameter was classified into three categories using machine
learning algorithms. The classification was based on color and
texture features extracted from the digital images. Three
classifiers were trained and tested with these features: Naïve
Bayes, Neural Networks and Support Vector Machine. A
comparative analysis on the classification accuracy and
computation time was made to the classification algorithms. The
best classification accuracy (92%) was obtained when using a
two-layer feed-forward Neural Network. The proposed method
can be used to objectively assess the psoriasis lesion’s erythema.
The major interest of this approach is to be cheap, fast, robust
and easy to use in a dermatological context, with very few
constraints on the acquisition protocol.
Keywords - psoriasis, objective assessment, classification, PASI
score, computer-aided diagnosis
I. INTRODUCTION
Psoriasis is a well known, chronic, inflammatory skin
disease that affects more than 100 million people worldwide
[1], [2]. Its characteristics of lesion thickness, redness and
scaliness are variable determining several grades of severity
[3]. Even though it is not contagious, psoriasis has a strong
emotional and social impact on the patient's quality of life [4],
[5]. There are five types of psoriasis: plaque, pustular, guttate,
erythrodermic and inverse; from which plaque is present in
80% of the diagnosed cases.
For the psoriasis severity evaluation, a series of scoring
systems have been developed. All are based on the
dermatologists' subjective assessment of different signs such as
the involved area of psoriatic lesions and the degree of redness,
thickness and desquamation [6]. One of such scoring tools is
the Psoriasis Area and Severity Index (PASI), which is
accepted as the gold standard assessment tool for psoriasis,
despite being criticized due to its lack of sensitivity, low
accuracy and scale non-linearity [7], [8]. The computation of
this score relies on the subjective appreciation of several
features of the affected skin regions (area, erythema, induration
and scaliness), as well as the location on the body of the
psoriasis lesions [9]. In addition, this method is time
consuming, the medical doctor spending approximately half
hour for its computation.
One important parameter of psoriasis severity assessment is
Erythema or redness of the skin. It displays different nuances
from light to dark red and it occurs with any inflammation of
the skin due to congestion of the capillaries. Erythema is
visually classified by the physicians into several grades by
matching the lesion appearance to the closest photograph from
an atlas, as the one proposed by Abbott Laboratories with four
erythema degrees varying from 1 to 4 as in Fig. 1.
The correct evaluation of erythema is one key element in
computing PASI, but it is highly dependent on the illumination
conditions and the expert subjective evaluation. The aim of this
study is to devise an efficient and objective method to assess
the erythema degree using image processing techniques. This
study underpins the development of a computer-based system
to assist the dermatologist in taking the correct therapeutic
decisions.
II. MATERIALS AND METHODS
In order to be useful and highly robust, all the approaches
need to take into account the acquisition conditions inside the
dermatologist's office. As the conditions are far from the ideal
ones, a complete color calibration is not possible and,
furthermore, not sharable or reproducible between different
dermatologists. The consequent problems lie in the fact that
the color cannot be compared and used to establish a valid
texture characterization criterion and, then, objective
assessment. To overcome this limit, a simple color-chart is
introduced as common ground between different
dermatologists and different acquisition settings. Then, an
adapted approach to normalize images from different
acquisitions (different date, expert, acquisition and
illumination systems) is developed. Second, the psoriasis
lesion is segmented and third, the psoriasis erythema is
classified and ranked.

Figure 1. Erythema reference in the Abbott PASI meter. Real (first row) and
synthetic (second row) images used as reference for visual assessment of
psoriasis erythema.
A. Color Correction
First, the image acquisition is carried out with a Canon
EOS 5D Mark II digital photographic camera, a device easy to
use by non-specialized persons. The reason behind this choice
is that the main objective of this study is to develop a robust,
cheap (a general digital camera can be used for image
acquisition) and easy to use method to objectively assess the
erythema severity with minimum acquisition constraints,
opposed to other author's proposals [10]. For example, this
study aims to overcome the complexity and economic aspects
raised when using chromameters and 3D laser scanners for
image acquisition. The images were photographed at various
distances from the lesions, the only constraint being that the
color checker must be present in all images in order for the
color correction to be accurately performed. The image
resolution was set to the highest level to minimize the number
of artifacts present when acquisition process is performed by a
digital camera.
Depending on the illumination conditions (natural,
artificial, combined / hybrid), the colors of a scene may be
altered as in Fig. 2. As it is quite impossible to obtain the same
exact acquisition conditions in each dermatologist office or at
two different visits, this constraint is reduced to a color chart
use. The ideal representation of this color checker is depicted in
Fig. 3.
For the color correction (CC) we propose a modified
version of the method described in [11], [12]. The authors
make a color correction for a series of uncalibrated images by
mapping selected pixel values onto reference values present in
the scene in the form of a target. The color correction transform
is a 3x4 matrix A mapping the mean values matrix of the color
checker patches M onto the sRGB (standard RGB(Red, Green,
Blue) color space) reference target values Tr. The difference
between the proposed color correction method and the one
presented in the original article is that the computations were
made in the RGB color space, due to the fact that the
information about the scene illumination is usually not
available.
By taking n color coordinates inside the R reference image,
we obtain a reference coordinates set: R3xn (the color
coordinates extracted from the color chart patches), I3xn (the
corresponding color coordinates inside the image I to
normalize). The linear transformation is express by:
Figure 2. Example of a psoriatic lesion photographed under different
illumination conditions.
Figure 3. Ideal color checker representation with RGB (red, green, blue)
coordinates for each color patch.
R3 Xn = M 3 Xn ⋅ I 3 Xn + Tr3 X 3 = M 3 X 4 ⋅ I 4 Xn (1)
where I’4xn is equal to I’3xn with an additional line of 1 to
embed the Tr translation inside the M’ vectorial transform. In
such expression, we search the M’ transform that normalizes the
image I in reference to the R image. The classical pseudo-
inverse transformation allows to solve such linear problem,
through the Moore-Penrose approach and allows to directly
express the M’ transformation.
M = R ⋅ I T ( I ⋅ I T ) −1 (2)
In Fig. 4 the reference-based color correction (CC) step is
presented: left part - the image before color correction, right
part - image after color correction; note that the color
references were chosen to maximize the image color dynamic,
so the colors on the colors checker look saturated and, in
addition, all the colors of the photographed scene have a better
dynamic range (which is qualitatively demonstrated by the 3D
RGB histograms depicted on the second row).
B. Image segmentation
In order to assess the redness only for the damaged skin,
the original images have to be segmented. Because this study
is mainly concentrated on the objective classification of lesion
erythema the lesions were manually segmented instead of
using computationally expensive segmentation algorithms.
Even though the manual segmentation takes time, it is less
compared to the computerized one which needs an
approximate half hour to finish its computations. The
manually segmented images are processed in Matlab to store
only the “red” pixels present inside the green boundaries.
C. Pixel classification
After the image segmentation step, where the lesion was
separated from the healthy skin area, a classification of pixels
in the lesion needs to be performed. In order to separate the
“red” pixels characteristic to the erythema, from the other
pixels on the pustules/squamous area the G (green) channel
from RGB color space was used. Fig. 5 depicts the manually
segmented lesion followed by the erythema areas (in white)
and the Green histogram.
Figure 4. Color correction of a psoriatic lesion. First row: Image before and
after color correction step. Second row: 3D RGB histograms for the top row
images.
III. ERYTHEMA CLASSIFICATION
Once the lesion is isolated from the skin and
pustules/squamous areas, its classification into different grades
of erythema must be performed. Three machine learning
classifiers were used for which a comparison of accuracy and
processing time was computed. The algorithms used in this
study are: Naïve Bayes classifier, two-layer feed forward
Neural Network classifier and Support Vector Machine
classifier. A set of 20 color and texture visual features that
contain information for the erythema grade discrimination
were selected.
Figure 5. Erythema separation from pustule/squamous areas. First image:
The manually segmented lesion. Second image: Separation of erythema areas
(white) from pustule/squamous and healthy skin areas (black). Third image:
The Green histogram.
A. Feature extraction
The 20 selected descriptors are: mean and standard
deviation of each channel in the RGB and HSV (hue,
saturation, value) color spaces, entropy, contrast, correlation,
energy and homogeneity from GLCM (Gray Level Co-
occurrence Matrix), difference between brightness of the skin
and brightness of the lesion area (ΔL), difference between skin
and lesion hues (ΔHab) and difference between the saturation
of skin and saturation of lesion (ΔCab) in CIELAB (CIE 1976
(Lightness and color opponent dimensions (a*(red-green
axis),b*(yellow-blue axis))) color space.
The lesions’ erythemas may exhibit similarity in color but
have different texture patterns. This motivated us to include
also texture features to increase the classification accuracy. To
determine the energy, entropy, contrast, homogeneity and
correlation texture features known as Haralick features the co-
occurrence matrix was computed. The Co-occurrence method
is a classical method used for pattern recognition on gray scale
images [13]. This matrix indicates the position of each pixel in
a grey scale image with respect to its eight surrounding
neighbors.
The human eye perceives the surrounding color by its hue,
saturation and brightness. Because the CIELAB color space is
linear with the human visual system, the differences between
the healthy skin color and the erythema color were computed
by converting the L*, a*, b* values to hue (Hab), chroma or
saturation (Cab) and brightness (L*), transformation depicted
by the following equations:
 *2 *2
C ab = a +b (3)
* equation:
−1 b
H ab = tan ( ) (4)
* N
a ∑ class (ti )
B. Computerized erythema severity classification
The color and texture characteristics extracted from the
digital images were used to train and test three machine
learning classification algorithms: Naïve Bayes, Neural
Networks and SVM.
The artificial neural network (ANN) represents a special
model of artificial intelligence based on the principles of
neural propagation and processing used in several fields of
medicine [14]. A two-layer feed-forward neural network was
used to classify the erythema into one of the three degrees
previously specified. The neural network is trained using a
pattern recognition process which assigns the correct target
classes (Mild or class 1, Moderate or class 2 and Severe or
class 3) to a set of input patterns (depicted in our case by the
20 different features). Once the network has been trained it
can be used to classify other sets of patterns it has not seen
before.
Naïve Bayesian classifier is a probabilistic classifier based
on Bayesian decision theory with naive independence
assumptions [15]. This method is easy to construct, easy to
understand and robust in many test cases. A discussion about
its merits can be found in [16].
SVM classifier is a supervised learning algorithm [17] that
requires only a dozen examples for training and is insensitive
to the number of dimensions.
IV. RESULTS AND DISCUSSION
To classify the erythema into one of the three categories
(Mild, Moderate and Severe) three machine learning
classification algorithms were used. The classifiers were
implemented using MATLAB software package version 7.10
(R2010a) (with neural networks toolbox) on an HP laptop with
Windows 7 (64-bits) operating system.
The feature extraction step was applied to 60 manually
selected erythema regions from 17 test images representing
lesions with erythema scores between 1 and 3 (currently there
are no test images with an erythema score of 4 in the image
database used for this study). Table 1 shows the PASI scoring
for the erythema (E) parameter.
TABLE I. PASI ERYTHEMA SCORES DISTRIBUTION
Lesion color E (score)
No lesion 0
Light red 1
Red (but not dark red) 2
Dark red 3
Very dark red (purple) 4
The classification accuracy and computation time were
used to evaluate the three classifiers. In this study, the
classification accuracies are measured using the following
accuracy (T ) = =1 N
i
(5)
{
1, classify (t )=class of item t , t ∈ T
class (t )= i
0, otherwise
where, T represents the dataset and classify(t) returns the
classified t by any of the 3 classifiers.
The three classifiers were trained using the information
given by the extracted features. After testing, the best accuracy
was obtained when using the Neural Networks classifier
(92%) followed by SVM (90%) and Naive Bayes
classification (82%). For each algorithm the elapsed time
needed for the models to be trained and tested was computed.
The CPU (computer processing unit) processing time was
calculated using the cputime function available in MATLAB.
The SVM classifier was the fastest (0.7 s), followed by Naive
Bayes (1.5 s) and the slowest classifier was the neural
Network which needed for the computations 2.7 seconds.
Overall results of the experiments are presented in Table
II. The authors in [18] obtained a classification accuracy of
90% when using a Fuzzy-ARTMAP neural network to classify
the information given by 40 extracted features from 31 color
images depicting psoriasis lesions. Compared with their
findings, the Neural Network classifier used in this study gave
a better accuracy (92%) when using only 20 extracted
features.
In this study the issue of reproducibility of skin image
acquisition in dermatological context using a color chart
reference and a normalization step by a reference image is
addressed. Performing the color correction step has at least
one major advantage: establishing the correct erythema
severity degree had no ambiguity for the medical doctor.
Furthermore, it allows comparing this measure between
different acquisition dates. The image database used in this
study is in the process of enlargement with various other test
cases in order to objectively assess the erythema severity. The
major interest of this approach is to be cheap, fast, robust and
easy to use in a dermatological context, with very few
constraints on the acquisition protocol.
TABLE II. COMPARISON OF CLASSIFICATION ACCURACY AND CPU
TIME FOR PASI ERYTHEMA SCORING
Classifier name Accuracy (%) CPU time (s)
Naive Bayes 82 1.5
Neural Networks 92 2.7
Support Vector Machine 90 0.7
 In this paper, a new approach for the objective assessment
of erythema degree is proposed. Seventeen images depicting
psoriasis lesions with different degrees of erythema severity
were classified into one of the three categories: mild, moderate
and severe, using three machine learning algorithms. The
classification was based on color and texture features
extracted from color digital images. The best classification
accuracy (92%) was obtained when using a two-layer feed-
forward Neural Network. The proposed method is intended to
assist the physician in objectively assess the erythema severity
and implicitly compute the PASI score.
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