2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)

Haemoglobin Distribution
D in Ulcers for Healing
Assessment
Ahmad Fadzil M. Hani1, Leena Arshad1, Aamir Saeed Malik1, Adaw
wiyah Jamil2,
Felix Yap Boon Bin3
1
Centre for Intelligent Signal & Imaging Research, Department of Electrical & Electrronics Engineering,
Universiti Teeknologi PETRONAS, 31750 Tronoh, Perak, Malaysiaa
2
Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, 56000 Kuaala Lumpur, Malaysia
3
Department of Dermatologgy, General Hospital Kuala Lumpur, 50586 Kuala Lum mpur, Malaysia

Abstract — Wounds that do not follow a predictable course

of healing within a specified period of time develop into ulcers
causing severe pain and discomfort to the patients.
p One of the
most prominent changes during wound healing is the colour of
the tissues. Describing the tissues in termms of percentages of
each tissue colour is an approved clinical method of wound
healing assessment. The growth of the red d granulation tissue
marks the beginning of ulcer healing. Granulation tissue
appears red in colour due to haemoglobin content
c in the blood Figure 1 Chroniic Leg Ulcers*
capillaries. An approach based on utillizing haemoglobin *
Images acquired at Dermatoloogy, Hospital Kuala Lumpur
content in chronic ulcers as an image maarker to detect the
growth of granulation tissue is investigaated in this study. The appearance of the ulcerr surface provides important
Independent Component Analysis is employyed to extract grey- information on the healing status of the wound [4]. The
level haemoglobin images from RGB colourr images of chronic
ulcer colour changes from blacck to yellow to red gradually
ulcers. Extracted haemoglobin images indicate areas of
haemoglobin distribution reflecting dettected regions of as it heals as shown in Figure 2 [5]. Depending on its initial
granulation tissue. Data clustering techniquues are implemented severity, the ulcer appears mostly
m covered with black
to classify and segment detected regions off granulation tissue necrotic tissue or overlaying laayers of black necrotic tissue
from the extracted haemoglobin images. Results obtained and yellow slough. As the ulceer heals, red granulation tissue
indicate that the developed algorithm perforrms fairly well with starts to grow from the base of o the ulcer slowly replacing
an average sensitivity of 88.24% and speecificity of 98.82%
black necrotic tissue and yelllow slough and filling the
when compared to the dermatologist’ss assessment. The
ultimate aim of this research work is to deevelop an objective wound cavity. Once the ulceer is filled with granulation
non-invasive wound healing assessment system capable of tissue, pink epithelial tissue sttarts to grow from the ulcer
evaluating the healing status of chronic ulcers in a more precise edges gradually covering thhe granulation tissue and
and reliable way. eventually closing the ulcer.

Keywords — Granulation, Haemoglobin, ICA,

I Ulcers

I. INTRODUCTION

U lcers are chronic wounds that faill to heal within a

specified period of time due to some underlying
aetiologies or improper wound managem ment which impairs
the natural process of healing [1][2]. According to the
underlying aetiologies that cause them, ulcers
u are generally
divided into three categories: vasculaar, pressure, and
diabetic ulcers. Approximately 1.0 - 3.0%% of the population
have the potential to develop chronic ulcers during the
course of their lifetime [1]. Ulcers aree most commonly
Figure 2 Typical Stagess of a Healing Ulcer*
found on the lower extremity below the knee and affect *
Reproduced from Goldm
man & Salcido (2002)
around 1% of adult population and 3.6% % of people older
than 65 years [3]. Chronic wounds geneerally introduce an At any one time all four tissuue types can be present on the
economic dilemma in wound managgement and care ulcer surface. Recognizing annd measuring the amount of
especially in the western countries such ass the United States each tissue is a well known andd approved clinical method of
and United Kingdom. Non-healing ulcerss cause severe pain wound assessment and understaanding of wound progression.
and discomfort to the patients and put thhem at the risk of In clinical practice, physicianns normally depend on non-
limb amputation. Figure 1 shows two chroonic leg ulcers. invasive methods of wound tissue assessment to avoid
causing any pain and discomfoort to the patients. However,
they are based on visual inspection of the wound [4] [5]
978-1-4577-1967-7/12/$26.00 ©2011 IEEE which is subjective and lacks precision
p and consistency and

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 2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)
hence not sufficient to perform tissue analysis. Thus,
imaging techniques utilizing colour digital images are
developed to provide precise, objective and reliable data that
aid medical practitioners to evaluate healing status of ulcers.
This paper describes a novel approach based on utilizing
haemoglobin content in chronic ulcers, as an image marker,
to detect the growth of granulation tissue which indicates the
healing of chronic ulcers. Section 2 of this paper
summarizes imaging based developed techniques of wound
tissue assessment. Section 3 elaborates on the research
hypothesis and the main objective of this study. Section 4
illustrates the novel approach explored in this study to detect
granulation tissue as a healing measure for chronic ulcers.
Results obtained are discussed and analyzed in section 5.
II. WOUND ASSESSMENT USING DIGITAL IMAGING
In medicine, colour photographs of chronic wounds provide
reliable chromatic data and a pictorial representation of the
wound’s environment, severity and healing progress
throughout the course of treatment. Imaging techniques have
been developed and implemented on colour images of
chronic wounds to classify and segment different types of
tissues of chronic wounds as a measure of their healing.
Most of the works developed in this area are based on three
main approaches:
A. Information from a Single Colour Channel
Earlier developed methods in the area of wound tissue
assessment are based on analyzing colour information from
a single colour channel in digital images using conventional
colour models such as RGB and HIS. Herbin et al.
developed methods to determine colour indices from
digitized RGB images of artificial created wounds [6] [7].
These indices are designed utilizing the R, G and B channels
separately and used to quantify the colour content in the
image as a healing index for wounds.
A group at University of Sao Paulo, Brazil developed
some algorithms that utilize region growing technique in
one of the colour channel R, G, B, I and S [8]. The channel
that gives better results based on higher contrast and better
standard deviation was then chosen to segment regions of
granulation and slough in original coloured images of
wounds. However, studies showed that for better
segmentation of tissues, separation of R, G and B frames is
not adequate and that colour pixels should be considered in
all three channels.
B. RGB histogram Distributions
Mekkes and Westerhof used large classifications tables for
segmentation of wound tissues and found that pixel clusters
in RGB space for a given type of tissue formed an irregular
shaped 3D cloud that distinguishes the three types of
necrotic, slough and granulation tissues [9]. Berris and
Sangwine proposed a 3D RGB colour histogram clustering
technique to automatically segment different types of tissues
within the wound site [10]. Their method scans the wound
image for pixels that carry similar RGB colouring features
and use them to form distinct clusters of pixels that belong
to different types of tissue.
H. Zheng et al. proposed a new protocol for binary
classification of wound tissues using three 2D R, G and B
histograms distribution of pixels in images of chronic
venous leg ulcers [11]. The classification utilized a Case-
Based Reasoning (CBR) approach that was performed by
comparing the R, G and B histograms of each tissue types in
the images with similar solved cases retrieved from a
previously generated database of wound images with
segmented and classified tissues.
C. Colour and Texture Descriptors
Most recently, as part of the ESCALE project dedicated to
the design of a complete 3D and colour wound assessment
tool, an unsupervised wound tissue segmentation method is
proposed [12], [13]. The algorithm is developed based on
an unsupervised segmentation driven supervised
classification in two main phases. First, three selected
unsupervised segmentation methods, J-SEG, Mean Shift and
CSC, are utilized to segment wound images into different
regions. The segmented regions are labelled according to
the tissue type mostly found across the segmented region
and compared with the ground truth. JSEG unsupervised
algorithm provided the best results to separate regions with
homogeneous colour and texture parameters. Figure 3 shows
the results of segmentation and classification of different
tissue regions based on the three selected methods.
Figure 3 Wound Tissue Segmentation and Classification Results of Three
Segmentation Methods used in ESCALE Project*
*
Reproduced from H.Wannous et al. (2007)
An SVM classifier is then utilized to obtain a supervised
learning of the three types of tissues from the developed
database of tissue regions traced by the clinicians. Both
colour and texture based descriptors are used to label each
type of tissue during the learning phase. Then, the same
descriptors were extracted from the segmented regions and
were input to the SVM based classifier for automatic
classification and labelling of these regions during the
testing phase. Automatic segmentation driven classification
was compared with expert ground truth. Best results are
obtained for granulation tissue (75%) while moderate results
are obtained for slough (60%).
Most of the work developed in the field of wound
assessment based on coloured image processing utilized
colour as the major component for analysis. However, the
interpretation of colour content in the image is always
compromised by the unavoidable differences in acquisition
conditions which are responsible for modification of colour
quality and scales in the image. In this study, the analysis is
venturing beyond the colour content into the main factor
contributing to the colour of ulcer tissues, in particular the
red granulation tissue as explained in the next section.
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 2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)
III. PROBLEM FORMULATION AND RESEEARCH OBJECTIVE
Colour is the perceptual sensation of lightt incident upon the
retina in the visible region of the spectruum which extends
from violet at about 380 nm to red at about 750 nm as
shown in Figure 4. Different colour coomponent exhibits
different reflectance ranges within the visible spectrum.
Red colour component exists at wavelenggths between 620-
740 nm from the visible light.
Figure 4 Reflectance Spectrum of the Viisible Light
The first indication of ulcer healing is the appearance of
the healthy red granulation tissue on o ulcer surface.
Granulation tissue contains small blood capillaries (small
arteries and veins) mixed with thee collagen based
extracellular matrix. One of the main skkin chromophores,
pigment haemoglobin, exists in the red blood cells in the
blood capillaries. Haemoglobin contaiins certain optical
characters that can be detected from colouur images and used
to show their content within human skin s [14-18]. The
absorption spectra of oxy-haemoglobbin and deoxy-
haemoglobin are shown in Figure 5 as repported by Anderson
et al [19]. It is clear that haemogloobin exhibits total
reflection (total absorption) at wavelenggths above 600nm.
The fact that pigment haemoglobin (bothh oxy-haemoglobin
and deoxy-haemoglobin) exhibits reflection at 600nm and
above explains why the granulation tisssue that contains
haemoglobin pigment appears red in colour when viewed
under visible light [20].
Figure 5 Absorption Spectra Absorption Spectra of Oxy-haemoglobin and
Deoxy-haemoglobin *
*
Reproduced from R.R. Anderson and J. A. Parrish
P (1981)
It is hence hypothesized that images duue to haemoglobin
could be extracted from colour images of chronic ulcers.
Images due to haemoglobin are of particuular interest as they
represent areas where blood vessels exisst on ulcer surface
which in return indicates areas of granulaation tissue. The
objective of this research work is to study the optical
characteristics of pigment haemoglobin anda utilize it as an
image marker to detect the newly growing healthy
granulation tissue in colour images of chroonic ulcers.
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IV. GRANULATION TISSUE DETECTION
A. Colour Images of Ulcers
Samples of high quality RGB colour images of ulcers that
contain a mixture of each typpe of tissues are required to
conduct a thorough analysis. This is very crucial to this
study as it ensures working onn ulcers images taken under
controlled acquisition conditionns. Colour images of chronic
ulcers are acquired at ulcer clinics at Hospital Kuala
Lumpur, Malaysia. Before data d acquisition session, the
ulcers are cleaned by the nursees at the hospital. Images are
acquired before the new dressinng is applied to the ulcers.
During data acquisition sessioons, colour casts are produced
due to the varying ambient illumination
i in the dressing
room. Hence, a 9x13mm whitee colour sticker is placed near
the ulcer during the photography sessions to provide a
reference for colour shifts correection.
B. Detection of Haemoglobin Distribution
D
The main objective of this sttudy is to utilize the optical
characteristics of pigment haemmoglobin to detect regions of
granulation tissue as a measure of ulcer healing. Figure 6
shows a flow chart of the deveeloped algorithm employed in
this study to extract grey-leevel images that show the
distribution of pigment haem moglobin from the acquired
colour images of chronic ulcerss.
Figure 6 Flow Chart of Haemoglobinn Distribution Detection Algorithm
Each colour ulcer image coomprises of three grey-level
images representing the spectrral bands of Red, Green and
Blue channels respectively. These
T images represent three
observations of linear combinaations of source signals. For
each ulcer image, these bandss are used to create column
vectors of data matrix comprrising an observation dataset
(observation matrix).
Independent Component Analysis
A is applied on the
observation dataset to extract thhe independent source images
from the observed ones. However, before applying the
algorithm, it is important that the dataset is processed
accordingly. The dataset is firstt normalized to centre on zero
point by extracting the mean vaalue from each spectral band.
Data whitening is then appliied by employing Principle
 2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)
Component Analysis (PCA) to transform the dataset linearly
so that its components are uncorrelated and their variances
equal unity. These steps are performed to simplify the ICA
algorithms and reduce the number of parameters to be
estimated. In this work, independent component analysis is
employed using the FastICA algorithm developed by
Hyvärinen and Oja based on a fixed-point iteration that uses
maximization of non-Gaussianity as a measure of
independence to estimate the independent components [21]
[22].
The algorithm is developed so that it estimates all the
independent source images at once. The output from the
ICA algorithm is a matrix that contains row vectors of
independent components equal to the number of
observations. These row vectors are rearranged as matrices,
each representing a grey-level image of estimated
independent source. One of the estimated source images is
an image that shows areas of haemoglobin distribution
reflecting existing regions of granulation tissue on ulcer
surface. Figure 7 shows a colour ulcer image and the
corresponding estimated independent source images. Figure
7(c) shows the second independent source image which
represents areas of significant intensity value range (dark
region in the image) that can be clearly distinguished from
the rest of the image. These areas indicate haemoglobin
distribution which reflects regions of granulation tissue.
Figure 7 Extracted Independent Sources from Observed Colour Ulcer
Image
C. Segmentation of Granulation Tissue
Classification based segmentation is implemented in this
work to segment areas of detected granulation tissue in the
images obtained from ICA algorithm. Clustering is a
common technique of unsupervised learning and
classification where elements of a dataset are partitioned
into several disjoint groups (clusters) so that points in one
group are similar to each other and are as different as
possible from points in other groups [23].
K-means clustering is first employed to classify the
extracted haemoglobin images into distinctive clusters based
on the Euclidean distance of each pixel value to the mean of
the cluster centre. Each cluster is assigned a class number
depending on the number of regions found in the image.
Since the detected granulation tissue appears as distinctive
dark region in the extracted haemoglobin image, the
clustering algorithm groups all the pixels that belong to the
granulation tissue into one cluster assigned with value 1.
Figure 8 shows the extracted haemoglobin image and
corresponding classified image with clustered granulation
tissue indicated by the arrow.
Figure 8 Classification of Extracted Haemoglobin Image using K-means
Algorithm
The classified image is then converted into a binary image
based on the intensity values of the clustered granulation
tissue. The segmentation algorithm scans the classified
image resulted from the clustering algorithm for pixels
values that belongs to cluster number 1 (clustered
granulation tissue) and converts them to value 0 (black)
while retaining all other pixels with value 1 (white). It
results in binary image where the detected granulation tissue
appears as black region separated from the rest of the image
which appear as white background. Figure 9 shows the
classified haemoglobin image with corresponding binary
image showing the segmented granulation tissue indicated
by the arrow.
Figure 9 Segmentation of Clustered Granulation Tissue in Classified Image
V. VALIDATION AND ANALYSIS
This research work aims to provide an objective reliable
healing assessment by detecting regions of granulation
tissue on ulcers surfaces and utilize them to monitor the
ulcer healing progression. The proposed algorithm is applied
on thirty acquired colour images of ulcers to detect
granulation regions on these ulcers surfaces.
In order to compare the results and validate the algorithm
performance, a reference image (ground truth) is created
based on dermatologist assessment of the ulcer images
included in this study. The ulcer images are shown to two
experienced dermatologists at Hospital Kuala Lumpur
whom are asked to trace the region of granulation tissue
manually by drawing a line around the region. Although the
assessment is visual and subjective, it is performed to the
best level of accuracy possible after detailed inspection of
each ulcer case by the dermatologists. The traced regions of
granulation tissue are then used to create binary images of
each ulcer image that contains segmented regions of
granulation tissue as ground truth. The regions produced by
each of the two dermatologist are combined together to
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 2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)

create a unique optimum ground truth image of granulation
tissue regions. Figure 10 shows a binary reference image
resulted from manual tracing of granulation tissue from a
colour ulcer image.
Furthermore, the detected regions of granulation tissue are
measured in relative to the overall area of the ulcer and
compared with the dermatologist traced regions. Figure 11
shows the comparison between the area of algorithm
detected granulation regions and the dermatologists traced
granulation region for each of the thirty ulcer cases
mentioned earlier.

Figure 10 Binary Assessment Reference Image Obtained from Manual

Tracing of Granulation Tissue

Sensitivity and specificity are two statistical measures

used in this study to validate and analyse the performance of
the developed algorithm. Sensitivity is defined in this Figure 11 Comparison of Overall Percentage of Detected Granulation
Tissue between Dermatologists and Algorithm
context as the probability of a detected white pixel that the
pixel is granulation pixel while specificity is the probability From Table 1, it is noted that in all cases the specificity is
of detected black pixel that the pixel is non-granulation. above 90% with an overall average specificity of 98.82%.
Sensitivity and specificity are defined as follows: This indicates that the algorithm performs very well in
TP distinguishing non-granulation regions from the rest of the
Sensitivity = ... (1)
TP + FN ulcer. On the other hand, the sensitivity analysis indicates
TN an overall sensitivity of 88.24%. In almost half of the cases
Specificity = ... (2) the sensitivity is above 90%. However, sensitivity is quite
TN + FP
low in some cases such as ulcers 2, 18, 20 and 28 due to
The terms TP, FP, TN and FN are identified as follows: false negatives detected because of specualr reflections
TP (True Positives): Granulation pixels that are correctly covering some regions of granulation tissue on ulcer surface.
detected as granulation. This can also be noticed from figure 11 as the percentage
FP (False Positives): Non-granulation pixels that are area of the detected region of granulation tissue is lower
incorrectly detected as granulation. than the dermatologists’ ground truth for those ulcer cases.
TN (True Negatives): Non-granulation pixels that are These specular reflections are not avoidable due to slight
correctly detected as non-granulation. exudates on the ulcer surface. Figure 12 shows an example
FN (False Negatives): Granulation pixels that are of a chronic ulcer case with undetected granulation regions
incorrectly detected as non-granulation. due specular reflections on the surface.
Table 1 lists the sensitivity and specificity of the algorithm
performance of the thirty ulcer cases included in this study
when compared to the dermatologists ground truth.
Table 1 Sensitivity and Specificity Analysis of Algorithm Performance
Ulcer Ulcer
Sensitivity Specificity Sensitivity Specificity
No. No.
1 79.3738 98.0418 16 97.9959 96.0535
2 82.0425 99.6181 17 97.2906 99.99
3 93.4925 94.5063 18 84.4551 99.99 Figure 12 A Chronic Ulcer with Specular Reflection on Surface
4 83.1057 99.3775 19 96.1217 98.794
In some other cases, such as ulcers 13, 15, 26 and 28 the
5 96.3946 97.6893 20 76.769 98.0245
6 88.9303 99.351 21 96.1719 98.1589 granulation is scattered all over the ulcer mixed with other
7 85.6115 98.9206 22 84.2351 93.4697 tissues on the ulcer surface especially with slough. These
8 88.4901 98.2789 23 98.9875 99.9024 ulcers pose a challenge when visually tracing the
9 87.9014 98.7134 24 98.7204 99.4856 granulation tissue and distinguish it from the rest of the
10 93.2665 98.9182 25 94.246 99.99 tissues which results in some non granulation regions traced
11 96.1423 99.4008 26 84.2601 98.8547 as granulation in the ground truth images. For those ulcers,
12 93.4493 95.8308 27 80.15 95.2392 the analysis shows low sensitivity due to false negatives
13 77.5489 97.6777 28 75.4543 99.7022 detected as the algorithm correctly identifies some traced
14 97.9152 99.1467 29 79.7682 99.3056 regions as non-granulation which results in low sensitivity.
15 73.4753 98.7124 30 85.4977 95.3777 Figure 13 shows an example of a chronic ulcer with non-
Average Sensitivity = 88.2421% granulation regions identified on the ulcer surface.
Average Specificity = 98.2084%

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 2012 4th International Conference on Intelligent and Advanced Systems (ICIAS2012)
Figure 13 A Chronic Ulcer with Granulation Mixed with Other Tissues on
Surface
Results obtained thus far indicate that the developed
algorithm is capable of assessing early stages of ulcer
healing by detecting the growth of granulation tissue on
ulcer surface. The developed algorithm performs fairly well
with an average sensitivity of 88.24% and specificity of
98.82%. The developed algorithm can distinguish non-
granulation regions on ulcer surface very well. On the other
hand, due to unavoidable challenges such as specular
reflections, the algorithm lacks the ability to detect all
granulation regions. However, the algorithm has the ability
to clearly distinguish granulation regions from non-
granulations ones even if the granulation tissue is scattered
all over the ulcer surface mixed with slough or other tissues
on ulcer surface.
VI. SUMMARY
In this work, the healing status of chronic ulcers is
investigated by detecting the newly growing healthy
granulation tissue on the ulcer surface. Granulation tissue
appears red in colour due to the presence of blood vessels
that contains pigment haemoglobin. Hence, a new approach
based on analysis of the optical characteristics of pigment
haemoglobin for the detection of granulation tissue is
investigated. The goal is to introduce a new objective non-
invasive technique to assess the healing status of chronic
ulcers in a more precise and reliable way.
VII. ACKNOWLEDGMENT
This is a collaborative work with the Department of
Dermatology, General Hospital Kuala Lumpur, Malaysia.
The authors would like to thank the hospital staff in
assisting them to acquire coloured images of chronic ulcers.
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