Submitted:
15 October 2024
Posted:
16 October 2024
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Abstract
Introduction: Chronic ulcers significantly burden healthcare systems, requiring precise measurement and assessment for effective treatment. Traditional methods, such as manual segmentation, are time-consuming and error-prone. This review evaluates the potential of artificial intelligence (AI)--powered mobile apps for automated ulcer segmentation and their application in clinical settings. Methods: A comprehensive literature search was conducted across PubMed, CINAHL, Cochrane and Google Scholas databases. The review focused on mobile apps that use fully automatic AI algorithms for wound segmentation. Apps requiring additional hardware or needing more technical documentation were excluded. Vital technological features, clinical validation, and usability were analysed. Results: Ten mobile apps were identified, showing varying levels of segmentation accuracy and clinical validation. However, many apps did not publish sufficient information on the segmentation methods or algorithms used, and most lacked details on the databases employed for training their AI models. Additionally, several apps were unavailable in public repositories, limiting their accessibility and independent evaluation. These factors challenge their integration into clinical practice despite promising preliminary results. Discussion: AI-powered mobile apps offer significant potential for improving wound care by enhancing diagnostic accuracy and reducing the burden on healthcare professionals. Nonetheless, the lack of transparency regarding segmentation techniques, unpublished databases, and limited availability of many apps in public repositories remain substantial barriers to widespread clinical adoption. Conclusion: AI-driven mobile apps for ulcer segmentation could revolutionise chronic wound management. However, overcoming limitations related to transparency, data availability, and accessibility is essential for their successful integration into healthcare systems.

Keywords:
1. Introduction
2. Material and Methods
2.1. Literature Search Strategy
2.2. Data Extraction
2.3. App Selection Criteria and Scoring Classification
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- Up to 2 points if approved by FDA and/or European agencies.
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- Up to 2 points for the availability on mobile platforms (iOS or Android).
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- Up to 2 points in case of sufficient peer-reviewed studies or validation data supporting the app’s segmentation capabilities availability.
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Up to 2 points in case of a disclosed method/algorithms and public dataset.Up to 10 points based on the mean rates of inter-rater reliability data between AI apps and other assessment and segmentation accuracy metrics such as rule or pencil method, pixel-based accuracy, dice similarity coefficient, and area under the curve (AUC) scores, when available.
3. Results
3.1. Healthy.io’s Minuteful for Wound (2019, Israel)
3.2. Wound Vision Scout App Mobile (USA, 2019)
3.3. APD Skin Monitoring App (Singapore, 2019)
- GrabCut Algorithm: This method uses an interactive segmentation based on graph cuts, requiring the user to draw a rectangle around the wound. While accurate, it is slow and demands manual input, making it less efficient[27].
- Color Thresholding: The second approach leverages colour detection based on typical wound hues (e.g., shades of red). It quickly separates wound pixels from the background and uses contour detection for area calculation. This method is faster and more accurate[28].
3.4. NDKare App (Singapore, 2019)
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- For 2D wound segmentation, the NDKare app uses an image processing technique that automatically distinguishes the wound area from surrounding tissue based on pixel analysis. The app identifies the ulcer boundaries and allows users to adjust the outline if needed manually. This segmentation calculates 2D metrics such as length, width, perimeter, and surface area, offering precise measurements of wounds captured by the smartphone's camera.
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- For 3D wound segmentation is based on "structure from motion". This technique creates a 3D model by analysing a video of the wound, capturing images from different angles, identifying key points, and reconstructing the wound in 3D using triangulation. The app then generates a "dense 3D point cloud" and a smooth surface reconstruction for depth and volume measurement
3.5. Clinic Gram (Barcelona, 2019)
3.6. Swift Skin and Wound App (Canada, 2017)
3.7. Cares4wounds (Singapore, 2019)
3.8. Tissue Analysis (USA, 2014)
3.9. ImitoWound (Switzerland 2020)
3.10. WoundsWiseIQ (USA, 2015)
4. Discussion
5. Conclusions
Author Contributions
Funding
Patients’ Consent Form
Ethical Approval and/or Institutional Review Board (IRB)
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Olsson M, Järbrink K, Divakar U, Bajpai R, Upton Z, Schmidtchen A, et al. The humanistic and economic burden of chronic wounds: A systematic review. Wound Repair Regen. gennaio 2019;27(1):114–25. [CrossRef]
- Martinengo L, Olsson M, Bajpai R, Soljak M, Upton Z, Schmidtchen A, et al. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol. gennaio 2019;29:8–15. [CrossRef]
- Smet S, Verhaeghe S, Beeckman D, Fourie A, Beele H. The process of clinical decision-making in chronic wound care: A scenario-based think-aloud study. Journal of Tissue Viability. 1 maggio 2024;33(2):231–8. [CrossRef]
- Foltynski P, Ciechanowska A, Ladyzynski P. Wound surface area measurement methods. Biocybernetics and Biomedical Engineering. 1 ottobre 2021;41(4):1454–65.
- Yee A, Harmon J, Yi S. Quantitative Monitoring Wound Healing Status Through Three-dimensional Imaging on Mobile Platforms. J Am Coll Clin Wound Spec. 2016;8(1–3):21–7. [CrossRef]
- Khoo R, Jansen S. The Evolving Field of Wound Measurement Techniques: A Literature Review. Wounds. giugno 2016;28(6):175–81. [CrossRef]
- Wang C, Yan X, Smith M, Kochhar K, Rubin M, Warren SM, et al. A unified framework for automatic wound segmentation and analysis with deep convolutional neural networks. In: 2015 37th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). 2015. p. 2415–8.
- Le DTP, Pham TD. Unveiling the role of artificial intelligence for wound assessment and wound healing prediction. Explor Med. 31 agosto 2023;4(4):589–611. [CrossRef]
- Zhang R, Tian D, Xu D, Qian W, Yao Y. A Survey of Wound Image Analysis Using Deep Learning: Classification, Detection, and Segmentation. IEEE Access. 2022;10:79502–15. [CrossRef]
- Kermany DS, Goldbaum M, Cai W, Valentim CCS, Liang H, Baxter SL, et al. Identifying Medical Diagnoses and Treatable Diseases by Image-Based Deep Learning. Cell. 22 febbraio 2018;172(5):1122-1131.e9. [CrossRef]
- Scebba G, Zhang J, Catanzaro S, Mihai C, Distler O, Berli M, et al. Detect-and-segment: A deep learning approach to automate wound image segmentation. Informatics in Medicine Unlocked. 1 gennaio 2022;29:100884. [CrossRef]
- Sorour SE, El-Mageed AAA, Albarrak KM, Alnaim AK, Wafa AA, El-Shafeiy E. Classification of Alzheimer’s disease using MRI data based on Deep Learning Techniques. Journal of King Saud University - Computer and Information Sciences. 1 febbraio 2024;36(2):101940. [CrossRef]
- Anisuzzaman D m., Wang C, Rostami B, Gopalakrishnan S, Niezgoda J, Yu Z. Image-Based Artificial Intelligence in Wound Assessment: A Systematic Review. Advances in Wound Care. dicembre 2022;11(12):687–709. [CrossRef]
- Poon TWK, Friesen MR. Algorithms for Size and Color Detection of Smartphone Images of Chronic Wounds for Healthcare Applications. IEEE Access. 2015;3:1799–808. [CrossRef]
- Koepp J, Baron MV, Martins PRH, Brandenburg C, Kira ATF, Trindade VD, et al. The Quality of Mobile Apps Used for the Identification of Pressure Ulcers in Adults: Systematic Survey and Review of Apps in App Stores. JMIR mHealth and uHealth. 16 giugno 2020;8(6):e14266. [CrossRef]
- Shamloul N, Ghias MH, Khachemoune A. The Utility of Smartphone Applications and Technology in Wound Healing. Int J Low Extrem Wounds. settembre 2019;18(3):228–35. [CrossRef]
- Healthy.io | Digital wound management [Internet]. [citato 30 settembre 2024]. Disponibile su: https://healthy.io/services/wound/.
- Nussbaum SR, Carter MJ, Fife CE, DaVanzo J, Haught R, Nusgart M, et al. An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds. Value Health. gennaio 2018;21(1):27–32.
- Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Adv Wound Care (New Rochelle). 1 febbraio 2019;8(2):39–48. [CrossRef]
- Keegan AC, Bose S, McDermott KM, Starks White MP, Stonko DP, Jeddah D, et al. Corrigendum: Implementation of a patient-centered remote wound monitoring system for management of diabetic foot ulcers. Front Endocrinol [Internet]. 23 giugno 2023 [citato 30 settembre 2024];14. Disponibile su: https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1235970/full.
- Keegan AC, Bose S, McDermott KM, Starks White MP, Stonko DP, Jeddah D, et al. Implementation of a patient-centered remote wound monitoring system for management of diabetic foot ulcers. Front Endocrinol (Lausanne). 2023;14:1157518. [CrossRef]
- Kivity S, Rajuan E, Arbeli S, Alcalay T, Shiri L, Orvieto N, et al. Optimising wound monitoring: Can digital tools improve healing outcomes and clinic efficiency. Journal of Clinical Nursing. 2024;33(10):4014–23. [CrossRef]
- Wound Imaging Solutions - WoundVision [Internet]. [citato 30 settembre 2024]. Disponibile su: https://woundvision.com/.
- Langemo D, Spahn J, Snodgrass L. Accuracy and Reproducibility of the Wound Shape Measuring and Monitoring System. Adv Skin Wound Care. luglio 2015;28(7):317–23. [CrossRef]
- Langemo D, Spahn J, Spahn T, Pinnamaneni VC. Comparison of standardized clinical evaluation of wounds using ruler length by width and Scout length by width measure and Scout perimeter trace. Adv Skin Wound Care. marzo 2015;28(3):116–21. [CrossRef]
- Wu W, Yong KYW, Federico MAJ, Gan SKE. The APD Skin Monitoring App for wound monitoring: Image processing, area plot, and colour histogram. spamd [Internet]. 2019 [citato 30 settembre 2024]; Disponibile su: https://scienceopen.com/hosted-document?doi=10.30943/2019/28052019. [CrossRef]
- Tang M, Gorelick L, Veksler O, Boykov Y. GrabCut in One Cut. In 2013 [citato 30 settembre 2024]. p. 1769–76. Disponibile su: https://openaccess.thecvf.com/content_iccv_2013/html/Tang_GrabCut_in_One_2013_ICCV_paper.html.
- Gupta S, Girshick R, Arbeláez P, Malik J. Learning Rich Features from RGB-D Images for Object Detection and Segmentation. In: Fleet D, Pajdla T, Schiele B, Tuytelaars T, curatori. Computer Vision – ECCV 2014. Cham: Springer International Publishing; 2014. p. 345–60.
- Nair HKR. Increasing productivity with smartphone digital imagery wound measurements and analysis. J Wound Care. 1 settembre 2018;27(Sup9a):S12–9. [CrossRef]
- Clinicgram – The revolutionary app that allows you to diagnose diseases with your smartphone. [Internet]. [citato 30 settembre 2024]. Disponibile su: https://www.clinicgram.com/.
- Swift Skin and Wound Mobile App and Dashboards [Internet]. Swift. [citato 30 settembre 2024]. Disponibile su: https://swiftmedical.com/solution/.
- Wang SC, Anderson JAE, Evans R, Woo K, Beland B, Sasseville D, et al. Point-of-care wound visioning technology: Reproducibility and accuracy of a wound measurement app. PLOS ONE. 17 agosto 2017;12(8):e0183139. [CrossRef]
- Ramachandram D, Ramirez-GarciaLuna JL, Fraser RDJ, Martínez-Jiménez MA, Arriaga-Caballero JE, Allport J. Fully Automated Wound Tissue Segmentation Using Deep Learning on Mobile Devices: Cohort Study. JMIR mHealth and uHealth. 22 aprile 2022;10(4):e36977. [CrossRef]
- Redmon J, Farhadi A. YOLOv3: An Incremental Improvement [Internet]. arXiv; 2018 [citato 5 ottobre 2024]. Disponibile su: http://arxiv.org/abs/1804.02767.
- Liu Z, Agu E, Pedersen P, Lindsay C, Tulu B, Strong D. Chronic Wound Image Augmentation and Assessment Using Semi-Supervised Progressive Multi-Granularity EfficientNet. IEEE Open Journal of Engineering in Medicine and Biology. 2023;1–17. [CrossRef]
- EfficientNetB0 - Furiosa Models [Internet]. [citato 5 ottobre 2024]. Disponibile su: https://furiosa-ai.github.io/furiosa-models/latest/models/efficientnet_b0/.
- Au Y, Beland B, Anderson JAE, Sasseville D, Wang SC. Time-Saving Comparison of Wound Measurement Between the Ruler Method and the Swift Skin and Wound App. J Cutan Med Surg. 1 marzo 2019;23(2):226–8. [CrossRef]
- CARES4WOUNDS Wound Management System | Tetusyu Healthcare [Internet]. Tetsuyu Healthcare. [citato 5 ottobre 2024]. Disponibile su: https://tetsuyuhealthcare.com/solutions/wound-management-system/.
- Chan KS, Chan YM, Tan AHM, Liang S, Cho YT, Hong Q, et al. Clinical validation of an artificial intelligence-enabled wound imaging mobile application in diabetic foot ulcers. Int Wound J. gennaio 2022;19(1):114–24. [CrossRef]
- Kitamura A, Nakagami G, Okabe M, Muto S, Abe T, Doorenbos A, et al. An application for real-time, remote consultations for wound care at home with wound, ostomy and continence nurses: a case study. Wound Practice and Research [Internet]. 1 settembre 2022 [citato 5 ottobre 2024];30(3). Disponibile su: https://journals.cambridgemedia.com.au/wpr/volume-30-number-3/application-real-time-remote-consultations-wound-care-home-wound-ostomy-and-continence-nurses-case-study.
- Home [Internet]. Tissue Analytics. 2020 [citato 5 ottobre 2024]. Disponibile su: https://www.tissue-analytics.com/.
- Barakat-Johnson M, Jones A, Burger M, Leong T, Frotjold A, Randall S, et al. Reshaping wound care: Evaluation of an artificial intelligence app to improve wound assessment and management amid the COVID-19 pandemic. Int Wound J. ottobre 2022;19(6):1561–77. [CrossRef]
- Fong KY, Lai TP, Chan KS, See IJL, Goh CC, Muthuveerappa S, et al. Clinical validation of a smartphone application for automated wound measurement in patients with venous leg ulcers. Int Wound J. marzo 2023;20(3):751–60. [CrossRef]
- Wound Assessment Tool - imitoWound App [Internet]. imito AG. [citato 5 ottobre 2024]. Disponibile su: https://imito.io/en/imitowound.
- Guarro G, Cozzani F, Rossini M, Bonati E, Del Rio P. Wounds morphologic assessment: application and reproducibility of a virtual measuring system, pilot study. Acta Biomedica Atenei Parmensis. 3 novembre 2021;92(5):e2021227. [CrossRef]
- Schroeder AB, Dobson ETA, Rueden CT, Tomancak P, Jug F, Eliceiri KW. The ImageJ ecosystem: Open-source software for image visualization, processing, and analysis. Protein Sci. gennaio 2021;30(1):234–49.
- Sia DK, Mensah KB, Opoku-Agyemang T, Folitse RD, Darko DO. Mechanisms of ivermectin-induced wound healing. BMC Vet Res. 20 ottobre 2020;16:397. [CrossRef]
- Khac AD, Jourdan C, Fazilleau S, Palayer C, Laffont I, Dupeyron A, et al. mHealth App for Pressure Ulcer Wound Assessment in Patients With Spinal Cord Injury: Clinical Validation Study. JMIR mHealth and uHealth [Internet]. febbraio 2021 [citato 5 ottobre 2024];9(2). Disponibile su: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943335/. [CrossRef]
- WoundWiseIQ – Image Analytics. Improved Outcomes. [Internet]. [citato 5 ottobre 2024]. Disponibile su: https://woundwiseiq.com/.
- Phung SL, Bouzerdoum A, Chai D. Skin segmentation using color pixel classification: analysis and comparison. IEEE Transactions on Pattern Analysis and Machine Intelligence. gennaio 2005;27(1):148–54. [CrossRef]
- Kuang B, Pena G, Szpak Z, Edwards S, Battersby R, Cowled P, et al. Assessment of a smartphone-based application for diabetic foot ulcer measurement. Wound Repair and Regeneration. 2021;29(3):460–5. [CrossRef]
- Younis PHM, El Sebaie AEM, Waked IS, Bayoumi MBI. Validity And Reliability of a Smartphone Application in Measuring Surface Area of Lower Limb Chronic Wounds. The Egyptian Journal of Hospital Medicine [Internet]. 1 ottobre 2022 [citato 5 ottobre 2024]; Disponibile su: https://journals.ekb.eg/article_270504.html. [CrossRef]
- El-Rashidy N, El-Sappagh S, Islam SMR, M. El-Bakry H, Abdelrazek S. Mobile Health in Remote Patient Monitoring for Chronic Diseases: Principles, Trends, and Challenges. Diagnostics (Basel). 29 marzo 2021;11(4):607. [CrossRef]
- Ohura N, Mitsuno R, Sakisaka M, Terabe Y, Morishige Y, Uchiyama A, et al. Convolutional neural networks for wound detection: the role of artificial intelligence in wound care. J Wound Care. 1 ottobre 2019;28(Sup10):S13–24. [CrossRef]
- Dabas M, Schwartz D, Beeckman D, Gefen A. Application of Artificial Intelligence Methodologies to Chronic Wound Care and Management: A Scoping Review. Adv Wound Care (New Rochelle). aprile 2023;12(4):205–40. [CrossRef]
- Kim PJ, Homsi HA, Sachdeva M, Mufti A, Sibbald RG. Chronic Wound Telemedicine Models Before and During the COVID-19 Pandemic: A Scoping Review. Adv Skin Wound Care. 1 febbraio 2022;35(2):87–94. [CrossRef]
- Foltynski P, Ladyzynski P. Internet service for wound area measurement using digital planimetry with adaptive calibration and image segmentation with deep convolutional neural networks. Biocybernetics and Biomedical Engineering. 1 gennaio 2023;43(1):17–29. [CrossRef]
- Lucas Y, Niri R, Treuillet S, Douzi H, Castaneda B. Wound Size Imaging: Ready for Smart Assessment and Monitoring. Adv Wound Care (New Rochelle). novembre 2021;10(11):641–61. [CrossRef]
- Stoyanov SR, Hides L, Kavanagh DJ, Zelenko O, Tjondronegoro D, Mani M. Mobile app rating scale: a new tool for assessing the quality of health mobile apps. JMIR Mhealth Uhealth. 11 marzo 2015;3(1):e27.
- Curti N, Merli Y, Zengarini C, Giampieri E, Merlotti A, Dall’Olio D, et al. Effectiveness of Semi-Supervised Active Learning in Automated Wound Image Segmentation. International Journal of Molecular Sciences. gennaio 2023;24(1):706. [CrossRef]
- Curti N, Merli Y, Zengarini C, Starace M, Rapparini L, Marcelli E, et al. Automated Prediction of Photographic Wound Assessment Tool in Chronic Wound Images. J Med Syst. 16 gennaio 2024;48(1):14. [CrossRef]
- Deniz-Garcia A, Fabelo H, Rodriguez-Almeida AJ, Zamora-Zamorano G, Castro-Fernandez M, Ruano M del PA, et al. Quality, Usability, and Effectiveness of mHealth Apps and the Role of Artificial Intelligence: Current Scenario and Challenges. Journal of Medical Internet Research. 4 maggio 2023;25(1):e44030. [CrossRef]
- General data protection regulation (GDPR) | EUR-Lex [Internet]. [citato 5 ottobre 2024]. Disponibile su: https://eur-lex.europa.eu/EN/legal-content/summary/general-data-protection-regulation-gdpr.html.
- Huang PH, Pan YH, Luo YS, Chen YF, Lo YC, Chen TPC, et al. Development of a deep learning-based tool to assist wound classification. J Plast Reconstr Aesthet Surg. aprile 2023;79:89–97. [CrossRef]
- Patel Y, Shah T, Dhar MK, Zhang T, Niezgoda J, Gopalakrishnan S, et al. Integrated image and location analysis for wound classification: a deep learning approach. Sci Rep. 25 marzo 2024;14(1):7043.
- Malihi L, Hüsers J, Richter ML, Moelleken M, Przysucha M, Busch D, et al. Automatic Wound Type Classification with Convolutional Neural Networks. Stud Health Technol Inform. 29 giugno 2022;295:281–4. [CrossRef]
- Zhang P. Image Enhancement Method Based on Deep Learning. Mathematical Problems in Engineering. 2022;2022(1):6797367. [CrossRef]
- Chairat S, Chaichulee S, Dissaneewate T, Wangkulangkul P, Kongpanichakul L. AI-Assisted Assessment of Wound Tissue with Automatic Color and Measurement Calibration on Images Taken with a Smartphone. Healthcare (Basel). 16 gennaio 2023;11(2):273. [CrossRef]
- Gagnon J, Probst S, Chartrand J, Lalonde M. Self-supporting wound care mobile applications for nurses: A scoping review protocol. J Tissue Viability. febbraio 2023;32(1):79–84. [CrossRef]
| App name | State | Company, industry, other | Available on app stores and/or public repositories? | Studies | Healthcare agency evaluation? | Public dataset? | Segmentation technique | Reliability | Our classification |
|---|---|---|---|---|---|---|---|---|---|
| Wound at/home healthy.io Minuteful for Wound | Israel | Healthy.io, a private company | 2/2 (App-store, android store) | 1/2 | 2/2, Yes | No | N/A | N/A | 5/18 |
| Wound Vision Scout App Mobile | USA | WoundVision LLC, a private company | N/a | 2/2 | No | No | N/A | N/A | 2/18 |
| APD Skin Monitoring App | Singapore | APD Lab, Private Company | 2/2 (App-store, android store) | 1/2 Scarves | No | No | 1/1 Grabcut[27] , RBG threesholds[28] | N/A | 4/18 |
| NdKare app | Singapore | Nucleus Dynamics Pte. Ltd, Private Company | 2/2 (App-store, android store, other repositories) | 2/2 | 2/2, Yes | No | 1/1 For 2d reconstruction: pixel analysis[50]. | 10/10[51] | 17/18 |
| Clinicram | Spain | Skilled Skin SL, Private Company | No | No | 2/2, Yes | No | N/A | N/A | 2/18 |
| Swift Skin and Wound | Canada | Swift Medical Inc | No | 2/2 | 2/2, Yes | No | 1/1, AutoTissue: tissue segmentation model; AutoTrace: wound segmentation model | 10/10[37] | 15/18 |
| Care4wounds | Singapore | Tetsuyu Healthcare Holdings Pte Ltd | 2/2 (App-store, android store) | 2/2 | 2/2, Yes | No | N/A | 9/10[39] | 15/18 |
| Tissue Analysis | USA | Net Health Company | 2/2 (App-store, android store) | 2/2 | No | No | N/A | 10/10[43] | 14/18 |
| ImitoWound | Switzerland | Imito AG | 2/2 (App-store, android store) | 2/2 | No | No | N/A | 10/10[52] | 14/18 |
| WoundWiseIQ | USA | Med-Compliance IQ, Inc. | No | No | 2/2 | No | N/A | N/A | 2/18 |
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