International Academy of Clinical Thermology
Quality Assurance Guidelines

Standards and Protocols in Clinical Thermographic Imaging

Current Revision July 2015

Annual Review January 2020 - No Revisions


     The following document is issued as a quality assurance guideline for the clinical use of thermal imaging. The process of establishing standards and protocols was guided by the board of the International Academy of Clinical Thermology and represents a consensus from experts in the field of clinical thermology and consultants in relevant fields of expertise.

     The foundation of the methodological approach to the development of any guideline must be grounded in scientific evidence. In the guideline and development process, all available scientific evidence must be considered. This requires an extensive literature search followed by a critical review of all the relevant publications. To the extent possible, recommendations made in the guidelines should be based on the results of well-designed studies.

     The information in these guidelines is based primarily on a review of the current and past peer-reviewed indexed literature. Consultation with authorities in relevant fields of expertise, standards and guidelines issued by other qualified organizations, and clinical experience concerning the application of thermal imaging was also considered.

     It is not the purpose of this organization to regulate clinical thermography, but rather to promote scientific validity and quality imaging. The information that follows has been compiled to insure the highest standards in clinical thermal imaging and patient safety.

Committee Chair—

William Amalu, DC, DABCT

Committee Members—

Jerome Block, MD, PhD, FACP
William Hobbins, MD, FACS
Anand Chaudhry, DC, DABCT
Scott Miles, MD, FACOG
James Christiansen, PhD
Maria Papakyriacou, PhD
William Dudley, DC, DABCT
Valerie Quijano, DC, BCCT
Robert Elliot, MD, PhD
Charles Solano, DC, DABCT
Stephen Elliott, MD
Liezl Voshol, MD

The guidelines have been divided into the following sections: 

  1. Definition of Clinical Thermography
  2. Statement of Need
  3. Laboratory Requirements
  4. Imaging System Guidelines
  5. Other Thermal Detection Devices
  6. Patient Management Protocols
  7. Imaging Protocols
  8. Image Interpretation and Reporting
  9. Clinical Thermography Education Guidelines



     Thermography, when used in a clinical setting, is an adjunctive imaging procedure that detects, records, and produces an image (thermogram) of a patient’s skin surface temperatures and/or thermal patterns. The procedure uses equipment that can provide both qualitative and quantitative representations of these temperature patterns. 

     Thermography does not entail the use of ionizing radiation, venous access, or other invasive procedures; therefore, the examination poses no harm to the patient. 

     There are two currently recognized methods of clinical thermographic imaging: electronic infrared telethermography and liquid-crystal thermography. The following terminology is commonly used interchangeably for clinical thermographic analysis and computer interfaced infrared thermography systems: thermal imaging, thermography, infrared imaging, digital infrared imaging, digital infrared thermal imaging, computed thermal imaging, computerized infrared imaging, and medical infrared imaging among others.

Ref: 1, 2-4, 65, 12-19



     Clinical thermography is appropriate and germane to health care practice whenever a clinician feels a physiologic imaging test is needed for differential diagnostic purposes. Clinical thermography is a physiologic imaging technology that provides important information on the normal and abnormal functioning of the sensory and sympathetic nervous systems, vascular system, musculoskeletal system, and local inflammatory processes. The procedure also provides valuable diagnostic information with regard to dermatologic, endocrine, and breast conditions. Other imaging technologies such as radiography, mammography, ultrasonography, CT, and MRI do not provide the neurological, vascular, and metabolic information provided by thermography.

     Clinical thermography may contribute to the diagnosis and management of the patient by assisting in determining the location and degree of irritation, the type of functional disorder, and treatment prognosis. The procedure may also aid the clinician in the evaluation of the case, in determining the most effective treatment, and improving patient outcomes.

     Clinical thermography is an acceptable analytical procedure that may be performed by a doctor or technician who has been adequately trained and certified by a recognized organization. However, it is strongly recommended that the interpretation of the thermal images be made only by health care providers who are formally trained in clinical diagnosis and hold credentials as board certified clinical thermographers from a recognized organization. This is meant to insure that directed care and proper follow-up recommendations will be made available to the patient if warranted by the interpretation of the images.

Ref: 1, 12-19, 65



1.1 Imaging Room Design: As part of image quality control, the design and environmental conditions of the imaging room should conform to the thermodynamic attributes required in thermal image acquisition. The room itself should be of adequate size to maintain a homogenous temperature. There must be sufficient space for the placement of equipment and freedom of movement for both the technician and patient. It should also be large enough to allow for patients of all sizes to be positioned adequately for each anatomic image. A room approximately 8` x 10`, or dimensions similar in square footage, is adequate to meet these requirements. Larger rooms may also be used as long as a steady homogenous ambient temperature can be maintained (see Environmental Controls section below). During the examination, the patient should be able to be placed relatively equidistant and adequately spaced from each wall. The room should be carpeted. If this is not possible, a well-insulated area rug will suffice.

1.2 Environmental Controls: The temperature of the room should be such that the patient’s physiology is not altered to the point of shivering or perspiring. The temperature range should be maintained between 18 and 23 degrees C. Room temperature changes during the course of an examination must be gradual so that steady state physiology is maintained and all parts of the body can adjust uniformly. The temperature of the room should not vary more than one degree Celsius during the course of a study. The humidity of the room must also be controlled such that there is no air moisture build-up on the skin, perspiration, or vapor levels that can interact with radiant infrared energy. The examining room must have an ambient temperature thermometer to accurately monitor the temperature of the room.

     A complete infrared survey of the room should be performed to inspect for any infrared sources and leakage (e.g. windows, heating/AC ducts, light fixtures, hot water pipes). Any significant findings need to be remedied. All windows must be covered or shielded to prevent outside infrared radiation from entering the room. Shades or blinds may be adequate for this purpose depending on the amount of direct infrared radiation. The room must be free from drafts. Windows and doors should be adequately sealed to prevent airflow in the area where the patient is positioned. Heat and air conditioning sources must be minimized in the room and kept well away from the patient. Vents should be directed away from the patient and thoroughly diffused or turned off during the examination. Incandescent lighting should not be used during the examination due to the amount of infrared radiation produced. Standard fluorescent lighting is adequate.

Ref: 1, 4, 7, 9, 10, 12-19, 20, 22-26, 27-38, 41-42, 50-51, 57, 65, 66, 68-73



     In order to provide for quality image production and accurate clinical interpretations, certain minimum equipment standards should be maintained. There are two currently recognized types of thermographic imaging equipment: electronic infrared telethermography (IRT) and liquid-crystal thermography (LCT).

2.1 Liquid Crystal Thermography: LCT utilizes a range of interchangeable “screens” or “pillows” impregnated with cholesteric methyl-ester derivatives that change color as a function of their temperature. The “screens” or “pillows” are touched to the anatomic surface for development. A standard picture of the image is taken for later analysis and archive. The thermal precision and resolution of the equipment is well within accepted limits for clinical interpretation. 

2.2 Electronic Infrared Telethermography: IRT equipment incorporates single or multiple infrared detectors that sample the field-of-view in two directions simultaneously. The process does not involve contact with the surface of the skin. A current review of the literature suggests that in order to produce accurate and reproducible diagnostic images the following minimum specifications should be incorporated in the design of clinical IRT hardware and software systems for image-capture, display, and analysis:

  • Detector(s) response greater than 5 microns and less than 15 microns with the spectral bandwidth encompassing the 8-10 micron region.
  • System temperature range set to cover temperatures over the range of human emissions. 
  • Emissivity set to 0.98 (human skin).
  • Absolute resolution of at least 19,200 temperature points per image frame with an appropriate lens. The largest lens applicable to the detector is desired. 
  • Spatial resolution of 1 sq. mm at 40 cm from the detector(s) (2.5 mRad IFOV)
  • Thermal sensitivity of less than 80 mK NEDT.
  • Repeatability and precision of 0.1 degree C detection of temperature difference.
  • Thermal drift strictly controlled with corrective calibration to as close to 0.00 degrees C as possible at system equilibration to ambient temperature guidelines. 
  • Maintenance of detector uniformity to within 0.20 degree C Delta-T across 80% of the central field.
  • Absolute temperature accuracy of +/- 2 degree C or +/- 2% of reading or less.
  • Manual adjustment of temperature span.
  • Manual adjustment of level settings.
  • Manual adjustment of focus.
  • Minimum focus distance capable of close-up views of selected sectional anatomy.
  • Capture frame-rate set to allow for live image focusing and capture.
  • Ability to capture images in high-resolution grayscale.
  • High-resolution image display for interpretation.
  • Imaging software capable of accurate quantitative analysis.
  • Ability to perform accurate quantitative differential temperature analysis with a precision of 0.1 degree C.
  • Ability to annotate areas of interest with accurate temperature values.
  • Software manipulation of the images (both live and post-image processing) should be maintained within strict parameters to insure that the diagnostic qualities of the original images are not compromised.
  • Ability to archive images for future reference and image comparison. Proprietary formatting with an image convertible format such as JPEG or DICOM is acceptable.

     Due to the natural progression of technical advancements in the field of thermal imaging, infrared imaging systems for clinical use typically exceed these requirements. However, there is no evidence (Class 1 or Class 2) in the current research literature to support the need of using imaging systems that surpass the above minimum standards.

Ref: 1, 5, 7, 8, 11, 12-19, 38, 64, 65, 106, 351, 354, 377, 393, 422, 427, 430-433, 445-459



     As previously mentioned, certain minimum equipment standards should be maintained in order to produce infrared images that are diagnostic. There are many different types of thermal detection devices available that may be used for specific purposes (e.g. temporal and tympanic thermometers), but may not be suitable for body or breast examinations. A brief summary is given below regarding some of these devices.

3.1 Dual Sensor Paraspinal Devices: Since the early 1920’s, thermal detection devices have been used in the examination of the paraspinal region. These devices are designed to be hand-held and moved by the operator up or down the spine over the paraspinal surfaces. The equipment is composed of a linear array of two spot radiometers (infrared sensors) spaced adequately to straddle the spine and interfaced to a hard-copy readout device or computer. This creates a system best defined as surface thermometry or computerized surface thermometry if a computer interface is used. If enough plotted data is displayed for analysis (e.g. scan distance for anatomic location, direct and differential temperature displays) the system may be defined as paraspinal thermography. Earlier contact devices using thermocouples or thermistors have been replaced with infrared sensors to avoid the inherent errors produced when instruments of this type are used.

     These infrared devices are limited in their use to the evaluation of conditions arising from the area of the spine and paraspinal tissues. If the device is manufactured to the strict minimum standards imposed on all quality clinical infrared devices (e.g. accuracy, repeatability, and thermal stability), then the information yielded will be of diagnostic value.

     A review of the literature concerning infrared sensor instruments of this type suggests that in order to produce accurate, reproducible, and clinically relevant thermal data the following minimum specifications should be incorporated in their design:

  • An infrared detector response greater than 5 microns and less than 15 microns with the spectral bandwidth encompassing the 8-10 micron region.
  • System temperature range set to cover temperatures over the range of human emissions.
  • Emissivity set to 0.98 (human skin)
  • Accurate data repeatability in temperature value and location.
  • A direct linear correspondence between the distance traveled, anatomic location, and the displayed temperature values.
  • Controlled infrared sensor collimation to prevent sensor cross-talk.
  • Within a reasonable range of distance from the skin, the recorded temperature, and the spot size being measured, should not vary.
  • The skin surface covered by the sensor must be controlled within a small enough area to yield data with which a sufficiently detailed graph can be produced.
  • A sufficient number of infrared samples must be taken in order to maintain an adequately detailed graph resolution. The number of samples taken should be equivalent to the minimum standards of acceptable clinical infrared camera systems.
  • Repeatability and precision of 0.1 degree C detection of temperature difference.
  • Absolute temperature accuracy of +/- 2 degree C or +/- 2% of reading or less.
  • Ability to perform accurate quantitative differential temperature analysis.
  • High-resolution image display for interpretation.
  • Ability to archive images and graphs for future reference and image comparison.
  • Software manipulation of the images and graphs should be maintained within strict parameters to insure that the diagnostic qualities of the images and graphs are not compromised.

3.2 Microwave Thermography: Past research has determined that microwave thermography has some limited value in the evaluation of the breast. Studies have demonstrated that certain inherent problems exist with this technology. Concerns raised include: introduction of errors from surface contact, depth of analysis, area coverage, and low spatial and thermal resolution. Research on this technology suggests that infrared telethermography or liquid crystal thermography is better suited for clinical use.

3.3 Single Sensor Devices: The devices in this category are usually designed to be hand-held and moved by the operator over a particular area of the skin or to areas of the body where single spot temperature readings are taken (e.g. tympanic thermometers, skin surface thermometry). Thermal detection devices that fall into this category are best described as surface thermometry. Most of these devices are designed using a single spot radiometer (infrared sensor). If the device incorporates the need for surface contact, certain inherent problems can cause significant errors when a thermal analysis is performed. Incorporation of a computer interface to the sensor creates a system best defined as computerized surface thermometry. We are unaware of any acceptable level of peer-reviewed research in the body of literature to support the use of this type of equipment for body or breast analysis. Single sensor devices are not considered suitable for clinical use as they suffer from many data acquisition problems, notably of which is an extreme lack of absolute and spatial resolution. Devices of this type are considered obsolete.

Ref: 1, 45, 62, 65, 421



Proper management of the patient, both before and during the examination, decreases the chance of thermal artifacts and increases the accuracy of the images. It is the technician’s responsibility to ensure that all pre-imaging preparation and laboratory protocols are followed. 

4.1 Pre-examination Preparation: Pre-examination preparation instructions are of great importance in decreasing thermal artifacts. The following is a minimal list of instructions that should be given to the patient prior to the examination:

  • No sunbathing of the area to be imaged 5 days prior to the exam.
  • No use of lotions, oils, creams, powders, or makeup on the body area to be imaged the day of the exam.
  • For upper body and breast imaging, no use of deodorants or antiperspirants the day of the exam. 
  • If any body areas included in the images are to be shaved, this should be done the day before the exam.
  • No physical therapy, EMS, TENS, ultrasound treatment, acupuncture, chiropractic, physical stimulation, sauna or steam room use, hot or cold pack use for 24 hours before the exam.
  • No exercise the day of the exam.
  • If showering, it must be no closer than 1 hour before the exam. No baths for 24 hours prior to the exam.
  • If not contraindicated by the patient’s doctor, avoid the use of pain medications and vasoactive drugs the day of the exam. The patient must consult with their doctor before changing the use of any medications.
  • For breast imaging, if the patient is nursing they should try to nurse as far from 1 hour prior to the exam as possible. The last breast nursed should be identified (e.g. right or left).
  • If the patient has had any surgical procedure (e.g. any type of biopsy) within the last 12 weeks, the imaging office should be notified and the surgical procedure cleared before an appointment is made.

4.2 Intake Forms: Intake forms should be used and formatted to cover the areas of complaint along with specific pain diagrams, precise location of scars, previous tests and examinations, and a current and past history of any diagnoses, surgeries, and traumas. Intake forms for breast imaging should include additional questions pertaining to anatomic and physiologic changes noted in the breast along with breast diagrams for determining the precise locations of clinical and imaging findings. All of these forms should be designed to be thorough and specific to the body area(s) being imaged. 

4.3 Informed Consent: Informed consent is a process, not just a form. Information must be presented in such a manner that enables persons to voluntarily decide whether or not to participate in imaging. Each patient must sign the consent form in the presence of office personnel. The form needs to acknowledge that they have been provided with information applicable to informed consent that reflects expert consensus of the strengths and weaknesses of clinical infrared imaging. Informed consent forms must also contain clear wording that infrared imaging is an adjunctive procedure; and as such, is not a replacement for mammography, ultrasonography, CT, MRI, or any other form of imaging.

4.4 Patient Acclimation: Prior to imaging, the patient’s body must be given sufficient time to equilibrate with the ambient conditions of the laboratory such that an approximate steady physiologic state of thermodynamic equilibrium can be reached. A minimum equilibration period of 15 minutes should be observed; further equilibration results in minimal surface temperature changes. During the equilibration period, and the subsequent examination, the area to be imaged should remain completely uncovered of clothing or jewelry. To provide a level of modesty prior to certain examinations, a loose fitting gown may be worn during the equilibration period provided that it does not restrict airflow or constrict the skin surface in any way that would produce an artifactual result on the thermogram. Special gowning procedures, specific to the clinic or examination, may be required and are permitted as long as the above stipulations are observed.

The only exception to gowning is in breast imaging where the breasts should remain uncovered during the entire equilibration period, and subsequent examination, in order to avoid contact artifacts. Due to the individual anatomy of each patient, special positioning during the equilibration period and examination may be needed. If the patient is seated or standing, the last 5 minutes of the equilibration period should be spent with the patient placing their hands over their head in order to lift the breasts for adequate surface area exposure. Depending on the individual patient’s anatomy, this posture may need further modification during the acclimation period. This posture is also to be maintained throughout the examination.

4.5 Clinical Examination: When appropriate to the individual case, a clinical examination may be performed after thermal imaging to correlate specific findings. The examination may include visual inspection, palpation, neurologic, orthopedic or other forms of analyses as deemed necessary by the patient’s doctor or the interpreting clinician if attending. Visual observation for skin changes and irregularities (e.g. scars, redness) should also be part of the normal imaging process for the attending technician.

Ref: 1, 2-4, 8, 11, 22, 26, 30-32, 35, 37-51, 54-55, 57-65, 70-72, 74-404      



     The guidelines given for strict laboratory environmental controls and patient preparation provide for a subject that is physiologically ready for thermal imaging.

Note: It is absolutely essential that the capturing of thermal images for health care purposes be made only by personnel who hold credentials as certified clinical thermographic technicians or board certified clinical thermographers from a recognized organization.

5.1 Imaging Series: A thermographic series consists of one or more images, captured on archival media, which permit the evaluation of the body surface area relevant to the purpose of the examination. Each thermographic series should include all or as many body surfaces as possible that are relevant to the patient’s complaint and symptomatology, along with any anatomically and physiologically related areas. Standardized views of each body part have been established in order to provide adequate viewing of the skin surface for qualitative and quantitative analysis. A single thermographic series is considered clinically valid if performed under the conditions previously outlined.

5.2 Patient Positioning: The use of both electronic infrared and liquid crystal thermographic systems incorporate basic standardized patient and equipment positioning for each area of the body imaged. Typically, the entire upper body or lower body is imaged in sections in order to adequately analyze the physiology related to these areas. Specialized or limited views may be added, or taken as an individual study, as needed. 

     When positioning for breast imaging, multiple views from different angles are necessary to provide adequate imaging of the differing surface aspects of the breast and relevant anatomic areas. The minimum set of images taken should include the bilateral frontal, right oblique, and left oblique. In order to provide for an adequate view of the lateral aspect of the breast, the angle of the oblique views will vary depending on the patient’s presenting anatomy. It is highly recommended that the unilateral “bullseye” close-up view of each breast be included on every series taken. This view provides optimal use of the detector by dedicating the greatest number of infrared sensors to each individual breast; thus, providing for an image with the highest absolute and spatial resolution. With certain patients, additional views may be necessary to image specific surface areas that are obscured due to the individual’s anatomy (e.g. inferior quadrant lift views).

5.3 Imaging: Combined positioning of the equipment and the patient is critical to accurate imaging. Electronic infrared telethermography studies should be performed with the detector(s) as perpendicular as possible to the surface to be viewed. If other than perpendicular views are required, the angle must be kept exactly the same for comparable bilateral views. To maintain adequate spatial resolution and interpretation accuracy, the body part(s) of interest should be brought close enough to the detector(s) to fill the viewable image area. When multiple views are required for bilaterally equivalent areas of the body, the equipment settings (or temperature scale “screen” selection with LCT) must not be altered for the two views. Liquid crystal thermography studies should be performed using the proper temperature scale “screen” for the body area imaged along with an adequate number of images to cover the surface area(s) of interest. The screens must also be allowed to cool/equilibrate between views of the opposite sides of the body.

5.4 Additional Studies: Any additional studies and/or images may be requested and are up to the discretion of the interpreting thermologist. Stress studies involving symptom exacerbation or a thermoregulatory challenge may be performed following a baseline thermographic series. 

     The use of a thermoregulatory challenge (a.k.a. cold challenge) is defined as dynamic thermography. The thermoregulatory challenge may be added to an examination to clarify the extent of the nervous system’s involvement in a suspected pathologic process (e.g. Raynaud’s disease, CRPS). The procedure entails the use of a cold stimulus (ice water or equivalent temperature stimulus) applied to the hands, feet, or lower half of the central thoracic spine. The test is commonly performed via hand or feet immersion in an ice water bath for a minimum of 45 seconds (or until pain tolerance) followed by repeated imaging (a single duplicate study or a timed cooling/warming series may be used) of the body area(s) under study. Warmer water (e.g. tap water in temperate climate zones) may not provide a strong enough stimulus to the sympathetic nervous system and is considered questionable as to its reliability. The addition of a thermoregulatory challenge test is up to the discretion of the interpreting thermologist and not the technician.

     With regard to breast imaging, both direct airflow to the breast (fans) and ice water (hand, feet, or thoracic spine area stimulus) have been used as a thermoregulatory challenge in many thermal imaging studies. Studies have shown that the use of fans directed at the breast(s) generally produces an unreliable superficial effect while ice water (hand, feet, or thoracic spine area stimulus) assures a central nervous system mediated sympathetic reflex. The use of fans may also introduce many variables that cannot be controlled for which could adversely affect the quality of the images. The addition of a thermoregulatory challenge test is up to the discretion of the interpreting thermologist and not the technician. Studies have shown that the addition of the thermoregulatory challenge to the standard set of infrared breast images is not necessary to provide for accurate and reliable imaging. 

5.5 Documentation: Each thermographic image, captured on archival media, should contain an indication of the anatomic view along with the following minimum information; either included with the original image or immediately traceable to the patient’s individual database:

  1. The patient’s name or identification code and imaging date
  2. The imaging facility name and address

Ref: 1, 4, 6, 11, 20, 21, 25, 27, 51, 57, 65, 70, 95, 171, 184, 296, 354-356, 388, 414, 420, 422, 426-438, 440-446



Note: It is absolutely essential that the interpretation of thermal images for health care purposes be made only by health care providers who are formally trained in clinical diagnosis (e.g. MD, DC, DO) and hold credentials as board certified clinical thermographers from a recognized organization. Health care providers with specific specialties may also be included (e.g. DDS), with the use of thermography limited to the specialty.

6.1 Thermogram Interpretation: Interpretation of thermal images is based on a knowledge of thermography and its relation to human physiologic systems and processes. Interpretation provides information on the normal and abnormal functioning of the sensory and sympathetic nervous systems, vascular system, musculoskeletal system, endocrine system, and local inflammatory processes. Combining the information gained from the thermal images with clinical data allows for the formation of a clinical impression.

6.2 Breast Thermogram Interpretation: Standardized interpretation guidelines in thermal breast imaging have been utilized since the adoption of the 20 point TH (Thermobiological) interpretation and classification system in the early 1980’s. This system has been continually updated as ongoing research has dictated. Many large-scale studies, encompassing well over 300,000 women participants, confirm the objectivity and accuracy of this interpretation and classification system. This system of interpretation is the most up-to-date method for use in the analysis of thermal breast images. The 20 point TH interpretation and classification system is the accepted standard in thermal breast imaging analysis.

     The TH grading system was devised in order to provide a method for the universal interpretation of both qualitative and quantitative thermal data and to use this data to convey the level of risk and concern. The grading system allows for the objective monitoring of the progression of possible pathology and to provide an objective indicator of improvement of the health of the breasts under care. The TH classification system is as follows:

TH 1 Normal Symmetrical Non-Vascular

TH 2 Normal Symmetrical Vascular

TH 3 Questionable

TH 4 Abnormal

TH 5 Very Abnormal

     Depending on the patient’s recent clinical examination and imaging status, images that fall into the TH3 range and higher classification should be referred for further evaluation. This may include clinical examination, mammography, ultrasonography, magnetic resonance imaging (MRI) and/or a combination of these tests depending on the TH grading. 

6.3 Written Reporting: The format for reporting should include as a minimum the following information:

  • Imaging facility 
  • Patient name and age
  • Date of examination
  • Clinical data
  • Symptomatology
  • Relevant thermographic findings
  • Impression
  • Recommendations (if appropriate)
  • Signature of qualified thermologist

6.4 Follow-up Thermographic Studies: The clinical need for follow-up thermograms is ultimately up to the discretion of the interpreting thermologist and is based on the pathophysiology of the presenting images and the clinical presentation of the patient. The need for and/or timing of thermographic follow-up will also be predicated on the patient’s recent examination procedures and/or imaging.

     With regard to breast thermograms, follow-up evaluations are generally done on an annual basis if the images are normal (TH1 or TH2). The following recall recommendations are based on the average doubling time of malignant mammary neoplasms. Depending on the patient’s conventional risk factors, and other pertinent clinical data, the following recall times may be varied by the interpreting thermologist. 

     Patients who fall into the TH3 classification upon initial evaluation should be recalled at 6 months. If at the 6 month re-evaluation the thermogram remains stable as a TH3, or improves to a TH2 or TH1, the patient should be recalled once more at 6 months. If after 1 year of observation the patient remains stable as a TH3, or improves to a TH2 or TH1, a return to annual thermograms would be recommended. 

     Patients with an initial thermogram in the TH4 or TH5 classification should be recalled at 3 months. If at the 3 month re-evaluation the thermogram remains stable as a TH4 or TH5 (no increase to a higher classification), or improves to a lower classification, the patient should be recalled once more at 6 months. If at the 6 month re-evaluation the thermogram remains at a stable TH4 or TH5, thermograms should be performed at 6 month intervals until improvement to a TH3 or lesser classification or a pathology is discovered.

     All imaging and recalls should be accompanied by the recommendation that the patient should be seeing their doctor and maintaining their regularly scheduled health examinations. Recommendations for treatment must be made by the patient’s doctor.

Ref: 1, 11, 37, 49, 57, 59, 62, 63, 65, 95, 139, 142, 144, 146, 156, 195, 265, 276, 387-388, 405-411, 413-420, 422-425 



Adequate training in thermographic imaging is a necessity to insure quality image acquisition, accurate interpretation, and patient safety.

7.1 Certified Clinical Thermographic Technicians: Training courses leading to certification are comprised of both formal classroom hours and practical imaging experience. Courses typically cover basic thermal imaging principles, patient management, laboratory and imaging protocols, and a time period of supervised practical field experience. Technicians are not trained in the interpretation of thermographic images. Candidates that complete a recognized course of study, and successfully pass the required examination(s), hold credentials as certified clinical thermographic technicians.

7.2 Board Certified Clinical Thermologist: Educational courses at this level are comprised of both formal classroom hours and practical imaging experience. The course material typically covered includes: a review of relevant anatomy and physiology, pathophysiologic processes and their relation to thermographic presentations, laboratory and imaging protocols, patient management, thermal imaging principles, image analysis and interpretation, and a time period of closely supervised practical field experience. Candidates that complete a recognized course of study, and successfully pass the required examinations, hold credentials as board certified clinical thermologists.

7.3 Breast Thermologist: It is essential that extended training in breast thermography be completed by doctors who are intending on interpreting thermal breast images. This level of education exceeds the thermal breast imaging information covered in courses leading to general board certification. A typical course of study includes: a review of breast anatomy and physiology, pathophysiologic breast processes and their relation to thermographic presentations, laboratory and imaging protocols, patient management, thermal imaging principles, image analysis and interpretation, and a time period of closely supervised practical field experience. 

7.4 Certifying Organizations: Educational courses in clinical thermography are provided through recognized organizations. Due to the many non-clinical uses of thermographic imaging, only organizations specifically founded to serve the educational needs in clinical thermography are recognized.

     Quality educational courses have been offered by the International Academy of Clinical Thermology since its beginnings as the California Thermographic Society in the early 1980’s. The Academy provides training courses for both technicians and health care providers. The courses have been continually updated to meet the ongoing changes and advancements in the field of clinical thermology. 



The guidelines in this document are designed to assist practitioners in the use of clinical thermal imaging and to provide outside agencies with knowledge in the application of the procedure. The guidelines, however, should not be considered permanent. Research in this field is ongoing internationally within private practices, hospitals, and universities. This research can be expected to impact the utilization of thermal imaging on a continuous basis ensuring that there is progression and growth in knowledge and understanding of the benefits and role of thermal imaging in the health care delivery system. As the results of such research begin to have a practical impact, the utilization of thermal imaging will change and future guidelines will have to take such changes into account. The guidelines in this document are reviewed annually by the guidelines committee with revisions made as research dictates. 



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Clinical thermography

Clinical thermography entails the use of high-resolution infrared cameras and sophisticated computer processing to produce a topographic heat map display that bears a resemblance to the visible image of the body. Modern computerized thermography produces an accurate and reproducible high-resolution image that can be analyzed both qualitatively and quantitatively for minute changes in skin surface heat emissions. When found to be outside of established normal values, these surface areas of heat may indicate underlying neurologic, vascular, and/or metabolic pathologies.

Thermography is applied in the clinical environment as an aid in the diagnostic process. It is used for the thermal analysis of patients with various conditions in acute, chronic, and preventative health care.

The following images are examples of how this technology is used in health care. For answers to questions we frequently receive, please follow the questions below.


Breast Thermogram (Bilateral View): The above image shows a relatively cool left breast with a normal thermal pattern. The right breast is significantly hotter along with a network of large branching blood vessels. Further testing confirmed the presence of an invasive cancer.


Frontal Neck Thermogram: The image seen above shows a hot pattern over the region of the right side of the thyroid. A follow-up exam and laboratory testing was found to be positive for hypothyroidism.


Upper Back Thermogram: The image above shows a significant area of heat that is well defined from the center of the spine outward and over the right shoulder. This image demonstrates how well thermography detects problems with the nervous system. This heat pattern is thermographic evidence of a cervicothoracic sympathectomy. The sympathetic nervous system chain alongside the spine was surgically cut in a precise area. Notice how accurately the area of heat correlates with the spine and outward as if a line was drawn on the patient. Similar thermal evidence may be seen in any area of the body when there is sufficient nervous system irritation. As such, thermography may help a patient’s doctor find the cause of chronic pain that is responding poorly to treatment.

Frequently Asked Questions

The IACT has received many questions regarding the use of clinical thermography. Most of these questions are generated by the vast amount of misinformation found on the internet. Thermography is an incredible technology with a great deal of good to offer the health of every person. However, this misinformation can lead to the misuse of this lifesaving technology. As health care professionals we are extremely concerned about what we are hearing and seeing.

Education and certification are the ultimate answer to this problem. With an education founded in research, and following accepted standards and guidelines, the proper application of thermography benefits everyone. With quality instruction and certification comes quality thermal imaging. Our IACT certified members are prime examples.

We hope that the following will help to dispel the misinformation we see on the internet and bring about an understanding of how this lifesaving technology may benefit you.

The following topics are covered below –

Thermography Basics

Choosing a Qualified Imaging Center

Thermal Imaging Interpretation

New Cutting-Edge Thermography Systems

Thermography Myths

Thermography Basics

Thermography entails the use of specialized cameras that are sensitive to the detection of electromagnetic energy (light) in the infrared wavelengths (heat). As such, these imagers serve as a remote sensing system; nothing touches or harms the object under investigation. When the camera’s detectors sense the incoming infrared heat an electrical signal is produced that generates a visible image display.

Thermography, or infrared imaging, is used in numerous fields such as industrial fabrication, astronomy, building construction, military applications, surveillance, aerospace sciences, and of course medicine. Medical infrared imaging (MIR) entails the use of high-resolution infrared cameras and sophisticated computer processing to produce a topographic heat map display which bears a resemblance to the visible image of the body. Modern computerized thermography produces an accurate and reproducible high-resolution image that can be analyzed both qualitatively and quantitatively for minute changes in skin surface heat emissions.

MIR is applied in the clinical environment as an aid in the diagnostic process. It is used for the thermal analysis of patients with various conditions in acute, chronic, and preventative health care.

Yes! Infrared imaging (or thermography) uses no radiation or intravenous access and does not touch the body. The procedure is painless, completely safe, and FDA approved as an adjunctive imaging procedure (to be used in addition to other tests). Infrared imaging does not replace any other form of imaging (e.g. CT, MRI, mammography), but is designed to be used in addition to other tests to provide physiological information that cannot be obtained from any other examination procedure.

No! Based upon the available research data at the time, the U.S. Department of Health Education and Welfare (HEW) determined that thermography was beyond the experimental stage in 1972. Thermography was approved as an adjunctive imaging procedure by the FDA in 1982 (Federal Register, Vol 47, No. 20, pp 4419-4420, January 29, 1982). The FDA approved thermography as follows: “Telethermographic systems intended for adjunctive diagnostic screening for the detection of breast cancer or other uses” (Code of Federal Regulations – Title 21, Section 884.2980 Telethermographic Systems).

You do not need a referral and may schedule directly with our center.

We have also seen this news. If you look closely you will find a common thread among all of these negative reviews; the procedure is being done incorrectly. When personnel are properly trained, and guidelines are strictly followed, breast thermography can be a lifesaving technology. And, like any other procedure in healthcare, what is the expected outcome if things are done incorrectly?

No! The technologies are completely different. One cannot compare a functional imaging technology to a structural imaging tool. For example, an EKG does not replace an echocardiogram. The two technologies look at the heart in a completely different way, yet they complement each other.  Thermography provides information about the body that no other technology can offer, but it does not replace them. The reason why there are so many different medical imaging technologies is because no one technology can do it all. They all have strengths and weaknesses. 

Thermography does not replace any other form of imaging, but is designed to be used in addition to other tests to provide physiological information that cannot be obtained from other examination procedures. Thermography is an adjunctive physiologic imaging procedure that does not look inside the body. If you are interested in looking for structural changes such as broken bones, or viewing the colon, female reproductive organs, or the arteries of the heart, please see your doctor for the most appropriate test.

Absolutely not! However, do mammograms replace thermography? The answer to this is also a resounding no; the two tests complement each other. Thermography is adjunctive, it is to be used in addition to other imaging technologies as part of a woman’s regular breast health care. The consensus among health care experts is that no one procedure or method of imaging is solely adequate for breast cancer screening. The false negative and positive rates for currently used examination tests (including thermography) are too high for the procedures to be used alone. However, thermography may pick up thermal markers that indicate the risk of cancers not detected by other tests. An abnormal infrared image is also the single most important marker of high risk for developing breast cancer in the future. It is thermograpy’s unique ability to monitor the abnormal temperature (physiological) and blood vessel changes produced by pathological breast tissue that allows for extremely early detection. Since it has been determined that 1 in 8 women will get breast cancer, we should use every means possible to detect these tumors when there is the greatest chance for survival. Adding these tests together significantly increases the chance for early detection.

Keep in mind that no one test or imaging technology can provide a warning for 100% of all cases. As such, all tests and imaging technologies are adjunctive. As an example, no doctor would tell a woman that all she needs is a mammogram and that she does not need to come in for her yearly physical breast exam. All doctors know that a certain number of breast cancers will be detected on a physical exam of the breasts and not detected on a mammogram. As such, a mammogram is also adjunctive – it must be used along with a yearly physical exam of the breast. 

Another example of this “adjunctive” principle is the all too common experience of women having their yearly physical breast exam followed by their mammogram and then having to have a follow-up ultrasound to check on something seen on the mammogram. Now we are up to three “adjunctive” exams before a woman is told that everything looks fine. Now in some cases, if something needs to be watched on the mammogram and/or ultrasound, a woman might need to be called back in 6 months for another mammogram. Thermography might be the added technology that calls attention to something that needs a closer look.

It should be understood that all of these imaging technologies (thermography included) cannot tell you if you have breast cancer. They only provide a certain amount of suspicion based on what the individual technologies “see”. Only a biopsy can tell you if you have breast cancer. 

There just isn’t one single magic bullet that will do it all. As such, the best approach to providing every woman with the best in early breast cancer detection is a multi-modal approach (multiple modality – multiple tests).

The easy answer here is no. Thermography can only detect heat to a depth of 5mm from the surface of the body. As such, thermography cannot see into the cranial vault, thoracic cavity, abdomen, or pelvic basin. Remember the “visible man” model that was made for children? It had a clear plastic outer shell so that you could see the internal organs. With thermography, one cannot simply create a “visible man” image with heat at the surface of the body and think that you can transpose it to underlying anatomical structures. We have seen infrared images like this, but they are completely false and misleading.

Now, if an internal organ is damaged enough it may send a neural reflex message to the surface of the body creating an infrared marker (viscerosomatic reflex). This surface signal is rarely associated with the location of the underlying organ and is usually found in a remote location that only a well-trained board certified thermologist knows to look for. The problem is that by the time an internal organ is sending this signal there is usually a fair amount of damage. This viscerosomatic reflex can also burn out leaving no infrared marker. Combining this fact with an inability to offer an early warning means that thermography is also unable tell you that you are free of an internal disorder (rule out pathology). The technology is not sensitive enough to be used to screen for or rule-out internal disorders. There are much better tests and imaging tools that can provide for the early detection of pathologies of this type.

If you are concerned about a possible internal disorder, or the spread of cancer (metastasis), there are tests and imaging technologies that are better suited for this purpose. Please see your doctor for the most appropriate tests for your condition.

Choosing an Qualified Imaging Center

Choosing a qualified office or imaging center should be as simple as performing an internet search for an office in your area, but unfortunately it isn’t. There are many offices that have very poorly trained personnel using substandard imaging systems and doctors that are providing image interpretation without a proper education.

Just like any office or imaging center offering radiology services, a qualified thermography center should have certified technicians performing the imaging and a board certified thermologist providing the interpretation of the images. But are these “certified” technicians and “board certified” thermologists really well-educated and certified? This is the problem we are seeing. The caliber of the training of the technician and thermologist is of the utmost importance. I guess the best way to understand the current problems we encounter, and the solution to this problem, is to use an example that we can all understand.

I think that all of us could agree that Harvard University is a good example of a quality institution of higher learning. But how do we know this? Well, Harvard has a long history of providing an exceptional education through their well-educated faculty. And the students who graduate are a reflection of this level of education. The foundation of this level of quality education is lineage. The professor that is currently teaching was taught by a professor who also had this level of quality instruction and this professor also had ……… you get the point. Without a quality lineage of educators, you cannot produce a quality educated student.

Now it is up to you to ask the right questions when interviewing an office or imaging center providing thermography. Is the technician certified by an association or group that has a faculty that can trace their lineage? Does the technician provide imaging under recognized standards and guidelines? Has the thermologist providing their interpretations been board certified by a recognized group that can trace their lineage? Does the thermologist provide interpretation of breast thermograms using peer-reviewed and accepted guidelines – is each breast given a TH grading?

You will need to make the decision if the answer is no to any one of the above.

Yes, and without them the images would be useless. The standards and guidelines under which offices and imaging centers provide thermography have been in-place since the early 1980’s. There are both pre-imaging protocols that patients must follow before coming in for imaging and there are also strict protocols under which the images are taken in the laboratory.

In order to prevent artifacts on the images, every patient must be provided with a list of pre-imaging instructions that must be strictly followed. The imaging room must also be designed properly and environmentally controlled within strict guidelines. The room itself should be draft free and relatively cool (68-73 degrees F) with no incandescent lighting, no heat or cooling sources near the patient, no windows without coverings, and environmentally held steady within 1 degree C during the entire time of the imaging study. In other words, you should be placed in a draft-free cool room that is very thermally stable. You will also need to spend 15 minutes acclimating to the room before imaging (nude from the waist up for breast imaging or with suitable underwear and a loose-fitting gown for body imaging). And lastly, the imaging system itself must meet minimum acceptable specifications for medical use and be registered with the FDA in order to provide thermography. Without these standards in place the images would be useless.

We find it sad that when providing a lifesaving service that some cannot put the patient first. Our policy is to always refer patients to the imaging center closest to them for their convenience. Using fallacious marketing practices that are designed to force patients into one’s own office is truly unacceptable.  

There are established thermography imaging system standards that need to be met in order for an imaging center to provide thermography. These standards were drafted in the 1980’s and have been recently validated and updated. Almost all quality modern infrared camera systems that are designed for medical use exceed the minimum standards for thermography. The most important issue here is the phrase “designed for medical use”. Unfortunately, there are companies that claim that their imaging systems are “designed for medical use”, but in reality they are far from it. There are quite a few technical aspects of infrared imaging that need to be met in order to accurately analyze the surface temperatures of the human body. Most infrared cameras are designed to meet the average needs for military uses, police surveillance, or industrial applications. The demands of a medical imaging system far exceed these applications.

The question then remains, are there infrared imaging systems that just meet standards and others that far exceed them? Yes, but the question is are these exceptional systems better? In 2003, Dr. William Amalu, DC, DABCT, FIACT (Board certified clinical thermologist and executive board member of the IACT and ITS) was asked by the board of the International Thermographic Society (ITS) to investigate the need for a change in the imaging system standards. In other words, based on the quality of the newer imaging systems will offices and imaging centers need to retire their older equipment and purchase state-of-the-art imagers? At this point we need to be careful with what we are defining as quality in an imaging system. We need to be comparing apples to apples. The older equipment we are talking about was the state-of-the-art at the time and met every imaging qualification needed for accurate assessments of human infrared emissions. The newer imaging systems also meet or exceeded these standards along with a significant improvement in image quality.

At the 2004 ITS symposium, Dr. Amalu presented his findings. He had gathered 100 patients totaling 200 image sets for analysis. Each of the patients had to have images taken on both 1980’s imaging systems and modern thermal imagers for comparison. He used the current interpretation guidelines to analyze all of the images. Dr. Amalu was able to demonstrate that offices and imaging centers using the older imaging systems did not need to update their systems to the state-of-the-art. Now does this mean that we don’t appreciate the significant improvements in image quality, ease of use, and reduced cost? No, of course we do. But to say to a patient that because your office has the latest and greatest that you are better than the office down the street is simply not true.

Now, we have just made a comparison between apples and apples – older quality MIR imaging systems designed for medical use versus newer systems also designed for medical use. However, the real problem is that we are currently dealing with apples and oranges. Some companies and offices claiming that their imaging system is better actually have equipment that does not meet the requirements for medical imaging. Both the office using the equipment and the public have no idea that the images being produced may be completely inaccurate and a health risk.

Here we come back to education. If an office or imaging center has a well-educated staff, you may rest assured that they will have a quality thermography system. Educational courses at this level have sufficiently covered both infrared physics and the design requirements needed when choosing an infrared imaging system meant for medical uses. As such, the imaging center will be adhering to established standards and guidelines. The current problem is that some health care offices and imaging centers are not sending their staff for proper training before they purchase an imaging system. Without the knowledge gained in a quality course there is no way an office or imaging center will be able to know the difference between a real infrared imaging system or a costly substandard camera.

Thermal Imaging Interpretation

Within the healthcare specialties, DCs (Doctors of Chiropractic), MDs (Medical Doctors), and DOs (Doctors of Osteopathy) can become radiologists. Just as with radiology, DCs, MDs, and DOs can become thermologists. All of these doctors have the clinical acumen necessary to take additional training to specialize in radiology or thermology.

Absolutely! How could any medical imaging technology provide service without standards and guidelines? Quality peer-reviewed and published research studies performed in leading universities have established a normative database of objective topographic thermal gradients and temperature values. Almost 10,000 references exist in the literature using this normative database to examine for pathology.

With regard to breast thermography, over 800 references exist in the literature to support the standards and guidelines under which breast thermograms are interpreted. All breast thermogram reports should contain a TH (thermobiological) grading of each breast. If a report does not grade each breast into one of 5 TH grades, the competency of the interpreting thermologist comes into question. The TH grading system was devised in order to provide a method for the universal interpretation of both qualitative and quantitative thermal data and to use this data to convey the level of risk and concern. Without a grading system there would also be no way to objectively monitor the progression of possible pathology or provide an objective indicator of improvement of the health of the breasts under care.

The TH grading system has been in place since the early 1980’s. The American College of Radiology (ACR) established the BIRADS (Breast Imaging Reporting and Data System) grading system for mammography in order to provide the same information when interpreting a mammogram, MRI, or ultrasound of the breast. The ACR states the following: “The BI-RADS provides standardized breast imaging findings terminology, report organization, assessment structure and a classification system for mammography, ultrasound and MRI of the breast. The report organization enables radiologists to provide a succinct review of mammography, ultrasound and MRI findings and to communicate the results to the referring physician in a clear and consistent fashion with a final assessment and a specific course of action.” Thermography uses the TH grading system to accomplish the same objectives.

Absolutely not! It is the thermologist’s duty to NOT intervene in treatment. Your treatment must be directed by your doctor. 

Does the thermologist know your complete health history? Has he or she reviewed all of your recent and past laboratory exams? Does the thermologist know all of the medications, supplements, herbals, etc. you are taking? Has the thermologist consulted with or at least have your complete health history from all the other health care providers/specialists involved in your care? Has the thermologist provided you with a recent physical examination to be sure of certain health markers? Can you imagine the level of irresponsibility the thermologist would have to undertake to make treatment recommendations simply off the findings of a thermogram? There is a real possibility here that a patient could be seriously injured or worse.  

The findings and recommendations on the report are sufficient enough for your doctor to use in providing care. Have you ever seen a radiologist recommend anything other than further follow-up testing on a mammogram, X-ray, CT, ultrasound, or MRI report?

I think that we need to clarify this question first. If you are asking if there is an FDA approved computer program that will read the images and create a report without a board certified thermologist also reading the images, the answer is no. There is no place anywhere in health care where a machine provides interpretation of a test and creates a report without a doctor’s interpretation of the results. Have you ever seen a report from any imaging procedure that did not have a doctor’s signature (electronic or otherwise)? This is completely unacceptable in health care. Also, can you imagine the liability! No company would be foolish enough to want to accept this level of responsibility for their software program.

On the other hand, there are quite a few experimental programs currently being studied that are designed to aid thermologists when interpreting thermograms. However, we are not aware of any programs that have been proven to be accurate and approved by the FDA. As such, there is no adequate research proving that any of these programs are of value to the thermologist.

These programs are designed to work just like the FDA approved programs presently being used to aid radiologists when reading mammograms (e.g. ImageChecker). 

On a side note, research has shown that the skill level of radiologists in detecting suspicious areas on a mammogram is far greater than that of the CAD programs designed to aid them. It’s nice to know that we humans are still better than machines.

The use of the cold-challenge (placing the patient’s hands in ice-water, using ice mitts, or using ice packs placed on the mid-back) was stopped in the late 1980’s. The research at the time showed that using the cold-challenge did not increase the sensitivity or specificity of breast thermography. What we are finding is that some offices have websites telling women that they should never go to any office or imaging center that is not doing the cold-challenge. We have no idea why they are doing this as this is simply false information. Fortunately, the number of offices we see doing this is decreasing.

Back in the late 1990’s and early 2000’s the problem was so bad that Dr. William Hobbins (the leading expert in breast thermography at the time) encouraged Dr. William Amalu, DC, DABCT, FIACT (Board certified clinical thermologist) to review his database of cold-challenges and present a paper at the yearly symposium of the American Academy of Thermology (AAT). Dr. Hobbins and other experts in this field were concerned that these misleading offices were claiming that experts in this field were missing things by not performing breast thermography correctly. The paper went on to be presented at the international conference of the IEEE Engineering in Medicine and Biology Society. The end result was acceptance of the paper for peer-review and publication (click here or go to Medline/PubMed). As recently as 2013, the AAT formed a standards and guidelines committee that included Dr. Amalu, along with Dr. William Hobbins and a group of experts in this field, to review the current status of breast thermography and create an updated internationally peer-reviewed standards and guidelines document. With regard to the cold-challenge, a review of the literature along with a consensus among the experts reaffirmed that the cold-challenge did not improve the sensitivity or specificity of breast thermography; and as such, its use was not necessary to provide accurate infrared imaging of the breast.

New Cutting-Edge Thermography Systems

From time-to-time we see new thermography systems that make claims to significant superiority to the current imaging systems. What we find is that these systems are usually using methodologies that are untested and/or ignore the laws of thermodynamics. One of the most misleading of these “new” infrared imaging technologies is the claim of being able to look deep into the body. For a more detailed explanation, please see the first topic in the Thermography Myths section below.

Another problem we seeing is the use of imaging equipment in a manner that either introduces thermal artifacts or temperature measurement errors. This alone causes inaccurate data collection and interpretation errors. Another cause of errors comes in the form of unproven software interpretation programs that are used without a board certified thermologist interpreting the images. There is no place in healthcare where a machine provides an interpretation of a medical imaging procedure without a board certified radiologist or thermologist reading the images and signing the report (see previous topic above). Software programs such as ImageChecker (e.g. use in mammography) are used to assist the radiologist, but are not used alone.

The current infrared imaging system standards and interpretation guidelines have been established for over 34 years. These equipment and interpretation standards and guidelines have been continually monitored and updated by experts in this field through major associations worldwide. We are currently using the state-of-the-art in infrared imaging systems and interpretation methodologies. This involves infrared imaging systems that can withstand the scrutiny of the finest engineers in infrared sciences and the interpretation expertise from highly educated board certified thermologists.

The sophistication of an infrared imaging system has nothing to do with human physiology. All patients must undergo 15 minutes of acclimation in an environmentally controlled room. 

It doesn’t matter what type of imaging system you have, if you have been driving with your arm out the window and the AC blowing on the other side of your face you cannot be suddenly placed in front of a heat sensing camera to take images. When going from a hot environment to a cool one, and vice versa, the body needs to become attuned to the environment in order to express accurate thermal information. Clothing will also leave marks on the surface of the body (thermal artifacts) that have to be removed before imaging can take place. 

You could have the most accurate and sensitive thermometer in the world, drink a hot cup of coffee and stick the thermometer in your mouth. Do you think that you would get an accurate representation of temperature?

Thermography Myths

There is nothing new here. These claims were made in the 1990’s, 2000’s, and now again. Every time this has occurred no one has ever been able to prove it. They will tell you that research has been done. They will show you images that claim to prove that their system is the only one that can do this. In most of these instances what you are being shown is common digital subtraction methods that are built into all quality imaging systems.

In all of these instances basic research studies have never been replicated. We know that thermography can only see to a depth of 5mm. How do we know this? Research studies were performed long ago using both animals and humans. Multiple volunteers had heat generating modules surgically implanted at varying depths from the bone to the surface of the skin. The surgical procedures were allowed to completely heal and baseline MIR images taken to demonstrate normal thermal patterns. Each module was turned on individually and heated to just under the point of causing cellular death (This is well over any temperature that would be generated from a pathology). It was discovered that until the heat source was within 5mm of the surface of the skin it could not be detected. Now, has infrared technology advanced since then? Absolutely, but have the laws of thermodynamics changed? When asked if these “new” imaging systems have undergone research by reproducing these studies you will find that the answer is no. Until they do there is no proof. 

At this point we have something that may be very dangerous. If these claims were true why would we need basic radiology, CT, MRI, ultrasound, mammography, or any other medical imaging technology? Thermography offers significant advantages in many areas, but if patients are allowed to believe that thermography can see deep into the body and provide screening for the early detection of internal disorders we are endangering their lives. 

No! And this issue needs to be addressed as there are offices who are using this to scare patients into spending thousands of dollars on unnecessary dental procedures and thermograms.

Here are the simple reasons that none of this is possible:

  1. Due to the Zeroth Law of Thermodynamics, the lymphatic vessels are invisible to thermography.
  2. No lymphatic vessels lead from the face to the breast.
  3. The normal immune response does not allow an infection to move all over the body – it walls it off.
  4. There is no image on a thermogram alone that can be identified as lymphatic congestion or a lymphatic vessel.

Let’s start with the thermograms being seen on the internet. These thermograms show a hot “vessel” or “vessels” leading down from the side of the face, over the front of the neck, and down into the breast. This is assumed to be a lymphatic vessel(s) – error number one. 

  • All lymphatic vessels drain UP from the breasts. The right breast draining into the right lymphatic duct at the subclavian vein and the left breast draining into the left thoracic duct at the left subclavian vein.
  • All the lymphatics from the face drain DOWN and into these same ducts.
  • Lymphatics DO NOT drain from the face/head into the breasts.
  • What you are seeing on these thermograms are coincidental vein patterns.
  • Coincidence does not mean correlation, and correlation does not imply causation.

Lymphatic vessels begin in the tissues as a drainage system for fluid around the cells. All of these vessels travel up from the body below and down from the head above. 90% of these vessels drain into the left thoracic duct, while the remaining 10% drain into the right lymphatic duct. Lymphatics do not drain into the breasts. The lymphatics are a closed system with its own vessels just like the circulatory system. 

Another unique aspect of the lymphatic system is that it is completely unlike the circulatory system carrying blood. The pumping heart draws venous blood into it from the body while pushing arterial blood out to the body. The lymphatic vessels have no pump. As such, the flow of lymph (the fluid in the lymphatic vessels) is extremely slow in comparison to the blood circulating through the heart. This last aspect, the flow rate of lymph, is another reason that these vessels are incredibly rare to see on a thermogram. 

  • In order to see a vessel on a thermogram it must be hotter that the background temperature of the tissues (e.g. skin).
  • The Zeroth Law of Thermodynamics basically states that when two objects of differing temperature come in contact with each other they will eventually become the same temperature (they reach equilibrium).
  • Since the lymph is coming from the surrounding tissues, the temperature of the lymph is the same as the surrounding tissue. 
  • The flow rate of lymph through the lymphatics is so slow that the temperature of the fluid remains the same as the surrounding tissue.
  • These factors make the lymphatic vessels invisible on thermography. 
  • The blood flow rate through arteries and veins is fast. As such, the hotter blood moving through the vessels doesn’t have enough contact time with the surrounding tissues to reach equilibrium. 
  • What we see on a thermogram is the reflection of the blood flow through the skin (i.e. veins and arteries).

What about the root canal infection itself? The human body has evolved to do all it can to survive. The mouth is one of the dirtiest places in the body. Chewing causes tremendous pressures on the teeth and jaws. Due to the importance of having to eat, the mouth is one of the fastest healing areas in the body. Now, let’s introduce an infection. In an effort to survive, what should the body do? Should it wall the infection off isolating it to the tooth area, or should it allow the infection to become deadly by moving to other areas of the body? It does exactly what you just thought, it walls the infection off to fight it and protect the rest of the body. The infection doesn’t pick some specific blood vessel to travel to some specific organ. 

Now you might be saying to yourself, “Ok so you can’t see lymphatics. What about the concerns with some people getting heart infections from dental procedures?”. These infections come about from bacteria being dislodged, falling into the venous system, and draining from the mouth – there is no direct connection from the lymphatics to the heart. If the patient has a heart condition that is susceptible to infection (e.g. valve replacement), the bacteria may cause an infection. Keep in mind that bacteria are part of our normal environment both outside and inside our bodies. As such, and if knowing that no recent dental procedures have occurred, an infection of the heart can be coming from anywhere in the body through the venous system.

What about patients with lymphedema? First, there is no vascular pattern (thermal image) that can tell if a patient has lymphedema vs. some other neurovascular condition. As such, for a thermal image to correlate with this diagnosis the interpreting thermologist would need to already know that the patient has this condition (i.e. swollen limb). The accumulation of lymph causes swelling, which is seen on a thermogram as cold – not hot. Again, without the thermologist already knowing the diagnosis this cold image could also be caused by another pathology.

We have also seen statements from dentists and other thermography websites claiming that the teeth are connected to the breast acupuncture meridians. Please feel free to look up any acupuncture meridian chart. There is no such thing as a breast meridian. There are meridians that run through the breast, but there are no breast meridians. Perhaps some are trying to say that the stomach meridian runs directly from the mouth down to the breasts. However, the stomach meridian ends in the feet and not the breast. There is no direct connection.

It is so unfortunate that this topic needs to be addressed, but many patients are being needlessly scared and wasting thousands of dollars on unnecessary dental procedures and added thermograms. There is just no anatomic or physiologic evidence for this topic. A thermogram showing hot stripes from the face to the breast is simply coincidence. A broken clock is right twice a day. Coincidence does not mean correlation, and correlation does not imply causation.

As mentioned above, there are no thermal patterns or markers of any type that would allow for an interpretation of lymphatic congestion. It doesn’t matter if the image is of the breast, axilla (under arm area), or some other area of the body.

In breast cancer patients who have undergone the removal of a significant number of axillary (under arm) lymph nodes, and have obvious visual proof of lymphedema in the upper extremity, the resulting thermogram of the affected arm would then be a result of lymphatic congestion. However, without knowing the history of this patient, and visually confirming the condition, the interpretation of the upper extremity thermogram would be indistinguishable between some other form of circulatory and/or neurological abnormality.

Interpretations of thermal findings indicating cysts and fibrocysts shows a lack of the basic understandings of thermodynamics. Not to mention the research showing that we can only detect heat sources to a depth of 5mm from the surface of the skin. 

You will notice on these types of reports that the interpreter routinely calls attention to “cold areas” or “cold spots” as the location of cysts and/or fibrocysts in the breast. Since cysts are fluid filled sacs, one might think that this area under the skin would create a cold area at the surface. However, simple thermal conduction will not allow for a temperature difference between the cyst and the surrounding tissue. Take for example that a balloon filled with cold water (acting as the cyst) is placed inside a larger balloon filled with warm water (acting as the breast). What will happen over time? Both of the balloons will reach equilibrium and become the same temperature (Zeroth Law of Thermodynamics). This is the same thing that happens with cysts and fibrocysts in the breast. As such, there are no thermal signs of cysts or fibrocysts in the breasts.

This is another example of an inadequate education in thermal imaging. In this instance the interpreting thermologist is looking at a view of the side of the neck and sees a hot stripe leading from the area near the rear of the jaw down toward the front of the neck. This hot stripe is thought to be heat from an inflamed carotid artery. 

We have three very elementary errors here. The first is basic anatomy. We have seen websites that state that since the carotid artery is so close to the surface of the skin that it is easily evaluated using infrared imaging. We won’t bore you with an anatomy lesson numerating the layers of muscle, fascia, and other blood vessels that cover and protect this vital structure that conveys blood to the brain. Suffice it to say that the carotid artery is safely located deep in the neck close to the cervical spine. Remember that we cannot see anything deeper than 5mm from the surface of the skin. Secondly, if this heat stripe is a blood vessel how can one prove that it is inflamed only from the thermal image? Simply changing the volume of blood flow will change the size of the vessel; and thus, the appearance of increased heat. And lastly, true carotid inflammation (carotid vasculitis) carries with it a very specific set of symptoms.

So what is this heat stripe? It is the external jugular vein. One of the technical advantages inherent in performing thermography is that a live image is generated. As such, the technician or doctor can approach the patient and investigate the surface of the body for any interesting finding that appears on the live computer image. When seeing this hot stripe, the technician could use a pen to point at an obvious bluish line on the neck (external jugular vein) while looking at the infrared image. The results are obvious.

By now I think you have learned that we cannot see heat coming from the heart through layers of muscle, fascia, and bone. Remember that we cannot see anything deeper than 5mm from the surface of the skin. And by the time a viscerosomatic reflex occurs, creating a thermal signal from the heart, the patient already has obvious cardiac symptomatology. Thermography cannot provide any type of early warning of cardiac disease nor can it rule it out.

First, this has nothing to do with the type of camera used. Any office with a reasonable mount for the camera can leave the patient behind a wall or drape and provide imaging without the technician seeing the patient. However, this is not allowed in infrared imaging.

We all understand that we would prefer not to be undressed in front of a technician or doctor. But all of us also understand that when entering any health care facility the likelihood of having to disrobe is fairly high. As mature adults we understand that this can cause some anxiety, but disrobing in front of a technician or doctor of the same gender is something that is fairly common.

The real problem here is that providing imaging without the technician visually seeing the patient is against the standards and guidelines in thermography. It would be irresponsible of the technician not to observe the surface of the body being imaged. During the acclimation process the technician needs to properly position the patient to be sure that thermal artifacts will not be introduced into the images. Once the acclimation time has passed, the technician must re-enter the room to verify that the patient has not changed this position. This is part of the verification of proof of proper acclimation.

When performing breast imaging the technician has special responsibilities that would also preclude “privacy imaging’. Certain changes to the surface of the breast may occur due to surgeries or when a cancerous growth is present. It is the technician’s responsibility to visualize the surface of the breast in order to inform the interpreting thermologist if anything other than smooth uniformly colored skin is present. Surface changes can be critical in the thermal grading of the breast and the proper management of the follow-up recommendations.

With imaging the rest of the body the technician must also be observant for surface evidence of surgical sites (e.g. scars). At times, patients can forget these things when filling out their intake forms. Depending on the extent of certain surgical procedures, the thermal pattern in these regions of the body can be significantly altered. Without having a technician present to observe the surface of the body the interpretation of the thermogram may be in error due to the interpretation of a surgical artifact as a pathology.

It has also been said that many of these things can be overcome by having the patient acclimate in front of the camera in a “privacy imaging” setting. However, one cannot “see” these things in infrared, it’s just not possible. Even if a particular camera was able to provide additional visual imaging just like a regular video camera, you would have to let the patient know that you were looking at them just as if you were in the room. At this point you would be violating the entire “privacy imaging” idea. Decades of experience in thermography has shown that patients do not like having an infrared camera, much less a regular video camera, pointed at them during the acclimation time. It creeps them out.

“Privacy imaging” introduces the possibility of significant errors and violates the standards and guidelines in thermography.

Absolutely not! The argument for this practice seems to be that there is no way to know on your first thermogram whether or not your body was changing at the time. We have another question, if the follow-up 3 month thermogram showed that there was change, which image set would be the stable baseline? Would it be the first set or the 3 month later set? It sounds like you would need to do another set of images in another 3 months as a tie breaker. But what if this set also showed change? The bottom line here is that if you did need to return to do any of this the technology must be useless.

What would you think if your doctor took your temperature, noted it as a fever, and then told you to return the next day to see if this first reading was right? Reading core temperature is no different than a surface recording taken under proper thermal imaging guidelines. Either the information taken on the first thermogram is valuable or the technology is unstable and useless due to some variable in the patient’s physiology. Research following the same patients over a 5 year span has proven that the thermal patterns and differential temperatures at the surface of the body are remarkably stable and held within a very narrow range. These research studies were used to establish the normative database to which patients are compared when reading thermograms. Thermovascular patterns are as unique as a fingerprint and can be followed with accuracy for decades. It is when there is a change to this stable thermal fingerprint that a problem is signaled.

This begs the question as to why patients are being asked to return in 3 months. We recommend asking one of these offices for at least one peer-reviewed and published research paper demonstrating the need for this in order to establish a stable baseline. The research has already been done. In the early days of thermography each set of thermal images were taken in triplicate. The patient was acclimated in a temperature controlled imaging room under standard protocols for 15 minutes and then imaged. The patient would then be left for another 15 minutes and imaged again. This was finally repeated once more. In these early days thermologists were unsure about the stability of the process and the possibility of changes. Once the stability of the thermal data was established this practice was stopped. Then, as mentioned above, this was taken a step further by watching the thermal stability of patients for over 5 years. Studies have proven that a single set of thermal images taken under proper guidelines is completely accurate for analysis.

Under the established standards and guidelines for thermography, recalling patients for follow-up thermograms is based solely on clinical need. When it comes to breast thermography, follow-up thermograms are performed based on the known metabolism of breast cancers. Under these guidelines each breast must be graded into one of 5 thermobiological (TH) categories. The level of TH grading acts as an individualized risk assessment based on the patient’s own biology. Depending on the TH grading, and taking into consideration the metabolism of breast cancers, the patient will be asked to return in a reasonable amount of time.

Since it was established decades ago that a single thermogram is all that is needed for immediate analysis, why are some offices having all their initial thermogram patients return in 3 months?

White House

United States

William Amalu, DC, DABCT, FIACT
Pacific Chiropractic & Research Center – Infrared Imaging

Director of Medical Infrared Imaging – IACT
621 Middlefield Rd.
Redwood City, CA 94063, USA
Telephone 650-361-8908
Medical Infrared Imaging

Martin Bales
Wendy Sellers
Pink Image

444 South Cedros Avenue
Studio 120
Solano Beach, CA 92075, USA
Telephone 619-723-8769
Medical Infrared Imaging

Dr. Anand Chaudhry, DC, DABCT
Dr. A. Chaudry
2905 Stender Way #22
Santa Clara, CA 95054, USA
Telephone 408-748-1000
Medical Infrared Imaging

Michelle Hodge
Michelle Hodge, DC/Redding Thermography
2536 Old Eureka Way
Redding, CA 96001 USA
Telephone 530-945-0878
Medical Infrared Imaging

Shelley Lesar
Early Screen Thermography at Integrative Wellness Center
151 North Sunrise Avenue #815
Roseville, CA 95661 USA
Telephone 916-784-9355
Medical Infrared Imaging

Judy Mayer
Auburn Thermography

6000 Fairway Drive, Suite 1
Rocklin, CA 95677, USA
Telephone 530-524-5384
Medical Infrared Imaging

Donna Scippa
Thermography at Whole Health Associates
880 Las Gallinas, #1
San Rafael, CA 94903 USA
Telephone 415-299-0396
Medical Infrared Imaging

Paula Blatcher
Be Wholistice with Paula, Inc.

12717 West Sunrise Blvd. #271
Sunrise, FL 33323 USA
Telephone 954-203-8992
Medical Infrared Imaging

Valerie Quijano
Medical Wellnesss Centers of Hawaii

Board Member – IACT
64-1035 Mamalahoa Highway, Suite J&K
Kamuela, HI 96743 USA
Telephone 808-885-4503
Medical Infrared Imaging

Dr. Scott Miles, MD
Miles Ahead Health, Health and Wellness LLC
Board Member – IACT
5510 Lafayette Rd. Suite 240
Indianapolis, IN 46254, USA
Telephone 317-298-9550
Medical Infrared Imaging

Lisa Waknitz
Thermography of Iowa, Inc.
3290 100th Street
Urbandale, IA 50322, USA
Telephone 515-252-7705
Medical Infrared Imaging

Danny McInnis
FLIR Systems
25 Esquire Rd.
North Billerica, MA 01862, USA
Telephone 978-901-8380
Building Sciences
Condition Monitoring

Dave Sawyer
Sawyer Infrared
14 Newbury St.
Peabody, MA 01960, USA
Telephone 978-578-0641
Building Sciences
Condition Monitoring
Gas Imaging

James Swansey
S3 Thermal Imaging
PO Box 856
Norwood, MA 02062, USA
Telephone 781-762-2118
Building Sciences
Condition Monitoring
Medical Infrared Imaging

Stephen West
28 Tyndale St.
Roslindale, MA 02131, USA
Telephone 617-312-7401
Condition Monitoring

Sheryl Hargadon, C.T.T.
Full Circle Healing Arts
645 Ridgely Avenue
Annapolis, MD 21401 USA
Telephone 410-541-9759/410-266-9370 ext24
Medical Infrared Imaging

Julie Bennett
Advanced thermal Imaging of West Michigan, LLC.
7052 Springtree Lane S.W.
Grand Rapids, MI 49548 USA
Telephone 616-724-6368
Medical Infrared Imaging

Andrea Winarick
Atlantic Regional Thermography
213 Alexander Drive
Linwood, NJ 08221 USA
Telephone 609-513-3206
Medical Infrared Imaging

Christie McCoy Nichols
Thermal Discovery LLC.

c/o The Wanek Medical Center
6 North Pointe Court
Greensboro, NC 27410, USA
Telephone 336-944-2349
Medical Infrared Imaging

Elizabeth Carter
Primary Chiropractic center
610 Lancaster Avenue
Berwyn, PA 19312, USA
Telephone 610-251-9211
Medical Infrared Imaging

M. Erin Van Veldhuizen
Women’s Natural Health Center
4100 McEwen Road, Suite 130
Dallas, TX 75244 USA
Telephone 214-295-9671
Medical Infrared Imaging

Cindy Stillwell
Core Health Thermography and Wellness

5574 Richmond Road, Suite 205
Troy, VA 22974, USA
Telephone 434-882-5468
Medical Infrared Imaging

Rebecca Tenges
Equine BodyWorks, LLC.
2975 West Hidden Lake Road
Mequon, WI 53092 USA
Telephone 414-852-8621
Medical (Equine)


Jennifer Deng
Pure Pharmacy Health Centre

111-15388 24th Avenue
South Surry, BC V4A2J, Canada
Telephone 604-542-7780
Medical Infrared Imaging

Marlous Kelderman – de Haan, MSc. BSc. CCT

Izaak Evertslaan 78
The Netherlands
Telephone +31 26 4424323
Medical Infrared Imaging