ScaFE: Data-Efficient Scar Classification with LLM-Generated Clinical Feature Programs

Classifying pathological scars from clinical photographs requires distinguishing keloids from hypertrophic scars despite limited expert-labeled data and substantial acquisition variation across hospitals. End-to-end image models remain data-dependent, whereas sending photographs to a hosted vision-language model (VLM) may conflict with local data-governance requirements and yields decisions that are difficult to reproduce and audit. We introduce ScaFE (Scar Feature Engineering), which transfers clinical knowledge from a large language model (LLM) into deterministic, executable feature programs instead of asking the model to diagnose images. A web-enabled LLM retrieves clinical evidence and synthesizes programs that measure visually assessable scar attributes. Candidate programs execute in a restricted local environment, and only aggregate validation statistics and feature-level SHAP summaries are returned for iterative repair and refinement; raw images and patient-level outputs remain local. A lightweight Random Forest then operates on the resulting structured representation. On 600 photographs from three hospitals under leave-one-site-out evaluation, ScaFE achieves 81.0% site-macro balanced accuracy, exceeding the strongest baseline, BiomedCLIP, by 10.0 percentage points. With only 10% of the development data, ScaFE retains 72.0% balanced accuracy and an 11.8-point lead. Iterative refinement also raises the executable-program rate from 66.7% to 95.0%, with verified evidence for 91.7% of the final features. These results show that LLM knowledge can support data-efficient, cross-site medical image classification through local and auditable feature programs rather than direct VLM decisions.

When LLMs Analyze Scars: From Images to Clinically-Meaningful Features

Medical image classification faces a fundamental dilemma: while deep learning models achieve remarkable performance at scale, real-world clinical scenarios often suffer from severe data scarcity due to annotation costs, privacy constraints, and disease rarity. This challenge is particularly pronounced in pathological scar classification, where differentiating keloids from hypertrophic scars requires subtle expert knowledge and labeled images are extremely limited. We propose a novel paradigm that repositions large language models (LLMs) as knowledge-driven feature engineers rather than end-to-end classifiers. We call this framework ScaFE (Scar Feature Engineering). Our key insight is that LLMs encode rich medical knowledge that can be externalized as executable feature extraction code, enabling the transformation of high-dimensional images into low-dimensional, clinically interpretable representations. Specifically, we prompt an LLM with established scar assessment criteria to generate deterministic Python code that extracts features aligned with clinical scoring systems such as the Vancouver Scar Scale. Our approach offers three key advantages: (1) data efficiency, achieving robust performance with limited training samples by decoupling knowledge acquisition from statistical learning; (2) privacy preservation, as raw images are processed locally without exposure to external LLMs; and (3) interpretability, through explicit features grounded in clinical reasoning. Extensive experiments on scar classification demonstrate that our method consistently outperforms end-to-end deep learning baselines or using LLMs as black-box classifiers under limited data conditions, establishing a promising direction for integrating LLMs into data-efficient and clinically transparent medical AI systems.