dermayology scoring

1. SCORING
SYSTEMS IN
DERMATOLOGY
By: Dermatology Residents

2. SCORING SYSTEMS
IN ATOPIC
DERMATITIS
Ivy S. Cagulada, MD
1st year Dermatology Resident
Rizal Medical Center

3. Discussion Outline
■ Atopic Dermatitis Introduction
■ SCORAD
■ SASSAD
■ Rajka and Langerland Scale

4. Atopic Dermatitis
■ a chronic inflammatory skin disease primarily
beginning in childhood
■ Itch is the hallmark symptom
■ in severe cases leads to sleep disturbance and
excoriated, infection-prone skin
■ Comorbidities: allergic asthma and allergic rhinitis
Kang, S., Amagai, M., Bruckner, A. L., Enk, A., Margolis, D. J., McMichael, A. J., & Orringer, J. S. (2019).
Fitzpatrick's dermatology. In Fitzpatrick's dermatology. New York: McGraw Hill Education

5. Scoring Atopic Dermatitis
(SCORAD)
■ most extensively tested severity index for AD
■ Developed by the European Task Force on atopic dermatitis in 1993
■ It combines an assessment of disease extent using the rule of nines with 6
clinical features of disease intensity plus a visual analogue score for itch and
sleep loss
Kunz, B.; Oranje, A.P.; Labrèze, L.; Stalder, J.-F.; Ring, J.; Taïeb, A. (1997). Clinical Validation and Guidelines for the SCORAD Index:
Consensus Report of the European Task Force on Atopic Dermatitis. , 195(1), 10–19.doi:10.1159/000245677

6. The rule of 9 is used to calculate the
affected area (A) as a percentage of
the whole body.
•Head and neck 9%
•Upper limbs 9% each
•Lower limbs 18% each
•Anterior trunk 18%
•Back 18%
•Genitals 1%.
The score for each area is added up.
The total area is 'A', which has a
possible maximum of 100%.

9. SCORAD Interpretation
<25: Mild Eczema
25-50: Moderate Eczema
>50: Severe Eczema

10. Challenges in using SCORAD
■ difficulties of estimating body surface area involvement
■ interobserver variability occurred for edema, oozing, lichenification,
excoriations
■ Variations in the choice of a representative site for assessing disease
intensity were thought to have conributed to these results
■ Suggestion:
■ Observer training
Kunz, B.; Oranje, A.P.; Labr&egrave;ze, L.; Stalder, J.-F.; Ring, J.; Ta&iuml;eb, A. (1997). Clinical Validation and Guidelines for the SCORAD Index:
Consensus Report of the European Task Force on Atopic Dermatitis. , 195(1), 10–19.doi:10.1159/000245677

11. SASSAD Index
■ Six-Area, Six-Sign Atopic Dermatitis
■ involves assessing 6 clinical features of disease intensity (erythema,
exudation, excoriation, dryness, cracking, and lichenification) at 6 defined
body sites on a scale of 0 to 3, giving a maximum score of 108
■ Although it is said to be simply and quickly performed without previous
training, there are no published data on reliability testing
J. BERTH-JONES (1996). Six Area, Six Sign Atopic Dermatitis (SASSAD) severity score: a simple system for monitoring disease activity in atopic dermatitis. ,
135(Supplement s48), 25–30. doi:10.1111/j.1365-2133.1996.tb00706.x

12. 0 = absent: the sign cannot
be detected with certainty
even after careful inspection
1 = mild: the sign is certainly
present but requires careful
inspection to see it
2 = moderate: the sign is
immediately apparent
3 = severe: the sign is very
prominent.

13. Uses
■ Monitor the progress of treatment in clinical practice
■ Clinical trials: topical or systemic treatments

14. Rajka and Langerlad Scale
■ is a simple scale measuring clinical course, intensity, and extent of atopic
eczema
■ most suitable for baseline categorization of patients rather than to monitor
severity changes in trials, because of its broad categories
■ involves an assessment of body surface area involvement, into 1 of 3
categories only, and lacks any formal reliability testing

15. Rajka and Langerlad Scale
■ based on 3 domains (extent, course, and intensity); however, its validity is
not yet confirmed
■ enables a simple assessment of AD severity as well as the classification of
AD into mild, moderate or severe at a single clinical visit
■ The score is based on the grading of:
(i) eczema extent according to the rule of 9
(ii) eczema course based on the number of months with eczema during the
previous year, and
(iii) eczema intensity expressed in terms of nocturnal sleeplessness due to itch.

17. References
■ Kang, S., Amagai, M., Bruckner, A. L., Enk, A., Margolis, D. J., McMichael, A. J., &amp;
Orringer, J. S. (2019). Fitzpatrick's dermatology. In Fitzpatrick's dermatology. New York:
McGraw Hill Education
■ Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the
European Task Force on Atopic Dermatitis. Dermatology. 1993;186(1):23-31
■ J. BERTH-JONES (1996). Six Area, Six Sign Atopic Dermatitis (SASSAD) severity score: a
simple system for monitoring disease activity in atopic dermatitis. , 135(Supplement
s48), 25–30.doi:10.1111/j.1365-2133.1996.tb00706.x
■ Silverberg, J.I.; Lei, D.; Yousaf, M.; Janmohamed, S.R.; Vakharia, P.P.; Chopra, R.; Chavda,
R.; Gabriel, S.; Patel, K.R.; Singam, V.; Kantor, R.; Hsu, Derek Y. (2020). Measurement
properties of the Rajkaâ€
•
Langeland severity score in children and adults with atopic
dermatitis. British Journal of Dermatology, (), bjd.19159–.doi:10.1111/bjd.19159
■

18. P
S
O
R
I
A
S
I
S
P
S
O
R
I
A
S
I
S

19. PASI, PEST, NAPSI
Wendilyn B. Mejia, MD

22. Psoriasis Area and Severity Index (PASI)
● The gold standard to assess the physical severity of plaque-type psoriasis
● Validated tool
● Measures severity (erythema, scaling and induration) and extent of
involvement based on four regions (head and neck, upper limbs, trunk and
lower limbs) with score ranging from 0 - 72
● Improvement:
○ MODERATE TO SEVERE: PASI 75=75% reduction in PASI score after treatment
○ MILD: PASI 50=50% reduction in PASI score after treatment
Ref: Ministry of Health- Malaysian Clinical Practice Guideline on the Management of Psoriasis
Vulgaris (2013)

26. Translated and validated to Filipino by Dr. Camille Mundin, Dr. Rogelio Balagat, and Dr. Jamie Nuñez.
©G H Ibrahim 1 , M H Buch, C Lawson, R Waxman, P S Helliwell 2009

27. Translated and validated to Filipino by Dr. Camille Mundin, Dr. Rogelio Balagat, and Dr. Jamie Nuñez.
©G H Ibrahim 1 , M H Buch, C Lawson, R Waxman, P S Helliwell 2009

28. Ref: Rich P, Scher RK. Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis. J Am Acad Dermatol. 2003 Aug;49(2):206-12.

30. Leeds Enthesitis
Index
Bernadette B. Iglesia

31. Enthesitis • Distinguishing clinical feature of psoriatic
arthritis from rheumatoid arthritis and
other forms of arthritis
• Major entheses of the lower limb
around the calcaneum
• provide the hallmark features of
enthesitis in PsA
• Leeds Enthesitis Index
Ibrahim, G., Groves, C., Chandramohan, M., Beltran, A.,
Valle, R., Reyes, B., Healy, P., Harrison, A., & Helliwell, P. S.
(2011). Clinical and ultrasound examination of the leeds
enthesitis index in psoriatic arthritis and rheumatoid
arthritis. ISRN rheumatology, 2011, 731917.
https://doi.org/10.5402/2011/731917

32. Leeds
Enthesitis
Index (LEI)
• Enthesis index specific to PsA
• Examines 6 sites:
• Lateral epicondyles of the humerus
• Medial condyles of the femur
• Insertion of the achilles tendon
• Distinguishes between patients with active
disease and those without active disease.
• Assessment of inflammation on a more general
scale
• Reperesents localized inflammation at the
entheseal points
Healy, P. J., & Helliwell, P. S. (2008). Measuring clinical enthesitis in
psoriatic arthritis: assessment of existing measures and development
of an instrument specific to psoriatic arthritis. Arthritis and rheumatism,
59(5), 686–691. https://doi.org/10.1002/art.23568

33. Leeds Enthesitis Index
Ibrahim, G., Groves, C., Chandramohan, M., Beltran, A., Valle, R., Reyes, B., Healy, P., Harrison, A., & Helliwell, P. S. (2011). Clinical and ultrasound examination of the leeds
enthesitis index in psoriatic arthritis and rheumatoid arthritis. ISRN rheumatology, 2011, 731917. https://doi.org/10.5402/2011/731917

35. Leeds Dactylitis
Score

36. Dactylitis
• Uniform swelling such that the soft
tissues between the
metacarpophalangeal and proximal
interphalangeal, proximal and distal
interphalangeal and/or distal
interphalangeal joint and digital tuft
are diffusely swollen to the extent
that the actual joint swelling could no
longer be independently recognized
• Commonly observed in psoriatic
arthritis
• Occurs in 16-38% of PsA
• Clinical indicator of disease
severity in PsA
• Recurrent dactylitis: may be the
only clinical manifestation of PsA
Helliwell, P. S., Firth, J., Ibrahim, G. H., Melsom, R. D., Shah, I., & Turner, D. E. (2005).
Development of an assessment tool for dactylitis in patients with psoriatic arthritis.
The Journal of rheumatology, 32(9), 1745–1750.

37. Leeds Dactylitis Score
• Dactylitis
• 10% difference in the ratio of
circumference of the affected
digit to the contralateral digit
• Can be used to generate disease
activity scores
• Can be used to quantify treatment
effects

38. Steps in using the Leeds Dactylitis
Score
1. The fingers and toes are visually inspected by the
examiner. Those digits which look dactylitic are
measured.
2. Slip the loop of the dactylometer around the base
of the digit adjacent to the web space. Pull the
indicator strip tight so that the base of the digit
blanches slightly. The collar of the device should
be firmly pressed against the base of the digit, as
illustrated.
3. Record the circumference in mm on the
dactylometer record sheet

40. 4. Repeat the procedure on
the contralateral digit
5. If both ipsilateral and
contralateral digits are
thought to be dactylitic then
use the reference range as
the comparator.
6. Squeeze the digit at the
level of the proximal phalanx
and record the tenderness
score as indicated.Calculate
the total score as indicated.
Helliwell, P. S., Firth, J., Ibrahim, G. H., Melsom, R. D., Shah, I., & Turner, D. E. (2005).
Development of an assessment tool for dactylitis in patients with psoriatic arthritis.
The Journal of rheumatology, 32(9), 1745–1750.

42. Thank you for your
kind attention!

43. References
• Ibrahim, G., Groves, C., Chandramohan, M., Beltran, A., Valle, R., Reyes, B., Healy, P., Harrison, A., & Helliwell, P.
S. (2011). Clinical and ultrasound examination of the leeds enthesitis index in psoriatic arthritis and rheumatoid
arthritis. ISRN rheumatology, 2011, 731917. https://doi.org/10.5402/2011/731917
•
Healy, P. J., & Helliwell, P. S. (2008). Measuring clinical enthesitis in
• psoriatic arthritis: assessment of existing measures and development of an instrument specific to psoriatic
arthritis. Arthritis and rheumatism, 59(5), 686–691. https://doi.org/10.1002/art.23568
•
Helliwell, P. S., Firth, J., Ibrahim, G. H., Melsom, R. D., Shah, I., & Turner, D. E. (2005). Development of an
assessment tool for dactylitis in patients with psoriatic arthritis. The Journal of rheumatology, 32(9), 1745–1750.
•

44. SCORTEN
Severity of Illness Score for Toxic Epidermal Necrolysis
SHEEHAN MAE A.TOLENTINO
2ND YEAR RESIDENT

45. PROGNOSTIC FACTORS
AGE >40 yrs old
Heart rate >120bpm
Cancer or hematologic
malignancy
BSA >10%
Serum urea level >10mM
Serum Bicarbonate >20mM
Serum glucose >14mM
1
1
1
1
1
1
1
SCORE
Bastuji-Garin S, Fouchard N, Bertocchi M, et al: SCORTEN: A severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol.

46. SCORTEN MORTALITY
RATE (%)
0 - 1 3.2
2 12.1
3 35.8
4 58.3
5 90

47. THANK YOU
FOR
LISTENING

58. Scleroderma

63. AIBD

67. Definitions and outcome measures for bullous pemphigoid: Recommendations by an
international panel of experts. Journal of the American Academy of Dermatology. 66. 479-85.
10.1016/j.jaad.2011.06.032.

71. PEMPHIGUS DISEASE ACTIVITY AREA INDEX (PDAI)

72. PEMPHIGUS AREA AND ACTIVITY SCORE (PAAS)

73. Melasma

75. An Acne Grading Method Using
Photographic Standards
https://jamanetwork.com/journals/jama
dermatology/article-abstract/540127
Scoring systems in acne vulgaris.
https://ijdvl.com/scoring-systems-in-
acne-vulgaris/
A Study to Evaluate the Effectiveness
and Tolerance of Two Acne
Treatments on Subjects With Mild to
Moderate Acne.
https://clinicaltrials.gov/ct2/show/NCT0
2698436

76. Alopecia Areata
Scoring Systems
Tina Elaine M. Resuello, MD
Dermatology Resident

77. Severity Alopecia Tool (SALT)
• first published in 1999 and updated in 2004
• serves as a tool for alopecia research and a
clinical guideline for following progression
of disease
• visualize the amount of terminal hair loss in
each of 4 quadrants of the scalp
• captures the total area of the scalp bereft
of any terminal hair
Bhor U, Pande S. Scoring systems in dermatology. Indian Journal of Dermatology, Venereology, and Leprology. 2006
Jul 1;72(4).
Sardesai VR, Prasad S, Agarwal TD. A study to evaluate the efficacy of various topical treatment modalities for alopecia
areata. International journal of trichology. 2012 Oct;4(4):265.

78. Severity Alopecia Tool II (SALT II)
• first published in 2016
• include smaller increments of scalp
coverage to facilitate the assessment of
hair loss:
a. where small patches of hair loss
predominate
b. where only certain areas of the scalp are
involved
• analogous to the ‘‘rule of nines’’ and the
palm plus 5 fingers
Olsen EA, Canfield D. SALT II: a new take on the Severity of Alopecia Tool (SALT) for determining percentage scalp hair loss. Journal
of the American Academy of Dermatology. 2016 Dec 1;75(6):1268-70.

79. Semi-Quantitative Regrowth Score (RGS)
• 0: no regrowth
• 1: growth of <25%
• 2: growth of 25-50%
• 3: growth of 51-75%
• 4: growth of >75%
Moosavi ZB, Aliabdi M, Golfakhrabadi F, Namjoyan F. The comparison of therapeutic effect of Clobetasol propionate lotion and
squill extract in alopecia areata: a randomized, double-blind clinical trial. Archives of dermatological research. 2020 Apr;312(3):173-

80. Other Scoring Systems
Table 1. Methods of assessment for potential use in alopecia areata AA

81. Eczema

82. Dyshidrotic Eczema
Area & Severity Index
DASI
Based on the severity of single items- number of vesicles sq cm (V), erythema
(E), desquamation (S), and itch (I) and extension of the affected area
● Hand eczema scoring systems are applied to eczema on the palmar and dorsal
hands are not specific for the distinct features of dyshidrotic eczema
● Since the assessment methods for dyshidrotic eczema are not standardized,
therapeutic studies are not comparable and data cannot be utilized for epidemiologic
purposes.

83. Severity Grading
Four items were selected for severity grading:
(a) number of vesicles
(b) erythema
(c) desquamation
(d) itching
Each item has to be assessed according to an arbitrary
scale of 0–3:
0 = absent
1 = mild
2 = moderate
3 = severe
The grading of the items must be representative for all
affected areas (average intensity of the affected areas)
DASI – severity grading (mean severity grade of affected areas)
Vocks E, Plötz SG, Ring J. The Dyshidrotic Eczema Area and Severity
Index - A score developed for the assessment of dyshidrotic eczema.
Dermatology. 1999;198(3):265-9. doi: 10.1159/000018127. PMID:
10393450.

84. As the dyshidrotic vesicles mostly occur in
crops and affected areas are lacking
vesicles, the distribution of vesicles is
irregular, a representative area with an
“average” density of vesicles can hardly
be constituted for assessment
DISTRIBUTION
total number of vesicles ÷
total size of affected areas
(in square centimeters)
ESTIMATION
Number of Vesicles per Square Centimeter
Low DASI ( localized mild cases)
Medium DASI ( localized severe cases)
High DASI (largely affected severe cases)

85. Average vesicle density:
mean number of vesicles/sq cm
Mild: between 0 and 1
Severe: 20-30 cm/2
If multiple dense vesicles become confluent and
larger bullae occur in rare severe cases, the
examiner should estimate the numbers of
underlying dyshidrotic vesicles, which are not
bigger than 1–2 mm in diameter.
0 = no vesicles at all
grade 1 = > 0– <2 vesicles/cm2 affected area
grade 2 = 2–8 vesicles/cm 2 affected area
grade 3 = >8 vesicles/cm 2 affected area
(affected area = total area size of lesional skin).

86. Erythema
Grading of erythema is done according to the
common criteria also used in other dermatologic
scoring systems for inflammatory skin diseases

87. Desquamation
This item considers that scaling in dyshidrotic eczema
is usually less severe than in some other
palmoplantar hyperkeratotic conditions, like
hyperkeratotic palmar eczema, psoriasis or in some
erythrodermic diseases

88. Itch
The subjective item pruritus can only be
assessed by the patient
0 (absent)
1 (mild)
2 (moderate)
or 3 (severe)
Examiner grades the itch intensity as
follows:
grade 0 = 0 VAS points
grade 1 = 1–3 VAS points
grade 2 = 4–7 VAS points
grade 3 = 8–10 VAS points

89. Affected Area
The extension of the affected area is scored on a 6-
point scale and discriminates between none, up to
20, 40, 60, 80 or 100% affection of the palm/sole

90. Dyshidrotic Eczema Area & Severity Index
The total score of the DASI
results from the sum of
severity grade score points
of each of the four items (V
= vesicles, E = erythema, S
= desquamation, I= itch)
multiplied by the affected
area (A) score points: DASI
= (pV + pE + pS + pI) × pA
The maximum possible score is
60
defined score points
(p) as:
DASI = (p v+ p E= p S+ pI) ×
pA.
By the DASI, the dyshidrotic
eczema is graded as:
mild (0–15),
moderate (16–30)
severe (31–60) j

91. Eczema Area
and Severity
Index score

92. EASI score
An EASI score is a tool used to
measure the extent (area) and
severity of atopic eczema (Eczema
Area and Severity Index)
It takes a few minutes and
experience to calculate it
accurately
EASI score does not include a
grade for dryness or scaling
Include only inflamed areas

93. Body regions
Head and neck
Face occupies 33%
(17% each side), neck 33% (17%
front and back) and scalp 33% of the
head and neck region
Trunk (including genital area)
Front occupies 55% and back 45%
of the trunk
Upper limbs
Each arm occupies 50% of the upper
limbs region (front or back of one arm
is 25%)
Lower limbs (including
buttocks)
Each leg occupies 45% (front
or back of one leg is 22.5%)
and buttocks 10% of the
lower limbs region
Hanifin JM, et al. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. Exp Dermatol.
2001;10:11-18.

94. Area score is recorded for each of the four
regions of the body
The area score is the percentage of skin affected
by eczema for each body region
Area score
Severity Score

95. Four signs of eczema used to calculate EASI
severity score

96. Calculations
For each region, record the
intensity for each of four
signs and calculate the
severity score
Severity score = redness
intensity + thickness intensity +
scratching intensity +
lichenification intensity
For each region, multiple the
severity score by the area score
and by a multiplier

97. Multiplier
Head and neck:
severity score x area score x 0 .1 (in
children 0–7 years, x 0.2)
Trunk: severity score x area
score x 0.3
Upper limbs: severity score x
area score x 0.2
Lower limbs:
severity score x area score x 0 .4
(in children 0–7 years, x 0.3)
Add up the total scores for
each region to determine the
final EASI score
The minimum EASI score is
0 and the maximum EASI
score is 72

98. Interpretation
Head and neck:
severity score x ara score x 0 .1 (in
children 0–7 years, x 0.2)
Trunk: severity score x area
score x 0.3
Upper limbs: severity score x
area score x 0.2
Lower limbs:
severity score x area score x 0 .4
(in children 0–7 years, x 0.3)
Add up the total scores for
each region to determine the
final EASI score
The minimum EASI score is
0 and the maximum EASI
score is 72
Hanifin JM, et al. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. Exp Dermatol. 2001;10:11-18.

99. Patient Oriented
Eczema Measure

100. POEM for adults and
older children
https://www.nottingham.ac.uk/research/groups/cebd/resources/poem.aspx

101. POEM for children

102. POEM for all ages

103. Hand eczema
severity index
(HECSI)

104. • Erythema, induration ⁄papulation, vesicles, fissuring, scaling and
edema and graded on the following scale:
• 0, no skin changes
• 1, mild disease
• 2, moderate
• 3, severe
Each hand is divided into five areas [fingertips, fingers (except the tips),
palms, back of hands and wrists]
For each of these areas the intensity of the six following clinical signs:
Scoring system

105. For each location (total of both hands) the affected area is given a
score from
0 to 4 (0, 0%)
1 (1–25%)
2 (26–50%)
3 (51–75%)
4 (76–100%) for the extent of clinical symptoms
Finally, the score given for the extent at each location is multiplied by the
total sum of the intensity of each clinical feature, and the total sum called the
HECSI score was calculated, varying from 0 to a maximum severity score of
360 points

106. Vocks E, Plötz SG, Ring J. The Dyshidrotic Eczema Area and Severity Index - A score developed for the assessment of
dyshidrotic eczema. Dermatology. 1999;198(3):265-9. doi: 10.1159/000018127. PMID: 10393450

107. Reference
• https://www.Nottingham.ac
uk/research/groups/cebd/documents/methodological-
resources/poem-for-self-completion-or-proxy-completion
pdf
• The hand eczema severity index (HECSI): a scoring system for
clinical assessment of hand eczema
• A study of inter- and intraobserver reliability E.Held, R
• Skoet,* J.D. Johansen and T.Agner
• https://mediatum.ub.tum.de/doc/1218580/1218580.pdf
• https://dermnetnz.org/topics/easi-score

108. Leprosy

109. LE