Indian Journal of Paediatric Dermatology | Vol 14 | Issue 1-2 | January-August 2013 13

ADDRESS FOR CORRESPONDENCE Dr. Alpna Thakur,

House No. 72, Lane 3, North Avenue, Bhadson Road, Patiala 147 001, Punjab, India.

Email: alpna. 30@gmail.com

SCORING IN AD

Scoring systems are used in assessing therapeutic interventions in AD

The scoring atopic dermatitis (SCORAD) combines both disease extent and severity, is validated adequately on construct validity, interobserver reliability and sensitivity to change and is developed both for children and adult patients

The six area six sign atopic dermatitis (SASSAD) severity score measures six different severity signs on six different body parts, has adequate inter observer reliability and is equally applicable to children and adults.

AIMS AND OBJECTIVES

1. To evaluate the prognostic value of scoring systems SCORAD and SASSAD for AD

INTRODUCTION

Atopic dermatitis (AD) is a chronic or chronically relapsing hypersensitive manifestation of the skin with itching as a predominant feature. It affects infants, children and adults with a wide degree of severity. Measuring disease activity of AD is important for treatment. The diagnosis is mainly clinical and laboratory investigations do not seem to play a role.

Different scoring systems have been developed to determine the severity of AD. Although several scoring systems are available, they all have limitations with regard to the subjective expression of severity by patients.

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DOI:10.4103/2319-7250.116845

Scoring atopic dermatitis and six sign atopic dermatitis: Comparison of prognostic and predictive value in atopic dermatitisAlpna Thakur, Suresh Kumar Malhotra, Suhail MalhotraDepartment of Dermatology, Government Medical College, Amritsar, Punjab, India

ABSTRACT

Introduction: Atopic dermatitis is an enigmatic chronically relapsing dermatosis which is difficult to quantify. Present scoring systems have their inherent limitations.

Aims and Objectives: To evaluate and compare the scoring systems SCORAD and SASSAD for atopic dermatitis and to correlate values with clinical and hematological parameters.

Materials and Methods: Fifty patients of atopic dermatitis were selected and assessed at presentation and at four weeks using SCORAD and SASSAD. Appropriate haematological investigations were done at the time of assessments. The data obtained was assessed statistically.

Results: The changes in both the SCORAD and SASSAD correlated with the changes in clinical and hematological profile.

Conclusion: SCORAD seems to be a better scoring system as it addresses both the subjective and objective parameters.

Key words: Atopic dermatitis, scoring atopic dermatitis, six area six sign atopic dermatitis

ORIGINAL ARTICLE

Thakur, et al.: Scoring atopic dermatitis

Indian Journal of Paediatric Dermatology | Vol 14 | Issue 1-2 | January-August 201314

2. To compare three scoring systems: SCORAD Objective SCORAD SASSAD

3. To corelate the score values with clinical and hematological parameters.

MATERIALS AND METHODS

Fifty patients of AD reporting to the Dermatology OutPatient Department were evaluated at presentation and reassessed at 4 weeks of followup. Details and scoring were recorded on prescribed proforma.

Patients were investigated and routine hematological profile and absolute eosinophil counts were done.

Subjective symptoms were assessed as a part of SCORAD. Objective SCORAD, SCORAD with subjective symptoms and SASSAD were compared.

SCORAD comprises a measurement of six clinical signs at a representative body site, combined with an assessment of disease extent and visual analog scales of pruritus and sleep loss to give a maximum possible score of 103. It has been suggested that disease severity can be categorized as mild (40) according to the objective components of the index (clinical signs and disease extent), with typical changes in scores from 4550 to 2530 being demonstrated in recent clinical trials.[13]

The index has extensive published data on validity and reliability, although lichenification and body surface area measurements in particular have shown significant interobserver variation in some studies.[4] Although SCORAD is a composite score, the measurements of disease extent, signs and symptoms can easily be separated and presented as individual measurements if required.

The SASSAD index uses the same six signs as the SCORAD index, with the substitution of cracking for edema/population.[5] Clear definitions are included in the index and validity has been demonstrated in several trials.[6]

The objective SCORAD is a modification of the SCORAD that excludes subjective symptoms as pruritus and sleep loss, to minimize errors caused by variability in patients ages and backgrounds. A proposal for severity grading of AD by using only

objective criteria is as follows: (mild AD: Score 40).[7]

The data thus obtained was analyzed statistically. Corelation between the score values and clinical severity and hematological parameters was done.

OBSERVATIONS

The demographic profile of the patients is as shown in Table 1.

In the present study, 52% patients were males and 48% were females. Maximum number of patients (66%) was in the age group of 05 years, 18% in the age group of 510 years and 8% in 1015 years age group [Figures 14]. Urban patients were in the majority (68%).

SCORAD, SASSAD and objective SCORAD values were compared at presentation and at 4 weeks followup. The results are shown in Tables 25.

OBSERVATIONS AND RESULTS

The male to female ratio was 1.08:1.

The mean age of onset of symptoms was 2.49 years.

The mean reduction in SCORAD, SASSAD and objective SCORAD at 4 weeks of followup was 23.55 2.56, 16.22 1.99 and 10.46 1.75

Table 1: Demographic profile of study casesDemographic feature No. of cases (n=50) PercentageGender

Male 26 52Female 24 48

Age20 2 4

Rural/UrbanRural 16 32Urban 34 68

Family/personal history of atopy

Yes 24 48No 26 52

Seasonal variationMore in summer 10 20More in winter 11 22Change of season 7 14No change 22 44

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Figure 1: A 2-year-old child with severe atopic dermatitis

Figure 2: Atopic dermatitis: Flexural involvement

Figure 3: Neck involvement in atopic dermatitis Figure 4: Atopic dermatitis: Nipple eczema in a 14-year-old girl

Table 2: Comparison of SCORAD values at presentation and 4 weeksSex No. of

patientsSCORAD 50 (severe)

SCORAD1 (%) SCORAD2 (%) SCORAD1 (%) SCORAD2 (%) SCORAD1 (%) SCORAD2 (%)Male 26 4 25 19 1 3 0Female 24 0 24 17 0 7 0Total 50 4 (8) 49 (98) 36 (72) 1 (2) 10 (20) 0 (0)SCORAD 1 Score at presentation; SCORAD 2 Score at 4 weeks of followup; SCORAD Scoring atopic dermatitis

Table 3: Comparison of SASSAD values at presentation and at 4 weeks

Sex No. of patients

SASSAD10SASSAD 1 (%)

SASSAD 2 (%)

SASSAD 1 (%)

SASSAD 2 (%)

Male 26 10 25 16 1Female 24 4 20 20 4Total 50 14 (28) 45 (90) 36 (72) 5 (10)SASSAD 1 Score at presentation; SASSAD 2 Score at 4 weeks of followup; SASAD Six area six sign atopic dermatitis

Table 4: Comparison of obj-SCORAD values at presentation and 4 weeks

Sex No. of patients

obj-SCORAD10O. SCORAD

1 (%)O. SCORAD

2 (%)O. SCORAD

1 (%)O. SCORAD

2 (%)Male 26 0 26 9 17Female 24 0 24 7 17Total 50 0 (0) 50 (100) 16 (32) 34 (68)O. SCORAD 1 Score at presentation; O. SCORAD 2 Score at 4 weeks of followup; objSCORAD Objective scoring atopic dermatitis

respectively, which was statistically significant (P < 0.005). The mean reduction in absolute eosinophil count was 182 33/mm3 at 4 weeks of followup [Tables 25].

The reduction in scores corelated with the improvement in clinical and hematological profile.

The various factors affecting the course of disease are shown in Table 6.

DISCUSSION

AD is a very common inflammatory skin disease in childhood. A careful history, clinical examination and adequate documentation of disease severity are essential in all children with eczema, irrespective of their disease severity. AD is a clinical diagnosis; diagnostic criteria, can be helpful for an accurate definition of the disease. A careful history, including dermatological symptoms, respiratory symptoms and

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in the pathogenesis of AD, i.e., hygiene hypothesis, can explain the relatively low occurrence of AD in India and a rising trend of atopic diseases world over for more than last three decades. Declining family size, improvement in household amenities, improved hygiene and cleanliness reduces the opportunity of common crossinfections in families.[11]

Gender ratio has varied greatly between the studies. In the present study, the male to female ratio was 1.08:1. Previous studies have also reported a male predominance, i.e., 2.13:1 for infants and 1.09:1 for children,[10] 1.8:1,[12] 2.25:1 for infants and 1.6:1 for children,[13] 1.3:1[14] and 1.56:1.[13]

The mean age of onset in the present study was 2.49 years. In another study, the overall mean age of onset was 4.58 years.[14] Other authors have reported mean age to be 4.2 months for infantile AD and 4.1 years for childhood AD[3] 4.5 months for infantile AD and 4 years for childhood AD.[13]

Family or personal history of atopy was seen in 48% of the cases. In a similar study, family history of atopy was observed in 42.3% patients.[13] In yet another study, the personal or family history of atopy was observed in 54% and 65%, respectively.[14]

The present study showed that 14% of patients attributed onset of symptoms to a specific food (eggs, brinjal and spicy food) while 4% attributed it to weaning from breast milk and introduction of cow/buffalo milk or solid foods in infants. Elimination of the specific food items was advised in these patients.

Table 5: Difference in score values after 4 weeks of treatment

Score At presentation

At 4 weeks follow-up

Difference t value P value

SCORAD 38.8411.41 15.295.95 23.552.56 18.45

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Elimination diet is suggested for patients with AD either for diagnostic reasons to establish the presence of food allergies, for therapy or as a preventive measure in the newborns at risk. An openpilot study by us investigated the feasibility of dietary eliminations in the Indian scenario and also assessed the effect it has on Indian children with AD. A group of 100 children were assessed for severity of itching, surface area of involvement and SCORAD index. Children without any systemic disease or those who were not on systemic corticosteroids were included in the study and were advised to strictly adhere to a diet excluding milk and milk products, all kinds of nuts and nutcontaining foods, egg and eggcontaining foods, sea fish and prawns, brinjal and soybean for a period of 3 weeks. The food items to be included freely to maintain proper nutrition were dal and dal products, rohu fish, chicken and fruits. Infants who were 612 months old were given protein hydrolysate formula instead of milk. All the preintervention parameters were measured again after 3 weeks. The male to female ratio of the study group was 0.92. There was a statistically significant reduction in severity scores after dietary elimination alone.[15]

In the present study, 44% patients did not report a seasonal variation while aggravation in winters was reported in 22%, in summers by 20% and change of the season by 14%.

Majority of the patients in a study by Sarkar and Kanwar had aggravation of their eczema in the winters (62%) as a result of decreased moisture in the climate, 17% had aggravation in the summers probably due to hyperhidrosis, itch and secondary skin infection.[13] Similar was the findings of Dhar and Kanwar: 67.14% of infants had aggravation during winters and 23.36% had aggravation during summers. The corresponding figures in the childhood AD patients were 58% and 32.9%, respectively.[10] On the contrary, in the study by Dhar et al. in different climatic conditions in Eastern India, 40% patients had aggravation during summers and only 15% had winter exacerbation.[14]

AD is more common in the urban than in the rural set up. This is probably because of industrialization and changed lifestyle. This was evident as 68% of patients in the present study were from an urban background while 32% belonged to rural areas.

Pollution certainly plays a significant role not only in the precipitation of allergic rhinitis or bronchial asthma but also in AD. The incidence has been found to be higher among the new immigrants to the

industrialized countries.[16]

The reduced exposure to bacterial and parasitic infections in childhood leads to an abnormal development of the immune system, which tends to over react to relatively innocuous antigenshygiene hypothesis. A study comparing the severity of AD in Indian children in the UK or US and in India revealed a lesssevere form of the disease in children born and brought up in India. This study highlighted the influence of acquired factorstemperature, humidity, food habits, clothing and psychological impacts on the clinical expression and severity of the disease.[11,17]

The diagnosis of AD is based on a constellation of signs and symptoms. There is no laboratory gold standard for the diagnosis of AD. Of the named objective clinical scales, three scales have been most widely employed and tested: SCORAD, eczema area and severity index and SASS AD. All have shown evidence of criterion and construct validity against global assessments of disease severity, patientassessed pruritus and other variables such as topical steroid use. Some interobserver variation has been demonstrated with all three indices and is likely to be a problem with all scoring systems involving visual assessment by physicians. Each has advantages and disadvantages, making it difficult to recommend one index as superior, although the SCORAD index has been most widely used in trials.[18]

The present study showed SCORAD to be superior to SASSAD and objective SCORAD alone in assessing the disease severity, observing the response to treatment and predicting disease course and prognosis. Various studies have compared the scoring systems for assessing disease severity in AD, but none has compared these three scores.

The mean reduction in SCORAD, SASSAD and objective SCORAD at 4 weeks of followup was 23.55 2.56, 16.22 1.99 and 10.46 1.75 respectively, which was statistically significant (P < 0.005). The tvalue obtained after applying paired Students ttest showed maximum value for SCORAD, followed by SASSAD and objective SCORAD, showing that SCORAD was better in assessing the disease severity in patients of AD.

In the present study, there was mean reduction of 182 33 cells/mm3 in the absolute eosinophil count at 4 weeks of followup, which was statistically significant (P < 0.005). Serum immunoglobulin E (IgE) levels could not be performed due to lack of facility. Immunological abnormalities like excessive formation

Thakur, et al.: Scoring atopic dermatitis

Indian Journal of Paediatric Dermatology | Vol 14 | Issue 1-2 | January-August 201318

How to cite this article: Thakur A, Malhotra SK, Malhotra S. Scoring atopic dermatitis and six sign atopic dermatitis: Comparison of prognostic and predictive value in atopic dermatitis. Indian J Paediatr Dermatol 2013;14:13-8.

Source of Support: Nil, Conflict of Interest: Nil

2. Holm L, Bengtsson A, van HageHamsten M, Ohman S, Scheynius A. Effectiveness of occlusive bedding in the treatment of atopic dermatitis A placebocontrolled trial of 12 months duration. Allergy 2001;56:1528.

3. Capella GL, Grigerio E, Altomare G. A randomized trial of leukotriene receptor antagonist montelukast in moderatetosevere atopic dermatitis of adults. Eur J Dermatol 2001;11:20913.

4. Charman C, Williams H. Outcome measures of disease severity in atopic eczema. Arch Dermatol 2000;136:7639.

5. BerthJones J. Six area, six sign atopic dermatitis (SASSAD) severity score: A simple system for monitoring disease activity in atopic dermatitis. Br J Dermatol 1996;135 Suppl 48:2530.

6. Charman CR, Venn AJ, Williams HC. Reliability testing of the Six Area, Six Sign Atopic Dermatitis severity score. Br J Dermatol 2002;146:105760.

7. Sprikkelman AB, Tupker RA, Burgerhof H, Schouten JP, Brand PL, Heymans HS, et al. Severity scoring of atopic dermatitis: A comparison of three scoring systems. Allergy 1997;52:9449.

8. Dhar S. Atopic dermatitis: Indian scenario. Indian J Dermatol Venereol Leprol 1999;65:2537.

9. Karthikeyan K, Thappa DM, Jeevankumar B. Pattern of pediatric dermatoses in a referral center in South India. Indian Pediatr 2004;41:3737.

10. Dhar S, Kanwar AJ. Epidemiology and clinical pattern of atopic dermatitis in a North Indian pediatric population. Pediatr Dermatol 1998;15:34751.

11. Patki A. Eat dirt and avoid atopy: The hygiene hypothesis revisited. Indian J Dermatol Venereol Leprol 2007;73:24.

12. Dhar S, Kanwar AJ, Nagaraja. Personal and family history of atopy in children with atopic dermatitis in North India. Indian J Dermatol 1997;42:913.

13. Sarkar R, Kanwar AJ. Clinicoepidemiological profile and factors affecting severity of atopic dermatitis in north Indian children. Indian J Dermatol 2004;49:11722.

14. Dhar S, Mandal B, Ghosh A. Epidemiology and clinical pattern of atopic dermatitis in 100 children seen in city hospital. Indian J Dermatol 2002;47:2024.

15. Dhar S, Malakar R, Banerjee R, Chakraborty S, Chakraborty J, Mukherjee S. An uncontrolled open pilot study to assess the role of dietary eliminations in reducing the severity of atopic dermatitis in infants and children. Indian J Dermatol 2009;54:1835.

16. Dhar S, Banerjee R. Atopic dermatitis in infants and children in India. Indian J Dermatol Venereol Leprol 2010;76:50413.

17. Dhar S, Banerjee R, Dutta AK, Gupta AB. Comparison between the severity of atopic dermatitis in Indian Children born and brought up in UK and USA and that of Indian children born and brought up in India. Indian J Dermatol 2003;48:2002.

18. Charman C, Chambers C, Williams H. Measuring atopic dermatitis severity in randomized controlled clinical trials: What exactly are we measuring? J Invest Dermatol 2003;120:93241.

19. Dhar S, Malakar R, Chattopadhyay S, Dhar S, Banerjee R, Ghosh A. Correlation of the severity of atopic dermatitis with absolute eosinophil counts in peripheral blood and serum IgE levels. Indian J Dermatol Venereol Leprol 2005;71:2469.

of IgE, with a predisposition to anaphylactic sensitivity, some decrease in susceptibility to delayed hypersensitivity, abnormalities in the expression of surface molecules in antigenpresenting cells and dysregulation of cytokine mediators are often noted in patients of AD. The severity has some positive correlation with the absolute eosinophil count and serum IgE levels in AD patients.

In a study group, 102 consecutive patients, both children and adults, with AD were enrolled and 107 age and sexmatched persons without any personal or family history of atopy were taken as controls. Patients with AD having other systemic diseases were excluded from the study. The mean age at the onset of AD was 4.55 (standard deviation [SD] 3.63) years and in patients with AD, the mean absolute eosinophil count was 624 (SD 590) and the mean IgE level was 278.29 (SD 324.85); the corresponding values were 121 (SD 109) and 25.8 (SD 23.36), respectively, for the controls. The absolute eosinophil count and the IgE level were higher in patients with AD than in controls. Both absolute eosinophil count and the IgE level showed significant covariance with disease severity. There was a significant association of the absolute eosinophil count and the IgE level with a family history of AD only when both parents were affected. The eosinophil count and the IgE level also showed a significant association with a history of bronchial asthma in patients with AD, but not with allergic rhinitis. The elevated IgE response and eosinophilia observed in patients with AD may reflect increased responses of type 2 Th2 cytokines with a concomitant decrease in interferongamma production.[11,19]

CONCLUSION

SCORAD is better to assess the severity and monitor the progression of the disease as it assesses both subjective and objective parameters.

Objective SCORAD alone has better prognostic value than SASSAD. SCORAD is more sensitive to changes in the patients clinical condition as well as hematological profile.

REFERENCES1. Van Der Meer JB, Glazenburg EJ, Mulder PG, Eggink HF,

Coenraads PJ. The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group. Br J Dermatol 1999;140:111421.

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