Currently, there is no “gold standard” (meaning one agreed upon laboratory or serological test) for assessing the severity of atopic dermatitis. There are several scales that a healthcare provider will use to guide their assessment and determine severity.
Clinical signs (visible skin changes that are associated with disease activity)
Extent of the disease (the area of skin affected)
Patient reported symptoms (examples include itching and sleep disturbance)
An overall assessments of the disease activity this can be either by the physician, child or parent
Amount and strengths of treatment used
Impact of the disease on the quality of life (self-reported by either patient or parent.)1
After a healthcare provider assesses the patient, they will categorize atopic eczema in a severity category (examples include: mild, moderate and severe), these categories will help the doctor determine the best course of treatment. There are a number of scales that help measure the severity of the above parameters.
Scales to measure severity
There are many different clinical features that have been suggested as important indicators of atopic eczema’s disease intensity and therefore there is a lot of variation in what clinical features are included in different severity scales. For example, some scales include redness, swelling, and vesiculation (which typically occur in the acute phase) and leave out dryness and lichenification features, which tend to occur in the chronic atopic eczema stage. Some measurement scales only assess the most severely affected area of the body while others provide assess each body site for each of the clinical features.2 While there are many assessment tools, the EASI and SCORAD (currently) are the most valid and reliable instruments to assess clinical signs of atopic eczema.2
(EASI) Eczema Area and Severity Index
In 1998, an American group proposed the Eczema Area and Severity Index (EASI) to grade the severity of atopic eczema. The EASI scoring assessment multiplies the percentage of the affected area (of four specific skin regions) and then adds this number to the severity scores of the four specific symptoms. The EASI does not include a subjective measure of pruritus (intense itch), which is a key component of atopic eczema. It also does not grade dryness or scaling.
EASI Index: Area score
The area score is documented for each of the four regions of the body. The score is the percentage of skin affected by atopic eczema.
Region 1: Head and neck
Region 2: Trunk (including genital area)
Region 3: Upper limbs
Region 4: Lower limbs (including buttocks)3
EASI Index: Severity score
Severity score is documented for each of the four regions of the body listed above. The severity score is the sum of the intensity scores for four symptoms and is scored on a scale of 0-3. The four symptoms used as part of the severity score are:
The SCORAD is the only severity scale that has undergone testing for validity, reliability, sensitivity, and acceptability. The SCORAD was published in 1993 after 3 years of work by the European Task Force. The SCORAD takes into consideration both objective signs of atopic dermatitis (such as severity and extension), as well as subjective ones (like pruritus/itching and loss of sleep) when measuring severity. Dermatologists may use this tool before and after treatment to determine whether the treatment has been effective.4
SCORAD Index: Extent measure
To measure the extent of severity the healthcare provider conducts a physical exam and and documents the affected areas by shading in the percentage of the body that is impacted on a drawing of a body. The rule of 9 is used to calculate the affected area as a percentage of the whole body. After evaluation, a percentage is given to the spread/extent. A breakdown of the rule of 9 in adults and older children is included below:
Head and neck 9% (4.5% of the front of the head/neck and 4.5% of the back of the head/neck)
Upper limbs 9% each (4.5% of the front of the limb and 4.5% of the back of the limb)
Lower limbs 18% each (9% of the front of the limb and 9% of the back of the limb)
Anterior trunk 18% (Chest/stomach)
1% for genitals.4
SCORAD Index: Intensity measure
The healthcare provider chooses an area of the body that is a representative area of the extent of atopic eczema. In this area, the intensity of several symptoms (shown below) is assessed using the following scale none (score of 0), mild (score of 1), moderate (score of 2) or severe (score of 3).
Dryness (this is assessed in an area where there is no inflammation)4
Subjective symptoms (such as itch and loss of sleep) are also scored by the patient or family member/caregiver of a child using a scale where 0 is no itch (or no sleeplessness) and 10 is the worst imaginable itch (or sleeplessness).
The SCORAD, while one of the best-validated tools, is great for clinical trials as it provides a detailed and comprehensive assessment but may not be best for routine practice and screening and oftentimes the Three-Item Severity Score (TIS) is used, which is based on the evaluation of erythema, edema and excoriation (scratch marks) on a scale of 0-3.
So the next time you are at the dermatologist’s office and you get asked a series of questions or see them completeing an assessment, ask them what tool they use to determine your atopic eczema severity!
National Collaborating Centre for Women's and Children's Health (UK). Atopic Eczema in Children: Management of Atopic Eczema in Children from Birth up to the Age of 12 Years. London: RCOG Press; 2007 Dec. (NICE Clinical Guidelines, No. 57.) 4, Assessment of severity, psychological and psychosocial wellbeing and quality of life. Available from: https://www.ncbi.nlm.nih.gov/books/NBK49367/
Assessment of clinical signs of atopic dermatitis: A systematic review and recommendation
Schmitt, Jochen et al. Journal of Allergy and Clinical Immunology , Volume 132 , Issue 6 , 1337 - 1347 http://dx.doi.org/10.1016/j.jaci.2013.07.008
Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. EASI Evaluator Group. Exp Dermatol. 2001 Feb;10(1):11-8.
Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology. 1993;186(1):23-31