SCORING SYSTEM IN DERMATOLOGY TO ASSESS PSORIASIS: A REVIEW

Abstract

Psoriasis clinical trials have measured challenges in assessing disease severity and prognosis. Clinical trials require more objectively validated tools. To determine the severity of the skin disease, measurement systems should be objective, reproducible, easy to apply and practically useful. To maintain the objectivity of observations, different scoring systems have been developed. Scoring systems are essential to monitor the treatment response and evaluate the effectiveness of new drugs. The article reviews different scoring systems for assessing psoriasis and its strengths and weaknesses, as scores are useful for semi-objective assessment. A comprehensive literature search was performed using books, journals and websites. In this article, different scoring systems and their strengths and weaknesses have been summarized.

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SCORING SYSTEM IN DERMATOLOGY TO ASSESS PSORIASIS: A REVIEW
RR Patil 1*, DG Dipankar 2, GH Yeola 3
1 PhD Scholar, Department of Kayachikitsa, Dr. D. Y. Patil College of Ayurved &Research Centre, Pimpri,
Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), Maharashtra, India
2 Professor, Department of Kayachikitsa, Dr. D. Y. Patil College of Ayurved &Research Centre, Pimpri,
Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), Maharashtra, India
3 Professor & HOD, Department of Kayachikitsa, Dr. D. Y. Patil College of Ayurved &Research Centre, Pimpri,
Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), Maharashtra, India
Received on: 06/02/23 Accepted on: 14/05/23
*Corresponding author
E-mail: rupalipatil@adamc.ac.in
DOI: 10.7897/2277-4343.140387
ABSTRACT
Psoriasis clinical trials have measured challenges in assessing disease severity and prognosis. Clinical trials require more objectively validated tools.
To determine the severity of the skin disease, measurement systems should be objective, reproducible, easy to apply and practically useful. To maintain
the objectivity of observations, different scoring systems have been developed. Scoring systems are essential to monitor the treatment response and
evaluate the effectiveness of new drugs. The article reviews different scoring systems for assessing psoriasis and its strengths and weaknesses, as scores
are useful for semi-objective assessment. A comprehensive literature search was performed using books, journals and websites. In this article, different
scoring systems and their strengths and weaknesses have been summarized.
Keywords: Psoriasis, Assessment, Scores, Advantages, Limitations
INTRODUCTION
The word psoriasis is formed as “psora”, meaning “itch”, and
“iasis”, meaning “action or condition”1. It is an inflammatory,
autoimmune chronic disorder for which there is no definitive
cure. It disfigures and disables the person suffering from it, thus
negatively affecting the quality of life. Approximately 2 to 3 % of
people worldwide have psoriasis manifested as desquamation,
erythema, and induration2. The disease has a variable course but
is often chronic and relapsing. Extra-cutaneous manifestations
may occur in up to 20% of patients, often including nail
involvement and psoriatic arthritis3.
Psoriasis clinical trials have measured challenges in assessing
disease severity and prognosis. Clinical trials require more
objectively validated tools. The measurement system must be
objective, reproducible, easy to apply and practically useful. To
maintain the objectivity of observations, different tools have been
developed4. Scoring systems are essential to monitor the
treatment response and evaluate the effectiveness of new drugs.
This article focuses on reviewing different scoring systems for
assessing psoriasis and its strengths and weaknesses, as scores are
helpful for semi-objective assessment.
Psoriasis area and severity index
The most widely used method for determining the severity of the
disease condition and the efficacy of treatment regimens is
Psoriasis Area and Severity Index (PASI). It is regarded as the
gold standard for evaluating severe psoriasis. The PASI score was
created in 1978 by ‘Fredrikson’ and ‘Petterson’4. PASI is
completed by individually assessing the upper extremities, lower
extremities, head, neck, and trunk for plaque features and areas of
involvement. The three primary characteristics of psoriasis
lesions are erythema discolouration/redness), induration
(thickness) and desquamation (scaling), measured on a severity
scale of 0 to 4. The PASI is a calculation that averages three
characteristics and weights them according to area. The most used
scale is PASI, yet it has many drawbacks.5
The PASI score is a quantitative method used to assess the disease
severity based on the area involved and the appearance of skin
lesions.
Lesion Score Gradation
Erythema (E)
0=No symptoms,
1=Slight,
2=Moderate,
3=Marked,
4=Very Marked
Induration (I)
Scaling (S)
Area
0
1 %-9 %
10%-29%
30%-49%
50%-69%
70%-89%
90%100%
Area Score
0
1
2
3
4
5
6
Lesion Score
Head (H)
Trunk (T)
Upper Limb (UL)
Lower Limb (LL)
Erythema (E)

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Induration (I)
Scaling (S)
(A)=(E+I+S)
% affected area
Area Score (B)
Subtotal:(C) = A×B
Body surface area: Subtotal × amount
indicated
×0.1
×0.2
×0.3
×0.4
Total
H=0.1(Eh+Ih+hS)×Ah
T=0.2(Et+It+St)×At
UL=0.3(Eu+Iu+Su)×Au
LL=0.4(El+Il+Sl)×Al
PASI Score
H+T+UL+LL
PASI's maximum score is 72. The PASI 75, usually accepted as a
satisfactory outcome, is defined as the percentage of patients who
improve by at least 75% from their initial PASI score.6 PASI
derives from Psoriasis of Scalp Severity Index (PSSI) and
Palmer-Plantar Psoriasis Area and Severity Index (PPASI or
PPASI).7 The only difference is instead of four areas, only scalp
or palm and sole areas were assessed.
Advantage
Limitations
Widely used
Physicians do not routinely use it, and it is difficult to interpret
Used for extensive psoriasis
Less sensitive to the changes in relatively small areas and in mild to
moderate psoriasis
Accepted by approving agencies
Too complex and time-consuming to implement in clinical practice
Evidence demonstrating 75% improvements in PASI is a ‘clinically
significant result’, and 50% improvement is also meaningful 8.
A full range of scale is not used and does not correlate well with patients'
response
Simplified psoriasis area and severity index
SPASI is similar to the PASI score, a quantitative method based on the area involved and plaque appearance. The only difference is
that the average of lesion characteristics, redness, thickness and scaling for the entire body can be estimated in this method.9
A] Plaque Characteristics
Gradation
Total Body
1] Erythema
0
1
2
3
4
None
Slight
Moderate
Severe
Very severe
2] Induration
3] Desquamation
B] Body Surface Area Affected
0
Absent
1
1-9%
2
10-29%
3
30-49%
4
50-69%
5
70-89%
6
90-100%
SPASI (0-72)
SPASI= BSA× (E+I+D)
Advantage
Limitations
Provides an approximation of PASI
Physicians’ are believed to be able to estimate average redness, scaling and lesion
thickness throughout the body's surface lesions
Very similar to the original PASI score, easy to calculate
Relatively less sensitive to change where there is <10 percent body surface area
involvement
Primarily for patients with extensive disease
When the disease is localized to one region
Physician’s global assessment scale
Erythema(redness), induration, and desquamation(scaling) are
assessed individually for each psoriatic lesion. To calculate the
PGA score, the severity rating scores are added, the average is
calculated, and the average is rounded to the nearest integer.10-12.
Two types
1. Static assessment- The assessor is instructed to consider all
the plaques at once.
2. Dynamic assessment- assesses overall improvement from
baseline.
Physician’s Global Assessment Scale
Erythema
Score
Grade
Description
0
Clear
No evidence of erythema
1
Almost Clear
Light pink
2
Mild
Light red
3
Moderate
Moderate red
4
Marked
Bright red
5
Severe
Dark, deep red
Induration
0
Clear
No evidence of plaque elevation
1
Almost clear
Barely palpable
2
Mild
Slight but definite elevation, indistinct edge

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3
Moderate
Elevated with distinct edges
4
Marked
Marked plaque elevation,
5
Severe
Severe, hard/sharp borders
Scaling/Desquamation
0
Clear
No evidence of scaling
1
Almost Clear
Occasional fine scale
2
Mild
Fine-scale predominates
3
Moderate
Course scale predominates
4
Marked
Thick, non-tenacious scale
5
Severe
A very thick course scale predominates
PGA (0-5)
(E+I+D)/3
Advantage
Limitations
Simple
It does not quantify body surface area
PGA score can be used for both localized and extensive plaques
It does not evaluate individual lesion locations
Physician global assessment and body surface area
PGA×BSA (0-500) has been proposed as an easy-to-implement tool in clinical settings and research and thus has the potential to replace
PASI. One handprint covers approximately 1% of the body surface area. BSA can be measured by the patient’s hand area affected. 13
PGA × BSA = Percent of body surface area × (E+I+D)/3
Advantage
Limitations
Used for extensive as well as localized plaques and quantifies
body surface area.
It does not estimate individual lesion locations
Easy to perform, thus can be used in clinical trials as well as in
clinical practice
Correlates weakly with patient response
Dermatology life quality index
Patients with several lesions may not be concerned, but those with
a few lesions may be. This viewpoint holds that therapies that just
reduce lesions but do not enhance the quality of life are not
considered to produce clinically significant benefits.
Determining how much skin issues affect a patient's quality of life
is the aim of DLQI. In patients older than 16 years, the DLQI
questionnaire is used. The patient can do it without explanation
because it is simple to understand. By adding together each
question's score, the DLQI is determined. Scores ranged from 30
to 0. A higher score indicates a greater impact on life quality.
There are ten questions in it, and they represent the patient's
perspective. 14
Advantage
Limitations
DLQI measure disease impact and treatment efficacy to improve
quality of life
Not a direct method to evaluate the efficacy of drugs on disease
The two other quantitative methods for assessing psoriasis are
biopsies and photographs.
Nail psoriasis severity index
The NAPSI is the most frequently utilized investigator-measuring
nail assessment tool. For assessment purposes, four different
quadrants of the nail plate are done with imaginary horizontal and
vertical lines. The characteristics of each quadrant's nail are
evaluated, which include15
Nail plate changes: Nail pitting, red spots in the lunula,
Leukonychia (white nails), Crumbling (brittle nails)
Nail bed changes: Onycholysis (nail separation), Oil drop
(salmon patch dyschromia), Splinter haemorrhages, subungual
hyperkeratosis15
Score
Quadrants of nails involved
0
Absent
1
1 quadrant
2
2 quadrants
3
3 quadrants
4
4 quadrants
The total nail score is obtained by adding two scores, the ‘nail
plate score’ and ‘nail bed score’ (0-8). The NAPSI score is the
sum of all the total scores of the involved fingernails of that
patient at that time. Limitation: Lacking responsiveness to
change.
To address NAPSI's shortcomings, the modified NAPSI was
created as a validated nail psoriasis measure. NAPPA, a
composite tool for nail assessment in psoriasis and psoriatic
arthritis, was developed in 201416.
Psoriasis epidemiology screening tool
The Psoriasis Epidemiology Screening Tool is a reliable tool for
detecting Psoriatic arthritis17. Psoriatic skin lesions, along with
the presence of synovitis, dactylitis, enthesitis, and axial features,
are the manifestations of psoriatic arthritis. Psoriasis patients are
advised to complete the PEST for six months, and those who have
Yes to 3 or more questions, or a strong clinical suspicion should
be referred to the rheumatologist. The PEST questionnaire is as
follows. 18
1. Have you ever had swollen joint or joints? YES/NO
2. Has a doctor ever told you that you have arthritis? YES/NO
3. Do your fingernails or toenails have holes or pits? YES/NO
4. Have you had pain in your heels? YES/NO
5. Have you had a figure or toe wholly swollen and painful for
no apparent reason? YES/NO

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DISCUSSION
Various techniques were developed to evaluate the severity of
Psoriasis disease and the effectiveness of the treatment. Psoriasis
Area and Severity Index (PASI) is the gold standard for
moderate–severe psoriasis. It has been developed chiefly for the
evaluation of a single case. Though it is the most widely used, it
has many limitations. It is complex, takes a lot of time to
calculate, is challenging to interpret and less sensitive to change
for the small area involved. The Simplified Psoriasis Area
Severity Index is identical to PASI and mathematically similar.
SPASI evaluates the average erythema, induration, and
desquamation of lesions and the affected area. Compared to
PASI, SPASI is easy to calculate, simple and practically helpful
in assessing disease severity. When less than 10% of an area is
affected by the disease or when it is only present in one place,
SPASI is substantially less responsive to change. The PGA×BSA
can detect changes in both skin lesions and surface area. It is a
simple and sensitive tool being used widely.
The limitation of PASI and SPASI (less sensitive to small areas
<10%) is avoided with a continuous area score of PGA×BSA.
Therapies that reduce lesions but do not enhance the quality of
life are not considered to produce clinically significant benefits.
In this regard, the Dermatology Life Quality Index is used with
the lesion severity score to quantify the disease impact and
treatment efficacy by assessing the quality of life. After reviewing
different scoring methods and their advantages and limitations, it
was observed that no single "optimal" technique is sufficient to
facilitate psoriasis assessment.
Clinical studies require standard evaluation tools that accurately
identify modest changes and quality of life. Therefore,
considering all the factors, PGA × BSA and DLQI, two scoring
systems that assess the quality of life of patients and the severity
of the disease, can be used more effectively. 19,20
CONCLUSION
In evidence-based medicine for psoriasis, different tools are
designed to assess and guide clinical decision-making. Still, there
is no single optimal validated tool available. Considering the
strengths and weaknesses of varying scoring systems, the
PGA×BSA score, which measures extensive and localized
lesions, can be used.
The Dermatology Life Quality Index (DLQI) complements the
lesion severity scores in evaluating the effectiveness of the
treatment in enhancing a patient’s quality of life.
REFERENCES
1. Ritchlin CT, Fitz Gerald O. Psoriatic and Reactive Arthritis:
A Companion to Rheumatology Amsterdam: Mosby,
Elsevier; 2007. p. 4
2. Christophers E. Psoriasis epidemiology and clinical
spectrum. Clin Exp Dermatol. 2001;26:314-20.
3. Leslie P. Lawley, Calvin O. McCall, Thomas J. Lawley,
Eczema, Psoriasis, Cutaneous Infections, Acne, and Other
Common Skin Disorders, Harrison's principle of internal
medicine, Chapter 53, 20th Edition, P 333
4. Phyllis I. et al. How Good Are Clinical Severity and Outcome
Measures for Psoriasis?: Quantitative Evaluation in a
Systematic Review Spuls, Journal of Investigative
Dermatology, 130(4):933 - 943
5. Bhor U, Pande S. Scoring systems in dermatology. Indian J
Dermatol Venereol Leprol. 2006 Jul-Aug;72(4):315-21. DOI:
10.4103/0378-6323.26722. PMID: 16880586.
6. S.R Feldman, G.G. Krueger, Psoriasis assessment tools in
clinical trials, Annals of Rheumatic Diseases2005;64,ii65-
ii68
7. Duffin, K.C. (2018). Outcome Measures in Psoriasis and
Atopic Eczema. In: Yamauchi, P. (eds) Biologic and
Systemic Agents in Dermatology. Springer, Cham. DOI:
https://doi.org/10.1007/978-3-319-66884-0_2
8. Carlin CS, Feldman SR, Krueger JG, Menter A, Krueger GG.
A 50% reduction in the Psoriasis Area and Severity Index
(PASI 50) is a clinically significant endpoint in the
assessment of psoriasis. J Am Acad Dermatol. 2004
Jun;50(6):859-66. DOI: 10.1016/j.jaad.2003.09.014. PMID:
15153885.
9. Louden BA, Pearce DJ, Lang W, Feldman SR. A Simplified
Psoriasis Area Severity Index (SPASI) for rating psoriasis
severity in clinic patients. Dermatol Online J. 2004 Oct
15;10(2):7. PMID: 15530297.
10. Bożek A, Reich A. The reliability of three psoriasis
assessment tools: Psoriasis area and severity index, body
surface area and physician global assessment. Adv Clin Exp
Med. 2017 Aug;26(5):851-856. DOI: 10.17219/acem/69804.
PMID: 29068583.
11. Chow C, Simpson MJ, Luger TA, Chubb H, Ellis CN.
Comparison of three methods for measuring psoriasis severity
in clinical studies (Part 1 of 2): change during therapy in
Psoriasis Area and Severity Index, Static Physician's Global
Assessment and Lattice System Physician's Global
Assessment. J Eur Acad Dermatol Venereol. 2015
Jul;29(7):1406-14. DOI: 10.1111/jdv.13132. Epub 2015 Apr
27. PMID: 25917315.
12. Simpson MJ, Chow C, Morgenstern H, Luger TA, Ellis CN.
Comparison of three methods for measuring psoriasis severity
in clinical studies (Part 2 of 2): Uses of quality of life to assess
construct validity of the Lattice System Physician's Global
Assessment, Psoriasis Area and Severity Index and Static
Physician's Global Assessment. J Eur Acad Dermatol
Venereol. 2015 Jul;29(7):1415-20. DOI: 10.1111/jdv.12861.
Epub 2015 Apr 27. PMID: 25917214.
13. Walsh JA, Jones H, Mallbris L, Duffin KC, Krueger GG,
Clegg DO, Szumski A. The Physician Global Assessment and
Body Surface Area composite tool is a simple alternative to
the Psoriasis Area and Severity Index for assessment of
psoriasis: post hoc analysis from PRISTINE and PRESTA.
Psoriasis (Auckl). 2018 Oct 8;8:65-74. DOI:
10.2147/PTT.S169333. PMID: 30324088; PMCID:
PMC6181091.
14. Finlay AY, Khan GK. Dermatology Life Quality Index
(DLQI)- A simple practical measure for routine clinical use.
Clin Exp Dermatol 1994;19;210-16
15. Phoebe Rich, Richard K Scher, Nail psoriasis severity index:
a useful tool for evaluation of nail psoriasis, Journal of the
American Academy of Dermatology, 2003;49(2): 206-212,
DOI: https://doi.org/10.1067/S0190-9622(03)00910-1.
16. Augustin M, Blome C, Costanzo A, Dauden E, Ferrandiz C,
Girolomoni G, Gniadecki R, Iversen L, Menter A, Michaelis-
Wittern K, Morita A, Nakagawa H, Reich K. Nail Assessment
in Psoriasis and Psoriatic Arthritis (NAPPA): development
and validation of a tool for assessment of nail psoriasis
outcomes. Br J Dermatol. 2014 Mar;170(3):591-8. DOI:
10.1111/bjd.12664. PMID: 24117393.
17. Ibrahim GH, Buch MH, Lawson C, Waxman R, Helliwell PS.
Evaluation of an existing screening tool for psoriatic arthritis
in people with psoriasis and the development of a new
instrument: the Psoriasis Epidemiology Screening Tool

RR"Patil"et"al"/"Int."J."Res."Ayurveda"Pharm."14"(3),"2023"
84#
(PEST) questionnaire. Clin Exp Rheumatol. 2009 May-
Jun;27(3):469-74. PMID: 19604440.
18. Alenius GM, Stenberg B, Stenlund H, Lundblad M, Dahlqvist
SR. Inflammatory joint manifestations are prevalent in
psoriasis: prevalence study of joint and axial involvement in
psoriatic patients, and evaluation of a psoriatic and arthritic
questionnaire. J Rheumatol. 2002 Dec;29(12):2577-82.
PMID: 12465155.
19. Ashcroft DM, Wan Po AL, Williams HC, Griffiths CE.
Clinical measures of disease severity and outcome in
psoriasis: a critical appraisal of their quality. Br J Dermatol.
1999 Aug;141(2):185-91. DOI: 10.1046/j.1365-
2133.1999.02963.x. PMID: 10468786.
20. Oji V, Luger TA. The skin in psoriasis: assessment and
challenges. Clin Exp Rheumatol. 2015 Sep-Oct;33(5 Suppl
93):S14-9. Epub 2015 Oct 15. PMID: 26472560.
Cite this article as:
RR Patil, DG Dipankar and GH Yeola. Scoring system in
dermatology to assess psoriasis: A Review. Int. J. Res. Ayurveda
Pharm. 2023;14(3):80-84 DOI: http://dx.doi.org/10.7897/2277-
4343.140387
Source of support: Nil, Conflict of interest: None Declared
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