|Year : 2013 | Volume
| Issue : 1 | Page : 13-18
Scoring atopic dermatitis and six sign atopic dermatitis: Comparison of prognostic and predictive value in atopic dermatitis
Alpna Thakur, Suresh Kumar Malhotra, Suhail Malhotra
Department of Dermatology, Government Medical College, Amritsar, Punjab, India
|Date of Web Publication||23-Aug-2013|
House No. 72, Lane 3, North Avenue, Bhadson Road, Patiala - 147 001, Punjab
Source of Support: None, Conflict of Interest: None
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.
Keywords: Atopic dermatitis, scoring atopic dermatitis, six area six sign atopic dermatitis
|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
|How to cite this URL:|
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 [serial online] 2013 [cited 2020 Apr 8];14:13-8. Available from: http://www.ijpd.in/text.asp?2013/14/1/13/116845
| 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.
| 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, inter-observer 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|| |
- To evaluate the prognostic value of scoring systems SCORAD and SASSAD for AD
- To compare three scoring systems:
- Objective SCORAD
- To co-relate the score values with clinical and hematological parameters.
| Materials and Methods|| |
Fifty patients of AD reporting to the Dermatology Out-Patient Department were evaluated at presentation and re-assessed at 4 weeks of follow-up. 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 (<15), moderate (15-40) or severe (>40) according to the objective components of the index (clinical signs and disease extent), with typical changes in scores from 45-50 to 25-30 being demonstrated in recent clinical trials. ,,
The index has extensive published data on validity and reliability, although lichenification and body surface area measurements in particular have shown significant inter-observer variation in some studies.  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.  Clear definitions are included in the index and validity has been demonstrated in several trials. 
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 patient's ages and backgrounds. A proposal for severity grading of AD by using only objective criteria is as follows: (mild AD: Score <15; moderate AD: Score = 15-40 and severe AD: score >40). 
The data thus obtained was analyzed statistically. Co-relation 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 0-5 years, 18% in the age group of 5-10 years and 8% in 10-15 years age group [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Urban patients were in the majority (68%).
SCORAD, SASSAD and objective SCORAD values were compared at presentation and at 4 weeks follow-up. The results are shown in [Table 2], [Table 3], [Table 4], [Table 5].
| 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 follow-up was 23.55 ± 2.56, 16.22 ± 1.99 and 10.46 ± 1.75 respectively, which was statistically significant (P < 0.005). The mean reduction in absolute eosinophil count was 182 ± 33/mm 3 at 4 weeks of follow-up [Table 2], [Table 3], [Table 4], [Table 5].
The reduction in scores co-related 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 the impact of the disease on psychosocial functioning is important. Clinical scoring systems can add to the armamentarium of the treating physician as they can be useful tools in grading both severity of the disease and measuring response to treatment.
In India, especially in the last four decades, a rising trend has been observed in the incidence of AD.  Various studies done in India have reported the incidence to be 0.01%  to as high as 28.46%  from different parts of the country.
The pathogenesis of AD puzzled researchers for decades. Although important leads have been achieved in deciphering the mechanisms of precipitation of AD in genetically pre-disposed individuals, there are still many missing links that are to be discovered to put forth a unifying concept. The basic concept in the pathogenesis of AD is that the patients tend to display an elevated T-helper (Th2) response reflected by an increased frequency of allergen specific T-cells producing interleukin-4, 5 and 13 while a preferential apoptosis of Th1 cells, at least in the acute stages. Th2 to Th1 switching can be observed, in the chronic stages [Figure 5]. Although discussion on the pathogenesis of AD is out of the scope of this article, one aspect 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 cross-infections in families. 
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,  1.8:1,  2.25:1 for infants and 1.6:1 for children,  1.3:1  and 1.56:1. 
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.  Other authors have reported mean age to be 4.2 months for infantile AD and 4.1 years for childhood AD  4.5 months for infantile AD and 4 years for childhood AD. 
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.  In yet another study, the personal or family history of atopy was observed in 54% and 65%, respectively. 
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.
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 open-pilot 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 nut-containing foods, egg and egg-containing 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 6-12 months old were given protein hydrolysate formula instead of milk. All the pre-intervention 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. 
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.  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.  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. 
AD is more common in the urban than in the rural set up. This is probably because of industrialization and changed life-style. 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. 
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 antigens-hygiene hypothesis. A study comparing the severity of AD in Indian children in the UK or US and in India revealed a less-severe form of the disease in children born and brought up in India. This study highlighted the influence of acquired factors-temperature, humidity, food habits, clothing and psychological impacts on the clinical expression and severity of the disease. ,
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, patient-assessed pruritus and other variables such as topical steroid use. Some inter-observer 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. 
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 follow-up was 23.55 ± 2.56, 16.22 ± 1.99 and 10.46 ± 1.75 respectively, which was statistically significant (P < 0.005). The t-value obtained after applying paired Student's t-test 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/mm 3 in the absolute eosinophil count at 4 weeks of follow-up, 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 of IgE, with a predisposition to anaphylactic sensitivity, some decrease in susceptibility to delayed hypersensitivity, abnormalities in the expression of surface molecules in antigen-presenting 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 sex-matched 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 interferon-gamma production. ,
| 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 patient's clinical condition as well as hematological profile.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]