What is the Best Way to Assess Severity of Atopic Dermatitis in Practice?

For the purposes of clinical trials, and in clinical practice, it is useful to have an objective and reproducible measure of severity of atopic dermatitis. Since there are no labs that can capture itchiness, scaliness or general impact on quality of life, clinicians must rely on more subjective measures. Currently there are more than 60 tools to assess various symptoms and characteristics of disease, but they vary widely and it is not clear which one is best to use.

A recent study reviewed the most commonly used available scoring systems of atopic dermatitis signs with respect to their design and utility in specific settings. These systems all measure lesional intensity and/or extent, symptoms, disease course, and epidermal function. Scoring atopic dermatitis (SCORAD), Investigator Global Assessment (IGA), and Eczema Area and Severity Index (EASI) are the most commonly used assessments of atopic dermatitis signs and EASI has become the go-to in clinical trials. The authors note that while EASI has great relevance to lab studies and clinical trials, it is less useful in practice.

Rating itch intensity using either visual analog or numeric rating scales, or the Patient-Oriented Eczema Measure (POEM) stand out as the preferred patient-reported outcome (PRO) measure in clinical trials. These may also be better suited to clinical practice. The patients’ own assessment of symptoms may be a more accurate reflection of patient-burden. POEM is a self-reported eczema-specific tool that catalogs symptoms such as itch, sleep loss, bleeding, weeping/oozing, and skin cracking over the previous week. The tool is simple to use in the clinic, but POEM’s structural validity, cross-cultural validity, reliability, measurement error, and lack of assessment of intensity of symptoms raise major concerns about its use in clinical practice. Other scales such as gestalt clinician’s global assessments or the NRS-itch have similar pitfalls.

In this review, the authors report the benefits and drawbacks within each commonly used measurement. Overall, they found that while some tools may be feasible in clinical practice they lacked validity and did not fully capture disease burden.

The authors state that for use in clinical practice a tool must require minimal training, be time-efficient, and seamlessly integrate into day-to-day practice.