Development and validation of a comprehensive acne severity scale

BACKGROUND: Although more than 25 acne grading systems exist, only 2 are inclusive of truncal acne. There is neither a gold standard nor a consistently used standardized system. PURPOSE: Our purpose was to develop and validate an acne grading system incorporating severity at the face, chest, and back. METHODS: We developed a comprehensive acne severity scale (CASS) by modifying a preexisting facial acne scale, the Investigator Global Assessment, to include truncal acne. The validity and responsiveness of CASS grades were correlated with Leeds scores at baseline and after 6 months of standard acne treatment. RESULTS: Spearman correlations were significant between Leeds and CASS grades for the face (0.823), chest (0.854), and back (0.872), respectively (p < .001). After 6 months of therapy, changes in these scores were also significantly correlated (p < .001) at all three sites. CONCLUSION: Concurrent validity of CASS is demonstrated by a very strong correlation with Leeds grading. CASS is simpler to use than the Leeds system and more appropriate for translation of research trial results to clinical practice.     

The 5‐D itch scale: a new measure of pruritus

Background Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being unidimensional, for example only measuring intensity without impact on quality of life, or only measuring scratching activity. None has actually been demonstrated to be able to detect change over time, which is essential to using them as an outcome measure of response to an intervention. The 5‐D itch scale was developed as a brief but multidimensional questionnaire designed to be useful as an outcome measure in clinical trials. The five dimensions are degree, duration, direction, disability and distribution. Objectives To study the 5‐D with respect to validity, reliability and response to change. Methods The 5‐D was administered to 234 individuals with chronic pruritus due to liver disease (n = 63), kidney disease (n = 36), dermatological disorders (n = 56), HIV/AIDS (n = 28) and burn injuries (n = 51). The 5‐D was administered at baseline and after a 6‐week follow‐up period. A subset of 50 untreated patients was retested after 3 days to assess test–retest reliability. Results The 5‐D score correlated strongly with a visual analogue score: r = 0·727 at baseline (P < 0·0001), r = 0·868 at the 3‐day repeat (P < 0·0001), and r = 0·892 at the 6‐week follow‐up (P < 0·0001). There was no change in mean 5‐D score between day 1 and day 3 in untreated individuals (intraclass correlation coefficient = 0·96, P < 0·0001). The 5‐D did, however, detect significant changes in pruritus over the 6‐week follow‐up period (P < 0·0001). Subanalysis of the different patient groups revealed similar response patterns and scores, with the exception of lower total scores for the burn victims due to lower scores on the distribution domain because they itched only at the site of their burn. Conclusions The 5‐D, therefore, is a reliable, multidimensional measure of itching that has been validated in patients with chronic pruritus to able to detect changes over time. The 5‐D should be useful as an outcome measure in clinical trials.     

The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective

OBJECTIVE: To develop a simple, valid, repeatable, and readily understandable patient-oriented assessment measure for monitoring disease activity in children and adults with atopic eczema. DESIGN: Qualitative semistructured patient interviews identified a list of symptoms of atopic eczema. These symptoms were quantitatively analyzed in a larger patient population to identify which symptoms were important to patients and amenable to monitoring as part of a scoring system. SETTING: The outpatient Department of Dermatology at the Queen's Medical Centre, University Hospital, Nottingham, England, and 5 local general practices. PATIENTS: Four hundred thirty-five patients with atopic eczema. RESULTS: Seven symptoms were incorporated into the final patient-oriented eczema measure using a simple 5-point scale of frequency of occurrence during the previous week, with a maximum total score of 28. Validity testing against the Dermatology Life Quality Index, Children's Dermatology Life Quality Index, and patients' global severity assessments showed good correlation (r = 0.78, r = 0.73, and r = 0.81, respectively; P<.001). Internal consistency was high (Cronbach alpha = 0.88), and test-retest reliability was good, with 95% of scores falling within 2.6 points on repeat testing (mean score difference, 0.04; SD, 1.32). Individual variables in the measure demonstrated sensitivity to change during a 4-week in-clinic period and an 18-week randomized controlled clinical trial. CONCLUSION: The patient-oriented eczema measure is a practical self-assessed measurement tool for monitoring aspects of atopic eczema that are important to patients in routine clinical practice or in the clinical trial setting.     

Anti‐IL5 decreases the number of eosinophils but not the severity of dermatitis in Sharpin‐deficient mice

Please cite this paper as: Anti‐IL5 decreases the number of eosinophils but not the severity of dermatitis in Sharpin‐deficient mice. Experimental Dermatology 2010; 19: 252–258. Abstract: Sharpin‐deficient (Sharpin^cpdm) mutant mice develop a chronic eosinophilic dermatitis. To determine the efficacy of eosinophil‐depletion in chronic inflammation, Sharpin^cpdm mice were treated with anti‐IL5 antibodies. Mice treated with anti‐IL5 had a 90% reduction of circulating eosinophils and a 50% decrease in cutaneous eosinophils after 10 days compared with sham‐treated littermates. Reducing the number of eosinophils resulted in increased severity of alopecia and erythema and a significant increase in epidermal thickness. Skin homogenates from mice treated with anti‐IL5 had decreased mRNA expression of arylsulfatase B (Arsb), diamine oxidase (amiloride‐binding protein 1, also called histaminase; Abp1) and Il10, which are mediators that eosinophils may release to quench inflammation. Skin homogenates from mice treated with anti‐IL5 also had decreased mRNA expression of Il4, Il5, Ccl11, kit ligand (Kitl) and Tgfa; and increased mRNA expression of Tgfb1, Mmp12 and tenascin C (Tnc). In order to further decrease the accumulation of eosinophils, Sharpin^cpdm mice were crossed with IL5 null mice. Il5^?/?, Sharpin^cpdm/Sharpin^cpdm mice had a 98% reduction of circulating eosinophils and a 95% decrease in cutaneous eosinophils compared with IL5‐sufficient Sharpin^cpdm mice. The severity of the lesions was similar between IL5‐sufficient and IL5‐deficient mice. Double mutant mice had a significant decrease in Abp1, and a significant increase in Tgfb1, Mmp12 and Tnc mRNA compared with controls. These data indicate that eosinophils are not essential for the development of dermatitis in Sharpin^cpdm mice and suggest that eosinophils have both pro‐inflammatory and anti‐inflammatory roles in the skin of these mice.     

Development and validation of a new instrument for the assessment of patient‐defined benefit in the treatment of acne

Background: Benefit assessment of drugs and medical products has become a legally established feature of medical research. A standardized assessment of benefits using scientifically sound and valid methods is essential. Objective: Development, validation and practical evaluation of an instrument to record patient benefit in treatment of acne. Patients and Methods: In open interviews with n = 50 patients, possible benefits of the therapy from the patients' point of view were recorded. The item pool thus generated was reviewed by a panel of dermatologists, psychologists and patients and transferred to a 23‐item questionnaire. This is used prior to therapy to assess patients' desired benefits and after therapy to record the perceived benefits. The therapy goals and the resulting benefits are then used to generate a weighted ‘Patient Benefit Index’ (PBI). The procedure has been tested for its validity and feasibility in n = 923 patients with acne. Results: Patients accepted the instrument and deemed it to be easily understandable. Additionally, the method proved itself to be internally consistent, constructively valid and sensitive to changes. Conclusions: The Patient Benefit Index (PBI) is a valid and highly accepted practical instrument for recording patient benefit. The PBI permits an individualized, patient‐weighted assessment of the benefits of acne therapy.     

Development and use of guideline‐derived quality indicators for community lymphoedema

Background Treatment of lymphoedema is complex and needs specific skills. There are no standards for the evaluation of quality of care. Objective Development and application of indicators for the measurement of quality of care in lymphoedema. Methods In a three‐step process including a national Delphi expert consensus, quality indicators were derived from national and international guidelines. In a cross‐sectional study involving a large spectrum of care providers, the quality of lymphoedema care in the community was assessed by transforming the indicators to one unweighted quality index (QI). Results A total of 12 quality indicators were identified and applied to n = 348 patients with lymphoedema and lipolymphoedema of any origin in the metropolitan area of Hamburg (90.8% female, mean age 57, SD 14.5 years). On average, 55% of the quality indicators were met, and 64.8% of the patients were satisfied with lymphoedema care. There was a significant correlation between QI and satisfaction. Conclusions The quality indicators and the QI are feasible and valid for the evaluation of quality of care. They can support optimizing lymphoedema care.     

Intra‐ and inter‐observer reliability of the application of the cellulite severity scale to a Spanish female population

Background ‘Hexsel, dal’Forno and Hexsel Cellulite Severity Scale’ (CSS) was developed to evaluate cellulite with an objective and easy to apply tool. Objective Study CSS intra‐ and inter‐observer reliability in a Spanish female population by evaluating patients’ cellulite through photographs of their overall gluteofemoral zone as opposed to its creators who distinguished between buttocks and thigh. Methods Cellulite Severity Scale was applied to 27 women, evaluating gluteofemoral cellulite, differentiating between left and right. Evaluations were made by three expert examiners each at three times with a 1‐week separation. Variables were the five CSS dimensions (number of evident depressions; depth of depressions; morphological appearance of skin surface alterations; grade of laxity, flaccidity, or sagging skin; and the Nürnberger and Müller classification scale), and the overall CSS score. Cronbach’s alpha, intra‐class correlation and item total correlation were analysed. Results Cronbach’s alpha values were 0.951 (right) and 0.944 (left). In the intra‐observer reliability analysis, intra‐class correlation coefficient ranged from 0.993 to 0.999 (P < 0.001) and in the inter‐observer analysis were 0.937 (right) and 0.947 (left) (P < 0.001). Item total correlation showed all dimensions to be needed except grade of laxity, flaccidity or sagging skin (0.959 right; 0.955 left). Conclusion Cellulite Severity Scale has excellent reliability and internal consistency when used to evaluate cellulite on the buttocks and back of the thighs considered together. Nevertheless, the dimension grade of laxity, flaccidity or sagging skin does not contribute positively to the final consistency of the scale. This dimension needs to be analysed in greater depth in future studies.     

Effects of anti‐TNF‐α agents on circulating endothelial‐derived and platelet‐derived microparticles in psoriasis

Psoriasis involves TNF‐α secretion leading to release of microparticles into the bloodstream. We investigated the effect of TNF blockers on microparticles levels before and after treatment in patients (twenty treated by anti‐TNF‐α agents and 6 by methotrexate) with severe psoriasis. Plasmatic microparticles were labelled using fluorescent monoclonal antibodies and were analysed using cytometry. Three months later, 70% of patients treated with anti‐TNF‐α agents achieved a reduction in PASI score of at least 75%. The clinical improvement in patients treated with anti‐TNF‐α agents was associated with a significant reduction of the mean number of platelet microparticles (2837/μl vs 1849/μl, P = 0.02) and of endothelial microparticles (64/μl vs 22/μl, P = 0.001). Microparticles are significantly decreased in psoriatic patients successfully treated by anti‐TNF‐α. Microparticles levels as circulating endothelial cells represent signs of endothelial dysfunction and are elevated in psoriasis. Then, TNF blockade may be effective to reduce cardiovascular risk through the reduction of circulating microparticles.     

Linear Morhpea,Nevus Comedonicus,and Lichen Striatus in a 5‐Year‐Old Girl

Abstract: Linear morphea, lichen striatus, and nevus comedonicus are rare conditions. We describe a five‐year‐old girl in whom all three of these dermatoses are present.