Practical issues on interpretation of scoring atopic dermatitis: the SCORAD index, objective SCORAD and the three-item severity score

It is important to determine the severity of atopic dermatitis (AD) for evaluation of disease improvement after and during therapy. Scoring of the severity of AD is demanded in clinical trials. The European Task Force on Atopic Dermatitis (ETFAD) has developed the SCORAD (SCORing AD) index to create a consensus on assessment methods for AD, so that study results of different trials can be compared. However, modification of the SCORAD index has led on several occasions to wrong and incorrect use of the system. To measure the extent of AD, the rule of nines is applied on a front/back drawing of the patient's inflammatory lesions. The extent can be graded 0-100. The intensity part of the SCORAD index consists of six items: erythema, oedema/papulation, excoriations, lichenification, oozing/crusts and dryness. Each item can be graded on a scale 0-3. The subjective items include daily pruritus and sleeplessness. Both subjective items can be graded on a 10-cm visual analogue scale. The maximum subjective score is 20. All items should be filled out in the SCORAD evaluation form. The SCORAD index formula is: A/5 + 7B/2 + C. In this formula A is defined as the extent (0-100), B is defined as the intensity (0-18) and C is defined as the subjective symptoms (0-20). The maximum SCORAD score is 103. Based on training sessions by the ETFAD, the SCORAD index was modified by excluding the subjective symptoms (objective SCORAD). The objective SCORAD consists of just the extent and intensity items, the formula being A/5 + 7B/2. The maximum objective SCORAD score is 83 (plus an additional 10 bonus points). Bonus points are given for severe disfiguring eczema (on face and hands). The three-item severity (TIS) score involves the scoring of erythema (redness), oedema and excoriations (scratches) in one representative lesion, marked as R-O-S. The TIS score corresponds well with the more detailed objective SCORAD and can be used as a prescreening system or as a quick system in studies and is excellent for epidemiological studies.