Assessing eczema severity: A comprehensive review of scoring systems

INTRODUCTION

Eczema, a chronic inflammatory skin condition, requires accurate severity assessment for effective management and research. Standardized scoring systems, such as the eczema area and severity index (EASI), SCORing atopic dermatitis (SCORAD), investigator’s global assessment (IGA), patient- oriented eczema measure (POEM), and atopic dermatitis severity index (ADSI), evaluate lesion extent, severity, and quality of life (QoL) impact. These objective scores are crucial in chronic disease management, as guidelines from organizations, such as the National Institute for Health and Care Excellence, American Academy of Dermatology, and European Dermatology Forum focus on treatment based on severity scores. Developed since the 1990s, over 20 scoring systems are now available, including EASI (1993), SCORAD (1993), IGA (2005), POEM (2007), and ADSI (2010), alongside QoL measures, such as dermatology life quality index (DLQI), Skindex-29, and POEM. Objective scores help to determine treatment strategies, monitor disease progression, and decide when to use immunomodulators or immunosuppressives and biologics. Accurate scoring enables personalized treatment plans, improves patient outcomes, and enhances research comparability, underscoring the importance of objective assessment in eczema management. Commonly used severity scoring systems for eczema and the assessment criteria are tabulated in Table 1.

These systems help guide treatment decisions, monitor progress, and compare outcomes across studies.

EASI

The EASI is a widely used tool to assess the severity of atopic dermatitis (eczema). It evaluates two main components:

1. Area: The percentage of body surface area affected by eczema.

2. Severity: The intensity of eczema symptoms, including:

   • Erythema (redness)

   • Edema (swelling)

   • Lichenification (thickening of skin)

   • Excoriations (scratches)

The EASI score calculation includes the following steps:

1. Calculate the affected body area: Head/neck, upper limbs, trunk, lower limbs; estimate the percentage affected (0–100%)

2. Evaluate symptom severity (0–3): Erythema (redness), edema (swelling), excoriation (scratching), lichenification (thickening)

3. Calculate EASI score*: (Severity × Area) × Region multiplier.

Region multipliers:

1. Head/neck: 0.1

2. Upper limbs: 0.2

3. Trunk: 0.3

4. Lower limbs: 0.4.

The total EASI score ranges from 0 (no eczema) to 72 (maximum severity).

Interpretation of EASI scores:

• Mild: 0–7

• Moderate: 8–21

• Severe: 22–48

• Very severe: 49–72.

The EASI scoring is useful for assessing the disease severity, monitoring treatment response, and comparing outcomes in clinical trials. As it requires fewer calculations, it is the most practical scoring system for training dermatologists.^[1]

SCORAD INDEX

The SCORAD index is another tool used to assess the severity of atopic dermatitis (eczema). The calculation involves the following steps.

1. *Assess affected body area (%)*: Estimate percentage affected (0–100%)

2. *Evaluate symptom severity (0–3)*: Erythema, edema, excoriation, lichenification, dryness

3. *Calculate intensity score*: Sum symptom severity scores (0–15)

4. *Subjective symptoms (0–10)*: Patient-reported pruritus (itching) and sleep disturbance

5. *Calculate SCORAD score*: (Intensity/15 + Extent/100 + Subjective/10) × 3.5.

The SCORAD index combines these components to provide a total score ranging from 0 to 103.

Interpretation of SCORAD scores:

• Mild: 0–24

• Moderate: 25–49

• Severe: 50–74

• Very severe: 75–103.

The SCORAD index is useful for assessing disease severity, monitoring treatment response, and comparing outcomes in clinical trials. SCORAD is the most useful scoring system for research purposes.^[2]

IGA

The IGA for eczema, also known as the physician’s global assessment, is a single-item measure that evaluates the overall severity of eczema based on:

1. Erythema (redness)

2. Induration (thickness)

3. Lichenification (skin thickening)

4. Excoriations (scratches)

5. Oozing/Crusting.

The IGA score ranges from 0 to 5, with:

• 0: Clear (no eczema)

• 1: Almost clear (slightly detectable eczema)

• 2: Mild (light pink, slightly raised)

• 3: Moderate (pink, moderately raised)

• 4: Severe (deep pink, greatly raised)

• 5: Very severe (fiery red, greatly raised)

The IGA is often used in conjunction with other assessment tools, such as EASI or SCORAD, to provide a comprehensive understanding of eczema severity.^[3]

POEM

The POEM assesses the severity of atopic dermatitis (eczema) from the patient’s perspective. It’s a short, 7-item questionnaire that evaluates:

1. Frequency of itching

2. Sleep disturbance

3. Dryness

4. Crusting

5. Redness

6. Clearing (skin clearing)

7. Flaking.

Patients rate each item on a scale from 0 (no problem) to 4 (severe problem). The total POEM score ranges from 0 to 28, with higher scores indicating more severe eczema.

Interpretation of POEM scores:

• 0–2: Clear or almost clear

• 3–7: Mild

• 8–12: Moderate

• 13–18: Severe

• 19–28: Very severe

The POEM is a simple, patient–centered scoring system useful for assessing patient-reported symptoms and facilitating patient-physician communication.^[4] Free usage details and approximate time taken for each eczema assessment tool are mentioned in Table 2.

PATIENT REPORTED OUTCOME (PRO) SCORES

PRO scores play a vital role in healthcare, particularly in chronic conditions, such as eczema, offering numerous benefits. PROs facilitate patient-centric care by capturing patients’ perspectives on symptoms, QoL, and treatment effectiveness, improving patient-clinician communication and treatment adherence. They provide valuable insights into treatment effectiveness, enable personalized care, and inform clinical trials, regulatory approvals, and healthcare policy decisions. Patients benefit from empowerment, improved QoL, and increased satisfaction, while clinicians gain informed decision-making, enhanced patient engagement, and better outcome tracking.

Commonly used PROs in eczema:

1. POEM

2. DLQI

3. Skindex-29

4. Pruritus severity scale (PPS)

The scoring ranges and interpretations of these scoring systems are tabulated in Table 3.

Incorporating PROs into clinical practice and research can deliver more patient-centered, effective, and personalized care. ^[5]

PRURITIC SCORES

Pruritic scores, or itch assessments, measure the severity of pruritus (itching) in eczema patients. Commonly used pruritic scores include:

1. Visual analog scale for pruritus

   • Measures: Intensity of itching (0–100 mm)

   • Scoring: 0 (no itching) to 100 (worst imaginable itching)

   • Time: 2–5 min

2. Numeric rating scale for pruritus

   • Measures: Intensity of itching (0–10)

   • Scoring: 0 (no itching) to 10 (worst imaginable itching)

   • Time: 2–5 min

3. Pruritus severity scale (PPS)

   • Measures: Frequency, duration, and intensity of itching

   • Scoring: 0–20 (mild) to 21–40 (moderate) to 41–60 (severe)

   • Time: 5–10 min

4. Itch severity scale (ISS)

   • Measures: Intensity and impact of itching

   • Scoring: 0–4 (mild) to 5–8 (moderate) to 9–12 (severe)

   • Time: 5–10 min

5. Eczema itch questionnaire (EIQ)

   • Measures: Itch frequency, duration, and impact

   • Scoring: 0–100 (higher scores indicate worse itching)

   • Time: 10–15 min

Pruritic scores help to assess itch severity, monitor treatment effectiveness, adjust treatment plans, and evaluate QoL impact. Furthermore, these scores are essential for diagnosing eczema severity, guiding informed treatment decisions, evaluating treatment response, and ultimately improving the QoL.^[6]

QOL IN ECZEMA

QoL in eczema is significantly impacted by the condition. Eczema can affect various aspects of a person’s life, including:

1. Physical discomfort: Chronic itching, pain, and sleep disturbances

2. Emotional well-being: Anxiety, depression, and low self- esteem

3. Social relationships: Embarrassment, stigma, and social isolation

4. Daily activities: Limitations in work, school, or leisure activities

5. Mental health: Increased risk of suicidal thoughts and behaviors

Studies have shown that eczema can lead to reduced productivity and missed work/school days, increased healthcare utilization and costs, strained relationships with family and friends, decreased participation in social activities, and a negative impact on mental health and overall well-being.

Assessing QoL in eczema is crucial to understanding the full impact of the condition. Tools such as the DLQI and the QoL index for atopic dermatitis (QoLIAD) help measure the effects of eczema on daily life.

THE QOLIAD

The QoLIAD is a self-reported questionnaire that evaluates various aspects of life affected by eczema, including;

1. Symptoms and feelings (e.g., itching, pain, frustration)

2. Daily activities (e.g., work, school, leisure)

3. Social relationships (e.g., relationships with family, friends)

4. Sleep and emotional well-being (e.g., anxiety, depression)

5. Treatment and overall satisfaction

The QoLIAD consists of 25 questions, and patients rate their experiences on a scale from 0 (not at all) to 4 (almost all the time). The scores are then calculated to provide a total score ranging from 0 to 100, with higher scores indicating a greater impact on QoL.

The QoLIAD is useful for developing personalized treatment plans to improve the QoL.^[7,8]

CARETAKER QUALITY INDICES IN ECZEMA

Caretaker quality indices in eczema assess the impact of eczema on caregivers’ QoL. These indices evaluate the physical, emotional, and social burdens on caregivers, including:

1. QoL Index for Parents of Children with Atopic

2. Dermatitis (QoLIAD-P)

3. Parent’s Index of QoL in Atopic Dermatitis

4. Caregiver’s QoL Index for Eczema (CQoLI-E)

5. Family DLQI (FDLQI)

These indices assess aspects such as emotional distress, sleep disturbances, social isolation, relationship difficulties, daily activity limitations, and financial burdens. They help in recognizing the caregiver’s role in eczema management, addressing caregiver burnout and support needs, developing family-centered treatment plans, and improving overall family well-being.

These indices help ensure that caregivers receive the necessary support, leading to better outcomes for both caregivers and patients with eczema. These scoring systems and their interpretations are tabulated in Table 4.

QOL INDEX FOR PARENTS OF CHILDREN WITH ATOPIC DERMATITIS (QOLIAD-P)

The QoL index for parents of children with atopic dermatitis (QoLIAD-P) is a tool used to assess the impact of atopic dermatitis (eczema) on parents’ QoL. It’s a 28-item questionnaire that evaluates:

1. Emotional distress (e.g., worry, guilt)

2. Sleep disturbances

3. Daily activities (e.g., household chores, social activities)

4. Personal relationships (e.g., relationships with partner, friends)

5. Leisure activities (e.g., hobbies, travel)

6. Work or school (e.g., impact on productivity)

Each item is scored from 0 (not at all) to 6 (almost all the time), and the total QoLIAD-P score ranges from 0 to 168. Higher scores indicate a greater impact on parents’ QoL.

Interpretation of QoLIAD-P scores:

• 0–50: Small impact

• 51–100: Moderate impact

• 101–150: Large impact

• 151–168: Very large impact

QoLIAD-P scoring system can address the unique challenges faced by parents of children with eczema and improve their overall well-being.

QoLIAD-P is similar to PUQoL-AD but with some differences in question wording and scoring. Both tools aim to assess the impact of eczema on parents’ QoL.^[9]

PARENTS’ QUALITY OF LIFE INDEX FOR ATOPIC DERMATITIS (PUQOL-AD)

PUQOL-AD is a disease-specific, parent-reported outcome measure assessing the impact of atopic dermatitis on parents’ QoL.

The scoring system has 28 items across 5 domains:

1. Emotional Distress (8 items)

2. Sleep Disturbance (4 items)

3. Daily Routines (6 items)

4. Social Activities (5 items)

5. Treatment Burden (5 items)

5-point Likert scale (0–4) for each item.

Thus, the total score ranges between 0 and 112. It can be transformed to a 0–100 scale for easier interpretation.

Interpretation:

• 0–20: Minimal impact

• 21–40: Mild impact

• 41–60: Moderate impact

• 61–80: Severe impact

• 81–100: Extremely severe impact.

The PUQoL-AD helps to address the unique challenges faced by parents of children with eczema and to develop family- centered treatment plans.^[10]

FDLQI

The FDLQI assesses the impact of skin diseases, including eczema, on the QoL of family members or caregivers.

FDLQI questionnaire structure:

The FDLQI consists of 16 questions, divided into four components, including family Activities (6 questions), emotions (4 questions), daily Life (3 questions), and Social Life (3 questions). Each question is scored on a 0–3 scale:

• 0: Not at all

• 1: A little

• 2: A lot

• 3: Very much

The total score is calculated by summing the scores for each question, ranging from 0 to 30.

The FDLQI scores can be interpreted as follows:

• 0–5: No impact

• 6–15: Small impact

• 16–25: Moderate impact

• 26–30: Large impact

The FDLQI can address the broader impact of eczema on families and develop family-centered treatment plans.^[11]

CQoLI-E

The CQoLI-E is a 25-item questionnaire that evaluates:

1. Emotional burden (e.g., worry, frustration)

2. Physical burden (e.g., sleep disturbances, fatigue)

3. Social burden (e.g., social isolation, relationship strain)

4. Practical burden (e.g., time management, financial stress)

5. Emotional support (e.g., feeling supported and confident)

Each item is scored from 0 (not at all) to 4 (almost all the time), and the total CQoLI-E score ranges from 0 to 100. Higher scores indicate a greater impact on the caregiver’s QOL.

Interpretation of CQoLI-E scores:

• 0–25: Small impact

• 26–50: Moderate impact

• 51–75: Large impact

• 76–100: Very large impact

The CQoLI-E helps to identify areas for support, develop caregiver-centered interventions, and evaluate treatment effectiveness. CQoLI-E helps to address the unique challenges faced by caregivers and improve their overall well-being.^[12]

The integration of technology has revolutionized eczema management, enhancing the utilization of objective scores. Mobile apps, such as Eczema Tracker, Skin Tracker, and Dermatologist OnCall, enable patients to track their symptoms, monitor disease severity, and report outcomes using validated scales, such as POEM, DLQI, and PPS. Digital platforms, including electronic PRO systems, streamline data collection and facilitate clinician-patient communication. Artificial intelligence-powered algorithms analyze photographic images to assess eczema severity, while wearable devices track scratch counts and sleep patterns. Telemedicine platforms incorporate objective scoring tools, ensuring remote consultations are informed by quantitative data. Recent studies demonstrate the efficacy of these technologies in improving eczema management, treatment adherence, and patient QOL. By harnessing technology, healthcare providers can optimize objective scoring, personalize care, and enhance patient outcomes. ^[13,14]

CONCLUSION

The utilization of scoring systems in eczema management has revolutionized the way clinicians assess disease severity, monitor treatment effectiveness, and improve patient outcomes. Validated tools such as POEM, DLQI, PPS, ISS, and EIQ provide a standardized framework for evaluating eczema symptoms, QOL impact, and treatment response. By incorporating these scoring systems into clinical practice, healthcare providers can deliver personalized, evidence-based care, enhance patient engagement, and optimize treatment strategies. Moreover, the integration of technology, including mobile apps and digital platforms, has facilitated the collection and analysis of scoring data, further streamlining eczema management. Ultimately, scoring systems play a vital role in improving eczema care, and their continued development and refinement will remain essential in addressing the complex needs of patients with this chronic and debilitating condition.