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      Both Educational Lectures and Reference Photographs Are Necessary to Improve the Accuracy and Reliability of Psoriasis Area and Severity Index (PASI) Assessment: Results from Korean Nation-Wide PASI Educational Workshop

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          Abstract

          Background

          Accurate assessment of the severity of psoriasis is important in daily practice and clinical studies. However, the assessment of psoriasis area and severity index (PASI) reflects the physician's experience, and thus evaluations by physicians are inherently subjective, with intra-rater and inter-rater variability.

          Objective

          To elucidate the effectiveness of PASI educational lectures and the use of reference photographs on the improvement of accuracy and reliability in PASI assessments and to develop effective educational programs for PASI assessments.

          Methods

          We performed a before-and-after comparison study during nation-wide PASI educational workshops. The participants were asked to assess the severity components of PASI (erythema, thickness, scale, and affected area) three times: in the test administered before an educational lecture, the test immediately after the lecture, and lastly the test with the use of reference photographs. The improvement of accuracy and reliability was analyzed by comparing the results of three tests.

          Results

          Ninety-six board-certified dermatologists and residents participated and 72 participants completed all three tests. The accuracy and reliability of the assessment of severity components of PASI increased significantly after the educational lecture and the use of reference photographs. Use of reference photographs resulted in limited improvements when the recognition of three-dimensional structures was required, such as in the assessment of thickness or scale.

          Conclusion

          Our study confirmed that the combination of standardized educational training and reference photographs can improve the accuracy and reliability of PASI assessments. Understanding how to evaluate three-dimensional psoriatic lesions can help with proper assessment of the severity of psoriasis.

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          What are the best outcome measures for assessing plaque psoriasis severity? A systematic review of the literature.

          P-A Gourraud, J P Ortonne, E Puzenat … (2010)
          A wide variety of scoring systems have been proposed to assess severity of psoriasis. Given its importance as a health issue both for patients and health care systems, it is critically important to evaluate the validity and reliability of existing outcome measures. The objective of this systematic review was to assess the extent of validation including the validity, reliability, sensitivity to change and ease of use of available outcome measures for psoriasis. We conducted a systematic review of all clinical studies (prospective and retrospective) investigating the severity of psoriasis patients and published between January 1980 and June 2009. The following methodological validation and quality criteria were recorded systematically: construct validity, content validity and internal consistency, intra-observer variation and inter-observer variation, sensitivity to change and acceptability/ease of use assessed as time required to perform measurement. Based on methodological validation and quality criteria, six clinical severity scores were selected and analysed (PASI, BSA, PGA, LS-PGA, SPI and SAPASI scores). We did not find substantial evidence of construct validity for any of the psoriasis clinical severity scores. Content validity was studied by considering the PASI score as gold standard. The relative content validity was good for the LS-PGA, PGA, and SPI scores, which correlated strongly with the PASI score. The SAPASI and PASI scores showed moderate correlation. Internal consistency was good for the PASI and LS-PGA scores. The PASI, BSA, PGA and LS-PGA scores displayed limited intra-observer variation. The inter-observer variation was low for LS-PGA (ICC 0.8). The PASI score and the SAPASI displayed moderate sensitivity to change. Based on this systematic review, it appears that none of the severity scores used for psoriasis meets all of the validation criteria required for an ideal score. However, we can conclude that the PASI score is the most extensively studied psoriasis clinical severity score and the most thoroughly validated according to methodological validation criteria. Despite certain limitations, use of the PASI score can be recommended for scientific evaluation of the clinical severity of psoriasis.
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            Physician Global Assessment (PGA) and Psoriasis Area and Severity Index (PASI): why do both? A systematic analysis of randomized controlled trials of biologic agents for moderate to severe plaque psoriasis.

            Amanda Robinson, Marisa Kardos, Alexandra B. Kimball (2012)
            Although there are many psoriasis assessment tools currently published, one of the unmet needs in psoriasis research remains consensus about the single best validated and reproducible assessment tool. In this systematic review we sought to determine the degree of correlation between two commonly used psoriasis assessment tools, the Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA). Randomized controlled systemic trials in moderate to severe psoriasis were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We recorded and compared the percent of patients achieving both 75% reduction in PASI score (PASI 75) and PGA 0 or 1 (clear or almost clear) at 8 to 16 weeks, 17 to 24 weeks, and greater than 24 weeks of treatment with the investigational drug. Our literature review yielded 30 randomized controlled trials using biologic agents in moderate to severe psoriasis. We found that the two assessment tools correlate very tightly except at the lower bounds of therapeutic efficacy. The r(2) values for the correlation between PASI 75 and a score of clear or almost clear on the PGA were 0.9157 at 8 to 16 weeks and 0.892 at 17 to 24 weeks. Limitations of our study include the small number of randomized controlled trials publishing the percent of patients achieving 75% reduction in PASI score and a score of clear or almost clear on the PGA after 24 weeks of therapy. In addition, our results are not generalizable beyond the patients with moderate to severe plaque psoriasis. The two assessment tools are substantially redundant and either alone is a sufficient tool for assessing psoriasis severity in patients with moderate to severe disease. Because the PASI is better validated and more detailed, it remains the score of choice for clinical trials, but the simpler PGA may be well suited for community-based outcomes projects. Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.
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              Superiority of a cognitive education with photographs over ABCD criteria in the education of the general population to the early detection of melanoma: a randomized study.

              Sophie Girardi, Caroline Gaudy, Joanny Gouvernet … (2006)
              Most education campaigns for melanoma (MM) detection in the general population have used the "ABCD" algorithm, although recognition of objects in the real life is based on a holistic image recognition rather than on analytic criteria. The objective was to compare analytic (ABCD) and cognitive (photographs) strategies for teaching self-recognition of MM. A prospective 4-arm stratified randomized trial in 255 individuals compared 3 realistic educative interventions by leaflets: 1) ABCD algorithm ("ABCD"), 2) a set of photographs chosen to stimulate recognition of MM among benign pigmented lesions ("Cog"), 3) photographs + explanations ("Cog-Ex" arm) and 4) no intervention ("NI"). A 40-slides test was performed before intervention (T0), 1 week after (T1) and after induction of anxiety (T2). In the "ABCD" arm, sensitivity slightly improved (80 to 83.8%, p = 0.04), but specificity dropped from 65.1 to 56.3% (p < 0.001), with no benefit in accuracy as compared to "NI". In "Cog" arm, there was no change in sensitivity, but a strong increase in specificity (65.9 to 81.1%, p < 0.001) and accuracy (42.1 to 53.1%, p < 0.001). "Cog-ex" resulted in similar although lower benefit. Under stress (T2), there was a dramatic loss of specificity and accuracy in "ABCD" arm (65.1 to 44.1%, p < 0.001 and 40.8% to 35.8%, p < or = 0.001) without higher gain in sensitivity, while sensitivity and accuracy increased (p < 0.005) after "Cog" leaflet, without decreasing specificity. Finally, the "ABCD" message alone does not seem efficacious and is even worse in the context of anxiety, whereas a quick look at a few photographs is sufficient to improve the ability of the laymen to recognize a MM just by optimizing their spontaneous image recognition capacities. Education by photographs is a realistic strategy which should replace or complete "ABCD" message in the campaigns for self-detection of MM.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Dermatol
                Journal ID (iso-abbrev): Ann Dermatol
                Journal ID (publisher-id): AD
                Title: Annals of Dermatology
                Publisher: The Korean Dermatological Association; The Korean Society for Investigative Dermatology
                ISSN (Print): 1013-9087
                ISSN (Electronic): 2005-3894
                Publication date (Print): June 2018
                Publication date (Electronic): 23 April 2018
                Volume: 30
                Issue: 3
                Pages: 284-289
                Affiliations
                Department of Dermatology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
                Author notes
                Corresponding author: Sang Woong Youn, Department of Dermatology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea. Tel: 82-31-787-7319, Fax: 82-31-787-4058, swyoun@ 123456snu.ac.kr
                Author information
                https://orcid.org/0000-0002-5602-3530
                Article
                DOI: 10.5021/ad.2018.30.3.284
                PMC ID: 5929944
                PubMed ID: 29853741
                SO-VID: 1d7004cb-28eb-4ef2-aef3-16521c5b436e
                Copyright © Copyright © 2018 The Korean Dermatological Association and The Korean Society for Investigative Dermatology
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 12 June 2017
                Date revision received : 30 October 2017
                Date accepted : 06 November 2017
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Dermatology
                Keywords: education,psoriasis,psoriasis area and severity index,reference photograph,severity of illness index
                Data availability:
                ScienceOpen disciplines: Dermatology
                Keywords: education, psoriasis, psoriasis area and severity index, reference photograph, severity of illness index

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