Tuesday, July 9, 2024

Body Surface Area Assessment Psoriasis

Tools For The Determination Of The Severity Of Psoriasis

25th EADV Congress day 3 highlight: Clinical assessment of disease severity in psoriasis

After an assessment of your well being, physical changes, and effects on the body, psychological changes after the disease, Redness of the skin, scales and thickness of the lesions and pustules etc a dermatologist can conclude the severity of psoriasis.

Self-administered PASI also called a self-administered psoriasis area and severity index is the tool to self assess your psoriasis severity. The scale ranges from 5 to 7. It can be categorized as most clear, almost clear skin, mild psoriasis, moderate psoriasis to severe and most severe psoriasis.

PsoriasisArea and Severity Index is another tool which is very complex to use. It calculates the thickness of the raised bumps, area of the skin under psoriasis spread, the extent of scales, redness and inflammation. These are not used for children. There is yet another measuring tool that determines the severity of psoriasis in children.

Childrens dermatology life qualityindex is one such. This assesses the skin wholly, from physical to psychological conditions of the child and determines the severity scale.

PASI or psoriasis assessmentseverity score is also cited as tools for the estimation of severity. While the dermatology life quality index is used for adults. When the body surface area is considered, it is early measured as the area covered by psoriasis.

A hand covers almost one per cent of the body surface area. One can use a hand to estimate how much body surface area is occupied by psoriasis spread.

How This Guides Treatment

With mild psoriasis, for example, your practitioner may prescribe moisturizing creams and topical medications or recommend that you quit smoking or lose weight to reduce your risk of flares.

With moderate psoriasis, additional treatments may be incorporated, including immunosuppressant drugs like methotrexate or retinoids.

With severe psoriasis, additional interventions may be prescribed, including and injectable biologic drugs like Humira and Enbrel .

Quality-of-life tests can also inform treatment decisions, particularly if the disease is causing anxiety or depression. In the end, treating psoriasis to address its physical symptoms is just as important as treating it to ease its emotional ones.

Selection Of Indices To Be Included In The Definition: Delphi Study

The Delphi study was answered by 73 dermatologists . The indices with an agreement over 80% were PASI, BSA, and DLQI. The indices with an intermediate agreement were included in the second round, as follows: static Physician Global Assessment , Scalp Physician Global Assessment , static Physician Global Assessment of Genitalia , palmoplantar psoriasis Physician Global Assessment , fingernail Physician Global Assessment , and itching visual analogue scale . Of the 73 dermatologists who participated in the first round, 62 responded to the second . In the second round, sPGA and itching VAS had agreements over 80% and were thus added to PASI, BSA, and DLQI for the next phase.

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Physical Examination Of Musculoskeletal Disease Activity

Joint inflammation can affect all peripheral joints, with a predilection for the involvement of distal interphalangeal joints. Therefore, it is important to evaluate the joints more broadly than in RA: number of painful joints on 68 and number of joints swollen on 66 .

Figure 5.2. Joints and entheses proposed to be assessed in the monitoring of psoriatic arthritis.

Dactylitis can concern fingers or toes and corresponds to synovial and tenosynovial inflammation: dactylitis is present in up to 40% of cases and can be followed simply by the number of dactylitis.

Enthesitis also affects about 35% of patients similar to axSpA, the most frequent sites are the Achilles tendon and plantar enthesitis . The quantification of enthesitis refers to the number of painful insertions at palpation the simplest enthesis score is the Leeds score because it consists of only six points: Achilles tendons, median femoral condyles, and lateral epicondyles of the humerus .

Axial involvement is less frequent and can be monitored similarly to axSpA.

5.2.1Skin Evaluation

Nail involvement is quantified by the number of nails affected.

John K. Nia MD, Mark G. Lebwohl MD, in, 2016

Whats Your Psoriasis Severity

[Full text] The Physician Global Assessment and Body ...

Understanding psoriasis

Psoriasis is a common chronic autoimmune disease. It causes fast growth of skin cells. Its marked by raised, scaly, itchy, dry, and red skin patches. These patches are called psoriasis plaques.

Psoriasis is a very complex disease. There are many types of psoriasis, and they can range in severity. One big question you may have is, How severe is my psoriasis?

The severity of plaque psoriasis differs greatly from person to person. Certain treatments work better on mild to moderate psoriasis, while more powerful drugs help moderate to severe psoriasis. To treat your psoriasis, your doctor has to know how severe your psoriasis is.

However, it can be challenging for a doctor to classify how severe someones psoriasis is. Theres currently no consensus on how to define it. In general, psoriasis is classified on a scale from mild to severe. Your classification depends on many factors. These include how much surface area the condition affects and your specific physical symptoms. Keep reading for more on how psoriasis is classified.

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Psoriasis With Low Body

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Psoriasis of the scalp, face, intertriginous areas, genitals, hands, feet and nails are frequently underdiagnosed and undertreated, despite the severity of symptoms associated with these manifestations.

In a systematic review, Joseph F. Merola, MD, MMSc, director of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Womens Hospital, and colleagues conducted PubMed literature searches using the following terms: psoriasis and face/facial, psoriasis and palmoplantar, psoriasis and intertriginous or inverse, psoriasis and genital, psoriasis and scalp, and psoriasis and nail.

Merola and colleagues screened abstracts from all articles written in English over the past 10 years.

The researchers found that psoriasis in these areas comprise a small overall body surface area and may therefore be categorized as mild disease according to Psoriasis Area Severity Index score. However, despite the small body-surface area involvement in these cases, patients with psoriasis of the scalp, face, intertriginous areas, genitals, hands, feet and nails may experience significant physical and emotional difficulties.

The researchers emphasized the importance of understanding and recognizing psoriasis in these small-surface area cases.

Body Surface Area Of Psoriasis Strongly Predicts Psoriatic Arthritis Risk

Body surface area affected by psoriasis, along with obesity and depression, can be used to predict risk of developing psoriatic arthritis , according to study results published in Rheumatology.

It is known that the early identification of PsA, though important in improving outcomes, is challenging for clinicians. Assessment of psoriasis may be helpful as most patients with PsA have a history of psoriasis.

The objective of the current prospective population-based cohort study was to assess the risk for PsA based on psoriasis severity and other factors that are associated with PsA development, including obesity and depression.

Patients aged between 25 and 60 years with psoriasis were randomly selected from The Health Improvement Network, a large population-based health database in the United Kingdom, between 2008 and 2011. Questionnaires were sent to patients general practice providers to determine the approximate BSA of psoriasis, measured using the Patient Report of Extent of Psoriasis Involvement tool. The BSA categories were less than 3% , 3% to 10% , and more than 10% . The cohort was followed up with prospectively for incident cardiovascular disease and PsA.

Among 8881 patients with psoriasis and available BSA data, 52% had mild, 36% had moderate, and 12% had severe psoriasis. The incidence of PsA was 5.4 cases per 1000 person-years over a mean follow-up period of 4.2 years.


This article originally appeared on Rheumatology Advisor

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More Recent Assessment Tools

Other important psoriasis measurement tools are being developed. The lattice system provides a global psoriasis score that ranges over eight steps from clear to very severe. The investigator rates the elevation , erythema, and scaliness of the lesion, each on a none to mild, moderate, marked scale. The percentage of body surface area involved is also measured in categories of 0%, 13%, 49%, 1020%, 2129%, 3050%, and 51100%. By combining these areas of involvement with the character of the plaques, the psoriasis can be categorised into one of eight categories on the clear to very severe scale. This system shows a good correlation with both physician global assessment and PASI scores and provides better intrarater and interrater reliability than PASI. Although it first appears difficult to use, with experience the lattice system actually becomes quite easy to use and provides a static step score that has meaning for both doctors and patients. Still, determining what endpoint is clinically significant will need to be addressed. Is a one step change meaningful , or should a change of two or more steps be required? It is to be appreciated that the Food and Drug Administration , at this time, prefers a step score endpoint as it is believed to be more reflective of a physicians assessment in non-study settings.

Table 4

Elements of National Psoriasis Foundation Psoriasis Score

How Do Doctors Determine Severity And Type Of Psoriasis

Plaque Psoriasis: Initiating Therapy
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Plaque psoriasis is a chronic skin disease that causes patches of a persons skin to become inflamed, thickened, and covered in silvery scales. These patches can often be painful and itchy. When a person is first diagnosed with psoriasis or is experiencing a flare up of symptoms, healthcare providers will work with the person to assess the current level of psoriasis severity. This will enable the healthcare provider and person living with psoriasis to figure out the best possible treatment plan.

Plaque psoriasis is generally classified into three categories: mild, moderate, or severe. Approximately 80% of people diagnosed with psoriasis have mild to moderate disease, and 20% are diagnosed with severe psoriasis.

Read Also: Skin Conditions Like Eczema And Psoriasis

How Is The Affected Body Surface Area Measured

To measure the amount of body surface area affected by plaque psoriasis, healthcare providers work with a patient to help estimate the percentage of the persons body that is affected. The reference point they use is that 1% of a persons total body area is roughly equal to the size of the persons hand 1.

In terms of affected body surface area2:

  • Mild psoriasis affects an area that is less than 3% of the persons total body surface
  • Moderate psoriasis affects an area that is between 3% and 10% of the persons total body surface
  • Severe psoriasis affects 10% or more of the persons total body surface

Statistical Analysis Definitions And Diagnostic Performance

Once the patients were classified into one of the three severity categories, two subgroups were created, comprising mild versus moderate forms, and moderate vs. severe forms. In each of these two subgroups, an array of analyses was performed.

Comparison between severity subgroups. The subgroups were described in terms of the chosen indices using descriptive statistics and compared using parametric or non-parametric tests, depending on the respective distributions.

Contribution of the indices to the classification. A bivariate logistic regression analysis was carried out to assess the association strength of each of the indices selected by the Delphi study with the classification variable of subgroups .

Cut-off points and performance. As possible cut-off points, statistical parameters were calculated for each index, both in the mild and severe forms. For the mild forms, the 90th and 95th percentiles were considered, while for the severe forms, the 5th and 10th percentiles were chosen. In order to enable the classification of patients, the cut-off points for some scores had to be integers, and as a result, some cut-offs were rounded-up. The correct classification percentage according to the gold standard based on the 90th percentile of each index was then calculated.

All analyses were performed using Stata 12 statistical software .

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Mild To Moderate Psoriasis

Mild to moderate psoriasis is when plaques cover less than 5 percent of your body surface area. Psoriatic plaques look like raised surfaces with a silvery cover of dead skin cells. These are called scales.

Mild to moderate psoriasis does not occur in sensitive regions on your body. These include your genitals, face, hands, and feet. Topical treatments, like corticosteroids and vitamin D analogues, often work well to treat this type of psoriasis.

Critical Appraisal Of Overall Value To The Rheumatology Community

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Joint assessment for tenderness and swelling plays a similar role as it does in RA, i.e., as a marker for presence of inflammation in joints. Because of the involvement of DIP joints and the tendency for PsA to be more asymmetric and oligoarticular, an expanded joint count of 68 tender and 66 swollen joints is recommended to more accurately assess the total burden of joint involvement. It appears that although tender joint count appears to be reliably assessed, there are still challenges in interrater reliability in swollen joint counts. In a study using dolorimetry, it has been suggested that patients with PsA display less tenderness with joint pressure than patients with RA .

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Patient Preference Counts Too

In combination with the IPCs initial approach to disease assessment, the patients wishes and preferences should be taken into consideration. One study showed that patient expectations did not align with those of the clinician almost a third of the time. Discordance between the provider and patient expectations is a consequence of poor communication, which often leads to undertreatment.2 Clinicians may rely on objective measures and forget to take into consideration the patients expectations about the treatment outcomes.

Clinicians need to be upfront in asking patients how psoriasis impacts their daily life, including asking about symptoms of depression and anxiety. My personal approach is to ask patients directly, How does psoriasis affect your daily life? What about your psoriasis bothers you the most? What are your treatment goals?

Patient expectations often relate directly to personal goals but also include a broad range of considerations of medication safety and skin clearance. Some personal goals include: better interpersonal relationships, enjoyment of physical intimacy, less psychological discomfort about the disease, or simply to stop itching.

How You Find Out

Severity and body surface area are used together to calculate something called a Psoriasis Area and Severity Index score. It combines the severity and surface area for six regions of your body. Scores range from 0 to 72. A score of more than 10 generally translates to âmoderate-to-severe.â A score of more than 40 is rare.

Usually, the higher your PASI score, the lower your quality of life.

Your doctor may use one of three surveys to figure out how your psoriasis affects your quality of life:

Psoriasis Index of Quality of Life : This tool focuses on how psoriasis changes how you deal with the needs of daily life. Questions cover things like sleep, your social life, and emotions.

Psoriasis Life Stress Inventory : It’s a 15-item questionnaire that asks you how stressful various daily tasks are for you.

Psoriasis Disability Index : The PDI looks at how psoriasis affects your daily activities, including work, leisure time, and personal relationships.

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Composite Measures Of Multiple Domains In Psoriatic Arthritis

Composite response measures, which focus on joint disease as well as patient global/pain, clinician global, and acute-phase reactant patient global ± acute-phase reactant and patient/clinician global , have shown reliable discriminant and response characteristics in randomized controlled trials , but have not been formally validated in psoriatic arthritis . In the past decade, the ACR 20% response criteria have typically been employed as the primary outcome measure of PsA RCTs, and the ACR50 and ACR70, DAS or DAS28, and PsARC have been secondary measures. The ACR and DAS criteria are described in detail in the rheumatoid arthritis section of this article.

Recognizing that PsA is a complex disease that not only involves the domains noted above, but also enthesitis, dactylitis, spine, and skin and nail disease, several groups, including the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and Outcome Measures in Rheumatology, are working on development of composite measures of disease severity and response to therapy that take into account most, if not all, of these domains. The work on development of these measures is discussed below.

Where To Search For The Symptoms Of Psoriasis In The Body

What are some available Treatments for Psoriasis?

Psoriasis does not confine to just skin, it reaches to nails and joints. They are destroyed entirely or partially due to this condition. Intensity measure of psoriasis depends upon the skin, scales, lesions, pustules, and raised bumps on the skin.

In mild psoriasis, less than three per cent of the body surface area is affected. There will be a single isolated patch scattered in few places across the body. Mild psoriasis can be observed in limbs, elbows, and scalp which are more vulnerable areas of psoriasis infection. If a topical medication can clear the skin psoriasis, with certain creams, ointments and solutions, then it is considered as mild psoriasis. This doesnt make any drastic changes in the life of an individual. A little discomfort in social well being is noticed in general.

Moderate psoriasis is determined if the spread of psoriasis is more than three per cent and ten per cent. Moderate psoriasis can be treated with topical medication, retinoid analogues, calcineurin inhibitors, light therapies like UVA, UVB and excimer laser. This has remarkable impacts on an individuals lifestyle and well being of ut not so significant as in severe psoriasis. It can be observed in-ground, torso, elbows, limbs, and head.

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Associated Features And Comorbidities

Assess risk factors and comorbid disease of psoriasis at presentation and as indicated thereafter.

  • Cardiovascular risk factors, and management of these
  • Measure blood pressure, lipid studies and fasting glucose at least annually.
  • Risk of venousthromboembolism and its management .
  • Depression and its management
  • Alcohol consumption
  • Signs of lymphoma, skin cancer, and solidtumours, according to guidelines for age, immune suppression, and phototherapy
  • Children

    Children with psoriasis may have higher rates of associated comorbid disease. Recommended screening for risk factors and comorbid disease depend on the childs age .

    • All ages psoriatic arthritis, lipids, annually for depression and anxiety
    • From age 2 annually for elevated body mass index
    • From age 3 annually for hypertension
    • From age 10 3 yearly for diabetes in patients who are obese or overweight and have 2 or more risk factors for diabetes screen for NAFLD in those who are obese or overweight with additional risk factors for NAFLD.
    • From age 11 annual substance abuse screening

    Eye conditions may occur more commonly in people with psoriasis . Consider asking patients about ocular symptoms at each follow-up appointment .

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