ORIGINAL ARTICLE

Scoring atopic dermatitis and six sign atopic

dermatitis: Comparison of prognostic and predictive
value in atopic dermatitis
Alpna Thakur, Suresh Kumar Malhotra, Suhail Malhotra
Department of Dermatology, Government Medical College, Amritsar, Punjab, India
ABSTRACT
Introduction: Atopic dermatitis is an enigmatic chronically relapsing dermatosis which is difficult to quantify. Present
scoring systems have their inherent limitations.
Aims and Objectives: To evaluate and compare the scoring systems SCORAD and SASSAD for atopic dermatitis and to
correlate values with clinical and hematological parameters.
Materials and Methods: Fifty patients of atopic dermatitis were selected and assessed at presentation and at four weeks
using SCORAD and SASSAD. Appropriate haematological investigations were done at the time of assessments. The data
obtained was assessed statistically.
Results: The changes in both the SCORAD and SASSAD correlated with the changes in clinical and hematological profile.
Conclusion: SCORAD seems to be a better scoring system as it addresses both the subjective and objective parameters.
Key words: Atopic dermatitis, scoring atopic dermatitis, six area six sign atopic dermatitis

INTRODUCTION

SCORING IN AD

topic dermatitis(AD) is a chronic or chronically

relapsing hypersensitive manifestation of the
skin with itching as a predominant feature. It affects
infants, children and adults with a wide degree of
severity. Measuring disease activity of AD is important
for treatment. The diagnosis is mainly clinical and
laboratory investigations do not seem to play a role.

Scoring systems are used in assessing therapeutic

interventions in AD
The scoring atopic dermatitis(SCORAD) combines
both disease extent and severity, is validated
adequately on construct validity, interobserver
reliability and sensitivity to change and is developed
both for children and adult patients
The six area six sign atopic dermatitis(SASSAD)
severity score measures six different severity signs
on six different body parts, has adequate inter
observer reliability and is equally applicable to
children and adults.

Different scoring systems have been developed to

determine the severity of AD. Although several
scoring systems are available, they all have limitations
with regard to the subjective expression of severity by
patients.
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Website:
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DOI:
10.4103/2319-7250.116845

AIMS AND OBJECTIVES

1. To evaluate the prognostic value of scoring systems
SCORAD and SASSAD for AD
ADDRESS FOR CORRESPONDENCE
Dr.Alpna Thakur,
House No.72, Lane 3, North Avenue, Bhadson Road,
Patiala147001, Punjab, India.
Email:alpna. 30@gmail.com

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Thakur, etal.: Scoring atopic dermatitis

2. To compare three scoring systems:

SCORAD
Objective SCORAD
SASSAD
3. To corelate the score values with clinical and
hematological parameters.

objective criteria is as follows:(mild AD: Score<15;

moderate AD: Score=1540 and severe AD:
score>40).[7]
The data thus obtained was analyzed statistically.
Corelation between the score values and clinical
severity and hematological parameters was done.

MATERIALS AND METHODS

Fifty
patients
of
AD
reporting
to
the
DermatologyOutPatient Department were evaluated
at presentation and reassessed at 4weeks of followup.
Details and scoring were recorded on prescribed
proforma.
Patients were investigated and routine hematological
profile and absolute eosinophil counts were done.
Subjective symptoms were assessed as a part
of SCORAD. Objective SCORAD, SCORAD
with subjective symptoms and SASSAD were
compared.
SCORAD comprises a measurement of six clinical
signs at a representative body site, combined with an
assessment of disease extent and visual analog scales
of pruritus and sleep loss to give a maximum possible
score of 103. It has been suggested that disease severity
can be categorized as mild(<15), moderate(1540) or
severe(>40) according to the objective components
of the index(clinical signs and disease extent), with
typical changes in scores from 4550 to 2530 being
demonstrated in recent clinical trials.[13]
The index has extensive published data on validity and
reliability, although lichenification and body surface
area measurements in particular have shown significant
interobserver variation in some studies.[4] Although
SCORAD is a composite score, the measurements
of disease extent, signs and symptoms can easily be
separated and presented as individual measurements
if required.
The SASSAD index uses the same six signs as the
SCORAD index, with the substitution of cracking for
edema/population.[5] Clear definitions are included
in the index and validity has been demonstrated in
several trials.[6]
The objective SCORAD is a modification of the
SCORAD that excludes subjective symptoms as
pruritus and sleep loss, to minimize errors caused
by variability in patients ages and backgrounds.
Aproposal for severity grading of AD by using only
14

OBSERVATIONS
The demographic profile of the patients is as shown
in Table1.
In the present study, 52% patients were males
and 48% were females. Maximum number of
patients(66%) was in the age group of 05years, 18%
in the age group of 510years and 8% in 1015years
age group [Figures 1-4]. Urban patients were in the
majority(68%).
SCORAD, SASSAD and objective SCORAD values
were compared at presentation and at 4weeks
followup. The results are shown in Tables25.

OBSERVATIONS AND RESULTS

The male to female ratio was 1.08:1.
The mean age of onset of symptoms was 2.49years.
The mean reduction in SCORAD, SASSAD and
objective SCORAD at 4weeks of followup was
23.552.56, 16.221.99 and 10.461.75
Table 1: Demographic profile of study cases
Demographic feature
Gender
Male
Female
Age
<5
5-10
10-15
15-20
>20
Rural/Urban
Rural
Urban
Family/personal
history of atopy
Yes
No
Seasonal variation
More in summer
More in winter
Change of season
No change

No. of cases (n=50)

Percentage

26
24

52
48

33
9
4
2
2

66
18
8
4
4

16
34

32
68

24
26

48
52

10
11
7
22

20
22
14
44

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Thakur, etal.: Scoring atopic dermatitis

respectively, which was statistically significant

(P<0.005). The mean reduction in absolute
eosinophil count was 18233/mm3 at 4weeks of
followup [Tables25].
The reduction in scores corelated with the
improvement in clinical and hematological profile.
The various factors affecting the course of disease are
shown in Table6.

DISCUSSION
AD is a very common inflammatory skin disease in
childhood. Acareful history, clinical examination
and adequate documentation of disease severity are
essential in all children with eczema, irrespective
of their disease severity. AD is a clinical diagnosis;
diagnostic criteria, can be helpful for an accurate
definition of the disease. Acareful history, including
dermatological symptoms, respiratory symptoms and

Figure 1: A 2-year-old child with severe atopic dermatitis

Figure 2: Atopic dermatitis: Flexural involvement

Figure 4: Atopic dermatitis: Nipple eczema in a 14-year-old girl

Figure 3: Neck involvement in atopic dermatitis

Table 2: Comparison of SCORAD values at presentation and 4 weeks

Sex
Male
Female
Total

No. of
patients

SCORAD1 (%)

SCORAD <25 (mild)

SCORAD2 (%)

SCORAD1 (%)

SCORAD 25-50 (moderate)

SCORAD2 (%)

SCORAD1 (%)

SCORAD >50 (severe)

SCORAD2 (%)

26
24
50

4
0
4 (8)

25
24
49 (98)

19
17
36 (72)

1
0
1 (2)

3
7
10 (20)

0
0
0 (0)

SCORAD 1 - Score at presentation; SCORAD 2 - Score at 4 weeks of follow-up; SCORAD - Scoring atopic dermatitis

Table 3: Comparison of SASSAD values at presentation

and at 4 weeks
Sex

Male
Female
Total

No. of
patients
26
24
50

SASSAD<10

SASAD>10

SASSAD
1 (%)

SASSAD
2 (%)

SASSAD
1 (%)

SASSAD
2 (%)

10
4
14 (28)

25
20
45 (90)

16
20
36 (72)

1
4
5 (10)

SASSAD 1 - Score at presentation; SASSAD 2 - Score at 4 weeks of follow-up;

SASAD - Six area six sign atopic dermatitis

Table 4: Comparison of obj-SCORAD values at

presentation and 4 weeks
Sex

Male
Female
Total

No. of
obj-SCORAD<10
obj-SCORAD>10
patients O. SCORAD O. SCORAD O. SCORAD O. SCORAD
1 (%)
2 (%)
1 (%)
2 (%)
26
24
50

0
0
0 (0)

26
24
50 (100)

9
7
16 (32)

17
17
34 (68)

O. SCORAD 1 - Score at presentation; O. SCORAD 2 - Score at 4 weeks of

follow-up; obj-SCORAD - Objective scoring atopic dermatitis

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Thakur, etal.: Scoring atopic dermatitis

the impact of the disease on psychosocial functioning

is important. Clinical scoring systems can add to the
armamentarium of the treating physician as they can
be useful tools in grading both severity of the disease
and measuring response to treatment.
In India, especially in the last four decades, a rising
trend has been observed in the incidence of AD.[8]
Various studies done in India have reported the
incidence to be 0.01%[9] to as high as 28.46%[10] from
different parts of the country.
The pathogenesis of AD puzzled researchers for
decades. Although important leads have been achieved
in deciphering the mechanisms of precipitation of
AD in genetically predisposed individuals, there are
still many missing links that are to be discovered to
put forth a unifying concept. The basic concept in
the pathogenesis of AD is that the patients tend to
display an elevated Thelper(Th2) response reflected
by an increased frequency of allergen specific Tcells
producing interleukin4, 5 and 13 while a preferential
apoptosis of Th1cells, at least in the acute stages. Th2
to Th1 switching can be observed, in the chronic stages
[Figure 5]. Although discussion on the pathogenesis
of AD is out of the scope of this article, one aspect
Table 5: Difference in score values after 4 weeks
oftreatment
Score

At
At 4 weeks
presentation follow-up

SCORAD
OBJ
SCORAD
SASSAD
AEC

38.8411.41
27.918.85
15.908.60
644324

Difference

15.295.95 23.552.56
11.694.96 16.221.99
5.443.26
461327

10.461.75
18233

t value P value
18.45
16.37

<0.001
<0.001

12.01
11.23

<0.001
<0.001

in the pathogenesis of AD, i.e.,hygiene hypothesis,

can explain the relatively low occurrence of AD in
India and a rising trend of atopic diseases world over
for more than last three decades. Declining family
size, improvement in household amenities, improved
hygiene and cleanliness reduces the opportunity of
common crossinfections in families.[11]
Gender ratio has varied greatly between the studies.
In the present study, the male to female ratio was
1.08:1. Previous studies have also reported a male
predominance, i.e.,2.13:1 for infants and 1.09:1 for
children,[10] 1.8:1,[12] 2.25:1 for infants and 1.6:1 for
children,[13] 1.3:1[14] and 1.56:1.[13]
The mean age of onset in the present study was
2.49years. In another study, the overall mean age of
onset was 4.58years.[14] Other authors have reported
mean age to be 4.2months for infantile AD and
4.1years for childhood AD[3] 4.5months for infantile
AD and 4years for childhood AD.[13]
Family or personal history of atopy was seen in 48%
of the cases. In a similar study, family history of atopy
was observed in 42.3% patients.[13] In yet another
study, the personal or family history of atopy was
observed in 54% and 65%, respectively.[14]
The present study showed that 14% of patients
attributed onset of symptoms to a specific food(eggs,
brinjal and spicy food) while 4% attributed it to
weaning from breast milk and introduction of cow/
buffalo milk or solid foods in infants. Elimination of
the specific food items was advised in these patients.

SCORAD - Scoring atopic dermatitis; SASAD - Six area six sign

atopic dermatitis; OBJ SCORAD - Objective scoring atopic dermatitis;
AEC - Absolute eosinophil count

Table 6: Associations and triggering factors for AD

Association
Age of onset
<6 months
6 m2 years
>2 years
Associated diseases
Asthma
Fever
Rhinitis
GI upset
Seborrhea
Nil
Precipitating factors
Weaning
Food
Dont know
No factor
AD - Atopic dermatitis

16

No. of patients (n=50)

Percentage

22
16
12

44.0
32.0
24.0

3
4
3
8
1
31

6.0
8.0
6.0
16.0
2.0
62.0

2
7
3
38

4.0
14.0
6.0
76.0

Figure 5: Etiological factors in atopic dermatitis

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Thakur, etal.: Scoring atopic dermatitis

Elimination diet is suggested for patients with AD either

for diagnostic reasons to establish the presence of food
allergies, for therapy or as a preventive measure in the
newborns at risk. An openpilot study by us investigated
the feasibility of dietary eliminations in the Indian
scenario and also assessed the effect it has on Indian
children with AD. Agroup of 100 children were assessed
for severity of itching, surface area of involvement and
SCORAD index. Children without any systemic disease
or those who were not on systemic corticosteroids were
included in the study and were advised to strictly adhere
to a diet excluding milk and milk products, all kinds of
nuts and nutcontaining foods, egg and eggcontaining
foods, sea fish and prawns, brinjal and soybean for a
period of 3weeks. The food items to be included
freely to maintain proper nutrition were dal and dal
products, rohu fish, chicken and fruits. Infants who
were 612months old were given protein hydrolysate
formula instead of milk. All the preintervention
parameters were measured again after 3weeks. The
male to female ratio of the study group was 0.92. There
was a statistically significant reduction in severity scores
after dietary elimination alone.[15]
In the present study, 44% patients did not report a
seasonal variation while aggravation in winters was
reported in 22%, in summers by 20% and change of
the season by 14%.
Majority of the patients in a study by Sarkar and
Kanwar had aggravation of their eczema in the
winters(62%) as a result of decreased moisture in
the climate, 17% had aggravation in the summers
probably due to hyperhidrosis, itch and secondary
skin infection.[13] Similar was the findings of Dhar
and Kanwar: 67.14% of infants had aggravation
during winters and 23.36% had aggravation during
summers. The corresponding figures in the childhood
AD patients were 58% and 32.9%, respectively.[10] On
the contrary, in the study by Dhar etal. in different
climatic conditions in Eastern India, 40% patients had
aggravation during summers and only 15% had winter
exacerbation.[14]
AD is more common in the urban than in the rural set
up. This is probably because of industrialization and
changed lifestyle. This was evident as 68% of patients
in the present study were from an urban background
while 32% belonged to rural areas.
Pollution certainly plays a significant role not only
in the precipitation of allergic rhinitis orbronchial
asthma but also in AD. The incidence has been
found to be higher among the new immigrants to the

industrialized countries.[16]
The reduced exposure to bacterial and parasitic
infections in childhood leads to an abnormal
development of the immune system, which tends to
over react to relatively innocuous antigenshygiene
hypothesis. Astudy comparing the severity of AD in
Indian children in the UK or US and in India revealed
a lesssevere form of the disease in children born
and brought up in India. This study highlighted the
influence of acquired factorstemperature, humidity,
food habits, clothing and psychological impacts on
the clinical expression and severity of the disease.[11,17]
The diagnosis of AD is based on a constellation of
signs and symptoms. There is no laboratory gold
standard for the diagnosis of AD. Of the named
objective clinical scales, three scales have been most
widely employed and tested: SCORAD, eczema area
and severity indexand SASS AD. All have shown
evidence of criterion and construct validity against
global assessments of disease severity, patientassessed
pruritus and other variables such as topical steroid use.
Some interobserver variation has been demonstrated
with all three indices and is likely to be a problem
with all scoring systems involving visual assessment by
physicians. Each has advantages and disadvantages,
making it difficult to recommend one index as
superior, although the SCORAD index has been most
widely used in trials.[18]
The present study showed SCORAD to be superior
to SASSAD and objective SCORAD alone in
assessing the disease severity, observing the response
to treatment and predicting disease course and
prognosis. Various studies have compared the scoring
systems for assessing disease severity in AD, but none
has compared these three scores.
The mean reduction in SCORAD, SASSAD and
objectiveSCORAD at 4weeks of followup was
23.552.56, 16.221.99 and 10.461.75 respectively,
which was statistically significant(P<0.005). The tvalue
obtained after applying paired Students ttest showed
maximum value for SCORAD, followed by SASSAD
and objective SCORAD, showing that SCORAD was
better in assessing the disease severity in patients of AD.
In the present study, there was mean reduction of
18233cells/mm3 in the absolute eosinophil count
at 4weeks of followup, which was statistically
significant(P<0.005). Serum immunoglobulin E(IgE)
levels could not be performed due to lack of facility.
Immunological abnormalities like excessive formation

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Thakur, etal.: Scoring atopic dermatitis

of IgE, with a predisposition to anaphylactic

sensitivity, some decrease in susceptibility to delayed
hypersensitivity, abnormalities in the expression of
surface molecules in antigenpresenting cells and
dysregulation of cytokine mediators are often noted
in patients of AD. The severity has some positive
correlation with the absolute eosinophil count and
serum IgE levels in AD patients.
In a study group, 102 consecutive patients, both
children and adults, with AD were enrolled and 107
ageand sexmatched persons without any personal
or family history of atopy were taken as controls.
Patients with AD having other systemic diseases were
excluded from the study. The mean age at the onset
of AD was 4.55(standard deviation[SD] 3.63) years
and in patients with AD, the mean absolute eosinophil
count was 624(SD 590) and the mean IgE level was
278.29(SD 324.85); the corresponding values were
121(SD 109) and 25.8(SD 23.36), respectively, for
the controls. The absolute eosinophil count and the IgE
level were higher in patients with AD than in controls.
Both absolute eosinophil count and the IgE level
showed significant covariance with disease severity.
There was a significant association of the absolute
eosinophil count and the IgE level with a family
history of AD only when both parents were affected.
The eosinophil count and the IgE level also showed
a significant association with a history of bronchial
asthma in patients with AD, but not with allergic
rhinitis. The elevated IgE response and eosinophilia
observed in patients with AD may reflect increased
responses of type2 Th2 cytokines with a concomitant
decrease in interferongamma production.[11,19]

CONCLUSION
SCORAD is better to assess the severity and monitor
the progression of the disease as it assesses both
subjective and objective parameters.
Objective SCORAD alone has better prognostic
value than SASSAD. SCORAD is more sensitive to
changes in the patients clinical condition as well as
hematological profile.

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How to cite this article: Thakur A, Malhotra SK, Malhotra S. Scoring atopic
dermatitis and six sign atopic dermatitis: Comparison of prognostic and
predictive value in atopic dermatitis. Indian J Paediatr Dermatol 2013;14:13-8.
Source of Support: Nil, Conflict of Interest: Nil

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