Clinical study assessment, SAPASI, PASI Clinical evaluation ()f SAPASI Clinical evaluation of the Self- Admin-istered Psorias-is Area and Severity lndex (SAPASJ) J. C. Szepietowski, M. Sikora, T. Pacholek and A. Dmochowska ABSTRACT lntroduction: Psoriasis Area and Severity lndex (PASI) is used by dermatologists to assess psoriasis disease intensity. The Self-Administered Psoriasis Area and Severity lndex (SAPASI) was developed to allow patients to evaluate the intensity of psoriasis by themselves. Objectives: This study was undertaken to evaluate the validity and usefulness of the SAPASI scoring method in Polish psoriatic patients. Material and methods: 51 patients suffering from psoriasis were included into the study. PASI assess- ment was performed by trained staff and the Extent Score from Salfard Psoriasis lndex (SPI) was calcu- lated. Moreover, the patients were asked to complete SAPASI evaluation. The studied indexes, as well as their elements (area involvement, severity), were compared using Spearman rank correlation test. Results. SAPASI significantly correlated with PASI and Extent Score from SPI far the whole group of patients. Both females and males assessed their total skin symptoms (SAPASI) similarly to PASI evalua- tion, however stronger correlation between SAPASI and PASI was faund far female than male patients. There was no significant correlation between severity SAPASI and severity PASI when assessed by male patients. The age of patients did not influence their evaluation of skin lesions. Patients with longer history of psoriasis assessed intensity of the disease more accurately than those with shorter duration of psoriasis. Conclusion: SAPASI appeared to be a useful instrument in measuring clinical intensity of psoriasis. Introduction The Psoriasis Area and Severity Index (PASI) was originally clescribed as a method for quantifying the in- tensity of psoriasis, ancl for evaluating its improvement with treatment (1). This inclex is based on the quantita- tive assessment of three typical signs of psoriatic lesions: erythema, infiltration, ancl desquamation, combinecl with the skin surface area involvement. Since its cleve- lopment in 1978 (1) this instrument has been used Acta Dermatoven APA Vol 10, 2001, No 3 ----- ---------- ----- - --------- - - 79 Clinical evaluation of SAPASI throughout the worlcl by clinical investigators. Because PASI measures require trainecl staff, its application to large-scale research on psoriasis is limitecl. Self-Aclmin- isterecl Psoriasis Area ancl Severity Inclex (SAPASI) was clevelopec.l for self-measurement of psoriasis severity for its use in the future large-scale studies (2,3). The purpose of this stucly was to evaluate validity ancl usefulness of SAPASI scoring methocl in popula- tion of Polish psoriatic patients with respect to sex, age and cluration of the clisease. Material and methods The stucly group consistec.l of 51 inclivicluals (18 fe- males , 33 males) in the age group from 12 to 78 years, mean 46.6±17.3 years. The shortest period of c.lisease was 2 months anc.l the Iongest one 48 years, mean 17.8±11.9 years. 40 patients sufferecl from psoriasis vul- garis, ancl 11 from arthropathic psoriasis. Each patient hac.l performecl PASI assessment. The PASI values were from 0.6 to 48.8 points, mean 16.1±11.9 points. SAP ASI instrument consistecl of two parts (2,3) . The first was a line-clrawing silhouette of the front ancl back of patient's bocly ancl patients were instructecl to shacle areas affected by psoriasis. A single investigator (MS) assignecl a numeric value of O to 6 corresponcling to O to 100% involvement for each of the 4 areas: head, upper extremities, trunk ancl lower extremities. Both the original PASI score ancl the SAPASI cover the in- volvement of these above mentionecl areas: as 10%, 20%, 30% ancl 40% ofthe total body surface area, 10% (head), 20% (upper extremities) , 30% (trunk), 40% (lower ex- tremities) of the total bocly surface area. The second part of this sheet contained three moclifiecl visual ana- log scales (VAS) enablec.l patients to clescribe the color, thickness, anc.l scaling of an "average" psoriatic Iesion. The VAS for erythema contains the following worc.l de- scriptions: no rec.lness, slight pink, pink, reci, and c.lark red. Simila rly, the VAS for thickness contained the c.le- scriptions: no thickness, feels firm , raisecl, thick, ancl ve1y thick; scaling VAS contained: no scale , s light scale, scaly, flaky, very flaky. The SAPASI was calculated from the equation given below: SAPASI=[(O.Lx,\)+(0,2x1\)+(0,3xA,.)+(0,4x1\)J[0,0333x(VASE+VAS,+VAS)] A11 - heacl area score; Au- upper extremity area score; Ar- trunk area score; A1.- lower extremity area score ; VASE- VAS e1ythema score; VAS 1 - VAS inc.luration score; VAS 5 - VAS scale score We calcu latecl ancl comparecl the fo llowing clata: SAPASI, PASI, area SAPASI , area PASI, severity SAPASI (sum of e1ythema, induration, and scaling for "average" lesion chosen by patient), severity PASI (sum of e1ythema, incluration, ancl scaling for region chosen by patient, total severity PASI (sum of e1ythema, inclura- tion , ancl scaling for ali parts of the bocly), ancl Extent 80 Table 1. Conversion table PASI to Extent Score from SPI (4) o o O 1-3 1 3 1-5 2 51-8 3 8.1-11 4 11 .1-14 5 14.1-18 6 18.1-23 7 23.1-29 8 29.1-36 9 36+ 10 Score from Salforcl Psoriasis Index (SPI) (Table 1) ( 4). Statistical analysis was performecl using Spearman rank correlation test. P-values 55 years old 0.82 <0.001 <2 years duration of psoriasis 1 NS 2-1 O years dura ti on of psoriasis 0.78 <0.01 > 10 years duration of psoriasis 0.56 <0.001 SAPASI & Extent Score wholegroup 0.62 <0.00001 fromSPI males 0.47 <0.01 females 0.82 <0.0001 <30 years old 0.75 <0.01 30-55 years old 0.51 <0.01 >55 years old 0.83 <0.001 <2 years duration of psoriasis 0.94 <0.06 NS 2-1 O years dura ti on of psoriasis 0.49 <0.1 NS > 10 years dura ti on of psoriasis 0.39 <0.03 Area SAPASI & area PASI whole group 0.82 <0.000001 males 0.76 <0.000001 females 0.92 <0.000001 <30 years old 0.92 <0.0001 30-55 years old 0.8 <0.00001 >55 years old 0.9 <0.0001 <2 years duration of psoriasis 0.94 <0.06 NS 2-1 O years dura ti on of psoriasis 0.83 <0.001 > 1 O years duration of psoriasis 0.77 <0.000001 Severity SAPASI & whole group 0.35 <0.01 severity PASI males 0.24 <0.2 NS females 0.64 <0.01 <30 years old 0.06 <0.9 NS 30-55 years old 0.3 <0.2 NS >55 years old 0.78 <0.001 <2 years duration of psoriasis 0.94 <0.06 NS 2-1 O years duration of psoriasis 0.49 <0.09 NS > 1 O years dura ti on of psoriasis 0.39 <0.03 Severity SAPASI & whole group 0.33 <0.02 total severity PASI males 0.14 <0.43 NS females 0.77 <0.001 <30 years old 0.46 <0.2 . NS 30-55 years old 0.81 <0.000001 >55 years old 0.67 <0.01 <2 years duration of psoriasis 0.83 <0.16 NS 2-1 O years dura ti on of psoriasis 0.71 <0.01 > 10 years dura ti on of psoriasis 0.26 <0.2 NS Acta Dermatoven APA Vol 10, 2001, No 3 81 Clinical evaluation of SAPASI tients older than 55 years (p<0.001) (Table 2). Analysis of correlations between studied indexes according to the duration of the disease revealed that patients with long-lasting psoriasis assessed their total intensity of psoriasis (SAPASI) and severity of the le- sions (severity SAPASI) more accurately than patients with shorter history of the disease (Table 2). There was no significant clifference in the evalua- tion of skin lesions in the compared indexes between patients suffering from psoriasis vulgaris and arthro- pathic psoriasis (data not shown). Discussion Psoriasis is a common chronic dermatosis. It affects up to 2% of general population (5 ,6,7). A huge number of clinical investigations of psoriasis are published each year. However, the evaluation of clinical symptoms in psoriasis is stil! a clilemma. Severa! clinical scoring meth- ods have been proposecl, among them PASI being the most popular one (8-12). Moreover, severa! substances, such as serum levels of cytokines, aclhesion molecules and other agents have been studiecl as eventual mark- ers of psoriasis intensity (13-16). In 1994 a new scoring method - SAPASI was proposecl (2). This methocl seems to be interesting due to possibility of its use for bigger stuclies , as the patients could monitor disease intensity by themselves. To the best of our knowleclge only two papers evaluating validity and usefulness of SAPASI scor- ing methocl have been published in English literature (2,3). Both these studies showecl significant correlation between SAPASI and PASI, indicating that SAPASI could be successfully used in psoriatic patients (2,3). Both studies were performed in the States only in one center ancl the American psoriatic patients were incluclecl into them (2,3). As there are severa! clifferences in health care system organization ancl eclucation of psoriatic patients between United States and Polanc!, the results of the mentioned papers on SAPASI, coulcl not be cli- rectly applied in our count1y. In Polanc! there are stil! no organized eclucation groups for psoriatic patients. Moreover, more patients are hospitalized. Therefore, the present study seems to be relevant to confirm validity and usefulness of SAPASI in Polish psoriatic patients. SAPASI appearecl to be a useful scoring method for our patients, as we were able to demonstrate signifi- cant correlation between SAPASI ancl PASI, which is in agreement with previously published data (2,3). Felclman et al. (3) founcl evaluation of intensity of inclu- ration performed by female patients less accurate than done by male patients. However when erythema and scaling were considered, SAPASI performed by females showed stronger correlation with PASI than compared to males (3). Interestingly, our female patients evalu- ated their skin symptom more accurately than males, especially if severity of all lesions together was assessecl. Moreover, patients suffering from psoriasis for longer periocls evaluatecl intensity of psoriasis better than pa- tients clicl with shorter history of the disease. This is not very surprising, as these patients have more experience with their disease and probably are better dermato- logically educatecl. Conclusion The study showed strong relationship between SAPASI and PASI assessments. Based on our cletailed analysis it seems that SAPASI - evaluation of psoriatic lesions by patients - could be successfully used world- wide in future clinical stuclies for ali psoriatic patients except those suffering over short periods. For those patients PASI evaluation shoulcl be recommendecl. More objective methocls for clinical evaluation of the inten- sity of psoriasis are still required. Acknowledgements: This study was supported by the grant No. 870 pro- vided by Wroclaw University of Medicine. Figure 1 . Correlation between SAPASI and PASI in the whole group of studied patients (n=51, r=0.62, p<0.00001) Clinical study 2,6 ,-----------------------, 2,2 1,8 1,4 1,0 (/) t 0,6 ~ 0,2 o o o -0,2 '------------------~--~ -5 5 15 25 PASI 35 45 55 82 -------- -------- ---------- ---------Acta Dermatoven APA Vol 10, 2001, No 3 C l in i c a l s t u d y Clinical evaluation of SAPASI 1-l E F E H E N C E S 1. Fredriksson T, Petersson U: Severe psoriasis - oral therapy with a new retinoid. Dermatologica 1978; 157: 238-41. 2. Fleischer AB, Jr, Rapp SR, Reboussin DM, Vanarthos JC, Feldman SR: Patient measurement of psoriasis disease severitywith a structured instrument. J Invest Dermatol 1994; 102: 967-9. 3. Feldman SR, Fleischer AB Jr, Reboussin DM, Rapp SR, Exum ML, Clark AR, Nurre L: The self-adminis- tered psoriasis area and severity index is valid and reliable. J Invest Dermatol 1996; 106: 183-6. 4. Kirby B, Fortune DG, Bhushan M., Chalmers RJG, Griffiths CEM: The Salford Psoriasis Index: an holis- tic measure of psoriasis severity. Br J Dermatol 2000; 142: 728-32. 5. Farbor EM, Nall L: Epidemiology: natura! history and genetics [in] Roenigk HH, Jr, Maibach HI. Pso- riasis. New York, Marcel Dekker Inc, 1998; 107-10. 6. Barisic-Drusco V, Paljan D, Kansky A, Vujasinovic S: Prevalence of psoriasis in Croatia. Acta Derm Venereol (Stockh) 1989; suppl. 146: 178-9. 7. Braethen LR, Botten G, Bjerkedal T: Prevalence of psoriasis in Norway. Acta Derm Venereol (Stockh) 1984; suppl. 142: 5-8. 8. Harari M, Shani J, Hristakieva E, Stanimirovic A, Seidl W, Burdo A: Clinical evaluation of a more rapid and sensitive Psoriasis Assessment Severity Score (PASS), and its comparison with the classic method of Psoriasis Area and Severity Index (PASI) , before and after climatotherapy at the Dead-Sea. Int. J Dermatol 2000; 39: 913-8. 9. Marks R, Barton SP, Shuttleworth S, Finlay AY: Assessment of disease progress in psoriasis. Acta Derm- Venereol (Stockh) 1989; 125: 235-40. 10. Vardy DA, Guberman D, Lichtenstein DA, Klaus SN: Assessment of severity score in patients with psoriasis. Br J Dermatol 1993; 129: 349-50. 11. Van der Kerkhof PCM: The Psoriasis Area and Severity Index and alternative approaches for the assessment of severity: persisting areas of confusion. Br J Dermatol 1997; 137: 661-3. 12. Ramsay B, Lawrence CM: Measurement of involved surface area in patients ,vith psoriasis. Br J Dermatol 1991; 124: 565-70. 13. Szepietowski J, Wasik F, Bielicka E, Nockowski P, Noworolska A: Soluble E-selectin serum levels correlate ,vith disease activity in psoriatic patients. Ciin Exp. Dermatol 1999; 24: 33-6. 14. SzepietowskiJ, Bielicka E, Nockowski P, Noworolska A, Wasik F: Increased inerleukin-7 levels in the serum of psoriatic patients: Jack of correlation with interleukin-6 levels and disease intensity. Ciin Exp Dermatol 2000; 25: 643-7. 15. Sanchez-Ragana M., Catasus M., Creus M., Umbert P: Serum neopterin as an objective marker of psoriasis disease severity. Acta Dermatol Venereol (Stockh) 2000; 80: 185-7. 16. Bonifatic C, Mussi A, Carducci M., Pittarello A, D'Auria L, Venuti A, Bagnato A, Salani D, Fazio M., Ameglio F: Endothelin-1 levels are increased in serum and lesi ona! skin extracts of psoriasis patients and correlate \vith disease severity. Acta Derm Venereol (Stockh) 1998; 78: 22-6. A U T H O R S ' Jacek Szepietowski, MD, PhD, Associate Projessor, Department oj A D D R E S S E S Dermatology and Venereology, University oj Medicine, Ul. Chalubifiskiego 1, 50-368 Wroclaw, Poland, E-mail: žszepiet@derm.am.wroc.pl Magdalena Sikora, same address Tomasz Pacholek, same address Aldona Dmochowska, same address Acta Dermatoven APA Vol 10, 2001, No 3 - ----------------------- --- ------- 83