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British Journal of Dermatology 2000; 142: 728732.

The Salford Psoriasis Index: an holistic measure of psoriasis


severity
B.KIRBY,* D.G.FORTUNE,* M.BHUSHAN,* R.J.G.CHALMERS* AND C.E.M.GRIFFITHS*
*Dermatology Centre and Department of Behavioural Medicine, University of Manchester, Hope Hospital, Salford M6 8HD, U.K.
Accepted for publication 3 December 1999

Summary

We have developed, tested and validated a new scoring system for psoriasis: the Salford Psoriasis
Index (SPI). The SPI incorporates the current clinical extent of psoriasis based on the Psoriasis Area
and Severity Index (PASI), a score indicating psychosocial disability, and past severity based on
treatment history. The resultant three-figure SPI (signs, psychosocial disability, interventions) is a
similar paradigm to the TNM (tumour, nodes, metastasis) classification used for cancer staging. The
first figure transforms the PASI into a number from 0 to 10 reflecting extent of psoriasis. The second
assesses the psychosocial impact of psoriasis on each patient using a 010 visual analogue scale.
The third figure reflects historical severity of disease as judged by the need for systemic treatment,
admission to hospital and number of episodes of erythroderma.
The SPI was prospectively employed in assessing 150 consecutive patients with psoriasis.
Furthermore, in a separate cohort of 100 patients we tested the Psychosocial Impact Score against a
recognized self-report psoriasis-specific measure, the Psoriasis Disability Index. There was a strong
correlation between the two (r = 059, P , 0001). However, the Psychosocial Impact Score
correlated poorly with clinical extent scores such as the PASI (r = 028, P , 005) and the Selfadministered PASI in 72 patients tested (r = 019, P = 01). There was a high correlation between
all six observers in 20 patients for both PASI (r = 071; 95% confidence interval, CI 051086)
and the Extent Score (r = 070; 95% CI 056089). We believe that the SPI will be more relevant
to real-life categorization of psoriasis severity in that it takes an holistic approach based not only on
physician assessment but also psychological disability and treatment resistance.
Key words: Psoriasis Area and Severity Index, psoriasis, psychological disability, treatment

The most widely used tool for assessing psoriasis


severity is the Psoriasis Area and Severity Index
(PASI).13 The PASI provides a measure of disease
severity at the time of assessment by combining
estimates of overall disease extent (percentage area of
skin involved) with a score for erythema, induration
and desquamation in each of four body sites (head,
trunk, upper limbs, lower limbs). Although it gives a
reasonable `snapshot' of psoriasis activity at a single
time-point, it cannot assess the psychosocial impact of
psoriasis, its resistance to treatment or the speed of
relapse following treatment. Modern dermatological
practice demands an individual, tailored approach to
disease therapy, wherein important factors such as
psychological disability and prior responsiveness to and
Correspondence: Professor C.E.M.Griffiths.
E-mail: cgriffiths@fs1.ho.man.ac.uk
This paper was presented in part at the Annual Meeting of the British
Association of Dermatologists, Edinburgh, U.K., 2 July 1999.

728

tolerance of different therapies are taken into


account.3,4 Various studies have indicated that the
PASI and other estimates of global psoriasis severity are
insufficient to cope with these demands.46 In an
attempt to address these concerns we have developed
and validated a new measurement tool for psoriasis, the
Salford Psoriasis Index (SPI).

Patients and methods


The Salford Psoriasis Index
The SPI is derived from combining a score of current
severity of psoriasis based on the PASI, a score
indicating psychosocial disability, and a score based
on historical information. The resultant three-figure
SPI (signs, psychosocial disability, interventions) is a
similar paradigm to the TNM (tumour, nodes, metastasis) classification used for cancer staging.7
q 2000 British Association of Dermatologists

SALFORD PSORIASIS INDEX 729

Table 1. Conversion table: Psoriasis Area and Severity Index (PASI)


to Extent Score
PASI

Extent Score

0
013
315
518
8111
11114
14118
18123
23129
29136
36 +

0
1
2
3
4
5
6
7
8
9
10

Initially, a patient's PASI is calculated by the


standard method:13 PASI = 01 (Eh + Ih + Dh) Ah
+ 03 (Et + It + Dt)At + 02 (Eu + Iu + Du) Au + 04
(El + Il + Dl)Al, where E = erythema, I = induration,
D = desquamation and A = area at the sites h, head; t,
trunk; u, upper limbs; l, lower limbs. A numerical value
is given to the extent of the lesions in these areas as
follows: 1, , 10%; 2, 10 to , 30%; 3, 30 to , 50%; 4,
50 to , 70%; 5, 70 to , 90%; 6, 90 to 100%. E, I and
D are assessed according to a five-point scale: 0, no
psoriasis; 1, slight; 2, moderate; 3, marked; 4, very
marked. The first figure of the SPI transforms the PASI
into a number from 0 to 10, with each number
corresponding to a band of PASI values (Table 1).
The second figure indicates the psychosocial impact
of psoriasis on each patient using a 010 visual
analogue scale (VAS). As presented to patients, this is
vertically orientated with 10 (completely affected) at
the top and 0 (not at all affected) at the bottom.
Patients are asked to mark on this scale the extent to
which they perceive that their psoriasis is affecting
their day-to-day life at the time of the assessment.
The third figure reflects historical disease severity as
judged by the need for systemic treatment or admission
to hospital and by the number of episodes of
erythroderma (Table 2). Thus, each systemic therapy,
including psoralen-ultraviolet A (PUVA), is assigned a
score of 1 if given for less than 12 months and 2 if
received for more than that. One extra point is
assigned: (i) for every five admissions for in-patient

treatment; (ii) if the total cumulative dose of PUVA


exceeds 200 treatments or 1000 J cm22; and (iii) for
every episode of erythroderma.
Validation
The SPI was employed prospectively in 150 consecutive
patients with psoriasis seen in the Psoriasis Specialty
Clinic at the Dermatology Centre, Hope Hospital,
Salford. Additionally, the VAS-derived psychosocial
impact score was tested against two well-documented
subjective measures of psoriasis severity, the Selfadministered PASI (SAPASI)8 and the Psoriasis Disability Index (PDI)9 in 100 consecutive patients with
psoriasis. The level of interobserver agreement for all
three components of the SPI was assessed and
compared with the PASI in 20 patients with psoriasis
by six trained clinical observers (two consultant
dermatologists, two specialist registrars in dermatology
and two specialist dermatology nurses). The SPI was
also compared with the PASI as a tool for assessing
treatment responses in a subsequent cohort of 20
patients.
Statistical methods
The results were analysed using Spearman's correlation coefficient, and a two-tailed test was used to
assess the significance of the correlations. Values are
given as mean ^ SD.

Results
The SPI proved easy to implement, even in a busy
clinic, and the SPI values obtained from individual
patients were easily translatable into clinically relevant
information for the dermatologist managing the
patient. For instance, an overall value of 1 : 1 : 0
indicates minimal extent; minimal psychosocial impact;
no systemic treatments, no episodes of erythroderma
and fewer than five admissions to hospital. In contrast
to this, a value of 10 : 10 : 6 would indicate erythrodermic psoriasis, a large psychological disturbance and
significant past requirement for systemic therapy
and/or repeated hospital admissions. We illustrate the

Table 2. Calculation of Historical Disease Severity Scores for the Salford Psoriasis Index
1
1
1
1
1

point
extra
extra
point
point

for each individual systemic treatment including PUVA


point for each treatment received for . 1 year
point if patient has received . 200 treatments or . 1000 J cm22 of PUVA
for every five hospital admissions for the treatment of psoriasis
for every episode of erythroderma

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730 B.KIRBY et al.

clinical use of SPI with three patients from the


cohort of 150.
Patient 1
A 36-year-old man with a 15-year history of psoriasis
had in the past required PUVA, acitretin, cyclosporin,
hydroxyurea and 10 admissions to hospital to manage
his psoriasis. At a recent assessment his PASI was 320
(Extent Score 9), and his Psychosocial Impact Score
was 10. He had had a cumulative dose of 200 J cm22
of PUVA therapy, but one episode of severe erythema
while on PUVA had resulted in a severe flare of
psoriasis; he was therefore reluctant to have PUVA
again. Acitretin 50 mg daily for 6 months did not
control the disease and at a higher dose resulted in
intolerable cheilitis and in hyperlipidaemia. He
responded well to cyclosporin therapy 45 mg kg21
daily, but developed hypertension which was not
controlled by the addition of nifedipine. His psoriasis
was poorly controlled at the reduced dose of 3 mg kg21
daily, and hydroxyurea 500 mg twice daily was added
with little effect on the severity of disease. He drinks
approximately 20 units of alcohol weekly and is
unwilling to alter his alcohol intake. Methotrexate
therapy is therefore contraindicated. He has never been
erythrodermic. His SPI of 9 : 10 : 7 reflects extensive
psoriasis, a large degree of psychological disability due
to the disease and past difficulty in managing his
psoriasis.

7 years and had been admitted to hospital twice for


control of psoriasis. At assessment his PASI was 68
(Extent Score 3) and his Psychosocial Impact Score was
2, giving an SPI of 3 : 2 : 5. This reflects mild disease
extent at the time of assessment, with mild psychosocial
disability. However, the Historical Disease Severity Score
of 5 suggests that his disease had been difficult to
manage in the past.
These representative cases indicate that the SPI
provides a sophisticated tool for assessing overall
disease severity and difficulty of disease management
in patients with psoriasis.
Validation
The individual components of the SPI were validated
against each other and against known measures of
disease severity in psoriasis.
Correlation between components of the Salford Psoriasis
Index. In a cohort of 150 patients, there was a modest
correlation between the Extent Score and both the
Psychosocial Impact Score (r = 036, P , 001) and
the Historical Disease Severity Score (r = 032,
P , 001), indicating that separately, all three components of the SPI give an indication of disease
severity.
Correlation between Psychosocial Impact Score and
Psoriasis Disability Index. In a different cohort of 100

Patient 2
An 18-year-old girl has had psoriasis for 2 years. In the
past she had required two admissions to hospital and
one course of out-patient ultraviolet (UV) B therapy.
She had never been erythrodermic nor had required
systemic therapy. At assessment her PASI was 32
(Extent Score 2) and her Psychosocial Impact Score
was 10. Therefore the SPI was 2 : 10 : 0. Despite
psoriasis of minimal extent her psychological disability
was considerable. Although her Historical Disease
Severity Score was 0, suggesting that her psoriasis
may be readily amenable to treatment, the Psychosocial
Impact Score indicates that she may not accept
anything less than total clearance of her psoriasis.
Patient 3
A 72-year-old man has had psoriasis for 20 years. In
the past he had received . 1000 J cm22 of PUVA
therapy, razoxane for 2 months, methotrexate for

Figure 1. The Psychosocial Impact Score (visual analogue scale,


VAS) correlates with the Psoriasis Disability Index (PDI). (r = 059,
P , 0001.)

q 2000 British Association of Dermatologists, British Journal of Dermatology, 142, 728732

SALFORD PSORIASIS INDEX 731

patients, we found that the Psychosocial Impact Score


correlated well with the PDI (r = 059, P , 0001;
Fig. 1).
Correlation between Psychosocial Impact Score, Psoriasis
Area and Severity Index (PASI) and Self-administered PASI.
In the same cohort, the correlation between the
Psychosocial Impact Score and PASI was much weaker
(r = 028, P , 005) and less than that between the
PDI and PASI (r = 045, P , 0001). Seventy-two
patients from this cohort completed the SAPASI,
which is derived from the patients' own estimates
of psoriasis extent and erythema, infiltration and
scale. The Psychosocial Impact Score did not
correlate with SAPASI (r = 019, P = 01), although
a weak correlation between the PDI and SAPASI was
found (r = 027, P , 005). The SAPASI did, however,
correlate with the PASI (r = 054, P , 0001), as has
been previously demonstrated.9
Reproducibility of Salford Psoriasis Index and Psoriasis
Area and Severity Index. The reproducibility between
observers of the SPI and PASI was assessed in a
subsequent cohort of 20 patients, each of whom was
examined at the same session by six trained observers
(two consultant dermatologists, two specialist registrars
and two specialist dermatology nurses). There was a
high correlation between the six observers for both
the PASI (r = 071; 95% confidence interval, CI
051086) and the Extent Score (r = 070; 95%
CI 056089). The PASI correlated well with the
Extent Score for all six observers (r = 095099,
P , 0001). As would be expected, the reproducibility of the Psychosocial Impact Score for each
patient was very high (r = 0997; 95% CI 0994
0999). The intraclass correlation coefficient for the
Historical Disease Severity Score was 086 (95% CI
076094).
Influence of treatment on Salford Psoriasis Index. In a
separate cohort of 20 patients, we measured the SPI
on patients prior to and after 6 weeks treatment
with a number of modalities. The mean SPI
decreased from mean ^ SD 63 ^ 19: 78 ^ 20:
25 ^ 11 to 36 ^ 21: 38 ^ 23: 25 ^ 11. This
was statistically significant for both the Extent and
Psychosocial Impact Scores (P , 00001). Unsurprisingly, the mean Historical Disease Severity Score
was not significantly changed after 6 weeks of therapy
(P = 016).

Discussion
We have developed and validated a new index of
psoriasis severity that addresses the concept of
assessing whether an individual patient will be `easy'
or `difficult' to manage. By using the extent of psoriasis
as just one component of the total index, we were able
to lessen the emphasis that may be inappropriately
placed on current clinical extent in assessing overall
disease severity. Each figure in the SPI represents an
important entity in itself and, consequently, the three
figures should not be summed but remain separate. As
an aide memoire, the three components of the SPI can
be easily recalled if the mnemonic `signs, psychosocial
disability, interventions' is utilized. The SPI provides
more information on disease than previous assessment
tools for psoriasis, particularly as it provides an
indication of potential difficulty in management of the
individual patient. We have also demonstrated that the
SPI can be used to document the effects of therapy both
on the extent of psoriasis and on its psychosocial
impact on the patient. Indeed, over time it is only these
components of SPI that are amenable to change in a
downward direction.
As might be expected, our Extent Score correlates
significantly with PASI, and no significant loss of
sensitivity results from converting PASI to our simplified Extent Score. This is the largest study, to date, to
investigate the interobserver variability for PASI, an
important concept for clinical researchers who use
this assessment tool. A good correlation, r = 071,
indicates that in the hands of trained observers the
PASI is a reliable measure of current psoriasis extent.
We are currently studying methods of simplifying the
calculation of the Extent Score, without using PASI and
without affecting reproducibility. We would hope
thereby to produce an instrument which can be used
routinely by dermatologists to record psoriasis extent.
Some patients have a large degree of psychological
disability from psoriasis despite having a low PASI or
Extent Score, whereas the reverse may be true for
others. Indeed, research has demonstrated the desynchrony between clinical severity and psychosocial
functioning in psoriasis.10,11 The second component
of SPI, the Psychosocial Impact Score, is able to reflect
this, as is shown by its poor correlation with scores of
current psoriasis extent (PASI and SAPASI). It correlates well with the PDI but has the advantage of being
much quicker and simpler to measure. In a minority of
patients, the correlation between our psychosocial
disability score and PDI was poor. This may be due to

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732 B.KIRBY et al.

the fact that PDI assesses psychosocial disability over a


4-week period whereas our score measures the current
situation.
The third component of SPI is the Historical Disease
Severity Score, which puts the difficulty in managing
an individual patient into an historical context. For
example, a patient who has required four different
systemic treatments either because of resistance to or
intolerance of individual therapies and has been
erythrodermic in the past presents a therapeutic
challenge. Even if such a patient achieves clearance
with a particular therapy, rapid relapse can be
anticipated. This score will not decrease with
successful treatment, unlike the Extent and Psychosocial Disability Scores.
When developing the Historical Disease Severity
Score, we did not incorporate narrow-band UVB
(TL-01) therapy or day-care treatment. The place of
narrow-band UVB therapy in the therapeutic ladder for
psoriasis is not certain and at this time is not regarded
as a systemic therapy. If in time it comes to be regarded
as the equivalent of a systemic therapy or PUVA, the
SPI is flexible enough to allow that addition. Day
treatment centre/day case management of psoriasis is
used increasingly in place of in-patient admission in
many parts of the U.K. and elsewhere. It is probably
justifiable to interpret a course of day treatment centre
management as equivalent to a single in-patient
admission, and the former could be substituted for
the latter in the treatment component of the SPI.
Although the PASI has become internationally
accepted as a tool for documenting psoriasis severity,
there is a need for a more sophisticated instrument
capable of meeting the challenges of managing
psoriasis in the twenty-first century. We believe that
the SPI, by incorporating scores for current extent,
psychosocial disability and historical severity, provides
a simple, comprehensive and easily comprehensible
overview of psoriasis severity. The three-figure index is
readily interpretable by dermatologists who may be
involved in a patient's subsequent management and
provides all the basic information required to assess

whether an individual patient will be `easy' or `difficult'


to manage. Future studies will examine the value of the
SPI as a predictor of treatment outcomes for psoriasis,
the development of an Extent Score not derived from
the PASI, and the reproducibility of the SPI.

Acknowledgments
We acknowledge the assistance of Susan Bowcock and
Sally Kelly in assessing the interobserver variability of
the SPI and PASI. We thank Dr A.Fleischer (Wake
Forest, NC, U.S.A.) and Professor A.Finlay (University of
Wales, Cardiff, U.K.) for kindly allowing us to use their
scoring indices, the SAPASI and PDI, respectively.
Dr B.Kirby is in receipt of a grant from Novartis
Pharmaceuticals Limited.

References
1 Fredriksson T, Pettersson U. Severe psoriasisoral therapy with a
new retinoid. Dermatologica 1978; 157: 23844.
2 van de 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: 6613.
3 van de Kerkhof PCM. On the limitations of the psoriasis area and
severity index (PASI). (Letter.) Br J Dermatol 1992; 126: 205.
4 Ramsay B, Lawrence CM. Measurement of involved surface area
in patients with psoriasis. Br J Dermatol 1991; 124: 56570.
5 Marks R, Barton S, Shuttleworth D, Finlay AY. Assessment of
disease progress in psoriasis. Arch Dermatol 1989; 125: 23540.
6 Vardy OA, Guberman D, Lichtenstein DA, Klaus SN. Assessment
of severity score in patients with psoriasis. Br J Dermatol 1993;
129: 34950.
7 Sobin LH, Fleming ID. TNM classification of malignant tumours,
5th edn. 1997. Union Internationale Contre le Cancre and the
American Joint Committee on Cancer. Cancer 1997; 80: 18034.
8 Feldman SR, Fleischer AB, Reboussin DM et al. The selfadministered psoriasis area and severity index is valid and
reliable. J Invest Dermatol 1996; 106: 1836.
9 Finlay AY, Khan GK, Luscombe DK, Salek MS. Validation of
sickness impact profile and psoriasis disability index in psoriasis.
Br J Dermatol 1990; 123: 7516.
10 Ginsburg IH, Link BG. Feelings of stigmatization in patients with
psoriasis. J Am Acad Dermatol 1989; 20: 5363.
11 Fortune DG, Richards HL, Main CJ, Griffiths CEM. What patients
with psoriasis believe about their condition. J Am Acad Dermatol
1998; 39: 197201.

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