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
728
Extent Score
0
013
315
518
8111
11114
14118
18123
23129
29136
36 +
0
1
2
3
4
5
6
7
8
9
10
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
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
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
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.
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