Are AD Severity Tools Essential in Routine Practice?

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Atopic dermatitis (AD) symptoms, such as persistent itching, skin lesions, and sleep disturbances, can lead to substantial physical and psychological distress. While clinical trials frequently use standardized severity assessment tools to measure treatment efficacy, their necessity in routine clinical practice remains a subject of debate.¹ Recent research explored the advantages and limitations of these measurement tools in AD management.²

Methods

A comprehensive literature review was conducted using Google Scholar and PubMed, employing key terms such as “atopic dermatitis severity measures,” “AD assessment tools,” and “validity of AD measures.” Various objective and subjective measurement tools were analyzed to determine their utility in both research and clinical settings.

Objective Measures (Clinician-Reported Outcomes)

One widely used tool is the Investigator Global Assessment (IGA), a standardized 5-point scale that evaluates the severity of AD at a single time point. “The IGA is convenient for determining the severity of psoriasis and other skin manifestations, as it requires no special equipment or extensive training,” researchers behind the review noted.However, its reliance on clinician judgment introduces variability, limiting its reliability across different practitioners.

The Eczema Area and Severity Index (EASI) is another commonly used assessment, incorporating 4 severity indicators: erythema, induration, excoriation, and lichenification. Though EASI provides a comprehensive evaluation, it does not account for subjective symptoms like itch intensity or sleep disturbances. Similarly, the Scoring Atopic Dermatitis (SCORAD) Index includes both objective and subjective measures but is time-consuming and impractical for routine clinical use.

Researchers stated a combined approach, such as the IGAxBSA (Body Surface Area), aims to address these limitations by incorporating both severity scoring and disease extent. The correlation between IGAxBSA and EASI has been established in several studies, indicating its potential as a viable alternative in clinical practice. However, despite the practicality of IGAxBSA, its implementation remains inconsistent across healthcare settings.

Subjective Measures (Patient-Reported Outcomes)

Patient-reported outcome measures (PROMs) offer insight into patients’ experiences, with the Numerical Rating Scale (NRS) being a widely used tool for assessing itch severity. “The Peak Pruritus (worst itch) and Average Itch Numerical Rating Scale are often used to measure the severity of itching in the preceding 24 hours,” researchers wrote.While these tools provide valuable patient-centered data, they lack clinician objectivity and may not be sufficient for treatment monitoring.

Other subjective tools include the Patient-Oriented SCORAD and the Dermatology Life Quality Index, both of which emphasize patient quality of life. Although these tools add depth to AD assessment, their results can be highly variable based on individual perceptions and external factors such as stress and environmental triggers.

Limitations of Formal Assessment Tools

Researchers recognized the use of standardized tools in clinical trials ensures consistency in treatment evaluation, but their application in everyday practice may not always be necessary. Clinicians often rely on patient satisfaction and symptom control to guide treatment decisions, rather than rigid assessment scores. Additionally, the review noted insurance companies may require specific severity indices for coverage of advanced therapies, which can complicate clinical decision-making. Formal assessments can also be time-consuming, making their routine implementation challenging in busy dermatology clinics.

Some critics argue that real-world AD management should focus more on patient-centered approaches rather than rigid severity scales. Tools like the 2-Point Static Patient Global Assessment and 3-Point Dynamic Patient Global Assessment offer quick, subjective evaluations that can help guide treatment modifications. These approaches prioritize patient perception and satisfaction, which may be more reflective of treatment success than strictly numerical severity scores.

Conclusion

While formal AD severity measurement tools provide objective benchmarks for disease progression and treatment efficacy, the review found their routine use in clinical practice is debatable. Researchers suggested clinicians may benefit from integrating simpler, patient-centered assessments alongside traditional objective tools to ensure a holistic approach to AD management. They noted future research should focus on the cost-effectiveness and practicality of incorporating these assessments into routine patient care. Additionally, a balance between objective and subjective tools should be explored to optimize patient outcomes without overburdening clinical workflows. Overall, researchers found the necessity of formal AD severity tools should be evaluated on a case-by-case basis, taking into account both clinical and patient-centered considerations.

References

1. Schmitt J, Spuls PI, Thomas KS, et al. The Harmonising Outcome Measures for Eczema (HOME) statement to assess clinical signs of atopic eczema in trials. J Allergy Clin Immunol. 2014;134(4):800-807. doi:10.1016/j.jaci.2014.07.043
2. Buttar BA, Yi RC, Ruley AJ, et al. Evaluating the necessity of formal atopic dermatitis severity measurement tools in clinical practice. J Dermatolog Treat. 2025;36(1):2469646. doi:10.1080/09546634.2025.2469646