Month: January 2022

Table of contents

• Introduction
• Calculating EASI score
• Severity score
• How are the calculations done?
• How do you record the EASI score?
• Severity score X Area score X Multiplier
• What are the advantages of calculating EASI?
• Summary

Introduction

Atopic dermatitis, commonly known as eczema is a common chronic skin condition. Therefore, it is important for doctors or dermatologists to assess its severity and to measure the extent or the area involved in order to manage this condition, as well as to assess the response to treatment in their patients. EASI score is a tool which is used for this purpose. Once you learn how to calculate eczema severity index accurately, it will take only a few minutes to assess an eczema patient. EASI is actually easy!

The Eczema Area and Severity Index (EASI) is a validated scoring system which grades the physical signs of eczema (atopic dermatitis). EASI is a core outcome for measuring the clinical signs of eczema in all clinical trials. However, EASI score includes only the inflamed regions in the body and it does not include a grade for scaling and dryness.

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Calculating Eczema Area and Severity Index score

When calculating EASI, 4 body regions are considered. They are;

1. Head and neck

• Scalp – 33%
• Face – 17% each side, occupies 33%
• Neck – 17% front and back, occupies 33%

2. Trunk including the genital region

• Front – 55%
• Back of trunk – 45%

3. Upper limbs

• 50% right arm
• 50% left arm

Front of each arm is 25% and back of each arm is 25%

4. Lower limbs including the buttocks

• R/leg – 45%
• L/leg – 45%

Front of each leg is 22.5% and back of each leg is 22.5%

For each of the 4 regions of the body, the area score is recorded. Area score is the total percentage of skin affected with eczema for each body region.

Area score	Percentage of skin affected by eczema in each region
0	No active eczema in this region
1	1–9%
2	10–29%
3	30–49%
4	50–69%
5	70–89%
6	90–100%: the entire region is affected by eczema

 

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Severity score

The severity score is also recorded for each region of the body. It is calculated as the sum of the intensity score using 4 different signs. These 4 signs include;

1. Scratching and excoriation
2. Redness of skin (erythema and inflammation)
3. Thickness of skin (swelling and induration in acute eczema)
4. Lichenification (lined skin with furrows and prurigo nodules in chronic eczema.

Half scores are permitted. It is difficult to assess redness in patients with a dark complexion. Therefore, if you are in doubt, you can increase the average redness score by 1 level.

Score	Intensity of redness, thickness/swelling, scratching, lichenification
0	None, absent
1	Mild (just perceptible)
2	Moderate (obvious)
3	Severe

 

How are the calculations done?

You have to record the intensity of each 4 signs for all 4 regions separately and calculate the severity score.

• Severity score = scratching intensity + thickness intensity + redness intensity + lichenification intensity

For each region, multiple the area score by the severity score and by a multiplier. Note that the multiplier is different for each of the body region and is also different in children.

• Head and neck: severity score x area score x 0.1 (in children from 0–7 years the multiplier is 0.2)
• Trunk: severity score x area score x 0.3
• Upper limbs: severity score x area score x 0.2
• Lower limbs: severity score x area score x 0.4 (in children from 0–7 years the multiplier is 0.3)

To determine the final EASI score, add up the total scores for each region. The minimum EASI score is 0. The maximum EASI score will be 72.

How do you record the EASI score?

Body region	Redness	Thickness	Scratching	Lichenification	Severity score	Area score	Multiplier	Region score
Head/neck	_______	+_______	+_______	+_______	=_______	X_______	X 0.1 (If ≤7 yrs, X 0.2)	=_______
Trunk	_______	+_______	+_______	+_______	=_______	X_______	X 0.3	=_______
Upper limbs	_______	+_______	+_______	+_______	=_______	X_______	X 0.2	=_______
Lower limbs	_______	+_______	+_______	+_______	=_______	X_______	X 0.4 (If ≤7 yrs, X 0.3)	=_______
The final EASI score: add up the 4 region scores								=_______ (0-72)

 

All regions has to be added up separately to get each region score. Then the values of each region score in all 4 regions must be added together. Then you will be able to calculate the final EASI score which will be between 0-72.

To help you understand better, let us look at an example of a child with an acute flare of eczema and calculate the EASI score.

Ex: A 5 year old girl has developed an acute flare up of eczema. This flare up has affected all her limb flexures. The trunk of this child is reddish and dry.

Now let us calculate the region scores.

• Since the head and neck is not affected, the score in this region is zero. (severity score = 0 and area score is also 0)
• The trunk is mildly red which gets 1 point. Since it is not scratched and not lichenified no points are given. Skin is thickened only mildly, therefore, can give 1 point. When the points are added thee severity score is 2.

The trunk is affected around 60%, therefore the area score is 4.

• Skin in both elbow flexures are affected by eczema and it is moderately red (2), moderately scratched (2), only mildly thickened (1) but since it is not lichenified it is 0. The severity score adds to 8.

Area score is 1 because less than 10% of both upper limbs are affected.

• Eczema behind both knees are extremely red and is quite severe. 3 points are given. They are severely scratched (3), with severe thickening (3) and mild lichenification (1) is seen. Therefore thee severity score is 10.

Area score is 2, because around 20% of the legs are affected.

Now let us calculate the region score for each of the regions.

Severity score X Area score X Multiplier

• Head and neck = 0
• Trunk = 2 x 4 x 0.3 = 2.4
• Upper limbs = 5 x 1 x 0.2 = 1
• Lower limbs = 10 x 2 x 0.3 = 6.0

EASI score = 2.4 + 1.0 + 6.0 = 9.4

The 5 year old girl with an acute flare of eczema was found to have an EASI score of 9.4.

What are the advantages of calculating EASI?

EASI (Eczema Area and Severity Index ) is a tool or a scale used in clinical trials to assess the extent and severity of eczema. The highest score is 72 which indicates worse severity of eczema. It has been suggested that severity of eczema based on EASI score can be categorized as follows;

• 0 = Clear
• 1 – 1.0 = Almost clear
• 1 – 7 = Mild atopic dermatitis
• 1 – 21 = Moderate severity of atopic dermatitis
• 1 – 50 = Severe atopic dermatitis
• 1 – 72 = Very severe atopic dermatitis

In the example stated above, the 5 year old girl who had an acute flare of eczema falls to the category of moderate severity.

EASI score can also be used to assess the response to treatment.

Summary

The Eczema Area and Severity Index (EASI) is a validated scoring system which grades the physical signs of eczema. The body is divided in to 4 regions and the calculation is done by adding up scores of each region.

EASI score = Severity score X Area score X Multiplier

The severity and extent of eczema can be assessed by calculating thee EASI score and it is an important tool used in clinical trials.

References:

https://dermnetnz.org/topics/easi-score

https://journals.sagepub.com/doi/10.1177/1203475420923644

https://www.ncbi.nlm.nih.gov/books/NBK539234/

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Table of contents

• Eczema vs. Atopic Dermatitis: What is the difference?
• What are the different types of eczema?
• What is atopic dermatitis and how does it differ from other types of eczemas?
• What are the features that are common to all types of eczemas including atopic dermatitis?
• What are the differences between other types of eczemas and atopic dermatitis?
• Summary

Eczema vs. Atopic Dermatitis: What is the difference?

Eczema is a common chronic skin condition. Eczema is the name given for a group of skin conditions that cause your skin to become inflamed, red and itchy. The lighter skin tones usually become red, while darker skin tones become brown, gray or ashen. Eczema is not a contagious skin disease and you cannot ‘catch it’ from someone. However, the exact cause is unknown, but there is a combination of genes and environmental factors that play a role. When an allergen or an irritant which may be from outside (extrinsic) or even inside (intrinsic) your body activates your immune system so that inflammation can set in. The symptoms occur because of this inflammation and it is common to almost all the different types of eczema.

What are the different types of eczema?

There are 7 different types of eczema. They are;

• Atopic dermatitis
• Seborrheic dermatitis
• Contact dermatitis
• Stasis dermatitis (varicose eczema)
• Nummular eczema (discoid eczema)
• Dyshidrotic eczema (pompolyx)
• Neurodermatitis (lichen simplex chronicus)

The above different types of eczema has its own effects on the skin and should be treated accordingly

Although atopic dermatitis is commonly referred to as eczema, it is only a type of eczema. This is probably because atopic dermatitis is the commonest form of eczema. It is the reason why many people simply refers to it as eczema. Research suggests that atopic dermatitis affect 15- 20% of children and 1-3% of adults worldwide.

It is possible to get more than one type of eczema at the same time. However, each type of eczema has its own triggers and the treatment methods can be different. Therefore, it is important to consult a dermatologist who specializes in eczema in order to diagnose the exact type or different types of eczema you have. He or she will be able to formulate a management plan accordingly so that you will be able to prevent future flare ups.

We should be aware about these different types of eczema and take precautions accordingly.

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What is atopic dermatitis and how does it differ from other types of eczemas?

Atopic dermatitis is the commonest type of eczema which makes your skin dry, itchy and cracked. It is commonly seen in children and it develops often before their first birthday. However, atopic dermatitis can develop in adults for the first time.

The difference is that other types of eczemas are commonly seen in adults than in children.

Just like other types of eczemas atopic dermatitis is a chronic (long term) skin condition. In some children it can clear completely or improve significantly as they grow older. This type of improvement with age is seen in atopic dermatitis and not usually in other types of eczemas.

The symptoms of atopic dermatitis may vary. Some will have dry, itchy skin in small patches while others have wide spread inflamed skin throughout their bodies. Atopic dermatitis commonly affects hands, insides of elbows and backs of knees. Although it can affect any part of your body. Face and scalp are affected especially in younger children. Atopic dermatitis may come as flare ups. These are periods when symptoms become more severe.

Like other types of eczemas, atopic dermatitis does not have a clear or an exact cause. ‘Atopic’ means sensitivity to various allergens. Therefore, atopic dermatitis occurs often in people who are prone to get allergies. Atopy runs in families and can associate with other allergic conditions like hay fever and asthma.

Certain triggers like soap, detergents, hot and humid weather and stress can lead to symptoms or flares. Especially in young children even food allergies may play a role.

Here is a brief overview of other types of eczemas.

• Seborrheic dermatitis – also known as seborrheic eczema. It is a type of eczema where red and scaly patches develop on your eye brows, sides of the nose, scalp and ears. Seborrheic dermatitis commonly affects the hair growing areas and areas where oils (sebum) are secreted. It has a scaly, dry appearance and may be caused by a reaction to yeast, which is a commensal organism on our skin.There is an associated over production of Malassezia yeast. This leads to an over reactive immune response that causes skin inflammation. Cradle cap is seborrheic dermatitis seen in infants, and it typically develops within a few weeks after birth and disappears after some time on its own.
• Contact dermatitis – When your body comes in to contact with a certain substance, skin will start to react and this type of eczema can occur. Ex: metals like nickel in watch straps, rubber, certain perfumes, poison ivy, bleach, detergents and other irritants.

This rash is typically red and can itch and burn. Blisters can be seen when severe.

• Stasis dermatitis (varicose eczema) – This type of eczema commonly affects your lower legs. It is caused by problems with blood flow through your leg veins. Gravity causes stasis of venous blood. When there is reduced blood circulation in elderly and in those with varicose veins the blood can seep out. Skin discoloration can occur along with ankle swelling. Chronic venous eczema can associate with non-healing varicose ulcers.
• Nummular eczema (discoid eczema) – in this type of eczema, circular or oval shaped patches occur on skin. There can be triggers like insect bites, chemical burns, skin trauma and dry skin to develop discoid eczema.
• Dyshidrotic eczema (pompolyx) – This is a type of eczema which causes tiny blisters to erupt especially in the palms of your hands. These blisters are often painful. Dyshidrotic eczema can develop in the soles of feet too. It is commonly seen in adults under the age of 40 and in females. Occupational exposure to certain metals, stress, moist hands and hot weather can be common triggers.
• Neurodermatitis(Lichen simplex chronicus)– This is a skin condition that starts with an itchy patch of skin. Scratching makes the lesion itchier. This itch – scratch cycle causes the skin which is affected to become thick and leathery. Several itchy spots may develop typically on the wrists, forearms, neck, legs and anal region. These lesions are very itchy most of the time. Scratching can cause bleeding and even scarring.

What are the features that are common to all types of eczemas including atopic dermatitis?

• The rash occurs due to an inflammation of the skin and sometimes irritation.
• The exact cause is unknown
• Eczema is not contagious.
• All types of eczemas are almost always itchy, including atopic dermatitis.
• Family history is commonly seen
• Treatment commonly includes antihistamines, topical steroids and emollients and especially adhering to self-care measures. However, atopic dermatitis where there are trigger factors removal of such triggers are helpful.
• Eczema is not curable and it can be controlled only.

What are the differences between other types of eczemas and atopic dermatitis?

It can be challenging to differentiate the various types of eczemas because symptoms can be common such as dry skin and inflammation. However, there are a few differences. Taking a proper history and examination will help the dermatologists to differentiate between atopic dermatitis and other types of eczemas.

• Age – Atopic dermatitis commonly affects infants and young children. Other types may occur at any age, but more prevalent in adults.
• Location of the rash – Atopic dermatitis typically present in cheeks or inner aspect of elbows and knees in infants and young children. In adults atopic dermatitis can occur in other areas like back of elbows and around eyes.

Seborrheic dermatitis occur in scalp and other hair growing, oil secreting regions.

Dyshidrotic eczema occur in palms and soles.

Varicose eczema typically occur in lower legs.

• Type of lesions – Distinct characteristics are found in certain types of eczema.

Ex: Discoid eczema – round shaped distinctive lesions

Contact dermatitis – lesions appear typically in areas exposed to the irritant. There can be clear borders with a visible edge.

Dyshidrotic eczema – small painful blisters in palms and soles

• Associated comorbidities – Atopic dermatitis is often associated with other atopic conditions like asthma, hay fever and allergic conjunctivitis. Other types of eczema are not associated with atopy.

Summary

Eczema is a common term for a group of chronic skin conditions that cause skin inflammation and irritation. Atopic dermatitis is the most common type of eczema and many individuals often refer to it as eczema. However, there are many other types of eczema. While they have similar features and symptoms, each type differs in its causes and progression of the condition. Being able to identify the type of eczema in a person is crucial for treatment and prevention.

 

References:

https://nationaleczema.org/eczema/types-of-eczema/

https://www.nhs.uk/conditions/atopic-eczema/