Assessing Psoriasis in the Clinic: PGA and BSA Hello, my name is Kristina Callis Duffin and I am an assistant professor of dermatology at the University of Utah.  I have been asked to present this training module on behalf of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, or GRAPPA.

Why are you taking this module? 6-point PGA and BSA (insert video here or delete slide, to explain why sPGA is a quality measure)

6-point PGA and BSA Learning Objectives After completing this module, you should be able to: Assess plaque psoriasis for erythema, induration, and scale to obtain a PGA score Quantify plaque psoriasis by the handprint BSA method Scores and assessments are the opinion of Dr. Kristina Callis Duffin, Associate Professor of Dermatology at the University of Utah, and dermatology members of GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

PGA Physician Global Assessment

Averaged over the entire body 6-point PGA The PGA, or Physician Global Assessment, is a 6-point, 0-5 measure of psoriasis based on degree of Erythema Induration Scale Averaged over the entire body

sPGA for assessment of psoriasis Each of the 3 clinical signs is assessed on a 0-5 (6 point) scale: 0=none 1=minimal 2=mild 3=moderate 4=severe 5=very severe

Scoring induration, erythema, and scale The guidelines for scoring for induration, erythema, and scale for doing TPSS for a target lesion are roughly the same as for doing some versions of a 0-4 physician global assessment, but there is no averaging of scores over a body area.

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) INDURATION SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 1 = faint erythema INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 2 = Light red INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 3 = moderate red INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 4= bright red INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 5= dusky-deep red coloration INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 0=no plaque elevation above normal skin INDURATION SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 1= minimal (~0.25 mm) INDURATION SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 2 = mild (~0.5 mm) INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 3 = moderate (0.75 mm) INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 4=marked elevation (~1 mm) INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 5=severe (>1.25 mm) INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 0 = no evidence of scale INDURATION SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 1 = minimal – Occasional fine scale over less than 5% of the lesion INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 2 = mild – Fine scale predominates INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 3 = moderate – coarse scale predominates INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 4=marked; thick, non-tenacious scale predominates INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

PGA for the Assessment of Psoriasis: Erythema Induration Scale 5 4 3 2 1 ERYTHEMA 5= Very thick tenacious scale predominates INDURATION 0=no evidence of erythema (post-inflammatory hyperpigmentation and/or hypopigmentation may be present) 1=Light pink 2=Light red 3=Red 4=Dark, deep red SCALE

Now put it all together The guidelines for scoring for induration, erythema, and scale for doing TPSS for a target lesion are roughly the same as for doing some versions of a 0-4 physician global assessment, but there is no averaging of scores over a body area.

PGA for the Assessment of Psoriasis final PGA score The final PGA score is an average of the erythema, induration, and scale Erythema 1 2 3 4 5 Induration 1 2 3 4 5 To perform a TPSS, each lesion is assessed for the three plaque qualities erythema, induration, and scale on a 5 point, 0-4 scale that is similar in definition to PGA scoring. The scores are then summed for a maximum possible of 12. Scale 1 2 3 4 5 AVERAGE 1 2 3 4 5

PGA for the Assessment of Psoriasis: final PGA score The final PGA score is an average of the erythema, induration, and scale Erythema 1 2 3 4 5 Induration 1 2 3 4 5 To perform a TPSS, each lesion is assessed for the three plaque qualities erythema, induration, and scale on a 5 point, 0-4 scale that is similar in definition to PGA scoring. The scores are then summed for a maximum possible of 12. Scale 1 2 3 4 5 AVERAGE 1 2 3 4 5

PGA for the Assessment of Psoriasis final PGA score The final PGA score is an average of the erythema, induration, and scale Erythema 1 2 3 4 5 Induration 1 2 3 4 5 To perform a TPSS, each lesion is assessed for the three plaque qualities erythema, induration, and scale on a 5 point, 0-4 scale that is similar in definition to PGA scoring. The scores are then summed for a maximum possible of 12. Scale 1 2 3 4 5 AVERAGE 1 2 3 4 5

PGA for the Assessment of Psoriasis final PGA score The final PGA score is an average of the erythema, induration, and scale Erythema 1 2 3 4 5 Induration 1 2 3 4 5 To perform a TPSS, each lesion is assessed for the three plaque qualities erythema, induration, and scale on a 5 point, 0-4 scale that is similar in definition to PGA scoring. The scores are then summed for a maximum possible of 12. Scale 1 2 3 4 5 AVERAGE 1 2 3 4 5

Body Surface Area Hello, my name is Kristina Callis Duffin, and I am a dermatologist at the University of Utah. This module will cover measuring body surface area, specifically covering the handprint method used in most psoriasis clinical trials.

Body Surface Area (BSA) BSA is a commonly used measure of severity of skin disease Defined as the percentage of the total body surface area affected by psoriasis The body surface area, or BSA, is a commonly used measure of severity of skin disease. It is typically defined as the percentage of surface area of the body involved with the condition being assessed.

Body Surface Area (BSA) methods Historically, BSA is typically calculated by one of two methods: Rule of Nines: From burn literature, first described in 1940’s Divides body into regions or multiples of 9% (perineum/genitals 1%) Handprint Method: Use of full handprint to estimate 1% Most common method in psoriasis clinical trials The body surface area can be estimated in several ways. The two most common ways include the Rule of Nines and the handprint method. The Rule of Nines was developed by burn surgeons to estimate area affected by a burn. This method, which divides the body into regions or multiples of 9%, is still in use by burn surgeons and is sometimes used in studies for dermatologic conditions such as psoriasis. The handprint method, also described in the burn literature, is commonly used in studies of dermatologic conditions. Wallace AB. Some experiences in local burn care. Br J Plast Surg. 1951 Agarwal P, Sahu S. Determination of hand and palm area as a ratio of body surface area in Indian population. Indian J Plast Surg. 2010. Long CC, Finlay AY, Averill RW. The rule of hand: 4 hand areas = 2 FTU = 1 g. Arch Dermatol 1992. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns 1996 Thomas CL, Finlay AY. The 'handprint' approximates to 1% of the total body surface area whereas the 'palm minus the fingers' does not. Br J Dermatol. 2007

BSA for psoriasis handprint method for estimating BSA Patient’s full HANDPRINT can be used to estimate 1% body surface area ~1% ~1% For most psoriasis studies today, the handprint method is used to estimate the percentage of body surface area involvement. To do this, the patient’s handprint, including the entire area of the palm and all 5 digits, is used as a guide to estimate 1% of the BSA. Long CC, Finlay AY, Averill RW. The rule of hand: 4 hand areas = 2 FTU = 1 g. Arch Dermatol 1992; 128:1129–30. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns 1996; 22:230–1. Thomas CL, Finlay AY. The 'handprint' approximates to 1% of the total body surface area whereas the 'palm minus the fingers' does not. Br J Dermatol. 2007 Nov;157(5):1080-1. Epub 2007 Sep 13. 34

BSA for psoriasis handprint method for estimating BSA Patient’s full HANDPRINT can be used to estimate 1% body surface area ~1% For most psoriasis studies today, the handprint method is used to estimate the percentage of body surface area involvement. To do this, the patient’s handprint, including the entire area of the palm and all 5 digits, is used as a guide to estimate 1% of the BSA. Although some publications and opinion leaders have advocated variations (e.g., that the palm + fingers to DIP +thumb), studies examining this do NOT support partial handprints as 1% Long CC, Finlay AY, Averill RW. The rule of hand: 4 hand areas = 2 FTU = 1 g. Arch Dermatol 1992; 128:1129–30. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns 1996; 22:230–1. Thomas CL, Finlay AY. The 'handprint' approximates to 1% of the total body surface area whereas the 'palm minus the fingers' does not. Br J Dermatol. 2007 Nov;157(5):1080-1. Epub 2007 Sep 13. 35

BSA for psoriasis handprint method for estimating BSA Head and Neck = 10% (10 handprints) Upper extremities = 20% (20 handprints) Trunk (axillae and groin) = 30% (30 handprints) Lower extremities (buttocks) = 40% (40 handprints) Total BSA = 100% (100 handprints) ~1% ~1% Using the handprint method, the head and neck area is made up of about 10 handprints, the upper extremities, about 20 handprints, the trunk, about 30, and the lower extremities including the buttocks, about 40 handprints.

How to do a BSA with the handprint method

First, consider area of patient’s full handprint. Example 1: First, consider area of patient’s full handprint. First, consider the area of the patient’s full handprint, and use it to estimate 1% of the body surface area.

First, consider area of patient’s full handprint Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were virtually “pushed together.” Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were virtually “pushed together”.

First, consider area of patient’s full handprint Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were virtually “pushed together.” (this builds on the first)

First, consider area of patient’s full handprint Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were “pushed together” virtually. In this example, lesions outlined in white fill one handprint, In this example, lesions outlined in white fill one handprint,

First, consider area of patient’s full handprint Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were “pushed together” virtually. In this example, lesions outlined in white fill one handprint, and lesions outlined in yellow fill about half of another handprint. and lesions outlined in yellow fill about half of another handprint.

First, consider area of patient’s full handprint Second, identify the psoriatic lesions and consider how many handprints the lesions would fill if they were virtually “pushed together.” In this example, lesions outlined in white fill one handprint, and lesions outlined in yellow fill about half of another handprint. Using this method, the body surface area for this patient is estimated at 1.5%. Using this method, the body surface area of psoriasis involvement for this patient is estimated at 1.5%.

Determine 1% of BSA from patient’s handprint Example 2: Determine 1% of BSA from patient’s handprint Similarly, In this example, we first determine what 1% BSA would be from the patient’s handprint, as outlined in white.

Determine 1% of BSA from patient’s handprint Using the outline, there are roughly 4 full handprints – but there are remaining plaques that don’t fit neatly into handprint-sized areas. Using this outline, we can see that there are 4 full handprints outlined in white, but there are remaining plaques that don’t fit neatly into handprint-sized areas.

Determine 1% of BSA from patient’s handprint Using the outline, there are roughly 4 full handprints – but there are remaining plaques that don’t fit neatly into handprint-sized areas. Another 2 partial handprints can be outlined in yellow Another 2 partial handprints can be outlined in yellow,

Determine 1% of BSA from patient’s handprint Using the outline, there are roughly 4 full handprints – but there are remaining plaques that don’t fit neatly into handprint-sized areas. Another 2 partial handprints can be outlined in yellow The yellow outlines can be virtually “filled” with the remaining plaque areas The yellow outlines can be virtually filled with the remaining plaque areas.

Determine 1% of BSA from patient’s handprint Using the outline, there are roughly 4 full handprints – but there are remaining plaques that don’t fit neatly into handprint-sized areas. Another 2 partial handprints can be outlined in yellow The yellow outlines can be virtually “filled” with the remaining plaque areas Total BSA pictured here: ~6% Using this method, the percentage of body surface area involvement would be roughly 6%.