1. 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.

2. 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)

3. 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.

4. PGA
Physician Global Assessment

5. 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

6. 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

7. 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.

8. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 4 3 2 1
ERYTHEMA
0=no evidence of erythema
(post-inflammatory hyperpigmentation and/or hypopigmentation may be present)
INDURATION
SCALE

9. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

10. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

11. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

12. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

13. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

14. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 4 3 2 1
ERYTHEMA
0=no plaque elevation above normal skin
INDURATION
SCALE

15. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 4 3 2 1
ERYTHEMA
1= minimal
(~0.25 mm)
INDURATION
SCALE

16. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

17. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

18. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

19. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

20. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 4 3 2 1
ERYTHEMA
0 = no evidence of scale
INDURATION
SCALE

21. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

22. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

23. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

24. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

25. PGA for the Assessment of Psoriasis: Erythema Induration Scale5 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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.

32. 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.

33. 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
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

34. 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 Nov;157(5): Epub 2007 Sep 13. 34

35. 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 Nov;157(5): Epub 2007 Sep 13. 35

36. 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.

37. How to do a BSA with the handprint method

38. 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.

39. 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”.

40. 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)

41. 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,

42. 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.

43. 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%.

44. 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.

45. 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.

46. 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,

47. 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.

48. 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%.