1. Integrated Scoring Scale for Visual Evaluation of Heel Skin Condition
12. September 2018
Integrated Scoring Scale for Visual Evaluation of Heel Skin Condition
EA Moyer, PSM, CCRC and LK Lockhart, PhD, Henkel Consumer Goods Inc., Scottsdale AZ
Background
Descriptive scoring scales are often preferable to global scales to promote consistency between evaluators and are often required by regulatory agencies. Visual descriptors of xerosis are usually described in terms of the degree of defect in corneocyte sloughing around the dermatoglyphic triangles. Dry skin traditionally presents with flaking and peeling.
Heel Dryness and Fissuring
The skin on the heel is unique in that the stratum corneum is considerably thicker than any other body area and the heels are subject to considerable mechanical stress. Skin on the heel also experiences fissuring (cracking) but increased dryness does not necessarily correlate with increased fissuring. As a result, traditional approaches to evaluating skin dryness do not correlate well when applied skin on the heels.
Severity as a Function of
Dryness and Fissuring
Application of Scoring Scale
Subjects were evaluated at baseline, 1 week, and 2 weeks following use of a moisturizer.
Each heel was evaluated using the individual dryness and fissuring scoring scales.
The New Qualified Global Score is the best score as it takes into account both dryness and fissuring weighted appropriately.
Plot of Dryness vs. Fissuring verified that there is not a good direct correlation between the two variables.
Heels were then assigned a overall severity rating on a global 9-point scale ranging from none, mild, moderate, severe, and extreme.
Unqualified Global Score
Fissuring
Dryness
Qualified Global Score
3.50
3.75
3.25
3.52
2.50
3.00
2.75
2.89
2.65
Baseline
Figure 1. Degrees of skin condition on the heels
1week
No Dryness
No Fissuring
Fissuring
Slight Dryness
Dryness
Severity scale shows relative correlation between dryness and fissuring and total score.
2 weeks
A regression analysis was run to better understand how dryness and fissuring are weighted when ranked by a global severity scale scores. Dryness and fissuring both play a significant role in the overall score. Dryness accounts for 66% of the score while fissuring accounts for 34% of the overall score.
Global Score = *dryness *fissuring †
R2= †Patent Pending
Independent Scales Developed
Heels of employees were first evaluated to understand the varying degrees of damage present and to develop dryness descriptors unique to the heel. Heels were initially evaluated according to the traditional dryness scoring scale.
Further evaluation of the traditional scoring scale determined cracking and fissuring did not always follow a logical progression as first hypothesized. Separate scoring scales were developed to rate dryness and fissuring independently.
Expert Evaluations vs. Subjective
In addition to expert evaluations of dryness and fissuring, subjects who participated in the study were also asked to evaluate their heel condition. The subjective evaluations did not correlate well with the expert evaluations.
Those with relatively “good” heels often viewed their condition as worse than the expert.
Subject evaluations did not realize improvement, differed more from the expert as the study continued.
Grade
Dryness
None
0.5
Perceptible dryness
1.0
Mild (uniform powdery white)
2.0
Moderate (uniform, marked flaking covering more than 50% of the test site)
3.0
Severe (Moderate to severe scaling with uplifting scales)
4.0
Extreme (dryness with areas of loose skin or epidermis absent)
Cosmetic vs. Dermatologist View
A Dermatologist, Dr. Zoe Diana Draelos evaluated photos taken of damaged heels.
Of the 131 heels evaluated, 87% of the scores were within 0.5 points and the correlation coefficient between the two data sets was
This validates the global scoring scale and demonstrates little difference between the cosmetic and dermatologist approach.
Grade
Traditional Scoring Scale
None
0.5
Barely detectable dryness
1.0
Uniform dryness
1.5
Peeling without cracking
2.0
Moderate cracking
2.5
Moderate cracking with peeling
3.0
Shallow fissuring
3.5
Shallow to deep fissuring
4.0
Deep fissuring
Grade
Fissuring
None
0.5
Barely detectable fine lines
1.0
Mild fissuring (linear cracks)
2.0
Moderate fissuring (shallow)
3.0
Deep fissuring
4.0
Deep fissuring with blood
Acknowledgements: Heidi Goldfarb, PhD, Statistics & Data Corporation
Zoe Diana Draelos, MD, Dermatologist or