C.Y. Zhao , , A. Wijayanti , ,M.J. Doria , , A.G. Harris , S.V. Jain , K. Legaspi , N.C. Dlova , M.G. Law , D.F. Murrell ,
Introduction: Skin diseases are more difﬁcult to assess in
skin of colour. Outcome measures of common diseases such
as atopic dermatitis (AD) for these patients have not been
1. To compare the reliability and validity of AD outcome
measures in patients with various levels of skin
2. To evaluate the effect of erythema perception on interrater
3. To determine the inter-rater variations in the perception
of skin darkness.
Method: Full body photography of 18 AD patients were
assessed by 5 trained clinicians using EASI (Eczema Area
and Severity Index), objective SCORing Atopic Dermatitis
(oSCORAD), Three Items Severity index (TIS) and Six Areas,
Six Sites Atopic Dermatitis (SASSAD). Each patient’s pigmentation
was scored by all clinicians from 0–10 and categorised
into: 0–3 (non-pigmented), 3.1–7 (mildly
pigmented) and 7.1–10 (highly pigmented).
Results: AD severity: The inter-rater reliability was poorest
for highly pigmented patients, fair for mildly pigmented
patients, and best in non-pigmented patients. All measures
correlated signiﬁcantly to one another (Rho > 0.7, p < 0.05) in non-pigmented patients, but not in highly pigmented patients. Coefﬁcient of variation analysis showed erythema perception contributed to the inter-rater variability. Pigmentation perception: In non- and mildly pigmented patients, there were large inter-rater variations. In highly pigmented patients variations were minimal. Conclusion: All AD instruments have unacceptably low reliability and validity in highly pigmented patients, likelydue to variations in erythema perception. Contrastingly, for pigmentation assessment, best inter-rater reliability was found amongst patients with highly pigmented skin and decreased as the skin became paler.