Clinician Severity Assessment Grading Scale on Erythematotelangiectatic Rosacea.

Sir,

Rosacea is a chronic cutaneous inflammatory disease that primarily affects the central face and is often characterized by flushing, erythema, telangiectasia, papules, and pustules.[1] Erythematotelangiectatic rosacea (ETR), a subtype of rosacea, is primarily characterized by flushing, persistent central facial erythema, and telangiectasia.[2]

Variety of scales are used to measure the severity of ETR according to its different clinical features. Despite these various measures, larger-scale studies and validated scales are needed for precise and consistent severity assessment of clinical rosacea features. In this study, we devised a new tool that reflects these factors and is limited to ETR. Our purpose was to evaluate the reliability and objectivity of new erythema and telangiectasia severity index on ETR by determining interrater and intrarater agreement.

We performed a retrospective chart review of patients who visited the Department of Dermatology at Kyung Hee Medical Center (KHMC), Seoul, Korea, from 1 February 2015 to 30 April 2016. All 80 (60 females and 20 males) patients with ETR were aged 18 years or older (the mean age was 50.93 years). The new assessment method investigated in this study consists of three scales: Clinician's Erythema Assessment (CEA), area, and telangiectasia [Figure 1]. We thus named this new tool CAT (CEA, Area, and Telangiectasia).

Figure 1

CAT (CEA, Area, and Telangiectasia) scale components. (a) Clinical erythema assessment (CEA) severity score is a 5-point scale for measuring erythema severity. (b) Area score consists of 3-point values using the palm method that measure the range of erythema on the face. (c) Telangiectasia severity score measures severity on a 3 point scale

Each six trained clinicians rated each subject twice with at least a 2-h interval between evaluation sessions. The data were analyzed using the weighted kappa statistic and intraclass correlation coefficient (ICC) to evaluate interrater and intrarater reliability. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 20.0 (SPSS Inc., Chicago, IL, USA). Compared with previous studies,[3] our study showed higher ICC values for CEA in interrater, but the weighted kappa values were somewhat lower, and both values in intrarater reliability were higher [Table 1]. The weighted kappa statistic and ICC of CEA and area indicate a fair to good reproducibility.

Table 1

CAT validation (A) interrater reliability (agreement among 6 raters) (B) intrarater reliability at session 1 and session 2

(A)	Session 1 (n=80)					Session 2 (n=80)
Parameter	ICC	-	+	P*	Fleiss’ κ	ICC	-	+	P*	Fleiss’ κ
CEA	0.744	0.709	0.833	0.000	0.588	0.762	0.694	0.824	0.000	0.569
AREA	0.717	0.642	0.788	0.000	0.540	0.726	0.652	0.795	0.000	0.537
Telangiectasia	0.566	0.473	0.661	0.000	0.215	0.541	0.446	0.638	0.000	0.228
Result†	0.841	0.790	0.884	0.000	0.314	0.846	0.797	0.889	0.000	0.303
CEA=Clinician Erythema Assessment; ICC=intraclass correlation coefficient. †Result=CEA × AREA + Telangiectasia. *A P<0.05 is considered statistically significant
(B)
Parameter	mean κ ± SD			mean ICC±SD			Minimum ICC		Maximum ICC
CEA	0.715±0.085			0.857±0.046			0.794		0.924
AREA	0.692±0.099			0.801±0.073			0.720		0.887
Telangiectasia	0.360±0.052			0.740±0.070			0.652		0.844
Result†	0.515±0.067			0.907±0.025			0.861		0.929

CEA=Clinician Erythema Assessment; ICC=intraclass correlation coefficient. †Result=CEA × AREA + Telangiectasia. *A P<0.05 is considered statistically significant

The previously used methods for severity assessment of rosacea had practical issues. First, most of the papers using the severity assessment of rosacea did not consider the rosacea area and were limited to erythema intensity.[4] Second, because most of the papers assessed a specific sign or symptom of rosacea, there was a limit to the ability to assess its overall status. In contrast, the Investigator's Global Assessment could not completely evaluate the detailed signs and symptoms of rosacea. There has been almost no method to judge both rosacea specific signs and the overall condition.[5]

The index used in our study includes the lesion area, similar to the Eczema Area and Severity Index for atopic dermatitis. These severity score systems quantify the lesion area. And unlike the clinician global assessment, our index is superior to clinical judgment because it addresses the detailed signs of ETR.

We confirmed that the CEA is reliable, and the area index also showed high reliability. The telangiectasia scale showed lower reliability than the CEA and area scales, indicating the necessity for other evaluation approaches such as dermoscopy. CAT could provide valid ETR severity assessment and assess the efficacy of treatment.

Financial support and sponsorship

This work was supported by a grant from the Korean Research Foundation in 2017 (NRF-2017R1C1B5076162).

Conflicts of interest

There are no conflicts of interest.