Dermoscopy assisted topical steroid-dependent/damaged face (TSDF) severity score (DATS Score): Reliability assessment and validation of a new scoring method.

Sir,

Topical steroid-dependent or damaged face (TSDF) shows an alarming prevalence of 90.5% in patients abusing topical corticosteroids (TCS).[1] They may produce a red face after a variable duration with unsupervised use, challenging to manage for both patients and dermatologists.[2] Dermoscopy can noninvasively help in identifying patients with TSDF before the appearance of clinical findings, especially when a history of such abuse is not forthcoming or the patient is unaware of it.[3] Erythema, dyspigmentation, papulopustular lesions, and hypertrichosis are common clinical signs in patients with TSDF.[4] Brown globules, red structureless areas, vessels, white hair, thick terminal hair, Demodex tails, papules/pustules, and white structureless areas are seen on dermoscopy.[5] However, there is no validated method to quantify the severity of damage due to TCS application. We propose a dermoscopy-assisted TSDF severity (DATS) score for estimating disease severity and response to treatment in TSDF.

DATS score includes assessment of facial areas involved and dermoscopic findings visualized. Concisely, the scoring system divides the face into four regions, and the disease severity is assessed by dermoscopy characteristics and the area of involvement, and a multiplication factor is used to calculate the total score [Table 1 and Figure 1]. This study was undertaken to determine the reliability and validity of the DATS score. Three researchers (RJ, PC, and SS) independently rated 15 patients (14 women and one man) with TSDF on two consecutive days within one week to determine intra-rater and inter-rater reliability. Patients (18 years or above) with clinical symptoms and signs suggestive of TSDF (redness, itching, acne, burning, swelling, photosensitivity, pigmentation, and striae) and with a history of application of TCS on the face for a period of more than 1 month were included. Validation was performed by comparing the DATS score with the physician global assessment (PGA) score (value ranging from 1 to 5, with 1 being least, 2 being mild, 3 being moderate, 4 being severe, and 5 being very severe disease). Content validity index for items (I-CVI) assessed in DATS score was constructed as a four-point ordinal scale; ratings of 1 and 2 were labeled nonrelevant, and 3 and 4 as relevant for each item in the questionnaire [Table 2]. Four consultants, two senior residents, and two final-year junior residents of our department completed I-CVI.

Table 1

Dermoscopy-assisted topical steroid-dependent/damaged face (TSDF) severity score (DATS score)

Dermoscopic features	Sub-headings	Score
Vascular (v)	Background erythema	1
	Linear vessels	1
	Polygonal/Y-shaped/Arborizing/Tortuous vessels	2
Atrophy (a)	White/Yellow structureless areas	2
Hypertrichosis (h)	Thin white hair	1
	Thick terminal hair	2
Rosacea like features (r)	Demodex tails	1
	Papules/Pustules	1
Area assessment
Region	Area	Multiplication factor
Forehead (F)	30%	0.3
Right cheek (R)	30%	0.3
Left cheek (L)	30%	0.3
Chin (C)	10%	0.1
Area involved (A)
No involvement	0
1%-19%	1
20%-39%	2
40%-59%	3
60%-79%	4
≥80%	5
Total Score (0-55)	[0.3(v+a+h+r) AF]+[0.3(v+a+h+r) AR] + [0.3(v+a+h+r) AL]+[0.1(v+a+h+r) AC]

Figure 1

DATS score calculation in a representative patient. DATS score = [0.3 x (4+2+2+0) x 4] + [0.3 x (4+2+3+1) x4] + [0.3 x (4+2+3+1) x 4] + [0.1 x (0+0+0+0) x 0] = 33.6

Table 2

Content validity index for items (I-CVI)

Questions	Not relevant ratings	Relevant ratings	I-CVI
Is dermoscopy relevant for the measurement of TSDF severity?	0	8	1.000
Is vascularity relevant for the measurement of TSDF severity?	0	8	1.000
Is atrophy relevant for the measurement of TSDF severity?	0	8	1.000
Is hypertrichosis relevant for the measurement of TSDF severity?	0	8	1.000
Are rosacea-like features (Demodex tails and papules/pustules) relevant for the measurement of TSDF severity?	1	7	0.875
Is surface area (facial) involved relevant for the measurement of TSDF severity?	1	7	0.875
Does dermoscopy, surface area involved, and the above features taken together comprehensively reflect the measurement of TSDF severity?	0	8	1.000
Is dermoscopy relevant for the purpose of application of the DATS score?	0	8	1.000
Is the area involved relevant for the purpose of application of DATS score?	2	6	0.750
Are the above-mentioned features relevant for the purpose of application of the DATS score?	0	8	1.000

Mean I-CVI for DATS score=0.95

Test-retest reliability of individual raters tested by “Pearson's r” showed strong correlation for all three raters (r = 0.967, 0.991, and 0.984, respectively; P < 0.05). Inter-rater agreement computed by intra-class correlation coefficient showed substantial agreement (ICC = 0.6682; P < 0.05). Internal consistency measured by Cronbach's alpha was 0.856 (good internal consistency). Score fared well in content validity (I-CVI of 0.95) [Table 3]. Concurrent validity analysis was performed using Spearman's rank-order correlation between the DATS score and PGA scores of all three observers (RJ, PC, and SS) at both intervals [Table 3]. Scores were statistically significant across rater on both days (P < 0.001) with a very strong relationship. On usability assessment, the scale (1–5) had a mean of 4.8 ± 0.41 for RJ, 4.7 ± 0.52 for PC, and 4.3 ± 0.52 for SS.

Table 3

Results and interpretation of test-retest reliability, inter-rater agreement, internal consistency, concurrent validity, and usability assessment

Parameters	Tests done	Results and interpretation*
Test-retest reliability (SS, RJ, PC)	Pearson’s r	0.967, 0.991, 0.984 (Strong correlation for all)
Inter-rater agreement	Intra-class correlation coefficient	0.668 (Substantial agreement)
Internal consistency	Cronbach’s alpha	0.856 (Good internal consistency)
Usability assessment (SS, RJ, PC)	Likert scale	SS=4.3 0.52 RJ=4.8 0.41 PC=4.7 0.52
Spearman’s rank-order correlation coefficients to assess the validity of DATS score as compared to PGA
Day	Observer	Spearman’s rank-order correlation	P
Day 1	SS	0.799	0.0003
	RJ	0.832	0.0001
	PC	0.929	0.0001
	Average	0.931	0.0001
Day 2	SS	0.819	0.0129
	RJ	0.849	0.0001
	PC	0.872	0.0001
	Average	0.897	0.0001

*P<0.05

Thus, the DATS score appears to be a reliable and reproducible measure of TSDF severity. More extensive studies should be performed to identify the true potential of the DATS score in assessing the response to treatment. Dermoscopy decreases inter and intra-observer variation, resulting in a more objective score.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.