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Filling the gap in the scoring of pigmentary disorders

Acquired dermal macular hyperpigmentation (ADMH) is a term which includes lichen planus pigmentosus (LPP), Riehl’s melanosis, pigmented contact dermatitis and erythema dyschromicum perstans. These conditions do not only share common clinical and histological presentations, but they also strongly impact the quality of life of affected individuals and induce a strong therapeutic demand. Validated scores are important tools to assess the severity of dermatoses. They allow robust comparison in epidemiological studies and are mandatory for clinical trials. As an example, the development of the MASI followed by the modified MASI score for the assessment of the severity of melasma provided a robust and reproducible tool for evaluating the efficacy of treatments for this frequent hyperpigmentary disorder. Despite its high prevalence, ADMH did not have a validated scoring method before, and Physician Global Assessment (PGA) was one of the only tools to evaluate the severity of ADMH. Although useful, PGA was not standardized for ADMH and does not allow for a precise evaluation of the spread and severity of the disease. Thus, the efficacy of oral isotretinoin, which appears to be one of the most promising approach to treat LPP, was only assessed by a global score that rates the improvement as none, mild, moderate and good. Such a grading system is too subjective and too vague to allow comparisons between upcoming studies on this condition and its treatment modalities. In this issue of the Journal, Kumaran et al. validate the dermal pigmentation area and severity score (DPASI). The same team developed this score, but a validation was still lacking. Here, they rated 55 patients and demonstrated a very good interrated and intrarated reliability. Importantly, the score was also tested by non-expert dermatologists. The score was evaluated as ‘very easy to score’. Moreover, seven experts were consulted to examine that all relevant aspects of ADMH have been included in DPASI. The major limitation of this score, so far, is the absence of validation after a therapeutic approach to assess the responsiveness to change. Despite this limitation, the validation of DPASI is mostly welcome and fills the gap in the scoring of ADMH. This is the first step of a long journey that should hopefully lead to better therapeutic approaches for ADMH.