Clinician versus patient versus technology: Who decides?
Aditya Gupta, MD, PhD, MBA, Department of Medicine, Sunnybrook and Women’s College Health Sciences Center (Sunnybrook site) and the University of Toronto, ON, Canada and Mediprobe Research Inc., London, ON, Canada; Andrea Cherman, Elizabeth Cooper, Melissa Gover, Mediprobe Research Inc, London, ON, Canada
Efficacy of treatment is primarily judged by the clinician; the patient may not agree, nor may digital measurements carried out to evaluate efficacy. The validity of assessments used for onychomycosis, psoriasis and rosacea is discussed herein. Visual assessment of affected nail area is typically used in onychomycosis, producing subjective evidence of nail clearance. Digital imaging can now accurately and objectively determine affected nail area. Mycology testing is an objective evaluation of whether there is growth of fungal species in culture. Rates of ‘‘cure’’ are limited by many factors, and the presence of objective measures has not improved the treatment of onychomycosis. Clinicians use a variety of lesion area estimates and lesion quality estimates to produce psoriasis severity gradings (body surface area, BSA; Psoriasis Area and Severity Index, PASI). These estimates are subjective and may vary with clinician training and experience. There is variation in how much score reduction is ‘‘effective treatment.’’ No technology-based objective methods are used regularly for evaluating psoriasis. Also problematic is that an improvement judged by clinicians may not be perceived as improvement by patients. Patient grading methods, such as quality-of-life surveys, provide some correlation with clinical outcome. A combination of subjective measures by clinician and patient may be used to demonstrate ‘‘effective’’ therapy in psoriasis.There is no standard definition for rosacea due to the varied presentation of symptoms, and no standard grading system exists, subjective or otherwise. Global gradings of efficacy by clinicians using labels (‘‘improved,’’ ‘‘worse’’) or numbers (1 = mild, 2 = moderate, etc) provide subjective assessment. Colorimeters could objectively measure reduction in erythema, but are not in general use. Though papule/pustule counts are relatively objective, the amount of reduction required for efficacy is subjective. Also, as with psoriasis, the clinical reduction of rosacea may not be perceived by the patient as significant. A combination of objective and subjective measures for rosacea is often used to ensure that treatment provides satisfactory therapy in all eyes. Though objective measurement can standardize measures, this may not in itself answer clinical issues. There remains a prominent place for the clinician and patient in dermatology assessment.
Author disclosure: Nothing disclosed at press time. Commercial support: None.
Poster Discussion Session P558, American Academy of Dermatology, 64th Annual Meeting, March 3-7 2006, San Francisco.
Supplement to Journal of The American Academy of Dermatology, March 2006, Volume 54, Number 3.
