Exploring Reliability of Scar Rating Scales Using Photographs of Burns From Children Aged up to 15 Years

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Abstract

Assessing burn scars from photographs is a common practice given the growing trend to support health service delivery via electronic media (eg, email, videoconferencing). Scar rating scales, originally designed for in-person assessment, have been used to rate scars from photographic images. Evidence for the reliability of this practice is lacking. Five raters completed three scar rating scales (Patient and Observer Scar Scale, Manchester Scar Scale, modified Vancouver Scar Scale), both in-person and using photographs on 12 participants (seven male, five female) with 18 scar areas (3 × 3 cm). Interrater reliability for the scar parameters of vascularity, color, contour, pliability, and overall opinion achieved intraclass correlation coefficient values of between 0.71 and 0.87 (in-person) and 0.72 and 0.77 (using photographs) for multiple raters. The level of agreement between in-person and photographic assessment was below acceptable levels, which brings into question construct validity when scar rating scales are used in a way for which they were not designed. Reliability estimates in this study were likely reduced by the underrepresentation of scars in the more severe range. This limitation needs to be addressed in future research. Advances are required in the development and refinement of burn scar rating scales, specifically for photographic use, given their routine use in clinical care.

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A new quantitative scale for clinical scar assessment.

C Orton, Blair Floyd, W. Ferguson … (1998)

Wound healing in adult human skin results in varying degrees of scar formation, ranging clinically from fine asymptomatic scars to problematic hypertrophic and keloid scars, which may limit function and restrict further growth. At present, no good objective method of clinically assessing scars exists, which is problematic for the evaluation of scar prevention or treatment regimens. Similarly lacking are histologic correlates of what we consider good and bad clinical scars. The objective of this study was to quantitatively assess human scarring (1) clinically, by developing a comprehensive rating scale, (2) photographically, using an image capture system and a scar assessment panel, and (3) by histologic analysis following scar excision. We assessed 69 scars, with a wide clinical range of severity, in patients who were undergoing surgery, for whatever reason, that involved removal of an old scar. Preoperatively, patients had their scars assessed, clinically using our newly developed scale and photographically using a computerized image capture system. These photographs were then sent to a panel for assessment using similar criteria to those used clinically. Assessment of scars from photographs correlated well with the clinical scar evaluation, indicating its potential utility in multicenter scar prevention/treatment trials. Following excision, scars were processed and analyzed for histology. We also found a strong correlation between the macroscopic and microscopic appearance of scars, particularly between the clinical appearance and histologic scores of features in the epidermis and papillary dermis. This suggests that our clinical scale is a sensitive instrument in scar assessment, allowing validated quantification of the severity of a wide range of scars.

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A systematic review of the quality of burn scar rating scales for clinical and research use.

Zephanie Tyack, Megan A Simons, Anneliese Spinks … (2012)

Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales. Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies. A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity. The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale. Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.

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Skin elasticity meter or subjective evaluation in scars: a reliability assessment.

F R H Tempelman, C A Botman, Robert W. Kreis … (2004)

Various methods are available for evaluating the elasticity of scars. However, the reliability and validity of these methods have been sparsely examined. The aim of this study was to examine the reliability of the subjective evaluation of scar pliability, while at the same time testing the reliability of the measurements of a non-invasive suction device (Cutometer Skin Elasticity Meter 575) on scars. Four observers assessed 49 scar areas of 20 patients with a subjective assessment of pliability. Subsequently, each observer measured the scar areas with the Cutometer. The intraclass correlation coefficients (ICC) of the elasticity (Ue) and extension (Uf) parameters of the Cutometer were acceptable (r = 0.76 and 0.74, respectively) when a single observer carried out the measurements. The subjective assessment of pliability needs to be completed by two or more observers to make the evaluation reliable (r = 0.79). The concurrent validities between the subjective pliability-assessment and each of the Cutometer parameters were statistically significant and ranged from r = 0.29-0.53. The correlations between each of the Cutometer parameters were high and statistically significant (r > or = 0.71). A single observer can reliably use the Cutometer for the elasticity measurements of scars. Furthermore, either Ue or Uf, instead of all five elasticity values provided by the Cutometer, can be adequately used for the elasticity measurements of scars. The subjective assessment of pliability of scars can only be assessed reliably when completed by two or more observers. The concurrent validity showed that all Cutometer parameters, except for visco-elasticity (Uv), and the subjective assessment of pliability measured the same characteristic of a scar.