no. 20 lemonas reconstructive trunk proof...these variables is relevant to keloid scars which,...

RECONSTRUCTIVE

Patient-Related Keloid Scar Assessment andOutcome Measures

Rebecca S. Nicholas,M.B.B.S.

Hannah Falvey,B.Sc.(Hons.), D.Clin.Psy-

chol.Pambos Lemonas, M.D.,

M.R.C.S.Gopinath Damodaran,

B.Sc., Ph.D.Ali Ghannem, M.R.C.S.,

M.D., Ph.D.Florendyn Selim,

Harshad Navsaria, Ph.D.Simon Myers, Ph.D.,

F.R.C.S.(Plas.)London, United Kingdom

Background: Keloid scars cause pain, itching, functional limitation, and disfig-urement, leading to psychological distress. Progress in treatment regimens is hin-dered by the lack of a universally accepted outcome measure. The Patient andObserver Scar Assessment Scale is a tool for the assessment of scars that includesscar assessment by both clinician and patient. This study evaluates the applicationof the scale to keloid scars, in addition to comparing it to the widely used VancouverScar Scale which, although originally designed for burns, is in wide use in many unitsacross the world as the standard mode of assessment for scars.Methods: Thirty-four patients with 41 keloid scars were assessed independently bythree observers using the Vancouver Scar Scale and the Patient and Observer ScarAssessment Scale. Patients evaluated their own scars simultaneously using the pa-tient component of the Patient and Observer Scar Assessment Scale. Internalconsistency, interobserver reliability, and convergent validity were examined.Results: Both components of the Patient and Observer Scar Assessment Scalehad high internal consistency (0.82 and 0.86 for patient and observer compo-nents, respectively), and were higher than the Vancouver Scar Scale (0.65).Interobserver reliability was “substantial” for the Vancouver Scar Scale (0.65)and “almost perfect” for the observer component of the Patient and ObserverScar Assessment Scale (0.85). Convergent validity between the two was verystrong (0.83, p ! 0.01), although the patient component did not correlate wellwith either of the observer scales. Patients rated their scars worse than theobserver average for 83 percent of the scars, and were influenced by color,stiffness, thickness, and irregularity (p ! 0.05).Conclusion: The findings support the use of the Patient and Observer ScarAssessment Scale as a reliable and valid method of assessing keloid scars in aclinical context. (Plast. Reconstr. Surg. 129: 1, 2012.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Keloid scars arise from pathologic woundhealing following trauma and inflamma-tion, and occur most commonly in those

with darker pigmented skin. The resulting raised,irregular clusters of scar tissue extend well beyondthe original wound margins, and their color isoften discrepant to the surrounding skin, leadingto significant disfigurement. The scars are associ-ated with physical discomfort (pruritus and pain),functional limitation (particularly when locatedover joints), and significant psychological morbid-ity associated with their disfiguring appearance.1,2

Keloid scars are notoriously difficult to treat. Ex-tralesional surgical excision alone results in recur-rence that can be worse than the original lesion.Other therapeutic methods include intralesionalexcision (debulking), extralesional excision andexternal superficial radiotherapy, interstitial irra-diation, intralesional steroid injections, systemicchemotherapy, cryotherapy, ultrasound, zinc tapestrapping, pressure garments, and silicone gels.Despite the wide range of therapeutic methodsavailable, keloid scars typically remain refractoryto treatment and have a high rate of recurrence.In addition, treatment complications such as localatrophy following steroid injections and late tu-

From the Academic Burn and Microsurgery Group, BlizardInstitute of Cell and Molecular Science.Received for publication May 6, 2011; accepted September21, 2011.Copyright ©2012 by the American Society of Plastic SurgeonsDOI: 10.1097/PRS.0b013e3182402c51

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

www.PRSJournal.com 1rich3/zpr-prs/zpr-prs/zpr00312/zpr5320-12z xppws S!1 1/15/12 23:37 4/Color Figure(s): F4 Art: PRS204008 Input-nlm

Foot

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mor induction following radiotherapy are wellrecognized.1,3,4

Progress in the identification of effective treat-ment regimens through clinical research has beenhampered by the lack of a universally acceptedmethod of measuring outcome.5,6 In addition,much research has focused on improving physicaloutcomes as judged by the clinician, although verylittle is known about whether such outcomes areperceived by patients as satisfactory. A suitable,feasible, and reproducible outcome measure inwide use would both allow comparison of keloidscar treatment outcomes across different clinicalsites and also be useful in the local clinical settingfor measuring individual patient responses totreatment.

The specialist keloid service at the Royal LondonHospital is probably the largest multidisciplinary ke-loid clinic in Europe. The ethnically diverse com-munities surrounding the hospital present a highincidence of patients with keloid scars.

The Vancouver Scar Scale, first described bySullivan et al. in 1990 (Fig. 1),7 has become one ofthe most widely applied scar assessment scales inclinical research.5 Although originally designedfor burns, the Vancouver Scar Scale has beenfound to be clinically useful in evaluating a wide

range of scar types and has become established inmany units across the world as the standard modeof assessment. It allows assessment of pigmenta-tion, vascularity, pliability, and scar height. Each ofthese variables is relevant to keloid scars which,without treatment, are typically pigmented, vascu-lar (especially apparent in patients with light skintones), stiff, and raised. In our clinical experience,each of these scar characteristics can respond pos-itively to effective treatment, producing paler, lessred, more supple, and flatter scars. Although theVancouver Scar Scale is simple to use in a clinicalsetting and is well received by clinicians, it does notallow assessment of the patient perspective or symp-toms associated with the scar, which are particularlyrelevant to keloid scar patients. The newer Patientand Observer Scar Assessment Scale is a scar evalu-ation tool that allows assessment of the same ob-served scar characteristics as the Vancouver ScarScale in addition to incorporating the patient per-spective (Figs. 2 and 3).8,9 For this reason, it is apotentially promising tool for the assessment of ke-loid disease. This study evaluates the application ofthe Patient and Observer Scar Assessment Scale tokeloid scars and compares it to the widely used Van-couver Scar Scale in a clinical setting.

PATIENTS AND METHODSThirty-four patients attending the specialist

keloid service at The Royal London Hospital,Whitechapel, Barts and The London NHS Trustwere assessed as part of routine clinical practicebetween June 15 and July 15, 2010. Their meanage was 33 years (median, 29 years; range, 17 to 56years). A total of 41 keloid scars were evaluated: 11on the ear, 10 presternal keloids, eight on theshoulder, four on the anterior abdominal wall,four on the lower limb, two on the face, one on thebreast, and one nuchal keloid. The surface area ofthe scars ranged from 25 mm2 (5 " 5-mm scar) to21,700 mm2 (155 " 140-mm scar). Median surfacearea was 825 mm2. Five patients (15 percent) hadFitzpatrick skin type I to IV (white-beige skintone), and 29 patients (85 percent) had Fitzpat-rick skin type V to VI (brown-black skin tone).10

Seven patients were new to the clinic and hadreceived no previous treatment. Most patientswere already undergoing treatment with intral-esional steroid injections: on average, patients hadreceived six previous injections.

Scar Assessment ScalesAll scars were assessed independently by three

observers (one clinical nurse specialist, one spe-Fig. 1. The Vancouver Scar Scale.

Plastic and Reconstructive Surgery • March 2012

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cialist registrar in plastic surgery, and one final-year medical student) on the same day and usingboth the Vancouver Scar Scale and the Patient andObserver Scar Assessment Scale (observer compo-nent). The three observers were blinded to eachothers’ scores. These scoring scales are shown inFigures 1 through 3. Each scar scale allowed theobserver to rate a number of physical character-istics on a numerical scale. The Vancouver ScarScale had four components—vascularity, pigmen-tation, pliability, and height—to give a total scarscore ranging from of 0 to 13 (where 0 representsnormal skin).7The Observer Scar AssessmentScale rates six physical characteristics—vascular-ity, pigmentation, pliability, thickness, relief, andsurface area—in addition to an “overall opinion”component. The total score was calculated as asum of all seven components of the scale, to givea score of 7 to 70 (where 7 represents normalskin).9 Examples of three keloid scars and corre-sponding observer scores are shown in Figure 4.

Patients were asked to rate their own scars onthe same day as the observers, using the patientcomponent of the Patient and Observer Scar As-sessment Scale. They were blinded from the ob-servers’ scores. This part of the scale asked the

patient to rate four physical characteristics of theirscar—color, stiffness, thickness, and irregularity(defined as “bumpiness—in addition to two symp-tom scales for pain and itching associated with thescar. Patients were also asked to rate their “overallopinion” of their scar. As for the observer scale,each component was rated 1 to 10, with the totalcalculated as a sum of all scale components (7 to70, where 7 represents normal skin without asso-ciated pain or itching).9

Statistical AnalysisThe data were analyzed using the statistical

program PASW 18.0 (SPSS, Inc., Chicago, Ill.).Cronbach’s !, a reliability coefficient, was used tomeasure internal consistency for each of the twoscales.11 Internal consistency is defined as the ex-tent to which a set of items—in this case, the scalecomponents—behave as a group. If the value ishigh, this is evidence that the scale componentsmeasure the same underlying construct. A reli-ability coefficient of 0.70 or higher is considered“acceptable.”12,13

Interobserver reliability is the degree to whichassessments from two or more observers agree.

Fig. 2. The Patient and Observer Scar Assessment Scale: Patient scale.

Volume 129, Number 3 • Patient-Related Keloid Scar Assessment

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This was measured by calculating the intraclasscorrelation coefficient using a two-way mixedmodel with measures of consistency. The intra-class correlation coefficient was calculated bothfor single observer (single measure) and for thethree observers (average measure). In evaluatingthis, a correlation coefficient of 0 to 0.2 was in-terpreted as “slight”; 0.21 to 0.40, “fair”; 0.41 to0.60, “moderate”; 0.61 to 0.80, “substantial”; and0.81 to 1.0, “almost perfect.”14

Convergent validity refers to the degree towhich a rating is similar to another independentlygathered rating to which it should be theoreticallysimilar. We used the Pearson correlation coeffi-cient to determine the degree of correlation be-tween each of the components of the VancouverScar Scale and both parts of the Patient and Ob-server Scar Assessment Scale.15

We performed simple linear regression anal-ysis to identify factors that significantly influenced

patients’ overall opinion of their scars. In additionto examining each component of the Patient ScarAssessment Scale (scar-related pain, itchiness,color, stiffness, thickness, and irregularity), theamount of treatment received to date (number ofsteroid injections—the mainstay of treatment inthe keloid clinic), and the scar surface area werealso tested in the regression model.16

RESULTSInternal Consistency

Both components of the Patient and ObserverScar Assessment Scale were found to have rela-tively high internal consistency, with reliability co-efficients of 0.82 for the patient component and0.86 for the observer component. However, a re-liability coefficient of only 0.65 was found for theVancouver Scar Scale, suggesting that the scaleitems have relatively low internal consistency.

Fig. 3. The Patient and Observer Scar Assessment Scale: Observer scale.


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Interobserver ReliabilityThe interobserver reliability of the Vancouver

Scar Scale and the observer component of thePatient and Observer Scar Assessment Scale aresummarized in Table 1. The intraclass correlationcoefficient was consistently greater for the groupof three observers (average measure) comparedwith the single observer (single measure). Look-ing at the total score for each of the scales, inter-observer reliability was “substantial” for the Van-couver Scar Scale, and “almost perfect” for theobserver component of the Patient and ObserverScar Assessment Scale. For the individual Vancou-ver Scar Scale variables, the interobserver reliabil-ity was “almost perfect” for pigmentation andheight, “moderate” for pliability, but only “slight”

for vascularity. For the observer component of thePatient and Observer Scar Assessment Scale, in-terobserver reliability was “almost perfect” for pli-ability, surface area, and overall opinion; “substan-tial” for pigmentation, thickness, and relief; and“moderate” for vascularity.

Convergent ValidityAs Table 2 shows, the two scales had a strong

correlation with each other, with values of p ! 0.01for all. The scores for pliability and height had thestrongest correlation coefficients (0.88 and 0.85,respectively), whereas correlations for pigmenta-tion and vascularity scores were the lowest of thegroup of variables (0.64 and 0.70, respectively).

Fig. 4. Examples of keloid scars and corresponding observer scores. (Left) Total score, 55 of 70. Componentsinclude vascularity, 9 of 10; pigmentation, 6 of 10 (vascularity differentiated from pigmentation by physicallyblanching the scar and observing dark pigmentation when blanched, then extent of capillary refill on release);thickness, 7 of 10; relief, 8 of 10; pliability, 8 of 10; surface area, 8 of 10; and overall opinion, 9 of 10. (Above, right)Total score, 16 of 70. Components include vascularity, 2 of 10; pigmentation, 1 of 10; thickness, 2 of 10; relief, 1of 10; pliability, 2 of 10; surface area, 6 of 10; and overall opinion, 2 of 10. (Below, right) Total score, 33 of 70.Components include vascularity, 1 of 10; pigmentation, 1 of 10; thickness, 8 of 10; relief, 1 of 10; pliability, 8 of 10;surface area, 8 of 10; and overall opinion, 6 of 10.


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Correlation between each of the observerscales and the patient component of the Patientand Observer Scar Assessment Scale were not sta-tistically significant for any of the variables oneither scale (Table 3). However, it was notable thatpatients’ total scores were higher than the averageobserver total for the same scar in 83 percent ofcases (n # 33).

Patient Scar Assessment ScaleForty-three percent of patients reported that

their scar had been painful over the preceding fewweeks, and scar-related itching was reported by 70

percent of patients. Almost all patients reportedthat scar color (93 percent), thickness (95 per-cent), stiffness (98 percent), and surface irregu-larity (98 percent) were different from their nor-mal skin, and at least half of the patients (53, 50,50, and 50 percent, respectively) rated these phys-ical scar characteristics as very different from theirnormal skin (8 to 10 of 10). Seventy percent ofpatients had an overall opinion of their scar of 8to 10 of 10.

Simple Linear Regression AnalysisTable 4 shows that patients’ overall opinion of

their scars was significantly influenced by scarcolor, stiffness, thickness, and irregularity (p !

Table 1. Interobserver Reliability of the VancouverScar Scale and the Observer Component of thePatient and Observer Scar Assessment Scale

SingleMeasure ICC

(95% CI)

AverageMeasure ICC

(95% CI)

Vancouver ScarScale

Vascularity 0.054 (–0.11–0.26)* 0.14 (–0.43–0.51)*Pigmentation 0.59 (0.43–0.74)§ 0.82 (0.69–0.89)!Pliability 0.34 (0.15–0.54)† 0.60 (0.34–0.78)‡Height 0.69 (0.55–0.81)§ 0.87 (0.78–0.93)!Total score 0.38 (0.19–0.57)‡ 0.65 (0.41–0.80)§

Observercomponent ofthe POSAS

Vascularity 0.24 (0.05–0.45)† 0.49 (0.15–0.71)‡Pigmentation 0.54 (0.36–0.7)‡ 0.77 (0.62–0.87)§Pliability 0.59 (0.43–0.74)‡ 0.81 (0.69–0.89)!Thickness 0.57 (0.4–0.72)‡ 0.80 (0.66–0.88)§Relief 0.43 (0.245–0.61)‡ 0.70 (0.50–0.83)§Surface area 0.60 (0.43–0.75)‡ 0.82 (0.70–0.90)!Overall opinion 0.66 (0.51–0.79)§ 0.85 (0.76–0.91)!Total score 0.66 (0.51–0.79)§ 0.85 (0.76–0.91)!

CI, confidence interval; Single Measure ICC, intraclass correlationcoefficient for a single observer; Average Measure ICC, intraclasscorrelation coefficient for the group of three observer; POSAS, Pa-tient and Observer Scar Assessment Scale.Key: *slight; †fair; ‡moderate; §substantial; !almost perfect.

Table 2. Correlation between the Vancouver ScarScale and the Observer Component of the Patientand Observer Scar Assessment Scale*

PearsonCorrelationCoefficient p

VSS pigmentation score vs. OSASpigmentation score 0.64 !0.01

VSS vascularity score vs. OSASvascularity score 0.70 !0.01

VSS pliability score vs. OSASpliability score 0.88 !0.01

VSS height score vs. OSAS thicknessscore 0.85 !0.01

VSS total score vs. OSAS total score 0.83 !0.01VSS, Vancouver Scar Scale; OSAS, Observer Scar Assessment Scale.*All 41 scars, all three observers.

Table 3. Correlation between the Patient andObserver Scores Using the Vancouver Scar Scale andthe Observer Component of the Patient andObserver Scar Assessment Scale

PearsonCorrelationCoefficient p

VSS pliability score vs. PSAS stiffnessscore 0.24 0.14

VSS pigmentation score vs. PSAScolour score 0.20 0.21

VSS vascularity score vs. PSAS colourscore 0.04 0.83

VSS height score vs. PSAS thicknessscore 0.10 0.55

VSS total score vs. PSAS total score 0.17 0.29OSAS pliability score vs. PSAS stiffness

score 0.19 0.23OSAS pigmentation score vs. PSAS

colour score 0.18 0.26OSAS vascularity score vs. PSAS colour

score 0.24 0.88OSAS thickness score vs. PSAS thickness

score 0.18 0.26OSAS total score vs. PSAS total score 0.15 0.34VSS, Vancouver Scar Scale; PSAS, Patient Scar Assessment Scale;OSAS, Observer Scar Assessment Scale.

Table 4. Simple Linear Regression Analysis ofVariables Associated with the Patient ScarAssessment Scale*

Patient ScaleComponent

Coefficient ofDetermination

(r2)Slope

Coefficient (") p

Irregularity 0.32 0.56 0.001Color 0.24 0.49 0.001Thickness 0.21 0.46 0.002Stiffness 0.11 0.34 0.031Pain 0.08 0.29 0.07†Itchiness 0.07 0.26 0.10†No. of treatments — — †Scar surface area — — †*Dependent variable: patient’s overall opinion of scar.†Not significant (p $ 0.05).


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0.05 for all), with color, thickness, and irregularitybeing the strongest determinants of the variationin overall opinion [coefficients of determination(r 2) of 0.24, 0.21, and 0.32 respectively]. Theinfluence of scar-related pain, itchiness, numberof treatments, or scar surface area on patients’overall opinion was not shown to be significant(p $ 0.05).

DISCUSSIONA simple and reproducible way of assessing

keloid scars in routine clinical practice is neededto monitor treatment outcomes. An accurate anduniversally accepted method of keloid scar assess-ment will assist the development of improvedtreatment regimens. Such an assessment tool mustbe valid, consistent, reliable, and feasible for usein the outpatient clinic setting.

The Vancouver Scar Scale is a widely respectedand commonly used scar assessment scale.5,7,8,17

Before this study, it was the scar assessment tool ofchoice in the Royal London Hospital KeloidClinic. However, the Vancouver Scar Scale fails tocapture clinical information from the patient’sperspective, the importance of which is increas-ingly being recognized as we seek to attain patientsatisfaction with scar outcome.18 For this reason,the Patient and Observer Scar Assessment Scale isa promising new scar assessment scale, as it com-bines an observer’s clinical assessment with pa-tient evaluation.

This study is the first to evaluate the applica-tion of the Patient and Observer Scar AssessmentScale for the assessment of keloid disease specif-ically. It provides evidence to support the use ofthe Patient and Observer Scar Assessment Scalefor the assessment of keloid scars; when comparedwith the current best available observer scale, theVancouver Scar Scale, the Patient and ObserverScar Assessment Scale observer componentshowed excellent concurrent validity. In addition,the Patient and Observer Scar Assessment Scalewas shown to have a number of advantages overthe Vancouver Scar Scale. In particular, it scoredhigher on measures of internal consistency andreliability: both components of the Patient andObserver Scar Assessment Scale were found tohave excellent internal consistency, whereas theresults for the Vancouver Scar Scale failed to dem-onstrate acceptable internal consistency. A lack ofconsistency of the Vancouver Scar Scale was alsofound by Draaijers et al. in 2004.8 They suggestedthat this may be attributable to the pigmentationvariable on the Vancouver Scar Scale appearingnominal, rather than being a “proper numerical

scale” as seen on the Patient and Observer ScarAssessment Scale. However, on reviewing the orig-inal article that first describes the Vancouver ScarScale, the rationale for the pigmentation score isexplained: hypopigmentation scored 1, as it wasdeemed to be less significant than hyperpigmen-tation (scoring 2) for white, Indian, and Asianpopulations.7 However, as keloid disease predom-inates in extreme Fitzpatrick skin types (those withdarker skin), this original rationale for pigmen-tation in the Vancouver Scar Scale does not seemapplicable: hypopigmentation can be just as dis-figuring for patients with dark skin as extremehyperpigmentation in lighter skin. The Patientand Observer Scar Assessment Scale scores pig-mentation ranging from the patient’s normal skincolor (score of 1) to the opposite or most differentextreme of pigmentation (score of 10) and there-fore seems more suitable for the assessment ofaltered scar pigmentation in a population com-prising diverse Fitzpatrick skin types. Further-more, the interobserver reliability of the Patientand Observer Scar Assessment Scale completedboth by multiple observers and by a single observerwas significantly better than the Vancouver ScarScale. Perhaps, as would be expected, the inter-observer reliability for both the Patient and Ob-server Scar Assessment Scale and the VancouverScar Scale was better for three observers than fora single observer, but the reliability for three ob-servers was “almost perfect” for the Patient andObserver Scar Assessment Scale and only “sub-stantial” for the Vancouver Scar Scale. The reli-ability of the observer scale for a single observerwas 0.66 for the Patient and Observer Scar Assess-ment Scale—higher than for the Vancouver ScarScale (0.38). Although this does not quite meetthe recommended value of 0.70, it is worth notingthat it is higher than the results for a comparablestudy that concluded the Patient and ObserverScar Assessment Scale had “acceptable interob-server reliability” with 0.33 for a single measureand 0.60 for an average measure with threeobservers.19 Consequently, it seems there needs tobe greater agreement in such evaluations regard-ing what degree of reliability is “acceptable” forclinical practice.

The Patient Scar Assessment Scale showed ex-cellent internal consistency; however, it did notcorrelate well with the observer scales. This in itselfis a valuable finding because, as clinicians, we maythink we know what the patient perceives as asuccessful outcome when in fact our views can bedifferent from those of our patients. On the whole,patients thought worse of their scars than did the


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observers, and most had a very negative overallopinion. A similar discrepancy between observerand patient scores was noted in the 2005 article byvan de Kar et al., who suggested this could bepartly attributed to itching and pain.9 However,unlike the study by van de Kar et al., here patients’overall opinions were not shown to be significantlyinfluenced by pain and itching. Instead, we sug-gest that patients’ impression of their scar may berelated to the degree of psychological distress as-sociated with the visible disfigurement caused bykeloid disease, as patients’ overall opinion wasmost strongly influenced by the visible character-istics of their scars. Anecdotally, when completingthe self-assessment scale, many of the patients in-volved in this study expressed a wish to describethe wider impact of their keloid scars on their life,mentioning factors such as clothing, relationships,and social activities. This merits further study, witha view to possibly incorporating such factors intothe patient assessment scale for keloid scars.

It is important that any tool that forms part ofroutine clinical assessment is feasible for use in abusy outpatient clinic setting. In this study, giveninitial training and some practice, we found thatthe Patient and Observer Scar Assessment Scalewas quick and easy to use. From our experience ofusing the scale in a busy clinical setting, we rec-ommend some amendments to the scale proforma that we found helpful: to make a clear dis-tinction between the numerical score and the ad-ditional clinical information under the six cate-gory headings, we reformatted the scale to makethe order of completion clear. In addition, ob-servers found it helpful to annotate the pro formawith the definitions and clarifications provided bythe authors (Figs. 2 and 3). As the meaning of theterm “relief” was not immediately clear to all usersof the scale, we recommend renaming this cate-gory “surface irregularities” or “bumpiness,” as de-fined by the original authors.20 Figure 5 showsguidelines that we adapted from the original pub-

Fig. 5. Guidelines for completion of the observer component of the Patient and Observer Scar Assessment Scale.


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lication after consultation with the authors on ar-eas of potential confusion.9,20 This was used fortraining observers. We recommend that the orig-inal authors might supplement this with an officialtraining package, complete with “anchor photo-graphs” correlating to each 1-to-10 scale compo-nent. This would improve training and enhancethe reliability of the scale. We also suggest a pa-tient-friendly instruction guide to assist patientswho are new to using the patient component thescale. Finally, “overall opinion”, although notstrictly a clinical parameter, was a particularly use-ful indicator of response to treatment in a clinicalsetting. This article demonstrates that the inclu-sion of this category in the total score does notdetract from the scale’s reliability or validity, andwe would therefore advocate its inclusion in thetotal score.

CONCLUSIONSFor the assessment of keloid scars, the Patient

and Observer Scar Assessment Scale is associatedwith high internal consistency and “almost per-fect” interobserver reliability. It is more compre-hensive than the Vancouver Scar Scale, which hadlower internal consistency and lower interobserverreliability by comparison. Neither scale correlatedwell with patients’ ratings, although the patientcomponent of the Patient and Observer Scar As-sessment Scale provides valuable clinical informa-tion about the patient’s symptoms and perspectiveon their scar, which is currently missing from anyother scar assessment scoring system. The findingsof this study support the use of the Patient andObserver Scar Assessment Scale as a more useful,reliable, and valid method of assessing keloid scarsin a clinical context.

Pambos Lemonas, M.D., M.R.C.S.The Barts and the London NHS Trust

WhitechapelLondon E1 1BB, United Kingdom

ACKNOWLEDGMENTThis study was supported by the Healing Founda-

tion in association with the British Association of Plasticand Reconstructive Surgeons.

REFERENCES1. Datubo-Brown DD. Keloids: A review of the literature. Br J

Plast Surg. 1990;43:70–77.2. Butler PD, Longaker MT, Yang GP. Current progress in

keloid research and treatment. J Am Coll Surg. 2008;206:731–741.

3. Lahiri A, Tsiliboti D, Gaze NR. Experience with difficultkeloids. Br J Plast Surg. 2001;54:633–635.

4. Mustoe TA. The patient and observer scar assessment scale:A reliable and feasible tool for scar evaluation. Plast ReconstrSurg. 2004;113:1966–1967.

5. Fearmonti R, Bond J, Erdmann D, Levinson H. A review ofscar scales and scar measuring devices. J Plast Surg. 2010;10:354–363.

6. Idriss N, Maibach HI. Scar assessment scales: A dermatolog-ical overview. Skin Res Technol. 2009;15:1–5.

7. Sullivan T, Smith J, Kermode J, McIver E, Courtemanche DJ.Rating the burn scar. J Burn Care Rehabil. 1990;11:256–260.

8. Draaijers LJ, Tempelman FR, Botman YA, et al. The patientand observer scar assessment scale: A reliable and feasibletool for scar evaluation. Plast Reconstr Surg. 2004;113:1960–1965; discussion 1966–1967.

9. van de Kar AL, Corion LU, Smeulders MJ, Draaijers LJ, vander Horst CM, van Zuijlen PP. Reliable and feasible evalu-ation of linear scars by the Patient and Observer Scar As-sessment Scale. Plast Reconstr Surg. 2005;116:514–522.

10. Fitzpatrick TB. Soleil et peau. J Med Esthet. 1975;2:33–34.11. Streiner DL, Norman GR. Health Measurement Scales: A Prac-

tical Guide to Their Development and Use. 4th ed. Oxford: Ox-ford University Press; 2008.

12. Bland JM, Altman DG. Statistics notes: Cronbach’s alpha.BMJ. 1997;314:572.

13. Bland JM, Altman DG. Statistics notes: Validating scales andindexes. BMJ. 2002;324:606–607.

14. Landis JR, Koch GG. The measurement of observer agree-ment for categorical data. Biometrics 1977;33:159–174.

15. Saw SM, Ng TP. The design and assessment of questionnairesin clinical research. Singapore Med J. 2001;42:131–135.

16. Field A. Discovering Statistics Using SPSS for Windows: AdvancedTechniques for the Beginner. London: Sage; 2000.

17. van Zuijlen PP, Angeles AP, Kreis RW, Bos KE, MiddelkoopE. Scar assessment tools: Implications for current research.Plast Reconstr Surg. 2002;109:1108–1122.

18. Durani P, McGrouther DA, Ferguson MW. Current scales forassessing human scarring: A review. J Plast Reconstr AesthetSurg. 2009;62:713–720.

19. Truong PT, Lee JC, Soer B, Gaul CA, Olivotto IA. Reliabilityand validity testing of the Patient and Observer Scar Assess-ment Scale in evaluating linear scars after breast cancersurgery. Plast Reconstr Surg. 2007;119:487–494.

20. van Zuijlen PP, Draaijers LJ, Nicholas RS. Personal commu-nication, 2010.


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