Research

JAMA Dermatology | Original Investigation

Development and Initial Validation of a Multidimensional Acne Global

Grading System Integrating Primary Lesions and Secondary Changes
Elena Bernardis, PhD; Haochang Shou, PhD; John S. Barbieri, MD, MBA; Patrick J. McMahon, MD;
Marissa J. Perman, MD; Leigh Ann Rola, PA-C; Jenna L. Streicher, MD; James R. Treat, MD;
Leslie Castelo-Soccio, MD, PhD; Albert C. Yan, MD

Supplemental content
IMPORTANCE The qualitative grading of acne is important for routine clinical care and clinical
trials, and although many useful systems exist, no single acne global grading system has had
universal acceptance. In addition, many current instruments focus primarily on evaluating
primary lesions (eg, comedones, papules, and nodules) or exclusively on signs of secondary
change (eg, postinflammatory hyperpigmentation, scarring).

OBJECTIVES To develop and validate an acne global grading system that provides a
comprehensive evaluation of primary lesions and secondary changes due to acne.

DESIGN, SETTING, AND PARTICIPANTS This diagnostic study created a multidimensional acne
severity feature space by analyzing decision patterns of pediatric dermatologists evaluating
acne. Modeling acne severity patterns based on visual image features was then performed to
reduce dimensionality of the feature space to a novel 2-dimensional grading system, in which
severity levels are functions of multidimensional acne cues. The system was validated by 6
clinicians on a new set of images. All images used in this study were taken from a
retrospective, longitudinal data set of 150 patients diagnosed with acne, ranging across the
entire pediatric population (aged 0-21 years), excluding images with any disagreement on
their diagnosis, and selected to adequately span the range of acne types encountered in the
clinic. Data were collected from July 1, 2001, through June 30, 2013, and analyzed from
March 1, 2015, through December 31, 2016.

MAIN OUTCOMES AND MEASURES Prediction performance was evaluated as the mean square
error (MSE) with the clinicians’ scores.

RESULTS The scale was constructed using acne visual features and treatment decisions of 6
pediatric dermatologists evaluating 145 images of patients with acne ranging in age from 0 to
21 years. Using the proposed scale to predict the severity scores on a new set of 40 images
achieved an overall MSE of 0.821, which is smaller than the mean within-clinician differences
(MSE of 0.998).

CONCLUSIONS AND RELEVANCE By integrating primary lesions and secondary changes, this
novel acne global grading scale provides a more clinically relevant evaluation of acne that may
be used for routine clinical care and clinical trials. Because the severity scores are based on
actual clinical practice, this scoring system is also highly correlated with appropriate
treatment choices.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Elena
Bernardis, PhD, Department of
Dermatology, Perelman School of
Medicine, University of Pennsylvania,
3400 Spruce St, 2 E Gates Bldg,
Room GA02060, Philadelphia, PA
JAMA Dermatol. doi:10.1001/jamadermatol.2019.4668 19104 (elena.bernardis@
Published online January 29, 2020. pennmedicine.upenn.edu).

(Reprinted) E1
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 Research Original Investigation Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes
A
cne vulgaris is one of the most common skin disor-
ders managed by pediatricians and dermatologists, af-
fecting 85% of adolescents, and is responsible for a
greater global burden of disease than psoriasis, cellulitis, and
melanoma.1 Although qualitative grading of acne is impor-
tant in the clinic to select appropriate treatment and as an out-
come for clinical trials, acne grading remains a topic of de-
bate with no universally accepted global acne severity scale.2,3
Most acne scoring systems can be divided into quantita-
tive lesion counting and qualitative acne global grading sys-
tems. Lesion counting involves quantifying noninflamma-
tory (ie, comedones) and inflammatory (ie, papules,
pustules, and nodules) lesions. In contrast, global grading
systems seek to provide a qualitative estimate of disease
severity that can complement quantitative lesion counting.
Several dozen useful acne global grading systems have been
developed, most of which categorize severity through a text
description and/or photographic templates.4-11 These quali-
tative scales have been shown to be more practical and
clinically relevant than lesion counting alone. However, the
varying and sometimes inexact definitions used in these
tools reflect the inherent challenges of classifying the visual
complexity of acne lesions on the skin.9,12
Notably, most of these systems do not account for the
presence of scarring, which can have important implica-
tions for treatment decisions and thus can significantly alter
the clinical severity of the acne. Although several scales are
available to assess acne scarring, these typically do not have
the ability to simultaneously consider other acne lesion
types (eg, comedones, papules, pustules, and nodules).13-16
In addition, these acne global grading systems often do not
incorporate measurements for postinflammatory changes or
erythema, which can often have significant relevance to
patients with respect to their perceived severity of disease.
Given the limitations of current grading systems, we sought
to develop and validate a novel acne global grading system
that could account for primary lesions (eg, comedones, pap-
ules, and nodules) as well as secondary changes (eg, postin-
flammatory hyperpigmentation, scarring).
Methods
This diagnostic study was deemed exempt from institutional re-
view board approval and informed consent by the Children’s Hos-
pital of Philadelphia institutional review board because of the use
of deidentified patient images. The study followed the Transpar-
ent Reporting of a Multivariable Prediction Model for Individual
Prognosis or Diagnosis (TRIPOD) reporting guideline.
An overview of the methods used to create and validate
the new grading system is summarized in Figure 1. The pro-
cess was divided into 4 main steps: (1) high-level image analy-
sis to understand how clinicians interpret acne on a visual in-
spection; (2) data collection, in which clinicians quantified acne
visual cues and chose a corresponding treatment intensity; (3)
feature analysis and thematic content analysis to condense the
information into a clinically intuitive, low-dimensional sever-
ity table; and (4) validation of the scale. We start with a brief
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Key Points
Question Is it possible to develop a global grading system for acne
assessing primary lesions (eg, comedones, papules) and secondary
changes (eg, postinflammatory changes, scarring)?
Findings This diagnostic study presents a multidimensional acne
grading system linking the most relevant visual features of acne to
a severity score and validates the scale with correlation of
treatment decisions by 6 clinicians evaluating images of patients
with acne. The proposed 2-dimensional scale achieved an overall
mean square error smaller than the mean within-clinician
differences.
Meaning This grading system pilot provides a possible
groundwork to reformulate acne severity as a dimensionality
reduction problem.
overview of development of the scale and refer the reader to
the eMethods in the Supplement for complete details.
To capture the clinicians’ thought process when analyz-
ing acne on a visual inspection, we started by creating a new
representation for acne severity (step 1): a multidimensional
space linking acne’s visual features to classes of increasing
treatment intensities (eFigure1 in the Supplement and Table).
This was achieved by designing experiments that asked clini-
cians to evaluate images of patients with acne to define new
acne severity groups in terms of increasing treatment inten-
sities as well as to extract and collect features indicative of acne
that influenced decisions of how to treat the patients (step 2).
In step 3, we validated which features were most signifi-
cantly associated with the severity scores via statistical mod-
els (eg, eFigure2 in the Supplement). Features included scars
(acne-related and overall), inflammation, number of pap-
ules, and number of nodules, followed by the combined pres-
ence of postinflammatory color changes due to the resolving
acne or acne treatment (eTable 2 in the Supplement). By using
pattern analysis—in particular choosing feature combina-
tions via content thematic analysis and validating the choices
via visualizations to ensure a continuous and clinically intui-
tive distribution of the final severity levels—the multidimen-
sional space of acne features that was discovered was then re-
duced to 2 dimensions (step 4). The first dimension captures
primary lesions (comedones, papules/pustules, and nod-
ules), whereas the second dimension encodes all other visual
cues indicative of acne: (1) inflammation, defined as areas of
redness associated with primary acne activity (excluding areas
within the acne primary lesions); (2) scars; and (3) postinflam-
matory color variations associated with resolving activity or
ongoing treatment, manifested as presence of focal color
changes and/or erythema not associated with primary lesion
inflammation (eg, macular erythema, postinflammatory ery-
thema), hyperpigmentation, and dryness, redness, and/or color
changes due to treatment.
To validate the scale, 6 clinicians (5 board-certified der-
matologists, 4 of whom had an additional board certification
in pediatric dermatology, and 1 physician’s assistant [L.A.R.])
who did not participate in the data collection phase to create
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 Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes Original Investigation Research

Figure 1. Overview of Developing and Validating the New Grading System

Acne features and Statistical models to confirm Quantitative evaluation via

corresponding quantifiers relevance of acne features data-driven models

1 High-level image analysis: 2 Annotating acne images: individuating 3 Feature space analysis and 4 Proposed grading system:
analyzing what physicians acne features and selecting dimensionality reduction 2-dimensional acne severity scale
see when looking at acne corresponding treatment level linking visual cues to treatments

Severity groups and corresponding Thematic content analysis to Clinician validation

treatment intensity groups analyze severity as a function (methods and results)
of feature combinations

The scale development was divided into the following main steps: (1) high-level image analysis; (2) acne data collection; (3) pattern analysis to condense the
information down to a clinically intuitive, low-dimensional severity table; and (4) scale validations.

Table. Severity Label Definitions and Corresponding Treatment Intensity Groups

Obtained From Initial Clinical Assessmentsa
Acne
Severity Associated Severity Final Clinical Severity Label
Level Treatment Intensity Group Label by Clinicians Used in the Proposed Scale
1 No treatment necessary Clear Clear
2 Benzoyl peroxide wash and/or a mild topical Almost clear Almost clear
retinoid
3 Benzoyl peroxide wash and a topical retinoid Mild Mild
4 Benzoyl peroxide wash and a stronger topical Mild to moderate Mild to moderate
retinoid or a topical retinoid and consideration
of an oral antibiotic
a
Acne images were grouped into sets
5 Benzoyl peroxide wash, topical treatment, and Moderate Moderate
an oral antibiotic of lowest to highest perceived
severity along with corresponding
6 Same as 5, but start considering isotretinoin Moderate to severe Moderate to less severe
treatment intensities; severity labels
7 Same as 5, but recommend isotretinoin Severe Less severe were assigned to each group by
8-9 Should be on isotretinoin (more severe = 8) More severe Severe (case 1) or very clinicians in the initial experiments,
(case 1) or, in very severe cases, start with a severe (case 2) and the final severity labels were
lower dosage of isotretinoin (to avoid flaring) definitions used in the proposed
and add corticosteroids (case 2)
scale.

the scale rated 40 new test images of acne patients’ skin (in-
cluding face, back, and chest) that were not used in the cre-
ation of the scale itself. Patient consent for all images used in
this study was waived by the institutional review board. Each
clinician was provided with a hard copy of the scale (Figure 2)
and instructed to choose 1 of 9 treatment intensities (Table)
and to use the proposed table to provide a severity score. Cli-
nicians were approached individually and provided with a form
to fill out in private to minimize any bias in their choices. Pre-
diction performance was evaluated as the mean squared er-
ror (MSE) comparing the proposed scales with the treatment
choices of the clinicians. The MSE is a measure of the ex-
pected deviation between the predicted and observed scales.
It assesses the accuracy of the scale’s prediction by quantify-
ing the mean squared difference between the clinicians’ scores
from the 2 clinical interviews (the mean score of images evalu-
ated within a group of images vs images evaluated individu-
ally) and those obtained by using the proposed scale. The
smaller the MSE, the more closely the predicted value is to the
desired one.
In addition, we evaluated the predictions of our pro-
posed scale for the 145 images used during the development
phase and compared them with the predictions obtained via
the data-driven learning models as well as the 1-dimensional
version of our scale based only on active lesion count (eFig-
ure 3C in the Supplement). Prediction performance was again
evaluated as the MSE with the mean of clinicians’ ratings. For
the regression models, to avoid overfitting, we cross-
validated the prediction models with 80% randomly selected
images and calculated the MSEs on the remaining 20% of test-
ing samples, repeating the procedures 1000 times. The intra-
rater variability of each clinician was derived by computing the
mean squared difference between the scores obtained from 2
sets of ratings given by the same clinicians (images evaluated
within a group vs images evaluated individually). Data were
collected from July 1, 2001, through June 30, 2013, and ana-
lyzed from March 1, 2015, through December 31, 2016.
Results
All images used in this study were taken from a retrospective
longitudinal data set of 150 patients diagnosed with acne in
the dermatology clinic, ranging across the entire pediatric
population (aged 0-21 years) and skin phototypes (with ap-
proximately 70% types I-III and 30% types IV-VI), excluding

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 E4
Figure 2. Proposed 9-Point Multidimensional Acne Global Grading System

Papules/
Nodules Pustules Comedones

Many Covered ———— Less severe Less severe Severe Very severe Very severe

Many None ————

Moderate to less severe Moderate to less severe Less severe Severe Very severe
Research Original Investigation

Some ———— ————

Few Many ———— Moderate Moderate Moderate to less severe Less severe Severe

1 Some ———— Mild to moderate Mild to moderate Moderate Moderate to less severe Less severe

None Few ———— Mild + Mild + Mild to moderate Moderate Moderate to less severe

JAMA Dermatology Published online January 29, 2020 (Reprinted)

None None Many; Covered Mild + Mild + Mild + Mild to moderate Moderate

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None None Few; Some Almost clear Mild Mild Mild to moderate Moderate

None None None Clear Clear Almost clear Mild Mild to moderate Moderate

Mild/ Mild/ Mild/

None ———— None None Severe Severe Severe Inflammation
Moderate Moderate Moderate

Mild/

© 2020 American Medical Association. All rights reserved.

Mild/ Mild/
———— None None None Moderate; None Severe Severe Scars
Moderate Moderate
Severe

None None Yes Yes Yes ———— Yes ———— ———— ———— Postinflammatory

Primary lesions and secondary changes can be encoded into a score by first counting lesions (nodules, papules/
pustules, and comedones), choosing the highest corresponding row, and then selecting the degree of secondary
changes (and choosing the correct combination). The dashed lines indicate any possible entry (ie, the final severity is
independent of that specific feature/variable). For example, if papules or nodules are present, the number of
comedones is no longer relevant to the score. Similarly, if scars and inflammation are both present, the degree of
postinflammatory hyperpigmentation is also no longer relevant to the score. For nodule quantifiers, few indicates 2
to 3; some, 4 to 6; and many, more than 6. For papule/pustule quantifiers, few indicates 1 to 3; some, 4 to 8; and
many, more than 8. For comedone quantifiers, few indicates 1 to 3; some, 4 to 12; and many, more than 12. Scars and
inflammation should be categorized into none, mild/moderate, or severe. Postinflammatory encodes any postinflam-
matory color changes and should be marked yes if any of the following cues are present: focal color changes and/or
diffuse erythema not associated with primary acne lesion activity; hyperpigmentation; and redness, dryness, or color
due to treatment. Mild + allows for differentiation of severe comedonal acne: if comedones are covered, the classifi-
cation becomes severe comedonal; otherwise, the classification is the same as mild. An additional (lower-left) entry
includes older acne cases that have completely cleared (only valid with >0 scars).

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Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes
 Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes
Figure 3. Acne Assessment Examples Using the Proposed Acne Scale
A Mild B Mild to moderate
Lesions Some comedones (R2) Some comedones, few
papules/pustules (R4)
Inflammation None Mild/Moderate
Scars Mild/Moderate Mild/Moderate
Postinflammatory Yes Yes
A, Mild indicates approximately 5 (some) comedones with the presence of
postinflammatory color changes and some ice-pick scars (mild/moderate).
Lesion count fixes row 2 (R2) in Figure 2, whereas background activity moves
the rating to column 3 in Figure 2. B, Mild to moderate indicates
approximately 8 comedones, 1 to 2 pustules/papules, and postinflammatory
color (in particular, color changes due to treatment) with mild/moderate
inflammation and scars (column 3 in Figure 2). This acne was more severe in the
past, but because it is at the end of treatment, it now falls in the category of
images with any disagreement on their diagnosis, and se-
lected to adequately span the range of acne types encoun-
tered in the clinic. These acne types included less than 10%
clear, approximately 10% almost clear, approximately 40%
mild, approximately 30% moderate, and more than 10% se-
vere (eTable 1 in the Supplement).
The proposed 9-point, multidimensional acne severity
scale is presented in Figure 2. By having the raters count ac-
tive lesions and detect the presence of secondary changes
(binary in the case of postinflammatory changes and divided
into 3 levels of severity in the case of inflammation and scars),
it provides a way to map acne’s visual appearance into the fol-
lowing 9 categories: clear, almost clear, mild, mild to moder-
ate, moderate, moderate to less severe, less severe, severe, or
very severe (Table). Each severity label corresponds to an in-
creased treatment intensity group (Table). In addition, we
added a mild plus category to allow for differentiation of se-
vere comedonal acne, which is usually treated without the use
of any oral antibiotics.
Details on how to use the scale are included in the cap-
tion of Figure 2, whereas Figure 3 shows some examples of acne
grading using the proposed new scale. By providing specific
guidelines, the scale eliminates potential overlaps between the
groups and, by design, counteracts counting uncertainties, for
example, those due to lesions that may appear similar (eg, larger
papules vs smaller nodules). Because the development of the
scale was based on mapping what clinicians saw to how they
would treat what they saw, it provides an assessment of the
area that is being inspected assuming nothing else is present.
Comparing the proposed scale with the clinicians’ scores
on the 40 new test images, we achieved an overall MSE of 0.821.
In other words, the mean mistake of acne classification was
less than 1 point when comparing it with the criterion stan-
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Original Investigation Research
C Moderate D Moderate to less E Severe
severe
Many comedones, some Many papules/pustules (R6) Many papules/pustules,
papules/pustules (R5) 1 nodule (R6)
Mild/Moderate Mild/Moderate Severe
None Mild/Moderate Severe
Yes Yes Yes
topical disease with consideration (in this case, continue) of oral therapy. C,
Moderate indicates increased papules (4-5), more than 12 comedones,
postinflammatory color changes, and mild/moderate inflammation (column 3 in
Figure 2). D, Moderate to less severe indicates more than 8 papules,
postinflammatory color changes, and mild/moderate inflammation and scars
(column 3 in Figure 2). E, Severe indicates more than 8 papules and 1 nodule
and severe inflammation and scarring (column 5 in Figure 2).
dard (clinical scores). The MSE of the proposed scale and the
clinicians’ scores falls below the MSE of within-clinician dif-
ferences measured in the development phase. In addition, for
comparison with experiments presented in the eMethods in
the Supplement, the interrater reproducibility is also higher
when using the scale, yielding an intraclass correlation coef-
ficient of 0.91.
A comparison of severities predicted by the model (ie, se-
verity levels in direct correspondence with treatment inten-
sity groups) vs treatment groups reported by clinicians are il-
lustrated in Figure 4, where treatment intensities (y-axis), or
clinical scores, are plotted against the scale scores (x-axis). We
highlight this comparison in the plot by using 2-colored mark-
ers when the treatments differ: the marker’s outer color rep-
resents the treatment associated with the clinical score,
whereas the inner color represents the one associated with the
score from the new scale. Marker sizes represent the number
of images in each group. Circles below the diagonal line indi-
cate overestimated scores, whereas the ones above the line in-
dicate the underestimated ones. There are only 5 colors for the
markers. As can be noted in the Table, although 9 categories
were needed to properly account for all acne scenarios, the ac-
tual treatment intensities that the patients would be receiv-
ing (Table) are limited to 5 groups (eg, moderate and moder-
ate to less severe would both have the same treatments).
The proposed 2-dimensional scale also showed the best
prediction performance on the 145 images used during the de-
velopment phase when compared with the predictions using
the data-driven learning models as well as the 1-dimensional
version of the scale based only on active lesion count. The MSE
obtained using the proposed new acne severity scale (Figure 2)
showed the best prediction score (MSE = 0.660), whereas the
learning models using regressions performed slightly worse,
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 Research Original Investigation
Figure 4. Comparison of Severities Predicted by the Proposed 9-Point
Severity Scale vs Clinician-Reported Treatment Intensity Groups
Isotretinoin and steroids
Isotretinoin
Oral antibiotic, topical retinoid,
and benzoyl peroxide
10 Topical retinoid and benzoyl peroxide
Benzoyl peroxide
8 sions and secondary changes, it is possible to use each of these
Clinicians’ Scores
6 and column.
4
2
0 cluding among live patients. For example, although the con-
0 2 4 6
Proposed Multidimensional Acne Global Grading System
The validation was performed by 6 unbiased clinicians on 40 new images
showing varying severities, skin types, and acne locations. Clinician-reported
severities (derived by mapping treatment intensity groups to their
corresponding severity label as detailed in the Table) are plotted vs severities
predicted using the new scale. Marker colors correspond to increasing
treatment options (see the Table for more details on treatment intensity
correspondences). Marker size corresponds to the number of images within
each group. The proposed clinical severity scale achieved an overall mean
square error of 0.821. The outer color indicates treatment recommended by the
clinician; inner color, treatment recommended by the scale.
with an MSE of 1.014 (SE, 0.185) for the tree model, 0.768 (SE,
0.131) for linear regression, and 0.774 (SE, 0.127) for the mixed-
effect model. The 1-dimensional version (eFigure 3C in the
Supplement), while hav ing the worst performance
(MSE = 1.132), also had a relatively low error when compared
with the clinicians’ scores (MSE = 0.998).
Discussion
Global acne grading scales are generally limited by focusing on
lesional activity or secondary changes, such as scarring, which
prevents a complete assessment of the burden of acne. The pro-
posed scale presented herein represents a novel global acne grad-
ing system that incorporates primary lesions and secondary
changes into a single comprehensive instrument. In addition, by
mapping visual cues to disease severity as assessed by the treat-
ment decisions of clinicians, we were able to create a scale that
reduces subjectivity when using this instrument.
This scale has several potential applications. In clinical
practice, the scale has the potential to facilitate more accu-
rate assessment of the complete burden of acne to improve
ARTICLE INFORMATION
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Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes
medical decision-making (because it provides an entry point
for treatment, which can then be adjusted by the treating cli-
nician depending on patient history or preferences) or to moni-
tor for improvement after treatment. In a research setting, by
providing a more comprehensive evaluation of the patient, it
will be possible to better stratify patients for enrollment in clini-
cal trials and to more accurately capture the improvement of
their acne with therapy, enabling more robust studies. In ad-
dition, because the instrument includes scales for primary le-
subscales to monitor for improvement of these separate cat-
egories simply by tracking the component scores from each row
Limitations
The results of this study should be interpreted in the context
of the study design. Because this validation study only in-
cluded clinical images evaluated by pediatric dermatologists
at 1 health center, future validation studies are needed to con-
firm the validity and generalizability of this instrument, in-
8 10 clusions were validated in a pediatric population—and we
would anticipate that this scale could be extrapolated to an
adult population—further work should also explore the appli-
cability of this system in adults. Furthermore, the treatment
correspondence was based on the clinical practice in a major
children’s hospital of board-certified dermatologists and der-
matology clinicians with US-based treatments in mind. Al-
though the ordering of the severity levels should be univer-
sally valid, in future work, it would be important to investigate
country-specific adaptions for the treatment intensity corre-
spondences.
Finally, the table itself is relatively complex and may be
cumbersome to administer in a busy clinical setting. We have
created a software version of the table that can be down-
loaded from the project website (https://dermatology.upenn.
edu/labs/codelab/acne). In the future, the table may be
integrated with automated lesion detection image analysis
algorithms to further reduce the burden of administration and
improve standardization.17
Conclusions
Acne vulgaris continues to be an area of active research and
is one of the most common diseases worldwide. Currently
available grading systems provide limited utility in terms of
how to translate existing disease states into appropriate
therapeutic plans because they do not account for overall
disease activity. Following additional development and vali-
dation, this novel acne severity scale, which also captures
information on secondary postinflammatory changes and
scarring, has the potential to improve the care of patients
with acne in the clinical and research settings.
Published Online: January 29, 2020. Author Affiliations: Department of Dermatology,
doi:10.1001/jamadermatol.2019.4668 Perelman School of Medicine, University of
jamadermatology.com
 Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes
Pennsylvania, Philadelphia (Bernardis, Barbieri,
McMahon, Perman, Rola, Streicher, Treat,
Castelo-Soccio, Yan); Department of Biostatistics,
Epidemiology and Informatics, Perelman School of
Medicine, University of Pennsylvania, Philadelphia
(Shou); Division of Pediatrics, Section of
Dermatology, The Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
(McMahon, Perman, Rola, Streicher, Treat,
Castelo-Soccio, Yan); Department of Pediatrics,
Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
(McMahon, Perman, Rola, Streicher, Treat,
Castelo-Soccio, Yan).
Author Contributions: Drs Bernardis and Yan had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Bernardis, Yan.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Bernardis, Shou,
Barbieri, Yan.
Critical revision of the manuscript for important
intellectual content: Bernardis, Barbieri, McMahon,
Perman, Rola, Streicher, Treat, Castelo-Soccio, Yan.
Statistical analysis: Bernardis, Shou.
Obtained funding: Bernardis, Yan.
Administrative, technical, or material support:
Bernardis, Rola, Yan.
Supervision: Castelo-Soccio, Yan.
Conflict of Interest Disclosures: Dr Yan reported
receiving personal fees from Ortho Pharmaceutical,
Johnson & Johnson, and Valeant Pharmaceuticals
outside the submitted work. No other disclosures
were reported.
Funding/Support: This study was supported in
part by the Children’s Hospital of Philadelphia’s
2013-2015 Chair’s Initiative Award (Drs Bernardis
and Yan), award T32-AR-007465 from the National
Institute of Arthritis and Musculoskeletal and Skin
Diseases of the National Institutes of Health (Dr
Barbieri), and a Pfizer Fellowship grant to the
Trustees of the University of Pennsylvania (Dr
Barbieri).
Role of the Funder/Sponsor: The sponsors had no
role in the design and conduct of the study;
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collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Additional Contributions: We thank the clinicians
in the Section of Dermatology who participated in
the clinical validation of the scale and the Penn
Libraries' Biomedical Library and the Library’s
Innovation Intern, James Bigbee, for the
implementation of the severity scale as a software
interface.
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