Introduction

SOCORAD32 is a dermatologic disease scoring system used to assess the severity and extent of skin manifestations in patients with cutaneous lupus erythematosus (CLE) and dermatomyositis (DM). It was first developed in 2005 by a group of European dermatologists and rheumatologists as a way to standardize assessment and reporting of skin disease in these conditions.

Since its inception, SOCORAD32 has been increasingly used in clinical trials and research studies of CLE and DM to evaluate treatment efficacy and disease progression. This article provides an overview of SOCORAD32 – its development, validation, scoring system, and clinical applications. We’ll also look at some of the benefits and limitations of using SOCORAD32 as an outcome measure in dermatologic research.

Development and Validation of SOCORAD32

Cutaneous lupus erythematosus (CLE) refers to a group of lupus-related skin conditions, the most common being chronic cutaneous lupus erythematosus (CCLE) and subacute cutaneous lupus erythematosus (SCLE). Dermatomyositis (DM) is an inflammatory myopathy characterized by muscle weakness and distinctive skin rashes.

Both CLE and DM can result in disfiguring skin manifestations that significantly impact patients’ quality of life. However, there was no standardized tool for objectively measuring the extent and severity of skin involvement in these diseases.

To address this need, the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) was developed in 2005 specifically for CLE. This scoring system divided the body into 18 distinct anatomic regions and had patients rate erythema, scale/hypertrophy, and damage in each region on a 0-3 scale. However, CLASI did not address skin findings in DM.

The same group of researchers thus devised SOCORAD (SCLE and DM Severity Index) combining elements of CLASI with assessment of skin findings unique to DM, such as Gottron’s papules and periungual changes. This iteration grouped the body into 32 areas and had two 0-3 scales for activity (erythema, scale, mucous membrane lesions) and damage (scarring, dyspigmentation, alopecia).

The SOCORAD index underwent testing and refinement between 2005-2009 in over 700 patients with CLE or DM across Europe. Based on analysis of inter-rater reliability, responsiveness to change, and correlation with other disease measures, a final 32-item SOCORAD measurement tool was validated.

The key properties of the SOCORAD32 index that support its use as an outcome instrument are:

• Reliability – SOCORAD32 total scores demonstrate good inter-rater and intra-rater (test-retest) reliability.
• Validity – SOCORAD32 activity scores correlate well with other indicators of CLE and DM disease activity and skin-specific quality of life.
• Responsiveness – SOCORAD32 detects changes in skin disease severity over time and with treatment.
• Feasibility – SOCORAD32 takes about 10 minutes to complete and requires no complex equipment.

SOCORAD32 Scoring System

The SOCORAD32 consists of a front body diagram and a 32-item checklist to evaluate disease activity and damage.

Body Diagram

The diagram outlines 32 distinct anatomic regions covering the entire body surface. Each area is assigned a specific number.

SOCORAD32 body diagram. Image source: DermNet NZ

Item Scoring

For each of the 32 regions, the rater assigns two separate 0-3 grades:

• Activity score: Evaluates erythema, scale/hypertrophy, and mucous membrane involvement.
  • 0 = No activity
  • 1 = Mild
  • 2 = Moderate
  • 3 = Severe
• Damage score: Evaluates dyspigmentation, scarring, and alopecia.
  • 0 = No damage
  • 1 = Mild
  • 2 = Moderate
  • 3 = Severe

The two scores per region are totaled into:

• Activity score: Ranges from 0 to 96
• Damage score: Ranges from 0 to 96

Lower scores indicate milder disease and skin involvement, while higher scores reflect more severe and extensive disease manifestations.

Interpretation of SOCORAD32 Scores

There are no firmly established cutoffs for mild, moderate, and severe disease based on total SOCORAD scores. However, some general guidelines have been proposed:

• Activity score:
  • Mild: up to 20
  • Moderate: 21 – 50
  • Severe: above 50
• Damage score:
  • Mild: up to 10
  • Moderate: 11 – 30
  • Severe: above 30

Individual studies may define severity categories differently. Trends in scores over time are more significant than absolute cutoffs. The key is that higher scores indicate worsening in terms of spread and intensity of skin disease, while decreases reflect improvement.

Clinical Applications of SOCORAD32

Some of the main uses of the SOCORAD32 tool in clinical dermatology include:

Monitoring Disease Progression

Serial SOCORAD32 assessments allow quantification of changes in skin disease severity over time. Worsening is indicated by higher total and regional activity/damage scores compared to a previous visit. This helps guide treatment modifications.

Assessing Treatment Efficacy

Calculating SOCORAD scores before and after an intervention provides an objective measure of therapeutic response. Skin disease improvement is shown by a reduction in erythema, scaling, and other activity parameters that lower the total SOCORAD activity score.

Standardizing Reporting in Research Studies

Use of SOCORAD32 as a primary or secondary outcome measure in clinical trials allows standardized data collection. This enables comparison of results across different studies evaluating treatments for cutaneous lupus and dermatomyositis.

Correlation with Other Disease Indicators

SOCORAD32 activity scores have been shown to correlate with systemic disease activity scores like SLEDAI in lupus and MITAX in dermatomyositis. Higher SOCORAD scores also associate with worse dermatology-specific quality of life. This helps validate the index.

Discriminating Disease Subtypes

The pattern of SOCORAD scores may help distinguish subtypes of lupus and dermatomyositis. For example, higher damage relative to activity scores suggests chronic CLE more than acute SCLE.

Advantages of Using SOCORAD32

Some benefits of using the SOCORAD32 tool as compared to other evaluation methods include:

• Objective – Provides standardized numerical severity scores instead of subjective descriptive assessments.
• Comprehensive – Covers the entire body surface area rather than selected regions.
• Reliable – Shows good inter-rater and intra-rater agreement.
• Sensitive – Detects subtle changes and gradations in disease severity.
• Feasible – Simple and quick to administer in the clinic setting.
• Validated – Extensively tested in large patient cohorts.
• Widely used – Facilitates comparison across clinical trials and research studies.

Limitations of SOCORAD32

Some disadvantages and weaknesses of the SOCORAD32 tool to consider are:

• Inter-rater reliability, while good, is not perfect. There may be variability between different raters.

-Does not distinguish specific skin lesions like malar rash vs. discoid lesions.

• Unidimensional 0-3 scales may not fully capture nuances in appearance.
• Activity and damage scales are weighted equally, although clinically damage may be more relevant in chronic CLE.
• Does not formally include body surface area (BSA) affected though higher scores suggest greater extent.
• Potential ceiling effect since maximal total scores are capped at 96.
• Time-consuming – Requires clinical examination of the full body.
• Does not assess symptoms like pruritus that impact quality of life.

Current and Emerging Alternatives

While SOCORAD32 remains one of the most widely used tools for measuring cutaneous disease in lupus and dermatomyositis, other indices have been introduced more recently:

• CLASI – Only includes lupus-specific skin findings. May have greater responsiveness than SOCORAD in CLE.
• CDASI – Adds assessment of pruritus and body surface area (BSA) involvement to provide more nuanced severity grading.
• CLEDAI – Covers mucocutaneous findings, symptoms, and medications used. Provides total score and by-organ domain subscores.
• DAREA/VASI – Use computerized imaging analysis to quantify erythema and affected BSA. More precise and sensitive to change than clinical scales.
• DLQI – Quality of life questionnaire allows systematic assessment of patient-reported symptoms and psychosocial impact.

The optimal approach may be to combine a clinical activity scale like SOCORAD or CLASI with a patient-reported outcome measure. Further comparative effectiveness research is needed to establish best practices.

Conclusion

The SOCORAD32 index is a validated, clinical scoring system that provides an objective and relatively simple approach to evaluating the full range of skin manifestations in cutaneous lupus erythematosus and dermatomyositis.

It allows standardized measurement of disease progression and response to therapy in clinical trials and longitudinal patient studies. However, SOCORAD has some limitations including potential inconsistencies in rater scoring and lack of assessment of symptoms and quality of life impact.

Emerging tools like computerized imaging quantification and patient-reported outcome measures may complement and improve upon SOCORAD32. Still, given its extensive use over the past 15+ years, SOCORAD remains an important instrument in dermatology research and clinical monitoring of these chronic skin conditions.

Frequently Asked Questions

What does SOCORAD stand for?

SOCORAD is an acronym that stands for “SCLE and Cutaneous Dermatomyositis Area and Severity Index”. It was originally called SCORAD but later renamed SOCORAD32 when expanded to 32 items.

What skin conditions is the SOCORAD scale used for?

SOCORAD32 was designed and validated specifically for assessing severity of skin manifestations in subacute cutaneous lupus erythematosus (SCLE), chronic cutaneous lupus erythematosus (CCLE) and dermatomyositis.

What are the components of the SOCORAD scale?

The SOCORAD32 consists of a body diagram dividing the skin into 32 distinct regions. Each area is scored from 0-3 for disease activity (erythema, scale, mucous lesions) and 0-3 for damage (dyspigmentation, scarring, alopecia).

How long does it take to complete the SOCORAD assessment?

It takes approximately 10 minutes for the provider/researcher to visually inspect all 32 body regions and assign the two 0-3 grades per region. No input is required from the patient.

What is the scoring range for SOCORAD32?

The total activity score ranges from 0 to 96. The total damage score also ranges from 0 to 96. Higher scores indicate greater severity and extent of skin involvement.

How often should SOCORAD32 be measured?

For monitoring disease progression and treatment response, experts recommend assessing SOCORAD32 at baseline and then at regular follow-up visits such as monthly, every 3 months or every 6 months.