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Making the grade: New acne severity index helps doctors assess lesions


The new Bikowski Acne Severity Index (BASI) effectively combines common medical jargon for describing acne lesions, which helps physicians grade these lesions more accurately.

Key Points

Sewickley, Pa. - Objectivity is important when assessing the severity of acne lesions.

"This innovative acne grading system not only allows a more precise grading of acne lesions, but also allows the practitioner to more accurately document the changes seen in patients for study purposes, as well as keep more exact medical records," says Joseph Bikowski M.D., F.A.A.D., director of the Bikowski Skin Care Center in Sewickley, Pa.

The BASI system determines acne severity based upon the type, number and location of acne lesions.


Lesions are classified by type as grade I (comedone - open or closed), grade II (papule), Grade III (pustule) and grade IV (nodule).

If the nodule is present long enough, it can become an enclosed and encapsulated cyst, and the goal is to treat the nodule before it becomes a cyst.


The number of lesions is classified as mild (1-10 lesions), moderate (11-20 lesions) and severe (greater than 20 lesions).

Dr. Bikowski says that these numbers are based on his clinical experience and observation of acne patients over the last 30 years.


When addressing the location of acne lesions, Dr. Bikowski divides anatomical areas into units.

When speaking of facial acne, for example, he divides the face into five separate anatomical units - forehead, left and right cheek, nose, and chin - because in acne, sometimes certain anatomical units are not affected.

Once separated into units, types of lesions are assessed and counted in each anatomical area.

"For example, severe grade I acne of the forehead would be greater than 20 open and/or closed comedones of the forehead unit. A moderate grade II or III acne of the chin would be 11 to 20 papules and pustules. A mild grade IV acne of the cheek is one nodule.

"This is actually mild acne if only one nodule and nothing else is present," Dr. Bikowski tells Dermatology Times.


According to Dr. Bikowski, there are four reasons to better document the severity of acne lesions in patients:

1. The quality of medical charting and, hence, the quality of medical care is better due to the more precise system the BASI uses. Dr. Bikowski says that most physicians do not take photographs of the patients' acne and, therefore, have no before-and-after images to compare. The BASI system can better quantify and qualify the acne lesions from visit to visit, yielding a much more precise medical record.

2. As with all diseases and conditions, physicians need to better document acne at each visit for legal reasons.

3. Insurance companies usually will reimburse physicians only if there is accurate documentation, so the more documentation and the more accurate the detail of the documentation, the better the chance for problem-free reimbursement for services rendered.

4. According to Dr. Bikowski, the systems currently used in documenting acne are insufficient. A universal standardized objective system when documenting the number, distribution and types of acne lesions is needed and crucial when evaluating the efficacy of drugs in medical trials.

Dr. Bikowski also says the older grading systems that are still being used - the Pillsbury, Shelly, Kligman, the Cook, and the Burke & Cunliffe grading systems - lack objectivity, are less accurate and, therefore, can be open to interpretation.

The BASI system will have all physicians "on the same page" when defining the severity of acne lesions in patients, he adds.

"I think that this system is simple and easy to do, and it makes better sense out of all the terminology we have been using in the past with other grading systems.

"The BASI helps you manage each individual patient objectively and more effectively," Dr. Bikowski says.

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