I would like to commend Brown et al.1 for their rigorous approach in developing the Patient-Reported Impact of Scars Measure, a patient-reported outcomes measure on the impact of scarring; however, I would like to challenge their assertion that this is “the first scar-specific patient-reported outcome measure to assess the impact of scars from the patient's perspective for use in clinical settings, research, and trials.” A comprehensive review of the literature would have highlighted our group's own endeavors in producing a validated patient-reported measure for scar, the Patient Scar Assessment Questionnaire (using an alternative but widely accepted traditional technique based on classic test theory) and the subsequent publication of that work in this very Journal.2 It is important to assess in which situations each of the two measures is more appropriate, if investigators decide to use one or the other.
The Patient-Reported Impact of Scars Measure has been derived by a robust interview-based methodology that continued until “theme-exhaustion”; however, a missing construct is the patient's perception of scar appearance. Other themes of importance may have been elucidated had the sample of 34 interviewees been more reflective of different scar groups. The cause or site of the scars in this sample group is not clearly stated, and it is accepted that such factors are important in scar perception. Further testing of the Patient-Reported Impact of Scars Measure in different scar population groups (from traumatic wounds and surgical populations) will be important in demonstrating that it has discriminative validity and can truly detect “known group differences.”
The study does not present adequate evidence as yet that the Patient-Reported Impact of Scars Measure can be reliably applied to the many different scar populations in clinical trials. The calibration of this scale has been specific to scar types at the poor end of the spectrum (the sample subjects for interview were selected from a “specialist scar clinic,” and in the subsequent validation survey, 77 percent of the subjects rated their scars as fair to very poor, nearly 60 percent hypertrophic or keloid). Importantly, many trials will evaluate therapies that may only improve certain aspects of the scar—appearance, symptoms, or psychological and functional impact. The ability to detect change along these separate domains will be an important attribute of a criterion standard multidimensional scale.
In conclusion, the Patient-Reported Impact of Scars Measure is likely to be more useful in evaluating therapeutic efficacy of interventions that improve the functional limitations related to scar symptoms (unlike the Symptoms subscale in the Patient Scar Assessment Questionnaire that requires further work) or psychological impact—more relevant for the very poor, potentially disfiguring hypertrophic or keloid scars. There is no evidence to suggest the measure can detect changes in scars caused by novel interventions that specifically change appearance in a wider range of scar types. In this regard, the Appearance and Satisfaction with Appearance subscales of the Patient Scar Assessment Questionnaire have already demonstrated an ability to detect change. Both studies have strengths and weaknesses, and an appreciation of the differences will highlight where further work and collaboration may be useful to produce a truly comprehensive patient-reported outcome measure instrument for scarring that covers all important domains.
Piyush Durani, M.R.C.S.
Department of Plastic Surgery
Leicester Royal Infirmary
Leicester LE1 5WW, United Kingdom
1. Brown BC, McKenna SP, Solomon M, Wilburn J, McGrouther DA, Bayat A. The Patient-Reported Impact of Scars Measure: Development and validation. Plast Reconstr Surg
2. Durani P, McGrouther DA, Ferguson MW. The Patient Scar Assessment Questionnaire: A reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr Surg
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.