Although composite scales may be useful in the early development of a drug in that they may show that something is happening, the key question within the framework of pursuing an evidence-based prescription is whether something useful is happening. Given the limitations of quantitative composite scales in dermatology, what should one look for in terms of outcomes that can best inform practice? My starting position would be to see what the patients who participated in the trials thought of their treatment, using simple measures such as proportion of participants with "good or excellent" response or other categorical measures such as percentage cleared. Did the quality of life of the patients improve? Although such measures are subjective, is not such subjective distress the precise treatment goal for many chronic skin diseases with significant psychological effects? Objective measures are of course also needed alongside measures that help to generalise the meaning of such subjective responses across cultures, since it is possible that some cultural groups may complain less about symptoms. Objective measures are also more useful in some diseases (for example to assess the response of treatments for basal cell carcinoma). Again, these need to be simple enough for most physicians and their patients to understand, for example the proportion of recurrences within 5 years rather than hazard ratios for first recurrence.
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