Assessing Atopic Dermatitis Control in Chinese Patients: Validation of the Chinese Version of Recap of Atopic Eczema Questionnaire (RECAP) and an Investigation into Its Interpretability
DOI:
https://doi.org/10.2340/actadv.v105.43458Keywords:
atopic dermatitis, reliability, responsiveness, outcome measurements, measurement propertiesAbstract
The lack of a validated Chinese version of the Recap of Atopic Eczema questionnaire (RECAP) questionnaire limits its applicability. This prospective study, conducted at a Chinese tertiary hospital between April and November 2024, aimed to evaluate measurement properties of the Chinese RECAP. Participants completed RECAP and reference instruments at baseline, 1–3 days, and 4–6 weeks. Construct validity was evaluated through hypothesis testing, while reliability was assessed using standard error of measurement (SEMagreement) and intraclass correlation coefficient (ICCagreement). Interpretability of both single and change scores was examined using anchor-based methods. In total, 153 adults with atopic dermatitis (AD) (mean age 28.4 years, 51.0% male) were included, with approximately half having moderate-to-severe disease. Of the predefined hypotheses, 57.1% (single score) and 71.4% (change score) were confirmed. The SEMagreement was 1.99, and the ICCagreement was 0.96. Final RECAP bandings were established, with a binary cutoff of ≥ 11 defining uncontrolled AD. The Smallest Detectable Change was 5.5. while the Minimally Important Change was 3.5 using the receiver operating characteristics (ROC) method and 0.6 after adjustment via predictive modelling. Our finding confirmed that the Chinese RECAP is a valid, reliable, and responsive tool for evaluating eczema control. An improvement of ≥ 6 represents a real and clinically meaningful change.
Downloads
References
Langan SM, Irvine AD, Weidinger S. Atopic dermatitis. Lancet 2020; 396: 345–360. DOI: https://doi.org/10.1016/S0140-6736(20)31286-1
Mao D, Li J, Liu S, Liu P, Tian J, Liu X, et al. Prevalence and risk factors of atopic dermatitis in Chinese adults: a nationwide population-based cross-sectional study. Chin Med J (Engl) 2023; 136: 604–606. DOI: https://doi.org/10.1097/CM9.0000000000002560
Schmitt J, Spuls P, Boers M, Thomas K, Chalmers J, Roekevisch E, et al. Towards global consensus on outcome measures for atopic eczema research: results of the HOME II meeting. Allergy 2012; 67: 1111–1117. DOI: https://doi.org/10.1111/j.1398-9995.2012.02874.x
Barbarot S, Rogers NK, Abuabara K, Aubert H, Chalmers J, Flohr C, et al. Strategies used for measuring long-term control in atopic dermatitis trials: a systematic review. J Am Acad Dermatol 2016; 75: 1038–1044. DOI: https://doi.org/10.1016/j.jaad.2016.05.043
Howells LM, Chalmers JR, Gran S, Ahmed A, Apfelbacher C, Burton T, et al. Development and initial testing of a new instrument to measure the experience of eczema control in adults and children: Recap of Atopic Eczema (RECAP). Br J Dermatol 2020; 183: 524–536. DOI: https://doi.org/10.1111/bjd.18780
Leshem YA, Chalmers JR, Apfelbacher C, Katoh N, Gerbens LAA, Schmitt J, et al. Measuring atopic eczema control and itch intensity in clinical practice: a consensus statement from the Harmonising Outcome Measures for Eczema in Clinical Practice (HOME-CP) Initiative. JAMA Dermatol 2022; 158: 1429–1435. DOI: https://doi.org/10.1001/jamadermatol.2022.4211
Williams HC, Schmitt J, Thomas KS, Spuls PI, Simpson EL, Apfelbacher CJ, et al. The HOME Core outcome set for clinical trials of atopic dermatitis. J Allergy Clin Immunol 2022; 149: 1899–1911. DOI: https://doi.org/10.1016/j.jaci.2022.03.017
Bhanot A, Peters TJ, Ridd MJ. Assessing the validity, responsiveness and reliability of the Recap measure of eczema control. Br J Dermatol 2021; 184: 955–957. DOI: https://doi.org/10.1111/bjd.19709
Yew YW, Phuan CZY, Zhao X, Howells L, Apfelbacher CJ. Validation of the Recap of Atopic Eczema (RECAP) measurement instrument for eczema control in adult patients in an Asian clinical setting. Acta Derm Venereol 2024; 104: adv32323. DOI: https://doi.org/10.2340/actadv.v104.32323
Gabes M, Ragamin A, Baker A, Kann G, Donhauser T, Gabes D, et al. Content validity of the Recap of atopic eczema (RECAP) instrument in Dutch, English and German to measure eczema control in young people with atopic eczema: a cognitive interview study. Br J Dermatol 2022; 187: 919–926. DOI: https://doi.org/10.1111/bjd.21767
Ragamin A, Zhang J, Pasmans SGMA, Schappin R, Romeijn GLE, van Reusel MA, et al. The construct validity, responsiveness, reliability and interpretability of the Recap of Atopic Eczema questionnaire (RECAP) in children. Br J Dermatol 2024; 190: 867–875. DOI: https://doi.org/10.1093/bjd/ljae017
Zhang J, Ragamin A, Romeijn GLE, Loman L, Oosterhaven JAF, Schuttelaar MLA. Validity, reliability, responsiveness and interpretability of the Recap of Atopic Eczema (RECAP) questionnaire. Br J Dermatol 2023; 189: 578–587. DOI: https://doi.org/10.1093/bjd/ljad247
Sigurdardottir G, Alsterholm M, Andersson CD, Bradley M, Sandström Falk M, Johansson EK, et al. Cross-cultural validation of the RECAP of Atopic Eczema Questionnaire in a Swedish population. Acta Derm Venereol 2024; 104: adv38889. DOI: https://doi.org/10.2340/actadv.v104.38889
Baker A, Stuart B, Howells L, Mitchell EJ, Thomas KS. Determining the minimal important change of the Recap of Atopic Eczema (RECAP) instrument in clinical trials. Skin Health Dis 2024; 4: e470. DOI: https://doi.org/10.1002/ski2.470
Fischer MJ, Inoue K, Matsuda A, Kroep JR, Nagai S, Tozuka K, et al. Cross-cultural comparison of breast cancer patients’ quality of life in the Netherlands and Japan. Breast Cancer Res Treat 2017; 166: 459–471. DOI: https://doi.org/10.1007/s10549-017-4417-z
Lima XT. Cumulative life course impairment across cultures and medical systems. Curr Probl Dermatol 2013; 44: 137–144. DOI: https://doi.org/10.1159/000350178
Mokkink LB, Prinsen CA, Patrick DL, et al. COSMIN study design checklist for patient-reported outcome measurement instruments. 2019
de Vet HC, Terwee CB, Mokkink L et al. Measurement in medicine: a practical guide. Cambridge: Cambridge University Press, 2011. DOI: https://doi.org/10.1017/CBO9780511996214
University of Nottingham. Recap of Atopic Eczema (RECAP): an outcome measurement instrument to capture ‘eczema control’ [accessed 25 May 2025]. Available from: https://www.nottingham.ac.uk/research/groups/cebd/resources/recap.aspx#:~:text = RECAP%20is%20a%20seven%2Ditem,reported%20version%20for%20younger%20children
Williams HC, Burney PG, Pembroke AC, Hay RJ. The U.K. Working Party’s Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation. Br J Dermatol 1994; 131: 406–416. DOI: https://doi.org/10.1111/j.1365-2133.1994.tb08532.x
Pariser DM, Simpson EL, Gadkari A, Bieber T, Margolis DJ, Brown M, et al. Evaluating patient-perceived control of atopic dermatitis: design, validation, and scoring of the Atopic Dermatitis Control Tool (ADCT). Curr Med Res Opin 2020; 36: 367–376. DOI: https://doi.org/10.1080/03007995.2019.1699516
Charman CR, Venn AJ, Ravenscroft JC, Williams HC. Translating Patient-Oriented Eczema Measure (POEM) scores into clinical practice by suggesting severity strata derived using anchor-based methods. Br J Dermatol 2013; 169: 1326–1332. DOI: https://doi.org/10.1111/bjd.12590
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19: 210–216. DOI: https://doi.org/10.1111/j.1365-2230.1994.tb01167.x
Yosipovitch G, Reaney M, Mastey V, Eckert L, Abbé A, Nelson L, et al. Peak Pruritus Numerical Rating Scale: psychometric validation and responder definition for assessing itch in moderate-to-severe atopic dermatitis. Br J Dermatol 2019; 181: 761–769. DOI: https://doi.org/10.1111/bjd.17744
Chopra R, Vakharia PP, Sacotte R, Patel N, Immaneni S, White T, et al. Severity strata for Eczema Area and Severity Index (EASI), modified EASI, Scoring Atopic Dermatitis (SCORAD), objective SCORAD, Atopic Dermatitis Severity Index and body surface area in adolescents and adults with atopic dermatitis. Br J Dermatol 2017; 177: 1316–1321. DOI: https://doi.org/10.1111/bjd.15641
Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. EASI Evaluator Group. Exp Dermatol 2001; 10: 11–18. DOI: https://doi.org/10.1034/j.1600-0625.2001.100102.x
Simpson E, Bissonnette R, Eichenfield LF, Guttman-Yassky E, King B, Silverberg JI, et al. The Validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD): the development and reliability testing of a novel clinical outcome measurement instrument for the severity of atopic dermatitis. J Am Acad Dermatol 2020; 83: 839–846. DOI: https://doi.org/10.1016/j.jaad.2020.04.104
Prinsen C a C, Mokkink LB, Bouter LM, Alonso J, Patrick DL, de Vet HCW, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res Int J Qual Life Asp Treat Care Rehabil 2018; 27: 1147–1157. DOI: https://doi.org/10.1007/s11136-018-1798-3
Anthoine E, Moret L, Regnault A, Sébille V, Hardouin J-B. Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures. Health Qual Life Outcomes 2014; 12: 176. DOI: https://doi.org/10.1186/s12955-014-0176-2
de Vet HCW, Terwee CB, Knol DL, Bouter LM. When to use agreement versus reliability measures. J Clin Epidemiol 2006; 59: 1033–1039. DOI: https://doi.org/10.1016/j.jclinepi.2005.10.015
Terluin B, Eekhout I, Terwee CB, de Vet HCW. Minimal important change (MIC) based on a predictive modeling approach was more precise than MIC based on ROC analysis. J Clin Epidemiol 2015; 68: 1388–1396. DOI: https://doi.org/10.1016/j.jclinepi.2015.03.015
Terluin B, Eekhout I, Terwee CB. The anchor-based minimal important change, based on receiver operating characteristic analysis or predictive modeling, may need to be adjusted for the proportion of improved patients. J Clin Epidemiol 2017; 83: 90–100. DOI: https://doi.org/10.1016/j.jclinepi.2016.12.015
McHorney CA, Tarlov AR. Individual-patient monitoring in clinical practice: are available health status surveys adequate? Qual Life Res 1995; 4: 293–307. DOI: https://doi.org/10.1007/BF01593882
Norman GR, Sridhar FG, Guyatt GH, Walter SD. Relation of distribution- and anchor-based approaches in interpretation of changes in health-related quality of life. Med Care 2001; 39: 1039–1047. DOI: https://doi.org/10.1097/00005650-200110000-00002
Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med 1993; 118: 622–629. DOI: https://doi.org/10.7326/0003-4819-118-8-199304150-00009
Cella D, Hahn EA, Dineen K. Meaningful change in cancer-specific quality of life scores: differences between improvement and worsening. Qual Life Res 2002; 11: 207–221. DOI: https://doi.org/10.1023/A:1015276414526
Revicki D, Hays RD, Cella D, Sloan J. Recommended methods for determining responsiveness and minimally important differences for patient-reported outcomes. J Clin Epidemiol 2008; 61: 102–109. DOI: https://doi.org/10.1016/j.jclinepi.2007.03.012
Onteniente-Gomis MM, Ortiz-Romero PL, Tous Romero F, Salamanca Castro AB, Ortiz de Frutos FJ. Spanish version of the RECAP questionnaire to assess control of atopic eczema: translation, cultural adaptation, validation, and correlations with other patient-reported outcome measures. Actas Dermosifiliogr 2023; 114: 488–493. DOI: https://doi.org/10.1016/j.ad.2023.05.009
Zhang J, Miltner L, Loman L, Ragamin A, Oosterhaven JAF, Schuttelaar MLA. Validation of the Atopic Dermatitis Control Tool (ADCT) and a comparison with the Recap of Atopic Eczema Questionnaire (RECAP). Acta Derm Venereol 2025; 105: adv42364. DOI: https://doi.org/10.2340/actadv.v105.42364
Vestergaard C, Skovsgaard C, Johansen C, Deleuran M, Thyssen JP. Treat-to-target in atopic dermatitis. Am J Clin Dermatol 2024; 25: 91–98. DOI: https://doi.org/10.1007/s40257-023-00827-y
van Kampen DA, Willems WJ, van Beers LWAH, Castelein RM, Scholtes VAB, Terwee CB. Determination and comparison of the smallest detectable change (SDC) and the minimal important change (MIC) of four-shoulder patient-reported outcome measures (PROMs). J Orthop Surg 2013; 8: 40. DOI: https://doi.org/10.1186/1749-799X-8-40
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Junfen Zhang, Shunmin Zhu, Liyan Yuan, Xiaoling Yu, Shiqi Ling, Jiao Zhang, Bin Yang
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized ActaDV contents is available freely online. The Society for Publication of Acta Dermato-Venereologica owns the copyright for all material published until volume 88 (2008) and as from volume 89 (2009) the journal has been published fully Open Access, meaning the authors retain copyright to their work.
Unless otherwise specified, all Open Access articles are published under CC-BY-NC licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
