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Skin Scores: A Review of Clinical Scoring Systems in Dermatology

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ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.15 If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.15

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.15 The ALT-70 score is available for free via the MDCalc app and website (

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.16 Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.16

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS17 (which an AUC coauthor18 and others19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),21 including counterintuitive scores,22 and omitting trials from Europe23 (which AUC coauthors also have defended24). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”16 The Mohs AUC app ( is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.


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