Throughout military history, dermatologic conditions have been a major cause of morbidity and have consumed significant medical resources in operational settings. The vast majority of the time, the service member is seen by a primary care provider without specialty training in dermatology, which results in diagnostic and treatment challenges unique to the military environment.
In this article, we present an overview of the impact of dermatologic conditions in military operations and suggest an approach to these cases for primary care providers in deployed settings. We include recent data on the impact of dermatologic diseases from Craig Joint Theater Hospital (CJTH), the largest level III facility in Operation Enduring Freedom in Afghanistan. Some specific cases are highlighted in more detail, to demonstrate some of the challenges faced by primary care providers. As A. N. Tasker pointed out in 1928, "Diseases of the skin ... are of great importance to an army operating in the field, by reason of the noneffectiveness they cause."' It is essential that medical providers deployed to operational military locations be adequately trained in managing dermatologic conditions. These problems are prevalent and can have a significant impact on the health of the individual, as well as the overall effectiveness of the military unit.
In Military Dermatology, Becker and James noted, "We must relearn after every conflict that early diagnosis and treatment of skin diseases, combined with close supervision, constant education, preventive measures, and adequate equipment, clearly are vital to preserving the fighting strength."1 The impact of dermatologic conditions on military units can be seen throughout the history of the United States. As early as the Civil War, disease and nonbattle injury reports showed >74,000 dermatology-related cases.2 During World War I, > 125,000 U.S. Army soldiers were hospitalized in the 33-month period from April 1917 to December 1919, resulting in >2 million lost days of service attributable to dermatologie diseases.1 During World War II, 15% to 25% of outpatient visits in temperate climates were for treatment of skin diseases; in tropical theaters, 60% to 75% of visits were for treatment of skin diseases.1 Dermatologic casualties were significant in the southwest Pacific Ocean region, accounting for ~15% of all patient evacuations from November 1944 to November 1945, which was more than the number of battle casualties.1 The conflict in Vietnam emphasized the impact of dermatologic diseases. Throughout the conflict, >1.5 million visits were recorded for skin diseases, twice as many as for any other category of illness.1 Almost 10% of all evacuations out of theater because of diseases were a result of dermatologic conditions.1 In more-recent history, one U.S. forward-deployed unit in the first Persian Gulf War reported cutaneous diseases as the cause of 7.1% of all disease and nonbattle injury cases.2 Another study from Operation Desert Storm showed a dermatologie disease frequency of 13.9%.3
CJTH EXPERIENCE DURING OPERATION ENDURING FREEDOM IN AFGHANISTAN
From May to September 2007, we deployed to Bagram Air Field (BAF) in Afghanistan. CJTH at BAF is a level III medical facility, caring for BAF personnel, local nationals, and many troops from surrounding forward operating bases (FOBs), which use CJTH as a referral center. Our experience at CJTH showed a prevalence of dermatologic complaints consistent with those of previous conflicts. We reviewed the notes from all outpatient clinic visits at CJTH in June and July 2007. During that time, 2,421 patients were seen. Of those patients, 485 (20.0%) had a dermatologic diagnosis documented. Even if the patients had comorbid illnesses, the skin condition was often their primary concern. If providers were able to arrive at a diagnosis, it usually resulted in significant relief to the troops, who were then able to focus on the mission at hand. Predictably, most dermatologic problems were managed through the outpatient clinic. However, of 73 U.S. military troops admitted to CJTH with nontraumatic diagnoses in this time frame, 5 (6.8%) were admitted because of a dermatologic condition. In addition, 5 (1.7%) of 291 patients evacuated out of theater during this time period were sent out because of dermatologic conditions such as cellulitis, leishmaniasis, and melanoma. Below we present several cases encountered during our deployment that are worthy of discussion.
A 27-year-old man presented with a pruritic rash on his feet, legs, arms, and penis, present for 2 weeks. He denied any sexual contacts in the previous 5 months. The history revealed no exposures to any topical irritants. The patient reported no changes in soaps or detergents and no recent new medications or diet changes. On examination, he had multiple light-pink papules on the dorsum of the feet, lower legs, and flexor side of the wrists (Fig. 1). He was initially diagnosed with possible scabies and was given permethrin cream, which did not help. Upon reevaluation in 1 week, the patient was diagnosed with contact dermatitis and treated with loratidine, ranitidine, and a methylprednisolone dose pack. The itching improved during steroid treatment, but the patient returned again 1 week later, complaining that the rash seemed to be worsening. On careful examination during the patient's third visit, many of the papules were noted to be flat, polygonal, and more violaceous. The lesions on the patient's feet were noted to have some fine white striae on them. Some of the lesions demonstrated apparent Koebner's phenomenon. Of note, the patient's liver function test results were normal, the patient had no risk factors for hepatitis C, and there were no visible lesions within the oropharynx. At that point, the patient was given a clinical diagnosis of lichen planus. A skin biopsy was obtained, and a 4-week course of orally administered prednisone, as well as topically administered triamcinolone, was initiated. One month later, the lesions had improved significantly, and the pruritis had resolved. Final pathologic results from the biopsy were consistent with lichen planus.
A 37-year-old man presented with a rash, present for 4 to 5 weeks. He was otherwise asymptomatic; the rash did not itch or hurt, and the patient had no fever, malaise, or recent illnesses. On examination, he had several 5- to 10-cm circular patches of numerous 2- to 3-mm petechiae. The patches were located on the lower legs and thighs bilaterally (Fig. 2). One of the patches was biopsied, and topical triamcinolone treatment was initiated. After 3 weeks, almost all of the lesions had completely resolved. The biopsy results were consistent with purpura pigmentosa chronica; clinically, the presentation was consistent with Majocchi's disease, a benign, self-limited condition.
A 25-year-old woman came into the emergency department complaining, "I think I feel something moving under my skin; do you know how to treat a botfly infection?" She was a U.S. contractor who had been vacationing in Belize 3 weeks before presentation. She had been active, doing many outdoor activities, while there. She had been diligent about applying N,N-diethyl-m-toluamide to her skin but had not put any on her scalp. She did not recall being bitten by a mosquito. On examination, she had three nodules on her scalp, 1 to 2 cm in diameter, each with a central punctum. Bacitracin ointment was applied to the nodules, and some bubbling was noted. A small cruciate incision was made, and lateral pressure was applied to the largest nodule. The opening was explored with hemostats, and a 1-cm botfly larva was extracted (Fig. 3). The same procedure resulted in another botfly larva being removed from the second nodule. Nothing was obtained from the third nodule, but the patient returned for follow-up evaluation a few days later stating that she no longer had any symptoms and felt fine.
A 33-year-old man developed several lesions consistent with insect bites on his feet and legs approximately 4 to 5 weeks before evaluation. He also developed right foot edema and similar skin lesions on the right triceps area (Fig. 4). On questioning, he admitted to numerous flies and mosquitoes around the FOB where he was stationed. At night, he took off his boots and outer shirt to relax. The patient was treated with doxycycline and a course of amoxicillin/clavulanate because of possible cellulitis. He was also initially treated with a topical antibiotic and steroid cream. He did not show any improvement after treatment, and a biopsy of the right arm was performed (Fig. 5). The patient was evacuated out of theater with probable cutaneous leishmaniasis, because of the extent of the lesions and persistent edema of the right foot. Biopsy results later confirmed the suspected diagnosis of cutaneous leishmaniasis.
We noted several factors that made the management of the cases described above, as well as other dermatologie cases, difficult at our facility. It is likely that these same obstacles would confront most primary care providers in deployed settings. First, it is obvious that, in the vast majority of deployed settings, it is usually not feasible to refer patients to dermatology for an expert opinion. Patients who do require referral typically need to be flown out of the operational theater, resulting in significant effects on the mission and considerable expense (approximately $80,000 for an evacuation mission from BAF to Landstuhl Regional Medical Center in Germany). Another challenge we faced was the turnaround time for pathology specimens, which needed to be sent to Landstuhl Regional Medical Center for review. A skin biopsy can often help in the diagnosis of perplexing cases, but it typically took 4 weeks to receive the final diagnosis on specimens from our clinic. In several instances, the initial pathology results were inconclusive and the specimen was sent for additional review at the Armed Forces Institute of Pathology, further delaying a diagnosis. The provider is often forced to treat empirically while waiting for results. Fortunately, in most of our cases the patient had experienced improvement with empiric therapy by the time the biopsy results were finalized. The obvious challenge for primary care physicians confronted with an unusual dermatologie case while deployed is to establish a reasonable diagnosis and treatment plan on their own. If a more-urgent disease process can be ruled out (for example, no fever or signs of meningitis for our patient with the petechial rash), then it is reasonable to make a presumptive diagnosis and to start treatment. It is always a good idea to monitor the patient closely if the diagnosis is uncertain. One final problem we encountered was treating patients who were referred from surrounding FOBs. Often, the patient had been seen by a medic at the FOB and was sent to BAF for evaluation by a physician. Additional challenges in such cases were arranging follow-up care, determining how to contact the patients if tests were performed, and deciding whether the patients were cleared to return to the FOB or they needed to stay at BAF until the response to treatment could be assessed.
The basic tenants of evaluation and management of dermatologic conditions in deployed settings are similar to those in the civilian sector. History and examination findings are still paramount in the evaluation of skin complaints. In the majority of cases, these findings alone are sufficient for diagnosis. A thorough history, including duration and evolution of the disorder and accompanying symptoms (e.g., itching or burning), is essential. As discussed below, there are additional questions that need to be answered for deployed patients, such as travel history and recent exposures. A simple physical examination focused on observation and palpation is critical for diagnosing dermatologie complaints. There are several diagnostic modalities that are often used in difficult cases, such as biopsy and scraping. Resources at deployed sites vary widely. Our location had access to microscopy, which allowed evaluation of potassium hydroxide-fixed slides for tinea versicolor or tinea corporis. Our site also had a laboratory facility, which allowed simple cultures and sensitivity tests to be performed. Biopsy specimens could be collected and then sent out of theater for examination. The extended turnaround time for biopsies, as mentioned previously, makes them less useful in deployed settings, although they still have an important role. Photography also can be a useful tool. Although no immediate information is gained from photographing a lesion, photography can allow the provider to assess changes and possibly send photographs to a dermatologist for an opinion while the patient remains in theater.
Unique Challenges in Deployed Settings
There are certainly unique considerations in deployed environments that must be taken into account when dermatologie conditions are being evaluated. Providers must maintain a broad differential diagnosis for every patient. Common conditions are still common, and providers can expect to see many of the same things they see in garrison, such as tinea pedis, insect bites, acne, and eczema. In fact, some common conditions may be seen with increased frequency because of the particular environmental conditions of the deployed location. However, there are a number of factors that require a broadened differential diagnosis. As Bacaner and Wilson4 pointed out, "The challenge is to distinguish the mundane skin lesions from the exotic." Providers must be aware of endemic diseases that may be rarely seen in the United States. Often, this means having a working knowledge of local insects, vectors, and parasites. For example, leishmaniasis is a parasitic infection transmitted by Phlebotomus papatasi sandflies.5 It is endemic to areas of Southwest Asia, including Iraq and Afghanistan. Recent military operations in those countries have led to the largest epidemic of cutaneous leishmaniasis in military forces since World War II, with >850 cases reported as of March 2006.6 It is estimated that up to 10% of military personnel serving in the Persian Gulf area may be infected with leishmaniasis.7
Environmental conditions in most deployed locations are significantly diiferent from those in the United States. Many of the locations where the military recently sent troops, including Southwest Asia, Africa, and Central America, expose service members to extremes of temperature and humidity. Conditions such as sunburn, urticaria (Figs. 6 and 7), tinea versicolor (Figs. 8 and 9), tinea pedis, tinea corporis, and tinea cruris can be seen with significantly increased frequency.4 Often, personal and population hygiene is a challenge. Shower and laundry facilities may be nonexistent. Therefore, a minor skin condition such as tinea pedis may more easily develop into a more serious problem such as cellulitis if not treated promptly. Military personnel living in close quarters and using the same equipment are at greater risk for developing and spreading contagious cutaneous diseases such as impetigo.8 Historically, military troops have suffered from epidemic cutaneous illnesses such as lice as well. In addition to tinea pedis, substandard hygiene in combination with a hot humid climate can lead to pitted keratolysis, a condition caused by overgrowth of cutaneous bacteria that leads to a malodorous foot rash, which can become severe.9 This condition has been reported for 48% to 58% of military personnel engaged in training where the feet are exposed to prolonged heat and moisture.9
Personnel also can come into contact with various materials to which they are not typically exposed, such as N,N-diethyl-mtoluamide, permethrin, and military equipment (such as body armor and gas masks). These, as well as other materials that may be novel exposures for the patient, can serve as irritants or allergens, leading to the development of cutaneous disease. Elmer and George10 described a case report of a military member who developed contact urticaria attributable to the silicone rubber in her gas mask. Ultimately, the patient underwent a medical board review and was discharged from the military. In addition, medications such as doxycycline may be taken for malaria prophylaxis and may cause photosensitivity, predisposing troops to sunburn.
Vaccinations such as smallpox and anthrax are required during deployment and can cause significant dermatologie problems in some individuals. Some studies suggest that rash after smallpox vaccination occurs as often as 14% of the time.11 These rashes may be benign, but there are some serious and even life-threatening reactions, such as progressive vaccinia and eczema vaccinatum.11 Anthrax vaccination can also cause cutaneous reactions. Department of Defense surveillance reported 30% to 60% occurrence of small local reactions to injections; 1% to 5% of vaccination recipients developed larger local reactions of 2.5 to 12.7 cm.12 The U.S. Army Medical Research Institute of Infectious Diseases reported 4% occurrence of local reactions, which they defined as swelling, erythema, induration, and itching at the injection site.12
Unfortunately, another diagnosis to keep in mind in a deployed setting is malingering. A study was performed with 14 Israel Defense Force soldiers in 2006 who presented with signs and symptoms of contact dermatitis and were ultimately diagnosed as having dermatitis artifacta.13 The soldiers intentionally caused the skin findings through various methods, presumably in attempts to obtain sick leave from their military duties. Factitious disorders are diagnosed through a process of exclusion but must be considered as part of the differential diagnosis. This is particularly true in situations where many of the patients are under a great deal of stress and did not volunteer for deployment. These attributes of deployment can make it difficult to accurately diagnose dermatologie conditions. Providers must maintain a broad differential diagnosis, realizing that patients present with problems commonly seen in the United States but may present with more-unusual illnesses as well.
Options for Managing Difficult Cases
Another important factor that makes the management of dermatologic conditions in deployed locations challenging is limited capabilities. As alluded to previously, deployed providers typically do not have access to a dermatologist in theater. Many diagnostic tests or procedures either are not available or require a substantial turnaround time, which significantly decreases their utility. Depending on how austere a particular location is, providers may have access to textbooks or online medical resources. In addition, there are some military-specific guidelines available online, such as for the management of leishmaniasis (http://www.pdhealth. mil/ leish.asp).
In Military Dermatology (available at http://www. bordeninstitute.army.mil/published_volumes/dermatology/ dermatology.html), the authors provide several algorithms for diagnosing dermatologie conditions on the basis of the type of lesions, such as pustules, vesicles, or macular erythema. These algorithms are specifically for nondermatologists in the field, without laboratory or biopsy resources.1 For more difficult cases that require an expert opinion, options include deploying a dermatologist, evacuating the patient out of theater to see a dermatologist in garrison, or employing teledermatology.
Evacuating the patient out of theater is the most costly method of obtaining expert consultation. Each air evacuation could entail multiple convoys and flights to transport the patient, potentially under combat conditions. This is expensive not only in dollars spent but also in decreased combat readiness of the deployed unit. There is also the potential for combat casualties sustained during convoy or air evacuation missions. Occasionally deploying a dermatologist for brief periods to provide consultation for difficult cases is potentially a better solution, which has been shown to be cost-effective.1 This would reduce the financial and productivity costs, although that benefit must be weighed against the cost associated with the absence of a specialist in garrison for that period of time. Teledermatology brings "the specialist to the primary provider who directly cares for service members in an austere, remote, and isolated environment."14 Real-time video-teleconferencing can be used. However, this is much more difficult logistically than "store-and-forward" applications, in which history findings and images are e-mailed to the specialist, who then replies with recommendations.14 Although video-teleconferencing has the advantage of allowing real-time evaluation, including further questioning by the specialist, it is problematic because of the specialized equipment required and the necessity to coordinate a time among the primary provider, patient, and specialist. These difficulties inherent in video-teleconferencing make store-and-forward applications much more attractive for use in deployed military operations. Teledermatology has been used in the military since the early 1990s and has generally been found to be clinically helpful and cost-effective.14 In 1993, a telemedicine project was conducted between Tripler Army Medical Center and Kwajalein Island, in an effort to improve services at remote locations. Forty percent of the 250 total encounters were for dermatologie cases, and a reduction in off-island travel for specialty care was observed.14 Teledermatology has also been used at Walter Reed Army Medical Center, where 29% of telemedicine consultations from deployed sites such as Haiti, Somalia, Macedonia, Croatia, Ivory Coast, Egypt, Panama, Germany, and Kuwait were dermatologie cases.14 COL Ron Poropatich, telemedicine consultant for the Army Medical Department, noted that the U.S. Army began using a teledermatology system for all current deployed sites, such as Iraq, Afghanistan, and Kuwait, in April 2004. By August 2005, 190 deployed providers had used the system. These teledermatology consultations resulted in 30 avoided aeromedical evacuations, saving an estimated $640,000.l5 In addition, seven evacuations were initiated because of teledermatology consultation and otherwise would likely not have been sent out of theater, potentially resulting in harm to the patient.15 An Israeli military study involving 438 dermatology patients demonstrated that 78% could be treated through teledermatology alone, without the need for face-to-face evaluation with a dermatologist.16 Teledermatology allows the dermatologist to provide further treatment recommendations when the diagnosis is known, as well as arriving at a diagnosis. Often, the primary care provider suspects the correct diagnosis, although with some level of uncertainty. Teledermatology is still useful in such instances, because "the value of confirmation to a deployed health care provider should not be underestimated. Provider uncertainty rather than medical necessity probably causes many (unnecessary) patient evacuations."14 Currently, teledermatology is available in Iraq and Afghanistan, although this capability is not uniformly communicated to fielded primary care providers.17
Two areas should be addressed to better allow deploying providers to deal with the inevitable dermatologie cases, that is, training and availability of pertinent resources. During the conflict in Vietnam, it was observed that a large proportion of the morbidity caused by cutaneous diseases was attributable to a lack of emphasis on education and training in dermatology.1 Becker and James1 noted that, in the Army in World War II, "Many physicians had so little opportunity for dermatologie training . . . that they were unable to arrive at a diagnosis of even the simplest conditions of the skin." Unfortunately, this is an area that is still problematic for many military primary care providers. It has been suggested that all military providers undergo training in dermatology.1 In addition, many of the special considerations of the deployed environment, such as endemic illnesses, unusual exposures, and hygienic challenges, could be incorporated as part of the routine annual or predeployment training for primary care providers.
In the current age of information, Internet access has dramatically improved the availability of reference materials for deployed providers. However, computer access is not always available, especially at FOBs. Often, these more-isolated locations are manned by middle-level providers with less dermatologie training, who are thus most in need of an on-hand resource. In 1942, the U.S. Army and the Committee of Medicine of the National Research Council developed a simple manual, which was distributed widely among providers in the Armed Forces, that dealt with the diagnosis and treatment of commonly encountered skin diseases.' In 1969, a military field manual on skin diseases was made available.1 At present, there is no such publication that is routinely given to military medical providers. Becker and James1 suggested that an updated manual of dermatology aimed at assisting deployed providers with the diagnosis and management of dermatologie diseases should be developed and universally distributed. In addition to providing appropriate reference materials to providers in the field, expanding the availability of dermatology specialist consultation should be accomplished. Either deploying a dermatologist in theater periodically or enhancing teledermatology capability and availability would allow providers to better treat patients and would keep troops with their units, where they can accomplish the mission. The utility of teledermatology needs to be further evaluated. As Vidmar14 noted, "Valid and reproducible measures of cost-effectiveness for teledermatology have been elusive." Further studies specifically examining the impact of teledermatology use in a deployed setting would be very beneficial.
We have attempted to demonstrate the importance of dermatologie conditions in a deployed military environment. Historically, dermatologie illnesses have had a significant impact on military units in the field. Experience from current military operations demonstrates that this continues to hold true. There are important factors that make diagnosing and treating cutaneous diseases a challenge for deployed providers. These factors include the need to consider a broad differential diagnosis and limited availability of resources. In the future, deployed primary care providers will continue to be confronted with many patients with dermatologie illnesses. It is imperative that these providers be equipped to accurately diagnose and to appropriately treat these patients, both to provide the best quality of care possible for the service members and to ensure that the ability of the deployed military unit to carry out its mission is not compromised.
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Source: Military Medicine