Military Dermatology

There are numerous intrinsic risks that military servicemembers face, such as the dangers of combat, handling firearms, operating ships and heavy machinery, undersea diving, and aircraft operations. Multiple studies also have identified an increased risk for melanomas and keratinocyte cancers in those who have served on active duty.

Epidemiology

Differences in demographics are important to consider given the differences among races in the risks of skin cancers. Important racial demographic differences exist between the US Military and the general US population. Racial demographic differences also exist among the various military branches themselves. The US population is 61.0% White, 20.7% racial minorities (defined as Black or African American, Asian, American Indian or Alaska native, Native Hawaiian or other Pacific Islander, multiracial, or unknown), and 18.3% Hispanic or Latino (Hispanic or Latino was not listed as a component of racial minorities).¹ According to 2018 data, the US Military population is 52.9% White, 31.0% racial minorities, and 16.1% Hispanic or Latino.² The percentage of White military members was highest in the US Marine Corps (58.4%) and lowest in the US Navy (46.5%). The percentage of racial minorities was highest in the US Navy (38.0%) and lowest in the US Marine Corps (20.0%).² The percentage of Hispanic and Latino military members was highest in the US Marine Corps (21.6%) and lowest in the US Air Force (14.5%).²

Melanoma in Military Members

It is estimated that the annual incidence rate of melanoma in the United States is 27 per 100,000 individuals for non-Hispanic Whites, 5 per 100,000 for Hispanics, and 1 per 100,000 for Black individuals and Asians/Pacific Islanders.³ Three studies have reviewed melanoma incidence in relation to service in the US Military.

A 2011 retrospective tumor registries study of US veterans aged 45 years or older demonstrated increased incidences of melanoma compared with the general population.⁴ With age, the melanoma incidence per 100,000 person-years increased in White veterans compared to their civilian counterparts (aged 45 to 49 years, 33.62 vs 27.49; aged 50 to 54 years, 49.76 vs 32.18; aged 55 to 59 years, 178.48 vs 39.17).⁴ An increased melanoma incidence of 62% also was seen in active-duty servicemembers aged 18 to 56 years compared to their age-matched civilian peers in a 2014 retrospective cohort study.⁵

Melanoma rates also vary depending on military service branch. Across 3 separate studies, service in the US Air Force was associated with the highest risk for melanoma development. A surveillance report of cancer incidence in active-duty US Armed Forces personnel between 2000 and 2011 conducted by the Defense Medical Surveillance System showed an incidence rate (per 100,000 person-years) for melanoma of 10.5 in all services, and a rate of 15.5 in the US Air Force vs 8.6 in the US Army, further highlighting the disparity between the services.⁶ The 2014 study also demonstrated a melanoma incidence rate of 17.80 in active-duty US Air Force personnel compared to 9.53 in active-duty US Army personnel.⁵ Among US Air Force active-duty personnel, one study showed a melanoma incidence rate (per 100,000 person-years) of 7.59 for men and 8.98 for women compared to 6.25 and 5.46, respectively, in US Army soldiers.⁴

Keratinocyte Cancers in Military Members

Although less well studied than melanoma, keratinocyte-derived skin cancers represent a major source of disease burden both during and after active-duty service. In a retrospective chart review of dermatology patients seen at the 86th Combat Support Hospital at Ibn Sina Hospital in Baghdad, Iraq, during a 6-month period in 2008, 8% of 2696 total visits were identified to be due to skin cancer, with the overwhelming majority being for keratinocyte cancers.⁷ A 1993 retrospective chart review of World War II veterans referred for Mohs micrographic surgery showed a considerably higher incidence in those who served in the Pacific Theater compared to those who served in the European Theater. Despite having approximately equal characteristics—age, skin type, and cumulative time spent outdoors—between the 2 groups, military servicemembers deployed to the Pacific represented 66% of the patients with basal cell carcinoma and 68% of the patients with squamous cell carcinoma.⁸

Contributing Factors

There are many factors related to military service that are likely to contribute to the increased risk for skin cancer. Based on a review of the literature, we have found an increased exposure to UV radiation, low utilization of sun-protective strategies, and low overall education regarding the risks for UV exposure to be the primary contributors to increased risks for skin cancer.

UV exposure is the primary mitigatable risk factor for developing melanoma and keratinocyte cancers.^9,10 In a 2015 study of 212 military servicemembers returning from deployments in Iraq and Afghanistan, 77% reported spending more than 4 hours per day working directly in the bright sun, with 64% spending more than 75% of the average day in the bright sun.¹¹ A 1984 study of World War II veterans diagnosed with melanoma also showed that 34% of those with melanoma had prior deployments to the tropics compared to 6% in age-matched controls.¹²

Even in those not deployed to overseas locations, military work still frequently involves prolonged sun exposure. In a 2015 cross-sectional study of US Air Force maintenance squadrons at Travis Air Force Base in Fairfield, California (N=356), 67% of those surveyed reported having careers that frequently involved direct sun exposure.¹³ This occupational sun exposure may be worsened by increased UV exposure during recreational activities, as active-duty military servicemembers may reasonably be expected to engage in more outdoor exercise and leisure activities than their civilian counterparts.

Other occupation-specific risk factors also may affect skin cancer rates in certain populations. In a study of aircraft personnel that included male military and civilian pilots, a meta-standardized incidence ratio for melanoma of 3.42 was identified compared to controls not involved in aircraft work.¹⁴ Theories to explain this increased incidence of melanoma include increased exposure to ionizing radiation at high altitudes, exposure to aviation-related chemicals, and alterations in circadian rhythm.^14,15

This increased sun exposure is compounded by the overall low rates of sun protection among military members. Of those returning from Iraq and Afghanistan in the 2015 study, less than 30% of servicemembers reported routine access to sunscreen, and only 13% stated that they routinely applied sunscreen when exposed to the sun. Of this same group, only 23% endorsed that the military made them very aware of their risk for skin cancer.¹¹ The low rates of sunscreen usage by those deployed to an active combat zone may partially be explained by the assumption that those individuals placed more emphasis on the acute dangers of combat rather than the perceived future dangers of skin cancer. A decreased availability of sunscreen for deployed military servicemembers, particularly those located at small austere bases where supplies are likely to be limited, likely makes the use of sunscreen even more difficult.

However, even within the continental United States, active-duty military servicemembers still exhibit low rates of sunscreen usage. In the 2015 study of US Air Force personnel in maintenance squadrons in California, less than 11% of those surveyed reported using sunscreen most of the time despite high rates of outdoor work.¹³

Another factor likely contributing to increased sun exposure and decreased sun-protection practices is the so-called invincibility complex, which is a common set of egocentric beliefs that leads to a perception that an individual is not likely to suffer the consequences of engaging in risky behaviors. Despite knowledge of the dangers associated with risky activity, individuals with an invincibility complex are more likely to view potential consequences as relevant only to others, not to themselves.¹⁶ A study of adolescent smokers in the Netherlands examined why subjects continue to smoke, despite knowledge of the potentially deadly consequences of smoking. Three common rationalizing beliefs were found: trivialization of the immediate consequences, that their smoking is only temporary and they have time in the future to stop, and that they have control over how much they smoke and can prevent fatal consequences with moderation.¹⁷ Such an invincibility complex is thought to directly run counter to the efforts of public health and educational campaigns. This belief set is thought to at least partially explain why adolescents in Australia are the most knowledgeable age cohort regarding the dangers of UV exposure but the least likely to engage in skin-protective measures.¹⁸ This inflated sense of invincibility may be leading active-duty military servicemembers to engage in unhealthy sun-exposure practices regardless of knowledge of the associated risks.

Members of the military may be uniquely susceptible to this invincibility complex. Growing evidence suggests that exposure to life-threatening circumstances may lead to long-lasting alterations in threat assessment.^19,20 A 2008 study of Iraq veterans returning from deployment found that direct exposure to violent combat and human trauma was associated with an increased perceived degree of invincibility and a higher propensity to engage in risky behaviors after returning from deployment.¹⁹ Additionally, it has been speculated that individuals with a higher degree of perceived invincibility may be more likely to pursue military service, as a higher degree of self-confidence in the face of the often dangerous circumstances of military operations may be advantageous.²⁰

In addition to scarce use of sun-protective strategies, military servicemembers also tend to lack awareness of the potential short-term and long-term harm from UV radiation. In a 2016 study of veterans undergoing treatment for skin cancer, patients reported inadequate education about skin cancer risks and strategies to decrease their chances of developing it.²¹ Sunscreen is less frequently used in males, specifically those aged 18 to 30 years; this demographic makes up 55.7% of the active-duty population.^2,22 Low income also has been associated with decreased sunscreen use; junior enlisted military servicemembers (ranks E1-E4) make up 43.8% of the military’s ranks and make less than the average annual American household income.^2,23,24

Prevention and Risk-Mitigation Strategies

Although many of the risk factors in the US Military promoting skin cancer are intrinsic to the occupation, certain steps could help minimize servicemembers’ risks. To be effective, any attempt to decrease the risk for skin cancer in the US Military must take into consideration the environment in which the military operates. To complete their mission, military personnel often are required to operate for extended periods outdoors in areas of high UV exposure, such as the deserts of Iraq or the mountains of Afghanistan. Outdoor work at times of peak sunlight often is required for successful mission completion, thus it would be ineffective to simply give blanket advice to avoid sun exposure.

Another important factor is the impact that official policy plays in shaping the daily actions of individual military servicemembers. In a hierarchical organization such as the US Military, unit commanders have substantial authority over the behaviors of their subordinates. Thus, strategies to mitigate skin cancer risks should be aimed at the individual servicemembers and unit commanders and at a policy level. Ultimately, a 3-pronged approach built on education, access to sun-protective gear, and increased availability to sunscreen is recommended.

Education
The foundation for any skin cancer prevention strategies should be built on the education of individual military servicemembers. The majority of active-duty members and veterans did not believe the military did enough to actively educate them on the risks for developing skin cancer.²¹ An effective educational program should focus on prevention and detection. Prevention programs should explain the role of UV exposure in the development of skin cancer, the intrinsic risks of UV exposure associated with outdoor activities, and strategies that can be implemented to reduce UV exposure and lifetime risk of skin cancer development. In a study of German outdoor workers, displays of support and concern by management regarding UV protection were associated with increases in sun-protective behaviors among the employees.²⁵

Because patient self-examinations have been shown to be associated with earlier melanoma diagnosis and a more superficial depth at diagnosis, detection programs also should focus on the identification of suspicious skin lesions, such as by teaching the ABCDEs of melanoma.²⁶ Among the general population, educational campaigns have been shown to be effective at reducing melanoma mortality.^27,28

Access to Sun-Protective Gear
The second aspect of reducing skin cancer risk should be aiming to protect military servicemembers from UV exposure. Any prevention strategy must fit within the military’s broader tactical and strategic framework.

The use of photoprotective strategies rather than the outright avoidance of sun exposure should be implemented to minimize the deleterious effects of outdoor work. The most recent study of the UV-protective properties of US Military uniforms found all tested uniforms to have either very good or excellent UV protection, with UV protection factors (UPFs) ranging from 35 to 50+.²⁹ However, this study was performed in 2002, and the majority of the uniforms tested are no longer in service. More up-to-date UPF information for existing military uniforms is not currently available. Most military commands wear baseball hat–style covers when operating outdoors, which generally provide good photoprotection with UPF ratings of 35 to 50 over the protected areas.²⁹ Unfortunately, these types of headgear offer less photoprotection than do wide-brimmed hats, which have demonstrated improved photoprotection, particularly of the neck, cheeks, ears, and chin.³⁰ A wide-brimmed hat, known as the boonie hat, was originally proposed for military use in 1966 to provide protection of servicemembers’ faces and necks from the intense sun of Vietnam. Currently, the use of the boonie hat typically is prohibited for units not engaged in combat or combat-support roles and requires authorization by the unit-level commander.³¹ Because of its perception as “unmilitary appearing” by many unit commanders and its restriction of use to combat-related units, the boonie hat is not consistently used. Increasing the use of this type of wide-brimmed hat would be an important asset in decreasing chronic UV exposure in military servicemembers, particularly on those parts of the body where skin cancer occurrence is the greatest.³² Policies should be aimed at increasing the use of the boonie hat, both through expanding its availability to troops in non–combat-related fields and by encouraging unit commanders to authorize its use in their units.

Sunscreen Availability
Improving the use of sunscreen is another impactful strategy that could be undertaken to decrease the risk for skin cancer in military servicemembers. The use of sunscreen is low in both those deployed overseas and those stationed within the United States. Improving access to sunscreen, particularly in the deployed setting, also could reduce barriers to use. Providing sunscreen directly to servicemembers, either when issuing gear or integrated within Meals Ready to Eat, could remove both the financial and logistical barriers to sunscreen utilization. Centralized troop-gathering locations, such as dining facilities, could be utilized both for the mass distribution of sunscreen and to display educational material. Unit commanders also could mandate times for servicemembers to stop work and apply sunscreen at regularly scheduled intervals.

The composition and delivery vehicle of sunscreen may have an impact on its efficacy and ease of use in the field. The American Academy of Dermatology (AAD) recommends using sunscreen that is broad spectrum, sun protection factor (SPF) 30 or greater, and water resistant.³³ However, the AAD does not make a recommendation of whether to use a physical sunscreen (such as titanium dioxide) or a chemical sunscreen. If applied in equal amounts, a chemical sunscreen and a physical sunscreen with an equal SPF should offer the same UV protection. However, a study in the British Journal of Dermatology showed that subjects applied only two-thirds the quantity of physical sunscreen compared to those applying chemical sunscreen, achieving approximately only one-half the SPF as provided by the chemical sunscreen.³⁴ Because sunscreen is only effective when it is used, consideration should be given to the preferences of the military population when selecting sunscreens. A review of consumer preferences of sunscreen qualities showed that sunscreens that were nongreasy and did not leave a residue were given the most favorable rankings.³⁵ In recent years, sunscreen sprays have become increasingly popular. When adequately applied, sprays have been shown to be equally effective as sunscreen lotions.³⁶ However, although recommendations have been issued by both the AAD and the US Food and Drug Administration on the application of sunscreen lotion to adequately cover exposed skin, no such recommendations have been given for sunscreen sprays.³³ Some safety concerns also remain regarding the flammability of aerosol sunscreens, which could be exacerbated in a combat situation.³⁷

However, there are some obvious downsides to sunscreen use. During certain operational tasks, particularly in combat settings, it may not be feasible or even safe to stop working to apply sunscreen at the 2-hour intervals required for effective UV protection.³⁸ Water exposure or large amounts of perspiration also would cause sunscreen to lose effectiveness earlier than expected. Logistically, it may be challenging to regularly supply sunscreen to small austere bases in remote locations.

Final Thoughts

The men and women of our armed forces already undertake great risk in the defense of our country. It should be ensured that their risk for developing skin cancer is made as low as possible, while still allowing them to successfully accomplish their mission. Multiple studies have shown servicemembers to be at an increased risk for skin cancer, particularly melanoma. We believe the primary factor behind this increased risk is occupational UV exposure, which is compounded by the suboptimal use of sun-protective strategies. By educating our servicemembers about their risk for skin cancer and promoting increased UV protection, we can effectively reduce the burden of skin cancer on our active-duty servicemembers and veterans.

There are numerous intrinsic risks that military servicemembers face, such as the dangers of combat, handling firearms, operating ships and heavy machinery, undersea diving, and aircraft operations. Multiple studies also have identified an increased risk for melanomas and keratinocyte cancers in those who have served on active duty.

Epidemiology

Differences in demographics are important to consider given the differences among races in the risks of skin cancers. Important racial demographic differences exist between the US Military and the general US population. Racial demographic differences also exist among the various military branches themselves. The US population is 61.0% White, 20.7% racial minorities (defined as Black or African American, Asian, American Indian or Alaska native, Native Hawaiian or other Pacific Islander, multiracial, or unknown), and 18.3% Hispanic or Latino (Hispanic or Latino was not listed as a component of racial minorities).¹ According to 2018 data, the US Military population is 52.9% White, 31.0% racial minorities, and 16.1% Hispanic or Latino.² The percentage of White military members was highest in the US Marine Corps (58.4%) and lowest in the US Navy (46.5%). The percentage of racial minorities was highest in the US Navy (38.0%) and lowest in the US Marine Corps (20.0%).² The percentage of Hispanic and Latino military members was highest in the US Marine Corps (21.6%) and lowest in the US Air Force (14.5%).²

Melanoma in Military Members

It is estimated that the annual incidence rate of melanoma in the United States is 27 per 100,000 individuals for non-Hispanic Whites, 5 per 100,000 for Hispanics, and 1 per 100,000 for Black individuals and Asians/Pacific Islanders.³ Three studies have reviewed melanoma incidence in relation to service in the US Military.

A 2011 retrospective tumor registries study of US veterans aged 45 years or older demonstrated increased incidences of melanoma compared with the general population.⁴ With age, the melanoma incidence per 100,000 person-years increased in White veterans compared to their civilian counterparts (aged 45 to 49 years, 33.62 vs 27.49; aged 50 to 54 years, 49.76 vs 32.18; aged 55 to 59 years, 178.48 vs 39.17).⁴ An increased melanoma incidence of 62% also was seen in active-duty servicemembers aged 18 to 56 years compared to their age-matched civilian peers in a 2014 retrospective cohort study.⁵

Melanoma rates also vary depending on military service branch. Across 3 separate studies, service in the US Air Force was associated with the highest risk for melanoma development. A surveillance report of cancer incidence in active-duty US Armed Forces personnel between 2000 and 2011 conducted by the Defense Medical Surveillance System showed an incidence rate (per 100,000 person-years) for melanoma of 10.5 in all services, and a rate of 15.5 in the US Air Force vs 8.6 in the US Army, further highlighting the disparity between the services.⁶ The 2014 study also demonstrated a melanoma incidence rate of 17.80 in active-duty US Air Force personnel compared to 9.53 in active-duty US Army personnel.⁵ Among US Air Force active-duty personnel, one study showed a melanoma incidence rate (per 100,000 person-years) of 7.59 for men and 8.98 for women compared to 6.25 and 5.46, respectively, in US Army soldiers.⁴

Keratinocyte Cancers in Military Members

Although less well studied than melanoma, keratinocyte-derived skin cancers represent a major source of disease burden both during and after active-duty service. In a retrospective chart review of dermatology patients seen at the 86th Combat Support Hospital at Ibn Sina Hospital in Baghdad, Iraq, during a 6-month period in 2008, 8% of 2696 total visits were identified to be due to skin cancer, with the overwhelming majority being for keratinocyte cancers.⁷ A 1993 retrospective chart review of World War II veterans referred for Mohs micrographic surgery showed a considerably higher incidence in those who served in the Pacific Theater compared to those who served in the European Theater. Despite having approximately equal characteristics—age, skin type, and cumulative time spent outdoors—between the 2 groups, military servicemembers deployed to the Pacific represented 66% of the patients with basal cell carcinoma and 68% of the patients with squamous cell carcinoma.⁸

Contributing Factors

There are many factors related to military service that are likely to contribute to the increased risk for skin cancer. Based on a review of the literature, we have found an increased exposure to UV radiation, low utilization of sun-protective strategies, and low overall education regarding the risks for UV exposure to be the primary contributors to increased risks for skin cancer.

UV exposure is the primary mitigatable risk factor for developing melanoma and keratinocyte cancers.^9,10 In a 2015 study of 212 military servicemembers returning from deployments in Iraq and Afghanistan, 77% reported spending more than 4 hours per day working directly in the bright sun, with 64% spending more than 75% of the average day in the bright sun.¹¹ A 1984 study of World War II veterans diagnosed with melanoma also showed that 34% of those with melanoma had prior deployments to the tropics compared to 6% in age-matched controls.¹²

Even in those not deployed to overseas locations, military work still frequently involves prolonged sun exposure. In a 2015 cross-sectional study of US Air Force maintenance squadrons at Travis Air Force Base in Fairfield, California (N=356), 67% of those surveyed reported having careers that frequently involved direct sun exposure.¹³ This occupational sun exposure may be worsened by increased UV exposure during recreational activities, as active-duty military servicemembers may reasonably be expected to engage in more outdoor exercise and leisure activities than their civilian counterparts.

Other occupation-specific risk factors also may affect skin cancer rates in certain populations. In a study of aircraft personnel that included male military and civilian pilots, a meta-standardized incidence ratio for melanoma of 3.42 was identified compared to controls not involved in aircraft work.¹⁴ Theories to explain this increased incidence of melanoma include increased exposure to ionizing radiation at high altitudes, exposure to aviation-related chemicals, and alterations in circadian rhythm.^14,15

This increased sun exposure is compounded by the overall low rates of sun protection among military members. Of those returning from Iraq and Afghanistan in the 2015 study, less than 30% of servicemembers reported routine access to sunscreen, and only 13% stated that they routinely applied sunscreen when exposed to the sun. Of this same group, only 23% endorsed that the military made them very aware of their risk for skin cancer.¹¹ The low rates of sunscreen usage by those deployed to an active combat zone may partially be explained by the assumption that those individuals placed more emphasis on the acute dangers of combat rather than the perceived future dangers of skin cancer. A decreased availability of sunscreen for deployed military servicemembers, particularly those located at small austere bases where supplies are likely to be limited, likely makes the use of sunscreen even more difficult.

However, even within the continental United States, active-duty military servicemembers still exhibit low rates of sunscreen usage. In the 2015 study of US Air Force personnel in maintenance squadrons in California, less than 11% of those surveyed reported using sunscreen most of the time despite high rates of outdoor work.¹³

Another factor likely contributing to increased sun exposure and decreased sun-protection practices is the so-called invincibility complex, which is a common set of egocentric beliefs that leads to a perception that an individual is not likely to suffer the consequences of engaging in risky behaviors. Despite knowledge of the dangers associated with risky activity, individuals with an invincibility complex are more likely to view potential consequences as relevant only to others, not to themselves.¹⁶ A study of adolescent smokers in the Netherlands examined why subjects continue to smoke, despite knowledge of the potentially deadly consequences of smoking. Three common rationalizing beliefs were found: trivialization of the immediate consequences, that their smoking is only temporary and they have time in the future to stop, and that they have control over how much they smoke and can prevent fatal consequences with moderation.¹⁷ Such an invincibility complex is thought to directly run counter to the efforts of public health and educational campaigns. This belief set is thought to at least partially explain why adolescents in Australia are the most knowledgeable age cohort regarding the dangers of UV exposure but the least likely to engage in skin-protective measures.¹⁸ This inflated sense of invincibility may be leading active-duty military servicemembers to engage in unhealthy sun-exposure practices regardless of knowledge of the associated risks.

Members of the military may be uniquely susceptible to this invincibility complex. Growing evidence suggests that exposure to life-threatening circumstances may lead to long-lasting alterations in threat assessment.^19,20 A 2008 study of Iraq veterans returning from deployment found that direct exposure to violent combat and human trauma was associated with an increased perceived degree of invincibility and a higher propensity to engage in risky behaviors after returning from deployment.¹⁹ Additionally, it has been speculated that individuals with a higher degree of perceived invincibility may be more likely to pursue military service, as a higher degree of self-confidence in the face of the often dangerous circumstances of military operations may be advantageous.²⁰

In addition to scarce use of sun-protective strategies, military servicemembers also tend to lack awareness of the potential short-term and long-term harm from UV radiation. In a 2016 study of veterans undergoing treatment for skin cancer, patients reported inadequate education about skin cancer risks and strategies to decrease their chances of developing it.²¹ Sunscreen is less frequently used in males, specifically those aged 18 to 30 years; this demographic makes up 55.7% of the active-duty population.^2,22 Low income also has been associated with decreased sunscreen use; junior enlisted military servicemembers (ranks E1-E4) make up 43.8% of the military’s ranks and make less than the average annual American household income.^2,23,24

Prevention and Risk-Mitigation Strategies

Although many of the risk factors in the US Military promoting skin cancer are intrinsic to the occupation, certain steps could help minimize servicemembers’ risks. To be effective, any attempt to decrease the risk for skin cancer in the US Military must take into consideration the environment in which the military operates. To complete their mission, military personnel often are required to operate for extended periods outdoors in areas of high UV exposure, such as the deserts of Iraq or the mountains of Afghanistan. Outdoor work at times of peak sunlight often is required for successful mission completion, thus it would be ineffective to simply give blanket advice to avoid sun exposure.

Another important factor is the impact that official policy plays in shaping the daily actions of individual military servicemembers. In a hierarchical organization such as the US Military, unit commanders have substantial authority over the behaviors of their subordinates. Thus, strategies to mitigate skin cancer risks should be aimed at the individual servicemembers and unit commanders and at a policy level. Ultimately, a 3-pronged approach built on education, access to sun-protective gear, and increased availability to sunscreen is recommended.

Education
The foundation for any skin cancer prevention strategies should be built on the education of individual military servicemembers. The majority of active-duty members and veterans did not believe the military did enough to actively educate them on the risks for developing skin cancer.²¹ An effective educational program should focus on prevention and detection. Prevention programs should explain the role of UV exposure in the development of skin cancer, the intrinsic risks of UV exposure associated with outdoor activities, and strategies that can be implemented to reduce UV exposure and lifetime risk of skin cancer development. In a study of German outdoor workers, displays of support and concern by management regarding UV protection were associated with increases in sun-protective behaviors among the employees.²⁵

Because patient self-examinations have been shown to be associated with earlier melanoma diagnosis and a more superficial depth at diagnosis, detection programs also should focus on the identification of suspicious skin lesions, such as by teaching the ABCDEs of melanoma.²⁶ Among the general population, educational campaigns have been shown to be effective at reducing melanoma mortality.^27,28

Access to Sun-Protective Gear
The second aspect of reducing skin cancer risk should be aiming to protect military servicemembers from UV exposure. Any prevention strategy must fit within the military’s broader tactical and strategic framework.

The use of photoprotective strategies rather than the outright avoidance of sun exposure should be implemented to minimize the deleterious effects of outdoor work. The most recent study of the UV-protective properties of US Military uniforms found all tested uniforms to have either very good or excellent UV protection, with UV protection factors (UPFs) ranging from 35 to 50+.²⁹ However, this study was performed in 2002, and the majority of the uniforms tested are no longer in service. More up-to-date UPF information for existing military uniforms is not currently available. Most military commands wear baseball hat–style covers when operating outdoors, which generally provide good photoprotection with UPF ratings of 35 to 50 over the protected areas.²⁹ Unfortunately, these types of headgear offer less photoprotection than do wide-brimmed hats, which have demonstrated improved photoprotection, particularly of the neck, cheeks, ears, and chin.³⁰ A wide-brimmed hat, known as the boonie hat, was originally proposed for military use in 1966 to provide protection of servicemembers’ faces and necks from the intense sun of Vietnam. Currently, the use of the boonie hat typically is prohibited for units not engaged in combat or combat-support roles and requires authorization by the unit-level commander.³¹ Because of its perception as “unmilitary appearing” by many unit commanders and its restriction of use to combat-related units, the boonie hat is not consistently used. Increasing the use of this type of wide-brimmed hat would be an important asset in decreasing chronic UV exposure in military servicemembers, particularly on those parts of the body where skin cancer occurrence is the greatest.³² Policies should be aimed at increasing the use of the boonie hat, both through expanding its availability to troops in non–combat-related fields and by encouraging unit commanders to authorize its use in their units.

Sunscreen Availability
Improving the use of sunscreen is another impactful strategy that could be undertaken to decrease the risk for skin cancer in military servicemembers. The use of sunscreen is low in both those deployed overseas and those stationed within the United States. Improving access to sunscreen, particularly in the deployed setting, also could reduce barriers to use. Providing sunscreen directly to servicemembers, either when issuing gear or integrated within Meals Ready to Eat, could remove both the financial and logistical barriers to sunscreen utilization. Centralized troop-gathering locations, such as dining facilities, could be utilized both for the mass distribution of sunscreen and to display educational material. Unit commanders also could mandate times for servicemembers to stop work and apply sunscreen at regularly scheduled intervals.

The composition and delivery vehicle of sunscreen may have an impact on its efficacy and ease of use in the field. The American Academy of Dermatology (AAD) recommends using sunscreen that is broad spectrum, sun protection factor (SPF) 30 or greater, and water resistant.³³ However, the AAD does not make a recommendation of whether to use a physical sunscreen (such as titanium dioxide) or a chemical sunscreen. If applied in equal amounts, a chemical sunscreen and a physical sunscreen with an equal SPF should offer the same UV protection. However, a study in the British Journal of Dermatology showed that subjects applied only two-thirds the quantity of physical sunscreen compared to those applying chemical sunscreen, achieving approximately only one-half the SPF as provided by the chemical sunscreen.³⁴ Because sunscreen is only effective when it is used, consideration should be given to the preferences of the military population when selecting sunscreens. A review of consumer preferences of sunscreen qualities showed that sunscreens that were nongreasy and did not leave a residue were given the most favorable rankings.³⁵ In recent years, sunscreen sprays have become increasingly popular. When adequately applied, sprays have been shown to be equally effective as sunscreen lotions.³⁶ However, although recommendations have been issued by both the AAD and the US Food and Drug Administration on the application of sunscreen lotion to adequately cover exposed skin, no such recommendations have been given for sunscreen sprays.³³ Some safety concerns also remain regarding the flammability of aerosol sunscreens, which could be exacerbated in a combat situation.³⁷

However, there are some obvious downsides to sunscreen use. During certain operational tasks, particularly in combat settings, it may not be feasible or even safe to stop working to apply sunscreen at the 2-hour intervals required for effective UV protection.³⁸ Water exposure or large amounts of perspiration also would cause sunscreen to lose effectiveness earlier than expected. Logistically, it may be challenging to regularly supply sunscreen to small austere bases in remote locations.

Final Thoughts

The men and women of our armed forces already undertake great risk in the defense of our country. It should be ensured that their risk for developing skin cancer is made as low as possible, while still allowing them to successfully accomplish their mission. Multiple studies have shown servicemembers to be at an increased risk for skin cancer, particularly melanoma. We believe the primary factor behind this increased risk is occupational UV exposure, which is compounded by the suboptimal use of sun-protective strategies. By educating our servicemembers about their risk for skin cancer and promoting increased UV protection, we can effectively reduce the burden of skin cancer on our active-duty servicemembers and veterans.

There are numerous intrinsic risks that military servicemembers face, such as the dangers of combat, handling firearms, operating ships and heavy machinery, undersea diving, and aircraft operations. Multiple studies also have identified an increased risk for melanomas and keratinocyte cancers in those who have served on active duty.

Epidemiology

Differences in demographics are important to consider given the differences among races in the risks of skin cancers. Important racial demographic differences exist between the US Military and the general US population. Racial demographic differences also exist among the various military branches themselves. The US population is 61.0% White, 20.7% racial minorities (defined as Black or African American, Asian, American Indian or Alaska native, Native Hawaiian or other Pacific Islander, multiracial, or unknown), and 18.3% Hispanic or Latino (Hispanic or Latino was not listed as a component of racial minorities).¹ According to 2018 data, the US Military population is 52.9% White, 31.0% racial minorities, and 16.1% Hispanic or Latino.² The percentage of White military members was highest in the US Marine Corps (58.4%) and lowest in the US Navy (46.5%). The percentage of racial minorities was highest in the US Navy (38.0%) and lowest in the US Marine Corps (20.0%).² The percentage of Hispanic and Latino military members was highest in the US Marine Corps (21.6%) and lowest in the US Air Force (14.5%).²

Melanoma in Military Members

It is estimated that the annual incidence rate of melanoma in the United States is 27 per 100,000 individuals for non-Hispanic Whites, 5 per 100,000 for Hispanics, and 1 per 100,000 for Black individuals and Asians/Pacific Islanders.³ Three studies have reviewed melanoma incidence in relation to service in the US Military.

A 2011 retrospective tumor registries study of US veterans aged 45 years or older demonstrated increased incidences of melanoma compared with the general population.⁴ With age, the melanoma incidence per 100,000 person-years increased in White veterans compared to their civilian counterparts (aged 45 to 49 years, 33.62 vs 27.49; aged 50 to 54 years, 49.76 vs 32.18; aged 55 to 59 years, 178.48 vs 39.17).⁴ An increased melanoma incidence of 62% also was seen in active-duty servicemembers aged 18 to 56 years compared to their age-matched civilian peers in a 2014 retrospective cohort study.⁵

Melanoma rates also vary depending on military service branch. Across 3 separate studies, service in the US Air Force was associated with the highest risk for melanoma development. A surveillance report of cancer incidence in active-duty US Armed Forces personnel between 2000 and 2011 conducted by the Defense Medical Surveillance System showed an incidence rate (per 100,000 person-years) for melanoma of 10.5 in all services, and a rate of 15.5 in the US Air Force vs 8.6 in the US Army, further highlighting the disparity between the services.⁶ The 2014 study also demonstrated a melanoma incidence rate of 17.80 in active-duty US Air Force personnel compared to 9.53 in active-duty US Army personnel.⁵ Among US Air Force active-duty personnel, one study showed a melanoma incidence rate (per 100,000 person-years) of 7.59 for men and 8.98 for women compared to 6.25 and 5.46, respectively, in US Army soldiers.⁴

Keratinocyte Cancers in Military Members

Although less well studied than melanoma, keratinocyte-derived skin cancers represent a major source of disease burden both during and after active-duty service. In a retrospective chart review of dermatology patients seen at the 86th Combat Support Hospital at Ibn Sina Hospital in Baghdad, Iraq, during a 6-month period in 2008, 8% of 2696 total visits were identified to be due to skin cancer, with the overwhelming majority being for keratinocyte cancers.⁷ A 1993 retrospective chart review of World War II veterans referred for Mohs micrographic surgery showed a considerably higher incidence in those who served in the Pacific Theater compared to those who served in the European Theater. Despite having approximately equal characteristics—age, skin type, and cumulative time spent outdoors—between the 2 groups, military servicemembers deployed to the Pacific represented 66% of the patients with basal cell carcinoma and 68% of the patients with squamous cell carcinoma.⁸

Contributing Factors

There are many factors related to military service that are likely to contribute to the increased risk for skin cancer. Based on a review of the literature, we have found an increased exposure to UV radiation, low utilization of sun-protective strategies, and low overall education regarding the risks for UV exposure to be the primary contributors to increased risks for skin cancer.

UV exposure is the primary mitigatable risk factor for developing melanoma and keratinocyte cancers.^9,10 In a 2015 study of 212 military servicemembers returning from deployments in Iraq and Afghanistan, 77% reported spending more than 4 hours per day working directly in the bright sun, with 64% spending more than 75% of the average day in the bright sun.¹¹ A 1984 study of World War II veterans diagnosed with melanoma also showed that 34% of those with melanoma had prior deployments to the tropics compared to 6% in age-matched controls.¹²

Even in those not deployed to overseas locations, military work still frequently involves prolonged sun exposure. In a 2015 cross-sectional study of US Air Force maintenance squadrons at Travis Air Force Base in Fairfield, California (N=356), 67% of those surveyed reported having careers that frequently involved direct sun exposure.¹³ This occupational sun exposure may be worsened by increased UV exposure during recreational activities, as active-duty military servicemembers may reasonably be expected to engage in more outdoor exercise and leisure activities than their civilian counterparts.

Other occupation-specific risk factors also may affect skin cancer rates in certain populations. In a study of aircraft personnel that included male military and civilian pilots, a meta-standardized incidence ratio for melanoma of 3.42 was identified compared to controls not involved in aircraft work.¹⁴ Theories to explain this increased incidence of melanoma include increased exposure to ionizing radiation at high altitudes, exposure to aviation-related chemicals, and alterations in circadian rhythm.^14,15

This increased sun exposure is compounded by the overall low rates of sun protection among military members. Of those returning from Iraq and Afghanistan in the 2015 study, less than 30% of servicemembers reported routine access to sunscreen, and only 13% stated that they routinely applied sunscreen when exposed to the sun. Of this same group, only 23% endorsed that the military made them very aware of their risk for skin cancer.¹¹ The low rates of sunscreen usage by those deployed to an active combat zone may partially be explained by the assumption that those individuals placed more emphasis on the acute dangers of combat rather than the perceived future dangers of skin cancer. A decreased availability of sunscreen for deployed military servicemembers, particularly those located at small austere bases where supplies are likely to be limited, likely makes the use of sunscreen even more difficult.

However, even within the continental United States, active-duty military servicemembers still exhibit low rates of sunscreen usage. In the 2015 study of US Air Force personnel in maintenance squadrons in California, less than 11% of those surveyed reported using sunscreen most of the time despite high rates of outdoor work.¹³

Another factor likely contributing to increased sun exposure and decreased sun-protection practices is the so-called invincibility complex, which is a common set of egocentric beliefs that leads to a perception that an individual is not likely to suffer the consequences of engaging in risky behaviors. Despite knowledge of the dangers associated with risky activity, individuals with an invincibility complex are more likely to view potential consequences as relevant only to others, not to themselves.¹⁶ A study of adolescent smokers in the Netherlands examined why subjects continue to smoke, despite knowledge of the potentially deadly consequences of smoking. Three common rationalizing beliefs were found: trivialization of the immediate consequences, that their smoking is only temporary and they have time in the future to stop, and that they have control over how much they smoke and can prevent fatal consequences with moderation.¹⁷ Such an invincibility complex is thought to directly run counter to the efforts of public health and educational campaigns. This belief set is thought to at least partially explain why adolescents in Australia are the most knowledgeable age cohort regarding the dangers of UV exposure but the least likely to engage in skin-protective measures.¹⁸ This inflated sense of invincibility may be leading active-duty military servicemembers to engage in unhealthy sun-exposure practices regardless of knowledge of the associated risks.

Members of the military may be uniquely susceptible to this invincibility complex. Growing evidence suggests that exposure to life-threatening circumstances may lead to long-lasting alterations in threat assessment.^19,20 A 2008 study of Iraq veterans returning from deployment found that direct exposure to violent combat and human trauma was associated with an increased perceived degree of invincibility and a higher propensity to engage in risky behaviors after returning from deployment.¹⁹ Additionally, it has been speculated that individuals with a higher degree of perceived invincibility may be more likely to pursue military service, as a higher degree of self-confidence in the face of the often dangerous circumstances of military operations may be advantageous.²⁰

In addition to scarce use of sun-protective strategies, military servicemembers also tend to lack awareness of the potential short-term and long-term harm from UV radiation. In a 2016 study of veterans undergoing treatment for skin cancer, patients reported inadequate education about skin cancer risks and strategies to decrease their chances of developing it.²¹ Sunscreen is less frequently used in males, specifically those aged 18 to 30 years; this demographic makes up 55.7% of the active-duty population.^2,22 Low income also has been associated with decreased sunscreen use; junior enlisted military servicemembers (ranks E1-E4) make up 43.8% of the military’s ranks and make less than the average annual American household income.^2,23,24

Prevention and Risk-Mitigation Strategies

Although many of the risk factors in the US Military promoting skin cancer are intrinsic to the occupation, certain steps could help minimize servicemembers’ risks. To be effective, any attempt to decrease the risk for skin cancer in the US Military must take into consideration the environment in which the military operates. To complete their mission, military personnel often are required to operate for extended periods outdoors in areas of high UV exposure, such as the deserts of Iraq or the mountains of Afghanistan. Outdoor work at times of peak sunlight often is required for successful mission completion, thus it would be ineffective to simply give blanket advice to avoid sun exposure.

Another important factor is the impact that official policy plays in shaping the daily actions of individual military servicemembers. In a hierarchical organization such as the US Military, unit commanders have substantial authority over the behaviors of their subordinates. Thus, strategies to mitigate skin cancer risks should be aimed at the individual servicemembers and unit commanders and at a policy level. Ultimately, a 3-pronged approach built on education, access to sun-protective gear, and increased availability to sunscreen is recommended.

Education
The foundation for any skin cancer prevention strategies should be built on the education of individual military servicemembers. The majority of active-duty members and veterans did not believe the military did enough to actively educate them on the risks for developing skin cancer.²¹ An effective educational program should focus on prevention and detection. Prevention programs should explain the role of UV exposure in the development of skin cancer, the intrinsic risks of UV exposure associated with outdoor activities, and strategies that can be implemented to reduce UV exposure and lifetime risk of skin cancer development. In a study of German outdoor workers, displays of support and concern by management regarding UV protection were associated with increases in sun-protective behaviors among the employees.²⁵

Because patient self-examinations have been shown to be associated with earlier melanoma diagnosis and a more superficial depth at diagnosis, detection programs also should focus on the identification of suspicious skin lesions, such as by teaching the ABCDEs of melanoma.²⁶ Among the general population, educational campaigns have been shown to be effective at reducing melanoma mortality.^27,28

Access to Sun-Protective Gear
The second aspect of reducing skin cancer risk should be aiming to protect military servicemembers from UV exposure. Any prevention strategy must fit within the military’s broader tactical and strategic framework.

The use of photoprotective strategies rather than the outright avoidance of sun exposure should be implemented to minimize the deleterious effects of outdoor work. The most recent study of the UV-protective properties of US Military uniforms found all tested uniforms to have either very good or excellent UV protection, with UV protection factors (UPFs) ranging from 35 to 50+.²⁹ However, this study was performed in 2002, and the majority of the uniforms tested are no longer in service. More up-to-date UPF information for existing military uniforms is not currently available. Most military commands wear baseball hat–style covers when operating outdoors, which generally provide good photoprotection with UPF ratings of 35 to 50 over the protected areas.²⁹ Unfortunately, these types of headgear offer less photoprotection than do wide-brimmed hats, which have demonstrated improved photoprotection, particularly of the neck, cheeks, ears, and chin.³⁰ A wide-brimmed hat, known as the boonie hat, was originally proposed for military use in 1966 to provide protection of servicemembers’ faces and necks from the intense sun of Vietnam. Currently, the use of the boonie hat typically is prohibited for units not engaged in combat or combat-support roles and requires authorization by the unit-level commander.³¹ Because of its perception as “unmilitary appearing” by many unit commanders and its restriction of use to combat-related units, the boonie hat is not consistently used. Increasing the use of this type of wide-brimmed hat would be an important asset in decreasing chronic UV exposure in military servicemembers, particularly on those parts of the body where skin cancer occurrence is the greatest.³² Policies should be aimed at increasing the use of the boonie hat, both through expanding its availability to troops in non–combat-related fields and by encouraging unit commanders to authorize its use in their units.

Sunscreen Availability
Improving the use of sunscreen is another impactful strategy that could be undertaken to decrease the risk for skin cancer in military servicemembers. The use of sunscreen is low in both those deployed overseas and those stationed within the United States. Improving access to sunscreen, particularly in the deployed setting, also could reduce barriers to use. Providing sunscreen directly to servicemembers, either when issuing gear or integrated within Meals Ready to Eat, could remove both the financial and logistical barriers to sunscreen utilization. Centralized troop-gathering locations, such as dining facilities, could be utilized both for the mass distribution of sunscreen and to display educational material. Unit commanders also could mandate times for servicemembers to stop work and apply sunscreen at regularly scheduled intervals.

The composition and delivery vehicle of sunscreen may have an impact on its efficacy and ease of use in the field. The American Academy of Dermatology (AAD) recommends using sunscreen that is broad spectrum, sun protection factor (SPF) 30 or greater, and water resistant.³³ However, the AAD does not make a recommendation of whether to use a physical sunscreen (such as titanium dioxide) or a chemical sunscreen. If applied in equal amounts, a chemical sunscreen and a physical sunscreen with an equal SPF should offer the same UV protection. However, a study in the British Journal of Dermatology showed that subjects applied only two-thirds the quantity of physical sunscreen compared to those applying chemical sunscreen, achieving approximately only one-half the SPF as provided by the chemical sunscreen.³⁴ Because sunscreen is only effective when it is used, consideration should be given to the preferences of the military population when selecting sunscreens. A review of consumer preferences of sunscreen qualities showed that sunscreens that were nongreasy and did not leave a residue were given the most favorable rankings.³⁵ In recent years, sunscreen sprays have become increasingly popular. When adequately applied, sprays have been shown to be equally effective as sunscreen lotions.³⁶ However, although recommendations have been issued by both the AAD and the US Food and Drug Administration on the application of sunscreen lotion to adequately cover exposed skin, no such recommendations have been given for sunscreen sprays.³³ Some safety concerns also remain regarding the flammability of aerosol sunscreens, which could be exacerbated in a combat situation.³⁷

However, there are some obvious downsides to sunscreen use. During certain operational tasks, particularly in combat settings, it may not be feasible or even safe to stop working to apply sunscreen at the 2-hour intervals required for effective UV protection.³⁸ Water exposure or large amounts of perspiration also would cause sunscreen to lose effectiveness earlier than expected. Logistically, it may be challenging to regularly supply sunscreen to small austere bases in remote locations.

Final Thoughts

The men and women of our armed forces already undertake great risk in the defense of our country. It should be ensured that their risk for developing skin cancer is made as low as possible, while still allowing them to successfully accomplish their mission. Multiple studies have shown servicemembers to be at an increased risk for skin cancer, particularly melanoma. We believe the primary factor behind this increased risk is occupational UV exposure, which is compounded by the suboptimal use of sun-protective strategies. By educating our servicemembers about their risk for skin cancer and promoting increased UV protection, we can effectively reduce the burden of skin cancer on our active-duty servicemembers and veterans.

Case Report

A 19-year-old female marine with a 10-year history of hidradenitis suppurativa (HS) presented with hyperpigmented nodules in the inguinal folds and a recurrent cyst in the right groin area of 2 to 3 weeks’ duration. She denied axillary or inframammary involvement. She underwent several incision and drainage procedures 1 year prior to her enlistment in the US Marine Corps at 18 years of age. She previously had been treated by dermatology with doxycycline 100-mg tablets twice daily, benzoyl peroxide wash 5% applied to affected areas and rinsed daily, and clindamycin solution 1% with minimal improvement. She denied smoking or alcohol intake and said she typically wore a loose-fitting uniform to work. As a marine, she was expected to participate in daily physical training and exercises with her military unit, during which she wore a standardized physical training uniform, including nylon shorts and a cotton T-shirt. She requested light duty—military duty status with physical limitations or restrictions—to avoid physical training that would cause further friction and irritation to the inguinal region.

Physical examination demonstrated a woman with Fitzpatrick skin type III and normal body mass index. There were hyperpigmented nodules and scarring in the inguinal folds, most consistent with Hurley stage 2. A single, 0.5-cm, draining lesion was visualized. No hyperhidrosis was noted. The patient was placed on light duty for 7 days, with physical training only at her own pace and discretion. Moreover, she was restricted from field training, rifle range training, and other situations where she may excessively sweat or not be able to adequately maintain personal hygiene. She was encouraged to continue clindamycin solution 1% to the affected area twice daily and was prescribed chlorhexidine solution 4% to use when washing affected areas in the shower. The patient also was referred to the dermatology department at the Naval Hospital Camp Pendleton (Oceanside, California), where she was treated with laser hair removal in the inguinal region, thus avoiding waxing and further aggravation of HS flares. Due to the combination of topical therapies along with laser hair removal and duty restrictions, the patient had a dramatic decrease in development of severe nodular lesions.

Comment

Presentation
Historically, the incidence of HS is estimated at 0.5% to 4% of the general population with female predominance.¹ Predisposing factors include obesity, smoking, genetic predisposition to acne, apocrine duct obstruction, and secondary bacterial infection.² During acute flares, patients generally present with tender subcutaneous nodules that drain malodorous purulent material.^3,4 Acute flares are unpredictable, and patients deal with chronic, recurrent, draining wounds, leading to a poor quality of life with resulting physical, psychological, financial, social, and emotional distress.^3-5 The negative impact of HS on a patient’s quality of life has been reported to be greater than other dermatologic conditions.⁶ Lesions can be particularly painful and can cause disfiguration to the surface of the skin.⁷ Lesion severity is described using the Hurley staging system. Patient quality of life is directly correlated with disease severity and Hurley stage. In stage 1, abscesses develop, but no sinus tracts or cicatrization is present. In stage 2, recurrent abscesses will form tracts and cicatrization. In stage 3, the abscesses become diffuse or near diffuse, with multiple interconnected tracts and abscesses across the entire area of the body.^8,9

Severe or refractory HS within the physically active military population may require consideration of light or limited duty or even separation from service. Similarly, severe HS may pose challenges with other physically demanding occupations, such as the police force and firefighters.

Prevention Focus
Prevention of flares is key for patients with HS; secondary prevention aims to reduce impact of the disease or injury that has already occurred,^10,11 which includes prevention of the infundibulofolliculitis from becoming a deep folliculitis, nodule, or fistula, as well as Hurley stage progression. Prompt diagnosis with appropriate treatment can decrease the severity of lesions, pain, and scarring. Globally, HS patients continue to experience considerable diagnostic delays of 8 to 12 years after onset of initial symptoms.^11,12 Earlier accurate diagnosis and initiation of treatment from the primary care provider or general medical officer is imperative. Initial accurate management may help keep symptoms from progressing to more severe painful lesions. Similarly, patients should be educated on how to prevent HS flares. Patients should avoid known triggers, including smoking, obesity, sweating, mechanical irritation, stress, and poor hygiene.¹¹

Shaving for hair reduction creates ingrown hair shafts, which may lead to folliculitis in mechanically stressed areas in skin folds, thus initiating the inflammatory cascade of HS.^11,13 Therefore, shaving along with any other mechanical stress should be avoided in patients with HS. Laser hair removal has been shown to be quite helpful in both the prevention and treatment of HS. In one study, 22 patients with Hurley stage 2 to 3 disease were treated with an Nd:YAG laser once monthly. Results demonstrated a 65% decrease in disease severity after 3 monthly treatments.¹¹ Similarly, other lasers have been used with success in several small case series; an 800-nm diode laser, intense pulsed light therapy, and a ruby laser have each demonstrated efficacy.¹⁴ Given these results, hair removal should be recommended to patients with HS. Military servicemembers (SMs) with certain conditions, such as polycystic ovary syndrome, pseudofolliculitis barbae, and HS, are eligible for laser hair removal when available at local military treatment facilities. Primary care providers for military SMs must have a working understanding of the disease process of HS and awareness of what resources are available for treatment, which allows for more streamlined care and improved outcomes.

Treatment Options
Treatment options are diverse and depend on the severity of HS. Typically, treatment begins with medical therapy followed by escalation to surgical intervention. Medical therapies often include antibiotics, acne treatments, antiandrogen therapy, immunosuppressive agents, and biologic therapy.^15,16 If first-line medical interventions fail to control HS, surgical interventions should be considered. Surgical intervention in conjunction with medical therapy decreases the chance for recurrence.^3,15,16

Although HS is internationally recognized as an inflammatory disease and not an infectious process, topical antibiotics can help to prevent and improve formation of abscesses, nodules, and pustules.¹¹ Agents such as clindamycin and chlorhexidine wash have proven effective in preventing flares.^11,16 Other antibiotics used alone or in combination also are efficacious. Tetracyclines are recommended as monotherapy for mild stages of HS.^17-19 Doxycycline is the most commonly used tetracycline in HS patients and has been demonstrated to penetrate Staphylococcus aureus biofilm in high enough concentrations to maintain its antibacterial activity.²⁰ Moreover, doxycycline, as with other tetracyclines, has a multitude of anti-inflammatory and immunomodulatory properties²¹ and can reduce the production of IL-1, IL-6, tumor necrosis factor α, and IL-8; downregulate chemotaxis; and promote lipo-oxygenase, matrix metalloproteinase, and nuclear factor κB (NF-κB) signaling inhibition.¹⁷

Clindamycin is the only known agent that has been studied for topical treatment and utilization in milder cases of HS.^17,22 Systemic combination of clindamycin and rifampicin is the most studied, with well-established efficacy in managing HS.^17,23,24 Clindamycin has bacteriostatic activity toward both aerobic and anaerobic gram-positive bacteria by binding irreversibly to the 50S ribosomal subunit, thereby inhibiting bacterial protein synthesis. Rifampicin binds to the beta subunit of DNA-dependent RNA polymerase, inhibiting bacterial DNA-dependent RNA synthesis. Rifampicin has broad-spectrum activity, mostly against gram-positive as well as some gram-negative bacteria. Moreover, rifampicin has anti-inflammatory and immunomodulatory properties, including evidence that it inhibits excessive helper T cell (T_H17) responses by reducing inducible nitric oxide synthase transcription and NF-κB activity.^25,26

Metronidazole, moxifloxacin, and rifampicin as triple combination therapy has been shown to be effective in reducing HS activity in moderate to severe cases that were refractory to other treatments.²⁷ Research suggests that moxifloxacin has anti-inflammatory properties, mainly by reducing IL-1β, IL-8, and tumor necrosis factor α; stabilizing IXb protein; suppressing NF-κB signaling; and reducing IL-17A.^28,29

Ertapenem can be utilized as a single 6-week antibiotic course during surgical planning or rescue therapy.¹⁸ Moreover, ertapenem can be used to treat complicated skin and soft tissue infections and has been shown to substantially improve clinical aspects of severe HS.^17,27

Disease-modifying antirheumatic drugs are effective in the treatment of moderate to severe HS.^17-19 In 2 phase 3 trials (PIONEER I and II), adalimumab was used as monotherapy or in conjunction with antibiotics in patients with moderate to severe HS compared to placebo.³⁰ Results demonstrated a disease burden reduction of greater than 50%. Antibiotic dual therapy was not noted to significantly affect disease burden.³⁰ Of note, use of immunosuppressants in the military affects an SM’s availability for worldwide deployment and duty station assignment.

Antiandrogen therapies have demonstrated some reduction in HS flares. Although recommendations for use in HS is based on limited evidence, one randomized controlled trial compared ethinyl estradiol–norgestrel to ethinyl estradiol and cyproterone acetate. Both therapies resulted in similar efficacy, with 12 of 24 (50%) patients reporting HS symptoms improving or completely resolved.³¹ In another retrospective study of women treated with antiandrogen therapies, including ethinyl estriol, cyproterone acetate, and spironolactone, 16 of 29 (55%) patients reported improvement.³² In another study, daily doses of 100 to 150 mg of spironolactone resulted in improvement in 17 of 20 (85%) patients, including complete remission in 11 of 20 (55%) patients. Of the 3 patients with severe HS, none had complete clearing of disease burden.³³ Patients with polycystic ovary syndrome or HS flares that occur around menstruation are more likely to benefit from treatment with spironolactone.^18,32,34

Retinoids frequently have been utilized in the management of HS. In some retrospective studies and other prospective studies with 5 or more patients, isotretinoin monotherapy was utilized for a 4- to 10-month period.^18,35-38 In the Alikhan et al¹⁸ study, 85 of 207 patients demonstrated improvement of HS symptoms, with more remarkable improvements in milder cases. Isotretinoin for management of patients with HS who have concomitant nodulocystic acne would have two-fold benefits.¹⁸

Wound Care
Given the purulent nodular formation in HS, adequate wound care management is vital. There is an abundance of HS wound care management strategies utilized by clinicians and patients. When selecting the appropriate dressing, consideration for the type of HS wound, cost, ease of application, patient comfort, absorbency, and odor management is important.³ However, living arrangements for military SMs can create difficulties applying and maintaining HS dressings, especially if deployed or in a field setting. Active-duty SMs often find themselves in austere living conditions in the field, aboard ships, or in other scenarios where they may or may not have running water or showers. Maintaining adequate hygiene may be difficult, and additional education about how to keep wounds clean must be imparted. Ideal dressings for HS should be highly absorbent, comfortable when applied to the anatomic locations of the HS lesions, and easily self-applied. Ideally, dressings would have atraumatic adhesion and antimicrobial properties.³ Cost-effective dressing options that have good absorption capability include sanitary napkins, adult briefs, infant diapers, and gauze.³ These dressings help to wick moisture, thus protecting the wound from maceration, which is a common patient concern. Although gauze dressings are easier to obtain, they are not as absorbent. Abdominal pads can be utilized, but they are moderately absorbent, bulky, and more challenging to obtain over-the-counter. Hydrofiber and calcium alginate dressings with silver are not accessible to the common consumer and are more expensive than the aforementioned dressings, but they do have some antimicrobial activity. Silver-impregnated foam dressings are moldable to intertriginous areas, easy to self-apply, and have moderate-heavy absorption abilities.

Final Thoughts

Hidradenitis suppurativa poses cumbersome and uncomfortable symptoms for all patients and may pose additional hardships for military SMs or those with physically demanding occupations who work in austere environments. Severe HS can restrict a military SM from certain duty stations, positions, or deployments. Early identification of HS can help reduce HS flares, disfigurement, and placement on limited duty status, therefore rendering the SM more able to engage in his/her operational responsibilities. Hidradenitis suppurativa should be discussed with the patient, with the goal to prevent flares for SMs that will be in the field, placed in austere environments, or be deployed. Use of immunosuppressants in active-duty SMs may affect their deployability, duty assignment, and retention.

For a military SM with HS, all aspects of prevention and treatment need to be balanced with his/her ability to remain deployable and complete his/her daily duties. Military SMs are not guaranteed the ideal scenario for treatment and prevention of HS. Unsanitary environments and occlusive uniforms undoubtedly contribute to disease process and make treatment more challenging. If a military SM is in a field setting or deployed, frequent daily dressing changes should still be attempted.

Case Report

A 19-year-old female marine with a 10-year history of hidradenitis suppurativa (HS) presented with hyperpigmented nodules in the inguinal folds and a recurrent cyst in the right groin area of 2 to 3 weeks’ duration. She denied axillary or inframammary involvement. She underwent several incision and drainage procedures 1 year prior to her enlistment in the US Marine Corps at 18 years of age. She previously had been treated by dermatology with doxycycline 100-mg tablets twice daily, benzoyl peroxide wash 5% applied to affected areas and rinsed daily, and clindamycin solution 1% with minimal improvement. She denied smoking or alcohol intake and said she typically wore a loose-fitting uniform to work. As a marine, she was expected to participate in daily physical training and exercises with her military unit, during which she wore a standardized physical training uniform, including nylon shorts and a cotton T-shirt. She requested light duty—military duty status with physical limitations or restrictions—to avoid physical training that would cause further friction and irritation to the inguinal region.

Physical examination demonstrated a woman with Fitzpatrick skin type III and normal body mass index. There were hyperpigmented nodules and scarring in the inguinal folds, most consistent with Hurley stage 2. A single, 0.5-cm, draining lesion was visualized. No hyperhidrosis was noted. The patient was placed on light duty for 7 days, with physical training only at her own pace and discretion. Moreover, she was restricted from field training, rifle range training, and other situations where she may excessively sweat or not be able to adequately maintain personal hygiene. She was encouraged to continue clindamycin solution 1% to the affected area twice daily and was prescribed chlorhexidine solution 4% to use when washing affected areas in the shower. The patient also was referred to the dermatology department at the Naval Hospital Camp Pendleton (Oceanside, California), where she was treated with laser hair removal in the inguinal region, thus avoiding waxing and further aggravation of HS flares. Due to the combination of topical therapies along with laser hair removal and duty restrictions, the patient had a dramatic decrease in development of severe nodular lesions.

Comment

Presentation
Historically, the incidence of HS is estimated at 0.5% to 4% of the general population with female predominance.¹ Predisposing factors include obesity, smoking, genetic predisposition to acne, apocrine duct obstruction, and secondary bacterial infection.² During acute flares, patients generally present with tender subcutaneous nodules that drain malodorous purulent material.^3,4 Acute flares are unpredictable, and patients deal with chronic, recurrent, draining wounds, leading to a poor quality of life with resulting physical, psychological, financial, social, and emotional distress.^3-5 The negative impact of HS on a patient’s quality of life has been reported to be greater than other dermatologic conditions.⁶ Lesions can be particularly painful and can cause disfiguration to the surface of the skin.⁷ Lesion severity is described using the Hurley staging system. Patient quality of life is directly correlated with disease severity and Hurley stage. In stage 1, abscesses develop, but no sinus tracts or cicatrization is present. In stage 2, recurrent abscesses will form tracts and cicatrization. In stage 3, the abscesses become diffuse or near diffuse, with multiple interconnected tracts and abscesses across the entire area of the body.^8,9

Severe or refractory HS within the physically active military population may require consideration of light or limited duty or even separation from service. Similarly, severe HS may pose challenges with other physically demanding occupations, such as the police force and firefighters.

Prevention Focus
Prevention of flares is key for patients with HS; secondary prevention aims to reduce impact of the disease or injury that has already occurred,^10,11 which includes prevention of the infundibulofolliculitis from becoming a deep folliculitis, nodule, or fistula, as well as Hurley stage progression. Prompt diagnosis with appropriate treatment can decrease the severity of lesions, pain, and scarring. Globally, HS patients continue to experience considerable diagnostic delays of 8 to 12 years after onset of initial symptoms.^11,12 Earlier accurate diagnosis and initiation of treatment from the primary care provider or general medical officer is imperative. Initial accurate management may help keep symptoms from progressing to more severe painful lesions. Similarly, patients should be educated on how to prevent HS flares. Patients should avoid known triggers, including smoking, obesity, sweating, mechanical irritation, stress, and poor hygiene.¹¹

Shaving for hair reduction creates ingrown hair shafts, which may lead to folliculitis in mechanically stressed areas in skin folds, thus initiating the inflammatory cascade of HS.^11,13 Therefore, shaving along with any other mechanical stress should be avoided in patients with HS. Laser hair removal has been shown to be quite helpful in both the prevention and treatment of HS. In one study, 22 patients with Hurley stage 2 to 3 disease were treated with an Nd:YAG laser once monthly. Results demonstrated a 65% decrease in disease severity after 3 monthly treatments.¹¹ Similarly, other lasers have been used with success in several small case series; an 800-nm diode laser, intense pulsed light therapy, and a ruby laser have each demonstrated efficacy.¹⁴ Given these results, hair removal should be recommended to patients with HS. Military servicemembers (SMs) with certain conditions, such as polycystic ovary syndrome, pseudofolliculitis barbae, and HS, are eligible for laser hair removal when available at local military treatment facilities. Primary care providers for military SMs must have a working understanding of the disease process of HS and awareness of what resources are available for treatment, which allows for more streamlined care and improved outcomes.

Treatment Options
Treatment options are diverse and depend on the severity of HS. Typically, treatment begins with medical therapy followed by escalation to surgical intervention. Medical therapies often include antibiotics, acne treatments, antiandrogen therapy, immunosuppressive agents, and biologic therapy.^15,16 If first-line medical interventions fail to control HS, surgical interventions should be considered. Surgical intervention in conjunction with medical therapy decreases the chance for recurrence.^3,15,16

Although HS is internationally recognized as an inflammatory disease and not an infectious process, topical antibiotics can help to prevent and improve formation of abscesses, nodules, and pustules.¹¹ Agents such as clindamycin and chlorhexidine wash have proven effective in preventing flares.^11,16 Other antibiotics used alone or in combination also are efficacious. Tetracyclines are recommended as monotherapy for mild stages of HS.^17-19 Doxycycline is the most commonly used tetracycline in HS patients and has been demonstrated to penetrate Staphylococcus aureus biofilm in high enough concentrations to maintain its antibacterial activity.²⁰ Moreover, doxycycline, as with other tetracyclines, has a multitude of anti-inflammatory and immunomodulatory properties²¹ and can reduce the production of IL-1, IL-6, tumor necrosis factor α, and IL-8; downregulate chemotaxis; and promote lipo-oxygenase, matrix metalloproteinase, and nuclear factor κB (NF-κB) signaling inhibition.¹⁷

Clindamycin is the only known agent that has been studied for topical treatment and utilization in milder cases of HS.^17,22 Systemic combination of clindamycin and rifampicin is the most studied, with well-established efficacy in managing HS.^17,23,24 Clindamycin has bacteriostatic activity toward both aerobic and anaerobic gram-positive bacteria by binding irreversibly to the 50S ribosomal subunit, thereby inhibiting bacterial protein synthesis. Rifampicin binds to the beta subunit of DNA-dependent RNA polymerase, inhibiting bacterial DNA-dependent RNA synthesis. Rifampicin has broad-spectrum activity, mostly against gram-positive as well as some gram-negative bacteria. Moreover, rifampicin has anti-inflammatory and immunomodulatory properties, including evidence that it inhibits excessive helper T cell (T_H17) responses by reducing inducible nitric oxide synthase transcription and NF-κB activity.^25,26

Metronidazole, moxifloxacin, and rifampicin as triple combination therapy has been shown to be effective in reducing HS activity in moderate to severe cases that were refractory to other treatments.²⁷ Research suggests that moxifloxacin has anti-inflammatory properties, mainly by reducing IL-1β, IL-8, and tumor necrosis factor α; stabilizing IXb protein; suppressing NF-κB signaling; and reducing IL-17A.^28,29

Ertapenem can be utilized as a single 6-week antibiotic course during surgical planning or rescue therapy.¹⁸ Moreover, ertapenem can be used to treat complicated skin and soft tissue infections and has been shown to substantially improve clinical aspects of severe HS.^17,27

Disease-modifying antirheumatic drugs are effective in the treatment of moderate to severe HS.^17-19 In 2 phase 3 trials (PIONEER I and II), adalimumab was used as monotherapy or in conjunction with antibiotics in patients with moderate to severe HS compared to placebo.³⁰ Results demonstrated a disease burden reduction of greater than 50%. Antibiotic dual therapy was not noted to significantly affect disease burden.³⁰ Of note, use of immunosuppressants in the military affects an SM’s availability for worldwide deployment and duty station assignment.

Antiandrogen therapies have demonstrated some reduction in HS flares. Although recommendations for use in HS is based on limited evidence, one randomized controlled trial compared ethinyl estradiol–norgestrel to ethinyl estradiol and cyproterone acetate. Both therapies resulted in similar efficacy, with 12 of 24 (50%) patients reporting HS symptoms improving or completely resolved.³¹ In another retrospective study of women treated with antiandrogen therapies, including ethinyl estriol, cyproterone acetate, and spironolactone, 16 of 29 (55%) patients reported improvement.³² In another study, daily doses of 100 to 150 mg of spironolactone resulted in improvement in 17 of 20 (85%) patients, including complete remission in 11 of 20 (55%) patients. Of the 3 patients with severe HS, none had complete clearing of disease burden.³³ Patients with polycystic ovary syndrome or HS flares that occur around menstruation are more likely to benefit from treatment with spironolactone.^18,32,34

Retinoids frequently have been utilized in the management of HS. In some retrospective studies and other prospective studies with 5 or more patients, isotretinoin monotherapy was utilized for a 4- to 10-month period.^18,35-38 In the Alikhan et al¹⁸ study, 85 of 207 patients demonstrated improvement of HS symptoms, with more remarkable improvements in milder cases. Isotretinoin for management of patients with HS who have concomitant nodulocystic acne would have two-fold benefits.¹⁸

Wound Care
Given the purulent nodular formation in HS, adequate wound care management is vital. There is an abundance of HS wound care management strategies utilized by clinicians and patients. When selecting the appropriate dressing, consideration for the type of HS wound, cost, ease of application, patient comfort, absorbency, and odor management is important.³ However, living arrangements for military SMs can create difficulties applying and maintaining HS dressings, especially if deployed or in a field setting. Active-duty SMs often find themselves in austere living conditions in the field, aboard ships, or in other scenarios where they may or may not have running water or showers. Maintaining adequate hygiene may be difficult, and additional education about how to keep wounds clean must be imparted. Ideal dressings for HS should be highly absorbent, comfortable when applied to the anatomic locations of the HS lesions, and easily self-applied. Ideally, dressings would have atraumatic adhesion and antimicrobial properties.³ Cost-effective dressing options that have good absorption capability include sanitary napkins, adult briefs, infant diapers, and gauze.³ These dressings help to wick moisture, thus protecting the wound from maceration, which is a common patient concern. Although gauze dressings are easier to obtain, they are not as absorbent. Abdominal pads can be utilized, but they are moderately absorbent, bulky, and more challenging to obtain over-the-counter. Hydrofiber and calcium alginate dressings with silver are not accessible to the common consumer and are more expensive than the aforementioned dressings, but they do have some antimicrobial activity. Silver-impregnated foam dressings are moldable to intertriginous areas, easy to self-apply, and have moderate-heavy absorption abilities.

Final Thoughts

Hidradenitis suppurativa poses cumbersome and uncomfortable symptoms for all patients and may pose additional hardships for military SMs or those with physically demanding occupations who work in austere environments. Severe HS can restrict a military SM from certain duty stations, positions, or deployments. Early identification of HS can help reduce HS flares, disfigurement, and placement on limited duty status, therefore rendering the SM more able to engage in his/her operational responsibilities. Hidradenitis suppurativa should be discussed with the patient, with the goal to prevent flares for SMs that will be in the field, placed in austere environments, or be deployed. Use of immunosuppressants in active-duty SMs may affect their deployability, duty assignment, and retention.

For a military SM with HS, all aspects of prevention and treatment need to be balanced with his/her ability to remain deployable and complete his/her daily duties. Military SMs are not guaranteed the ideal scenario for treatment and prevention of HS. Unsanitary environments and occlusive uniforms undoubtedly contribute to disease process and make treatment more challenging. If a military SM is in a field setting or deployed, frequent daily dressing changes should still be attempted.

Case Report

A 19-year-old female marine with a 10-year history of hidradenitis suppurativa (HS) presented with hyperpigmented nodules in the inguinal folds and a recurrent cyst in the right groin area of 2 to 3 weeks’ duration. She denied axillary or inframammary involvement. She underwent several incision and drainage procedures 1 year prior to her enlistment in the US Marine Corps at 18 years of age. She previously had been treated by dermatology with doxycycline 100-mg tablets twice daily, benzoyl peroxide wash 5% applied to affected areas and rinsed daily, and clindamycin solution 1% with minimal improvement. She denied smoking or alcohol intake and said she typically wore a loose-fitting uniform to work. As a marine, she was expected to participate in daily physical training and exercises with her military unit, during which she wore a standardized physical training uniform, including nylon shorts and a cotton T-shirt. She requested light duty—military duty status with physical limitations or restrictions—to avoid physical training that would cause further friction and irritation to the inguinal region.

Physical examination demonstrated a woman with Fitzpatrick skin type III and normal body mass index. There were hyperpigmented nodules and scarring in the inguinal folds, most consistent with Hurley stage 2. A single, 0.5-cm, draining lesion was visualized. No hyperhidrosis was noted. The patient was placed on light duty for 7 days, with physical training only at her own pace and discretion. Moreover, she was restricted from field training, rifle range training, and other situations where she may excessively sweat or not be able to adequately maintain personal hygiene. She was encouraged to continue clindamycin solution 1% to the affected area twice daily and was prescribed chlorhexidine solution 4% to use when washing affected areas in the shower. The patient also was referred to the dermatology department at the Naval Hospital Camp Pendleton (Oceanside, California), where she was treated with laser hair removal in the inguinal region, thus avoiding waxing and further aggravation of HS flares. Due to the combination of topical therapies along with laser hair removal and duty restrictions, the patient had a dramatic decrease in development of severe nodular lesions.

Comment

Presentation
Historically, the incidence of HS is estimated at 0.5% to 4% of the general population with female predominance.¹ Predisposing factors include obesity, smoking, genetic predisposition to acne, apocrine duct obstruction, and secondary bacterial infection.² During acute flares, patients generally present with tender subcutaneous nodules that drain malodorous purulent material.^3,4 Acute flares are unpredictable, and patients deal with chronic, recurrent, draining wounds, leading to a poor quality of life with resulting physical, psychological, financial, social, and emotional distress.^3-5 The negative impact of HS on a patient’s quality of life has been reported to be greater than other dermatologic conditions.⁶ Lesions can be particularly painful and can cause disfiguration to the surface of the skin.⁷ Lesion severity is described using the Hurley staging system. Patient quality of life is directly correlated with disease severity and Hurley stage. In stage 1, abscesses develop, but no sinus tracts or cicatrization is present. In stage 2, recurrent abscesses will form tracts and cicatrization. In stage 3, the abscesses become diffuse or near diffuse, with multiple interconnected tracts and abscesses across the entire area of the body.^8,9

Severe or refractory HS within the physically active military population may require consideration of light or limited duty or even separation from service. Similarly, severe HS may pose challenges with other physically demanding occupations, such as the police force and firefighters.

Prevention Focus
Prevention of flares is key for patients with HS; secondary prevention aims to reduce impact of the disease or injury that has already occurred,^10,11 which includes prevention of the infundibulofolliculitis from becoming a deep folliculitis, nodule, or fistula, as well as Hurley stage progression. Prompt diagnosis with appropriate treatment can decrease the severity of lesions, pain, and scarring. Globally, HS patients continue to experience considerable diagnostic delays of 8 to 12 years after onset of initial symptoms.^11,12 Earlier accurate diagnosis and initiation of treatment from the primary care provider or general medical officer is imperative. Initial accurate management may help keep symptoms from progressing to more severe painful lesions. Similarly, patients should be educated on how to prevent HS flares. Patients should avoid known triggers, including smoking, obesity, sweating, mechanical irritation, stress, and poor hygiene.¹¹

Shaving for hair reduction creates ingrown hair shafts, which may lead to folliculitis in mechanically stressed areas in skin folds, thus initiating the inflammatory cascade of HS.^11,13 Therefore, shaving along with any other mechanical stress should be avoided in patients with HS. Laser hair removal has been shown to be quite helpful in both the prevention and treatment of HS. In one study, 22 patients with Hurley stage 2 to 3 disease were treated with an Nd:YAG laser once monthly. Results demonstrated a 65% decrease in disease severity after 3 monthly treatments.¹¹ Similarly, other lasers have been used with success in several small case series; an 800-nm diode laser, intense pulsed light therapy, and a ruby laser have each demonstrated efficacy.¹⁴ Given these results, hair removal should be recommended to patients with HS. Military servicemembers (SMs) with certain conditions, such as polycystic ovary syndrome, pseudofolliculitis barbae, and HS, are eligible for laser hair removal when available at local military treatment facilities. Primary care providers for military SMs must have a working understanding of the disease process of HS and awareness of what resources are available for treatment, which allows for more streamlined care and improved outcomes.

Treatment Options
Treatment options are diverse and depend on the severity of HS. Typically, treatment begins with medical therapy followed by escalation to surgical intervention. Medical therapies often include antibiotics, acne treatments, antiandrogen therapy, immunosuppressive agents, and biologic therapy.^15,16 If first-line medical interventions fail to control HS, surgical interventions should be considered. Surgical intervention in conjunction with medical therapy decreases the chance for recurrence.^3,15,16

Although HS is internationally recognized as an inflammatory disease and not an infectious process, topical antibiotics can help to prevent and improve formation of abscesses, nodules, and pustules.¹¹ Agents such as clindamycin and chlorhexidine wash have proven effective in preventing flares.^11,16 Other antibiotics used alone or in combination also are efficacious. Tetracyclines are recommended as monotherapy for mild stages of HS.^17-19 Doxycycline is the most commonly used tetracycline in HS patients and has been demonstrated to penetrate Staphylococcus aureus biofilm in high enough concentrations to maintain its antibacterial activity.²⁰ Moreover, doxycycline, as with other tetracyclines, has a multitude of anti-inflammatory and immunomodulatory properties²¹ and can reduce the production of IL-1, IL-6, tumor necrosis factor α, and IL-8; downregulate chemotaxis; and promote lipo-oxygenase, matrix metalloproteinase, and nuclear factor κB (NF-κB) signaling inhibition.¹⁷

Clindamycin is the only known agent that has been studied for topical treatment and utilization in milder cases of HS.^17,22 Systemic combination of clindamycin and rifampicin is the most studied, with well-established efficacy in managing HS.^17,23,24 Clindamycin has bacteriostatic activity toward both aerobic and anaerobic gram-positive bacteria by binding irreversibly to the 50S ribosomal subunit, thereby inhibiting bacterial protein synthesis. Rifampicin binds to the beta subunit of DNA-dependent RNA polymerase, inhibiting bacterial DNA-dependent RNA synthesis. Rifampicin has broad-spectrum activity, mostly against gram-positive as well as some gram-negative bacteria. Moreover, rifampicin has anti-inflammatory and immunomodulatory properties, including evidence that it inhibits excessive helper T cell (T_H17) responses by reducing inducible nitric oxide synthase transcription and NF-κB activity.^25,26

Metronidazole, moxifloxacin, and rifampicin as triple combination therapy has been shown to be effective in reducing HS activity in moderate to severe cases that were refractory to other treatments.²⁷ Research suggests that moxifloxacin has anti-inflammatory properties, mainly by reducing IL-1β, IL-8, and tumor necrosis factor α; stabilizing IXb protein; suppressing NF-κB signaling; and reducing IL-17A.^28,29

Ertapenem can be utilized as a single 6-week antibiotic course during surgical planning or rescue therapy.¹⁸ Moreover, ertapenem can be used to treat complicated skin and soft tissue infections and has been shown to substantially improve clinical aspects of severe HS.^17,27

Disease-modifying antirheumatic drugs are effective in the treatment of moderate to severe HS.^17-19 In 2 phase 3 trials (PIONEER I and II), adalimumab was used as monotherapy or in conjunction with antibiotics in patients with moderate to severe HS compared to placebo.³⁰ Results demonstrated a disease burden reduction of greater than 50%. Antibiotic dual therapy was not noted to significantly affect disease burden.³⁰ Of note, use of immunosuppressants in the military affects an SM’s availability for worldwide deployment and duty station assignment.

Antiandrogen therapies have demonstrated some reduction in HS flares. Although recommendations for use in HS is based on limited evidence, one randomized controlled trial compared ethinyl estradiol–norgestrel to ethinyl estradiol and cyproterone acetate. Both therapies resulted in similar efficacy, with 12 of 24 (50%) patients reporting HS symptoms improving or completely resolved.³¹ In another retrospective study of women treated with antiandrogen therapies, including ethinyl estriol, cyproterone acetate, and spironolactone, 16 of 29 (55%) patients reported improvement.³² In another study, daily doses of 100 to 150 mg of spironolactone resulted in improvement in 17 of 20 (85%) patients, including complete remission in 11 of 20 (55%) patients. Of the 3 patients with severe HS, none had complete clearing of disease burden.³³ Patients with polycystic ovary syndrome or HS flares that occur around menstruation are more likely to benefit from treatment with spironolactone.^18,32,34

Retinoids frequently have been utilized in the management of HS. In some retrospective studies and other prospective studies with 5 or more patients, isotretinoin monotherapy was utilized for a 4- to 10-month period.^18,35-38 In the Alikhan et al¹⁸ study, 85 of 207 patients demonstrated improvement of HS symptoms, with more remarkable improvements in milder cases. Isotretinoin for management of patients with HS who have concomitant nodulocystic acne would have two-fold benefits.¹⁸

Wound Care
Given the purulent nodular formation in HS, adequate wound care management is vital. There is an abundance of HS wound care management strategies utilized by clinicians and patients. When selecting the appropriate dressing, consideration for the type of HS wound, cost, ease of application, patient comfort, absorbency, and odor management is important.³ However, living arrangements for military SMs can create difficulties applying and maintaining HS dressings, especially if deployed or in a field setting. Active-duty SMs often find themselves in austere living conditions in the field, aboard ships, or in other scenarios where they may or may not have running water or showers. Maintaining adequate hygiene may be difficult, and additional education about how to keep wounds clean must be imparted. Ideal dressings for HS should be highly absorbent, comfortable when applied to the anatomic locations of the HS lesions, and easily self-applied. Ideally, dressings would have atraumatic adhesion and antimicrobial properties.³ Cost-effective dressing options that have good absorption capability include sanitary napkins, adult briefs, infant diapers, and gauze.³ These dressings help to wick moisture, thus protecting the wound from maceration, which is a common patient concern. Although gauze dressings are easier to obtain, they are not as absorbent. Abdominal pads can be utilized, but they are moderately absorbent, bulky, and more challenging to obtain over-the-counter. Hydrofiber and calcium alginate dressings with silver are not accessible to the common consumer and are more expensive than the aforementioned dressings, but they do have some antimicrobial activity. Silver-impregnated foam dressings are moldable to intertriginous areas, easy to self-apply, and have moderate-heavy absorption abilities.

Final Thoughts

Hidradenitis suppurativa poses cumbersome and uncomfortable symptoms for all patients and may pose additional hardships for military SMs or those with physically demanding occupations who work in austere environments. Severe HS can restrict a military SM from certain duty stations, positions, or deployments. Early identification of HS can help reduce HS flares, disfigurement, and placement on limited duty status, therefore rendering the SM more able to engage in his/her operational responsibilities. Hidradenitis suppurativa should be discussed with the patient, with the goal to prevent flares for SMs that will be in the field, placed in austere environments, or be deployed. Use of immunosuppressants in active-duty SMs may affect their deployability, duty assignment, and retention.

For a military SM with HS, all aspects of prevention and treatment need to be balanced with his/her ability to remain deployable and complete his/her daily duties. Military SMs are not guaranteed the ideal scenario for treatment and prevention of HS. Unsanitary environments and occlusive uniforms undoubtedly contribute to disease process and make treatment more challenging. If a military SM is in a field setting or deployed, frequent daily dressing changes should still be attempted.

Acne treatment presents unique challenges in the active-duty military population. Lesions on the face may interfere with proper fit and seal of protective masks and helmets, while those involving the shoulders or back may cause considerable discomfort beneath safety restraints, parachute harnesses, or flak jackets. Therefore, untreated acne may limit servicemembers from performing their assigned duties. Treatments themselves also may be limiting; for instance, aircrew members who are taking oral doxycycline, tetracycline, or erythromycin may be grounded (ie, temporarily removed from duty) during and after therapy to monitor for side effects. Minocycline is considered unacceptable for aviators and is completely restricted for use due to risk for central nervous system side effects. Isotretinoin is restricted in aircrew members, submariners, and divers. If initiated, isotretinoin requires grounding for the entire duration of therapy and up to 3 months following treatment. Normalization of triglyceride levels and slit-lamp ocular examination also must take place prior to return to full duty, which may lead to additional grounding time. Well-established topical and oral treatments not impacting military duty are omitted from this review.

Antibiotics

Minocycline
Minocycline carries a small risk for development of systemic lupus erythematosus and other autoimmune treatment-emergent adverse effects. It has known gastrointestinal tract side effects, and long-term use also can lead to bluish discoloration of the skin.¹ Systemic minocycline is restricted in aircrew members due to its risk for central nervous system side effects, including light-headedness, dizziness, and vertigo.^2-5

A topical formulation of minocycline recently was developed and approved by the US Food and Drug Administration as a means to reduce systemic adverse effects. This 4% minocycline foam has thus far been safe and well tolerated, with adverse events reported in less than 1% of study participants.^1,6 In addition, topical minocycline was shown in a recent phase 3 study to notably reduce inflammatory lesion counts when compared to control vehicles at as early as 3 weeks.⁷ Topical minocycline may emerge as a viable treatment option for active-duty servicemembers in the future.

Doxycycline
Doxycycline is not medically disqualifying. Even so, it may still necessitate grounding for a period of time while monitoring for side effects.⁴ Doxycycline can lead to photosensitivity, which could be difficult to tolerate for active-duty personnel training in sunny climates. Fortunately, uniform regulations and personal protective equipment requirements provide cover for most of the body surfaces aside from the face, which is protected by various forms of covers. If the patient tolerates the medication well without considerable side effects, he/she may be returned to full duty, making doxycycline an acceptable alternative to minocycline in the military population.

Sarecycline
This novel compound is a tetracycline-class antibiotic with a narrower spectrum of activity, with reduced activity against enteric gram-negative bacteria. It has shown efficacy in reducing inflammatory and noninflammatory acne lesions, including lesions on the face, back, and chest. Common adverse side effects are nausea, headache, nasopharyngitis, and vomiting. Vestibular and phototoxic adverse effects were reported in less than 1% of patients.^1,8 The US Food and Drug Administration approved sarecycline as a once-daily oral formulation for moderate to severe acne vulgaris, the first new antibiotic to be approved for the disease in the last 40 years. Sarecycline is not mentioned in any US military guidelines with regard to medical readiness and duty status; however, given its lack of vestibular side effects and narrower activity spectrum, it may become another acceptable treatment option in the military population.

Isotretinoin

Isotretinoin is well established as an excellent treatment of acne and stands alone as the only currently available medication that alters the disease course and prevents relapse in many patients. Nearly all patients on isotretinoin experience considerable mucocutaneous dryness, and up to 25% of patients on high-dose isotretinoin develop myalgia.⁹ Isotretinoin causes serious retinoid embryopathy, requiring all patients to be enrolled in the iPLEDGE program (https://www.ipledgeprogram.com/iPledgeUI/home.u) and to use 2 methods of contraception during treatment. Although it is uncommon to have notable elevations in lipids and transaminases during treatment with isotretinoin, routine laboratory monitoring generally is performed until the patient reaches steady dosing.

Isotretinoin is not permitted for use in active aircrew members, submariners, or divers. Servicemembers pursuing isotretinoin therapy are removed from their duty and are nondeployable for the entirety of their treatment course and several months after completion.^4,5

Photodynamic Therapy

Aminolevulinic acid and photodynamic therapy (ALA-PDT) has been successfully used in the management of acne.¹⁰ In addition to inducing selective damage to sebaceous glands, it has been proposed that PDT also destroys Propionibacterium acnes and reduces keratinocyte shedding and immunologic changes that play key roles in the development of acne.¹⁰

A recent randomized controlled trial comparing the efficacy of ALA-PDT vs adapalene gel plus oral doxycycline for treatment of moderate acne included 46 patients with moderate inflammatory acne.¹⁰ Twenty-three participants received 2 sessions (spaced 2 weeks apart) of 20% ALA incubated for 90 minutes before red light irradiation with a fluence of 37 J/cm², and the other 23 received 100 mg/d of oral doxycycline plus adapalene gel 0.1%. By 6-week follow-up, there was a significantly higher reduction in total lesions within the PDT group (P=.038), which was sustained at the secondary 12-week follow-up (P=.026). There was a 79% total reduction of lesions in the ALA-PDT group vs 67% in the doxycycline plus adapalene group.¹⁰

Although some studies have shown promise for PDT as an emerging treatment option for acne, further research is needed. A 2016 systematic review of the related literature determined that although 20% ALA-PDT with red light was more effective than lower concentrations of ALA and also more effective than ALA-PDT with blue light—which offered no additional benefit when compared with blue light alone—high-quality evidence on the use of PDT for acne is lacking overall.¹¹ At the time of the review, there was little certainty as to the usefulness of ALA-PDT with red or blue light as a standard treatment for individuals with moderate to severe acne. A 2019 review by Marson and Baldwin¹² echoed this sentiment, recommending more stringently designed studies to elucidate the true role of PDT as a monotherapy or adjunctive treatment of acne.

Pulsed Dye Laser

Pulsed dye laser (PDL) was first shown to be a potential therapy for acne by Seaton et al,¹³ who conducted a small-scale, randomized, controlled trial with 41 patients, each assigned to either a single PDL treatment or a sham treatment. Patients were re-evaluated at 12 weeks, measuring acne severity by the Leeds revised acne grading system and taking total lesion counts. Acne severity (P=.007) and total lesion counts (P=.023) were significantly improved in the treatment group, with a 53% reduction in total lesion count following a single PDL treatment.¹³

In 2007, a Spanish study described use of PDL every 4 weeks for a total of 12 weeks in 36 patients with mild to moderate acne. Using lesion counts as their primary outcome measure, the investigators found results similar to those from Seaton et al,¹³ with a 57% decrease in active lesions.¹⁴ Others still have found similar outcomes. A 2009 study of 45 patients with mild to moderate acne compared patients treated with PDL every 2 weeks for 12 weeks to patients receiving either topical therapy or chemical peels with 25% trichloroacetic acid. At 12 weeks, they noted the best results were in the PDL group.¹⁵

Karsai et al¹⁶ compared PDL as an adjuvant treatment of acne to proven treatment with clindamycin plus benzoyl peroxide gel. Eighty patients were randomized to topical therapy plus PDL or topical therapy alone and were followed at 2 and 4 weeks after the initial treatment. Although both groups showed improvement as measured by inflammatory lesion count and dermatology life quality index, there was no statistically significant difference noted between groups.¹⁶

Case Report

A 24-year-old active-duty male servicemember was referred to the dermatology department for evaluation of treatment-resistant nodulocystic scarring acne. Prior to his arrival to dermatology, he had completed 2 weeks of isotretinoin before discontinuation due to notable mood alteration. Following the isotretinoin, he was then switched to doxycycline 100 mg twice daily, which he trialed for 3 months. Even on the antibiotic, the patient continued to develop new pustules and cysts, prompting referral to dermatology for additional treatment options (Figure, A). All of the previous topical and oral medications had been discontinued at the current presentation.

The patient received 3 treatments with the 595-nm PDL (spot size, 10 mm; fluence, 7 J/cm²; pulse width, 6 milliseconds) spaced 4 weeks apart. At each treatment, fewer than 10 total inflammatory lesions were treated, including inflammatory papules, pustules, and nodules. Nodular lesions were treated with 2 pulses. After each treatment, the patient reported that all treated lesions resolved within 2 days (Figure, B). Subsequent treated lesions all occurred at previously uninvolved sites.

Final Thoughts

Antibiotic resistance is a known and growing problem throughout the medical community. In 2013, the US Centers for Disease Control and Prevention reported that dermatologists prescribe more antibiotics than any other specialty.¹⁷ Aside from antibiotic stewardship, systemic antibiotics come with various considerations when selecting ideal acne treatment regimens in military populations, as they are either medically disqualifying or lead to temporary grounding status. Numerous guidelines on acne have recommended limiting the use of antibiotics, instead pursuing alternative therapies such as spironolactone, oral contraceptives, or isotretinoin.^9,18 Both spironolactone and oral contraceptives work well via antiandrogenic and antisebogenic properties; however, these therapies are limited to female patients only, who make up a minority of patients in the active-duty military setting. Isotretinoin is highly effective in the treatment of acne, but it requires grounding for the entirety of treatment and for months afterward, which comes at great personal and financial costs to servicemembers and their commanders due to limited-duty status and inability to deploy.

Given the operational constraints with isotretinoin and the continual rise of antibiotic resistance, PDL appears to be a safe and effective alternative therapy for acne. In our case, the patient had complete resolution of active inflammatory lesions after each of his treatments. He had no adverse effects and tolerated the treatments well. We report this case here to highlight the use of PDL as an effective therapy for spot treatment in patients limited by personal or operational constraints and as a means to reduce antibiotic use in the face of a growing tide of antibiotic resistance.

Acne treatment presents unique challenges in the active-duty military population. Lesions on the face may interfere with proper fit and seal of protective masks and helmets, while those involving the shoulders or back may cause considerable discomfort beneath safety restraints, parachute harnesses, or flak jackets. Therefore, untreated acne may limit servicemembers from performing their assigned duties. Treatments themselves also may be limiting; for instance, aircrew members who are taking oral doxycycline, tetracycline, or erythromycin may be grounded (ie, temporarily removed from duty) during and after therapy to monitor for side effects. Minocycline is considered unacceptable for aviators and is completely restricted for use due to risk for central nervous system side effects. Isotretinoin is restricted in aircrew members, submariners, and divers. If initiated, isotretinoin requires grounding for the entire duration of therapy and up to 3 months following treatment. Normalization of triglyceride levels and slit-lamp ocular examination also must take place prior to return to full duty, which may lead to additional grounding time. Well-established topical and oral treatments not impacting military duty are omitted from this review.

Antibiotics

Minocycline
Minocycline carries a small risk for development of systemic lupus erythematosus and other autoimmune treatment-emergent adverse effects. It has known gastrointestinal tract side effects, and long-term use also can lead to bluish discoloration of the skin.¹ Systemic minocycline is restricted in aircrew members due to its risk for central nervous system side effects, including light-headedness, dizziness, and vertigo.^2-5

A topical formulation of minocycline recently was developed and approved by the US Food and Drug Administration as a means to reduce systemic adverse effects. This 4% minocycline foam has thus far been safe and well tolerated, with adverse events reported in less than 1% of study participants.^1,6 In addition, topical minocycline was shown in a recent phase 3 study to notably reduce inflammatory lesion counts when compared to control vehicles at as early as 3 weeks.⁷ Topical minocycline may emerge as a viable treatment option for active-duty servicemembers in the future.

Doxycycline
Doxycycline is not medically disqualifying. Even so, it may still necessitate grounding for a period of time while monitoring for side effects.⁴ Doxycycline can lead to photosensitivity, which could be difficult to tolerate for active-duty personnel training in sunny climates. Fortunately, uniform regulations and personal protective equipment requirements provide cover for most of the body surfaces aside from the face, which is protected by various forms of covers. If the patient tolerates the medication well without considerable side effects, he/she may be returned to full duty, making doxycycline an acceptable alternative to minocycline in the military population.

Sarecycline
This novel compound is a tetracycline-class antibiotic with a narrower spectrum of activity, with reduced activity against enteric gram-negative bacteria. It has shown efficacy in reducing inflammatory and noninflammatory acne lesions, including lesions on the face, back, and chest. Common adverse side effects are nausea, headache, nasopharyngitis, and vomiting. Vestibular and phototoxic adverse effects were reported in less than 1% of patients.^1,8 The US Food and Drug Administration approved sarecycline as a once-daily oral formulation for moderate to severe acne vulgaris, the first new antibiotic to be approved for the disease in the last 40 years. Sarecycline is not mentioned in any US military guidelines with regard to medical readiness and duty status; however, given its lack of vestibular side effects and narrower activity spectrum, it may become another acceptable treatment option in the military population.

Isotretinoin

Isotretinoin is well established as an excellent treatment of acne and stands alone as the only currently available medication that alters the disease course and prevents relapse in many patients. Nearly all patients on isotretinoin experience considerable mucocutaneous dryness, and up to 25% of patients on high-dose isotretinoin develop myalgia.⁹ Isotretinoin causes serious retinoid embryopathy, requiring all patients to be enrolled in the iPLEDGE program (https://www.ipledgeprogram.com/iPledgeUI/home.u) and to use 2 methods of contraception during treatment. Although it is uncommon to have notable elevations in lipids and transaminases during treatment with isotretinoin, routine laboratory monitoring generally is performed until the patient reaches steady dosing.

Isotretinoin is not permitted for use in active aircrew members, submariners, or divers. Servicemembers pursuing isotretinoin therapy are removed from their duty and are nondeployable for the entirety of their treatment course and several months after completion.^4,5

Photodynamic Therapy

Aminolevulinic acid and photodynamic therapy (ALA-PDT) has been successfully used in the management of acne.¹⁰ In addition to inducing selective damage to sebaceous glands, it has been proposed that PDT also destroys Propionibacterium acnes and reduces keratinocyte shedding and immunologic changes that play key roles in the development of acne.¹⁰

A recent randomized controlled trial comparing the efficacy of ALA-PDT vs adapalene gel plus oral doxycycline for treatment of moderate acne included 46 patients with moderate inflammatory acne.¹⁰ Twenty-three participants received 2 sessions (spaced 2 weeks apart) of 20% ALA incubated for 90 minutes before red light irradiation with a fluence of 37 J/cm², and the other 23 received 100 mg/d of oral doxycycline plus adapalene gel 0.1%. By 6-week follow-up, there was a significantly higher reduction in total lesions within the PDT group (P=.038), which was sustained at the secondary 12-week follow-up (P=.026). There was a 79% total reduction of lesions in the ALA-PDT group vs 67% in the doxycycline plus adapalene group.¹⁰

Although some studies have shown promise for PDT as an emerging treatment option for acne, further research is needed. A 2016 systematic review of the related literature determined that although 20% ALA-PDT with red light was more effective than lower concentrations of ALA and also more effective than ALA-PDT with blue light—which offered no additional benefit when compared with blue light alone—high-quality evidence on the use of PDT for acne is lacking overall.¹¹ At the time of the review, there was little certainty as to the usefulness of ALA-PDT with red or blue light as a standard treatment for individuals with moderate to severe acne. A 2019 review by Marson and Baldwin¹² echoed this sentiment, recommending more stringently designed studies to elucidate the true role of PDT as a monotherapy or adjunctive treatment of acne.

Pulsed Dye Laser

Pulsed dye laser (PDL) was first shown to be a potential therapy for acne by Seaton et al,¹³ who conducted a small-scale, randomized, controlled trial with 41 patients, each assigned to either a single PDL treatment or a sham treatment. Patients were re-evaluated at 12 weeks, measuring acne severity by the Leeds revised acne grading system and taking total lesion counts. Acne severity (P=.007) and total lesion counts (P=.023) were significantly improved in the treatment group, with a 53% reduction in total lesion count following a single PDL treatment.¹³

In 2007, a Spanish study described use of PDL every 4 weeks for a total of 12 weeks in 36 patients with mild to moderate acne. Using lesion counts as their primary outcome measure, the investigators found results similar to those from Seaton et al,¹³ with a 57% decrease in active lesions.¹⁴ Others still have found similar outcomes. A 2009 study of 45 patients with mild to moderate acne compared patients treated with PDL every 2 weeks for 12 weeks to patients receiving either topical therapy or chemical peels with 25% trichloroacetic acid. At 12 weeks, they noted the best results were in the PDL group.¹⁵

Karsai et al¹⁶ compared PDL as an adjuvant treatment of acne to proven treatment with clindamycin plus benzoyl peroxide gel. Eighty patients were randomized to topical therapy plus PDL or topical therapy alone and were followed at 2 and 4 weeks after the initial treatment. Although both groups showed improvement as measured by inflammatory lesion count and dermatology life quality index, there was no statistically significant difference noted between groups.¹⁶

Case Report

A 24-year-old active-duty male servicemember was referred to the dermatology department for evaluation of treatment-resistant nodulocystic scarring acne. Prior to his arrival to dermatology, he had completed 2 weeks of isotretinoin before discontinuation due to notable mood alteration. Following the isotretinoin, he was then switched to doxycycline 100 mg twice daily, which he trialed for 3 months. Even on the antibiotic, the patient continued to develop new pustules and cysts, prompting referral to dermatology for additional treatment options (Figure, A). All of the previous topical and oral medications had been discontinued at the current presentation.

The patient received 3 treatments with the 595-nm PDL (spot size, 10 mm; fluence, 7 J/cm²; pulse width, 6 milliseconds) spaced 4 weeks apart. At each treatment, fewer than 10 total inflammatory lesions were treated, including inflammatory papules, pustules, and nodules. Nodular lesions were treated with 2 pulses. After each treatment, the patient reported that all treated lesions resolved within 2 days (Figure, B). Subsequent treated lesions all occurred at previously uninvolved sites.

Final Thoughts

Antibiotic resistance is a known and growing problem throughout the medical community. In 2013, the US Centers for Disease Control and Prevention reported that dermatologists prescribe more antibiotics than any other specialty.¹⁷ Aside from antibiotic stewardship, systemic antibiotics come with various considerations when selecting ideal acne treatment regimens in military populations, as they are either medically disqualifying or lead to temporary grounding status. Numerous guidelines on acne have recommended limiting the use of antibiotics, instead pursuing alternative therapies such as spironolactone, oral contraceptives, or isotretinoin.^9,18 Both spironolactone and oral contraceptives work well via antiandrogenic and antisebogenic properties; however, these therapies are limited to female patients only, who make up a minority of patients in the active-duty military setting. Isotretinoin is highly effective in the treatment of acne, but it requires grounding for the entirety of treatment and for months afterward, which comes at great personal and financial costs to servicemembers and their commanders due to limited-duty status and inability to deploy.

Given the operational constraints with isotretinoin and the continual rise of antibiotic resistance, PDL appears to be a safe and effective alternative therapy for acne. In our case, the patient had complete resolution of active inflammatory lesions after each of his treatments. He had no adverse effects and tolerated the treatments well. We report this case here to highlight the use of PDL as an effective therapy for spot treatment in patients limited by personal or operational constraints and as a means to reduce antibiotic use in the face of a growing tide of antibiotic resistance.

Acne treatment presents unique challenges in the active-duty military population. Lesions on the face may interfere with proper fit and seal of protective masks and helmets, while those involving the shoulders or back may cause considerable discomfort beneath safety restraints, parachute harnesses, or flak jackets. Therefore, untreated acne may limit servicemembers from performing their assigned duties. Treatments themselves also may be limiting; for instance, aircrew members who are taking oral doxycycline, tetracycline, or erythromycin may be grounded (ie, temporarily removed from duty) during and after therapy to monitor for side effects. Minocycline is considered unacceptable for aviators and is completely restricted for use due to risk for central nervous system side effects. Isotretinoin is restricted in aircrew members, submariners, and divers. If initiated, isotretinoin requires grounding for the entire duration of therapy and up to 3 months following treatment. Normalization of triglyceride levels and slit-lamp ocular examination also must take place prior to return to full duty, which may lead to additional grounding time. Well-established topical and oral treatments not impacting military duty are omitted from this review.

Antibiotics

Minocycline
Minocycline carries a small risk for development of systemic lupus erythematosus and other autoimmune treatment-emergent adverse effects. It has known gastrointestinal tract side effects, and long-term use also can lead to bluish discoloration of the skin.¹ Systemic minocycline is restricted in aircrew members due to its risk for central nervous system side effects, including light-headedness, dizziness, and vertigo.^2-5

A topical formulation of minocycline recently was developed and approved by the US Food and Drug Administration as a means to reduce systemic adverse effects. This 4% minocycline foam has thus far been safe and well tolerated, with adverse events reported in less than 1% of study participants.^1,6 In addition, topical minocycline was shown in a recent phase 3 study to notably reduce inflammatory lesion counts when compared to control vehicles at as early as 3 weeks.⁷ Topical minocycline may emerge as a viable treatment option for active-duty servicemembers in the future.

Doxycycline
Doxycycline is not medically disqualifying. Even so, it may still necessitate grounding for a period of time while monitoring for side effects.⁴ Doxycycline can lead to photosensitivity, which could be difficult to tolerate for active-duty personnel training in sunny climates. Fortunately, uniform regulations and personal protective equipment requirements provide cover for most of the body surfaces aside from the face, which is protected by various forms of covers. If the patient tolerates the medication well without considerable side effects, he/she may be returned to full duty, making doxycycline an acceptable alternative to minocycline in the military population.

Sarecycline
This novel compound is a tetracycline-class antibiotic with a narrower spectrum of activity, with reduced activity against enteric gram-negative bacteria. It has shown efficacy in reducing inflammatory and noninflammatory acne lesions, including lesions on the face, back, and chest. Common adverse side effects are nausea, headache, nasopharyngitis, and vomiting. Vestibular and phototoxic adverse effects were reported in less than 1% of patients.^1,8 The US Food and Drug Administration approved sarecycline as a once-daily oral formulation for moderate to severe acne vulgaris, the first new antibiotic to be approved for the disease in the last 40 years. Sarecycline is not mentioned in any US military guidelines with regard to medical readiness and duty status; however, given its lack of vestibular side effects and narrower activity spectrum, it may become another acceptable treatment option in the military population.

Isotretinoin

Isotretinoin is well established as an excellent treatment of acne and stands alone as the only currently available medication that alters the disease course and prevents relapse in many patients. Nearly all patients on isotretinoin experience considerable mucocutaneous dryness, and up to 25% of patients on high-dose isotretinoin develop myalgia.⁹ Isotretinoin causes serious retinoid embryopathy, requiring all patients to be enrolled in the iPLEDGE program (https://www.ipledgeprogram.com/iPledgeUI/home.u) and to use 2 methods of contraception during treatment. Although it is uncommon to have notable elevations in lipids and transaminases during treatment with isotretinoin, routine laboratory monitoring generally is performed until the patient reaches steady dosing.

Isotretinoin is not permitted for use in active aircrew members, submariners, or divers. Servicemembers pursuing isotretinoin therapy are removed from their duty and are nondeployable for the entirety of their treatment course and several months after completion.^4,5

Photodynamic Therapy

Aminolevulinic acid and photodynamic therapy (ALA-PDT) has been successfully used in the management of acne.¹⁰ In addition to inducing selective damage to sebaceous glands, it has been proposed that PDT also destroys Propionibacterium acnes and reduces keratinocyte shedding and immunologic changes that play key roles in the development of acne.¹⁰

A recent randomized controlled trial comparing the efficacy of ALA-PDT vs adapalene gel plus oral doxycycline for treatment of moderate acne included 46 patients with moderate inflammatory acne.¹⁰ Twenty-three participants received 2 sessions (spaced 2 weeks apart) of 20% ALA incubated for 90 minutes before red light irradiation with a fluence of 37 J/cm², and the other 23 received 100 mg/d of oral doxycycline plus adapalene gel 0.1%. By 6-week follow-up, there was a significantly higher reduction in total lesions within the PDT group (P=.038), which was sustained at the secondary 12-week follow-up (P=.026). There was a 79% total reduction of lesions in the ALA-PDT group vs 67% in the doxycycline plus adapalene group.¹⁰

Although some studies have shown promise for PDT as an emerging treatment option for acne, further research is needed. A 2016 systematic review of the related literature determined that although 20% ALA-PDT with red light was more effective than lower concentrations of ALA and also more effective than ALA-PDT with blue light—which offered no additional benefit when compared with blue light alone—high-quality evidence on the use of PDT for acne is lacking overall.¹¹ At the time of the review, there was little certainty as to the usefulness of ALA-PDT with red or blue light as a standard treatment for individuals with moderate to severe acne. A 2019 review by Marson and Baldwin¹² echoed this sentiment, recommending more stringently designed studies to elucidate the true role of PDT as a monotherapy or adjunctive treatment of acne.

Pulsed Dye Laser

Pulsed dye laser (PDL) was first shown to be a potential therapy for acne by Seaton et al,¹³ who conducted a small-scale, randomized, controlled trial with 41 patients, each assigned to either a single PDL treatment or a sham treatment. Patients were re-evaluated at 12 weeks, measuring acne severity by the Leeds revised acne grading system and taking total lesion counts. Acne severity (P=.007) and total lesion counts (P=.023) were significantly improved in the treatment group, with a 53% reduction in total lesion count following a single PDL treatment.¹³

In 2007, a Spanish study described use of PDL every 4 weeks for a total of 12 weeks in 36 patients with mild to moderate acne. Using lesion counts as their primary outcome measure, the investigators found results similar to those from Seaton et al,¹³ with a 57% decrease in active lesions.¹⁴ Others still have found similar outcomes. A 2009 study of 45 patients with mild to moderate acne compared patients treated with PDL every 2 weeks for 12 weeks to patients receiving either topical therapy or chemical peels with 25% trichloroacetic acid. At 12 weeks, they noted the best results were in the PDL group.¹⁵

Karsai et al¹⁶ compared PDL as an adjuvant treatment of acne to proven treatment with clindamycin plus benzoyl peroxide gel. Eighty patients were randomized to topical therapy plus PDL or topical therapy alone and were followed at 2 and 4 weeks after the initial treatment. Although both groups showed improvement as measured by inflammatory lesion count and dermatology life quality index, there was no statistically significant difference noted between groups.¹⁶

Case Report

A 24-year-old active-duty male servicemember was referred to the dermatology department for evaluation of treatment-resistant nodulocystic scarring acne. Prior to his arrival to dermatology, he had completed 2 weeks of isotretinoin before discontinuation due to notable mood alteration. Following the isotretinoin, he was then switched to doxycycline 100 mg twice daily, which he trialed for 3 months. Even on the antibiotic, the patient continued to develop new pustules and cysts, prompting referral to dermatology for additional treatment options (Figure, A). All of the previous topical and oral medications had been discontinued at the current presentation.

The patient received 3 treatments with the 595-nm PDL (spot size, 10 mm; fluence, 7 J/cm²; pulse width, 6 milliseconds) spaced 4 weeks apart. At each treatment, fewer than 10 total inflammatory lesions were treated, including inflammatory papules, pustules, and nodules. Nodular lesions were treated with 2 pulses. After each treatment, the patient reported that all treated lesions resolved within 2 days (Figure, B). Subsequent treated lesions all occurred at previously uninvolved sites.

Final Thoughts

Antibiotic resistance is a known and growing problem throughout the medical community. In 2013, the US Centers for Disease Control and Prevention reported that dermatologists prescribe more antibiotics than any other specialty.¹⁷ Aside from antibiotic stewardship, systemic antibiotics come with various considerations when selecting ideal acne treatment regimens in military populations, as they are either medically disqualifying or lead to temporary grounding status. Numerous guidelines on acne have recommended limiting the use of antibiotics, instead pursuing alternative therapies such as spironolactone, oral contraceptives, or isotretinoin.^9,18 Both spironolactone and oral contraceptives work well via antiandrogenic and antisebogenic properties; however, these therapies are limited to female patients only, who make up a minority of patients in the active-duty military setting. Isotretinoin is highly effective in the treatment of acne, but it requires grounding for the entirety of treatment and for months afterward, which comes at great personal and financial costs to servicemembers and their commanders due to limited-duty status and inability to deploy.

Given the operational constraints with isotretinoin and the continual rise of antibiotic resistance, PDL appears to be a safe and effective alternative therapy for acne. In our case, the patient had complete resolution of active inflammatory lesions after each of his treatments. He had no adverse effects and tolerated the treatments well. We report this case here to highlight the use of PDL as an effective therapy for spot treatment in patients limited by personal or operational constraints and as a means to reduce antibiotic use in the face of a growing tide of antibiotic resistance.

Acne keloidalis nuchae (AKN) is a chronic inflammatory disorder most commonly involving the occipital scalp and posterior neck characterized by the development of keloidlike papules, pustules, and plaques. If left untreated, this condition may progress to scarring alopecia. It primarily affects males of African descent, but it also may occur in females and in other ethnic groups. Although the exact underlying pathogenesis is unclear, close haircuts and chronic mechanical irritation to the posterior neck and scalp are known inciting factors. For this reason, AKN disproportionately affects active-duty military servicemembers who are held to strict grooming standards. The US Military maintains these grooming standards to ensure uniformity, self-discipline, and serviceability in operational settings.¹ Regulations dictate short tapered hair, particularly on the back of the neck, which can require weekly to biweekly haircuts to maintain.^1-5

First-line treatment of AKN is prevention by avoiding short haircuts and other forms of mechanical irritation.^1,6,7 However, there are considerable barriers to this strategy within the military due to uniform regulations as well as personal appearance and grooming standards. Early identification and treatment are of utmost importance in managing AKN in the military population to ensure reduction of morbidity, prevention of late-stage disease, and continued fitness for duty. This article reviews the clinical features, epidemiology, and treatments available for management of AKN, with a special focus on the active-duty military population.

Clinical Features and Epidemiology

Acne keloidalis nuchae is a chronic inflammatory disorder characterized by the development of keloidlike papules, pustules, and plaques on the posterior neck and occipital scalp.⁶ Also known as folliculitis keloidalis nuchae, AKN is seen primarily in men of African descent, though cases also have been reported in females and in a few other ethnic groups.^6,7 In black males, the AKN prevalence worldwide ranges from 0.5% to 13.6%. The male to female ratio is 20 to 1.⁷ Although the exact cause is unknown, AKN appears to develop from chronic irritation and inflammation following localized skin injury and/or trauma. Chronic irritation from close-shaved haircuts, tight-fitting shirt collars, caps, and helmets have all been implicated as considerable risk factors.^6-8

Symptoms generally develop hours to days following a close haircut and begin with the early formation of inflamed irritated papules and notable erythema.^6,7 These papules may become secondarily infected and develop into pustules and/or abscesses, especially in cases in which the affected individual continues to have the hair shaved. Continued use of shared razors increases the risk for secondary infection and also raises the concern for transmission of blood-borne pathogens, as AKN lesions are quick to bleed with minor trauma.⁷

Over time, chronic inflammation and continued trauma of the AKN papules leads to widespread fibrosis and scar formation, as the papules coalesce into larger plaques and nodules. If left untreated, these later stages of disease can progress to chronic scarring alopecia.⁶

Prevention

In the general population, first-line therapy of AKN is preventative. The goal is to break the cycle of chronic inflammation, thereby preventing the development of additional lesions and subsequent scarring.⁷ Patients should be encouraged to avoid frequent haircuts, close shaves, hats, helmets, and tight shirt collars.^6-8

A 2017 cross-sectional study by Adotama et al⁹ investigated recognition and management of AKN in predominantly black barbershops in an urban setting. Fifty barbers from barbershops in Oklahoma City, Oklahoma, were enrolled and interviewed for the study. Of these barbers, only 44% (22/50) were able to properly identify AKN from a photograph. Although the vast majority (94% [47/50]) were aware that razor use would aggravate the condition, only 46% (23/50) reported avoidance of cutting hair for clients with active AKN.⁹ This study, while limited by its small sample size, showed that many barbers may be unaware of AKN and therefore unknowingly contribute to the disease process by performing haircuts on actively inflamed scalps. For this reason, it is important to educate patients about their condition and strongly recommend lifestyle and hairstyle modifications in the management of their disease.

Acne keloidalis nuchae that is severe enough to interfere with the proper use and wear of military equipment (eg, Kevlar helmets) or maintenance of regulation grooming standards does not meet military admission standards.^10,11 However, mild undiagnosed cases may be overlooked during entrance physical examinations, while many servicemembers develop AKN after entering the military.¹⁰ For these individuals, long-term avoidance of haircuts is not a realistic or obtainable therapeutic option.

Treatment

Topical Therapy
Early mild to moderate cases of AKN—papules less than 3 mm, no nodules present—may be treated with potent topical steroids. Studies have shown 2-week alternating cycles of high-potency topical steroids (2 weeks of twice-daily application followed by 2 weeks without application) for 8 to 12 weeks to be effective in reducing AKN lesions.^8,12 Topical clindamycin also may be added and has demonstrated efficacy particularly when pustules are present.^7,8

Intralesional Steroids
For moderate cases of AKN—papules more than 3 mm, plaques, and nodules—intralesional steroid injections may be considered. Triamcinolone may be used at a dose of 5 to 40 mg/mL administered at 4-week intervals.⁷ More concentrated doses will produce faster responses but also carry the known risk of side effects such as hypopigmentation in darker-skinned individuals and skin atrophy.

Systemic Therapy
Systemic therapy with oral antibiotics may be warranted as an adjunct to mild to moderate cases of AKN or in cases with clear evidence of secondary infection. Long-term tetracycline antibiotics, such as minocycline and doxycycline, may be used concurrently with topical and/or intralesional steroids.^6,7 Their antibacterial and anti-inflammatory effects are useful in controlling secondary infections and reducing overall chronic inflammation.

When selecting an appropriate antibiotic for long-term use in active-duty military patients, it is important to consider their effects on duty status. Doxycycline is preferred for active-duty servicemembers because it is not duty limiting or medically disqualifying.^10,13-15 However, minocycline, is restricted for use in aviators and aircrew members due to the risk for central nervous system side effects, which may include light-headedness, dizziness, and vertigo.

UV Light Therapy
UV radiation has known anti-inflammatory, immunosuppressive, and antifibrotic effects and commonly is used in the treatment of many dermatologic conditions.¹⁶ Within the last decade, targeted UVB (tUVB) radiation has shown promise as an effective alternative therapy for AKN. In 2014, Okoye et al¹⁶ conducted a prospective, randomized, split-scalp study in 11 patients with AKN. Each patient underwent treatment with a tUVB device (with peaks at 303 and 313 nm) to a randomly selected side of the scalp 3 times weekly for 16 weeks. Significant reductions in lesion count were seen on the treated side after 8 (P=.03) and 16 weeks (P=.04), with no change noted on the control side. Aside from objective lesion counts, patients completed questionnaires (n=6) regarding their treatment outcomes. Notably, 83.3% (5/6) reported marked improvement in their condition. Aside from mild transient burning and erythema of the treated area, no serious side effects were reported.¹⁶

Targeted UVB phototherapy has limited utility in an operational setting due to accessibility and operational tempo. Phototherapy units typically are available only at commands in close proximity to large medical treatment facilities. Further, the vast majority of servicemembers have duty hours that are not amenable to multiple treatment sessions per week for several months. For servicemembers in administrative roles or serving in garrison or shore billets, tUVB or narrowband UV phototherapy may be viable treatment options.

Laser Therapy
Various lasers have been used to treat AKN, including the CO₂ laser, pulsed dye laser, 810-nm diode laser, and 1064-nm Nd:YAG laser.⁶ Kantor et al¹⁷ utilized a CO₂ laser with a focused beam for surgical excision of a late-stage AKN case as early as 1986. In these patients, it was demonstrated that focused CO₂ laser could be used to remove fibrotic lesions in an outpatient setting with only local anesthesia. Although only 8 patients were treated in this report, no relapses occurred.¹⁷

CO₂ laser evaporation using the unfocused beam setting with 130 to 150 J/cm² has been less successful, with relapses reported in multiple cases.⁶ Dragoni et al¹⁸ attempted treatment with a 595-nm pulsed dye laser with 6.5-J/cm² fluence and 0.5-millisecond pulse but faced similar results, with lesions returning within 1 month.

There have been numerous reports of clinical improvement of AKN with the use of the 1064-nm Nd:YAG laser.^6,19 Esmat et al¹⁹ treated 16 patients with a fluence of 35 to 45 J/cm² and pulse duration of 10 to 30 milliseconds adjusted to skin type and hair thickness. An overall 82% reduction in lesion count was observed after 5 treatment sessions. Biopsies following the treatment course demonstrated a significant reduction in papule and plaque count (P=.001 and P=.011, respectively), and no clinical recurrences were noted at 12 months posttreatment.¹⁹ Similarly, Woo et al²⁰ conducted a single-blinded, randomized, controlled trial to assess the efficacy of the Nd:YAG laser in combination with topical corticosteroid therapy vs topical corticosteroid monotherapy. Of the 20 patients treated, there was a statistically significant improvement in patients with papule-only AKN who received the laser and topical combination treatment (P=.031).²⁰

Laser therapy may be an available treatment option for military servicemembers stationed within close proximity to military treatment facilities, with the Nd:YAG laser typically having the widest availability. Although laser therapy may be effective in early stages of disease, servicemembers would have to be amenable to limitation of future hair growth in the treated areas.

Surgical Excision
Surgical excision may be considered for large, extensive, disfiguring, and/or refractory lesions. Excision is a safe and effective method to remove tender, inflamed, keloidlike masses. Techniques for excision include electrosurgical excision with secondary intention healing, excision of a horizontal ellipse involving the posterior hairline with either primary closure or secondary intention healing, and use of a semilunar tissue expander prior to excision and closure.⁶ Regardless of the technique, it is important to ensure that affected tissue is excised at a depth that includes the base of the hair follicles to prevent recurrence.²¹

Final Thoughts

Acne keloidalis nuchae is a chronic inflammatory disease that causes considerable morbidity and can lead to chronic infection, alopecia, and disfigurement of the occipital scalp and posterior neck. Although easily preventable through the avoidance of mechanical trauma, irritation, and frequent short haircuts, the active-duty military population is restricted in their preventive measures due to current grooming and uniform standards. In this population, early identification and treatment are necessary to manage the disease to reduce patient morbidity and ensure continued operational and medical readiness. Topical and intralesional steroids may be used in mild to moderate cases. Topical and/or systemic antibiotics may be added to the treatment regimen in cases of secondary bacterial infection. For more severe refractory cases, laser therapy or complete surgical excision may be warranted.

Acne keloidalis nuchae (AKN) is a chronic inflammatory disorder most commonly involving the occipital scalp and posterior neck characterized by the development of keloidlike papules, pustules, and plaques. If left untreated, this condition may progress to scarring alopecia. It primarily affects males of African descent, but it also may occur in females and in other ethnic groups. Although the exact underlying pathogenesis is unclear, close haircuts and chronic mechanical irritation to the posterior neck and scalp are known inciting factors. For this reason, AKN disproportionately affects active-duty military servicemembers who are held to strict grooming standards. The US Military maintains these grooming standards to ensure uniformity, self-discipline, and serviceability in operational settings.¹ Regulations dictate short tapered hair, particularly on the back of the neck, which can require weekly to biweekly haircuts to maintain.^1-5

First-line treatment of AKN is prevention by avoiding short haircuts and other forms of mechanical irritation.^1,6,7 However, there are considerable barriers to this strategy within the military due to uniform regulations as well as personal appearance and grooming standards. Early identification and treatment are of utmost importance in managing AKN in the military population to ensure reduction of morbidity, prevention of late-stage disease, and continued fitness for duty. This article reviews the clinical features, epidemiology, and treatments available for management of AKN, with a special focus on the active-duty military population.

Clinical Features and Epidemiology

Acne keloidalis nuchae is a chronic inflammatory disorder characterized by the development of keloidlike papules, pustules, and plaques on the posterior neck and occipital scalp.⁶ Also known as folliculitis keloidalis nuchae, AKN is seen primarily in men of African descent, though cases also have been reported in females and in a few other ethnic groups.^6,7 In black males, the AKN prevalence worldwide ranges from 0.5% to 13.6%. The male to female ratio is 20 to 1.⁷ Although the exact cause is unknown, AKN appears to develop from chronic irritation and inflammation following localized skin injury and/or trauma. Chronic irritation from close-shaved haircuts, tight-fitting shirt collars, caps, and helmets have all been implicated as considerable risk factors.^6-8

Symptoms generally develop hours to days following a close haircut and begin with the early formation of inflamed irritated papules and notable erythema.^6,7 These papules may become secondarily infected and develop into pustules and/or abscesses, especially in cases in which the affected individual continues to have the hair shaved. Continued use of shared razors increases the risk for secondary infection and also raises the concern for transmission of blood-borne pathogens, as AKN lesions are quick to bleed with minor trauma.⁷

Over time, chronic inflammation and continued trauma of the AKN papules leads to widespread fibrosis and scar formation, as the papules coalesce into larger plaques and nodules. If left untreated, these later stages of disease can progress to chronic scarring alopecia.⁶

Prevention

In the general population, first-line therapy of AKN is preventative. The goal is to break the cycle of chronic inflammation, thereby preventing the development of additional lesions and subsequent scarring.⁷ Patients should be encouraged to avoid frequent haircuts, close shaves, hats, helmets, and tight shirt collars.^6-8

A 2017 cross-sectional study by Adotama et al⁹ investigated recognition and management of AKN in predominantly black barbershops in an urban setting. Fifty barbers from barbershops in Oklahoma City, Oklahoma, were enrolled and interviewed for the study. Of these barbers, only 44% (22/50) were able to properly identify AKN from a photograph. Although the vast majority (94% [47/50]) were aware that razor use would aggravate the condition, only 46% (23/50) reported avoidance of cutting hair for clients with active AKN.⁹ This study, while limited by its small sample size, showed that many barbers may be unaware of AKN and therefore unknowingly contribute to the disease process by performing haircuts on actively inflamed scalps. For this reason, it is important to educate patients about their condition and strongly recommend lifestyle and hairstyle modifications in the management of their disease.

Acne keloidalis nuchae that is severe enough to interfere with the proper use and wear of military equipment (eg, Kevlar helmets) or maintenance of regulation grooming standards does not meet military admission standards.^10,11 However, mild undiagnosed cases may be overlooked during entrance physical examinations, while many servicemembers develop AKN after entering the military.¹⁰ For these individuals, long-term avoidance of haircuts is not a realistic or obtainable therapeutic option.

Treatment

Topical Therapy
Early mild to moderate cases of AKN—papules less than 3 mm, no nodules present—may be treated with potent topical steroids. Studies have shown 2-week alternating cycles of high-potency topical steroids (2 weeks of twice-daily application followed by 2 weeks without application) for 8 to 12 weeks to be effective in reducing AKN lesions.^8,12 Topical clindamycin also may be added and has demonstrated efficacy particularly when pustules are present.^7,8

Intralesional Steroids
For moderate cases of AKN—papules more than 3 mm, plaques, and nodules—intralesional steroid injections may be considered. Triamcinolone may be used at a dose of 5 to 40 mg/mL administered at 4-week intervals.⁷ More concentrated doses will produce faster responses but also carry the known risk of side effects such as hypopigmentation in darker-skinned individuals and skin atrophy.

Systemic Therapy
Systemic therapy with oral antibiotics may be warranted as an adjunct to mild to moderate cases of AKN or in cases with clear evidence of secondary infection. Long-term tetracycline antibiotics, such as minocycline and doxycycline, may be used concurrently with topical and/or intralesional steroids.^6,7 Their antibacterial and anti-inflammatory effects are useful in controlling secondary infections and reducing overall chronic inflammation.

When selecting an appropriate antibiotic for long-term use in active-duty military patients, it is important to consider their effects on duty status. Doxycycline is preferred for active-duty servicemembers because it is not duty limiting or medically disqualifying.^10,13-15 However, minocycline, is restricted for use in aviators and aircrew members due to the risk for central nervous system side effects, which may include light-headedness, dizziness, and vertigo.

UV Light Therapy
UV radiation has known anti-inflammatory, immunosuppressive, and antifibrotic effects and commonly is used in the treatment of many dermatologic conditions.¹⁶ Within the last decade, targeted UVB (tUVB) radiation has shown promise as an effective alternative therapy for AKN. In 2014, Okoye et al¹⁶ conducted a prospective, randomized, split-scalp study in 11 patients with AKN. Each patient underwent treatment with a tUVB device (with peaks at 303 and 313 nm) to a randomly selected side of the scalp 3 times weekly for 16 weeks. Significant reductions in lesion count were seen on the treated side after 8 (P=.03) and 16 weeks (P=.04), with no change noted on the control side. Aside from objective lesion counts, patients completed questionnaires (n=6) regarding their treatment outcomes. Notably, 83.3% (5/6) reported marked improvement in their condition. Aside from mild transient burning and erythema of the treated area, no serious side effects were reported.¹⁶

Targeted UVB phototherapy has limited utility in an operational setting due to accessibility and operational tempo. Phototherapy units typically are available only at commands in close proximity to large medical treatment facilities. Further, the vast majority of servicemembers have duty hours that are not amenable to multiple treatment sessions per week for several months. For servicemembers in administrative roles or serving in garrison or shore billets, tUVB or narrowband UV phototherapy may be viable treatment options.

Laser Therapy
Various lasers have been used to treat AKN, including the CO₂ laser, pulsed dye laser, 810-nm diode laser, and 1064-nm Nd:YAG laser.⁶ Kantor et al¹⁷ utilized a CO₂ laser with a focused beam for surgical excision of a late-stage AKN case as early as 1986. In these patients, it was demonstrated that focused CO₂ laser could be used to remove fibrotic lesions in an outpatient setting with only local anesthesia. Although only 8 patients were treated in this report, no relapses occurred.¹⁷

CO₂ laser evaporation using the unfocused beam setting with 130 to 150 J/cm² has been less successful, with relapses reported in multiple cases.⁶ Dragoni et al¹⁸ attempted treatment with a 595-nm pulsed dye laser with 6.5-J/cm² fluence and 0.5-millisecond pulse but faced similar results, with lesions returning within 1 month.

There have been numerous reports of clinical improvement of AKN with the use of the 1064-nm Nd:YAG laser.^6,19 Esmat et al¹⁹ treated 16 patients with a fluence of 35 to 45 J/cm² and pulse duration of 10 to 30 milliseconds adjusted to skin type and hair thickness. An overall 82% reduction in lesion count was observed after 5 treatment sessions. Biopsies following the treatment course demonstrated a significant reduction in papule and plaque count (P=.001 and P=.011, respectively), and no clinical recurrences were noted at 12 months posttreatment.¹⁹ Similarly, Woo et al²⁰ conducted a single-blinded, randomized, controlled trial to assess the efficacy of the Nd:YAG laser in combination with topical corticosteroid therapy vs topical corticosteroid monotherapy. Of the 20 patients treated, there was a statistically significant improvement in patients with papule-only AKN who received the laser and topical combination treatment (P=.031).²⁰

Laser therapy may be an available treatment option for military servicemembers stationed within close proximity to military treatment facilities, with the Nd:YAG laser typically having the widest availability. Although laser therapy may be effective in early stages of disease, servicemembers would have to be amenable to limitation of future hair growth in the treated areas.

Surgical Excision
Surgical excision may be considered for large, extensive, disfiguring, and/or refractory lesions. Excision is a safe and effective method to remove tender, inflamed, keloidlike masses. Techniques for excision include electrosurgical excision with secondary intention healing, excision of a horizontal ellipse involving the posterior hairline with either primary closure or secondary intention healing, and use of a semilunar tissue expander prior to excision and closure.⁶ Regardless of the technique, it is important to ensure that affected tissue is excised at a depth that includes the base of the hair follicles to prevent recurrence.²¹

Final Thoughts

Acne keloidalis nuchae is a chronic inflammatory disease that causes considerable morbidity and can lead to chronic infection, alopecia, and disfigurement of the occipital scalp and posterior neck. Although easily preventable through the avoidance of mechanical trauma, irritation, and frequent short haircuts, the active-duty military population is restricted in their preventive measures due to current grooming and uniform standards. In this population, early identification and treatment are necessary to manage the disease to reduce patient morbidity and ensure continued operational and medical readiness. Topical and intralesional steroids may be used in mild to moderate cases. Topical and/or systemic antibiotics may be added to the treatment regimen in cases of secondary bacterial infection. For more severe refractory cases, laser therapy or complete surgical excision may be warranted.

Acne keloidalis nuchae (AKN) is a chronic inflammatory disorder most commonly involving the occipital scalp and posterior neck characterized by the development of keloidlike papules, pustules, and plaques. If left untreated, this condition may progress to scarring alopecia. It primarily affects males of African descent, but it also may occur in females and in other ethnic groups. Although the exact underlying pathogenesis is unclear, close haircuts and chronic mechanical irritation to the posterior neck and scalp are known inciting factors. For this reason, AKN disproportionately affects active-duty military servicemembers who are held to strict grooming standards. The US Military maintains these grooming standards to ensure uniformity, self-discipline, and serviceability in operational settings.¹ Regulations dictate short tapered hair, particularly on the back of the neck, which can require weekly to biweekly haircuts to maintain.^1-5

First-line treatment of AKN is prevention by avoiding short haircuts and other forms of mechanical irritation.^1,6,7 However, there are considerable barriers to this strategy within the military due to uniform regulations as well as personal appearance and grooming standards. Early identification and treatment are of utmost importance in managing AKN in the military population to ensure reduction of morbidity, prevention of late-stage disease, and continued fitness for duty. This article reviews the clinical features, epidemiology, and treatments available for management of AKN, with a special focus on the active-duty military population.

Clinical Features and Epidemiology

Acne keloidalis nuchae is a chronic inflammatory disorder characterized by the development of keloidlike papules, pustules, and plaques on the posterior neck and occipital scalp.⁶ Also known as folliculitis keloidalis nuchae, AKN is seen primarily in men of African descent, though cases also have been reported in females and in a few other ethnic groups.^6,7 In black males, the AKN prevalence worldwide ranges from 0.5% to 13.6%. The male to female ratio is 20 to 1.⁷ Although the exact cause is unknown, AKN appears to develop from chronic irritation and inflammation following localized skin injury and/or trauma. Chronic irritation from close-shaved haircuts, tight-fitting shirt collars, caps, and helmets have all been implicated as considerable risk factors.^6-8

Symptoms generally develop hours to days following a close haircut and begin with the early formation of inflamed irritated papules and notable erythema.^6,7 These papules may become secondarily infected and develop into pustules and/or abscesses, especially in cases in which the affected individual continues to have the hair shaved. Continued use of shared razors increases the risk for secondary infection and also raises the concern for transmission of blood-borne pathogens, as AKN lesions are quick to bleed with minor trauma.⁷

Over time, chronic inflammation and continued trauma of the AKN papules leads to widespread fibrosis and scar formation, as the papules coalesce into larger plaques and nodules. If left untreated, these later stages of disease can progress to chronic scarring alopecia.⁶

Prevention

In the general population, first-line therapy of AKN is preventative. The goal is to break the cycle of chronic inflammation, thereby preventing the development of additional lesions and subsequent scarring.⁷ Patients should be encouraged to avoid frequent haircuts, close shaves, hats, helmets, and tight shirt collars.^6-8

A 2017 cross-sectional study by Adotama et al⁹ investigated recognition and management of AKN in predominantly black barbershops in an urban setting. Fifty barbers from barbershops in Oklahoma City, Oklahoma, were enrolled and interviewed for the study. Of these barbers, only 44% (22/50) were able to properly identify AKN from a photograph. Although the vast majority (94% [47/50]) were aware that razor use would aggravate the condition, only 46% (23/50) reported avoidance of cutting hair for clients with active AKN.⁹ This study, while limited by its small sample size, showed that many barbers may be unaware of AKN and therefore unknowingly contribute to the disease process by performing haircuts on actively inflamed scalps. For this reason, it is important to educate patients about their condition and strongly recommend lifestyle and hairstyle modifications in the management of their disease.

Acne keloidalis nuchae that is severe enough to interfere with the proper use and wear of military equipment (eg, Kevlar helmets) or maintenance of regulation grooming standards does not meet military admission standards.^10,11 However, mild undiagnosed cases may be overlooked during entrance physical examinations, while many servicemembers develop AKN after entering the military.¹⁰ For these individuals, long-term avoidance of haircuts is not a realistic or obtainable therapeutic option.

Treatment

Topical Therapy
Early mild to moderate cases of AKN—papules less than 3 mm, no nodules present—may be treated with potent topical steroids. Studies have shown 2-week alternating cycles of high-potency topical steroids (2 weeks of twice-daily application followed by 2 weeks without application) for 8 to 12 weeks to be effective in reducing AKN lesions.^8,12 Topical clindamycin also may be added and has demonstrated efficacy particularly when pustules are present.^7,8

Intralesional Steroids
For moderate cases of AKN—papules more than 3 mm, plaques, and nodules—intralesional steroid injections may be considered. Triamcinolone may be used at a dose of 5 to 40 mg/mL administered at 4-week intervals.⁷ More concentrated doses will produce faster responses but also carry the known risk of side effects such as hypopigmentation in darker-skinned individuals and skin atrophy.

Systemic Therapy
Systemic therapy with oral antibiotics may be warranted as an adjunct to mild to moderate cases of AKN or in cases with clear evidence of secondary infection. Long-term tetracycline antibiotics, such as minocycline and doxycycline, may be used concurrently with topical and/or intralesional steroids.^6,7 Their antibacterial and anti-inflammatory effects are useful in controlling secondary infections and reducing overall chronic inflammation.

When selecting an appropriate antibiotic for long-term use in active-duty military patients, it is important to consider their effects on duty status. Doxycycline is preferred for active-duty servicemembers because it is not duty limiting or medically disqualifying.^10,13-15 However, minocycline, is restricted for use in aviators and aircrew members due to the risk for central nervous system side effects, which may include light-headedness, dizziness, and vertigo.

UV Light Therapy
UV radiation has known anti-inflammatory, immunosuppressive, and antifibrotic effects and commonly is used in the treatment of many dermatologic conditions.¹⁶ Within the last decade, targeted UVB (tUVB) radiation has shown promise as an effective alternative therapy for AKN. In 2014, Okoye et al¹⁶ conducted a prospective, randomized, split-scalp study in 11 patients with AKN. Each patient underwent treatment with a tUVB device (with peaks at 303 and 313 nm) to a randomly selected side of the scalp 3 times weekly for 16 weeks. Significant reductions in lesion count were seen on the treated side after 8 (P=.03) and 16 weeks (P=.04), with no change noted on the control side. Aside from objective lesion counts, patients completed questionnaires (n=6) regarding their treatment outcomes. Notably, 83.3% (5/6) reported marked improvement in their condition. Aside from mild transient burning and erythema of the treated area, no serious side effects were reported.¹⁶

Targeted UVB phototherapy has limited utility in an operational setting due to accessibility and operational tempo. Phototherapy units typically are available only at commands in close proximity to large medical treatment facilities. Further, the vast majority of servicemembers have duty hours that are not amenable to multiple treatment sessions per week for several months. For servicemembers in administrative roles or serving in garrison or shore billets, tUVB or narrowband UV phototherapy may be viable treatment options.

Laser Therapy
Various lasers have been used to treat AKN, including the CO₂ laser, pulsed dye laser, 810-nm diode laser, and 1064-nm Nd:YAG laser.⁶ Kantor et al¹⁷ utilized a CO₂ laser with a focused beam for surgical excision of a late-stage AKN case as early as 1986. In these patients, it was demonstrated that focused CO₂ laser could be used to remove fibrotic lesions in an outpatient setting with only local anesthesia. Although only 8 patients were treated in this report, no relapses occurred.¹⁷

CO₂ laser evaporation using the unfocused beam setting with 130 to 150 J/cm² has been less successful, with relapses reported in multiple cases.⁶ Dragoni et al¹⁸ attempted treatment with a 595-nm pulsed dye laser with 6.5-J/cm² fluence and 0.5-millisecond pulse but faced similar results, with lesions returning within 1 month.

There have been numerous reports of clinical improvement of AKN with the use of the 1064-nm Nd:YAG laser.^6,19 Esmat et al¹⁹ treated 16 patients with a fluence of 35 to 45 J/cm² and pulse duration of 10 to 30 milliseconds adjusted to skin type and hair thickness. An overall 82% reduction in lesion count was observed after 5 treatment sessions. Biopsies following the treatment course demonstrated a significant reduction in papule and plaque count (P=.001 and P=.011, respectively), and no clinical recurrences were noted at 12 months posttreatment.¹⁹ Similarly, Woo et al²⁰ conducted a single-blinded, randomized, controlled trial to assess the efficacy of the Nd:YAG laser in combination with topical corticosteroid therapy vs topical corticosteroid monotherapy. Of the 20 patients treated, there was a statistically significant improvement in patients with papule-only AKN who received the laser and topical combination treatment (P=.031).²⁰

Laser therapy may be an available treatment option for military servicemembers stationed within close proximity to military treatment facilities, with the Nd:YAG laser typically having the widest availability. Although laser therapy may be effective in early stages of disease, servicemembers would have to be amenable to limitation of future hair growth in the treated areas.

Surgical Excision
Surgical excision may be considered for large, extensive, disfiguring, and/or refractory lesions. Excision is a safe and effective method to remove tender, inflamed, keloidlike masses. Techniques for excision include electrosurgical excision with secondary intention healing, excision of a horizontal ellipse involving the posterior hairline with either primary closure or secondary intention healing, and use of a semilunar tissue expander prior to excision and closure.⁶ Regardless of the technique, it is important to ensure that affected tissue is excised at a depth that includes the base of the hair follicles to prevent recurrence.²¹

Final Thoughts

Acne keloidalis nuchae is a chronic inflammatory disease that causes considerable morbidity and can lead to chronic infection, alopecia, and disfigurement of the occipital scalp and posterior neck. Although easily preventable through the avoidance of mechanical trauma, irritation, and frequent short haircuts, the active-duty military population is restricted in their preventive measures due to current grooming and uniform standards. In this population, early identification and treatment are necessary to manage the disease to reduce patient morbidity and ensure continued operational and medical readiness. Topical and intralesional steroids may be used in mild to moderate cases. Topical and/or systemic antibiotics may be added to the treatment regimen in cases of secondary bacterial infection. For more severe refractory cases, laser therapy or complete surgical excision may be warranted.

Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.¹ Today, there are 14 indications² for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.³ The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.⁴

Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.

Overview of HOT

Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O₂) at increased atmospheric pressure, which specifically involves breathing near 100% O₂ while inside a monoplace or multiplace chamber⁵ that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).²

A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.^5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O₂ is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.⁷ Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.⁷ A television often is provided to help the patient pass the time.⁸

Long-standing Use in Decompression Sickness

Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.

Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O₂ failed to resolve their DCS symptoms.¹⁰

Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O₂ at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury⁹; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.

The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.¹¹ He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.¹¹

Other Indications

Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.¹² These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.¹³

Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O₂ dissolves in plasma, thus improving the O₂ tissue cellular diffusion gradient.⁷ An increased level of systemic O₂ promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.¹³

In a study, 105 patients with an ischemic flap or graft were treated with HOT; most (89% of threatened flaps and 91% of threatened grafts) were salvaged. In this series, the duration of latency from the creation of the flap to initiation of HOT was directly proportional to the failure rate of this treatment modality.¹⁴

Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.¹⁵ In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.¹⁶ Hampson et al¹⁷ reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.¹⁷

Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.¹⁸

Efrati et al¹⁹ reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.

Mirasoglu et al²⁰ reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.

Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.

Uittenbogaard et al²² reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.²²

Complications and a Contraindication

Hyperbaric oxygen therapy generally is safe, but there is potential for complications.

Fire
This rare risk has a catastrophic outcome.²³ Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.²⁴

Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.^7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.²⁶ Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.²⁷

Reversible Myopia
Caused by direct O₂ toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.²⁷

Other Complications
Central nervous system complications, such as seizures, and pulmonary O₂ toxicity are rare, more serious complications.²⁷

Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.⁷

Conclusion

Hyperbaric O₂ therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.

Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.¹ Today, there are 14 indications² for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.³ The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.⁴

Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.

Overview of HOT

Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O₂) at increased atmospheric pressure, which specifically involves breathing near 100% O₂ while inside a monoplace or multiplace chamber⁵ that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).²

A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.^5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O₂ is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.⁷ Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.⁷ A television often is provided to help the patient pass the time.⁸

Long-standing Use in Decompression Sickness

Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.

Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O₂ failed to resolve their DCS symptoms.¹⁰

Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O₂ at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury⁹; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.

The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.¹¹ He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.¹¹

Other Indications

Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.¹² These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.¹³

Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O₂ dissolves in plasma, thus improving the O₂ tissue cellular diffusion gradient.⁷ An increased level of systemic O₂ promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.¹³

In a study, 105 patients with an ischemic flap or graft were treated with HOT; most (89% of threatened flaps and 91% of threatened grafts) were salvaged. In this series, the duration of latency from the creation of the flap to initiation of HOT was directly proportional to the failure rate of this treatment modality.¹⁴

Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.¹⁵ In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.¹⁶ Hampson et al¹⁷ reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.¹⁷

Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.¹⁸

Efrati et al¹⁹ reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.

Mirasoglu et al²⁰ reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.

Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.

Uittenbogaard et al²² reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.²²

Complications and a Contraindication

Hyperbaric oxygen therapy generally is safe, but there is potential for complications.

Fire
This rare risk has a catastrophic outcome.²³ Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.²⁴

Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.^7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.²⁶ Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.²⁷

Reversible Myopia
Caused by direct O₂ toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.²⁷

Other Complications
Central nervous system complications, such as seizures, and pulmonary O₂ toxicity are rare, more serious complications.²⁷

Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.⁷

Conclusion

Hyperbaric O₂ therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.

Hyperbaric oxygen therapy (HOT) is a treatment modality dating to 1861 in the United States.¹ Today, there are 14 indications² for HOT (Table), issued by the Undersea & Hyperbaric Medical Society, which also administers an accreditation program for facilities providing HOT.³ The 14 indications also are relevant because it is unlikely that HOT will be covered by insurance for unapproved indications.⁴

Although HOT is not commonly seen as a first-line intervention in dermatology, there are scenarios in which it can be used to good effect: compromised grafts and flaps; poorly healing ulceration related to vasculitis and autoimmune disorders; and possibly for vascular compromise, including cutaneous ischemia caused by fillers. We review its indications, dermatologic applications, and potential complications.

Overview of HOT

Hyperbaric oxygen therapy involves sitting or lying in a special chamber that allows for controlled levels of oxygen (O₂) at increased atmospheric pressure, which specifically involves breathing near 100% O₂ while inside a monoplace or multiplace chamber⁵ that is pressurized to greater than sea level pressure (≥1.4 atmosphere absolute).²

A monoplace chamber is designed to treat a single person (Figure 1); a multiplace chamber (Figure 2) accommodates as many as 5 to 25 patients.^5,6 The chambers also accommodate hospital beds and medical attendants, if needed. Hyperbaric O₂ is inhaled through a mask, a tight-fitting hood, or an endotracheal tube, depending on the patient’s status.⁷ Treatment ranges from only 1 or 2 iterations for acute conditions to 30 sessions or more for chronic conditions. Individual sessions last 45 minutes to 5 hours; 120 minutes is considered a safe maximum duration.⁷ A television often is provided to help the patient pass the time.⁸

Long-standing Use in Decompression Sickness

Hyperbaric oxygen therapy is best known for its effectiveness in treating decompression sickness (DCS) and carbon monoxide poisoning. Decompression sickness involves liberation of free gas from tissue, in the form of bubbles, when a person experiences a relative decrease in atmospheric pressure, which results in an imbalance in the sum of gas tensions in tissue compared to ambient pressure.

Decompression sickness has special military significance because it can affect divers and pilots, particularly those flying at high altitude. Over the course of 12 years, approximately 50 pilot trainees at an Air Force training site in Colorado required HOT when ground-level O₂ failed to resolve their DCS symptoms.¹⁰

Symptoms of DCS range from musculoskeletal pain to severe neurologic and pulmonary complications. First-line therapy for DCS is 100% O₂ at ground level. When symptoms are severe or persistent, HOT is the treatment of choice. It works by decreasing the volume of air bubbles (as predicted by Boyle’s Law), providing oxygenation to hypoxic tissue and mitigating inflammatory responses implicated in tissue injury⁹; HOT can be considered salvage treatment for rare, severe, or unresponsive complications of DCS during common activities such as diving and flying.

The emergent nature of DCS often necessitates an on-call, on-site HOT facility or contracted community services. Although DCS is a rare complication, it can be devastating, as was the case for a military pilot flying an ultrahigh altitude reconnaissance aircraft.¹¹ He developed a near fatal case of neurologic DCS during a military mission and required treatment with emergent HOT. Although his symptoms were reduced with therapy, he has persistent cognitive deficits.¹¹

Other Indications

Dermatologic Flaps and Grafts
Although less commonly discussed in dermatologic literature, the use of HOT in compromised grafts and flaps has been addressed in the plastic surgery literature. In a large multicenter study, researchers evaluated 20,821 Mohs micrographic surgery procedures and reported 149 adverse events, of which 20.1% were dehiscence and partial or full necrosis.¹² These complications, though rare, are potentially devastating, particularly in cosmetically sensitive locations such as the face. Traditional care for compromised grafts and flaps includes local wound care, surgical debridement, and additional reconstructive procedures. These interventions can be expensive and uncomfortable for patients and carry risk for further morbidity.¹³

Grafts become compromised when their metabolic demand outpaces the ability of the recipient bed due to characteristics of the graft or the recipient bed or both. Flaps carry their own blood supply, which can be compromised if the flap is too long or too large for the pedicle, there is notable tension on the wound, or blood flow is mechanically obstructed by kinking or twisting. Under these conditions, HOT can be beneficial, as O₂ dissolves in plasma, thus improving the O₂ tissue cellular diffusion gradient.⁷ An increased level of systemic O₂ promotes wound healing and graft or flap survival by improving fibroblast function, blood flow, and vascularity, and by mitigating ischemia-reperfusion injury.¹³

In a study, 105 patients with an ischemic flap or graft were treated with HOT; most (89% of threatened flaps and 91% of threatened grafts) were salvaged. In this series, the duration of latency from the creation of the flap to initiation of HOT was directly proportional to the failure rate of this treatment modality.¹⁴

Radiation-Induced Ulceration
Radionecrosis, a complication of radiotherapy, is caused by progressive obliterating endarteritis with resultant vascular stenosis and fibroatrophy, which eventually cause stromal fibrosis.¹⁵ In a study that looked at 1267 nonmelanoma skin cancers that had been treated with radiotherapy, the ulceration rate was 6.3%. Most of the ulcerated lesions were treatable conservatively, but some were more treatment resistant.¹⁶ Hampson et al¹⁷ reported on 58 patients with cutaneous wounds due to soft-tissue radionecrosis who were treated with HOT as part of a larger observational case series in which investigators looked at multiple types of radionecrosis. They found that 76% of these patients improved: 26% showed complete resolution and the remaining 50% had 50% to 90% improvement.¹⁷

Vasculitis or Autoimmune Ulceration
Vasculitis and vasculopathy can occur independent of, or in association with, connective tissue disease and can result in chronic ulceration. At our institution, a patient with antimelanoma differentiation-associated protein 5 dermatomyositis who had refractory digital ulcerations despite intensive systemic therapy had an excellent response to HOT; ulcerations resolved after 37 treatments.¹⁸

Efrati et al¹⁹ reported on 35 patients who had chronic nonhealing vasculitic ulcerations despite immunosuppression medication who were treated with HOT. Twenty-eight patients completely healed, 4 had partial healing, and 3 had no improvement.

Mirasoglu et al²⁰ reported on a case series of 6 systemic sclerosis patients who had ulcerations that persisted despite other treatments. After initiation of HOT, 4 patients experienced complete response and 2 experienced partial response, which is notable because such ulcerations are often extremely difficult to treat and have usually failed multiple therapies before being addressed with HOT.

Cutaneous Vascular Compromise
At our institution, a 36-year-old man was referred to the dermatology clinic 2 days after undergoing embolization of a symptomatic arteriovenous malformation in the right knee (Figure 3A). The procedure was complicated by cutaneous purpura concerning for necrosis, a known complication of this procedure. We referred the patient for evaluation to consider HOT. Although he was outside the ideal window for starting treatment, HOT was initiated. With a late start in treatment, areas of skin had already progressed to full necrosis, which did not respond to treatment; however, contiguous areas that initially looked very similar clinically did respond to treatment (Figure 3B). This case suggests a penumbralike effect in which vulnerable tissue that would most likely have been lost was salvaged by HOT.

Uittenbogaard et al²² reported the treatment of a patient who experienced dermal ischemia after receiving calcium hydroxylapatite at an aesthetic clinic. She did not improve with standard treatment but subsequently experienced resolution of symptoms after treatment with HOT. She had an excellent cosmetic outcome at 6-month follow-up.²²

Complications and a Contraindication

Hyperbaric oxygen therapy generally is safe, but there is potential for complications.

Fire
This rare risk has a catastrophic outcome.²³ Standards for fire prevention in hyperbaric facilities are issued by the National Fire Protection Association, covering construction and building materials, lighting, electrical wiring, exposure to flammable materials, and other possible ignition sources.²⁴

Middle Ear Barotrauma
The incidence of the most common adverse effect of HOT is reported at 2% to 30%.^7,25 Middle ear barotrauma occurs most commonly during the compression phase of treatment. It is more common in patients treated in a monoplace chamber because they are kept supine and are less able to regulate middle ear pressure.²⁶ Symptoms of middle ear barotrauma can be relieved by teaching patients autoinflation technique, such as the Valsalva maneuver, or by placing tympanoplasty tubes.²⁷

Reversible Myopia
Caused by direct O₂ toxicity to the lens, this complication can last for weeks, though it eventually resolves spontaneously. Reversible myopia has been reported to be at least as common as middle ear barotrauma.²⁷

Other Complications
Central nervous system complications, such as seizures, and pulmonary O₂ toxicity are rare, more serious complications.²⁷

Untreated Pneumothorax
The only absolute contraindication to HOT, pneumothorax can decompensate during HOT if left untreated. However, HOT can proceed once pneumothorax is addressed.⁷

Conclusion

Hyperbaric O₂ therapy can make a positive contribution to the dermatologic therapeutic armamentarium, in specific patients, for impending graft or flap failure, chronic wounds and ulcerations, and cutaneous vascular compromise. Although HOT is not a commonly needed treatment in dermatology, it is important to be aware of its potential because delay in treatment can decrease its effectiveness. It is recommended that dermatologists locate the nearest HOT facility and become familiar with its capabilities.

Dermatologic conditions historically have affected military members’ ability to serve during times of peace and conflict. These conditions range from chronic dermatologic diseases to environment- or occupation-related dermatologic diseases. Mild to moderate atopic dermatitis (AD) typically is a manageable skin condition. However, in a deployed setting, a flare of AD can result in the inability of a member to perform their military duty, which directly compromises mission safety and effectiveness. The military developed and updates medical standards for entry and retention of service members. These standards are designed to ensure the greatest potential for a military member to successfully serve at home station and during combat operations.

Impact of Injuries in Military

Historically, disease and nonbattle injuries have resulted in notably more hospitalizations and time lost than injuries sustained on the battlefield.¹ A review of major conflicts dating from World War II shows approximately 10% of all dermatologic concerns were related to eczematous dermatitis, with 2% specifically related to AD. These numbers varied remarkably depending on the location and environment of the conflict, with eczema accounting for 25% of dermatologic concerns during the Gulf War.² During the initial phases of Operation Iraqi Freedom, approximately 75% of hospitalizations were from disease and nonbattle injuries, of which dermatologic disease accounted for 3%.¹ From 2003 to 2006 in Iraq, 35 service members were evacuated from combat zones specifically for uncontrolled AD.³ In a deployed environment, each member is critical to the unit’s success in completing their mission. A single member of a unit often is the only person qualified to perform a function for that team. There are rarely extra people with similar skills to replace a member unable to complete his/her duties. The loss of a single member compromises the effectiveness and safety of the team and can lead to mission failure. Therefore, AD can have a profound impact on military operations in a deployed environment.

Military Medical Standards for Accession and Retention

There are 2 main goals of the military medical standards. First, the individual health of the applicant or military member is of utmost importance. Applicants with medical conditions that will be exacerbated by military service or that limit the ability for successful military operations are not accepted for military service. Once an active-duty member is diagnosed with a medical condition, the military determines if limitations are needed for military assignments and deployments based on available medical care in those locations. Second, mission accomplishment in combat operations requires that healthy military members are able to complete their jobs in extreme environments and under notable stress. If an applicant has a medical condition unsuitable for military service, it is in the best interest of the applicant and the military to deny entry.

The Medical Standards for Appointment, Enlistment, or Induction Into the Military Services (DoD Instruction 6130.03) lists conditions that are disqualifying for military service.⁴ Section 5.21 lists the following as disqualifying for military service in relation to eczematous dermatitis:

d. History of AD or eczema after the 12th birthday. History of residual or recurrent lesions in characteristic areas (face, neck, antecubital or popliteal fossae, occasionally wrists and hands).

 

 

 

e. History of recurrent or chronic nonspecific dermatitis within the past 2 years to include contact (irritant or allergic) or dyshidrotic dermatitis requiring more than treatment with topical corticosteroid.⁴

Although cases of incorrect diagnosis or very mild AD can be considered for a waiver, the process can be laborious and consideration or approval is not guaranteed. For current military members with new chronic eczematous dermatitis, each service has a process for evaluation and treatment. Some special operational jobs, such as aircrew, missile operators, and divers, have more restrictive medical requirements that are monitored by physicians with special training in these populations.

Atopic dermatitis affects 25% of children and 2% to 3% of adults.⁵ Approximately 60% of patients with AD will develop their first eruption by 1 year of age, and 90% by 5 years of age. Although the majority of patients will have resolution of their disease during childhood, 10% to 30% will have persistent disease into adulthood.⁵ Because the majority of AD resolves in childhood, it is understandable that asymptomatic individuals with a history of AD before 12 years of age meet military entrance medical standards.

Provoking Factors

The US Military maintains stringent medical standards because of the nature of the dynamic, rapidly changing military environment and its demands. Whether training for readiness in an austere location, deploying to extreme climates, or being stationed overseas, service members must be prepared to encounter a myriad of environmental extremes, physical stress, and psychological stressors. Environmental factors commonly experienced in the military can provoke or exacerbate symptoms of AD (Figures 1 and 2). Ideally, an individual with AD lives in a stable climate, has access to moisturizers and topical steroids, bathes regularly to remove dust and debris, wears 100% cotton garments to avoid irritation, and avoids using gear that would cause exacerbations. Service members rarely have such accommodations in deployed settings. A recent article in Military Medicine explained quite well, “If someone wanted to design an experience with the explicit goal to flare a person with otherwise well controlled atopic dermatitis it would probably look like a military deployment.”³

The United States has a military presence in countries with extreme temperature and humidity variations all over the world. Uniforms are standardized, and members are required to wear prescribed clothing with no alternatives. Uniforms are made of durable sturdy material. If uniforms can be laundered, they often are grouped together, and sensitive detergent cannot be specified. Bathing is challenging in deployed locations, with troops often going weeks using baby wipes for self-hygiene. These conditions increase risk for development of contact allergens, and little access to proper hygiene practices also increases risk for secondary infections in members with AD.

In addition to environmental challenges, the military gear and equipment used can flare AD. Service members must wear protective gear such as body armor. These heavy hard pieces of material are bulky; difficult to wash; and cause friction, sweating, and irritation. The military prepares for operations in chemical, biological, radiological, or nuclear environments, which requires wearing a rubber mask, multiple layers of boots and gloves, and thick charcoal impregnated over garments for many hours. Such conditions may flare AD or make it intolerable.

Although stress is a part of any deployment experience, excessive or prolonged stress can lead to combat operational stress reactions that inhibit a service member’s ability to function.⁶ Stressors during deployment can accumulate and may be caused by the operational environment, loss of fellow service members to injury or death, illness, leadership demands, personal choices, issues on the home front, interpersonal conflicts, and sleep loss.⁷ Atopic dermatitis can be exacerbated by such stress, leading to increased pruritus and scratching.^7-9 Symptomatic AD also can play a role in worsening combat stress. Although severe pruritus may affect attentiveness to job duties during the day, these symptoms, if uncontrolled, also can negatively affect sleep. As many as 60% of patients with AD at baseline and 83% of patients with exacerbations experience sleep disturbance due to their disease.⁵ These stressors experienced by deployed military personnel can contribute to combat stress reactions, which may vary from simple inattentiveness to more serious behaviors such as suicidal ideation.⁶ Combat stress reactions inhibit a military member’s ability to function properly in the deployed environment and can lead to notable safety concerns and potential mission failure.

Vaccinations

Military members deploying overseas are required to receive specific vaccinations, including the smallpox vaccine. Although the virus was eradicated in 1980, the concern for smallpox to be used as a biological weapon in certain areas of the world necessitates continued vaccination of military populations. According to the Centers for Disease Control and Prevention, the only known reservoir for the virus is humans, and the disease has a mortality rate of 30%.¹⁰ A history of or present AD is a contraindication for primary smallpox vaccination and revaccination for nonemergency use because of the risk for eczema vaccinatum.¹¹ The risk also applies to close contacts of vaccinated members. For 30 days after vaccination, service members must avoid skin-to-skin contact with anyone who has active AD.¹² Eczema vaccinatum in vaccinated individuals is typically self-limited; however, eczema vaccinatum in nonvaccinated contacts can be severe. One case report described a 28-month-old child with refractory AD who developed severe eczema vaccinatum after contact with her recently vaccinated military parent. The child required a 48-day admission to the intensive care unit and multiple skin grafts; fortunately, the child did not develop any apparent long-term sequelae.¹³ This case highlights the importance of understanding the risks associated with smallpox vaccination in military members with AD and the responsibility of health care providers to properly screen and counsel individuals prior to administering smallpox vaccines.

Treatment

Treatment of mild to moderate AD is relatively straightforward in developed countries with good access to medical care. The most recent American Academy of Dermatology clinical guidelines for AD focus on minimizing irritants and triggers, regularly using moisturizers soon after bathing, and using topical steroids as needed.⁵ Military members face specific challenges regarding treatment of AD, particularly when deployed to remote locations without access to treatment facilities or medications. Military members are required to carry all necessary personal medications with them for at least 6 months and preferably the duration of the deployment, sometimes up to 1 year. Military members carry a large amount of gear for deployments, and it is not feasible to pack an additional 10 to 20 lb worth of emollients and topical steroids to last the entire deployment. Routine laboratory monitoring is limited or completely unavailable. Refrigeration typically is not available, making use of systemic medications nearly impossible during deployments. In the event of complications such as eczema herpeticum or secondary bacterial infection, service members could require evacuation from the deployed location to a larger field hospital or to the United States, which is costly and also removes a valuable team member from the deployed unit. These limitations in access to care, medications, and treatment options make AD a difficult condition to treat in the deployed setting.

Nonmilitary Medical Providers

Civilian providers play an important role in diagnosing and treating AD. It is vital to completely and accurately document treatment of all skin diseases; however, it is especially important for those who desire to or currently serve in the military. Military primary care providers or military dermatologists must review the information from civilian providers to aid in determining suitability for entry or retention in the military. Clearly documenting the morphology, extent of disease involvement (eg, body surface area), treatment plan, response to treatment, and exacerbating factors will aid in ensuring the patient’s medical record accurately reflects their skin disease. Ultimately, this record often is the only information available to make health determinations regarding military service.

Conclusion

A career in the military is challenging and rewarding for those who volunteer to serve. Because of the demanding and unpredictable lifestyle inherent with military service, the Department of Defense maintains strict medical standards for entrance and retention. These standards ensure members are capable of safely completing training and deploying anywhere in the world. Although AD is a relatively common and treatable skin disease in locations with well-established medical care, it can pose a notable problem for service members while deployed to austere locations with variable environments around the world. Environmental factors and gear requirements, coupled with limited access to treatment facilities and medications, render AD a potentially serious issue. Atopic dermatitis in military members can affect individual medical readiness and unit success. It is important that all providers understand the myriad effects that AD can have on an individual who wishes to join or continue service in the military.

Dermatologic conditions historically have affected military members’ ability to serve during times of peace and conflict. These conditions range from chronic dermatologic diseases to environment- or occupation-related dermatologic diseases. Mild to moderate atopic dermatitis (AD) typically is a manageable skin condition. However, in a deployed setting, a flare of AD can result in the inability of a member to perform their military duty, which directly compromises mission safety and effectiveness. The military developed and updates medical standards for entry and retention of service members. These standards are designed to ensure the greatest potential for a military member to successfully serve at home station and during combat operations.

Impact of Injuries in Military

Historically, disease and nonbattle injuries have resulted in notably more hospitalizations and time lost than injuries sustained on the battlefield.¹ A review of major conflicts dating from World War II shows approximately 10% of all dermatologic concerns were related to eczematous dermatitis, with 2% specifically related to AD. These numbers varied remarkably depending on the location and environment of the conflict, with eczema accounting for 25% of dermatologic concerns during the Gulf War.² During the initial phases of Operation Iraqi Freedom, approximately 75% of hospitalizations were from disease and nonbattle injuries, of which dermatologic disease accounted for 3%.¹ From 2003 to 2006 in Iraq, 35 service members were evacuated from combat zones specifically for uncontrolled AD.³ In a deployed environment, each member is critical to the unit’s success in completing their mission. A single member of a unit often is the only person qualified to perform a function for that team. There are rarely extra people with similar skills to replace a member unable to complete his/her duties. The loss of a single member compromises the effectiveness and safety of the team and can lead to mission failure. Therefore, AD can have a profound impact on military operations in a deployed environment.

Military Medical Standards for Accession and Retention

There are 2 main goals of the military medical standards. First, the individual health of the applicant or military member is of utmost importance. Applicants with medical conditions that will be exacerbated by military service or that limit the ability for successful military operations are not accepted for military service. Once an active-duty member is diagnosed with a medical condition, the military determines if limitations are needed for military assignments and deployments based on available medical care in those locations. Second, mission accomplishment in combat operations requires that healthy military members are able to complete their jobs in extreme environments and under notable stress. If an applicant has a medical condition unsuitable for military service, it is in the best interest of the applicant and the military to deny entry.

The Medical Standards for Appointment, Enlistment, or Induction Into the Military Services (DoD Instruction 6130.03) lists conditions that are disqualifying for military service.⁴ Section 5.21 lists the following as disqualifying for military service in relation to eczematous dermatitis:

d. History of AD or eczema after the 12th birthday. History of residual or recurrent lesions in characteristic areas (face, neck, antecubital or popliteal fossae, occasionally wrists and hands).

 

 

 

e. History of recurrent or chronic nonspecific dermatitis within the past 2 years to include contact (irritant or allergic) or dyshidrotic dermatitis requiring more than treatment with topical corticosteroid.⁴

Although cases of incorrect diagnosis or very mild AD can be considered for a waiver, the process can be laborious and consideration or approval is not guaranteed. For current military members with new chronic eczematous dermatitis, each service has a process for evaluation and treatment. Some special operational jobs, such as aircrew, missile operators, and divers, have more restrictive medical requirements that are monitored by physicians with special training in these populations.

Atopic dermatitis affects 25% of children and 2% to 3% of adults.⁵ Approximately 60% of patients with AD will develop their first eruption by 1 year of age, and 90% by 5 years of age. Although the majority of patients will have resolution of their disease during childhood, 10% to 30% will have persistent disease into adulthood.⁵ Because the majority of AD resolves in childhood, it is understandable that asymptomatic individuals with a history of AD before 12 years of age meet military entrance medical standards.

Provoking Factors

The US Military maintains stringent medical standards because of the nature of the dynamic, rapidly changing military environment and its demands. Whether training for readiness in an austere location, deploying to extreme climates, or being stationed overseas, service members must be prepared to encounter a myriad of environmental extremes, physical stress, and psychological stressors. Environmental factors commonly experienced in the military can provoke or exacerbate symptoms of AD (Figures 1 and 2). Ideally, an individual with AD lives in a stable climate, has access to moisturizers and topical steroids, bathes regularly to remove dust and debris, wears 100% cotton garments to avoid irritation, and avoids using gear that would cause exacerbations. Service members rarely have such accommodations in deployed settings. A recent article in Military Medicine explained quite well, “If someone wanted to design an experience with the explicit goal to flare a person with otherwise well controlled atopic dermatitis it would probably look like a military deployment.”³

The United States has a military presence in countries with extreme temperature and humidity variations all over the world. Uniforms are standardized, and members are required to wear prescribed clothing with no alternatives. Uniforms are made of durable sturdy material. If uniforms can be laundered, they often are grouped together, and sensitive detergent cannot be specified. Bathing is challenging in deployed locations, with troops often going weeks using baby wipes for self-hygiene. These conditions increase risk for development of contact allergens, and little access to proper hygiene practices also increases risk for secondary infections in members with AD.

In addition to environmental challenges, the military gear and equipment used can flare AD. Service members must wear protective gear such as body armor. These heavy hard pieces of material are bulky; difficult to wash; and cause friction, sweating, and irritation. The military prepares for operations in chemical, biological, radiological, or nuclear environments, which requires wearing a rubber mask, multiple layers of boots and gloves, and thick charcoal impregnated over garments for many hours. Such conditions may flare AD or make it intolerable.

Although stress is a part of any deployment experience, excessive or prolonged stress can lead to combat operational stress reactions that inhibit a service member’s ability to function.⁶ Stressors during deployment can accumulate and may be caused by the operational environment, loss of fellow service members to injury or death, illness, leadership demands, personal choices, issues on the home front, interpersonal conflicts, and sleep loss.⁷ Atopic dermatitis can be exacerbated by such stress, leading to increased pruritus and scratching.^7-9 Symptomatic AD also can play a role in worsening combat stress. Although severe pruritus may affect attentiveness to job duties during the day, these symptoms, if uncontrolled, also can negatively affect sleep. As many as 60% of patients with AD at baseline and 83% of patients with exacerbations experience sleep disturbance due to their disease.⁵ These stressors experienced by deployed military personnel can contribute to combat stress reactions, which may vary from simple inattentiveness to more serious behaviors such as suicidal ideation.⁶ Combat stress reactions inhibit a military member’s ability to function properly in the deployed environment and can lead to notable safety concerns and potential mission failure.

Vaccinations

Military members deploying overseas are required to receive specific vaccinations, including the smallpox vaccine. Although the virus was eradicated in 1980, the concern for smallpox to be used as a biological weapon in certain areas of the world necessitates continued vaccination of military populations. According to the Centers for Disease Control and Prevention, the only known reservoir for the virus is humans, and the disease has a mortality rate of 30%.¹⁰ A history of or present AD is a contraindication for primary smallpox vaccination and revaccination for nonemergency use because of the risk for eczema vaccinatum.¹¹ The risk also applies to close contacts of vaccinated members. For 30 days after vaccination, service members must avoid skin-to-skin contact with anyone who has active AD.¹² Eczema vaccinatum in vaccinated individuals is typically self-limited; however, eczema vaccinatum in nonvaccinated contacts can be severe. One case report described a 28-month-old child with refractory AD who developed severe eczema vaccinatum after contact with her recently vaccinated military parent. The child required a 48-day admission to the intensive care unit and multiple skin grafts; fortunately, the child did not develop any apparent long-term sequelae.¹³ This case highlights the importance of understanding the risks associated with smallpox vaccination in military members with AD and the responsibility of health care providers to properly screen and counsel individuals prior to administering smallpox vaccines.

Treatment

Treatment of mild to moderate AD is relatively straightforward in developed countries with good access to medical care. The most recent American Academy of Dermatology clinical guidelines for AD focus on minimizing irritants and triggers, regularly using moisturizers soon after bathing, and using topical steroids as needed.⁵ Military members face specific challenges regarding treatment of AD, particularly when deployed to remote locations without access to treatment facilities or medications. Military members are required to carry all necessary personal medications with them for at least 6 months and preferably the duration of the deployment, sometimes up to 1 year. Military members carry a large amount of gear for deployments, and it is not feasible to pack an additional 10 to 20 lb worth of emollients and topical steroids to last the entire deployment. Routine laboratory monitoring is limited or completely unavailable. Refrigeration typically is not available, making use of systemic medications nearly impossible during deployments. In the event of complications such as eczema herpeticum or secondary bacterial infection, service members could require evacuation from the deployed location to a larger field hospital or to the United States, which is costly and also removes a valuable team member from the deployed unit. These limitations in access to care, medications, and treatment options make AD a difficult condition to treat in the deployed setting.

Nonmilitary Medical Providers

Civilian providers play an important role in diagnosing and treating AD. It is vital to completely and accurately document treatment of all skin diseases; however, it is especially important for those who desire to or currently serve in the military. Military primary care providers or military dermatologists must review the information from civilian providers to aid in determining suitability for entry or retention in the military. Clearly documenting the morphology, extent of disease involvement (eg, body surface area), treatment plan, response to treatment, and exacerbating factors will aid in ensuring the patient’s medical record accurately reflects their skin disease. Ultimately, this record often is the only information available to make health determinations regarding military service.

Conclusion

A career in the military is challenging and rewarding for those who volunteer to serve. Because of the demanding and unpredictable lifestyle inherent with military service, the Department of Defense maintains strict medical standards for entrance and retention. These standards ensure members are capable of safely completing training and deploying anywhere in the world. Although AD is a relatively common and treatable skin disease in locations with well-established medical care, it can pose a notable problem for service members while deployed to austere locations with variable environments around the world. Environmental factors and gear requirements, coupled with limited access to treatment facilities and medications, render AD a potentially serious issue. Atopic dermatitis in military members can affect individual medical readiness and unit success. It is important that all providers understand the myriad effects that AD can have on an individual who wishes to join or continue service in the military.

Dermatologic conditions historically have affected military members’ ability to serve during times of peace and conflict. These conditions range from chronic dermatologic diseases to environment- or occupation-related dermatologic diseases. Mild to moderate atopic dermatitis (AD) typically is a manageable skin condition. However, in a deployed setting, a flare of AD can result in the inability of a member to perform their military duty, which directly compromises mission safety and effectiveness. The military developed and updates medical standards for entry and retention of service members. These standards are designed to ensure the greatest potential for a military member to successfully serve at home station and during combat operations.

Impact of Injuries in Military

Historically, disease and nonbattle injuries have resulted in notably more hospitalizations and time lost than injuries sustained on the battlefield.¹ A review of major conflicts dating from World War II shows approximately 10% of all dermatologic concerns were related to eczematous dermatitis, with 2% specifically related to AD. These numbers varied remarkably depending on the location and environment of the conflict, with eczema accounting for 25% of dermatologic concerns during the Gulf War.² During the initial phases of Operation Iraqi Freedom, approximately 75% of hospitalizations were from disease and nonbattle injuries, of which dermatologic disease accounted for 3%.¹ From 2003 to 2006 in Iraq, 35 service members were evacuated from combat zones specifically for uncontrolled AD.³ In a deployed environment, each member is critical to the unit’s success in completing their mission. A single member of a unit often is the only person qualified to perform a function for that team. There are rarely extra people with similar skills to replace a member unable to complete his/her duties. The loss of a single member compromises the effectiveness and safety of the team and can lead to mission failure. Therefore, AD can have a profound impact on military operations in a deployed environment.

Military Medical Standards for Accession and Retention

There are 2 main goals of the military medical standards. First, the individual health of the applicant or military member is of utmost importance. Applicants with medical conditions that will be exacerbated by military service or that limit the ability for successful military operations are not accepted for military service. Once an active-duty member is diagnosed with a medical condition, the military determines if limitations are needed for military assignments and deployments based on available medical care in those locations. Second, mission accomplishment in combat operations requires that healthy military members are able to complete their jobs in extreme environments and under notable stress. If an applicant has a medical condition unsuitable for military service, it is in the best interest of the applicant and the military to deny entry.

The Medical Standards for Appointment, Enlistment, or Induction Into the Military Services (DoD Instruction 6130.03) lists conditions that are disqualifying for military service.⁴ Section 5.21 lists the following as disqualifying for military service in relation to eczematous dermatitis:

d. History of AD or eczema after the 12th birthday. History of residual or recurrent lesions in characteristic areas (face, neck, antecubital or popliteal fossae, occasionally wrists and hands).

 

 

 

e. History of recurrent or chronic nonspecific dermatitis within the past 2 years to include contact (irritant or allergic) or dyshidrotic dermatitis requiring more than treatment with topical corticosteroid.⁴

Although cases of incorrect diagnosis or very mild AD can be considered for a waiver, the process can be laborious and consideration or approval is not guaranteed. For current military members with new chronic eczematous dermatitis, each service has a process for evaluation and treatment. Some special operational jobs, such as aircrew, missile operators, and divers, have more restrictive medical requirements that are monitored by physicians with special training in these populations.

Atopic dermatitis affects 25% of children and 2% to 3% of adults.⁵ Approximately 60% of patients with AD will develop their first eruption by 1 year of age, and 90% by 5 years of age. Although the majority of patients will have resolution of their disease during childhood, 10% to 30% will have persistent disease into adulthood.⁵ Because the majority of AD resolves in childhood, it is understandable that asymptomatic individuals with a history of AD before 12 years of age meet military entrance medical standards.

Provoking Factors

The US Military maintains stringent medical standards because of the nature of the dynamic, rapidly changing military environment and its demands. Whether training for readiness in an austere location, deploying to extreme climates, or being stationed overseas, service members must be prepared to encounter a myriad of environmental extremes, physical stress, and psychological stressors. Environmental factors commonly experienced in the military can provoke or exacerbate symptoms of AD (Figures 1 and 2). Ideally, an individual with AD lives in a stable climate, has access to moisturizers and topical steroids, bathes regularly to remove dust and debris, wears 100% cotton garments to avoid irritation, and avoids using gear that would cause exacerbations. Service members rarely have such accommodations in deployed settings. A recent article in Military Medicine explained quite well, “If someone wanted to design an experience with the explicit goal to flare a person with otherwise well controlled atopic dermatitis it would probably look like a military deployment.”³

The United States has a military presence in countries with extreme temperature and humidity variations all over the world. Uniforms are standardized, and members are required to wear prescribed clothing with no alternatives. Uniforms are made of durable sturdy material. If uniforms can be laundered, they often are grouped together, and sensitive detergent cannot be specified. Bathing is challenging in deployed locations, with troops often going weeks using baby wipes for self-hygiene. These conditions increase risk for development of contact allergens, and little access to proper hygiene practices also increases risk for secondary infections in members with AD.

In addition to environmental challenges, the military gear and equipment used can flare AD. Service members must wear protective gear such as body armor. These heavy hard pieces of material are bulky; difficult to wash; and cause friction, sweating, and irritation. The military prepares for operations in chemical, biological, radiological, or nuclear environments, which requires wearing a rubber mask, multiple layers of boots and gloves, and thick charcoal impregnated over garments for many hours. Such conditions may flare AD or make it intolerable.

Although stress is a part of any deployment experience, excessive or prolonged stress can lead to combat operational stress reactions that inhibit a service member’s ability to function.⁶ Stressors during deployment can accumulate and may be caused by the operational environment, loss of fellow service members to injury or death, illness, leadership demands, personal choices, issues on the home front, interpersonal conflicts, and sleep loss.⁷ Atopic dermatitis can be exacerbated by such stress, leading to increased pruritus and scratching.^7-9 Symptomatic AD also can play a role in worsening combat stress. Although severe pruritus may affect attentiveness to job duties during the day, these symptoms, if uncontrolled, also can negatively affect sleep. As many as 60% of patients with AD at baseline and 83% of patients with exacerbations experience sleep disturbance due to their disease.⁵ These stressors experienced by deployed military personnel can contribute to combat stress reactions, which may vary from simple inattentiveness to more serious behaviors such as suicidal ideation.⁶ Combat stress reactions inhibit a military member’s ability to function properly in the deployed environment and can lead to notable safety concerns and potential mission failure.

Vaccinations

Military members deploying overseas are required to receive specific vaccinations, including the smallpox vaccine. Although the virus was eradicated in 1980, the concern for smallpox to be used as a biological weapon in certain areas of the world necessitates continued vaccination of military populations. According to the Centers for Disease Control and Prevention, the only known reservoir for the virus is humans, and the disease has a mortality rate of 30%.¹⁰ A history of or present AD is a contraindication for primary smallpox vaccination and revaccination for nonemergency use because of the risk for eczema vaccinatum.¹¹ The risk also applies to close contacts of vaccinated members. For 30 days after vaccination, service members must avoid skin-to-skin contact with anyone who has active AD.¹² Eczema vaccinatum in vaccinated individuals is typically self-limited; however, eczema vaccinatum in nonvaccinated contacts can be severe. One case report described a 28-month-old child with refractory AD who developed severe eczema vaccinatum after contact with her recently vaccinated military parent. The child required a 48-day admission to the intensive care unit and multiple skin grafts; fortunately, the child did not develop any apparent long-term sequelae.¹³ This case highlights the importance of understanding the risks associated with smallpox vaccination in military members with AD and the responsibility of health care providers to properly screen and counsel individuals prior to administering smallpox vaccines.

Treatment

Treatment of mild to moderate AD is relatively straightforward in developed countries with good access to medical care. The most recent American Academy of Dermatology clinical guidelines for AD focus on minimizing irritants and triggers, regularly using moisturizers soon after bathing, and using topical steroids as needed.⁵ Military members face specific challenges regarding treatment of AD, particularly when deployed to remote locations without access to treatment facilities or medications. Military members are required to carry all necessary personal medications with them for at least 6 months and preferably the duration of the deployment, sometimes up to 1 year. Military members carry a large amount of gear for deployments, and it is not feasible to pack an additional 10 to 20 lb worth of emollients and topical steroids to last the entire deployment. Routine laboratory monitoring is limited or completely unavailable. Refrigeration typically is not available, making use of systemic medications nearly impossible during deployments. In the event of complications such as eczema herpeticum or secondary bacterial infection, service members could require evacuation from the deployed location to a larger field hospital or to the United States, which is costly and also removes a valuable team member from the deployed unit. These limitations in access to care, medications, and treatment options make AD a difficult condition to treat in the deployed setting.

Nonmilitary Medical Providers

Civilian providers play an important role in diagnosing and treating AD. It is vital to completely and accurately document treatment of all skin diseases; however, it is especially important for those who desire to or currently serve in the military. Military primary care providers or military dermatologists must review the information from civilian providers to aid in determining suitability for entry or retention in the military. Clearly documenting the morphology, extent of disease involvement (eg, body surface area), treatment plan, response to treatment, and exacerbating factors will aid in ensuring the patient’s medical record accurately reflects their skin disease. Ultimately, this record often is the only information available to make health determinations regarding military service.

Conclusion

A career in the military is challenging and rewarding for those who volunteer to serve. Because of the demanding and unpredictable lifestyle inherent with military service, the Department of Defense maintains strict medical standards for entrance and retention. These standards ensure members are capable of safely completing training and deploying anywhere in the world. Although AD is a relatively common and treatable skin disease in locations with well-established medical care, it can pose a notable problem for service members while deployed to austere locations with variable environments around the world. Environmental factors and gear requirements, coupled with limited access to treatment facilities and medications, render AD a potentially serious issue. Atopic dermatitis in military members can affect individual medical readiness and unit success. It is important that all providers understand the myriad effects that AD can have on an individual who wishes to join or continue service in the military.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.

Limb amputation is a major life-changing event that markedly affects a patient’s quality of life as well as his/her ability to participate in activities of daily living. The most prevalent causes for amputation include vascular diseases, diabetes mellitus, trauma, and cancer, respectively.^1,2 For amputees, maintaining prosthetic use is a major physical and psychological undertaking that benefits from a multidisciplinary team approach. Although individuals with lower limb amputations are disproportionately impacted by skin disease due to the increased mechanical forces exerted over the lower limbs, patients with upper limb amputations also develop dermatologic conditions secondary to wearing prostheses.

Approximately 185,000 amputations occur each year in the United States.³ Although amputations resulting from peripheral vascular disease or diabetes mellitus tend to occur in older individuals, amputations in younger patients usually occur from trauma.² The US military has experienced increasing numbers of amputations from trauma due to the ongoing combat operations in the Middle East. Although improvements in body armor and tactical combat casualty care have reduced the number of preventable deaths, the number of casualties surviving with extremity injuries requiring amputation has increased.^4,5 As of October 2017, 1705 US servicemembers underwent major limb amputations, with 1914 lower limb amputations and 302 upper limb amputations. These amputations mainly impacted men aged 21 to 29 years, but female servicemembers also were affected, and a small group of servicemembers had multiple amputations.⁶

One of the most common medical problems that amputees face during long-term care is skin disease, with approximately 75% of amputees using a lower limb prosthesis experiencing skin problems. In general, amputees experience nearly 65% more dermatologic concerns than the general population.⁷ In one study of 97 individuals with transfemoral amputations, some of the most common issues associated with socket prosthetics included heat and sweating in the prosthetic socket (72%) as well as sores and skin irritation from the socket (62%).⁸ Given the high incidence of skin disease on residual limbs, dermatologists are uniquely positioned to keep the amputee in his/her prosthesis and prevent prosthetic abandonment.

Complications Following Amputation

Although US military servicemembers who undergo amputations receive the very best prosthetic devices and rehabilitation resources, they still experience prosthesis abandonment.⁹ Despite the fact that prosthetic limbs and prosthesis technology have substantially improved over the last 2 decades, one study indicated that the high frequency of problems affecting tissue viability at residual limbs is due to the age-old problem of prosthetic fit.¹⁰ In patients with the most advanced prostheses, poor fit still results in mechanical damage to the skin, as the residual limb is exposed to unequal and shearing forces across the amputation site as well as high pressures that cause a vaso-occlusive effect.^11,12 Issues with poor fit are especially important for more active patients, as they normally want to immediately return to their vigorous preinjury lifestyles. In these patients, even a properly fitting prosthetic may not be able to overcome the fact that the residual limb skin is not well suited for the mechanical forces generated by the prosthesis and the humid environment of the socket.^1,13 Another complicating factor is the dynamic nature of the residual limb. Muscle atrophy, changes in gait, and weight gain or loss can lead to an ill-fitting prosthetic and subsequent skin breakdown.

There are many case reports and review articles describing the skin problems in amputees.^1,14-17 The Table summarizes these conditions and outlines treatment options for each.^15,18-20

Most skin diseases on residual limbs are the result of mechanical skin breakdown, inflammation, infection, or combinations of these processes. Overall, amputees with diabetes mellitus and peripheral vascular disease tend to have skin disease related to poor perfusion, whereas amputees who are active and healthy tend to have conditions related to mechanical stress.^{7,13,14,17,21,22} Bui et al¹⁷ reported ulcers, abscesses, and blisters as the most common skin conditions that occur at the site of residual limbs; however, other less common dermatologic disorders such as skin malignancies, verrucous hyperplasia and carcinoma, granulomatous cutaneous lesions, acroangiodermatitis, and bullous pemphigoid also are seen.^23-26 Buikema and Meyerle¹⁵ hypothesize that these conditions, as well as the more common skin diseases, are partly from the amputation disrupting blood and lymphatic flow in the residual limb, which causes the site to act as an immunocompromised district that induces dysregulation of neuroimmune regulators.

It is important to note that skin disease on residual limbs is not just an acute problem. Long-term follow-up of 247 traumatic amputees from the Vietnam War showed that almost half of prosthesis users (48.2%) reported a skin problem in the preceding year, more than 38 years after the amputation. Additionally, one-quarter of these individuals experienced skin problems approximately 50% of the time, which unfortunately led to limited use or total abandonment of the prosthesis for the preceding year in 56% of the veterans surveyed.²¹

Other complications following amputation indirectly lead to skin problems. Heterotopic ossification, or the formation of bone at extraskeletal sites, has been observed in up to 65% of military amputees from recent operations in Iraq and Afghanistan.^27,28 If symptomatic, heterotopic ossification can lead to poor prosthetic fit and subsequent skin breakdown. As a result, it has been reported that up to 40% of combat-related lower extremity amputations may require excision of heterotopic ossificiation.²⁹

Amputation also can result in psychologic concerns that indirectly affect skin health. A systematic review by Mckechnie and John³⁰ suggested that despite heterogeneity between studies, even using the lowest figures demonstrated the significance anxiety and depression play in the lives of traumatic amputees. If left untreated, these mental health issues can lead to poor residual limb hygiene and prosthetic maintenance due to reductions in the patient’s energy and motivation. Studies have shown that proper hygiene of residual limbs and silicone liners reduces associated skin problems.^19,31

Role of the Dermatologist

Routine care and conservative management of amputee skin problems often are accomplished by prosthetists, primary care physicians, nurses, and physical therapists. In one study, more than 80% of the most common skin problems affecting amputees could be attributed to the prosthesis itself, which highlights the importance of the continued involvement of the prosthetist beyond the initial fitting period.¹³ However, when a skin problem becomes refractory to conservative management, referral to a dermatologist is prudent; therefore, the dermatologist is an integral member of the multidisciplinary team that provides care for amputees.

The dermatologist often is best positioned to diagnose skin diseases that result from wearing prostheses and is well versed in treatments for short-term and long-term management of skin disease on residual limbs. The dermatologist also can offer prophylactic treatments to decrease sweating and hair growth to prevent potential infections and subsequent skin breakdown. Additionally, proper education on self-care has been shown to decrease the amount of skin problems and increase functional status and quality of life for amputees.^32,33 Dermatologists can assist with the patient education process as well as refer amputees to a useful resource from the Amputee Coalition website (www.amputee-coalition.org) to provide specific patient education on how to maintain skin on the residual limb to prevent skin disease.

Current Treatments and Future Directions

Skin disorders affecting residual limbs usually are conditions that dermatologists commonly encounter and are comfortable managing in general practice. Additionally, dermatologists routinely treat hyperhidrosis and conduct laser hair removal, both of which are effective prophylactic adjuncts for amputee skin health. There are a few treatments for reducing residual limb hyperhidrosis that are particularly useful. Although first-line treatment of residual limb hyperhidrosis often is topical aluminum chloride, it requires frequent application and often causes considerable skin irritation when applied to residual limbs. Alternatively, intradermal botulinum toxin has been shown to successfully reduce sweat production in individuals with residual limb hyperhidrosis and is well tolerated.³⁴ A 2017 case report discussed the use of microwave thermal ablation of eccrine coils using a noninvasive 3-step hyperhidrosis treatment system on a bilateral below-the-knee amputee. The authors reported the patient tolerated the procedure well with decreased dermatitis and folliculitis, leading to his ability to wear a prosthetic for longer periods of time.³⁵

Ablative fractional resurfacing with a CO₂ laser is another key treatment modality central to amputees, more specifically to traumatic amputees. A CO₂ laser can decrease skin tension and increase skin mobility associated with traumatic scars as well as decrease skin vulnerability to biofilms present in chronic wounds on residual limbs. It is believed that the pattern of injury caused by ablative fractional lasers disrupts biofilms and stimulates growth factor secretion and collagen remodeling through the concept of photomicrodebridement.³⁶ The ablative fractional resurfacing approach to scar therapy and chronic wound debridement can result in less skin injury, allowing the amputee to continue rehabilitation and return more quickly to prosthetic use.³⁷

One interesting area of research in amputee care involves the study of novel ways to increase the skin’s ability to adapt to mechanical stress and load bearing and accelerate wound healing on the residual limb. Multiple studies have identified collagen fibril enlargement as an important component of skin adaptation, and biomolecules such as decorin may enhance this process.^38-40 The concept of increasing these biomolecules at the correct time during wound healing to strengthen the residual limb tissue currently is being studied.³⁹

Another encouraging area of research is the involvement of fibroblasts in cutaneous wound healing and their role in determining the phenotype of residual limb skin in amputees. The clinical application of autologous fibroblasts is approved by the US Food and Drug Administration for cosmetic use as a filler material and currently is under research for other applications, such as skin regeneration after surgery or manipulating skin characteristics to enhance the durability of residual limbs.⁴¹

Future preventative care of amputee skin may rely on tracking residual limb health before severe tissue injury occurs. For instance, Rink et al⁴² described an approach to monitor residual limb health using noninvasive imaging (eg, hyperspectral imaging, laser speckle imaging) and noninvasive probes that measure oxygenation, perfusion, skin barrier function, and skin hydration to the residual limb. Although these limb surveillance sensors would be employed by prosthetists, the dermatologist, as part of the multispecialty team, also could leverage the data for diagnosis and treatment considerations.

Final Thoughts

The dermatologist is an important member of the multidisciplinary team involved in the care of amputees. Skin disease is prevalent in amputees throughout their lives and often leads to abandonment of prostheses. Although current therapies and preventative treatments are for the most part successful, future research involving advanced technology to monitor skin health, increasing residual limb skin durability at the molecular level, and targeted laser therapies are promising. Through engagement and effective collaboration with the entire multidisciplinary team, dermatologists will have a considerable impact on amputee skin health.

Limb amputation is a major life-changing event that markedly affects a patient’s quality of life as well as his/her ability to participate in activities of daily living. The most prevalent causes for amputation include vascular diseases, diabetes mellitus, trauma, and cancer, respectively.^1,2 For amputees, maintaining prosthetic use is a major physical and psychological undertaking that benefits from a multidisciplinary team approach. Although individuals with lower limb amputations are disproportionately impacted by skin disease due to the increased mechanical forces exerted over the lower limbs, patients with upper limb amputations also develop dermatologic conditions secondary to wearing prostheses.

Approximately 185,000 amputations occur each year in the United States.³ Although amputations resulting from peripheral vascular disease or diabetes mellitus tend to occur in older individuals, amputations in younger patients usually occur from trauma.² The US military has experienced increasing numbers of amputations from trauma due to the ongoing combat operations in the Middle East. Although improvements in body armor and tactical combat casualty care have reduced the number of preventable deaths, the number of casualties surviving with extremity injuries requiring amputation has increased.^4,5 As of October 2017, 1705 US servicemembers underwent major limb amputations, with 1914 lower limb amputations and 302 upper limb amputations. These amputations mainly impacted men aged 21 to 29 years, but female servicemembers also were affected, and a small group of servicemembers had multiple amputations.⁶

One of the most common medical problems that amputees face during long-term care is skin disease, with approximately 75% of amputees using a lower limb prosthesis experiencing skin problems. In general, amputees experience nearly 65% more dermatologic concerns than the general population.⁷ In one study of 97 individuals with transfemoral amputations, some of the most common issues associated with socket prosthetics included heat and sweating in the prosthetic socket (72%) as well as sores and skin irritation from the socket (62%).⁸ Given the high incidence of skin disease on residual limbs, dermatologists are uniquely positioned to keep the amputee in his/her prosthesis and prevent prosthetic abandonment.

Complications Following Amputation

Although US military servicemembers who undergo amputations receive the very best prosthetic devices and rehabilitation resources, they still experience prosthesis abandonment.⁹ Despite the fact that prosthetic limbs and prosthesis technology have substantially improved over the last 2 decades, one study indicated that the high frequency of problems affecting tissue viability at residual limbs is due to the age-old problem of prosthetic fit.¹⁰ In patients with the most advanced prostheses, poor fit still results in mechanical damage to the skin, as the residual limb is exposed to unequal and shearing forces across the amputation site as well as high pressures that cause a vaso-occlusive effect.^11,12 Issues with poor fit are especially important for more active patients, as they normally want to immediately return to their vigorous preinjury lifestyles. In these patients, even a properly fitting prosthetic may not be able to overcome the fact that the residual limb skin is not well suited for the mechanical forces generated by the prosthesis and the humid environment of the socket.^1,13 Another complicating factor is the dynamic nature of the residual limb. Muscle atrophy, changes in gait, and weight gain or loss can lead to an ill-fitting prosthetic and subsequent skin breakdown.

There are many case reports and review articles describing the skin problems in amputees.^1,14-17 The Table summarizes these conditions and outlines treatment options for each.^15,18-20

Most skin diseases on residual limbs are the result of mechanical skin breakdown, inflammation, infection, or combinations of these processes. Overall, amputees with diabetes mellitus and peripheral vascular disease tend to have skin disease related to poor perfusion, whereas amputees who are active and healthy tend to have conditions related to mechanical stress.^{7,13,14,17,21,22} Bui et al¹⁷ reported ulcers, abscesses, and blisters as the most common skin conditions that occur at the site of residual limbs; however, other less common dermatologic disorders such as skin malignancies, verrucous hyperplasia and carcinoma, granulomatous cutaneous lesions, acroangiodermatitis, and bullous pemphigoid also are seen.^23-26 Buikema and Meyerle¹⁵ hypothesize that these conditions, as well as the more common skin diseases, are partly from the amputation disrupting blood and lymphatic flow in the residual limb, which causes the site to act as an immunocompromised district that induces dysregulation of neuroimmune regulators.

It is important to note that skin disease on residual limbs is not just an acute problem. Long-term follow-up of 247 traumatic amputees from the Vietnam War showed that almost half of prosthesis users (48.2%) reported a skin problem in the preceding year, more than 38 years after the amputation. Additionally, one-quarter of these individuals experienced skin problems approximately 50% of the time, which unfortunately led to limited use or total abandonment of the prosthesis for the preceding year in 56% of the veterans surveyed.²¹

Other complications following amputation indirectly lead to skin problems. Heterotopic ossification, or the formation of bone at extraskeletal sites, has been observed in up to 65% of military amputees from recent operations in Iraq and Afghanistan.^27,28 If symptomatic, heterotopic ossification can lead to poor prosthetic fit and subsequent skin breakdown. As a result, it has been reported that up to 40% of combat-related lower extremity amputations may require excision of heterotopic ossificiation.²⁹

Amputation also can result in psychologic concerns that indirectly affect skin health. A systematic review by Mckechnie and John³⁰ suggested that despite heterogeneity between studies, even using the lowest figures demonstrated the significance anxiety and depression play in the lives of traumatic amputees. If left untreated, these mental health issues can lead to poor residual limb hygiene and prosthetic maintenance due to reductions in the patient’s energy and motivation. Studies have shown that proper hygiene of residual limbs and silicone liners reduces associated skin problems.^19,31

Role of the Dermatologist

Routine care and conservative management of amputee skin problems often are accomplished by prosthetists, primary care physicians, nurses, and physical therapists. In one study, more than 80% of the most common skin problems affecting amputees could be attributed to the prosthesis itself, which highlights the importance of the continued involvement of the prosthetist beyond the initial fitting period.¹³ However, when a skin problem becomes refractory to conservative management, referral to a dermatologist is prudent; therefore, the dermatologist is an integral member of the multidisciplinary team that provides care for amputees.

The dermatologist often is best positioned to diagnose skin diseases that result from wearing prostheses and is well versed in treatments for short-term and long-term management of skin disease on residual limbs. The dermatologist also can offer prophylactic treatments to decrease sweating and hair growth to prevent potential infections and subsequent skin breakdown. Additionally, proper education on self-care has been shown to decrease the amount of skin problems and increase functional status and quality of life for amputees.^32,33 Dermatologists can assist with the patient education process as well as refer amputees to a useful resource from the Amputee Coalition website (www.amputee-coalition.org) to provide specific patient education on how to maintain skin on the residual limb to prevent skin disease.

Current Treatments and Future Directions

Skin disorders affecting residual limbs usually are conditions that dermatologists commonly encounter and are comfortable managing in general practice. Additionally, dermatologists routinely treat hyperhidrosis and conduct laser hair removal, both of which are effective prophylactic adjuncts for amputee skin health. There are a few treatments for reducing residual limb hyperhidrosis that are particularly useful. Although first-line treatment of residual limb hyperhidrosis often is topical aluminum chloride, it requires frequent application and often causes considerable skin irritation when applied to residual limbs. Alternatively, intradermal botulinum toxin has been shown to successfully reduce sweat production in individuals with residual limb hyperhidrosis and is well tolerated.³⁴ A 2017 case report discussed the use of microwave thermal ablation of eccrine coils using a noninvasive 3-step hyperhidrosis treatment system on a bilateral below-the-knee amputee. The authors reported the patient tolerated the procedure well with decreased dermatitis and folliculitis, leading to his ability to wear a prosthetic for longer periods of time.³⁵

Ablative fractional resurfacing with a CO₂ laser is another key treatment modality central to amputees, more specifically to traumatic amputees. A CO₂ laser can decrease skin tension and increase skin mobility associated with traumatic scars as well as decrease skin vulnerability to biofilms present in chronic wounds on residual limbs. It is believed that the pattern of injury caused by ablative fractional lasers disrupts biofilms and stimulates growth factor secretion and collagen remodeling through the concept of photomicrodebridement.³⁶ The ablative fractional resurfacing approach to scar therapy and chronic wound debridement can result in less skin injury, allowing the amputee to continue rehabilitation and return more quickly to prosthetic use.³⁷

One interesting area of research in amputee care involves the study of novel ways to increase the skin’s ability to adapt to mechanical stress and load bearing and accelerate wound healing on the residual limb. Multiple studies have identified collagen fibril enlargement as an important component of skin adaptation, and biomolecules such as decorin may enhance this process.^38-40 The concept of increasing these biomolecules at the correct time during wound healing to strengthen the residual limb tissue currently is being studied.³⁹

Another encouraging area of research is the involvement of fibroblasts in cutaneous wound healing and their role in determining the phenotype of residual limb skin in amputees. The clinical application of autologous fibroblasts is approved by the US Food and Drug Administration for cosmetic use as a filler material and currently is under research for other applications, such as skin regeneration after surgery or manipulating skin characteristics to enhance the durability of residual limbs.⁴¹

Future preventative care of amputee skin may rely on tracking residual limb health before severe tissue injury occurs. For instance, Rink et al⁴² described an approach to monitor residual limb health using noninvasive imaging (eg, hyperspectral imaging, laser speckle imaging) and noninvasive probes that measure oxygenation, perfusion, skin barrier function, and skin hydration to the residual limb. Although these limb surveillance sensors would be employed by prosthetists, the dermatologist, as part of the multispecialty team, also could leverage the data for diagnosis and treatment considerations.

Final Thoughts

The dermatologist is an important member of the multidisciplinary team involved in the care of amputees. Skin disease is prevalent in amputees throughout their lives and often leads to abandonment of prostheses. Although current therapies and preventative treatments are for the most part successful, future research involving advanced technology to monitor skin health, increasing residual limb skin durability at the molecular level, and targeted laser therapies are promising. Through engagement and effective collaboration with the entire multidisciplinary team, dermatologists will have a considerable impact on amputee skin health.

Limb amputation is a major life-changing event that markedly affects a patient’s quality of life as well as his/her ability to participate in activities of daily living. The most prevalent causes for amputation include vascular diseases, diabetes mellitus, trauma, and cancer, respectively.^1,2 For amputees, maintaining prosthetic use is a major physical and psychological undertaking that benefits from a multidisciplinary team approach. Although individuals with lower limb amputations are disproportionately impacted by skin disease due to the increased mechanical forces exerted over the lower limbs, patients with upper limb amputations also develop dermatologic conditions secondary to wearing prostheses.

Approximately 185,000 amputations occur each year in the United States.³ Although amputations resulting from peripheral vascular disease or diabetes mellitus tend to occur in older individuals, amputations in younger patients usually occur from trauma.² The US military has experienced increasing numbers of amputations from trauma due to the ongoing combat operations in the Middle East. Although improvements in body armor and tactical combat casualty care have reduced the number of preventable deaths, the number of casualties surviving with extremity injuries requiring amputation has increased.^4,5 As of October 2017, 1705 US servicemembers underwent major limb amputations, with 1914 lower limb amputations and 302 upper limb amputations. These amputations mainly impacted men aged 21 to 29 years, but female servicemembers also were affected, and a small group of servicemembers had multiple amputations.⁶

One of the most common medical problems that amputees face during long-term care is skin disease, with approximately 75% of amputees using a lower limb prosthesis experiencing skin problems. In general, amputees experience nearly 65% more dermatologic concerns than the general population.⁷ In one study of 97 individuals with transfemoral amputations, some of the most common issues associated with socket prosthetics included heat and sweating in the prosthetic socket (72%) as well as sores and skin irritation from the socket (62%).⁸ Given the high incidence of skin disease on residual limbs, dermatologists are uniquely positioned to keep the amputee in his/her prosthesis and prevent prosthetic abandonment.

Complications Following Amputation

Although US military servicemembers who undergo amputations receive the very best prosthetic devices and rehabilitation resources, they still experience prosthesis abandonment.⁹ Despite the fact that prosthetic limbs and prosthesis technology have substantially improved over the last 2 decades, one study indicated that the high frequency of problems affecting tissue viability at residual limbs is due to the age-old problem of prosthetic fit.¹⁰ In patients with the most advanced prostheses, poor fit still results in mechanical damage to the skin, as the residual limb is exposed to unequal and shearing forces across the amputation site as well as high pressures that cause a vaso-occlusive effect.^11,12 Issues with poor fit are especially important for more active patients, as they normally want to immediately return to their vigorous preinjury lifestyles. In these patients, even a properly fitting prosthetic may not be able to overcome the fact that the residual limb skin is not well suited for the mechanical forces generated by the prosthesis and the humid environment of the socket.^1,13 Another complicating factor is the dynamic nature of the residual limb. Muscle atrophy, changes in gait, and weight gain or loss can lead to an ill-fitting prosthetic and subsequent skin breakdown.

There are many case reports and review articles describing the skin problems in amputees.^1,14-17 The Table summarizes these conditions and outlines treatment options for each.^15,18-20

Most skin diseases on residual limbs are the result of mechanical skin breakdown, inflammation, infection, or combinations of these processes. Overall, amputees with diabetes mellitus and peripheral vascular disease tend to have skin disease related to poor perfusion, whereas amputees who are active and healthy tend to have conditions related to mechanical stress.^{7,13,14,17,21,22} Bui et al¹⁷ reported ulcers, abscesses, and blisters as the most common skin conditions that occur at the site of residual limbs; however, other less common dermatologic disorders such as skin malignancies, verrucous hyperplasia and carcinoma, granulomatous cutaneous lesions, acroangiodermatitis, and bullous pemphigoid also are seen.^23-26 Buikema and Meyerle¹⁵ hypothesize that these conditions, as well as the more common skin diseases, are partly from the amputation disrupting blood and lymphatic flow in the residual limb, which causes the site to act as an immunocompromised district that induces dysregulation of neuroimmune regulators.

It is important to note that skin disease on residual limbs is not just an acute problem. Long-term follow-up of 247 traumatic amputees from the Vietnam War showed that almost half of prosthesis users (48.2%) reported a skin problem in the preceding year, more than 38 years after the amputation. Additionally, one-quarter of these individuals experienced skin problems approximately 50% of the time, which unfortunately led to limited use or total abandonment of the prosthesis for the preceding year in 56% of the veterans surveyed.²¹

Other complications following amputation indirectly lead to skin problems. Heterotopic ossification, or the formation of bone at extraskeletal sites, has been observed in up to 65% of military amputees from recent operations in Iraq and Afghanistan.^27,28 If symptomatic, heterotopic ossification can lead to poor prosthetic fit and subsequent skin breakdown. As a result, it has been reported that up to 40% of combat-related lower extremity amputations may require excision of heterotopic ossificiation.²⁹

Amputation also can result in psychologic concerns that indirectly affect skin health. A systematic review by Mckechnie and John³⁰ suggested that despite heterogeneity between studies, even using the lowest figures demonstrated the significance anxiety and depression play in the lives of traumatic amputees. If left untreated, these mental health issues can lead to poor residual limb hygiene and prosthetic maintenance due to reductions in the patient’s energy and motivation. Studies have shown that proper hygiene of residual limbs and silicone liners reduces associated skin problems.^19,31

Role of the Dermatologist

Routine care and conservative management of amputee skin problems often are accomplished by prosthetists, primary care physicians, nurses, and physical therapists. In one study, more than 80% of the most common skin problems affecting amputees could be attributed to the prosthesis itself, which highlights the importance of the continued involvement of the prosthetist beyond the initial fitting period.¹³ However, when a skin problem becomes refractory to conservative management, referral to a dermatologist is prudent; therefore, the dermatologist is an integral member of the multidisciplinary team that provides care for amputees.

The dermatologist often is best positioned to diagnose skin diseases that result from wearing prostheses and is well versed in treatments for short-term and long-term management of skin disease on residual limbs. The dermatologist also can offer prophylactic treatments to decrease sweating and hair growth to prevent potential infections and subsequent skin breakdown. Additionally, proper education on self-care has been shown to decrease the amount of skin problems and increase functional status and quality of life for amputees.^32,33 Dermatologists can assist with the patient education process as well as refer amputees to a useful resource from the Amputee Coalition website (www.amputee-coalition.org) to provide specific patient education on how to maintain skin on the residual limb to prevent skin disease.

Current Treatments and Future Directions

Skin disorders affecting residual limbs usually are conditions that dermatologists commonly encounter and are comfortable managing in general practice. Additionally, dermatologists routinely treat hyperhidrosis and conduct laser hair removal, both of which are effective prophylactic adjuncts for amputee skin health. There are a few treatments for reducing residual limb hyperhidrosis that are particularly useful. Although first-line treatment of residual limb hyperhidrosis often is topical aluminum chloride, it requires frequent application and often causes considerable skin irritation when applied to residual limbs. Alternatively, intradermal botulinum toxin has been shown to successfully reduce sweat production in individuals with residual limb hyperhidrosis and is well tolerated.³⁴ A 2017 case report discussed the use of microwave thermal ablation of eccrine coils using a noninvasive 3-step hyperhidrosis treatment system on a bilateral below-the-knee amputee. The authors reported the patient tolerated the procedure well with decreased dermatitis and folliculitis, leading to his ability to wear a prosthetic for longer periods of time.³⁵

Ablative fractional resurfacing with a CO₂ laser is another key treatment modality central to amputees, more specifically to traumatic amputees. A CO₂ laser can decrease skin tension and increase skin mobility associated with traumatic scars as well as decrease skin vulnerability to biofilms present in chronic wounds on residual limbs. It is believed that the pattern of injury caused by ablative fractional lasers disrupts biofilms and stimulates growth factor secretion and collagen remodeling through the concept of photomicrodebridement.³⁶ The ablative fractional resurfacing approach to scar therapy and chronic wound debridement can result in less skin injury, allowing the amputee to continue rehabilitation and return more quickly to prosthetic use.³⁷

One interesting area of research in amputee care involves the study of novel ways to increase the skin’s ability to adapt to mechanical stress and load bearing and accelerate wound healing on the residual limb. Multiple studies have identified collagen fibril enlargement as an important component of skin adaptation, and biomolecules such as decorin may enhance this process.^38-40 The concept of increasing these biomolecules at the correct time during wound healing to strengthen the residual limb tissue currently is being studied.³⁹

Another encouraging area of research is the involvement of fibroblasts in cutaneous wound healing and their role in determining the phenotype of residual limb skin in amputees. The clinical application of autologous fibroblasts is approved by the US Food and Drug Administration for cosmetic use as a filler material and currently is under research for other applications, such as skin regeneration after surgery or manipulating skin characteristics to enhance the durability of residual limbs.⁴¹

Future preventative care of amputee skin may rely on tracking residual limb health before severe tissue injury occurs. For instance, Rink et al⁴² described an approach to monitor residual limb health using noninvasive imaging (eg, hyperspectral imaging, laser speckle imaging) and noninvasive probes that measure oxygenation, perfusion, skin barrier function, and skin hydration to the residual limb. Although these limb surveillance sensors would be employed by prosthetists, the dermatologist, as part of the multispecialty team, also could leverage the data for diagnosis and treatment considerations.

Final Thoughts

The dermatologist is an important member of the multidisciplinary team involved in the care of amputees. Skin disease is prevalent in amputees throughout their lives and often leads to abandonment of prostheses. Although current therapies and preventative treatments are for the most part successful, future research involving advanced technology to monitor skin health, increasing residual limb skin durability at the molecular level, and targeted laser therapies are promising. Through engagement and effective collaboration with the entire multidisciplinary team, dermatologists will have a considerable impact on amputee skin health.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

Military dermatologists complete their residency training at 1 of 3 large military medical centers across the country: Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Health System (San Antonio, Texas), or Naval Medical Center San Diego (San Diego, California). While in training, army dermatology residents in particular fall under the US Army Medical Command, or MEDCOM, which provides command and control of the army’s medical, dental, and veterinary treatment facilities. Upon graduating from residency, army dermatologists often are stationed with MEDCOM units but become eligible for deployment with US Army Forces Command (FORSCOM) units to both combat and noncombat zones depending on each individual FORSCOM unit’s mission.

The process by which dermatologists and other army physicians are tasked to a deploying FORSCOM unit is referred to as the Professional Filler System, or PROFIS, which was designed to help alleviate the financial cost and specialty skill degradation of having a physician assigned to a FORSCOM unit while not deployed.¹ In general, the greater the amount of time that an army medical officer has not been deployed, the more likely they are to be selected for deployment with a FORSCOM unit. For the army dermatologist, deployment often comes shortly after completing residency or fellowship.

In this article, we review the various functions of the deployed dermatologist and also highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

THE FIELD SURGEON

With rare exceptions, the US Army does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases. Typically, a dermatologist will be assigned to a FORSCOM unit in the role of field surgeon. Other medical specialties including emergency medicine, family practice, internal medicine, pediatrics, and obstetrics and gynecology also are eligible for deployment as field surgeons.² Field surgeons typically are assigned to a battalion-sized element of 300 to 1000 soldiers and are responsible for all medical care rendered under their supervision. Duties include combat resuscitation, primary care services, preventive medicine, medical training of battalion medical personnel, and serving as the medical adviser to the battalion commander.¹ In some instances, a field surgeon will be stationed at a higher level of care co-located with a trauma surgeon; in those cases, the field surgeon also may be expected to assist in trauma surgery cases.

ARMY DEPLOYMENT MEDICAL SYSTEM

To better understand the responsibilities of a field surgeon, it is important to discuss the structure of the army’s deployment medical system. The US Military, including the army, has adopted a system of “roles” that have specific requirements regarding their associated medical capabilities.³ There are 4 roles designated within the army. Role 1 facilities are known as battalion aid stations (BASs). Capabilities include initial treatment, triage, and evacuation, with a goal of returning soldiers to combat or stabilizing and evacuating them to a higher-role facility. Role 2 facilities are capable of providing a higher level of emergency care, including basic radiology, laboratory services, transfusion of blood products, and surgical interventions when co-located with a forward surgical team (Figure 1). Role 3 facilities, also known as combat support hospitals, have inpatient hospitalization capabilities including subspecialty surgery and intensive care. Role 4 facilities are fully capable medical centers located in the United States and other noncombat locations.³

Role of the Field Surgeon

Within the broader structure of the army, approximately 5 battalions (each composed of 300 to 1000 soldiers) comprise a single brigade combat team. Role 1 medical facilities typically have a single battalion surgeon assigned to them. Field surgeons most commonly serve in this battalion surgeon position. Additionally, Role 2 facilities may have slots for up to 2 battalion surgeons; however, field surgeons are less commonly tasked with this assignment.¹ Occasionally, in one author’s (N.R.M.) personal experience, these roles are more fluid than one might expect. A field surgeon tasked initially with a Role 1 position may be shifted to a Role 2 assignment on an as-needed basis. This ability for rapid change in roles and responsibilities underscores the need for a fluid mind-set and thorough predeployment training for the field surgeon.

PREDEPLOYMENT TRAINING

As one might expect, dermatologists who have just graduated residency or fellowship are unlikely to have honed their trauma support skills to the degree needed to support a deployed battalion actively engaging in combat. Fortunately, there are many opportunities for military dermatologists to practice these skills prior to joining their FORSCOM colleagues. The initial exposure to trauma support comes during medical internship at the mandatory Combat Casualty Care Course (C4), an 8-day program designed to enhance the operational medical readiness and predeployment trauma training skills of medical officers.⁴ The C4 program includes 3 days of classroom training and 5 days of intensive field training. During C4, medical officers become certified in Advanced Trauma Life Support, a 3-day course organized by the American College of Surgeons.⁵ This course teaches medical officers how to quickly and judiciously triage, treat, and transport patients who have sustained potentially life-threatening traumas.

The next components of predeployment training, Tactical Combat Casualty Care and Tactical Combat Medical Care, occur in the months to weeks immediately preceding deployment.^1,6 Tactical Combat Casualty Care prepares participants in the initial stabilization of trauma to occur at the point of injury.⁶ Tactical Combat Casualty Care principles generally are employed by medics (enlisted personnel trained in point-of-care medical support) rather than physicians; however, these principles are still critical for medical officers to be aware of when encountering severe traumas.⁶ In addition, the physician is responsible for ensuring his/her medics are fully trained in Tactical Combat Casualty Care. Tactical Combat Medical Care is geared more toward the direct preparation of medical officers. During the 5-day course, medical officers learn the gold standard for trauma care in both the classroom and in hands-on scenarios.¹ This training not only allows medical officers to be self-sufficient in providing trauma support, but it also enables them to better maintain quality control of the performance of their medics continuously throughout the deployment.¹

DEPLOYMENT RESPONSIBILITIES

Dermatologists who have completed the above training typically are subsequently deployed as field surgeons to a Role 1 facility. Field surgeons are designated as the officer in charge of the BAS and assume the position of medical platoon leader. A field surgeon usually will have both a physician assistant and a field medical assistant/medical plans officer (MEDO) to assist in running the BAS. The overarching goal of the field surgeon is to maintain the health and readiness of the battalion. In addition to addressing the day-to-day health care needs of individual soldiers, a field surgeon is expected to attend all staff meetings, advise the commander on preventative health and epidemiological trends, identify the scope of practice of the medics, ensure the BAS is prepared for mass casualties, and take responsibility for all controlled substances.

To illustrate the value that the properly trained dermatologist can provide in the deployed setting, we will outline field surgeon responsibilities and provide case examples of the first-hand experiences of one of the authors (N.R.M.) as a Role 2 officer in charge and field surgeon. The information presented in the case examples may have been altered to ensure continued operational security and out of respect to US servicemembers and coalition forces while still conveying important learning points.

Sick Call

In the deployed environment, military sick call functions as an urgent care center that is open continuously and serves the active-duty population, US government civilians and contractors, and coalition forces. In general, the physician assistant should treat approximately two-thirds of sick call patients under the supervision of the field surgeon, allowing the field surgeon to focus on his/her ancillary duties and ensure overall medical supervision of the unit. As a safeguard, patients with more than 2 visits for the same concern must be evaluated by the field surgeon. Sick call concerns range from minor traumas and illnesses to much more serious disease processes and injuries (as outlined in Medical Emergencies). As a field surgeon, it is critical to track disease nonbattle illnesses to ensure medical readiness of the unit. In the deployed environment, close quarters and austere environments commonly lend themselves to gastrointestinal illnesses, respiratory diseases, heat injuries, vector-borne diseases, and sexually transmitted infections.

Case Examples 
During an 8-month deployment in Afghanistan, one of the authors (N.R.M.) provided or assisted in the care of more than 2300 routine sick call appointments, or approximately 10 patients per day. Epidemiology of disease was tracked, and the condition of the unit was presented daily to the battalion commander for consideration in upcoming operations. The top 5 most common categories of diagnoses included musculoskeletal injuries, gastrointestinal diseases, dermatologic concerns (eg, dermatitis, bacterial infections [cellulitis/abscess], fungal infections, arthropod assault, abrasions, lacerations, verruca vulgaris), respiratory illnesses, and mental health care, respectively. Maintaining a familiarity with general medicine is critical for the military dermatologist, and an adequate medical library or access to online medical review sources is critical for day-to-day sick call.

Medical Emergencies

In the event of a more serious injury or illness, a Role 1 BAS has very little capability in performing anything beyond the most basic interventions. Part of the art of being an effective field surgeon lies in stabilization, triage, and transport of these sometimes very ill patients. Both the decision to transport to a higher level of care (eg, Role 2 or 3 facility) as well as selection of the means of transportation falls on the field surgeon. The MEDO plays an essential role in assisting in the coordination of the transfer; however, the responsibility ultimately falls on the field surgeon.^1,6 The field surgeon at the Role 2 BAS may be expected to perform more advanced medical and surgical interventions. More advanced pharmacotherapies include thrombolytics, antivenin, and vasopressors. Some procedural interventions include intubations, central lines, and laceration repairs. The Role 2 BAS has the capability to hold patients for up to 72 hours.

Case Examples
Specific conditions one of the authors (N.R.M.) treated include heat injury, myocardial infarction, disseminated tuberculosis, appendicitis, testicular torsion, malaria, suicidal ideation, burns, and status epilepticus. Over 8 months, the Role 2 BAS received 91 medical emergencies, with 53 necessitating evacuation to a higher level of care. Often, the more serious or rare conditions presented in the foreign contractor and coalition force populations working alongside US troops.

In one particular case, a 35-year-old man with an electrocardiogram-confirmed acute ST-segment elevation myocardial infarction was administered standard therapy consisting of intravenous morphine, oxygen, sublingual nitroglycerin, an angiotensin-converting enzyme inhibitor, and a beta-blocker. Given the lack of a cardiac catheterization laboratory at the next highest level of care as well as a low suspicion for aortic dissection (based on the patient’s history, physical examination, and chest radiograph), fibrinolysis with tenecteplase was performed in the deployed environment. After a very short observation for potential hemorrhage, the patient was then evacuated to the Role 3 hospital, where he made a near-complete recovery. Preparation with advanced cardiac life support courses and a thorough algorithmic review of the 10 most common causes of presentation to the emergency department helped adequately prepare the dermatologist to succeed.

Trauma Emergencies

The same principles of triage and transport apply to trauma emergencies. Mass casualties are an inevitable reality in combat, so appropriate training translating into efficient action is essential to ensure the lowest possible mortality. This training and the actions that stem from it are an additional responsibility that the field surgeon must maintain. During deployment, continued training organized by the field surgeon could quite literally mean the difference between life and death. In addition to the organizational responsibilities, field surgeons should be prepared to perform initial stabilization in trauma patients, including application of tourniquets, establishment of central lines, reading abdominal ultrasounds for free fluid, placement of chest tubes, intubation, and ventilator management. The Joint Trauma System Clinical Practice Guidelines also offer extensive and invaluable guidance on the most up-to-date approach to common trauma conditions arising in the deployed environment.⁷ At the Role 2 level, the field surgeon also must be prepared to coordinate ancillary services, manage the Role 2/forward surgical team intensive care unit, and serve as first assist in the operating room, as needed (Figure 2).

Case Examples 
One of the authors (N.R.M.) assisted or provided care in approximately 225 trauma cases while deployed. A mass casualty event occurred, in which the Role 2 BAS received 34 casualties; of these casualties, 11 were immediate, 10 were delayed, 11 were minimal, and 2 were expectant. Injury patterns included mounted and dismounted improvised explosive device injuries (eg, blast, shrapnel, and traumatic brain injuries) as well as gunshot wounds. Direct care was provided for 13 casualties, including 10 abdominal ultrasound examinations for free fluid, placement of 2 chest tubes, 1 intubation, establishment of 3 central lines, and first-assisting 1 exploratory laparotomy. Of the casualties, 22 were evacuated to the Role 3 hospital, 8 were dispositioned to a coalition hospital, 2 were returned to active duty, and 2 died due to their injuries. The military trauma preparation as outlined in the predeployment training can help adequately prepare the military dermatologist to assist in these cases.

Ancillary Services

An important part of the efficacy of initial evaluation and stabilization of both medical and traumatic emergencies involves expedited laboratory tests, imaging, and the delivery of life-saving blood products to affected patients. The field surgeon is responsible for the readiness of these services and may play a critical role in streamlining these tasks for situations where a delay in care by minutes can be lethal. The MEDO assists the field surgeon to ensure the readiness of the medical equipment, and the field surgeon must ensure the readiness of the medics and technicians utilizing the equipment. In a deployed environment, only a finite amount of blood products may be stored. As a result, the design and implementation of an efficient and precise walking blood bank is critical. To help mitigate this issue, servicemembers are prescreened for their blood types and bloodborne illnesses. If a situation arises in which whole blood is needed, the prescreened individuals are screened again, and their blood is collected and transfused to the patient under the supervision of the physician. This task is critical in saving lives, and this process is the primary responsibility of the field surgeon.

Case Example 
A 37-year-old man presented to the BAS with abdominal and pelvic gunshot wounds, as well as tachycardia, rapidly decreasing blood pressure, and altered consciousness. An exploratory laparotomy was performed to look for the sources of bleeding. The patient’s blood type was confirmed with a portable testing kit. Due to the injury pattern and clinical presentation, a call was immediately placed to begin screening and preparing servicemembers to donate blood for the walking blood bank. As expected, the Role 2 supply of blood products was exhausted during the exploratory laparotomy. With servicemembers in place and screened, an additional 12 units of whole blood were collected and administered in a timely fashion. The patient was stabilized and transported to the next highest level of care. Due to the process optimization performed by the laboratory team, whole-blood transfusions were ready within an average of 22 minutes, well ahead of the 45-minute standard of care. Local process was studied by the military leadership and implemented throughout Afghanistan.

Operating Room First Assist

If a field surgeon is stationed at a Role 2 BAS with a forward surgical team, he/she may be required to adopt the role of operating room first assist for the trauma surgeon or orthopedic surgeon on the team, which is especially true for isolated major traumas when triage and initial stabilization measures for multiple patients are of less concern. Dermatologists receive surgical training as part of the Accreditation Council for Graduate Medical Education requirements to graduate residency, making them more than capable of surgical assisting when needed.⁸ In particular, dermatologists’ ability to utilize instruments appropriately and think procedurally as well as their skills in suturing are helpful.

Case Example 
A 22-year-old man with several shrapnel wounds to the abdomen demonstrated free fluid in the left lower quadrant. The field surgeon (N.R.M.) assisted the trauma surgeon in opening the abdomen and running the bowel for sources of bleeding. The trauma surgeon identified the bleed and performed a ligation. The patient was then packed, closed, and prepared for transfer to a higher level of care.

Preventive Medicine

As a result of the field surgeon being on the front line of medical care in an austere environment, implementation of preventive medicine practices and disease pattern recognition are his/her responsibility. Responsibilities may include stray animal euthanasia due to prevalence of rabies, enforcement of malaria prophylaxis, medical training and maintenance of snake antivenin, and assistance with other local endemic disease. The unique skill set of dermatologists in organism identification can further bolster the speed with which vector-borne diseases are recognized and prevention and treatment measures are implemented.

Case Example 
As coalition forces executed a mission in Afghanistan, US servicemembers began experiencing abdominal distress, chills, fevers (temperature >40°C), debilitating headaches, myalgia, arthralgia, and tachycardia. Initially, these patients were evacuated to the Role 2 BAS, hindering the mission. Upon inspection, patients had numerous bug bites; one astute soldier collected the arthropod guilty of the assault and brought it to the aid station. Upon inspection, the offender was identified as the Phlebotomus genus of sandflies, organisms that are well known to dermatologists as a cause of leishmaniasis. Clinical correlation resulted in the presumed diagnosis of Pappataci fever, and vector-borne disease prevention measures were then able to be further emphasized and implemented in at-risk areas, allowing the mission to continue.⁹ Subsequent infectious disease laboratory testing confirmed the Phlebovirus transmitted by the sandfly as the underlying cause of the illness.

CONCLUSION

The diverse role of the field surgeon in the deployed setting makes any one specialist underprepared to completely take on the role from the outset; however, with appropriate and rigorous trauma training prior to deployment, dermatologists will continue to perform as invaluable assets to the US military in conflicts now and in the future.

The US military enforces grooming standards to ensure the professional appearance and serviceability of soldiers in all operational settings. Although most individuals are able to uphold these regulations without incident, there is a growing cohort of servicemembers with skin diseases that were exacerbated or even initiated by haircuts, hairstyling, and shaving required to conform to these grooming standards. These skin diseases, which can affect both sexes and may not be appreciated until years into a soldier's service commitment, can have consequences related to individual morbidity and medical readiness for deployment, making it an important issue for medical practitioners to recognize and manage in servicemembers.

This review highlights several disorders of the pilosebaceous unit of the head and neck that can be caused or exacerbated by military grooming standards, including inflammatory hair disorders, traction alopecia, and pseudofolliculitis barbae. Discussion of each entity will include a review of susceptibility and causality as well as initial treatment options to consider (Table).

Inflammatory Hair Disorders

The proper appearance of servicemembers in uniform represents self-discipline and conformity to the high standards of the military. This transition occurs as a rite of passage for many new male recruits who receive shaved haircuts during their first days of basic training. Thereafter, male servicemembers are required to maintain a tapered appearance of the hair per military regulations.¹ Clipping hair closely to the scalp or shaving the head entirely are authorized and often encouraged; therefore, high and tight haircuts and buzz cuts are popular among male soldiers due to the general ease of care and ability to maintain the haircut themselves. Conversely, these styles require servicemembers to get weekly or biweekly haircuts that in turn can lead to chronic trauma and irritation. In more susceptible populations, inflammatory hair disorders such as acne keloidalis nuchae (AKN), dissecting cellulitis of the scalp, and folliculitis decalvans may be incited.

Acne Keloidalis Nuchae
Acne keloidalis nuchae, also called folliculitis keloidalis, is a chronic scarring folliculitis presenting with papules and plaques on the occiput and nape of the neck that may merge to form hypertrophic scars or keloids. This disorder most commonly develops in young black men but also can be seen in black females and white patients of both sexes.² Acne keloidalis nuchae shares many histologic features with central centrifugal cicatricial alopecia, which may suggest a similar pathogenesis. Apart from frequent haircuts, tight-collared shirts, such as those on military service uniforms, also have been associated with AKN. Because of these suspected etiologies, first-line treatment focuses on preventing further trauma by avoiding mechanical irritation and short haircuts, which may be difficult in the military setting. For earlier disease stages, topical and intralesional corticosteroids, oral retinoids, and topical and oral antibiotics are used for their anti-inflammatory properties.³ In refractory cases, surgical excision with healing by secondary intention may be attempted.⁴ Additional treatment options include the 1064-nm Nd:YAG and 810-nm diode lasers,³ UVB light therapy, CO₂ laser, and radiotherapy.

Dissecting Cellulitis of the Scalp
Similar to AKN, dissecting cellulitis of the scalp is another inflammatory hair disorder that is worsened by frequent short haircuts.⁵ Dissecting cellulitis of the scalp is a primary cicatricial alopecia proposed to be secondary to follicular occlusion. It often is seen in black males aged 20 to 40 years and is characterized by boggy suppurative nodules and cysts with draining sinus tracts, abscesses, and resultant scarring alopecia. Dissecting cellulitis of the scalp is part of the follicular occlusion tetrad, which also includes hidradenitis suppurativa, acne conglobata, and pilonidal cysts. First-line therapies include topical and oral antibiotics, topical retinoids, intralesional corticosteroids, incision and drainage of fluctuant nodules, and oral isotretinoin with or without rifampin. Alternative treatments include oral zinc supplementation, oral corticosteroids, tumor necrosis factor α inhibitors, laser therapies, radiotherapy, and surgical management with wide local excision or total scalpectomy.^6,7

Folliculitis Decalvans
Folliculitis decalvans is a primary cicatricial alopecia of the scalp that most commonly presents in middle-aged men without racial predilection.⁸ Folliculitis decalvans presents with multiple pustules, crusts, tufted hairs, and perifollicular hyperkeratosis, leading to scarring of the scalp, which often is most severe on the posterior vertex. Staphylococcus aureus is a presumed player in the pathogenesis of folliculitis decalvans with superantigens causing release of cytokines stimulating follicular destruction. Close haircuts in conformation with military grooming standards can contribute to this condition due to mechanical trauma and subsequent inflammation. It typically is diagnosed clinically, but if histologic confirmation is desired, a sample from the periphery of early lesions is preferred.⁹ Initial treatment consists of antibacterial shampoos, topical corticosteroids, topical antibiotics, and combination oral antibiotic therapy with rifampin and clindamycin. Studies using oral isotretinoin have shown variable results,^10,11 and the most effective treatment of recalcitrant lesions appears to be intralesional corticosteroids.¹²

Follicular and Scarring Disorders

In addition to inflammatory hair disorders, military grooming standards have been linked to the pathogenesis of diseases such as pseudofolliculitis barbae, traction alopecia, and keloids, specifically through irritation of the face, neck, and scalp, as well as damage to the follicular unit.⁵ These conditions develop because grooming regulations necessitate certain hair practices such as close shaving of facial and neck hair and keeping long hair secured relatively tightly to the scalp.

Pseudofolliculitis Barbae
Males in the military are obligated to keep their faces clean-shaven.¹ They may acquire a medical waiver for a specified beard length if deemed appropriate by the treating physician,¹ which often leads to the need for continual waiver renewal and also may warrant possible negative perception from peers, subordinates, and leadership. One of the most prevalent conditions that is closely associated with shaving is pseudofolliculitis barbae. The combination of close shaving and tightly coiled hairs causes the hairs to grow toward and penetrate the skin, particularly on the neck.¹³ In some cases, the hairs never actually exit the skin and simply curl within the superficial epidermis. A foreign body reaction often arises, leading to inflamed follicular papules and pustules. Affected individuals may experience pain, pruritus, and secondary infections. Postinflammatory hyperpigmentation, hypertrophic scarring, and keloid formation are common sequelae in cases of untreated disease. Pseudofolliculitis barbae also is exacerbated by pulling the skin taut and shaving against the grain, making behavioral interventions a key component in management of this condition. Preliminary recommendations include using a new or electric razor, leaving hair at least 2 mm in length, and shaving in the direction of hair growth. Other treatment options with varying effectiveness include daily alternation of a mild topical corticosteroid and one of the following: a topical retinoid, topical antibiotics, or glycolic acid. The only treatments that approach definitive cure are laser hair removal and electrolysis for which patient skin type plays an important role in laser selection.⁵

Traction Alopecia
Similar to their male counterparts, female military members must also present a conservative professional appearance, including hair that is neatly groomed.¹ If the length of the hair extends beyond the uniform collar, it must be inconspicuously fastened or pinned above the collar. As a result, loosely tied hair is unauthorized, and females with long hair must secure their hair tightly on a daily basis. Traction alopecia results from tight hairstyling over a prolonged period and commonly affects female soldiers. The etiology is presumed to be mechanical loosening of hair within the follicles, leading to inflammation. Although traditionally seen in black women along the frontal and temporal hairlines, traction alopecia has been identified in individuals of all races and can occur anywhere on the scalp.⁵ Perifollicular erythema may be the first sign, and papules and pustules may be visible. Although the hair loss in traction alopecia usually is reversible if the traction is ceased, end-stage disease may be permanent.6 Halting traction-inducing practices is paramount, and other treatment options that may slow progression include topical or oral antibiotics and topical or intralesional corticosteroids. Recovery of hair loss also may be aided by topical minoxidil.⁵

Keloids
Keloid formation is an important pathology to address, as it may result from several of the aforementioned conditions. Keloids are most commonly seen in black individuals but also can occur in Hispanic and Asian patients. The cause has not been fully elucidated but is thought to be a combination of dysfunctional fibroblasts with a genetic component based on racial predilection and twin concordance studies.⁵ The chest, shoulders, upper back, neck, and earlobes are particularly susceptible to keloid formation, which can appear from 1 to 24 years following dermal trauma.5 Unlike hypertrophic scars, keloids generally do not regress and frequently cause discomfort, pruritus, and emotional distress. They also can hinder wearing a military uniform. Sustained remission is problematic, making prevention a first-line approach, including proper care of wounds when they occur and avoiding elective procedures such as piercings and tattoos. Intralesional corticosteroids, adjuvant injections (eg, 5-fluorouracil), silicone sheeting, cryotherapy, radiation, laser therapy, and excision are some of the treatment options when keloids have formed.⁵

Final Comment

It is important to recognize military grooming standards as a cause or contributor to several diseases of the head and neck in military servicemembers. Specifically, frequent haircuts in male soldiers are associated with several inflammatory hair disorders, including AKN, dissecting cellulitis of the scalp, and folliculitis decalvans, while daily shaving predisposes individuals to pseudofolliculitis barbae with possible keloid formation. Females may develop traction alopecia from chronically tight, pulled back hairstyles. All of these conditions have health implications for the affected individuals and can compromise the military mission. Awareness, prevention, and recognition are key along with the knowledge base to provide anticipatory avoidance and initiate appropriate treatments, thereby mitigating these potential consequences.

The US military enforces grooming standards to ensure the professional appearance and serviceability of soldiers in all operational settings. Although most individuals are able to uphold these regulations without incident, there is a growing cohort of servicemembers with skin diseases that were exacerbated or even initiated by haircuts, hairstyling, and shaving required to conform to these grooming standards. These skin diseases, which can affect both sexes and may not be appreciated until years into a soldier's service commitment, can have consequences related to individual morbidity and medical readiness for deployment, making it an important issue for medical practitioners to recognize and manage in servicemembers.

This review highlights several disorders of the pilosebaceous unit of the head and neck that can be caused or exacerbated by military grooming standards, including inflammatory hair disorders, traction alopecia, and pseudofolliculitis barbae. Discussion of each entity will include a review of susceptibility and causality as well as initial treatment options to consider (Table).

Inflammatory Hair Disorders

The proper appearance of servicemembers in uniform represents self-discipline and conformity to the high standards of the military. This transition occurs as a rite of passage for many new male recruits who receive shaved haircuts during their first days of basic training. Thereafter, male servicemembers are required to maintain a tapered appearance of the hair per military regulations.¹ Clipping hair closely to the scalp or shaving the head entirely are authorized and often encouraged; therefore, high and tight haircuts and buzz cuts are popular among male soldiers due to the general ease of care and ability to maintain the haircut themselves. Conversely, these styles require servicemembers to get weekly or biweekly haircuts that in turn can lead to chronic trauma and irritation. In more susceptible populations, inflammatory hair disorders such as acne keloidalis nuchae (AKN), dissecting cellulitis of the scalp, and folliculitis decalvans may be incited.

Acne Keloidalis Nuchae
Acne keloidalis nuchae, also called folliculitis keloidalis, is a chronic scarring folliculitis presenting with papules and plaques on the occiput and nape of the neck that may merge to form hypertrophic scars or keloids. This disorder most commonly develops in young black men but also can be seen in black females and white patients of both sexes.² Acne keloidalis nuchae shares many histologic features with central centrifugal cicatricial alopecia, which may suggest a similar pathogenesis. Apart from frequent haircuts, tight-collared shirts, such as those on military service uniforms, also have been associated with AKN. Because of these suspected etiologies, first-line treatment focuses on preventing further trauma by avoiding mechanical irritation and short haircuts, which may be difficult in the military setting. For earlier disease stages, topical and intralesional corticosteroids, oral retinoids, and topical and oral antibiotics are used for their anti-inflammatory properties.³ In refractory cases, surgical excision with healing by secondary intention may be attempted.⁴ Additional treatment options include the 1064-nm Nd:YAG and 810-nm diode lasers,³ UVB light therapy, CO₂ laser, and radiotherapy.

Dissecting Cellulitis of the Scalp
Similar to AKN, dissecting cellulitis of the scalp is another inflammatory hair disorder that is worsened by frequent short haircuts.⁵ Dissecting cellulitis of the scalp is a primary cicatricial alopecia proposed to be secondary to follicular occlusion. It often is seen in black males aged 20 to 40 years and is characterized by boggy suppurative nodules and cysts with draining sinus tracts, abscesses, and resultant scarring alopecia. Dissecting cellulitis of the scalp is part of the follicular occlusion tetrad, which also includes hidradenitis suppurativa, acne conglobata, and pilonidal cysts. First-line therapies include topical and oral antibiotics, topical retinoids, intralesional corticosteroids, incision and drainage of fluctuant nodules, and oral isotretinoin with or without rifampin. Alternative treatments include oral zinc supplementation, oral corticosteroids, tumor necrosis factor α inhibitors, laser therapies, radiotherapy, and surgical management with wide local excision or total scalpectomy.^6,7

Folliculitis Decalvans
Folliculitis decalvans is a primary cicatricial alopecia of the scalp that most commonly presents in middle-aged men without racial predilection.⁸ Folliculitis decalvans presents with multiple pustules, crusts, tufted hairs, and perifollicular hyperkeratosis, leading to scarring of the scalp, which often is most severe on the posterior vertex. Staphylococcus aureus is a presumed player in the pathogenesis of folliculitis decalvans with superantigens causing release of cytokines stimulating follicular destruction. Close haircuts in conformation with military grooming standards can contribute to this condition due to mechanical trauma and subsequent inflammation. It typically is diagnosed clinically, but if histologic confirmation is desired, a sample from the periphery of early lesions is preferred.⁹ Initial treatment consists of antibacterial shampoos, topical corticosteroids, topical antibiotics, and combination oral antibiotic therapy with rifampin and clindamycin. Studies using oral isotretinoin have shown variable results,^10,11 and the most effective treatment of recalcitrant lesions appears to be intralesional corticosteroids.¹²

Follicular and Scarring Disorders

In addition to inflammatory hair disorders, military grooming standards have been linked to the pathogenesis of diseases such as pseudofolliculitis barbae, traction alopecia, and keloids, specifically through irritation of the face, neck, and scalp, as well as damage to the follicular unit.⁵ These conditions develop because grooming regulations necessitate certain hair practices such as close shaving of facial and neck hair and keeping long hair secured relatively tightly to the scalp.

Pseudofolliculitis Barbae
Males in the military are obligated to keep their faces clean-shaven.¹ They may acquire a medical waiver for a specified beard length if deemed appropriate by the treating physician,¹ which often leads to the need for continual waiver renewal and also may warrant possible negative perception from peers, subordinates, and leadership. One of the most prevalent conditions that is closely associated with shaving is pseudofolliculitis barbae. The combination of close shaving and tightly coiled hairs causes the hairs to grow toward and penetrate the skin, particularly on the neck.¹³ In some cases, the hairs never actually exit the skin and simply curl within the superficial epidermis. A foreign body reaction often arises, leading to inflamed follicular papules and pustules. Affected individuals may experience pain, pruritus, and secondary infections. Postinflammatory hyperpigmentation, hypertrophic scarring, and keloid formation are common sequelae in cases of untreated disease. Pseudofolliculitis barbae also is exacerbated by pulling the skin taut and shaving against the grain, making behavioral interventions a key component in management of this condition. Preliminary recommendations include using a new or electric razor, leaving hair at least 2 mm in length, and shaving in the direction of hair growth. Other treatment options with varying effectiveness include daily alternation of a mild topical corticosteroid and one of the following: a topical retinoid, topical antibiotics, or glycolic acid. The only treatments that approach definitive cure are laser hair removal and electrolysis for which patient skin type plays an important role in laser selection.⁵

Traction Alopecia
Similar to their male counterparts, female military members must also present a conservative professional appearance, including hair that is neatly groomed.¹ If the length of the hair extends beyond the uniform collar, it must be inconspicuously fastened or pinned above the collar. As a result, loosely tied hair is unauthorized, and females with long hair must secure their hair tightly on a daily basis. Traction alopecia results from tight hairstyling over a prolonged period and commonly affects female soldiers. The etiology is presumed to be mechanical loosening of hair within the follicles, leading to inflammation. Although traditionally seen in black women along the frontal and temporal hairlines, traction alopecia has been identified in individuals of all races and can occur anywhere on the scalp.⁵ Perifollicular erythema may be the first sign, and papules and pustules may be visible. Although the hair loss in traction alopecia usually is reversible if the traction is ceased, end-stage disease may be permanent.6 Halting traction-inducing practices is paramount, and other treatment options that may slow progression include topical or oral antibiotics and topical or intralesional corticosteroids. Recovery of hair loss also may be aided by topical minoxidil.⁵

Keloids
Keloid formation is an important pathology to address, as it may result from several of the aforementioned conditions. Keloids are most commonly seen in black individuals but also can occur in Hispanic and Asian patients. The cause has not been fully elucidated but is thought to be a combination of dysfunctional fibroblasts with a genetic component based on racial predilection and twin concordance studies.⁵ The chest, shoulders, upper back, neck, and earlobes are particularly susceptible to keloid formation, which can appear from 1 to 24 years following dermal trauma.5 Unlike hypertrophic scars, keloids generally do not regress and frequently cause discomfort, pruritus, and emotional distress. They also can hinder wearing a military uniform. Sustained remission is problematic, making prevention a first-line approach, including proper care of wounds when they occur and avoiding elective procedures such as piercings and tattoos. Intralesional corticosteroids, adjuvant injections (eg, 5-fluorouracil), silicone sheeting, cryotherapy, radiation, laser therapy, and excision are some of the treatment options when keloids have formed.⁵

Final Comment

It is important to recognize military grooming standards as a cause or contributor to several diseases of the head and neck in military servicemembers. Specifically, frequent haircuts in male soldiers are associated with several inflammatory hair disorders, including AKN, dissecting cellulitis of the scalp, and folliculitis decalvans, while daily shaving predisposes individuals to pseudofolliculitis barbae with possible keloid formation. Females may develop traction alopecia from chronically tight, pulled back hairstyles. All of these conditions have health implications for the affected individuals and can compromise the military mission. Awareness, prevention, and recognition are key along with the knowledge base to provide anticipatory avoidance and initiate appropriate treatments, thereby mitigating these potential consequences.

The US military enforces grooming standards to ensure the professional appearance and serviceability of soldiers in all operational settings. Although most individuals are able to uphold these regulations without incident, there is a growing cohort of servicemembers with skin diseases that were exacerbated or even initiated by haircuts, hairstyling, and shaving required to conform to these grooming standards. These skin diseases, which can affect both sexes and may not be appreciated until years into a soldier's service commitment, can have consequences related to individual morbidity and medical readiness for deployment, making it an important issue for medical practitioners to recognize and manage in servicemembers.

This review highlights several disorders of the pilosebaceous unit of the head and neck that can be caused or exacerbated by military grooming standards, including inflammatory hair disorders, traction alopecia, and pseudofolliculitis barbae. Discussion of each entity will include a review of susceptibility and causality as well as initial treatment options to consider (Table).

Inflammatory Hair Disorders

The proper appearance of servicemembers in uniform represents self-discipline and conformity to the high standards of the military. This transition occurs as a rite of passage for many new male recruits who receive shaved haircuts during their first days of basic training. Thereafter, male servicemembers are required to maintain a tapered appearance of the hair per military regulations.¹ Clipping hair closely to the scalp or shaving the head entirely are authorized and often encouraged; therefore, high and tight haircuts and buzz cuts are popular among male soldiers due to the general ease of care and ability to maintain the haircut themselves. Conversely, these styles require servicemembers to get weekly or biweekly haircuts that in turn can lead to chronic trauma and irritation. In more susceptible populations, inflammatory hair disorders such as acne keloidalis nuchae (AKN), dissecting cellulitis of the scalp, and folliculitis decalvans may be incited.

Acne Keloidalis Nuchae
Acne keloidalis nuchae, also called folliculitis keloidalis, is a chronic scarring folliculitis presenting with papules and plaques on the occiput and nape of the neck that may merge to form hypertrophic scars or keloids. This disorder most commonly develops in young black men but also can be seen in black females and white patients of both sexes.² Acne keloidalis nuchae shares many histologic features with central centrifugal cicatricial alopecia, which may suggest a similar pathogenesis. Apart from frequent haircuts, tight-collared shirts, such as those on military service uniforms, also have been associated with AKN. Because of these suspected etiologies, first-line treatment focuses on preventing further trauma by avoiding mechanical irritation and short haircuts, which may be difficult in the military setting. For earlier disease stages, topical and intralesional corticosteroids, oral retinoids, and topical and oral antibiotics are used for their anti-inflammatory properties.³ In refractory cases, surgical excision with healing by secondary intention may be attempted.⁴ Additional treatment options include the 1064-nm Nd:YAG and 810-nm diode lasers,³ UVB light therapy, CO₂ laser, and radiotherapy.

Dissecting Cellulitis of the Scalp
Similar to AKN, dissecting cellulitis of the scalp is another inflammatory hair disorder that is worsened by frequent short haircuts.⁵ Dissecting cellulitis of the scalp is a primary cicatricial alopecia proposed to be secondary to follicular occlusion. It often is seen in black males aged 20 to 40 years and is characterized by boggy suppurative nodules and cysts with draining sinus tracts, abscesses, and resultant scarring alopecia. Dissecting cellulitis of the scalp is part of the follicular occlusion tetrad, which also includes hidradenitis suppurativa, acne conglobata, and pilonidal cysts. First-line therapies include topical and oral antibiotics, topical retinoids, intralesional corticosteroids, incision and drainage of fluctuant nodules, and oral isotretinoin with or without rifampin. Alternative treatments include oral zinc supplementation, oral corticosteroids, tumor necrosis factor α inhibitors, laser therapies, radiotherapy, and surgical management with wide local excision or total scalpectomy.^6,7

Folliculitis Decalvans
Folliculitis decalvans is a primary cicatricial alopecia of the scalp that most commonly presents in middle-aged men without racial predilection.⁸ Folliculitis decalvans presents with multiple pustules, crusts, tufted hairs, and perifollicular hyperkeratosis, leading to scarring of the scalp, which often is most severe on the posterior vertex. Staphylococcus aureus is a presumed player in the pathogenesis of folliculitis decalvans with superantigens causing release of cytokines stimulating follicular destruction. Close haircuts in conformation with military grooming standards can contribute to this condition due to mechanical trauma and subsequent inflammation. It typically is diagnosed clinically, but if histologic confirmation is desired, a sample from the periphery of early lesions is preferred.⁹ Initial treatment consists of antibacterial shampoos, topical corticosteroids, topical antibiotics, and combination oral antibiotic therapy with rifampin and clindamycin. Studies using oral isotretinoin have shown variable results,^10,11 and the most effective treatment of recalcitrant lesions appears to be intralesional corticosteroids.¹²

Follicular and Scarring Disorders

In addition to inflammatory hair disorders, military grooming standards have been linked to the pathogenesis of diseases such as pseudofolliculitis barbae, traction alopecia, and keloids, specifically through irritation of the face, neck, and scalp, as well as damage to the follicular unit.⁵ These conditions develop because grooming regulations necessitate certain hair practices such as close shaving of facial and neck hair and keeping long hair secured relatively tightly to the scalp.

Pseudofolliculitis Barbae
Males in the military are obligated to keep their faces clean-shaven.¹ They may acquire a medical waiver for a specified beard length if deemed appropriate by the treating physician,¹ which often leads to the need for continual waiver renewal and also may warrant possible negative perception from peers, subordinates, and leadership. One of the most prevalent conditions that is closely associated with shaving is pseudofolliculitis barbae. The combination of close shaving and tightly coiled hairs causes the hairs to grow toward and penetrate the skin, particularly on the neck.¹³ In some cases, the hairs never actually exit the skin and simply curl within the superficial epidermis. A foreign body reaction often arises, leading to inflamed follicular papules and pustules. Affected individuals may experience pain, pruritus, and secondary infections. Postinflammatory hyperpigmentation, hypertrophic scarring, and keloid formation are common sequelae in cases of untreated disease. Pseudofolliculitis barbae also is exacerbated by pulling the skin taut and shaving against the grain, making behavioral interventions a key component in management of this condition. Preliminary recommendations include using a new or electric razor, leaving hair at least 2 mm in length, and shaving in the direction of hair growth. Other treatment options with varying effectiveness include daily alternation of a mild topical corticosteroid and one of the following: a topical retinoid, topical antibiotics, or glycolic acid. The only treatments that approach definitive cure are laser hair removal and electrolysis for which patient skin type plays an important role in laser selection.⁵

Traction Alopecia
Similar to their male counterparts, female military members must also present a conservative professional appearance, including hair that is neatly groomed.¹ If the length of the hair extends beyond the uniform collar, it must be inconspicuously fastened or pinned above the collar. As a result, loosely tied hair is unauthorized, and females with long hair must secure their hair tightly on a daily basis. Traction alopecia results from tight hairstyling over a prolonged period and commonly affects female soldiers. The etiology is presumed to be mechanical loosening of hair within the follicles, leading to inflammation. Although traditionally seen in black women along the frontal and temporal hairlines, traction alopecia has been identified in individuals of all races and can occur anywhere on the scalp.⁵ Perifollicular erythema may be the first sign, and papules and pustules may be visible. Although the hair loss in traction alopecia usually is reversible if the traction is ceased, end-stage disease may be permanent.6 Halting traction-inducing practices is paramount, and other treatment options that may slow progression include topical or oral antibiotics and topical or intralesional corticosteroids. Recovery of hair loss also may be aided by topical minoxidil.⁵

Keloids
Keloid formation is an important pathology to address, as it may result from several of the aforementioned conditions. Keloids are most commonly seen in black individuals but also can occur in Hispanic and Asian patients. The cause has not been fully elucidated but is thought to be a combination of dysfunctional fibroblasts with a genetic component based on racial predilection and twin concordance studies.⁵ The chest, shoulders, upper back, neck, and earlobes are particularly susceptible to keloid formation, which can appear from 1 to 24 years following dermal trauma.5 Unlike hypertrophic scars, keloids generally do not regress and frequently cause discomfort, pruritus, and emotional distress. They also can hinder wearing a military uniform. Sustained remission is problematic, making prevention a first-line approach, including proper care of wounds when they occur and avoiding elective procedures such as piercings and tattoos. Intralesional corticosteroids, adjuvant injections (eg, 5-fluorouracil), silicone sheeting, cryotherapy, radiation, laser therapy, and excision are some of the treatment options when keloids have formed.⁵

Final Comment

It is important to recognize military grooming standards as a cause or contributor to several diseases of the head and neck in military servicemembers. Specifically, frequent haircuts in male soldiers are associated with several inflammatory hair disorders, including AKN, dissecting cellulitis of the scalp, and folliculitis decalvans, while daily shaving predisposes individuals to pseudofolliculitis barbae with possible keloid formation. Females may develop traction alopecia from chronically tight, pulled back hairstyles. All of these conditions have health implications for the affected individuals and can compromise the military mission. Awareness, prevention, and recognition are key along with the knowledge base to provide anticipatory avoidance and initiate appropriate treatments, thereby mitigating these potential consequences.