Dermatologic Considerations in Military Medicine

By Jamie L. Trapp
[originally published by The Journal of Drugs in Dermatology DermMatters blog: http://dermmatters.blogspot.com/2009/10/dermatologic-considerations-in-military.html]

Military personnel deal with unique work environments, accompanied by even more atypical medical — both physical and mental — conditions. This holds true for dermatologic issues relating to healing soldiers as well, and it is essential that physicians treating soldiers understand the pivotal role they play in helping rebuild a soldier’s life.

It is also important for clinicians to take into consideration the physical and mental circumstances of soldiers before treatment.

“As plastic surgeons, we use our general surgery training to help treat initial trauma in the field to save the patient’s life or limb…” said American Society of Plastic Surgeons (ASPS) member, Lieutenant Colonel (LTC) Andrew Friedman, MD. “Back in the United States, however, we are using our plastic surgery training to reconstruct soldiers’ injuries, close the wounds and help them feel whole again” (1).

According to the U.S. Department of Defense, nearly 29,800 soldiers had been wounded in action in the Iraq war as of April 15, 2008 and 1,927 wounded in Afghanistan operations as of April 12, 2008 (2).

Current Treatment Availability
Military personnel often suffer from unusual dermatologic problems due to geographic conditions and challenging, often dangerous, job requirements. Exposure to excessive heat, humidity and sunlight can result in specific skin conditions and diseases (e.g., tropical acne, phototoxicity and photoallergy, porphyria cutanea tarda), and it is important for clinicians treating soldiers to take into consideration these distinctive circumstances and work environments. “Skin diseases accounted for over 12% of total outpatient visits during the Vietnam conflict” (3).

One of the most common military-related injuries is keloid and hypertrophic scarring due to burns (e.g., second- and third-degree burns, flash burns, toxic epidermal necrolysis). Grafted skin can also result in scarring, and although a soldier may be physically healed, the mental and social repercussions can be devastating and can lead to low confidence and social discomfort. Treatment with the fractional CO2 laser, for example, has shown great promise for improving scar appearance.

When using the fractional CO2 laser, progress and improvement can be shown by recording objective measurements, as treatment courses with the fractional device may extend for up to two years before completion. Before beginning treatment, it is important for patients to be fully informed about the length and possible outcomes of treatment, to result in the proper expectations. As outlined by Air Force Maj. Chad Hivnor, MD, large areas of the body can be treated in one session, but some form of anesthetic will be beneficial—and important—while doing so. Patients should also be informed of the potential pain that may be experienced one to two hours after treatment (4).

Future Advances
The Armed Forces Institute of Regenerative Medicine (AFIRM) — a network of plastic surgeons and other physicians specializing in regenerative medicine — has been awarded $85 million by the U.S. Department of Defense to help aid in the development of innovative, and effective, treatments for injured soldiers.

“This funding will serve as a vital step toward improving treatments for devastating injuries to the lower and upper extremities as well as the face,” said ASPS member and AFIRM physician, Joseph Rosen, MD. “We are proud to serve the troops and hope this research will help them to better heal, both physically and emotionally, provide a faster return to productive life, and improve their quality of life after injury. The therapies developed will also serve trauma and burn patients in the general public” (5).

Further research has already begun to prove beneficial, as a newly reconstituted elastin protein — derived from the human gene for elastin — has shown promise, and may one day be able to aid in building entire replacement body parts, including areas of skin, organs and blood vessels. The U.S. Army Combat Casualty Care program is funding the research of this newly adapted biomaterial, as well as a new “laser-fusion” technology that could help instantly suture and heal tissue and skin (5).

With current technology in place, and future advancements on the horizon, scientists, physicians (especially dermatologists) and surgeons are working to “put injured soldiers back together” — physically, socially and emotionally.

References
1. Plastic Surgeons Play Pivotal Role Healing Soldiers Injured in Iraq. Panel & Media Briefing Held at American Society of Plastic Surgeons Meetings. http://www.plasticsurgery.org/Media/Press_Releases/Plastic_Surgeons_Play.... 23 September 2005. Accessed 01 October 2009.
2. United States Department of Defense. http://www.defense.gov/. Accessed 04 October 2009.
3. Sperling L. Skin diseases associated with excessive heat, humidity and sunlight. In: Military Dermatology, Chapter 3. Office of the Surgeon General, Department of the Army; United States of America. 1994.
4. Warriors’ wounds: Fractional CO2 shines when treating soldiers’ scars. http://www.modernmedicine.com/modernmedicine/Cosmetic+Dermatology/Warrio.... Accessed 01 October 2009.
5. Medical breakthrough could help “repair” wounded soldiers. http://www.nationaldefensemagazine.org/ARCHIVE/2005/DECEMBER/Pages/UF-Me.... Accessed 01 October 2009.