Operational Dermatology

Military Medicine, Jun 2004 by Schissel, Daniel J, Wilde, Joseph L

Military dermatology encompasses all cutaneous manifestations that present to medical officers in a deployed situation, either in peacetime or in war. Medical officers in a field environment cannot avoid facing cutaneous quandaries. This article briefly highlights the omnipresent threat of cutaneous disease. It follows with a cost-effective look at periodically deploying a dermatologist to Bosnia. Volumes of historical data clearly justify the assignment of a dermatologist as a special consultant staff officer to every corps or theater medical staff. Despite this data, only two U.S. Army units in our present table of organization and equipment will have a dermatologist (60L) available for periodic direct-field consultation and teaching. After review of the historical data and the Stabilization Force-Bosnia statistics presented here, the table of organization and equipment restructuring that is required to meet the challenges of tomorrow will be clear. A dermatologist must be deployed as a theater or division consultant.

Introduction

Many of our great military leaders revisit the past in an attempt to glean knowledge that will help their troops attain the upper hand on the battlefields of tomorrow. Skin disease is of paramount importance in military operations as one looks forward to implementation of the Force XXI doctrine and even beyond to Joint Vision 2010. Although rarely fatal, skin disease can severely impact the combat effectiveness of any unit as will be demonstrated in this review. Our present challenges in Bosnia are in keeping with this trend. Nonetheless, the historical and military significance of dermatologie disease is often overlooked and forgotten. Our goal is to highlight the omnipresent cutaneous threat, to stimulate your input to change the supporting table of organization and equipment (TOE), and to allow the dermatologist (6OL) to help you in the field.

Military Dermatology: Past and Present

As the birth of dermatology as a independent specialty was forming with likes of Dr. Heinrich Auspitz, Dr. Moriz Kaposi, and Dr. Heinrick Kobner in Austria and Germany, the United States was at war with itself.1 The American Civil War brings one of our first disease nonbattle injury reports reflecting 74,182 dermatology-related patients.2,3 Measles, mumps, smallpox, chicken pox, gonorrhea, and syphilis were present in significant numbers. In the wounded, erysipelas and "phagedaena" were cited as complications onboard the hospital ships3,4 during this era.

A quick glimpse through the statistical reports of World War I notes the American Expeditionary Force (AEF) had 126,365 soldiers with cutaneous disorders resulting in hospital admissions between April 1917 and December 1919. Although no outpatient data are available, more than 2 million lost-man days from dermatology-related processes are annotated.4-6 In 1915, the British Army reported hospital admission rates approaching 5% for cutaneous disease. The French registered admission rates approaching 12% and again do not mention the outpatient statistics. However, later in the war, one British Army operating in France noted 90% of all sick call patients manifested a dermatologie disorder.5,7

Continuing in World War II, a conservative range between 15 and 25% of all outpatient visits in temperate climates were dermatologie in origin, and these numbers approached 75% in tropical climates.5,8,9 In the summer of 1945, numerous dispensaries in the southwest Pacific Theater listed up to 75% of those presenting for sick call evaluations were suffering from skin disease. During the entire Pacific Theater campaign, cutaneous disease was a more common cause of evacuation than all other battle injuries combined.9

The Korean War maintained the trend of cutaneous disease nonbattle injuries as a significant cause of lost-man days. Skin disease was ranked fifth highest for hospitalizations and fourth highest for outpatient visits. Shortcomings of this data are noted in that abrasions, blisters, and parasitic and infective diseases with cutaneous manifestations were not included in the skin disease section. These entities have significant overlap with dermatologie care and represent significant statistical power because of their large numbers.10

Moving to the constant wet and warm environment of Vietnam, cutaneous disease exploded to the forefront as the single greatest cause of outpatient visits to U.S. Army medical facilities. Cutaneous diseases were so overwhelming that they often exceeded the combined totals of the next two highest causes of presentation: diarrheal and respiratory disease. Hospital admission rates from U.S. Marines in DeNang in the summer of 1967 ranged from 12 to 41%, with cutaneous disease being cited as the fourth most common cause of admission.11 A typical sick call list from the Mekong Delta revealed that 33% of the men involved in a 4-day combat operation would report for sick call and the majority were presenting with dermatologie problems. The U.S. 9th Infantry Division showed 47% of the total lost-man days between 1968 to 1969 because of medical and surgical conditions (including battle wounds and disease nonbattle in juries) in infantry battalions was because of skin disease.12,13