Over 20,000 Marines are deployed in Iraq at any one time, many serving on their second, third, or even fourth deployment. Nearly all are between 18 and 28 years old, at a time in their lives when they are most likely to encounter difficulties with acne. In the military Dermatology office it is not unusual to see patients who are scheduled to deploy or change duty stations within months of their first visit. These unique considerations sometimes call for adapting our treatment plans based on individual circumstances when dealing with skin disease, particularly acne.
A common chief complaint at the Dermatology Clinic at Camp Pendleton in San Diego, California is moderate to severe acne in Marines returning from deployments to the Middle East. Many have only a history of mild acne, but upon return from warfront duty report cystic acne, predominantly covering their torso and face. Lesions occur especially in areas where heavy occlusive garments such as individual body armor suits, flak vests and helmet straps are worn. This complaint has become exceedingly common, dubbed "Iraqne" by staff Dermatologist, LCDR John Trafeli.
This form of acne is best described as acne mechanica, which is frequently inflammatory. Acne mechanica is believed to be caused by chronic skin irritation that leads to occlusion of the follicle.(l) Follicular occlusion is followed by proliferation of Propionibacterium acnes in the sebum along with associated inflammation. Continued occlusion and poor hygiene exacerbates the condition and moderate forms of acne develop into severe, nodulocystic acne. A very similar condition has been previously described as "tropical acne," occurring in hot and humid environments. Differences between tropical acne and Iraqne include the relatively arid environment in the Southwest Asia as well as an absence of the systemic illness has been noted to occur with tropical acne.(2)
THE MISSION
Marines deployed in Southwest Asia face demanding missions in extreme environmental conditions. Skin cleansing opportunities may be limited, with weeks between showers in some cases, and clothing may have to be worn even if it has not been washed after previous use. This has been especially true for troops embedded with Iraqi forces. One Marine, in particular, recalled rotating three polypropylene shirts over several months before having the opportunity to have them washed.
The heat and irritation under the heavy garments of the modern combat uniform, in addition to the lack of adequate cleansing opportunities create a condition where acne is likely to develop. Although symptoms are not necessarily disabling, cysts are painful and often become purulent. The condition is exacerbated by continued follicular occlusion and somewhat limited treatment options for General Medical Officers in remote environments. Access is generally limited to benzoyl peroxide, topical and oral antibiotics and the initiation of oral steroids in severe cases. Patient compliance and follow-up may also be limited by the demands of the mission.
We have seen many Marines return with permanent scarring, particularly on the back and upper chest, as well as a flaring of facial acne. Several Marines have expressed concern regarding disease duration and the potential for permanent disfigurement.
TREATMENT LOGISTICS
In addition to deployment conditions, another notable difficulty in treating Iraqne arises due to constant troop rotations. Most Marines are appropriately put on standard anti-acne medications upon their return from war. Their acne then appears to improve greatly due to the medications and the ability to wash regularly. The acne, however, recurs on a subsequent deployment. Another scenario is that upon return from deployment, the primary physician attempts to treat the acne with traditional medications, such as benzoyl peroxide wash or cream with or without oral antibiotics. If little improvement is seen after months of therapeutic trial, the primary physician makes the appropriate Dermatology referral. By the time the military member is seen in Dermatology, he or she is sometimes only a few months or even weeks away from leaving the geographic area. This scenario makes the initiation and completion of a recommended cumulative does of 120 to 150 milligrams per kilogram over five months of isotretinoin therapy impossible. Situations such as these can be even more difficult when treating females due to the necessary time constraint protocols of the iPLEDGE system.
Effective March 1, 2006 iPLEDGE sets strict guidelines with regards to who can prescribe isotretinoin. Monthly laboratory testing and a timeline where prescriptions expire if not filled within seven days are examples of requirements in place as part of iPLEDGE. The goal of this program is to improve patient safety and to prevent pregnant females from taking isotretinoin due to the potential for teratogenicity. A more complete description of this program can be found at https://www.ipledgeprogram.com.
In Afghanistan or Iraq difficult, many Marines are in areas managed by General Medical Officers who are not eligible for enrollment in iPLEDGE. Getting to the military Dermatologist stationed in Baghdad involves 3 days of travel for most military members (monthly), as well as added security risk due to travel by air or ground in hostile territory.
OUR SOLUTION
One solution is to offer that treatment which achieves the greatest disease resolution over the shortest period of time. Accordingly, we have started to use isotretinoin early in the treatment course, with the goal of getting patients on and off this medication before they deploy or redeploy. Often the acne is not what the civilian Dermatologist would typically regard as severe enough to initiate isotretinoin without a thorough exhaustion of standard treatments.
The decision to use isotretinoin in these individuals is not taken lightly. Every patient is screened for baseline mental well-being and counseled with regards to the potential for psychiatric disturbances. Individuals with personal or family history of major psychiatric illness, obsessive compulsive disorder or neurological injury have been found to be risk factors for psychosis.(3) Patients are also chosen carefully based on these factors as well as their job stress, the availability of weapons and with consideration of any possible symptoms that could be suggestive of post traumatic stress disorder. Marines with red flags are referred to psychiatry prior to the initiation of isotretinoin. Additional counseling is provided regarding sun sensitivity and potential for decreased night vision, with the warning that individuals treated for these conditions should not operate military vehicles or fire weapons at night.
FITNESS FOR DUTY
The goal of the Dermatologist in treating military members should be to keep individual fit for combat duty. More importantly, the physician needs to be able to predict how future conditions in the field of combat affect fitness for duty and, if necessary, to preemptively treat the acne. The modern combat soldier has many issues to deal with while deployed, and our goal is to not have acne or acne scarring among them. We are therefore proactive in initiating isotretinoin early, especially if the Marine has a history of moderate acne when not deployed or acne flaring on prior deployments.
For patients who cannot take isotretinoin, we typically start with doxycycline; minocycline can be associated with vestibular side effects such as dizziness, certainly an undesirable consequence in a combat scenario. Moreover, doxycycline has excellent anti-inflammatory properties. Members are likewise warned of the risk of photosensitivity when taking doxycycline, especially in light of the present field of military operations. We often provide an antimicrobial wash to be used when possible and a supply of portable benzoyl peroxide/erythromycin packets that can be mixed in the palm of the hand for daily use and do not require refrigeration.
In summary, we propose early and aggressive isotretinoin treatment in the combat scenario if appropriate. The goal is to get patients on and off of treatment in a period of time during which they can be closely monitored while achieving the greatest possible outcome. Vigilant monitoring for clinical improvement and side effects will direct the future of this treatment plan. At this point we are seeing positive results in over thirty patients treated with oral isotretinoin, nearly all with greater than 50% reductiop in the number of inflammatory lesions. There have not been any cases where a major psychiatric illness has been identified after initiation of medication.
© 2008 Association of Military Surgeons of the United States Provided by ProQuest LLC. All Rights Reserved.
Copyright 2008 Military Medicine
