General Medical Officer (GMO) Manual: Clinical Section: Acute Pain Management

General · Prevention/Minimization of Skin Disease · Hot/Humid Areas · Cold Weather Operations · Miliaria (Prickly Heat) · Intertrigo · Acne · Furuncles (Boils) · Impetigo · Herpes Simplex (HSV) · Herpes Zoster · Varicella (Chickenpox) · Inclusion Cysts · Pseudofolliculitis Barbae (PFB) · Verrucae (Warts) · Condyloma · Molluscum Contagiosum · Eczema and Contact Dermatitis · Psoriasis · Seborrheic Dermatitis · Scabies · Lice (Head and Body) · Tinea Pedis/Cruris (Athlete's Foot/Jock Itch) · Tinea Capitis · Tinea Versicolor · Basal Cell Carcinoma · Melanoma · Actinic Keratosis · Pityriasis Rosea · Urticaria/Angioedema

Dermatology in a Combat Environment Video

Dermatology Atlas

(1) General

Believe it or not, rare or exotic dermatoses are not the skin conditions that create the greatest difficulty for deployed military personnel. In fact, only about 20 or so conditions induce the majority of outpatient dermatologic visits and generate the lion's share of morbidity. Under field conditions, common dermatoses may have unusual clinical appearances or become more severe than what is encountered in routine "in garrison" or "in port" care.

This chapter of the GMO Manual is not just for Navy providers. The intended audience is the primary care providers of all U.S. Armed Forces. It is meant to supplement but not replace the commonly available dermatologic textbooks, online atlases, therapeutic manuals, PDR and CD-ROMs. It does however contain diagnostic and therapeutic "pearls" that are most useful to military primary care providers in an operational setting.

The chapter is restricted to conditions that are highly prevalent or produce disproportionate morbidity in a deployed military population.

(2) Prevention and Minimization of Skin Disease

The old adage that “an ounce of prevention is worth a pound of cure” is when applied to dermatologic conditions in the field. The presence of extremes of head and cold along with fewer opportunities for personal hygiene and clothing change have been the traditional enemies of deployed military personnel. Military unique dermatology can be thought of as a battle of the Sailor and Marine versus the hostile environment.

Included below are some prevention tips for hot and cold climates written by the U.S. Army in plain language for field troops. Some phrases are quoted verbatim in the next few paragraphs. This simple wisdom applies to any person in any of the Armed Forces. These words are just as true today as when they were written.

(3) Hot and Humid Areas

These tips were published in 1977 by the US Army in a small field manual entitled: FM 8-40 "Management of Skin Diseases in the Tropics at Unit Level".

(a) Keep the skin clean.

"Cleanliness helps preserve the skin's health. Bathing removes dirt, decreases the number of microorganisms and lessens body odor. For all these reasons, keeping clean is preferable to remaining dirty. In addition, showers are great for relaxation, morale and personal comfort."

"If bathing facilities are not handy, they (your personnel) can keep quite clean by washing with cold water from their helmets. Potable water is preferable for showers, but if not available, nonpotable water is adequate."

"Soap and water must be used judiciously and properly. Whatever soap is used must be rinsed off completely. As to the type of soap to use, scientific evidence does not support the notion that germ killing or deodorant soaps or detergents reduce the incidence of bacterial or fungal infections."

"Soldiers (military personnel) must not shower excessively, such as three showers a day with lots of lather. Too much soap and water removes the skin's moisteners and protective oils, causes the skin to become dry and irritated, and thereby reduces the skin's capacity to protect the body."

"Even though cleanliness helps preserve the skin's health, bathing cannot perform miracles in preventing skin disease. This is true regardless of the brand of soap used or the number of showers taken."

(b) Keep the skin dry.

"Tropical skin diseases would be greatly reduced if another rule of skin hygiene, keeping the skin dry, could be adhered to."

"The realities of combat and (other) military operations often make this difficult, but there are a few rules to follow:"

"Remove wet socks and boots as frequently as possible. If dry socks are not available, wring out the wet ones."

"Rinse mud off boots. Mud on boots prevents (the leather) from drying."

"Pay special attention to the skin fold areas; the armpits, groin, buttocks, and the areas between the toes, where several common skin diseases can erupt. Dry these areas frequently. In addition, get in the habit of using talcum (or other nonfragranced) powder. These two practices will promote drying, reduce friction, and prevent infections."

"Do not starch jungle fatigues (BDUs). Starch clogs the openings in the cloth, blocks sweat from escaping, and therefore prevents sweat from evaporating and cooling the skin."

"Air the skin as much as conditions permit."

"If underwear is aggravating an existing skin condition, do not wear it."

"In base camp, encourage the wearing of as little clothing as the commander will allow. Under some conditions, commanders may permit clothing, such as shortened fatigue (BDU) pants, tennis shoes or shower clogs, at base camp and particularly in the company area. It is the commander's responsibility to prescribe the uniform, however. The medic (medical personnel) can only recommend a uniform that is consistent with command policy."

“Unless you are reasonably sure the patient has a fungal or bacterial infection, it is better to soothe the skin than to “kill the germs”. More damage can be done by “over treatment” than by under treatment. As a rule, highly inflamed, blistered, or oozing areas require gentle and calmative treatment. The application of wet soaks (e.g. Burow's solution), removal of restrictive clothing, can encourage the patient to stop scratching by eliminating the itching.”

(4) Cold Weather Operations

These quotes are from the US Army TC 21-3 (1986) "Soldier's Handbook For Individual Operations and Survival In Cold-Weather Areas". This 1986 version is easily understood.

(a) Keep it Loose

"All items of the cold-weather uniform are large enough to allow wearing of the appropriate number of layers (of clothing). Your field jacket may appear too large without all of the layers designed to fit under it. If the uniform items do not fit loosely, the insulation that keeps you warm (a layer of warm air) will be greatly reduced."

(b) Keep it dry

"It is important to keep clothing dry, since wet clothing conducts heat away from the body more quickly than dry clothing. Moisture soaks into clothing from two directions: the inside and the outside. From the outside you must guard against melting snow; from the inside you must guard against sweating. Brush snow and frost from clothing before entering any heated shelter or vehicle, and avoid overheating."

(5) The Cold Weather Uniform

"The feet are hard to keep warm and dry, so protect them."..."When you are active, your feet will sweat and....the moisture will remain in the socks or in the bottom (and leather) of the boots. Drying (the feet), massaging with foot powder, warming and putting on dry socks will correct this."..."Don't wear socks that are too tight."..."Change your socks at least twice a day."

Dermatologic Conditions

Milaria (Prickly Heat)

(6) Miliaria (Prickly Heat)

This common condition is most frequently seen in service members who have been recently put in hot, humid environments. The trunk is commonly involved. Wearing occlusive clothing and military gear further exacerbates the effects of the climate. As a result, the patient does not sweat onto the skin. Instead, he or she sweats "into" the skin.

The most common form seen in the deployed military population is little discrete pink to red itchy papules on the trunk. Besides being a nuisance, the presence of miliaria reduces the service member's ability to cope with heat stress.

Removal of the occlusive clothing, thereby allowing the skin to air is effective yet simple. The use of calamine lotion with 1 % hydrocortisone as a shake lotion is effective for relief of symptoms. The good news is that most personnel will spontaneously resolve after acclimatization.

Intertrigo

(7) Interigo and Irritancy in Body Folds (Crotch Rot, Pit Rot)

Perspiration as well as other skin irritants (e.g. soap residue, petroleum products, sawdust, fiberglass etc) can collect in body folds and cause an irritant dermatitis. The condition is most commonly seen in patients in whom the body folds predispose to trap moisture and irritants rather than vent to the air. As you can imagine, service members who are constitutionally sweaty, who serve in hot, sweaty places, doing hot sweaty things or who are pregnant (figure 1) are more prone to this condition. In addition, what starts as a simple case of Interigo may, with time, become secondarily colonized with Staph and/or Candida.

The best way to prevent interigo is the use of hygienic measures outlined above. Strongly counsel your patient not to be overzealous in personal hygiene measures. Recommend avoiding over the counter (OTC) remedies and harsh soaps. If it occurs despite these measures, the use of mild topical corticosteroids (e.g. hydrocortisone or desonide cream) should be considered.

Inflammatory Acne

Nodular Acne

(8) Acne

All acne treatments require several weeks to work. Your patient will not wake up with a clear face tomorrow, next week or even next month. Be patient!

Patients should not "squeeze their zits" because it may enhance scarring and will delay resolution of the manipulated lesion.

Dietary effects on acne are inconsistent at best. If your patient repeatedly breaks out a couple of days after eating a certain food, tell him/her to avoid it. However, the complexions of most patients are not affected by diet.

(a) Comedonal (predominantly blackhead/whitehead acne)

Benzoyl Peroxide
Benzoyl peroxide (BOP) products are available in wash, gel, or cream forms. All of these products will bleach colored fabrics. Use the BOP washes in place of and exclusive of any other facial soaps or cleansers. They should be used as one would use a liquid soap washing using only fingertips or lightly with a white washcloth and rinsed thoroughly. The gel or cream BOP preparations should be applied just before sleep and left on overnight.

Benzoyl peroxide products will induce some drying. If you decide to start a patient on a wash and a gel/cream together, remember that you may end up inducing quite a bit of irritation (see Facial Dryness below).

Retinoids: Tretinoin (Retin-A)

Another alternative is the vitamin A derivative tretinoin. Facial irritation and dryness are the usual limiting factors for this medication. Most of the time this can either be avoided or minimized if some simple common sense guidelines are followed.

Start using the lower concentration of the appropriate medication. For patients with very greasy complexions, the 0.01% gel (green label) is appropriate while the 0.025% cream (gray label) is better tolerated by average complexions. Application should be just before sleep waiting at least 20-30 minutes after washing the face. Significant facial irritation, dryness, and scaling can be practically guaranteed if this is ignored. Only a "pea sized" amount of Retin-A is needed to cover a face and forehead. Avoid the skin immediately adjacent to the mouth, nose, and eyes.

A mild amount of irritation will occur and can usually be controlled (see Facial Dryness below). Another way to minimize irritation is to have your patient use Retin-A every other night for 2 weeks before advancing to every night treatment.

Retin-A is not a true photosensitizer in the classic sense of the word. It does however make the face more sensitive to all potential irritants such as sunlight, wind, salt water, fragrances, and/or irritating vapors.

Retin-A will make acne worse for a several weeks before it begins to improve. If your patient tolerates the initial therapy, you can advance after 3-4 months to the 0.025% gel or the 0.05% cream as appropriate.

If your patients complain about excessive irritation from Retin-A, ask them in some detail how they are using the product. You may be quite surprised to find that they have either never been told how to correctly use it or just have not followed the directions.

Alternative topical retinoids such as microsphere tretinoin and adapalene gel (Differin®) are niche products that are not widely used due to their expense. Ensure that your patient has CORRECTLY used Retin-A before trying these products.

(b) Facial Dryness and Irritation from Acne Therapy

Topical acne therapy will always create some mild dryness and irritation. It is usually easily controlled with a non-fragranced facial lotions (e.g. Purpose Facial Lotion, Lubriderm etc.) applied once or twice a day. Some facial drying is acceptable; a lot of dryness and irritation is not acceptable. If severe drying or irritation occurs, your patient needs to stop the treatment.

Benzoyl peroxide products are appropriate (as above).

(d) Topical Antibiotics

These must be applied twice a day to be effective. Most of them are compounded in water/alcohol based solutions (Cleocin-T, T-Stat, Staticin, and Erycette Pads) and will induce some drying. Patients with complexions that are prone to dryness (or who also have seborrheic dermatitis) should use Cleocin-T Lotion instead of the water/alcohol products. Patients taking disulfuram (Antabuse) should not use these water/alcohol products.

(e) Azaleic Acid

A newer product is 20% azeleic acid cream. This is a niche product primarily meant for resistant cases of simple papulopustular, inflammatory acne. This product is quite expensive and will have only limited use in a primary care setting.

(f) Oral Antibiotics

These are appropriate for patients with substantial numbers of inflamed acne lesions and a few small cysts.

Tetracycline

Tetracycline is the old standby. Unfortunately, it must be taken 1 hour before eating or 2 hours after eating... a real inconvenience. Particularly avoid dairy products, iron, and certain antacids. These interfere with the intestinal absorption of the medication. Start with 250 mg BID advancing to 250 mg (2) BID if needed. Side effects to consider are mostly G-I upset and candida vaginitis. Photosensitivity, while reported, is not a frequent problem.

Whether or not the tetracyclines interfere with the action of oral contraceptives is controversial. It would be prudent to counsel the patient about this issue and broach the possibility of using a supplemental form of contraception. The patient who has been previously stable on oral contraceptives should immediately report the new appearance of “spotting” to you. This potential problem has not been reported with Depo-Provera or Norplant.

Doxycycline

This cousin of tetracycline has the advantage of being able to be taken with food (although not large amounts of dairy products, or mineral supplements). In fact, taking it on an empty stomach is usually rewarded by G-I upset. As with all oral antibiotics, vaginal candidiasis is a possibility. The starting dose is 100 mg per day advancing to 100 mg BID if necessary.

Photosensitivity is a real possibility with this drug. It should be used with caution to those with significant sunlight exposure. Although it appears to be allowed by the Naval Aerospace Medical Institute (NAMI) for patients in flight status, a review of the current NAMI, Air Force, or Army flight medicine "allowable medications" list is highly advised. If in doubt, consult a flight surgeon from the appropriate service. It is not to be given to those in undersea status or patients in whom large exposures of ultraviolet light are probable.

Minocycline

This is another first cousin of tetracycline that should be taken with food as above. The side effect spectrum is the same as other tetracyclines. The risk of photosensitivity is much less than doxycycline. Headaches and vertigo are a real possibility. The starting dose is 100 mg per day advancing to 100 mg BID if necessary. It is contraindicated for aviation or undersea personnel in the Navy.

Erythromycin

This drug is best given on an empty stomach with two glasses of water. However, if G-I upset occurs, it can be given with a small amount of food, but about 20 percent of the drug will not be absorbed. Vaginal candidiasis is a possibility. The starting dose is 250 mg BID, advancing to 500 mg BID if needed.

Beware of multiple drug interactions: theophylline, digoxin, terfenadine, astemizole, loritidine, coumadin, barbiturates, phenytoin, and carbamazepine. Check the PDR for details.

(g) Other Oral Antibiotics

While many other antibiotics have been used in the treatment of acne, their use is probably best initiated by a dermatologist.

(h) Other Oral Medications

The use of medications to modify the hormonal milieu of acne is probably best left to the specialist.

(i) Nodulocystic Acne

Use of the medications above should be considered initially. Oral medications should be used at the higher doses listed above. If the patient does not respond within 2-3 months, a dermatology consult is appropriate. The use of isotretinoin (Accutane) may be indicated.

The decision to use isotretinoin is not a casual one and should be left to a dermatologist. This medication has predictable morbidity and teratogenicity as well as requiring monthly follow-up visits and lab testing (including serum pregnancy testing in women). The risk of teratogenicity in pregnant women is exceptionally high.

There are also several military-unique considerations to using this medication. In addition to the predictable dryness and skin fragility, frequent musculoskeletal side effects will further degrade combat readiness of personnel in a large number of military occupations. The dermatologist is obligated to coordinate this treatment and follow up with the service member's operational primary care provider.

Furuncle

(9) Boils (Furuncles)

If the lesion is fluctuant, incise and drain it. If not yet fluctuant, hot soaks three times a day are appropriate to "bring it to a head".

Oral antistaphylococcal antibiotics (preferably beta lactams) are indicated for 10 days (e.g. dicloxacillin 500 mg QID).

The majority of these lesions are staphylococcal and as such pose a public health risk in an operational setting if not aggressively treated. In particular, these patients should not be food handlers until treatment is complete.

Impetigo

(10) Impetigo

This rapidly spreading, highly contagious condition should be aggressively treated topically and systemically.

The oozing lesions should be dried with Burow's Solution (1 tablet dissolved in 1 pint of water) used as a compress for 5 to 10 minutes, 3 times a day.

Topical antibiotic ointments are optional. Systemic anti-staph drugs are your safest option.

Like a furuncle, impetigo is a public health hazard. These patients should not be food handlers until resolved. If the impetigo is on the central face, examine carefully to see if the lesions represent secondarily infected herpes simplex.

(11) Herpes Simplex (HSV), oral and genital

If there is a question of diagnosis, do a Tzanck smear (see technique below). While oral or genital HSV is usually painful, this is not always the case. Be suspicious, especially with penile erosions and ulcers.

Treatment should be individualized. Topical acyclovir ointment is useless. Tea bag soaks are quite helpful to dry out the blisters. Have the patient make a cup of tea, squeeze out the teabag, and then apply the bag to the lesions after it has cooled. The residual tannic acid in a tea bag is a surprisingly effective drying agent.

Oral HSV

Genital HSV

(a) Acyclovir

Oral acyclovir is effective only if given EARLY in the herpetic episode. In addition, it is not useful for the patient who gets only the occasional mild episode. Acyclovir is helpful for patients with an initial outbreak. They are frequently systemically ill and in pain.

For patients with recurrent disease, acyclovir should be reserved for those patients whose outbreaks are frequent, very painful, or have associated systemic findings (fever, painful adenopathy, malaise, etc.) The dose for treatment of an acute episode is 200 mg five times a day for 5 days. The use of 200 mg TID to 400 mg BID is useful for suppression in patients with frequent recurrences.

(b) Valacyclovir

This drug is a pro-drug of acyclovir. Its mechanism of action is identical to acyclovir. The advantage is that the medication needs to only be used twice a day instead of five. The dose for recurrent HSV is 500 mg BID for 5 days. The use of 500 mg QD is useful for suppression.

(d) Other Considerations

In the case of genital HSV, evaluation for concomitant STD should be strongly considered on an initial visit. STDs are a chummy group and are frequently transmitted in twos or threes. Look for them!

Although patients are most infectious when they have active lesions, they may continue to shed virus (albeit at a smaller rate) between outbreaks. As such, barrier contraception (e.g. condoms) is recommended at all times unless a couple is trying to conceive.

A couple trying to determine "who gave what to whom and when" is engaged in a hopeless and psychologically destructive task. Either partner may have had a dormant infection for weeks, months or even years. While serologic testing for antibodies to HSV I and II is available, a positive result is of little clinical utility because over 90 percent of adults will test positive due to previous exposure to oral or genital HSV.

Tzank Smear

Instructions for performing a Tzank Smear

Open an intact vesicle at the edge using a surgical blade. If no intact vesicles, gently soak off the crust.
Scrape the base of the vesicle (or the advancing border from an erosion/ulcer after crust soaked off) and smear on slide. Do not scrape to the point of bleeding, it makes the slide difficult to interpret.
Fix the slide using heat or 20 seconds in absolute alcohol.
Stain using Wright, Wright-Giemsa, Pap, etc. stains following the lab's standard operating procedures manual.
Dry the slide using gentle blotting motions of a paper towel and air movement.
Place 2 small drops of immersion oil on slide and then mount a cover slip.
Scan under 10-X for presence of multinucleated giant cells.

Herpes Zoster

(12) Zoster

The presence of itchy or painful vesicles on an erythematous base in a dermatomal distribution should be considered Zoster (shingles) until proven otherwise. Use a Tzanck smear (see Herpes Simplex above) to confirm the diagnosis. Thoracic segments are the most frequently affected.

The branches of the trigeminal nerve are also frequently involved and can be quite painful. The ophthalmic branch in particular is quite problematic. For patients with cranial nerve V¹ involvement, be sure to ask about eye symptoms and do examine the eye. Keratoconjunctivitis and/or iridocyclitis are potentially serious complications. Consult with an ophthalmologist.

Treatment of Zoster is threefold in nature: antiviral medications (if indicated), pain relief, and drying of the vesicles. Acyclovir 800 mg orally five times a day is helpful only if given with 48 hours of the onset of the rash. The appropriate doses of valacyclovir and famcyclovir are 1000 mg TID and 500 mg TID respectively.

The pain can be quite severe; prescribe narcotics if required. The use of Burow's solution to compress the vesicles (see Impetigo above) is soothing and will desiccate the blisters.

While the vesicular fluid of zoster lesions is minimally contagious, this is usually not a problem in immunocompetent patients. Patients can return to work with active vesicles as long as the involved area is covered with clothing.

Varicella (Chickenpox)

(13) Varicella

This condition is highly contagious and can cause a great deal of morbidity in the active duty age group. Even though the varicella vaccine is now commonly in use, there are still many service members who are susceptible.

For Chickenpox, treat the active duty age group with acyclovir 800mg 5 times a day for 10 days if the condition is recognized within 2-3 days of onset of rash. The course of the illness can be somewhat shortened. Unfortunately, it is unclear whether the serious complications of varicella (e.g. pneumonitis, meningoencephalitis, etc.) can be prevented with therapy.

Epidermal Inclusion Cyst

(14) Epidermal Inclusion Cysts (Sebaceous Cysts)

If the cyst is inflamed and fluctuant, surgically drain it. Larger amounts of local anaesthetic than expected are usually required to deaden the skin before incision and drainage.

After irrigation and removal of all visible cyst wall, pack it with iodoform gauze and let it granulate. Premature closure of the surgical wound is counterproductive...let it drain. Antibiotics are optional because this is not initially an infectious process. A few weeks later, evaluate the site to see if any cyst remains and consider the feasibility of elliptical excision.

Pseudofolliculitis Barbae (PFB)

(15) Pseudofolliculitis Barbae (PFB)

Although this is mostly an administrative problem, it is of importance to the operational primary care provider. The Department of Defense does not require clean shaven faces merely for the sake of military appearance. Grooming is important because bearded faces have greater difficulty in obtaining gas tight seals on a gas mask or oxygen breathing apparatus. The practice of liberally giving "no shave chits" besides being unprofessional may actually harm your patient in certain operational situations. BUPERS instruction 1000.22 and Marine Corps Order 6310.1B outline the current program and administrative procedures including the phases of therapy and how to properly use them.

Although some patients truly must grow short, well-trimmed beards as the only way to control their PFB, the majority of motivated patients can be helped by simple measures. Most PFB patients are quite motivated, but need your interest and guidance. Your attention to this frequently misunderstood problem will reap great rewards. You will be rewarded by the respect of your patients and better clinical results.

First of all, make sure that the patient truly has PFB. Some patients may also have coexistent acne, which is worsened by the act of shaving. Examine the skin carefully. Treatment of PFB alone in the presence of coexisting acne is doomed to failure. Both conditions must be approached simultaneously.

Most cases of PFB require a period of no shaving to give the inflamed hairs a change to grow out to let the inflammation die down. Mild cases may require only 2 weeks of "no shave" whereas more severe cases frequently need 4 weeks or longer. Impacted hairs can be delicately dislodged during this period by gently massaging them (barely touching the face) using a circular motion with an extra soft toothbrush.

Once grooming is resumed, remember that the goal is to have some "stubble" remain on the problematic areas. This is done by "shaving with the grain", whether one is using a PFB razor, electric razor, beard clipper, or removing with a chemical depilatory. Going "against the grain" defeats the whole strategy of leaving "stubble" because the hairs would be cut shorter. The act of hair removal is more physically irritating to the skin.

Chemical depilitory products can play a role in some, but not all patients. Several patients prefer to use these products despite an unpleasant smell during their use. The most widely available of several commercial products is Magic Shave. The instructions on the container need to be explicitly followed or else an irritant dermatitis will almost always occur. Even if properly used, many patients develop a mild tightness and chapping of the face and neck. Be careful.

Verrucae

(16) Verrucae

Everybody dislikes warts. Warts are a challenge for both you as well as your patient. Remember that the family of wart viruses is a lot smarter than we are. Even after the wart is visibly gone, virus persists in the skin and may recur later.

Make sure that both you and your patient have realistic expectations for treatment. Your goal is to minimize your patient's morbidity and encourage the immune system to control the infection. Permanently ridding your patient of the wart virus is not possible. Overly aggressive therapy is usually only rewarded with extra morbidity and is frequently not more likely to be successful.

Warts are passed between humans commonly in "communal" settings such as berthing compartments, recreational facilities, and equipment. Wear shower shoes, T-shirts, and weight lifting gloves to avoid exposure and the spread of warts to others.

The most common encountered morbidity from warts (especially on the feet) is pain. The pain is not caused by the wart itself, but rather by the mass effect of having a hard knot within and on top of the skin. Gently paring the wart with a scalpel blade just barely to the point of pinpoint bleeding is an easy way to debulk it, thereby decreasing the patient's discomfort as well as preparing the site for other treatment. Control any bleeding by applying Monsell's solution or 20% Aluminum chloride solution (DrySol).

Common treatments for warts whether chemical, electrical, or surgical are skin destructive in nature.

Chemical salicylic acid wart varnishes (e.g. Duofilm, Occlusal HP, Compound W, etc.) should be applied to the wart daily, preferably at bedtime. Consider protecting the surrounding normal skin by applying petrolatum. Place two or three coats on the wart, allowing each coat to dry; then apply a bandaid. Salicylic acid plasters (e.g. Mediplast) should be cut to fit the wart and then applied at bedtime and overlaid with a bandaid. The next day, the lesion can be pared or abraded with an Emory board or pumice stone. Stop treatment if there is substantial pain, irritation, or ulceration.

Trichloroacetic acid solution (TCA) can be used similar to the salicylic acid preparations, but has a larger potential for tissue destruction. Use it with respect.

Liquid nitrogen, if applied optimally, will induce a small blister allowing the wart to peel away from the underlying dermis. Freeze the wart quickly to the point of turning it white with a 1 mm zone of normal skin. A good method to minimize the damage to surrounding normal skin is to apply an appropriately sized otoscope speculum and spray the nitrogen through the open end. Let the wart thaw slowly, then repeat the freeze.

After freezing, the lesion will follow this sequence over the next few days: pink, red, purple, brown, and then maybe even black. A blister will likely form and should be approached as any other blister. Once the vesicle has opened and dried, pare off any remainder and see if any lesion remains. Repeat treatment should be considered every 1-2 weeks or so if any lesion remains.

Electrosurgery should be used only if you have had some training in its use. It can generate a fair degree of post-operative morbidity. Areas over joints, near the nails, or over the bony prominences are particularly difficult to treat.

Chemical vesicants such as cantharidin are quite destructive and are not recommended as initial therapy.

Condyloma

(17) Condyloma

Like other warts, subtypes of human papilloma virus also cause these lesions. Like other warts, the infection is a lifelong one. Sexually transmitted diseases such as condylomata love company. Make sure that your patient does not have other STDs. Evaluation for other STDs (e.g. syphilis, urethritis, and HIV) should be considered on the initial visit.

Once a patient has had condylomata, the skin always sheds virus to some degree. As such, barrier contraception (e.g. condoms) is recommended unless a couple is actually trying to conceive. The question of who gave the virus to whom is not a useful one. The virus may have been shed asymptomatically by either partner for quite some time before lesions develop.

The goal is to make your patient free of visible warts for as long as possible. Eradication of the virus from the skin is impossible. Destructive modalities delivered with precision such as liquid nitrogen, Trichloroacetic acid, electrosurgery, and podophyllin are helpful.

Podophyllin resin in tincture of benzoin has long been a mainstay of therapy. Apply it to external lesions (do not apply to vaginal or cervical warts in women or use during pregnancy) and wash off with soap and water after 4 - 6 hours. Re-evaluate your patient 1 week after treatment to determine whether additional therapy is necessary.

A new form of podophyllin (Condylox) is commercially available and should only be considered for emotionally mature, dexterous, and reliable patients. The active ingredient is podofilox, a purified and standardized form of podophyllin toxin suitable for self-application by a patient.

Podofilox is meant only for external condylomata and should not be used on mucous membrane lesions or during pregnancy in females. Follow the PDR recommendations carefully because over treatment will result in considerable irritation. This should be applied only to lesional skin. This medication is also quite expensive. It is not meant for everyone.

Other pharmacologic means to treat condylomata include biologic response modifiers such as topical imiquimod cream (Aldara) and intralesional interferon. These modalities are very costly and are only considered appropriate for treatment when prescribed by Dermatologists.

Molluscum Contagiosum

(18) Molluscum Contagiosum

A DNA containing pox virus causes these lesions. When seen in the active duty population, they are frequently sexually transmitted. As such, they are usually found on or near the genitalia, inner thighs, and waistline areas. Clinically the lesions are asymptomatic 1-5 mm umbilicated milky papules (figure 3).

Treatment is best accomplished with destructive modalities such as liquid nitrogen, light curettage, or light electrodessication.

The precise pinpoint application of salicylic acid wart varnish (protecting the normal skin with petrolatum) covered by a band aid is an alternative.

Vesicant agents, such as cantharidin, are best avoided by primary care providers unless they are quite experienced in the technique.

Atopic Dermatitis
Figure 4

Atopic Dermatitis
Figure 5

Dyshidrotic Eczema of Hands
Figure 6

(19) Eczema and Contact Dermatitis

(a) Administrative Notes

Hand eczema (endogenous and exogenous), atopic dermatitis, and other forms of eczema are the second most costly form of dermatologic, occupationally aggravated, or induced "illness" in the civilian world and DoD. In particular, endogenous hand eczema and atopic dermatitis are notoriously unpredictable.

For this and other reasons these conditions are disqualifying for entry into the United States Armed Forces. If present in a currently serving member, these conditions are considered to be disqualifying for aviation, submarine, and Special Forces duty as well as other specialized military duty.

Why is this so? The actuarial data of many decades gives us the answer. Even if a patient's eczema has been minimally active (or even totally quiescent) this is not an accurate predictor of future severity. Military dermatologists (like our civilian occupational dermatology colleagues) routinely encounter many patients whose "minimal" eczema ultimately flared badly in the military or special occupational environment.

Figures 4 and 5 illustrate such a case of Atopic Dermatitis in a Navy Mess Management Specialist. His eczema flared very badly during Operation Desert Shield/Storm, ultimately impetiginized and was the source of an outbreak of Staph food poisoning.

Figure 6 illustrates a case of a man with known Dyshidrotic Eczema of the hands who was granted a medical waiver for enlistment. His hands flared very badly during his training as a jet engine mechanic. He was ultimately medically separated from the Navy.

This group of skin diseases causes a great deal of morbidity, lost productivity and administrative burden to the military. Waivers for entry in a patient with known endogenous eczema or hand dermatitis should be rarely granted, only after thoughtful deliberation. Please remember this fact if you are doing entry physicals or special duty qualification exams.

(b) Treatment

The treatment of eczema can be likened to be a three legged footstool. If you remove one or more of the legs, the footstool will not stand. The same is true for eczema therapy. The three legs of this therapeutic footstool are lubrication, medication, and control of the skin's environment.

Lubrication of dry eczematous dermatitis can be done with a wide variety of emollients, the simpler the better. Frequent use of bland products such as Eucerin, Aquaphor, or Vaseline is preferable to the more expensive fragrance containing and chemically complex products. Fragranced products, while "elegant", are potential irritants and/or allergens and should be avoided on irritated skin of any kind, but especially in patients with eczema.

The medication leg of the footstool usually involves topical steroids. The advice here is similar; keep it simple. Topical steroids are available in a variety of potencies and vehicles. In general, do not use medium potency or higher products on the face or genitals. Gels or aerosolized steroid sprays are appropriate for moist and weepy dermatitis. Creams and ointments are effective on drier more chronic lesions. While topical steroid "allergies" do occur, the reactions to topical steroid medications more likely represent a sensitivity to a preservative, fragrance, or other ingredient in the vehicle.

Medication of acute or "wet" eczema (e.g. poison ivy or flare of atopic or dyshidrotic eczema of the hands) has additional considerations. Burow's Solution compresses (see Impetigo) can dry out a wet oozing eczema within a few days. Decrease the bacterial colonization of the eczema with a few days of antistaphyloccal antibiotic therapy.

Systemic steroids are reserved for cases of substantial morbidity or widespread involvement. If required, use 1 mg/kg of prednisone in a tapering dose over a 2-3 week period while initiating topical therapy. Shorter courses or lower doses frequently result in "rebound" of the dermatitis. Otherwise healthy active duty personnel tolerate brief courses of prednisone very well. If a patient has reached this point of severity, dermatology consult is highly advised.

The last leg of the footstool is environmental control. This simply means to decrease the skin's exposure to any identified offending substance, harsh bath soaps, occupationally related chemicals and the like.

Most cases of hand eczema are irritant or endogenous (i.e. a form of atopic dermatitis) rather than allergic. The proper use of protective gear (e.g. work gloves), minimizing repeated wet/dry exposures of the involved area etc will allow the skin to heal faster.

Here is a diagnostic "pearl" concerning eczematous dermatitis on the foot. If vesicles are present, especially on the plantar surface, do a KOH (potassium hydroxide) prep on the roof of a vesicle. If positive, the therapeutic strategy involves antifungal therapy. Eczematous dermatitis exclusively on the dorsum of the foot is usually not fungal.

Psoriasis

(20) Psoriasis

(a) Administrative Aspects

Like atopic dermatitis and endogenous hand eczema, psoriasis and its variants are listed as disqualifying for entry and the pursuit of certain special duty in the Armed Forces of the United States. The reasons are the same as eczema; the notorious unpredictability of the condition. A case of clinically banal psoriasis can sometimes explode into disease of a debilitating nature in the military environment. Waivers should be very judiciously granted for this condition only after consultation with a military dermatologist.

The "three legged stool" of medication, lubrication, and environmental control applies equally well to the treatment of psoriasis (see Eczema above). The novice primary care practitioner inappropriately neglects lubrication in favor of potent topical steroids. Psoriasis perpetuates itself on dry cracked skin. Moisturize, moisturize, and moisturize! Topical steroids are not a substitute for emollients.

Scalp lesions are best approached with sulfur/salicylic acid, zinc pyrithione, or coal tar based medicated shampoos. The key to success here is sufficient contact time. The shampoo must have several minutes in place on the scalp before rinsing. There are a large number of generic and proprietary products on the market: Tarsum, T-Gel, Pentrax, Sebulex, Sebutone, and other dandriff shampoo brands to name but a few.

Ketoconazole shampoo is also useful, but is best saved for situations where conventional shampoos do not help. This product is very expensive and should be used judiciously.

Topical steroid lotions (e.g. betamethasone valearate 0.1%) applied after shampoo are a nice way to deliver medication to lesions within and near hair bearing surfaces such as the scalp and eyebrows.

Do not use systemic steroids to control psoriasis. An impressive "rebound" usually occurs which can be very difficult to treat.

(21) Seborrheic Dermatitis

Scalp lesions (i.e., dandruff) are treated the same as psoriasis (see Psoriasis above). The areas of greasy scale with background erythema on the central face, forehead, retroauricular, genitalia, and periumbilical locations should be treated with a low potency steroid cream or ointment (e.g., hydrocortisone 1% or desonide 0.05%).

Scabies
Figure 7

(22) Scabies

The itching and rash associated with scabies is not due the infestation per se but are the consequence of the body's immune response to the presence of the mite and its waste products. Consider the diagnosis of scabies in any a patient with a smoldering itchy rash with itchy papules on the genitalia, web spaces, or wrists.

Some patients will have few if any symptoms with their infestation. While a positive scabies scrape preparation taken from a typical "burrow" is diagnostic, it is frequently negative, even in a "classic" case (figure 7).

While conceptually simple, the treatment of scabies is sometimes difficult to execute properly in practice. Do not use Kwell shampoo to treat scabies...it won't work. Use Kwell cream/lotion or Elimite cream at bedtime exactly as written in the PDR.

Thirty to sixty grams of the cream or 60-120 ml of lotion should cover the whole body. Be sure to treat from the neck all the way to the toes being sure to get every crack and crevice in between. Be sure to apply the medication to the web spaces, underneath the fingernails, and the genitalia. Do not wash the hands or fingers before going to sleep.

Retreat the patient the following evening. The itching usually takes a few days to subside. All scabies medications are somewhat irritating and drying to the skin. Use bland emollients or if necessary medium potency topical steroids after the second application is rinsed off to control residual irritation and dryness.

All clothing, underwear and nightclothes, linen and towels used in the past 2 weeks by the patient require washing in hot water or dry cleaning. All household and/or sexual contacts should be treated. Aboard ship or in a barracks or any other very "close living" situation, persons nearby should be checked carefully for evidence of infestation. If in doubt, treat the patient.

Nits (Head Lice)
Figure 8

(23) Lice (head or crab)

Like scabies, the presence of one patient with lice should prompt the search for other cases involving personnel who are billeted nearby. Look around, you might be surprised what you discover. The washing of involved clothing in water greater than 50 degrees celsius will kill the lice and any nits.

Use Kwell, Nix or Rid shampoos, or similar products. Adequate pre-cleaning followed by adequate medication contact time is the key. The hair should be routinely shampooed clean and toweled dry (i.e. moist but not dripping wet) before the application of the pediculocide shampoo.

The pediculocide shampoo should be directly applied from the bottle onto the affected areas and worked into lather without the addition of water. Kwell shampoo should have at least 4-5 minutes and other products about 10 minutes of contact time before rinsing off with water. Retreat one week later. Treatment failure is not due to resistant lice. The pediculocides available today do not kill nits as well as they kill live lice. Treatment failure is most frequently due to reinfestation or inadequate contact time.

If treating the scalp, be sure to treat behind the ears and the base of the neck. It is very easy to inadequately treat patients with long hair. Longer haired patients should use a plastic shower cap to insure coverage. Avoid the eyes.

Nits can be removed with a nit comb or picked off with tweezers (see figure 8). Rinsing the hair with a 2:1 dilution of table vinegar before combing will help loosen the nits. Combs and brushes should be soaked in the pediculocide shampoo for about an hour or heated to about 65 degrees Celsius for 5-10 minutes.

The treatment of crab lice should not just involve the pubic hair. It should also cover the hairy skin from the umbilicus down to mid thigh. In particularly hairy individuals, check the axilla and chest for involvement.

Lice on the eyelashes can be treated by thickly applying Vaseline 2-3 times a day for a week. This treatment smothers the lice. Ammoniated Mercury ointment 0.1% applied to the lids is also quite effective. The nits can then be mechanically removed.

(24) Fungal Infections

Branching Hyphae
Figure 9

(a) Tinea Pedis and Cruris

Not all that is red, itchy, and scaly on the feet or groin is fungal. Be sure to consider other causes such as contact dermatitis, eczema, and bacteria. Take a KOH preparation from the scaly advancing border of a groin rash or from scaling on the feet adjacent to (but not within) an area of maceration, or the roof of a vesicle on the foot to confirm the diagnosis. Branching hyphae should be visible (figure 9).

Fungus lives where it is wet, warm, and dark. The groin and foot are ideal locations for growing fungus. Control of the milieu is important to controlling tinea. Potent medications are not a substitute for simple preventative measures to make the fungus less welcome.

Web spaces and groins should be thoroughly dried after gently showering, followed by applying simple antifungal powders containing tolnaftate or miconazole. Shoes should fit well and socks should be frequently changed. If possible, two sets of routine footwear should be maintained; one for odd days, one for even days. In this fashion, the shoes will dry out on the "off day". Sweating of the feet can be treated with antiperspirants such as aluminum chloride solution (e.g. DrySol, Xerac AC, or Certain Dri) applied at bedtime. Boxer shorts are preferable to briefs... especially if wearing BDUs.

Tinea Pedis
Figure 10

If tinea develops, remember to use the preventive steps outlined previously in addition to the treatment plan. These actions will make the treatment much more effective, provide more rapid relief, and allow for better results over the long run.

Wet, very macerated tinea of the web spaces is best treated with antifungal lotions such as miconazole or clotrimazole after astringent compresses with Burow's solution (see Impetigo above) or dilute vinegar. These areas are frequently overgrown with a potpourri of gram negative bacteria (figure 10). The concurrent use of a drug such as oral ciprofloxacin accelerates recovery.

Typical web space tinea is treated with a cream or solution vehicle antifungal drug. Miconazole or clotrimazole are effective. Nizoral, Spectazole, Naftin, or Lamasil cream is also effective but quite a bit more expensive. At least 3 weeks of treatment are required.

Chronic, hyperkeratotic, cracked and peeling "moccasin foot" tinea is treated with keratolytics such as Whitfield's ointment, 10% salicylic acid in petrolatum or 12% ammonium lactate lotion (Lachydrin). Antifungal creams are also effective but are quite a bit more expensive. Localized vesicular plantar tinea can be treated with cream. Extensive vesicular tinea of the feet requires the addition of astringent soaks (see above) and strong consideration of oral antifungal therapy (see below).

Not all itchy perineums and groins are caused by tinea. Strongly consider the diagnosis of Candida if "satellite pustules" and extensive maceration are present, especially in females. The differential diagnosis frequently includes contact dermatitis (occupational and non-occupational), seborrheic dermatitis, and psoriasis. Take a history and look for diagnostic hints. Remember, in temperate climates Tinea and Candida rarely involve the scrotum.

Contact dermatitis as an overlay to another diagnosis on the genital and crural skin occurs more often than is appreciated. Patients with itchy groins are desperate to stop the itch and will try anything topical; topical benzocaine, deodorants, rubbing alcohol, strong antibacterial soaps, and Ben Gay to name a few. Insist that all applications be ceased except the ones that you prescribe. Wet and weepy groins need astringent solution compresses and ventilation to facilitate drying.

If the diagnosis is tinea cruris, begin with twice a day antifungal cream once if the area is not weeping. Treat for at least 3 weeks. Remember that nystatin powder, cream or lotion, while effective for Candida, will not work against the dermatophyte fungi which cause tinea. If the tinea is very macerated, strongly consider using oral antifungal therapy (see below) as well as astringent solution compresses.

The diagnosis of Tinea of the nails (tinea unguium) needs to be confirmed before you even consider treatment. Not all distorted nails are due to fungal infection. If you are not sure of the diagnosis, refer to dermatology.

Tinea unguium is not worth treating and will only rarely be permanently cured. While a period of remission can usually be achieved, the fungus usually returns within 1-2 years. It is frequently associated with tinea pedis in middle aged or older males who have some immunologic anergy to the organism (Trichophyton rubrum).

Topical treatment alone will not work. The use of oral therapy (e.g. griseofulvin, itraconazole, terbenifine) therapy is frequently ineffective, expensive, and risks some side effects and drug interactions (especially itraconazole). Because this condition is prone to recurrence carefully advise the patient about the various treatment regimens and the realistic potential for an unsatisfactory result.

Tinea Capitis/Alopecia Ariata
Figure 11

Alopecia Areata
Figure 12

Athrospores outside hair shaft fragments
Figure 13

(b) Tinea Capitis

Tinea capitis is classically thought to be a pediatric condition. However, it does occur in the active duty age group, especially black males. The most common cause of tinea capitis in the 1990s is Trichophyton tonsurans.

Trichophyton tonsurans infection of the scalp can produce a variable clinical picture. Asymptomatic scaly patches containing tiny black dots with minimal hair loss frequently confused with Alopecia Areata is the most frequent presentation (figure 11) although large, boggy inflamed plaques sometimes occur (figure 12). A Wood's light is of no use to diagnose Trichophyton tonsurans because this organism does not fluoresce.

Potassium hydroxide scrapings from the scalp should not be taken from the scale. Instead, they should include the broken fragments of hair or the tiny black dots. Use the tip of an 18-g needle. A curette will function. Be sure to let the preparation digest for several minutes (after gently heating) before viewing.

Instead of looking for branching hyphae, look for tiny athrospores (sometimes in chains) within and outside of the hair shaft fragments (figure 13).

Therapy of tinea capitis involves systemic antifungals (see below). Topical therapy alone is inadequate, it will not adequately penetrate the hair follicles. The use of an antifungal shampoo such as Selsun, Nizoral, or Head and Shoulders is good adjunctive therapy and will make your patient much less infectious to his/her shipmates. Griseofulvin is still the drug of choice. Oral treatment for at least 10 weeks is necessary.

The use of oral antifungal therapy is frequently misunderstood by the primary care provider. For now, griseofulvin is the drug of choice although this may change in the next year or two. The newer generation of oral antifungals is quite costly and is frequently unavailable to deployed units.

Griseofulvin

Griseofulvin is a reasonably safe and effective drug in healthy patients if properly used. Not all griseofulvin preparations are the same. The bioavailability and doses of micro-size and ultra micro- size forms of griseofulvin are quite different. Follow the PDR recommendations for dosing. One exception however, is the need to use the "upper end" of the dosing scales for tinea capitis.

Gastrointestinal side effects and headache are the most frequent problems with griseofulvin. These problems can usually be avoided if the drug is given with a meal, especially with some lipid. A piece of toast with margarine or oil and vinegar on a salad will provide sufficient fat. Bacon and eggs are not necessary. Phototoxicity is unusual but reported.

Unlike antibacterial agents, griseofulvin works quite slowly. The deposition of the drug in newly keratinizing epithelium allows it to work. This takes time so be patient. Pretreatment liver function tests repeated every month or two combined with a good follow up monthly will prevent significant hepatotoxicity. Be aware of the interactions with coumadin and do not prescribe for patients with porphyria.

Ketoconazole

This oral form of this medication is of limited use for treating tinea. This is best reserved for selected patients with candida or tinea versicolor.

Itraconazole (Sporanox)

This drug is very expensive. The use of "pulse" therapy for the treatment of the nails (tinea unguium) is equally effective as daily therapy in most patients. Use 200 mg twice a day (with food) for 7 consecutive days per month repeated for 3 or 4 months. Liver function tests are usually not needed for healthy patients using this "pulse" regimen. The list of drug-drug interactions is very long for this medication. Check the PDR for details.

Tebenafine (Lamasil)

This medication is also very expensive. However, it does not have the long list of drug interactions as itraconazole. The dose is 250 mg daily for 3-4 months. Follow the PDR concerning patient monitoring.

Tinea Versicolor with pseudohyphae
and spores
Figure 14

(d) Tinea Versicolor

The diagnosis of this condition is relatively easy in most instances. The presence of a confetti-like discoloration on the upper chest and back is the most frequent presentation. This condition is caused by the overgrowth of a normal follicular inhabitant, the yeast Pityrosporum orbiculare. Patients who are constitutionally sweaty, work in hot sweaty places, doing hot sweaty things, wearing hot sweaty clothing are the most likely to develop the problem.

Although the diagnosis is usually clinically obvious, a KOH taken from a scaly macule will frequently show the classic "spaghetti and meatballs" pattern of pseudohyphae and spores (figure 14).

The goal is to control of the yeast overgrowth on the skin. It can't be eradicated because it is part of the body's normal flora. Selenium sulfide suspension (Selsun) applied to the skin, rinsed after 5-10 minutes for 7-14 days initially then reduced to twice a week will usually suffice. Zinc pyrithione shampoos (e.g. Head and Shoulders) should be used similarly to Selsun. Ketoconazole shampoo is also effective but is relatively expensive. Antifungal creams and lotions (e.g. miconazole, etc.) while effective, are awkward (and expensive) to use over larger areas of the trunk.

Oral ketoconazole should not be used as mono-therapy. This is a common mistake among novice primary care providers. Although it is very effective in severe cases, it frequently creates complacency in both the physician and patient. It is not a long term solution and it should be used, if at all, as a "starter" therapy and topical therapy should be used for further treatment. It is merely an optional adjunct to the topical antifungal therapy above. Although the literature supports a variety of regiments, one preferred treatment is 200 mg daily for 7 days, taken on an empty stomach.

Basal Cell Carcinoma
Figure 15

(25) Basal Cell Carcinoma (BCC)

All dermatologic handbooks adequately describe this entity. BCC must be considered in the differential diagnosis of any persistent, bleeding, crusted papule on the head, neck, and other sun exposed areas (figure 15). While these carcinomas are slow growing and hardly ever metastasize, they are relentlessly destructive if inadequately treated.

Urgent referral involving medevac from a deployment is not needed in the majority of cases. The passage of several weeks will not usually change the patient's prognosis or type of therapy. However, you still need to approach these lesions carefully. Not all basal cell carcinomas are the same. Treatment may vary with histologic subtype, anatomic location, and other aspects of the clinical situation. Communicate with your consultant dermatologist.

Melanoma
Figure 16

(26) Melanoma

The early diagnosis and treatment of a melanoma is just as effective at saving a life as the proper resuscitation of a trauma victim. A suspicious pigmented lesion needs to be promptly evaluated. The delay of even a few weeks can make a difference in the clinical outcome.

Remember the basics of melanoma recognition. Irregularities of border, coloration, topography and a history of enlargement or spontaneous bleeding of a pigmented lesion are cause for evaluation (figure 16).

A lesion that is seriously suspected of melanoma is best excised down to the deep subcutaneous fat in toto. If this is not practical, a narrow, but long incisional biopsy should be taken through the worst appearing portion of the lesion.

Incisional biopsies can be difficult to interpret if the laboratory does not correctly process them. These samples should be "embedded whole and sectioned longitudinally" by the laboratory. Be sure to prominently add these instructions in bold red letters to the pathology request.

The definitive surgical treatment and prognosis of melanoma largely depends on the depth (Breslow Level) of the tumor. In-situ melanomas and superficially invasive melanomas (less than 0.76 mm deep) have a very good prognosis. Therefore, early diagnosis is very important. Suspicious lesions should be either promptly biopsied or referred to a dermatologist for evaluation.

General Medical Officer Manual: Clinical Section Operational Dermatology*

Dermatologic Conditions

General Medical Officer Manual: Clinical Section
Operational Dermatology*