(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.