(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."
Written and revised by CAPT Dennis A.
Vidmar, MC, USN, Department of Military and Emergency Medicine, and
Department of Dermatology, Uniformed Services University of the Health
Sciences, Bethesda, MD (1999).
*Additional images provided by CAPT Vidmar in
June, 2000, subsequent to the initial publication of this manual. |