Page 144 - Journal of Special Operations Medicine - Summer 2015

If the condition is localized and covers less than 5% of Military Implications
body surface area, a primary care physician can suc- Implications of psoriasis on military service and mis-
1
cessfully manage it with topical medications. All other sion completion are significant. Identifying and treating
cases should be referred to a dermatologist. 1
psoriasis appropriately is very important for the ac-
tive duty Servicemembers, especially divers and Naval
Therapy of localized psoriasis can be initiated with topi- Special Warfare (NSW) and Special Operations (SO)
cal glucocorticoids, keeping in mind the side effect of communities. According to the Manual of the Medical
thinning skin, striae, and telangiectasia with prolonged Department, NAVMED P-117, general standards for
steroid use. Vitamin D analogues are used as steroid- entrance into the military dictate that current diagno-
sparing medications or in combination with them. sis or history of psoriasis is disqualifying; however, a
Topical anthralin, pimecrolimus, tar, and retinoids waiver could potentially be considered depending on
(tazarotene) are other therapeutic adjuncts that can be the case. Additionally, divers whose psoriasis gets worse
used as first-line agents. With more than 10% skin in- while diving or wearing occlusive attire (wetsuit) are
2
volvement, topical medications can be combined with not qualified for diving duty. NSW and SO members
ultraviolet light B (UVB) phototherapy or psoralen ul- cannot perform their duties if psoriatic lesions are not
traviolet light A (PUVA) photochemotherapy. Systemic controlled with topical medications only or if skin integ-
therapy might be required for severe and erythrodermic rity is compromised. Potential complications from the
psoriasis. Generalized plaque psoriasis or lesions that systemic therapies are especially dangerous in austere
are resistant to topical modalities alone can be treated environments that Special Operation Forces frequently
with combination therapy of systemic medications (oral operate in. Those risks are not acceptable to allow for
retinoids, methotrexate, cyclosporine, and monoclonal continuous service. Evacuation of a military member for
antibodies and fusion proteins), topical agents, UVB, or psoriasis exacerbation due to stress or climate change
PUVA. Scalp psoriasis can be treated with ketoconazole while deployed can be financially costly and compro-
or tar shampoo in addition to potent topical steroid ap- mise an essential mission. Additional caution should be
plication. PUVA therapy in designated facilities along observed while taking antimalarial medications during
with glucocorticoids is effective for psoriasis of palms deployments. These drugs have been shown to exacer-
and soles and palmoplantar pustulosis.
bate cases of psoriasis requiring escalation of treatment
or even evacuation. 4
Inverse psoriasis treatment should be initiated with topi-
cal steroids; however, precautions need to be taken given Saturation diving is an important part of the Navy Div-
that the skin in the affected areas is already prone to ing program. It allows divers to stay at greater depths
atrophy. Nail abnormalities are more difficult and time for a prolonged period of time. However, due to wet ex-
consuming to treat because of the nail plate and matrix cursions, environment, and atmosphere in the chamber,
involvement. Intradermal steroid injections of the nail skin conditions and infections present a serious danger
fold, PUVA, long-term systemic retinoids, methotrexate, to the person as well as to the integrity of the mission. A
and cyclosporine have been tried with successful results. medical provider should be very cautious clearing a Ser-
Underlying streptococcal infection treatment is the opti- vicemember with psoriasis for saturation diving, given
mal initial therapy for acute guttate psoriasis, followed the increased risk of exacerbating the condition and no
by the standard topical medications, UVB phototherapy, safe means of quickly aborting the dive.
1
or PUVA. Generalized pustular psoriasis requires hos-
pitalization and supportive treatment with initiation
of oral retinoids. Even after remission of the plaques, Disclaimers
residual hyperpigmentation, hypopigmentation, or ery- The views expressed in this article are those of the au-
thema can persist. Patient should be warned about these thor and do not necessary reflect the official policy or
discolorations and educated that the treatment can be position of the Department of the Navy, the Department
decreased or terminated at that time. 2
of Defense, or the US Government.
Limited case reports have explored possible use of hy-
perbaric oxygen (HBO) in psoriasis. The theory behind Disclosure
3
the favorable outcomes of these observations is based The author has nothing to disclose.
on the data showing HBO having anti-inflammatory
and immunosuppressive effects. However, data are lim-
ited and this therapy is not currently recommended by References
the Undersea and Hyperbaric Medical Society (UHMS). 1. Fitzpatrick T, Wolff K, Johnson R. Color atlas and synopsis
Further research into HBO use for psoriasis treatment of clinical dermatology. 6th ed. New York, NY: McGraw-Hill;
is warranted. 2009.

134 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015