Page 22 - Journal of Special Operations Medicine - Summer 2015

Treatment of Psoriasis
in the Deployed Setting

Michelle A. Bongiorno, MD;
Shayna C. Rivard, MD; Jon H. Meyerle, MD

ABSTRACT

Psoriasis is a chronic immune-mediated disorder that can and hands. Over the next several weeks, the Sergeant’s
be triggered by environmental changes, illness, smoking, battalion deployed and his psoriatic plaques continued
or medications. This case describes a 25-year-old, active- to enlarge.
duty Marine Corps Sergeant with a severe perideploy-
ment psoriatic flare, and illustrates treatment limitations, In September 2013, the patient’s treatment regimen was
restricted access to specialized care, and the importance changed from triamcinolone to fluocinonide 0.05%
of mitigating triggers in the deployed setting. cream, which was to be applied daily to all affected ar-
eas except his scalp. That week, the patient also started
Keywords: psoriasis; psoriasis, plaque; psoriasis, guttate; taking doxycycline for malaria prophylaxis. Later that
arthritis, psoriatic; smoking, cessation; ultraviolet light, ex- month, he continued to have psoriasis progression with
posure; deployment; military provider new sites of involvement, including his chest and back
(Figure 1). At that time, when additional land-based re-
sources at a nearby Army base were available, the fol-
lowing regimen was started: scalp: 2 days of mineral oil,
Introduction
followed by 1 day of fluocinolone 0.1% oil (both with
Psoriasis has a bimodal age distribution (20–30 years occlusion); body: 2 weeks of fluocinonide 0.05% cream
and 50–60 years) and affects approximately 2% of the twice daily (with clear-wrap occlusion), then 1 week of
population worldwide. Affected individuals have poly- emollient therapy; and he was additionally counseled
1
genic predisposition plus an environmental trigger (com- to increase sun exposure via tanning (as tolerated), and
monly infections, change in environment, medication, asked to stop smoking.
psychogenic stress, alcohol consumption, smoking, and
trauma). The two most common variants of psoriasis The Sergeant continued to experience psoriasis flares
2–6
are plaque and guttate psoriasis. Plaque psoriasis com- and was evaluated in November 2013 by a dermatologist
monly appears as sharply demarcated, scaly, erythema-
tous plaques on the elbows, knees, and scalp. Guttate Figure 1 (Left) Bilateral dorsal hands with multiple mildly
psoriasis, on the other hand, typically manifests as small erythematous plaques with overlying, silver scale. (Right)
discrete papules and plaques, and can be a sequel to an Right ventral lower extremity with several plaques and
upper respiratory tract infection. 6–8 smaller discrete erythematous papules. (Below) Multiple
discrete and coalescing erythematous papules and plaques
with minimal overlying scale on ventral aspect of trunk.
Case Report
A 25-year-old, active-duty Marine Corps Sergeant began
to form pruritic plaques on his elbows, knees, and hands
in April 2013. After several months of treatment with
an over-the-counter lotion, the Sergeant reported for his
predeployment physical examination (August 2013),
during which he was first noted to have erythematous,
scaly plaques on his elbows, knees, bilateral dorsal
hands, and scalp, in the setting of increased stress due
to predeployment workups. At that time, he was started
on coal tar 0.5% shampoo daily to the scalp and tri-
amcinolone 0.5% cream twice daily to elbows, knees,

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