Page 23 - Journal of Special Operations Medicine - Summer 2015

practicing in the host nation. At that time, the recom- External and internal triggers have been recognized
mendation was made to start the patient on a targeted to elicit psoriasis in those patients who have a genetic
immune modulator; however, as this medication is con- predisposition. The Koebner phenomenon is the de-
traindicated by military regulation during deployment. velopment of psoriasis 2 to 6 weeks after an external
In lieu of targeted immune-modulator therapy, the fol- dermatologic trauma (e.g., sunburn, viral exanthema,
lowing regimen was adopted: scalp: calcipotriene/beta- drug eruption, minor skin trauma). Common infectious
methasone gel at bedtime, salicylic acid shampoo daily; triggers can be streptococcal pharyngitis, streptococcal
3,6
face: mometasone furoate 0.1% cream twice daily for impetigo or abscess, or HIV infection. Psychogenic
10 days, followed by topical tacrolimus 0.1% ointment stress, smoking, and alcohol consumption are internal
daily for 1 month; body: calcipotriene/betamethasone triggers that can be increased in the perideployment set-
11
ointment twice daily for 1 month followed by pimecro- ting. Finally, several medications have been implicated
limus 1% cream at bedtime for 1 month; genitals: beta- in contributing to psoriatic flares, including lithium,
methasone valerate cream twice daily for 2 weeks and beta blockers, calcium channel blockers, terbinafine,
whole-body use of an emollient as frequently as pos- and antimalarials (another significant risk factor in de-
sible. A rapid group A Streptococcus titer, throat cul- ployed Servicemembers). 4,7,8
ture, and rapid test for human immunodeficiency virus
(HIV) were completed at that time and were all found to In addition to the dermatologic manifestations of pso-
be negative. Shortly thereafter, the patient completed his riasis, it is important to recognize subtle clinical findings
recommended doxycycline course previously started at and appreciate the associated morbidity of psoriasis.
the beginning of deployment with no significant change Nail findings can be a helpful finding to make the diag-
in his psoriasis. nosis in patients with psoriasis and are found in approxi-
mately 79% of patients. 12,13 These cutaneous findings
The Sergeant’s clinical picture remained stable for the can be stigmatizing and psoriasis can markedly affect a
remainder of his deployment. The patient noted signifi- patient’s quality of life; approximately 20% of patients
cant psoriatic improvement starting several weeks after with psoriasis have depressive symptoms. 14
return from deployment, without medication alteration.
Shortly thereafter, he began to decrease the use of topi- The incidence of psoriatic arthritis increases in frequency
cal medication and his psoriasis is now controlled with with disease severity. It most commonly affects the bilat-
pulse dosing of calcipotriene/betamethasone alone and eral distal and proximal interphalangeal joints. Typically,
has not required systemic medication. 5% to 30% of patients with dermatologic findings will
have or will develop psoriatic arthritis. Radiographic
15
changes of psoriatic arthritis are similar to rheumatoid
Overview
arthritis, with erosion of terminal phalanges and tapering
Psoriasis can have multiple triggers that are present in the of proximal phalange. These findings typically warrant
perideployment period, including psychogenic stressors, systemic medications to prevent additional disease pro-
increased smoking, alcohol consumption, environmen- gression and joint destruction. 8
tal changes, medication, and illness. It is imperative to
remove or treat all triggers possible, use available ag- Differential Diagnosis
gressive topical medication with creative adjuncts, and
remove the patient from the deployed setting if a flare Common dermatologic conditions that can present
cannot be controlled with these interventions. similarly to psoriasis are seborrheic dermatitis, lichen
simplex chronicus, tinea, contact, or atopic dermatitis.
The prevalence of psoriasis in the United States is twice Things to consider for treatment-resistant generalized
that of the worldwide population: 4.6% worldwide vs psoriasis include cutaneous T-cell lymphoma and for a
1
2% in the US, respectively. Approximately 65% of the single lesion squamous cell carcinoma .7,8
active-duty military population is between 18 and 30
years old (the first of the bimodal ranges), illustrating the The scalp is a common area for psoriasis, seborrheic
increased incidence of psoriatic flares in this population. 9 dermatitis, and lichen simplex chronicus; all appear as
erythematous plaques with overlying crust or scale. Dif
The polygenetic predisposition to psoriasis can be evi- ferentiating between these conditions can be challenging
dent in the positive family history in 35% to 90% of so the distribution of the eruption is important. Sebor-
patients with psoriasis. However, an environmental rheic dermatitis often favors the eyebrows, glabellum,
10
factor is responsible for the manifestation of disease. The nasal labial folds, eyelids, ear canals, and central chest.
pathogenesis is not completely understood; however, Lichen simplex chronicus is most commonly found in
it is believed to be a mixed T-cell disease that induces the posterior aspect of the scalp and a history of re-
hyperproliferation. 7,8 peated rubbing/scratching/trauma can be elicited. These

Treatment of Psoriasis in the Deployed Setting 13