Page 24 - Journal of Special Operations Medicine - Summer 2015

three diagnoses can be treated similarly with topical cor- Scalp psoriasis may require a keratolytic in the form of
ticosteroids and emollients .7,8 a medicated shampoo. Either coal tar or salicylic acid
shampoo can be used daily in addition to a topical cor-
Tinea infection, contact dermatitis, and atopic dermati- ticosteroid; however, salicylic acid provides improved
16
tis can all have pruritic erythematous lesions with over- scalp plaque resolution. Many patients benefit from
lying scale. However, both atopic dermatitis and tinea alternating coal tar shampoo one day followed by sali-
infection typically favor the flexural surfaces rather than cylic acid the next.
extensor surfaces. Additionally, microscopic examina-
tion with potassium hydroxide often reveals fungal el- If a patient has an inadequate response to topical therapy
ements in a tinea infection. Differentiation of contact alone, phototherapy is a good addition in the deployed
dermatitis often requires a compelling history and will setting. Although controlled ultraviolet B (UVB), UVA,
have a distribution that corresponds to the areas of or UV laser treatments are preferred and more effica-
exposure. cious, a sunbathing/tanning recommendation by a health
care provider can be used while deployed. These rec-
7,8
Characteristic psoriatic lesions are well-demarcated ery- ommendations should be used for 2 h/d between 10:00
thematous plaques with hyperkeratotic silver scale that and 14:00, and the patient should be instructed to keep
can have local (elbows, knees, scalp, dorsal hands, glu- all uninvolved areas covered by clothing. Tanning is con-
teal cleft) or widespread distribution. The lesions may traindicated if the patient has a history of skin cancer,
have a positive Auspitz sign, where bleeding will occur atypical nevi, or is not capable of tanning, i.e. Fitzpatrick
with minor skin trauma as the scale is displaced. Com- Skin Type 1 or has had multiple sunburns in the past. 8
mon nail findings in psoriatic patients are pitting, ony-
cholysis, and oil spots. Numerous systemic medications are available for
patients that are resistant to outlined topical or UV
regimen; however, these options should not be initi-
Treatments
ated in the deployed setting. It is especially impor-
Mild psoriasis can often be controlled with topical tant to avoid systemic corticosteroids, due to the high
agents alone. In contrast, moderate to severe psoriasis probability of a severe psoriatic flare upon cessation.
may require the adjunct of phototherapy and and/or Targeted immune modulators: methotrexate, anti-
systemic medications. It is also important to consider TNF1 blockers, cyclosporine, can significantly alter
the removal of possible triggers such as medications. the disease course of psoriasis; however, they should
not be used while deployed, due to the monitoring re-
The mainstay of topical therapy includes vitamin D quired and the increased risk of infection. Specifically
analogues and topical corticosteroids. Most vitamin D targeted immune therapy can predispose patients
analogues can be used twice daily and are provided in to streptococcal pneumonia, and Mycobacterium
multiple formulations to assist with medication deliv- tuberculosis, hepatitis C virus, HIV, leishmaniasis,
17
ery. The weekly dose of vitamin D analogues should and Strongyloides infections. While active tuberculo-
not exceed 100g/wk and vitamin D analogues should be sis cases attributed to infection acquired in Iraq and
avoided in patients who have a history of hypercalcemia Afghanistan have been negligible to date, there have
or could likely develop it in the future. While vitamin D been increased rates of leishmaniasis (0.23% of de-
analogues are helpful, their efficacy is limited when used ployed ground forces). 18
as monotherapy.
All possible triggers should be investigated and then re-
Topical corticosteroids can be used alone or in conjunc- moved or mitigated, if possible. This includes a rapid
tion with other agents such as vitamin d analogues or group A Streptococcus titer, throat culture, and rapid
coal tar. High potency corticosteroids (Class 1 or Class HIV test; counseling about alcohol consumption, smok-
2), and a combination of potent corticosteroids and vita- ing cessation, and stress reduction; and investigation
16
min D analogues, are very efficacious. Multiple deliv- and then cessation of provoking medications.
ery vehicles exist. Ointments typically penetrate the best
and have the most potency within in a class, followed by Conclusion
creams, gels, and solution. It is important to simplify the
patient’s topical routines while still limiting the applica- Multiple trigger events for psoriasis are present in the
tion of potent steroids the face, groin, and axillae. There perideployment period for a genetically predisposed in-
may be limited pharmacologic variety in the deployed dividual. A trial of conservative management with trigger
setting; if the appropriate vehicle is unavailable, topical removal is appropriate. However, with limited resources,
steroids can be occluded with clear wrap or dressings taking advantage of any additional foreign or intermili-
such as tegaderm or telfa to increase potency. tary services and alternate treatments, such as tanning/

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