Vaccinations
Military members deploying overseas are required to receive specific vaccinations, including the smallpox vaccine. Although the virus was eradicated in 1980, the concern for smallpox to be used as a biological weapon in certain areas of the world necessitates continued vaccination of military populations. According to the Centers for Disease Control and Prevention, the only known reservoir for the virus is humans, and the disease has a mortality rate of 30%.10 A history of or present AD is a contraindication for primary smallpox vaccination and revaccination for nonemergency use because of the risk for eczema vaccinatum.11 The risk also applies to close contacts of vaccinated members. For 30 days after vaccination, service members must avoid skin-to-skin contact with anyone who has active AD.12 Eczema vaccinatum in vaccinated individuals is typically self-limited; however, eczema vaccinatum in nonvaccinated contacts can be severe. One case report described a 28-month-old child with refractory AD who developed severe eczema vaccinatum after contact with her recently vaccinated military parent. The child required a 48-day admission to the intensive care unit and multiple skin grafts; fortunately, the child did not develop any apparent long-term sequelae.13 This case highlights the importance of understanding the risks associated with smallpox vaccination in military members with AD and the responsibility of health care providers to properly screen and counsel individuals prior to administering smallpox vaccines.
Treatment
Treatment of mild to moderate AD is relatively straightforward in developed countries with good access to medical care. The most recent American Academy of Dermatology clinical guidelines for AD focus on minimizing irritants and triggers, regularly using moisturizers soon after bathing, and using topical steroids as needed.5 Military members face specific challenges regarding treatment of AD, particularly when deployed to remote locations without access to treatment facilities or medications. Military members are required to carry all necessary personal medications with them for at least 6 months and preferably the duration of the deployment, sometimes up to 1 year. Military members carry a large amount of gear for deployments, and it is not feasible to pack an additional 10 to 20 lb worth of emollients and topical steroids to last the entire deployment. Routine laboratory monitoring is limited or completely unavailable. Refrigeration typically is not available, making use of systemic medications nearly impossible during deployments. In the event of complications such as eczema herpeticum or secondary bacterial infection, service members could require evacuation from the deployed location to a larger field hospital or to the United States, which is costly and also removes a valuable team member from the deployed unit. These limitations in access to care, medications, and treatment options make AD a difficult condition to treat in the deployed setting.
Nonmilitary Medical Providers
Civilian providers play an important role in diagnosing and treating AD. It is vital to completely and accurately document treatment of all skin diseases; however, it is especially important for those who desire to or currently serve in the military. Military primary care providers or military dermatologists must review the information from civilian providers to aid in determining suitability for entry or retention in the military. Clearly documenting the morphology, extent of disease involvement (eg, body surface area), treatment plan, response to treatment, and exacerbating factors will aid in ensuring the patient’s medical record accurately reflects their skin disease. Ultimately, this record often is the only information available to make health determinations regarding military service.
Conclusion
A career in the military is challenging and rewarding for those who volunteer to serve. Because of the demanding and unpredictable lifestyle inherent with military service, the Department of Defense maintains strict medical standards for entrance and retention. These standards ensure members are capable of safely completing training and deploying anywhere in the world. Although AD is a relatively common and treatable skin disease in locations with well-established medical care, it can pose a notable problem for service members while deployed to austere locations with variable environments around the world. Environmental factors and gear requirements, coupled with limited access to treatment facilities and medications, render AD a potentially serious issue. Atopic dermatitis in military members can affect individual medical readiness and unit success. It is important that all providers understand the myriad effects that AD can have on an individual who wishes to join or continue service in the military.