SKIN DISORDERS

Rashes were among the most frequently reported health problem soon after the Gulf War (Murphy et al. 1999). Rash usually refers to dermatitis, an umbrella term covering several subtypes, including atopic dermatitis, contact dermatitis, seborrheic dermatitis, and psoriasis. In both the Gulf War and the Vietnam War, troops were exposed to several toxicants that could cause allergic skin reactions, including pesticides; Agent Orange has been associated with the chloracne seen in some Vietnam veterans.

For the purposes of this section on deployment-related stress and dermatologic effects, the committee defined a primary study according to methodologic rigor (Chapter 2) and use of a dermatologic examination. In a secondary study, the determination of a dermatologic effect was based on veterans’ self-reports of symptoms or self-reported physician-diagnosed conditions. This section excludes one skin condition, chloracne, because its cause in veterans was herbicide exposure peculiar to the Vietnam War (IOM 2007). Primary studies are summarized in Table 6-10.

Primary Studies

To determine the link between deployment-related stressors and dermatologic diseases, the committee identified four primary studies (CDC 1988b; Eisen et al. 2005; Higgins et al. 2002; Ishoy et al. 1999) and numerous secondary studies. In the large, nationally representative study of U.S. Gulf War veterans, Eisen et al. (2005) performed medical evaluations of more than 2,000 veterans. The study was performed 10 years after the Gulf War and used data derived from the 1995 VA National Health Survey of Gulf War Era Veterans and Their Families (Kang et al. 2000b). The investigators searched for dermatologic conditions by dividing them into two categories: group 1 consisted of freckles, seborrheic keratoses, moles, cherry hemangiomas, skin tags, and scars; group 2 consisted of dermatologic diagnoses not included in group 1. Diagnoses were made by a board-certified dermatologist, who evaluated group 2 conditions through teledermatology by using at least two digital photographs and results of a standardized history and physical examination. The prevalence of group 1 diagnoses did not differ between deployed and nondeployed veterans (OR 0.87, 95% CI 0.68-1.12). After adjustment for age, sex, race, years of education, cigarette-smoking, duty type, service branch, and rank, the prevalence of a diagnosis of one or more group 2 skin conditions was 34.6% in deployed veterans and 26.8% in nondeployed veterans (OR 1.38, 95% CI 1.06-1.80). Two skin conditions in group 2 were diagnosed more frequently (p = 0.02) in deployed than in nondeployed veterans: verruca vulgaris (warts) (1.6% vs 0.6%, OR 4.02, 95% CI 1.28-12.6) and atopic dermatitis (1.2% vs 0.3%, OR 8.1, 95% CI 2.4-27.7). Atopic dermatitis (a form of eczema) is an inflammatory condition manifested on the skin by dry, eczematous skin and papules. It tends to run in families (with allergic rhinitis and other allergies), and its course is often chronically relapsing (Leung 2000). Atopic dermatitis is not to be confused with contact dermatitis, a delayed hypersensitivity response to a specific agent that directly or indirectly injures the skin.

Researchers in the UK conducted in-person dermatologic evaluations of UK Gulf War-deployed veterans (111 disabled and 98 nondisabled) and 133 disabled veterans not deployed to the Gulf War (Higgins et al. 2002). The cross-sectional study was conducted in 1999-2000; participants were randomly selected from three representative cohorts that had served in the gulf



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