Other large cohort studies conducted in several countries reported similar findings in Gulf War veterans based on self-reports via questionnaires. The population-based survey of UK Gulf War-deployed veterans found the prevalence of dermatitis to be 21%, a rate higher than that in two control groups: one dispatched to Bosnia (OR 1.6, 95% CI 1.3-2.0) and the other era controls (OR 1.6, 95% CI 1.4-1.9) (Unwin et al. 1999). Simmons et al. (2004) found that male UK Gulf War veterans reported more skin allergies with onset after 1991 than their nondeployed counterparts (OR 3.3, 95% CI 3.0-3.7). Proctor et al. (1998) compared the prevalence of dermatologic conditions—such as rashes, eczema, and skin allergies—in 252 U.S. Gulf War-deployed veterans. The estimated prevalence was 15.5% for the 186 veterans from the Fort Devens cohort, 11.7% for the 66 veterans from the New Orleans cohort, and 1.9% for the 48 veterans deployed to Germany during the Gulf War. A higher prevalence of skin conditions was also reported in Australian population-based studies (Kelsall et al. 2004a). Moderate to severe rash and skin irritation was reported at a higher rate in 1456 deployed veterans than in 1588 nondeployed veterans (OR 2.0, 95% CI 1.6-2.5). On the basis of a diagnosis by a physician after 1991 (deemed by the investigators to be a probable diagnosis), deployed veterans reported more dermatitis (OR 1.8, 95% CI 1.3-2.6) and skin diseases other than dermatitis, skin cancer, eczema, or psoriasis (OR 1.3, 95% CI 1.1-1.7) compared with nondeployed veterans. In light of their reliance on self-reports or questionnaires, all those studies are susceptible to recall or reporting bias. They also lack specificity regarding specific skin effects.

Eisen et al. (1991) performed a co-twin study in 1987 to determine the health effects of the Vietnam War. One member of each of 2260 male monozygotic twin pairs reported having a health problem and the other did not; it was then determined how many of the affected twins and unaffected twins had served in Vietnam. The study established the validity of self-reported health responses against medical records for a subset of the twins. It also searched for relationships between health problems and levels of combat exposure. The investigators constructed a combat exposure index by using responses to a separate questionnaire. Twins with persistent skin conditions (such as severe acne and rashes) that were present at any time since service were more likely to have served in Vietnam than were unaffected twins (OR 2.1, 95% CI 1.5-3.0). The prevalence of skin problems (either currently or ever) was significantly associated with increasing levels of combat exposure. At the highest level of combat exposure, skin problems were 3 times more likely than at the lowest combat level. The study is limited in that skin problems included “severe acne,” which may have included chloracne associated with Agent Orange, although the VES showed its prevalence to be lower (1.9% in theater veterans) than that of other skin conditions (33% in theater veterans) upon examination (CDC 1988b).

A study of Australian veterans deployed to the Vietnam War (a simple random sample of Army veterans, n = 641) found that combat exposure, as determined by Army records and a self-reported combat exposure scale, was related to self-reported chronic “rash” in an increasing linear relationship (p = 0.041) (O’Toole et al. 1996b). There was nearly a linear dose-response relationship for eczema, but it did not reach significance (p = 0.062). The study did not have dermatologic examinations, but trained interviewers did ask questions about chronic health conditions in person through the standardized Australian Bureau of Statistics Health Interview Survey 1989-1990.

Posttraumatic Stress Disorder and Skin Disorders

Gulf War veterans with PTSD display higher rates of dermatologic symptoms or conditions, according to two studies, one of Gulf War veterans and one of Vietnam veterans. The



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