Several large cohort studies conducted in other countries reported similar findings in Gulf War veterans based on self-reports via questionnaires. Based on the lack of a physician’s examination or diagnosis, these studies are considered to be secondary. The population-based survey of UK 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). A higher prevalence of the following physician-diagnosed skin conditions was also reported in 1456 deployed veterans compared with 1588 nondeployed veterans in an Australian population-based study by Kelsall et al. (2004a): moderate to severe rash and skin irritation (OR 2.0, 95% CI 1.6-2.5); 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).
Several additional secondary studies were identified that indicated that the prevalence of generally nonspecified skin diseases or conditions in deployed Gulf War veterans was greater than in nondeployed veterans, but all of these studies relied on self-reports:
Goss Gilroy (1998)—Skin allergies or other skin conditions in Canadian veterans.
Cherry et al. (2001a)—Skin rashes, sweating, itching skin, hair loss, boils, or abscesses in UK veterans.
Simmons et al. (2004)—Skin allergies in UK veterans (OR 3.3, 95% CI 3.0-3.7).
Steele (2000)—Physician-diagnosed or treated skin conditions other than skin cancer (OR 3.83, 95% CI 2.50-5.87); rashes (OR 5.73, 95% CI 3.41-9.62); moderate or multiple skin symptoms (OR 4.09, 95% CI 2.53-6.63) in Kansas veterans.
Wolfe et al. (1998)—Akin rashes, eczema, skin allergies in veterans from Massachusetts and Louisiana.
Proctor et al. (2001a)—Skin rash (14.0% vs 4.3%).
Gray et al. (1999a)—Rash (OR 4.3, 95% CI 2.8-6.5).
A more recent secondary study is that of Kang et al. (2009), who in 2004-2005 conducted a follow-up study of the 15,000 deployed and 15,000 nondeployed veterans originally surveyed in the 1995 National Health Survey of Gulf War Era Veterans and Their Families (Kang et al., 2000). A mailed questionnaire asked veterans if their doctor had ever told them they had any of 23 medical conditions, including dermatitis or any other skin trouble. The relative risk for skin problems was 1.41 (95% CI 1.32-1.51) adjusted for age, sex, race, body mass index, current cigarette smoking, rank, branch of service, and unit component.
Three studies examined hospitalizations of Gulf War veterans for skin disorders. Gray et al. (1996) found no excess hospitalizations in 1991-1993 of Gulf War veterans compared with other veterans for skin diseases, as broadly defined by a range of ICD codes. That study compared hospitalizations at DoD facilities of almost 550,000 Gulf War veterans and almost 620,000 nondeployed veterans. The multivariate ORs ranged from about 0.97 in 1991 to almost 1.0 in 1993 (actual values and confidence intervals not given). An expansion of this study to capture veterans who may have left the military was conducted by Gray et al. (2000). This study covered the years 1991-1994 and examined records from DoD, VA, and California hospitals. Proportional morbidity ratios (PMRs) of hospital-discharge diagnoses for skin diseases in Gulf War deployed and nondeployed veterans were compared. PMRs for hospitalization for skin disease were not increased for Gulf War veterans in DoD hospitals (PMR 1.01, 95% CI 0.97-1.05), VA hospitals (PMR 1.14, 95% CI 1.00-1.27), or California hospitals (PMR 0.84, 95% CI