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Telemedicine Improves Management of Common Dermatologic Issues in Theater

by U.S. Medicine

June 18, 2013

By Sandra Basu

WASHINGTON — While battlefield injury, musculoskeletal injury and mental disorders top the list of reasons troops are medically evacuated from military theaters of operation, a variety of other conditions can force the removal of patients from battle areas.

Historically, dermatologic issues have always been on the list, and the conflicts in Iraq and Afghanistan were no exceptions.

A study conducted near the height of military action in operations Enduring Freedom and Iraqi Freedom noted that skin conditions ranging from hives and dermatitis to benign moles and cancerous skin lesions are among the most common diagnoses among military personnel who were evacuated from combat zones. 1

Staff Sgt. Brittany Holt, 455th Expeditionary Medical Operations Squadron medical technician, puts a dressing on Staff Sgt. Samuel Aldrich’s head after a biopsy at the Craig Joint Theater Hospital, Bagram Air Field, Afghanistan, in 2011. Photo by Staff Sgt. Sheila deVera

The study, published in a 2009 issue of the Archives of Dermatology, further noted, “Skin diseases during wartime are exacerbated by sun exposure, temperature and humidity extremes, native diseases, insects, crowded living conditions, difficulty maintaining personal hygiene and chafing and sweating caused by body armor, helmets and other protective gear,” adding, “In tropical and subtropical climates, skin diseases have accounted for more than half of the days lost by frontline units.”

Yet, dealing with those issues has resulted in significant advances in diagnosis and treatment by military dermatologists, including the growing use of telemedicine.

“It is Tri-service and … there has even been NATO involvement in that as well,” Col. Daniel J. Schissel, the Army Surgeon General’s consultant on dermatology told U.S. Medicine.

The study also underscored the value of dermatology expertise. Researchers examined data from Jan. 1, 2003, through Dec. 31, 2006, from aeromedical evacuation records and the military’s electronic medical records system, finding that a total of 170 patients had been evacuated from the combat zone for ill-defined dermatologic diseases.

The diagnoses used to justify the evacuation of patients with skin diseases were generated mostly by nondermatologists, according to study authors who suggested that vague diagnoses indicated that “the clinician who ordered the evacuation was uncertain of the patient’s cutaneous condition.”

Evaluated post-evacuation by a board-certified dermatologist, the servicemembers were given a defined diagnosis in nearly all cases. Dermatitis, benign melanocytic nevus, malignant neoplasms, benign neoplasms, urticaria, and a group of nonspecific diagnoses were the most common post-evacuation diagnoses. That study concluded that improving diagnostic accuracy and treatment plans via teledermatology were possible methods to reduce evacuations.

Skin Conditions

The Southern Regional Medical Command Teledermatology Program, has provided consultations since 2001. The Army Knowledge Online (AKO) Teleconsultation Program, meanwhile, has extended the reach of dermatology specialists, both on and off the battlefield.

Schissel said that, with the AKO, greater dermatology expertise has been extended into the war zones to help providers make a more accurate diagnosis. Military dermatologists from outside of theater are available for consultation through the program, which has participation from all service branches.

“Doctors can put in consults to our 24/7 manned dermatology consultation service and we can help guide the diagnosis and treatment from afar, which has helped a lot,” he said.

According to the Telemedicine and Advanced Technology Research Center website, the concept for the teledermatology program originated at a conference in 2003. Military dermatologists decided to create a formal, user-friendly teleconsultation program to support deployed military healthcare providers because they believed troops were being evacuated for medical conditions that could have been managed in theater with assistance from knowledgeable consultants. The program began formal operations in 2004.

In addition, an in-theater dermatology consultant was assigned to the theater to help with diagnoses, according to Schissel.

“If the telemedicine program could not assist enough, then this person would be transported to the major referral center in theater and evaluated by a dermatologist,” he said. “I think, then, 90% of the time they were treated appropriately and returned to duty. That other 10% that needed further care or further study were then evacuated, so that decreased the number of evacuations, as well.”

A 2010 study examined cost savings from the military teledermatology program in the deployed setting. The study, also published in the Archives of Dermatology, included 2,197 Army teledermatology consults between January 2005 and January 2009. 2

Deployed healthcare providers who needed a dermatology consult “took digital photographs and emailed them along with a brief history to a single email address at a monitored server. The emails were then distributed to the on-call consulting dermatologists,” the authors wrote.

The most prevalent diagnoses by the consultant dermatologists were eczema (13%), fungal infection (7%) and bacterial infection (7%). Forty of the 2,197 consults recommended evacuation back to the United States, which cost an estimated $562,380. Another 104 patients were referred for an in-person evaluation by the dermatologist in Iraq for a cost of approximately $416,000.

“A total of 2,157 patients could be managed in Iraq, which is an overall cost savings of approximately $30.4 million. One additional benefit of teledermatology in the combat setting is the incalculable savings of avoiding the risk of travel in a war zone,” the study authors wrote.

The authors added that the study “demonstrates the role and cost savings of teledermatology in the combat setting.”

“Dermatologic conditions remain a common complaint among deployed soldiers, and teledermatology can substantially reduce the number of patients who need to be evacuated for treatment, resulting in substantial cost savings,” they wrote.

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1: McGraw TA, Norton SA. Military aeromedical evacuations from central and southwest Asia for ill-defined dermatologic diseases. Arch Dermatol. 2009 Feb;145(2):165-70. doi: 10.1001/archdermatol.2008.554. PubMed PMID: 19221261.

2. Henning JS, Wohltmann W, Hivnor C. Teledermatology from a combat zone. Arch Dermatol. 2010 Jun;146(6):676-7. doi: 10.1001/archdermatol.2010.110. PubMed PMID: 20566937.


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