BETHESDA, MD — The U.S. military has always had specific guidelines regarding the entry and retention of personnel with eczema and atopic dermatitis. In most cases, a history of the skin conditions that requires treatment beyond over-the-counter hydrocortisone or moisturizers within the past 36 months or the presence of active lesions or residual hyperpigmentation or hypopigmentation at the time of examination, disqualifies a candidate from signing up.
Recent changes in guidelines, however, might allow more people with well-managed eczema to enlist. For those already serving, meanwhile, the focus is on whether the condition impacts their ability to perform necessary duties. Medical evaluation boards (MEBs) determine deployability based on disease severity and impact on required tasks.
Among the issues are that the chronic, immune-mediated skin disorders can cause difficulty wearing body armor and other protective equipment when poorly controlled, thus limiting a servicemember’s ability to train and deploy worldwide. In addition, military service might exacerbate the conditions because of increased exposure to austere environments, extreme temperatures, stress, skin injury, insect bites and vaccinations, according to a recent study in Military Medicine.1
Active-duty personnel have limited treatment options because of restrictions on systemic medications that can be used while deployed.
Researchers from the Uniformed Services University of the Health Sciences in Bethesda, MD, and the William Beaumont Army Medical Center in El Paso, TX, pointed out that newer systemic medications-in particular, biologic and oral immunomodulators-have evolved to be both extremely effective and safe.
Their recent study reviews more recent treatment options for psoriasis and atopic dermatitis in the context of DoD’s regulations guiding entry, and retention of personnel with psoriasis and eczema and makes recommendations on how to update DoD policy for systemic treatment options.
The study team performed a literature search using PubMed, Embase and Ovid with the last search done in the fall of 2023 from all years to date. The articles were further screened based on inclusion and exclusion criteria. Ultimately, 25 articles were included in the review.
At the same time, an internet search was performed on the DoD’s regulations guiding entry and retention of personnel with psoriasis and eczema. In addition, the authors examined medical requirements for deployment to the U.S. Central Command and U.S. European Command.
“Currently, U.S. Central Command and U.S. European Command do not allow the use of medications with special storage and handling requirements on deployments,” the study advised. “Newer biologics are safe and efficacious but require refrigeration, although other immunomodulators like deucravacitinib and apremilast are oral pills and do not have cold-storage requirements. However, the use of biologics in austere environments may be feasible because of increased intervals between dosing and the ability to store refrigerated medical supplies in most deployed environments.”
They suggested that, for military servicemembers with psoriasis, risankizumab and deucravacitinib “are excellent options given their favorable safety and efficacy profiles. Of the biologics available for atopic dermatitis, dupilumab is the safest and effective systemic medication available.”
The researchers noted that the Janus kinase inhibitors have shown excellent efficacy in treating atopic dermatitis but said more safety data are needed because of potential adverse events such as heart-related events, blood clots and cancers.
“Systemic treatments have evolved to become highly specific for both eczema and psoriasis,” the study concluded. “These newer biologics and immunomodulators may be compatible with use in the deployed setting, especially those that have long dosing intervals and proven efficacy and safety.”
The study team suggested that, of the biologics, dupilumab and risankizumab provided the best efficacy, safety and dosing intervals for atopic dermatitis and psoriasis, respectively.
“Deucravcitinib is a recently FDA-approved oral immunomodulator for psoriasis that has an excellent safety profile and efficacy,” the researchers added. “Allowing the use of these medications on deployments will enable more people with moderate to severe psoriasis and eczema to join and remain in the military while receiving effective treatment.”
- Russell A, Williamson S, Rosenberg A, Cho S. Reappraising the Use of Systemic Immunomodulators for Psoriasis and Eczema in the Military. Mil Med. 2024 Nov 5;189(11-12):e2374-e2381. doi: 10.1093/milmed/usae139. PMID: 38607726.
