A Case Report of Tumor Necrosis Factor Alpha Inhibitors in an Active Duty Service Member with Dissecting Cellulitis of the Scalp Resistant to Treatment.

Dissecting cellulitis of the scalp represents a disease of follicular occlusion that may be worsened by tight-fitting clothing, such as the patrol cap or advanced combat helmet used by military service members. Treatment poses a challenge to the clinician, and the treatment of choice, oral retinoids, may not improve the condition sufficiently to maintain active duty status. Early treatment augmentation with tumor necrosis factor-alpha inhibitors may improve efficacy of oral retinoids and prevent medical separation of the active duty service member.

Delayed Diagnosis of Leprosy in a Micronesian Soldier - Case Report.

Lepromatous leprosy represents a cutaneous infection by the bacterium Mycobacterium leprae. Once considered a common, fatal disease, leprosy has become increasingly rare with modern, inexpensive antibiotics. Most healthcare workers will never encounter a case of leprosy due to the low prevalence of the disease. However, military physicians, through deployments and contact with foreign-born servicemembers, are one of the first lines of defense against this disease. With an unknown method of transmission and an insidiously slow replication, it can take years for the disease to fully manifest. There are multiple cutaneous manifestations associated with the infection that can mimic other infectious etiologies, stalling appropriate diagnosis and treatment. To determine which treatment course is recommended requires evaluation of disease dissemination and the level of host immune response. As the incidence of reported leprosy cases continues to decline, disease education on diagnosis and treatment is imperative to enhance early detection and intervention. Understanding the populations at risk for leprosy and its insidious presentation will aid the practitioner in minimizing disease burden for both U.S. servicemembers and our foreign partners.

Combat dermatology: the role of the deployed army dermatologist.

Shortly after completing residency or fellowship, army dermatologists routinely deploy to combat zones as field surgeons. The US Army generally does not deploy dermatologists for their expertise in diagnosing and managing cutaneous diseases; rather, as field surgeons they provide routine, emergency, and trauma care for active-duty soldiers and coalition forces. In this article, we review the various functions of the deployed dermatologist and highlight the importance of maintaining basic emergency medical skills that could be generalized to the civilian population in case of local or national emergencies.

Diagnosing Pemphigus Foliaceus: A Rare Blistering Disease Masquerading as a Common Dermatologic Disorder.

Pemphigus foliaceus (PF) is an autoimmune dermatologic disease that typically presents with painful, superficial blisters that evolve into scaling erosions in a seborrheic distribution. This case study intends to demonstrate that due to the relative scarcity of the disease and its distribution on the body, PF can easily be misdiagnosed. We present a 43-year-old African American male that presented to the dermatology clinic with an 18-month history of non-pruritic, violaceous, scaling patches and plaques most prominent on the malar cheeks, upper chest and upper back. He had been evaluated at an outside hospital with a high suspicion for cutaneous lupus erythematosus (CLE) and seborrheic dermatitis. However, repeated biopsies revealed non-specific spongiotic dermatitis, not consistent with CLE or seborrheic dermatitis. Over the subsequent months, he received treatment for both conditions without improvement in his symptoms. When he was referred to our dermatology clinic, repeat biopsies were obtained which demonstrated acantholysis and dyskeratosis in the granular layer, consistent with PF. Direct immunofluorescence revealed intercellular IgG staining most prominent in the epidermis, also consistent with PF. Finally, enzyme-linked immunosorbent assay for anti-desmoglein 1 returned positive, confirming the diagnosis. Upon review of the previous biopsies, focal areas of acantholysis and dyskeratosis were noted in the granular layer, which would have pointed away from a diagnosis of CLE or seborrheic dermatitis if PF was included in the clinical differential diagnosis. This case serves as a reminder that when there is a discrepancy in clinical-pathologic correlation, it is important to revisit the case and consider other pathologies.

Squamoid Eccrine Ductal Carcinoma: An Aggressive Mimicker of Squamous Cell Carcinoma.

Squamoid eccrine ductal carcinoma (SEDC) is an uncommon cutaneous adnexal malignancy that has the potential for an aggressive clinical course. The authors present a case of SEDC that resulted in widespread metastases and death. The clinical, histological, and immunohistochemical features of SEDC and several entities on the differential diagnosis are reviewed.

Military grooming standards and their impact on skin diseases of the head and neck.

Military grooming standards assure that soldiers are able to meet their occupational demands and maintain a respectable appearance; however, following these standards can unmask or exacerbate various skin diseases of the head and neck. In this article, we emphasize some of the more common disorders caused by military grooming standards, including a discussion of the underlying pathogenesis and management considerations.

Diagnosing IgA Vasculitis in the Active Duty Population: The Importance of Early Diagnosis and Proper Biopsy Site Selection.

Immunoglobulin A associated vasculitis (IgAV), formerly called Henoch-Schönlein purpura, is a small vessel vasculitis which typically presents with upper and lower extremity palpable purpura and abdominal pain. It is the most common vasculitis in children, and is less common in adults. However, newer evidence suggests the incidence within the adult population is higher than previously reported. This case study demonstrates an adult military recruit presenting with new onset IgAV shortly after basic training. He noted a preceding upper respiratory tract infection, which is a common finding in those presenting with IgAV. The diagnosis was made by clinical findings, histopathological results and direct immunofluorescence. Adults tend to develop more necrotic and bullous lesions when compared with children. This can skew histopathology and direct immunofluorescence. There is no clear consensus in current literature for whether to obtain lesional or perilesional biopsies. Such recommendations could be particularly advantageous for adults given the abnormal lesions. This case study addresses the incidence of IgAV within the adult population, diagnostic criteria, long-term sequalea of IgAV, and the importance of a proper biopsy sight when making the diagnosis.

Management of trauma and burn scars: the dermatologist's role in expanding patient access to care.

Recent advances in laser surgery and our understanding of wound healing have ushered in a new era of trauma and burn scar management. Traditional therapy has centered around scar excision followed by primary closure or tissue replacement with flaps and grafts. This approach represents a perpetuation of the common fallacy that extensive scar improvement requires extensive surgical intervention. Laser surgery in conjunction with pharmacotherapy and minor tissue-conserving surgery produces well-healed and remodeled existing tissue that provides the most natural appearance and function of the skin. Now, patients' hypertrophic, contracted, and disfiguring scars represent their most valuable reconstructive anatomy. With this paradigm shift, dermatologists are uniquely positioned to provide transformative and cost-effective scar therapy due to their proficiency in the necessary treatment modalities and expertise in the utilization of local anesthesia. We hope to further expand military and civilian patient access to such care in their local community through peer education and advocacy. We present a brief overview and outline of scar treatment practices that can be performed by dermatologists in office using devices and techniques they often already possess.

The impact of ultraviolet radiation on sunburn-related search activity.

We establish a strong, positive relationship between the Ultraviolet Index and Google search engine activity for sunburn-related terms in the United States. Using the Google Trends utility and data available from the National Weather service, we combine data from a twelve-year period to produce panel data for each state. We fit a time-series regression model of search activity and perform statistical tests on the resulting parameter estimates. This study lays the groundwork for using search-related data to assess the prevalence of, and attitudes about sunburn. By tracking the frequency of searches about preventative measures like "sunscreen" or "protective clothing" versus treatment measures like "sunburn relief," researchers could measure the effectiveness of awareness and prevention programs.

Improving Health-Related Quality of Life in Wounded Warriors: The Promising Benefits of Laser Hair Removal to the Residual Limb-Prosthetic Interface.

BACKGROUND: Wounded warriors with lower limb amputations using prosthetics commonly develop dermatologic complaints at the residual limb-prosthetic interface, which impact their health-related quality of life (HRQOL). To optimize this interface, military dermatologists routinely treat the subset of issues related to the pilosebaceous unit with laser hair removal (LHR). OBJECTIVE: To characterize the impact of residual limb skin conditions on HRQOL in wounded warriors using lower limb prosthetics before and after treatment with LHR. METHODS AND MATERIALS: Twenty wounded warriors with lower limb amputations using prosthetics were administered a validated HRQOL survey, the Skindex-16, before and after an average of 3 treatments of LHR to their residual lower limbs. Responses were statistically analyzed within the symptoms, emotions, and functioning subscales of the survey and in aggregate. RESULTS: Statistically significant (p < .05) improvement in HRQOL was observed across the symptoms, emotions, and functioning subscales and in aggregate. CONCLUSION: Dermatologic complaints at the residual limb-prosthetic interface in patients with traumatic lower limb amputation are well-established in the literature. The authors present the first report subjectively quantifying this impact on HRQOL and the marked improvement observed with LHR to the residual limb.