239

Protection of the Skin

Chapter 9

PROTECTION OF THE SKIN

RICHARD A. KELLER, MD*; and WILLIAM R. SANTEE, PhD†

INTRODUCTION 

SKIN AND ITS CONTRIBUTION TO HEALTH

GENERAL SKIN CARE

FACTORS THAT CONTRIBUTE TO SKIN DISEASE DURING DEPLOYMENT

SKIN PROTECTION DURING DEPLOYMENT

SKIN DISEASES AFFECTED BY DEPLOYMENT

EFFECT OF SKIN DISEASE ON OPERATIONS DURING DEPLOYMENT

SKIN DISEASE AND MEDICAL PLANNING

SUMMARY

*Colonel (Ret), Medical Corps, US Army; Dermatology Surgery Section, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, Louisiana 

70121; formerly, Fellow, Mohs Micrographic Surgery, Department of Dermatology, Brooke Army Medical Center, Fort Sam Houston, Texas 78234-6200

†Research Physical Scientist, Biophysics & Biomedical Modeling Division, US Army Research Institute of Environmental Medicine, Building 42, Kansas 

Street (Office MCMR-EMB), Natick, Massachusetts 01760-5007; Dr. Santee assisted with updating this chapter
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Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

INTRODUCTION

exposure can also help prevent heat injuries. Many 

military personnel have been plagued by skin malignancies, as well as by skin infections and dermatitis 

from insufficient skin protection. These preventable 

diseases cause a significant loss of man-hours to garrison and field forces. However, once diagnosed, skin 

diseases can be treated easily, thus allowing the affected service member to return to duty (Figure 9-1).

When skin diseases occur from insufficient skin 

protection, service members might be evaluated by 

healthcare providers who have limited training and 

experience in the management of skin disease. Inexperienced providers use a set array of therapeutic 

options to treat patient symptoms without diagnosing the illness. Often, this results in multiple visits 

and failed patient treatments. In addition, it results 

in great cost to the military healthcare system (Figure 

9-2 and Figure 9-3). For the care and management of 

skin diseases, readers are referred to a more complete 

reference on the military importance of diagnosing 

and treating skin disease.1

The purpose of this chapter is to provide general 

information on the skin and its contribution to health, 

general skin care, factors that contribute to skin disease 

during deployment, skin protection during deployment, and skin diseases affected by deployment. This 

chapter includes a review of the effects of skin disease 

on military operations during deployment and the 

necessity of adequate medical planning for managing 

skin disease in the field.

Relative to the other immediate hazards of deployments, skin protection is seldom considered a 

priority in the US Armed Forces. For example, it is 

common to see personnel working in military installations without adequate skin protection from ultraviolet (UV) light. Actions that protect against UV 

Fig. 9-1. Benign neoplasms are the second most frequent 

dermatological cases in recent deployments; skin cancers 

are less frequent, but their early diagnosis and treatment are 

critical. This case of a malignant melanoma in a 30-year-old 

soldier was originally considered simply a cosmetic issue. 

AKO (Army Knowledge Online) teleconsultation from 

Afghanistan quickly led to evacuation, excision, treatment, 

and return to duty of this soldier, possibly saving his life. In 

April 2004, the US Army Medical Department approved the 

use of the US Army e-mail system (AKO) for teledermatology consultations from deployed providers in Iraq, Kuwait, 

and Afghanistan. 

Data sources: Henning JS, Firoz BF. Combat dermatology: 

the prevalence of skin disease in a deployed dermatology 

clinic in Iraq. J Drugs Dermatol. 2010;9:210–214. Poropatich 

RK, DeTreville R, Lappan C, Kohuth C. The US Army telemedicine program—general overview and current status in 

Southwest Asia. Telemed J e-Health. 2006;12:396–408).

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0274040909. 

Fig. 9-2. Pseudofolliculitis barbae (PFB) is a common form 

of skin irritation on the face in men with curly hair, where 

shaved hair tends to curl into the skin leading to an inflammatory reaction. The skin irritation can become a serious 

problem for some soldiers, leading to papules and over time 

cause keloid scarring in the beard area. This case illustrates 

a peculiar pattern of burns and depigmentation in a soldier 

who obtained incorrectly applied laser treatment for PFB and 

associated keloids from a local provider during deployment. 

He received successful corrective treatment from military 

dermatologists. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0293090815. 
241

Protection of the Skin

Media and public opinion focus on healthcare priorities and affect planning during military operations. 

Rapid communications magnify the effect of real or 

rumored skin diseases on operations (Figures 9-4 and 

9-5). Newspapers described the difficulty of controlling 

lice and skin disease among Cuban detainees during 

Operation Sea Signal.2 This media report resulted in 

The skin is our largest organ. It is also a complex 

organ composed of three layers: 

	 •	 epidermis

° stratum corneum

° keratinocytes

° basal layer

	 •	 dermis

° blood vessels

° lymph vessels

° hair follicles

° sweat glands

° nerves

° sebaceous glands

	 •	 subcutaneous fat.

The epidermis is the outermost layer that contains 

Fig. 9-3. Granulomatous tattoo reaction in a deployed 

34-year-old military contractor. Red tattoo ink is commonly 

associated with nodular tattoo reactions. Cinnabar (mercury 

sulfide) coloring is a likely cause of this reaction 4 months 

after the tattoo. Definitive treatment includes surgical excision or intralesional steroid injection, and should include 

patient education. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0493081022. 

Fig. 9-4. Vigorous response to smallpox immunization in a 

25-year-old airman during deployment to Afghanistan 10 

days after smallpox and typhoid vaccinations in the left arm 

and anthrax immunization in the right arm. Antihistamine 

therapy was prescribed, with resolution of the rash within 1 

week. Safety of militarily specific vaccines, such as anthrax 

and smallpox, has been a controversial issue in the past, with 

public perceptions fed in part by relatively infrequent and 

manageable immunological hyperresponsiveness. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0169110501. 

SKIN AND ITS CONTRIBUTION TO HEALTH

skin color. The dermis (or middle layer) provides skin 

pliability and elasticity. The subcutaneous fat layer is 

between the muscle fascia and the dermis. Skin is essential to a person’s survival, and it:

large-scale evaluation and treatment of all refugees in 

Guantanamo Bay, Cuba. Outbreaks of skin disease in a 

large number of Bosnian fusiliers were reported by a British newspaper, which forced a large-scale investigation 

of the involved unit.3 Unexpected demands on medical 

personnel and supplies are but one result of such media 

reports and are often difficult to anticipate in planning.
242

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

	 •	 provides a barrier that prevents harmful substances and microorganisms from entering the 

body,

	 •	 protects body tissues against injury,

	 •	 controls the loss of life-sustaining fluids (eg,

blood and water),

	 •	 helps regulate body temperature, and

	 •	 protects against the sun’s damaging UV

rays.

The epidermis provides the barrier function of the 

skin. The stratum corneum—an epidermal layer composed of interlocking acellular keratin plates—acts as 

a barrier against microbe invasion and loss of water. 

Sweat aids lipid distribution. The accumulation of 

sweat on the skin dilutes antigens and microbes that 

collect there. Through sweat accumulation, keratin 

plates become saturated by water on the skin. This 

antimicrobial barrier is augmented by Langerhans 

cells, which are an integral part of the cell-mediated 

immune system. These cells attach to foreign material 

and present it to the T lymphocytes for destruction. 

Disruption of this barrier causes a loss of body fluid 

(particularly noted in blisters and burns) and increases 

the risk of infection. 

Protection from UV radiation is provided by a 

protein barrier in the stratum corneum and melanin. 

Melanin is a pigment produced by melanosomes in 

the basal layer of the epidermis. It absorbs UV radiation and produces a “tanned” color. Skin that lacks 

the ability to produce melanin has a higher risk for 

production of UV or solar-induced skin cancer. Skin 

types with little melanin production seldom tan, but 

they burn easily. Although the ability to tan indicates a 

lower risk of sunburn, the long-held belief that a good 

tan is a healthy sign is false. A deep tan is indicative of 

excessive exposure to UV radiation without adequate 

skin protection.

The primary site for heat exchange between the 

body and the surrounding environment is the skin 

surface. Dermal blood vessels provide nutritional 

support to the skin and regulate body temperature 

by transferring heat to the body surface. Body temperature is maintained near 37°C primarily by action 

of the blood vessels and sweat glands. Blood flow to 

the skin is regulated by dilation and constriction of 

these blood vessels. When the body has excess heat, 

these dermal blood vessels dilate, thus allowing heat 

dissipation by radiation, convection, and conductance. 

Water is secreted by sweat glands in the dermis. Water 

reaching the skin surface reduces core body temperature by evaporation. Skin disease associated with a 

large buildup of scale impairs sweat. Impaired sweat 

production makes a service member vulnerable to 

hyperthermia.4

Psoriasis, atopic dermatitis, seborrheic dermatitis, 

eczema, and contact dermatitis are skin diseases that 

can cause a generalized inflammation of the skin. Patients with these conditions present with generalized 

erythema (redness), which is caused by vasodilation 

of the dermal blood vessels. Generalized cutaneous 

vasodilation brings additional heat from the body 

core to the skin surface, where it is normally lost to 

the external environment. Radiant heat loss, which 

is exclusively a function of surface temperature, can 

increase significantly. This loss of body heat, which is 

not controlled by any thermoregulatory mechanism, 

causes the core body temperature to fall. These patients 

have very warm red skin, complain of being cold, and 

shiver. Treatment is aimed at vasoconstricting the 

dermal blood vessels. 

The skin also plays a role in the synthesis of activated vitamin D. Activated vitamin D is essential 

in the regulation of calcium and in the differentiation of epidermal keratinocytes.5 The importance of 

vitamin D to overall health—including a possible 

protective function for nonskin cancer—and vitamin 

Fig. 9-5. Leishmaniasis is a parasitic infection transmitted 

to humans from rodents by sand flies and has been an important military issue since the first Gulf War, when soldiers 

deployed to areas where the infection is endemic. There 

was much misinformation about symptom complaints following the 1991 Gulf War; leishmania infection was briefly 

implicated in mystery illnesses, and redeploying soldiers 

were even banned from blood donations for a period of 

time. This case illustrates lesions on the hands of a soldier 

with cutaneous leishmania infection in Afghanistan in 2011. 

Data source: Martin S, Gambel J, Jackon J, et al. Leishmaniasis in the United States military. Mil Med. 1998;163:801–807.

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0020110119. 
243

Protection of the Skin

natural synthesis mediated by exposure to sunlight 

are also part of an ongoing debate, as described in 

Exhibit 9-1.

deficiencies in different populations must be balanced against concerns over rising skin cancer rates. 

The merits of dietary vitamin D supplements versus 

GENERAL SKIN CARE

Skin Cleansing and Lubrication

Guidelines for bathing frequency in the field were 

established to prevent body louse infestation and 

louse-borne disease.6,7 This bathing frequency, however, does not address its effect on morale or rate of 

bacterial skin infections among service members. 

Bathing frequency became important during deployments to Iraq and Afghanistan because of the logistical requirements of supplying water. In 1991, after 

reviewing after-action reports and correspondence 

on bathing and skin disease in field environments, 

Troychock8 noted that: 

	 •	 daily bathing/showering was recommended

but, at a minimum, bathing or showering 

should occur at least weekly; 

	 •	 loose clothing should be worn; and

	 •	 skin integrity must be maintained.

Operations in extremely cold environments also 

present challenges in terms of bathing frequency. In a 

1991 report on the role of showering frequency in the 

reduction of skin infections among military personnel in the field, the US Army Medical Research and 

Development Command made the following four 

recommendations9:

1. The interval between showers should not 

exceed 24 hours in personnel deployed to 

the tropics if chlorhexidine antiseptic or 

medicated soap is used with water. Using 

unmedicated soap requires more frequent 

showers.

2. In a tropical environment, wounded or 

abraded skin will need to be cleaned twice 

a day if medicated soap or chlorhexidine is 

used with water. Cleaning with unmedicated 

soap should be performed three times a day 

on damaged skin. 

3. Showers or baths should be taken at least 

every 7 days to prevent body lice infestations 

in the military.

4. The role of antimicrobial additives in preventing skin infections among service members in 

the field warrants further research. Chlorhexidine is the only substance shown to have 

prophylactic activity against skin infections.

Cleansing of the skin with soap and water enhances 

the removal of oil, grime, and microbes. Deodorant 

soaps have added antimicrobial ingredients to reduce 

skin bacterial counts, but these antimicrobial additives 

do not improve the cleaning ability of soaps or detergents.Using antibacterial/deodorant soapspromote the

growth of Streptococcus pyogenes on the skin.10 Plain soap 

reduces the growth of S pyogenes, but does not affect 

the growth of Staphylococcus aureus. Antibacterial soaps 

inhibit the growth of normal skin bacteria, which can 

have an inhibitory role in the growth of S pyogenes.

10,11

Skin cleansing during military operations in cold or 

minimal water environments is limited by water supply and the practicality of field bathing. Lipid-free skin 

cleansers (eg, Aquanil [Person & Covey, Inc, Glendale, 

Calif] or Cetaphil [Galderma Laboratories LP, Fort 

Worth, Tex]) can be used in these environments. These 

cleansers are wiped on and then wiped off. For years, 

these products have been used to cleanse patients suffering from skin diseases exacerbated by soap and water 

cleansing. Aquanil freezes at around 27.6°F to 28.4°F.

Extended freezing of Aquanil for a 10-day period caused 

the product to clump or become watery. This finding 

was not observed during periods of brief freezing (RA 

Crowell, Director of Quality Assurance, Person & Covey, 

Inc, personal communication, 1977). There are no other 

data available on the stability of these products in hot 

or freezing environments. These findings should be 

examined further for future deployments.

Solar Protection and Skin Cancer

Skin cancer is the most common form of cancer 

in the United States. It is estimated that more than 1 

million nonmelanoma skin cancers are diagnosed each 

year; nearly 60,000 cases of melanoma were diagnosed 

in 2005.12 Basal cell carcinoma (BCC), although seldom 

fatal, accounts for 80% of skin cancers. BCCs are locally 

destructive. Squamous cell carcinoma (SCC) is the second most common form of skin cancer.12 Its incidence 

has increased from 4% to 8% since 1960.13 SCC and 

BCC both cause local tissue destruction. Cutaneous 

SCC is responsible for about 2,300 deaths per year. 

Melanoma, the most aggressive form of skin cancer, 

caused almost 7,700 deaths in the United States in 2005. 

Nonmelanoma skin cancers caused approximately 

2,800 deaths in the same year.12

In the past 6 years, increasing numbers of service 
244

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

EXHIBIT 9-1

VITAMIN D VERSUS SKIN CANCER

Clothing, as well as the ultraviolet (UV) index, provides protection from UV radiation (UVR). Excessive exposure to 

sunlight is associated with an increase in morbidity from skin cancer and other skin diseases. There is a worldwide 

effort to reduce individual exposure to UVR, best illustrated by Australian government programs.(1–5) The take-home 

message from these public health programs has, in some cases, been reduced to a blanket directive to minimize exposure to UVR. 

However, some media(6) coverage has been given to contradictory scientific evidence that suggests excessive avoidance 

of UVR is detrimental to overall health.(7–10) The basis for this apparent contradiction lies in the following argument:

	 •	 Vitamin D provides protection against some cancers and represents other possible health benefits.(11)

	 •	 If the best human source for vitamin D is UVR-mediated synthesis, then complete avoidance of exposure to

UVR can result in vitamin D deficiencies and associated morbidity. 

Historically, diseases such as rickets have provided proof that vitamin D deficiencies can be detrimental, and, under 

some circumstances, exposure to sunlight can both prevent and treat the disease.(11,12)

The underlying science is more complicated than simply making a choice between complete protection and full exposure. The following factors can contribute to ensuring an adequate source of vitamin D:

	 •	 latitude and time of year,

	 •	 length of exposure,

	 •	 age,

	 •	 skin type (melanin),

	 •	 clothing coverage,

	 •	 lifestyle,

	 •	 body fat,

	 •	 natural dietary sources of vitamin D, and

	 •	 various vitamin D supplements.

Ironically, vitamin D deficiencies have been identified even in Australian populations.(13) Although vitamin D deficiencies 

are more common in older people, deficiencies have been identified in populations of young adults, including urban 

medical personnel in US cities.(14) Although UVR intensity is too low at higher latitudes during the winter months, there 

are seasonal variations in vitamin D (ie, fat storage from other seasons can offset that situation). In obese individuals, 

stored vitamin D might not be accessible.(11) More melanin reduces vitamin D production relative to the UVR exposure; 

therefore, individuals less prone to sunburn would need a longer exposure time to produce the recommended levels 

of vitamin D. Within some ethnic communities, religious or cultural practices set a standard of modesty that requires 

that, in public, clothing covers most or all of the body surface. Vitamin D deficiencies have also occurred within these 

groups.(15,16) This might be an important consideration when providing medical care to civilian populations. 

When UVR intensity is sufficient to simulate vitamin D production, only limited exposure of the face, hands, arms, 

and/or legs for 5 to 15 minutes, 2 to 3 times per week, is necessary.(11) Vitamin D production is determined by the 

finite amount of precursor; therefore, when the precursor supply is converted, additional exposure does not result in 

additional production of vitamin D. Thus, the length of exposure required to ensure optimal vitamin D production 

is not long. As noted during the winter months, UVR intensity is not sufficient to stimulate vitamin D synthesis. 

Holick(11) reported that the same conditions that decreased UVR during the winter months at higher latitudes, lowered 

solar angles, and created a longer pathway for light through the atmosphere (see Exhibit 9-6) also occurred in the 

early morning and late afternoon. Holick recommended specifically that the short exposure time occurred between 

1000 and 1500 hours local daylight time. This time period near solar noon corresponded to the guideline for skin 

cancer protection that sunlight exposure be minimized. He showed that the limited recommended exposure time 

would not cause sunburn.

To a degree, the media positions presented in the scientific literature might reflect professional biases. Public health 

officials, as well as many dermatologists, facing alarming statistical evidence of an increase in skin cancer with patients 

(Exhibit 9-1 continues)
245

Protection of the Skin

presenting with melanoma and other sun-related skin morbidity might be less than enthusiastic about the health benefit 

claims of maintaining adequate levels of vitamin D if it encourages greater UVR exposure.(12) In addition, nutritionists 

and scientists who examine cancer epidemiology might promote the importance of vitamin D. Also, some dermatologists might favor vitamin D supplements over calls for UVR exposure.

Other nutritionists might place more emphasis on external dietary or supplementary vitamin D. In Europe, vitamin 

D supplements in food is restricted because of toxicity from excessive supplement use.(11) For US military personnel, 

generally, the MRE (Meal, Ready-to-Eat) rations do not include many foods naturally rich in vitamin D, nor is there 

good access to foods with supplemental vitamin D under field conditions.

The problem of balancing concerns over vitamin D deficiencies versus skin cancer is similar to the dilemma of ensuring 

adequate hydration while avoiding hyponatremia (see Montain, Chapter 7). (Hyponatremia refers to a low concentration of sodium in the blood; also known as “water intoxication.”) Emphasis on the importance of hydration in the 

prevention of heat injury has, in a few cases, lead to hyponatremia and fatalities. During military deployment, both 

vitamin D deficiencies and overexposure to UVR are possible. The addition of dietary supplements to military rations is 

under consideration. Currently, most military training occurs in the southern latitudes of the continental United States, 

and the majority of military deployments are to the Middle East, other desert climates, or higher altitudes. Despite 

the emphasis on sunscreen—and directives to wear uniforms in a manner to maximize protection against sunburn, 

insects, and abrasion—it seems unlikely that most US Army personnel with outdoor duties would not receive enough 

UVR exposure to ensure adequate vitamin D production levels. Despite the apparent benefits of vitamin D, soldiers, 

generally, should avoid excessive exposure to solar radiation, tanning, and sunburn.

Note: Exhibit courtesy of Staff, US Army Research Institute of Environmental Medicine, Natick, Massachusetts.

Data sources: (1) World Health Organization, 2002. Global Solar UV Index: A Practical Guide. WHO/SDE/OEH/02.2. http://www.

who.int/uv/.2002 Accessed July 24, 2006. (2) McCarthy W. The Australian experience in sun protection and screening for melanoma. J Surg Oncol. 2004;86:236–245. (3) Albert MR, Ostheimer KG. The evolution of current medical and popular attitudes toward 

ultraviolet light exposure: part 3. J Am Acad Dermatol. 2003;49:1097–1106. (4) Ferrini RL. American College of Preventative Medicine 

Practice Policy: skin protection from ultraviolet light exposure. Am J Prev Med. 1998;14:83–86. (5) Kaminester LH. Current concepts: 

photoprotection. Arch Fam Med. 1996;5:289–295. (6) Klado B. The good sun? Boston Globe. August 29, 2005. (7) Ness AR, Frankel SJ, 

Gunnell DJ, Smith GD. Are we still dying for a tan? J Cosmetic Dermatol. 2002;1:43–46. (8) Grant WB. An estimate of premature cancer 

mortality in the U.S. due to inadequate doses of solar ultraviolet-B radiation. Cancer. 2002;94:1867–1875. (9) Grant WB, Strange RC, 

Garland CF. Sunshine is good medicine. The health benefits of ultraviolet-B induced vitamin D production. J Cosmetic Dermatol. 

2004;2:8698. (10) Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003;89:552–572. (11) 

Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. 

Am J Clin Nutr. 2004;80(suppl):1678S–1688S. (12) Albert MR, Ostheimer KG. The evolution of current medical and popular attitudes 

toward ultraviolet light exposure: part 2. J Am Acad Dermatol. 2003;48:909–918. (13) Nowson CA, Margerison C. Vitamin intake and 

vitamin D status of Australians. Med J Aust. 2002;177:149–152. (14) Tangpricha V, Pearce EN, Chen TC, Holick MF. Vitamin D insufficiency among free-living healthy young adults. Am J Med. 2002;112:659–662. (15) Glerup H, Mikkelsen K, Poulsen L, et al. Commonly 

recommended daily intake of vitamin D is not sufficient if sunlight exposure is limited. J Intern Med. 2000;247:260–268. (16) Matsuoka 

LY, Wortsman J, Dannenberg J, Hollis BW, Lu Z, Holick MF. Clothing prevents ultraviolet-B radiation-dependent photosynthesis of 

vitamin D3. J Clin Endocrinol Metab. 1992;75:1099–1103.

Exhibit 9-1 continued

members have been diagnosed with skin cancer. At 

least 2% of BCC occurs in an age group less than 30 

years old. These younger patients have an increased 

risk of developing additional skin cancers later in life. 

Seventy percent of BCCs in this age group are located 

on the nose and cheek, with most patients being women. Because of cosmetic concerns, younger patients are 

more likely referred for tissue-sparing procedures (ie, 

Mohs surgery). A second age group (31–55) accounts 

for 6% to 8% of the total number of BCC cases.14 People 

in both of these age groups serve in the military.

Recreational and occupational exposure to sunlight 

is associated with the development of skin cancer, as 

indicated by the predominant region of involvement. 

Although sunlight over the entire spectral range of 

solar radiation (200 to 8 × 104 nm) contributes to general body warming, only a small amount of the total 

solar energy—in the UV spectral range of 280 to 400 

nm—is associated with skin damage. The potential 

for skin damage from UV exposure is broken down 

further into UVA rays ([UV light ray A] UV radiation 

[UVR] from 320 to 400 nm) and UVB rays ([UV light 

ray B] UVR from 290 to 320 nm). In men, 75% of SCC 

and 80% of BCC develop on the face, head, and neck 

regions. An additional 18% of SCCs develop on the 

upper extremities in men; however, only 1.3% occur 

on their lower extremities.15,16 The involved areas correspond to regions that received the greatest amount 

of UV radiation on a daily basis.17

Prevention of these skin cancers among service 
246

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

members and, thus, eventual retirees, focuses on protecting the areas of the skin that develop the most skin 

cancers. The upper extremities can be protected by requiring the service member to wear the battle dress uniform (BDU) with the sleeves down. Wearing the uniform 

in this manner protects against UV light exposure and 

biting insects. Service members who wear their BDUs 

with the sleeves rolled up must wear sunscreens. These 

sunscreens need to be reapplied regularly, especially 

when the individual sweats. Uniforms currently worn 

by service members provide excellent protection from 

UVA and UVB rays to the covered areas (Table 9-1).

Headgear also provides protection against solar 

radiation. In general, headgear should shade the entire 

face and neck area from direct sunlight during the time 

of maximum exposure to solar radiation. Unfortunately, almost no issue headgear offers protection from 

solar radiation that is reflected off the ground or other 

surfaces; therefore, facial sunscreen is still essential. 

Additional information on the selection of headgear 

for protection against solar radiation is included 

in the section on Protection from Solar Radiation. 

FACTORS THAT CONTRIBUTE TO SKIN DISEASE DURING DEPLOYMENT

Service members are exposed to a wide range of environmental conditions during deployment. Physical 

factors in the environment that impact the skin include 

temperature, humidity, rainfall, wind, and sunlight. 

Individual factors that can affect skin disease include 

the following:

	 •	 age,

	 •	 gender,

	 •	 medications,

	 •	 stress, and

	 •	 general health.

In addition, the type of clothing and footwear worn 

alters conditions at the skin surface.18 In other disciplines, microclimate refers to meteorological factors 

that directly impact an individual for a given set of 

locations in time and space. Conditions at the interface 

between skin and the environment are so important 

that physiologists refer to physical conditions at the 

skin surface as “the microclimate.” Table 9-2 is a 

summary of known skin diseases that are affected by 

environmental and psychological changes.

The role that climate plays in skin disease is easily 

observed in tropical operations, which are characterized by an abundance of bacterial and fungal infections 

because of the combination of high temperatures and 

high humidity. Observations have shown that high levels of humidity, in combination with a lower dry bulb 

temperature, promote sweat duct occlusion with the 

formation of miliaria (or sweat rash) and hidradenitis 

suppurativa (a chronic inflammation of the apocrine 

glands).19 High temperatures promote increased sweating; however, high humidity reduces the evaporation 

of moisture from the skin. Buildup of moisture in the 

stratum corneum dilutes the surface lipids and reduces 

its barrier properties. Continued accumulation of moisture on the skin raises the protective acidic skin pH 

to a neutral level. Increased hydration of the stratum 

corneum promotes the growth of gram-positive cocci 

on the skin.19 In the tropics, bacterial skin infections 

are caused predominately by S pyogenes.

11,20

Climate also affects the activity of insects and, therefore, insect-borne disease. As a general rule, the risk of 

insect-vectored diseases is greater at lower latitudes 

and warmer climates; but, locally, the risk of exposure 

can also vary with season or time of day. Canizares,21

for example, found a relationship between temperature 

and insect numbers. Few cases of insect-borne disease 

were seen during Operation Desert Storm, because it 

occurred during the winter months. With year-round 

exposure, the incidence of leishmaniasis has increased 

significantlyduringOperationIraqiFreedom/Operation

Enduring Freedom, beginning in 200222 (Exhibit 9-2).

A decrease in humidity during the winter months 

causes its own problems by promoting the development of dry skin. Drying of the stratum corneum 

causes a loss of epidermal flexibility, with cracking 

and fissuring ensuing. Uncontrolled pruritus soon 

develops. The only satisfactory treatment is rehydration of the stratum corneum. Periods of low humidity 

also exacerbate skin diseases affecting the stratum 

corneum. Chapping of the skin has been associated 

with periods of low air moisture following periods of 

high air moisture.23 Extreme cold weather increases 

the granular layer of the skin on the dorsum of the 

hands. In addition, a loss of dermal elastic tissue was 

seen with this change.24 (Additional information on 

the effects of cold weather exposure can be found in 

Medical Aspects of Harsh Environments, Volume 1 [see 

Section II: Cold Environments].)

Clothing and footwear, especially if designed to 

be “waterproof” or impermeable, reduce the loss of 

body heat and impair or block evaporation of moisture from the skin. Close-fitting clothing allows heat 

and moisture buildup to produce a localized tropical 

environment on the skin folds, particularly the feet. 

Aly and colleagues25 noted that prolonged skin occlusion changed the normal, protective acidic skin pH to 

neutral. Skin maceration and loss of barrier function 
247

Protection of the Skin

TABLE 9-1

PERCENTAGE OF UVA AND UVB 

TRANSMISSION AND UPF VALUES FOR 

THREE CAMOUFLAGE FABRICS

Uniform Color Status UPF* %UVA %UVB

Desert 

BDU Lt tan Initial 240 1.35 0.31

Lt tan Washed† 414 0.76 0.17

Lt brown Initial 1,440 0.16 0.06

Lt brown Washed† 2,035 0.09 0.05

Khaki Initial 413 0.56 0.19

Khaki Washed† 687 0.31 0.12

Hot-weather woodland 

BDU Lt green Initial 856 0.23 0.10

Lt green Washed† 920 0.17 0.10

Dk green Initial 1,484 0.10 0.07

Dk green Washed† 1,698 0.07 0.06

Brown Initial 1,498 0.08 0.07

Brown Washed† 2,049 0.05 0.05

Black Initial 16,597 0.01 0.01

Black Washed† 6,262 0.02 0.02

Temperate woodland

BDU Lt green Initial 576 0.33 0.15

Lt green Washed† 666 0.26 0.13

Dk green Initial 884 0.17 0.11

Dk green Washed† 1,152 0.12 0.08

Brown Initial 977 0.13 0.10

Brown Washed† 1,328 0.09 0.08

Black Initial 2,237 0.06 0.04

Black Washed† 2,324 0.05 0.04

*All fabrics in the dyed colors would be labeled UPF 50+ (“Excellent 

UV Protection”) in accordance with ASTM D6603 standards.

†Washed = 40 wash cycles + UVR exposure to simulate 2 years of wear.

BDU: battle dress uniform; Dk: dark; Lt: light; UPF: ultraviolet 

protection factor; UVA: ultraviolet light ray A; UVB: ultraviolet 

light ray B.

Data source: Winterhalter C, DiLuna K, Bide M. Characterization of 

the Ultraviolet Protection of Combat Uniform Fabrics. Natick, Mass: US 

Army Soldier and Biological Chemical Command, January 2002. 

Technical Report NATICK/TR-02/006.

TABLE 9-2

FACTORS THAT AFFECT SKIN DISEASE

Factor Disease

Humidity 

Low Eczema, atopic dermatitis, psoriasis, dry skin, 

hand dermatitis, ichthyosis

High Fungal infections, bacterial infections, atopic 

dermatitis, Hailey-Hailey disease, acne, warts, 

miliaria, hidradenitis suppurativa

Sunshine Discoid lupus erythematosus, Darier’s disease, 

porphyria, herpes simplex

Stress Atopic dermatitis, psoriasis, lichen planus, 

acne

develop from this localized environment. Some service 

members experience this problem when wearing the 

Vapor-Barrier military boots (commonly known as 

“Mickey Mouse” boots; AirBoss Acton [Acton Vale, 

Quebec, Canada]), which were designed for extreme 

cold weather use.26 Impermeable footwear promotes 

the growth of bacteria and fungi, and it is not uncommon to see the rapid development of cellulitis arising 

from tinea pedis (or athlete’s foot; Figure 9-6). 

During deployment, service members are also 

exposed to new medications and vaccines. Military 

personnel should start all new medications about 2 

to 3 weeks before deployment. Development of drug 

reactions or exacerbations of preexisting disease might 

occur before deployment. (Table 9-3 lists skin diseases 

that flare up from medications during deployment.)

SKIN PROTECTION DURING DEPLOYMENT

Skin disease is a major factor in lost man-hours 

during ship operations. Vidmar et al27 found that 

pyoderma accounted for a large percentage of morbidity during cold water deployment. Commanders 

can reduce the incidence of skin disease among their 

personnel by preventing conditions that cause occlusion with skin maceration. (Maceration of the skin 

occurs when the skin is consistently wet. Thus, the 

skin softens, turns white, and becomes easily infected 

with bacteria or fungi.) Preventive measures are shown 

in Exhibit 9-3. The effect of skin disease in tropical 

operations is reduced by preventing maceration and 

occlusion through the reduction of moisture buildup 

on the skin. Measures should also be taken to reduce 

skin maceration when service members are not in the 

field (Exhibit 9-4). 

Protection from Hot Weather Environments

In a desert environment, low humidity and reliance on the use of a limited amount of potable water 

for all purposes can cause different skin problems. Table 9-4 lists clothing properties for current issue uniforms, including the water vapor permeability index 

(i

m) values. The im scale is 0 to 1, with 0 representing 
248

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

EXHIBIT 9-2

DERMATOLOGY INFORMATION AVAILABLE THROUGH ARMY KNOWLEDGE ONLINE 

Army Knowledge Online (AKO) provides dermatology information to all service members in the US Army who have 

AKO accounts. For example, this site provides information on leishmaniasis* and teledermatology.† To access this 

information, follow these eight steps:

	 1.	 Access the AKO Web site at https://www.us.army.mil/suite/login/welcome.html.

2. Select “Login to AKO.” 

3. Login with established user name and password.

4. Go to far left at top of screen and click “Home,” then use arrow to scroll down to click on “site maps.”

5. Scroll down to “search sites,” fill in “name of site” block as “60L Dermatology,” then click under “type of 

site,” then “organizational sites,” and then click “search.”

6. A series of organization names will appear; the first one should be “60L Dermatology”—click “Homepage.”

	 7.	 A page should appear with the first left-hand column heading in black—“Dermatology Support for OIF/

OEF.”

8. Scroll down through the items to the black heading entitled “Leishmaniasis Information.”

Although the layout of Web sites invariably changes with time, the basic approach to accessing information by narrowing the focus of the search through directories and subdirectories will be similar from one version to the next. 

Contact your unit’s information management officer if you have any difficulties accessing the AKO site or navigating 

through it.

*A parasitic disease spread by the bite of infected sand flies.

†Delivery of healthcare for persons with skin diseases using long-distance communication.

impermeable clothing and 1 representing bare skin28

(Table 9-4 and Figure 9-7). Commanders should 

consider that wearing heavy or starched clothing, 

body armor, or chemical-biological protective clothing significantly limits evaporation of perspiration. 

Service members wearing these types of clothing 

suffer acute, heat-related disease because of their 

inability to regulate core temperature when the 

pathways for heat exchange via convection, radiation, conductance, or especially evaporation are 

blocked or severely reduced. Long-term wear creates 

a tropical microclimate with eventual skin maceration. Exhibit 9-5 describes protective measures for 

desert deployment. 

Protection from Cold Weather Environments

Skin protective measures during cold weather operations are similar to those during desert operations. With 

a lack of humidity in the air, all exposed skin loses moisture and dries out. This drying of the stratum corneum 

causes chapping of the skin, which can be prevented by 

frequently applying an emollient lotion to lubricate the 

skin. Lubrication follows cleaning of the skin. Reversal 

of dry skin is achieved by applying an ointment to the 

skin after it has been moistened. The affected area (hands 

and feet) should be covered with socks, and other areas 

should be covered with clean, long underwear. Crisco (J. 

M. Smucker Company, Orrville, Ohio) or lard can be used 

as an ointment if white petroleum jelly is not available. 

Lip protection using a wax-based sunscreen is advised.

Relative to operations in cold, dry environments, 

there are additional concerns to consider during 

operations in cold, wet environments. In the wetter 

environments, clothing should keep the skin warm 

and dry. Being wet in cold weather is a life-threatening 

condition because of the danger of losing core body 

heat. Service members must dry the affected area immediately and put on dry clothing. Exposed areas of 

the skin can dry and crack. However, frequent applications of emollient creams or lotions29 can manage and 

prevent this problem.

Protection from Solar Radiation

During deployment, wearing effective sun protective headgear is essential. Many deployments 

require the use of the Kevlar (E. I. du Pont de 

Nemours and Company, Wilmington, Del) helmet 

for protection against fragments or gunshot wounds. 

When service members are not required to wear the 

Kevlar helmet, they should wear the hot weather hat. 
249

Protection of the Skin

Sometimes, a cotton neckerchief is issued for additional sun protection and as a sweat cloth. The solar 

protection provided by a brimmed hat is greater 

than the beret or the BDU cap—or the newer Army 

Combat Uniform-billed patrol cap—that is similar 

to civilian baseball caps. The BDU cap protects the 

forehead and nose; however, the ears, cheeks, and 

back of the neck have minimal or no protection30

(Figure 9-8). Diffey and Cheeseman31 found that a 

hat with at least a 7.5-cm brim provided the best 

protection for the face, cheeks, chin, and back of the 

neck, whereas peaked baseball-style caps protected 

only the nose and the forehead. 

The official headgear of the Army, the beret, 

provides less solar protection of the head and neck 

than the BDU cap. The beret is an asymmetric brimless hat. There is a 1-inch to 2-inch part of the beret 

that drapes over the right scalp and upper right ear. 

How far the beret drapes depends on the amount of 

molding performed by the wearer. Solar protection 

would only occur in hatband areas and in those areas 

covered by the draped beret. Schissel32 reported that 

the beret provided a 75% reduction in UVB radiation 

to the vertex of the scalp, an area that the beret covers 

when worn. Furthermore, he reported that the beret 

provided only a 2% reduction in UVB radiation to 

the ear and chin, and a 12% reduction to the neck. 

In this study, the ear monitor was located near the 

left ear, the side not covered by the beret.32 The beret 

might provide greater protection to the right scalp 

and right upper ear when it drapes over these areas. 

The 1989 study conducted by Keeling and colleagues30 monitored the upper and lower ear separately 

on live subjects and noted little change in the solar 

protection provided to those two areas. The headgear 

in their study covered either the entire ear or not at 

all. Bilateral solar protection in asymmetric headgear 

has not been measured. The beret, although limited in 

its design to protect the head and neck of the wearer, 

might provide equivalent protection to the right scalp 

TABLE 9-3 

SKIN REACTIONS CAUSED BY DIFFERENT CLASSES OF DRUGS

Skin Reaction Drug Class Examples

Phototoxic Antimicrobials Tetracylines, quinolones, sulfonamides, nalidixic acid

Cardiac Nifedipine, quinidine, propranol

Acne medication Retinoids

Tricyclic antidepressants Nortriptyline

Diuretics Furosemide, hydrochlorothiazide

Nonsteroidal antiinflammatory Ketoprofen, naproxen, piroxicam

Hyperglycemic agents Sulfonylureas

Pruritus Antimalarials Chloroquine

Psoriasis Cardiac Beta blockers, angiotensin-converting enzyme inhibitors, quinidine

Antimalarials Chloroquine, primaquine

Nonsteroidal antiinflammatory Ketoprofen, naproxen, ibuprofen, indomethacin

Xerosis H2-receptor blockers Cimetidine, rantidine, famotidine

Acne medication Isotretinoin, tretinoin

Data source: Litt JZ, Pawlak WA. Drug Eruption Reference Manual. New York, NY: Parthenon Publishing Group; 1997: 481, 485, 496–497.

Fig. 9-6. Tinea pedis with secondary bacterial infection in 

a 45-year-old seaman aboard ship. The bacterial infection 

often includes gram-negative organisms (Pseudomonas). This 

was treated following teleconsultation with a combination 

of antibiotic, oral antifungal, and attention to foot hygiene, 

including modification of foot wear. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0135110413. 
250

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

EXHIBIT 9-3 

PREVENTION OF SKIN DISEASE FOR 

SAILORS

Sailors should adhere to the following guidelines to 

help prevent skin disease:

	 •	 Dry all wet clothing after wearing. Avoid

continued wearing of wet clothing.

	 •	 Sleep in dry clothing only.

	 •	 Shower after work shift.

	 •	 Wear wet weather gear (including boots)

when working in wet environments (especially for service members working in the 

galley).

	 •	 Change shoes and socks daily. If appropriate,

wear sandals when not on duty to allow feet 

to dry.

	 •	 Wear rubber gloves when performing wet

work. After removing gloves, hands should 

be rinsed, dried, and lubricated with a lotion.

	 •	 Replace any wet weather footwear or handwear if it contains a hole.

	 •	 Personnel on deck should wear a lotionbased sunscreen on exposed skin areas and 

use a lubricating lotion when out of the sun.

EXHIBIT 9-4

SKIN PROTECTION FOR TROPICAL 

DEPLOYMENTS

Service members deployed to tropical areas should 

follow these guidelines for preventing skin disease:

	 •	 Wear well-ventilated clothing to prevent

the buildup of moisture on the skin. Clothing should be hung up to dry after being 

worn. Flies lay eggs in clothing dried on the 

ground, and myiasis* can develop. Clothing 

should be washed in potable water.

	 •	 Wear dry socks and footwear. Ventilated

footwear, such as hot weather boots, should 

be worn during tropical deployments.

	 •	 Wear sandals† when not in the field to allow 

feet to dry.

	 •	 Wear insect repellant and use mosquito nets

at night to reduce insect bites.

	 •	 Use sunscreens. Commanders should encourage personnel, whenever outside, to 

wear the hot weather jungle hat or a similar, 

wide-brim hat.

	 •	 Bathe immediately on return from field

operations. Cleansing with deodorant soap 

reduces the bacterial count on the skin.

	 •	 Encourage commanders to limit operations

in watery terrain to 48 hours if the tactical 

situation permits. Longer operations increase 

the risk of skin infection.

*Infestation of the organs/tissues of host animals by the

larvae (maggots or grubs) of flies.

†

From 1969 to 1970, the 9th Infantry and other units were 

issued lightweight footwear (officially labeled as “comfort 

shoes,” but also referred to as “bivouac slippers”) to be worn 

during bivouac and other situations so that soldiers could 

remove their jungle boots, but still have some foot protection. 

These shoes are described in the following source: Stanton 

S. U.S. Army Uniforms of the Vietnam War. Harrisburg, Pa: 

Stackpole Books; 1989: 139.

Data source: Memorandum on prevention of skin disease 

in the Ninth Infantry Division, HQ Ninth Infantry Division, 

APO San Francisco, Calif; October 28, 1968. Adapted from: 

Army Regulation 40-29. Prevention of Skin Disease Among 

Troops Operating in Inundated Areas. US Army Vietnam (USARV); January 10, 1968. 

and right upper ear similar to that provided to the 

vertex of the scalp. Because the beret provides limited 

solar protection to the facial area, service members 

with lupus, a history of melanoma, or multiple skin 

cancers should wear an alternative hat when assigned 

to sunny climates. 

Medical personnel need to advocate solar protection 

for soldiers in the field. Service members working on 

flight lines should wear a sunscreen preparation of 

titanium dioxide or zinc oxide (“clown white”) or both. 

Sunscreen should be applied to all exposed areas of the 

face and arms. Gel formulations of sunscreens can be 

applied to the face after shaving. Reapplication of sunscreen is essential after heavy sweating or swimming. 

The addition of titanium dioxide or zinc oxide, or both, 

to sunscreens provides total protection against UVB 

and UVA rays. Some commercially available preparations (eg, Total Block COTZ [Contains Only Titanium 

and Zinc—it is a mineral-based, sun care product 

produced by Fallene Ltd, King of Prussia, Pa]) have 

these compounds as their primary active sunscreens 

in a micronized particle form. These are usually water 

and sweat resistant and are nonirritating. Sun exposure should be limited during a time block centered 

around solar noon, when the solar irradiance and UVR 

is strongest. The width of the time block can vary with 

latitude, time of year, and assumed acceptable level of 

exposure. However, limiting UVR exposure is highly 

recommended during the summer months in the 

southern United States or during year-round overseas 

deployments to low latitude environments, 1000 to 

1600 hours Daylight Savings Time (Exhibit 9-6; with 
251

Protection of the Skin

accompanying Exhibit Table E6-1 and Exhibit Figures 

E6-1 and E6-2). Although this is not practical during 

an operational environment, training schedules should 

factor in sun exposure risk when planning exercises.

Commanders should discourage tanning as a means 

of reducing sun exposure risk among service members. 

Myths about the benefits of tanning cover a wide range. 

The facts are as follows:

	 • 	 Tanning does not promote heat endurance.

Only working in hot environments promotes 

heat endurance.

	 • 	 Tanning does not promote physical endurance. Only physical activity promotes physical 

endurance.

	 • 	 Atan obtained in a tanning salon does not protect against sunburn. Tanning salons have UVA 

light sources. These only protect against UVA 

burns. The immediate sunburn experienced 

from direct, as well as indirect (ie, reflection 

of the sun’s rays off water or other reflective 

surfaces), exposure to the sun is caused by UVB 

radiation. A UVA tan obtained in a tanning 

salon does not protect against a UVB burn.

	 • 	 A tan is not a sign of good health. Tanning

is only a sign that exposure to UVB or UVA 

radiation has occurred. Tanning is a fashion 

trend, not a health practice.

TABLE 9-4

WATER VAPOR PERMEABILITY AND 

INSULATION OF US ARMY UNIFORMS

 im/clo‡

Uniform IT*(clo) im

†

(ND) (ND)

Army Combat Uniform 1.35 0.45 0.34

Army Combat Uniform + Body 1.47 0.44 0.31

Armor with small arms 

protective inserts (SAPI plates)

Chemical and biological agent 2.53 0.39 0.15

protective ensemble with 

Joint Service Lightweight 

Integrated Suit Technology 

(JSLIST) overgarment over 

Army Combat Uniform fully

encapsulated

BDU: battle dress uniform; clo: units of total insulation; i

m: vapor 

permeability index; Im: permeability index; IT: total insulation measurement; ND: nondimensional units; SAPI: small arms protection 

inserts. 

*Total clothing insulation in clo units (1 clo = 0.155 K × m2/W). †

Water vapor permeability nondimensional (ND) index: values—0 

= impermeable, 1 = bare skin.

‡

Ratio approximate “cooling power” of clothing. Values measured 

at 0.4 m • s–1.

Data source: US Army Research Institute of Environmental Medicine 

(Natick, Mass).

Fig. 9-7. Clothing properties are tested on a thermal manikin. 

Values obtained for insulation and water vapor permeability 

are used to compare clothing as inputs to thermal models. 

The uniform ensemble shown is the Interceptor Body Armor 

worn with a Marine Corps Combat Utility Uniform with 

mismatched camouflage patterns. 

Photograph: Reproduced from the US Army Research Institute of Environmental Medicine (Natick, Mass).
252

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

	 • 	 Self-tanning lotions do not protect against sunburn. These preparations are cosmetic stains 

that change skin color. No UVR protection is 

gained from their application.

	 • 	 Sunscreens do not allow longer exposure to

the sun for tanning purposes. Sunscreens, by 

design, limit UVB or UVA radiation exposure 

to the skin and, therefore, prevent tanning.

	 • 	 Skin cancer affects people of all ages, not just

the elderly. Eighty percent of a person’s total 

lifetime exposure to solar radiation occurs prior to military service before the age of 18; thus, 

early prevention programs are important.

This incidence of skin cancer can be reduced by 

educating service members and their commanders 

about proper skin care and informing them about the 

tanning misconceptions (Figure 9-9).

EXHIBIT 9-5

SKIN CARE IN DESERT OPERATIONS(1–3)

Service members deployed to desert environments should follow these guidelines for avoiding skin disease:

	 •	 Use emollient-based sunscreen on the skin regularly. Protect lips by using a lip wax/sunscreen protectant.

Wear a wide-brimmed hat (or jungle hat) to protect the face from solar radiation.

	 •	 Wear ventilated footwear and clothing. Do not starch clothing. Keep clothing clean.

	 •	 Clean skin regularly with soap and water. Nonlipid skin cleansers (eg, Cetaphil or Aquanil)* can be used if 

water is unavailable for showering. These cleansers clean and lubricate the skin.

	 •	 Lubricate the skin. Use nonlipid cleansers. If skin becomes dry, use an emollient lotion after bathing.

	 •	 Wear insect repellant.

*Brand names: Cetaphil, Galderma Laboratories (Fort Worth, Tex); Aquanil, Person & Covey, Inc (Glendale, Calif). 

Data sources: (1) Pace JL. Sun, sand, and skin: the Persian Gulf. Int J Dermatol. 1991;30:247–249. (2) US Army Research Institute of 

Environmental Medicine, Walter Reed Army Institute of Research, US Army Medical Research and Materiel Command. Sustaining 

Soldier Health and Performance in Southwest Asia: Guidance for Small Unit Leaders. Natick, Mass: USARIEM; 1994. Technical Note 95-1. 

(3) US Army Research Institute of Environmental Medicine. Sustaining Health and Performance in the Desert: A Pocket Guide to Environmental Medicine for Operations in Southwest Asia. Natick, Mass: USARIEM; 1990. Technical Note 91-2.

SKIN DISEASES AFFECTED BY DEPLOYMENT

Common skin diseases can cause problems among 

military personnel. Field conditions—such as heat, 

humidity, poor hygiene, occlusive clothing, secondary infection, inadequate nutrition, UV light, etc—can 

exacerbate these disorders. An understanding of the 

following skin diseases and their management is vital:

	 •	 acne,

	 •	 hidradenitis suppurativa,

	 •	 psoriasis,

	 •	 atopic dermatitis,

	 •	 lichen planus,

	 •	 discoid lupus erythematosus,

	 •	 Darier’s disease, and

	 •	 hand dermatitis.

Acne

Acne is an inflammatory disease of the pilosebaceous apparatus. Hot-humid environments can 

cause the disease to flare up. The eruption can 

become infected secondarily by Staphylococcus or 

Streptococcus. Acne can localize to areas that are 

chronically rubbed, including the chin, shoulder, 

waist, and buttocks. These areas can become unresponsive to treatment unless the source of rubbing 

is removed.

Service members who handle petrochemical 

products and cutting fluids are susceptible to acne. 

This chronic oily residue on the skin predisposes it 

to acne development. It is important that these service members wear protective clothing to keep these 

compounds off the skin. Line supervisors should 

ensure that service members wear protective clothing 

and that soiled clothing is properly laundered rather 

than worn again.

In the field, cleaning of the skin with soap and water 

helps control acne. For some people, the addition of 

an oral antibiotic might be necessary. Service members 

with acne requiring the use of Accutane (Hoffman-
253

Protection of the Skin

Fig. 9-8. Solar protection of different head covers: jungle hat, BDU baseball hat, and beret. Jungle hat— front view (a) and 

side view (b). Illustrations show the areas protected by the jungle hat. All areas of the head and neck have at least a 50% 

reduction in direct radiation exposure. Facial areas have greater than a 80% reduction in direct solar radiation. BDU baseball 

hat—front view (c) and side view (d). Illustrations show the areas protected by the BDU baseball hat. The ears and posterior 

neck are not protected by this hat. The cheeks receive minimal protection (≤40% protection). Only the forehead and nose

have greater than a 80% reduction in direct solar radiation. Beret—front view (e) and side views (f and g). The beret was 

adopted in 2001 for use by all personnel in the US Army. Illustrations show the areas protected by the beret, which provides 

less than a 13% reduction in solar radiation to the forehead, nose, face, chin, left ear, and posterior neck. The protection is 

asymmetric because of the beret design, which provides up to a 75% reduction in the covered areas. 

BDU: battle dress uniform

Illustrations of jungle hat and BDU baseball hat protection: Adapted with permission from and courtesy of Visual Illustration Service, Brooke Army Medical Center, Fort Sam Houston, Texas. From data reported by Keeling JH, Kraus EW, Pathak 

M, Sober AJ. Hats: design and protection from ultraviolet radiation. Mil Med. 1989;154:250–255. 

Illustrations of beret protection: Courtesy of Visual Illustration Service, Brooke Army Medical Center, Fort Sam Houston, 

Texas. From data reported by Schissel DJ. Operation Shadow Warrior: a quantitative analysis of the ultraviolet radiation 

protection demonstrated by various headgear. Mil Med. 2001;166:783–785. 

LaRoche, Basel, Switzerland) should not be deployed 

until they have completed at least 3 months of drug 

treatment. This period of time allows the drug to be 

adjusted to the appropriate dose and any side effects 

monitored (as well as a response to therapy).

Hidradenitis Suppurativa

Hidradenitis suppurativa is chronic inflammation 

of the apocrine sweat gland. Clinical features of this 

disease include recurring, painful, fluctuant cysts 

and nodules of the axillae, buttocks, and genital area. 

The cysts are usually infected by gram-positive cocci. 

gram-negative bacteria are isolated with repeated 

infections. The disease flares up during conditions of 

high temperature, humidity, and stress. Patients with 

the disease can have frequent flare-ups that might 

require surgical intervention.

A similar eruption involves only the scalp and is 

called dissecting cellulitis. Service members with this 

condition cannot wear protective headgear. This is 

a rapidly progressive disease that eventually causes 

permanent scarring alopecia (hair loss). Dermatology 

evaluation is essential to treatment.
254

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

EXHIBIT 9-6 

ULTRAVIOLET INDEX

The ultraviolet (UV) index (UVI) provides general guidance regarding potential exposure to the risk of sunburn and 

skin damage due to UV radiation. The UVI can be presented as a forecast or derived from direct UV measurements. 

Based on the UVI value, different behaviors are recommended, such as applying sunscreen, wearing clothing or sunglasses, or limiting exposure time by seeking shade (Exhibit Table E6-1). A forecast is based on satellite measurements 

of the ozone layer and a model prediction of the UV portion of solar radiation reaching a given location on the Earth’s 

surface. The local forecast is adjusted for cloud cover in accordance with a statistical projection of local cloudiness. The 

methods used by the National Weather Service(1) are consistent with international standards sanctioned by the World 

Health Organization (WHO),(2) but they differ because many international sites use ground-based measurements rather 

than calculations based on satellite data. Ground-based measurements are technically more accurate for the locales near 

the monitoring site, but UV radiometers are uncommon. Thus, ground-based measurements are very limited, whereas 

satellite-based estimates are possible for almost any location. The following methodology is based primarily on Long 

et al.(1) As noted by these authors, the methodology continues to be refined and improved. Equivalent methods are 

used in other countries, such as the methodology reported by Lemus-Deschamps et al(3) in Australia. 

TABLE E6-1

GENERAL EPA GUIDELINES FOR PROTECTIVE MEASURES AGAINST OVEREXPOSURE 

TO UVR BASED ON THE UVI 

Exposure Category UV Index Protective Actions 

Minimal 0–2 SPF 15 sunscreen

Low 3–4 SPF 15 sunscreen and protective clothing (hat)

Moderate	 5-6	 SPF 15 sunscreen, protective clothing, and UVA/UVB sunglasses

High 7–9 SPF 15 sunscreen, protective clothing, sunglasses, and sun avoidance 10 am to 6 pm

Very high 10+ SPF 15, protective sunscreen clothing, sunglasses, and sun avoidance 10 am to 6 pm

EPA: Environmental Protection Agency; SPF: sun protection factor; UV: ultraviolet; UVA: ultraviolet light ray A; UVB: ultraviolet 

light ray B; UVI: ultraviolet index; UVR: ultraviolet radiation.

Data source: http://www.cpc.ncep.noaa.gov/products/stratosphere/uv_index/uv_info.html. Accessed July 27, 2006.

Ozone is not distributed evenly across the Earth’s surface, because it varies by season and hemisphere. A forecast 

of the ozone layer thickness or column is based on a weighted estimate from satellite observations. Incoming UV 

radiation is partially absorbed by ozone or scattered by particles in the atmosphere in proportion to the distance the 

radiation travels through the atmosphere. The shorter the distance or path, the greater the level of irradiance and 

corresponding risk of skin damage. The path is shortest at solar noon in proximity to the summer solstice and at 

higher altitudes, and increases relative to sunrise, sunset, the winter solstice, and lower elevations (Exhibit Figure 

E6-1, a and b). Values will be higher on an annual basis in the tropics and higher when the shadow cast by a standing individual is minimum. During the Hawaiian summer solstice, “no shadow day” is celebrated at solar noon. 

On that day, when the sun is directly overhead (zenith angle = 0), for a standing individual, there is no shadow. The 

concept of maximum exposure to UV radiation at solar noon has been expressed as the “shadow rule”—if you cast 

little or no shadow, you should get out of the sun, because this corresponds to a high zenith angle and maximum 

solar irradiance. The rule is most applicable in the tropical latitudes and is somewhat confounded by reflected 

radiation and/or overcast days.

Calculation of UVI is based on a radiation transfer model(4) that uses the following as inputs:

	 •	 ozone amount,

	 •	 latitude,

	 •	 longitude,

	 •	 date and time of day,

	 •	 solar position, and

	 •	 cloud cover.

(Exhibit 9-6 continues)
255

Protection of the Skin

Other inputs, such as surface reflection (albedo), are set as constants. See Chapter 8 for additional information on 

solar radiation. The model computes clear sky spectral irradiance as an energy flux (W/m2), which is adjusted for 

cloud cover or haze. Because only UV radiation in the 280- to 400-nm range are factors in sunburn—and the relative 

importance varies in accordance with the CIE (Commission Internationale de l’Eclairage) action spectrum(5)—the 

raw irradiances are weighted to compute an erythermal irradiance or dose rate. The original National Weather Service UV product was expressed as a 1-hour dosage in mJ/m–2, but is currently expressed as a true nondimensional 

scale in accordance with the World Meteorological Organization standard of 25 mW/m–2 = 1 UVI unit. The WHO 

equation for UVI is: 

Iuv = ker × 400∫

250 Eλ × ser(λ)dλ [ND],

where Eλ solar spectral irradiance in W/(m2 × nm)–1 for a given wavelength (λ) over dλ, the wavelength interval, 

and ser(λ) erythema action spectrum,(5) ker is a constant (40 m2/W–1). Eλ can be obtained from ground-based sensors or 

satellite-adjusted calculations. 

UVI Varies with Location

The United Kingdom’s Web page indicates that UVI values in the United Kingdom never exceed 8, whereas the example in the WHO guide (2002) indicates a value of 13 in Darwin, Australia. Exhibit Figure E6-2 shows the National 

Oceanic andAtmosphericAdministration/Environmental ProtectionAgency report format for UVI values for 58 cities

in the United States. 

Value of the UVI

The Environmental Protection Agency (EPA) established five categories for interpreting the UVI, which differ slightly 

from the WHO exposure categories, because a small adjustment was made to conform to the international standard. 

As noted previously, based on the UVI value, different protective measures are recommended, although it might be 

Exhibit 9-6 continued

Fig. E6-1. (a) Seasonal variation in ultraviolet index values for Albuquerque, New Mexico, forecast calculated for clear 

sky and predicted cloud cover conditions. (b) Erythemal dosage rates vary with time of day and latitude. Ultraviolet 

index forecast values are usually given for solar noon. 

DU: Dobson units; UV: ultraviolet.

Illustrations: (a) Adapted with permission from the National Oceanic and Atmospheric Administration (NOAA), US 

Department of Commerce, Washington, DC. (b) Adapted with permission from Long CS, Miller AJ, Lee H-T, et al. 

Ultraviolet index forecasts issued by the National Weather Service. Bull Am Meteorol Soc. 1996;77:729–748 (Fig. 3, p. 

732). Courtesy of the American Meteorological Society, Boston, Massachusetts.

b

Ozone = 300 DU Day of Year = June 22

Time of Solar Day

Diurnal Erythemal Dosage Rate

20°N 40°N 60°N

Erythemally Weighted Dosage Rate (mW/m) 275

250

225

200

175

150

125

100

75

50

25

0

5678 9 10 11 12 13 14 15 16 17 18 19

(Exhibit 9-6 continues)

a
256

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

more practical to make the applicable EPA recommendation into standard operating procedures for military populations. Long(6) carefully pointed out the following limitations of UVI calculations:

	 •	 statistical adjustment for cloud cover,

	 •	 assumptions on the use of satellite data to estimate ozone,

	 •	 use of constants to represent albedo, and

	 •	 emphasis in the forecast on the maximum value at solar noon.

In addition, the UVI is expressed on an artificial, nondimensional scale. Whereas users should be aware of these limitations required to develop a manageable forecast, the UVI provides both awareness and general guidance relative to 

the risks of exposure to solar radiation.

Fig. E6-2. Sample data sheet of the National Oceanic and Atmospheric Administration (NOAA)/Environmental

Protection Agency (EPA) Ultraviolet Index (UVI) forecast for US cities. http://www.cpc.ncep.noaa.gov/products/

stratosphere/uv_index. Accessed July 27, 2006.

UV: ultraviolet

Data sheet: Courtesy of the National Oceanic and Atmospheric Administration, US Department of Commerce, Washington, DC.

Exhibit 9-6 continued

(Exhibit 9-6 continues)
257

Protection of the Skin

Data sources: (1) Long CS, Miller AJ, Lee HT, Wild JD, Przywarty RC, Hufford D. Ultraviolet index forecasts issued by the National 

Weather Service. Bull Am Meteorol Soc. 1996;77:729–748. (2) World Health Organization, 2002. Global Solar UV Index: A Practical Guide. 

WHO/SDE/OEH/02.2. http://www.who.int/uv/. Accessed July 27, 2006. (3) Lemus-Deschamps L, Grainger S, Rikus L, Atkinson

R, Steinle P, Gies P. Australian UV and Ozone Forecasting System. http://www.bom.gov.au/bmrc/mdev/expt/uvindex/uvi.shtml.Accessed September 16, 2005. (4) Frederick JE, Lubin D. The budget of biologically active radiation on the earth-atmosphere. J Geophys 

Res. 1988;93:3825–3832. (5) Erythema Reference Action Spectrum and Standard Erythema Dose. Vienna, Austria: CIE Central Bureau; 1999. 

ISO 17166: 1999/CIE Standard ISO 17166/CIE S007-1998. (6) Long CS. Presentation to OFCM JAG/TI 2003. http://www.ofcm.gov/

jagti/jagti-start.html. Accessed July 27, 2006.

Exhibit 9-6 continued

Fig. 9-9. Sun Smart Cards TA-012-0403. (a) Shade and clothing. (b) Suncreen and eye wear.Available at: http://chppm-www.

apgea.army.mil/doem/pgm34/HIPP/sun_smart_card.pdf. Accessed July 27, 2006.

SPF: sun protection factor

Photograph: Reproduced from the Center for Health Promotion and Preventive Medicine (CHPPM), now US Army Public 

Health Command (PHC).

Patients with active disease should not be deployed. 

Those individuals in remission (under treatment with 

Accutane) might experience flare-ups when deployed. 

Service members are eligible for deployment if the 

disease has been in remission for at least 6 months.

Psoriasis

Psoriasis is a chronic, inflammatory skin disease 

that presents as scaly papules and plaques (Figure 

9-10). At times, the disease can have an unpredictable 

course. Any combination of factors (eg, stress, low 

humidity, minimal sunshine, or cold weather) can affect the progression of psoriasis in the Army garrison. 

Chloroquine and antimalarial chemoprophylaxis can 

also exacerbate psoriasis.33–35

The abundance of skin scale and odor produced 

by psoriasis complicates living in the field. Service 

members with psoriasis often have itching. Thus, daily 

bathing is essential to reduce the skin scale build-up. 

Lesions from psoriasis are often colonized by S aureus, 

and such bacterial infections can cause progression of 

the cutaneous lesions.

Treatment during deployment focuses on improving 

skin hygiene and lubrication, applying topical steroids, 

and taking oral antihistamines. Army Regulation 

40-501 (“Standards of Medical Fitness” [February 1, 

2005]), and Department of Defense Directive 6130.3 

(“Physical Standards for Appointment, Enlistment, 

and Induction” [December 15, 2000]), both bar people 

from entering the military if they have active, residual 

lesions or a history of atopic dermatitis after 8 years of 

age. Individuals with only mild psoriasis (without nail 

pitting) that does not interfere with the wearing of military equipment might enter military service. Military 

service personnel can be treated with the following:

	 •	 etritinate,

	 •	 isotretinoin,

	 •	 bexarotene,
258

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

	 •	 cyclosporine,

	 •	 methotrexate,

	 •	 mycophenolate mofetil,

	 •	 hydroxyurea,

	 •	 systemic biological agents for psoriasis (alefacept [Amevive], infliximab [Remicade], 

etanercept [Enbrel], and others), and

	 •	 psoralen with UVA.

Patients on narrow-beam UVB should be evaluated by 

a dermatologist prior to deployment to be switched to 

another treatment regimen. Most of these treatments 

are not available to deployed military personnel, nor 

can they interfere with a person’s immune system.

Atopic Dermatitis

Atopic dermatitis is a chronic skin disease that 

results from an intense pruritus of the skin. It is characterized by symmetrical, eczematous lesions of the 

face or antecubital or popliteal fossa. These lesions can 

be weepy, scaly, or lichenified papules and plaques 

(Figure 9-11). The skin is colonized by S aureus. Atopic 

dermatitis is triggered by airborne irritants, stress, 

foods, dry weather, cold weather, and hot weather.

Presentation of atopic dermatitis varies per individual. Patients with this condition rub their skin 

regularly, with pruritus as the main complaint. They 

do not tolerate wearing wool or scratchy fabrics. These 

patients are susceptible to heat injuries because of 

an impaired sweat mechanism. They have impaired 

cellular immunity of the skin. Infections caused by 

varicella, herpes simplex, vaccinia, and dermatophytes 

can easily involve all skin surfaces. Prophylaxis with 

an oral antiviral agent is indicated when these patients 

are exposed to herpes simplex. Service members with 

this condition usually do poorly in the field.

Lichen Planus

Lichen planus is an inflammatory skin disease 

characterized by the presence of flat-topped polygonal papules of the skin. The eruption can involve any 

cutaneous surface. These lesions are pruritic and are 

exacerbated by stress. Sunshine intensifies the eruption. Lichen planus can cause painful oral ulcerations. 

The eruption clears with the use of corticosteriods, but 

returns when the drug is stopped. In the field, healthcare workers have limited therapies for management 

of this disease.

Discoid Lupus Erythematosus 

Discoid lupus erythematosus is a cutaneous collagen vascular disease that has the propensity to become 

generalized. Service members with this disease have 

hypopigmented, atrophic skin scars. Active lesions 

Fig. 9-10. Psoriasis in a military contractor serving in Afghanistan. Normally, this individual’s condition is well controlled 

without medication in a more humid stateside environment. 

One recommendation from the teleconsultation was a few 

minutes per day sun exposure three times/week to help

control the condition until redeployment. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0003110103. 

Fig. 9-11. Atopic dermatitis (chronic eczema) with a nummular (coin-shaped) eruption on hands with itching and 

burning. This soldier was managed by teleconsultation from 

Afghanistan. Photograph: Courtesy of Chuck Lappan, AKO 

teleconsultation, case 0006110104. 
259

Protection of the Skin

usually present as pink-to-red papules and plaques. 

This eruption can be a source of permanent hair loss. 

In addition, affected areas tend to be sun-exposed. Both 

UVA and light can trigger flare-ups of discoid lupus 

erythematosus. 

Treatment focuses on limiting stress and sun exposure. Service members should wear the hot weather 

hat in lieu of the BDU cap or beret. The hot weather 

hat protects the cheeks, ears, nose, and neck. Frequent 

application of a broad-spectrum sunscreen with a 

solar (sun) protection factor (SPF) of 30 should be 

used. Commanders might need to limit activities that 

increase sun exposure. Service members might need 

job reclassification.

Darier’s Disease

Darier’s disease is an autosomal, dominant skin disease that is triggered by sunshine, heat, and humidity. 

When the disease is in remission, the only cutaneous 

findings appear in the fingernails. Red streaks and 

notching of the free edge of the nail present in one 

or more nails. Flaring of the disease is characterized 

by generalized intensely pruritic, weepy, and scaly 

papules that initially involve sun-exposed areas. Secondary bacterial infections are common. Treatment is 

aimed at placing the individual in an air-conditioned 

environment and administering oral antihistamines 

to control pruritus.

Hand Dermatitis

Hand dermatitis can be caused by atopic dermatitis, psoriasis, contact dermatitis, and chronic 

irritation. Similar conditions can affect the feet in 

occupational exposures such as in Figure 9-12. These 

factors play a major role in hand dermatitis and 

commonly result from frequent washing of the 

hands with soap and water or with water-free 

cleaning solvents. Depletion of the protective skin 

lipids of the stratum corneum is the result, with 

the stratum corneum drying out, losing pliability, 

and cracking. Stiffening of the stratum corneum is 

inversely related to the level of hydration. Thus, 

painful cracks and fissures can develop, with fissures extending down to the dermis. Treatment 

focuses on limiting exposure to an allergen/irritant

and rehydrating the skin (Exhibit 9-7).

Fig. 9-12. Contact dermatitis on the foot of a 29-year-old 

seaman aboard ship. Teleconsultation resulted in a recommendation of topical steroids and evaluation for dermatitis 

triggers, such as laundry soap and petroleum products, as 

well as antibiotic treatment for possible cellulitis. 

Photograph: Courtesy of Chuck Lappan, AKO teleconsultation, case 0116110331. 

EFFECT OF SKIN DISEASE ON OPERATIONS DURING DEPLOYMENT

Ship Operations

Little information exists on the prevalence of skin 

disease during ship deployments. Some information is provided in a study by Vidmar et al,27 who 

prospectively examined all sick call visits during 

a 3-month, cool weather deployment of an aircraft 

carrier. He found that skin disease accounted for 

40% of all sick call visits. Skin disease and sexually transmitted diseases accounted for 24.5% of all 

lost man-days (916/3,737) during the deployment.

Based on the reported values, pyoderma and eczema 

accounted for 72% of the dermatology/sexually

transmitted disease lost man-days, and pyoderma 

caused 48% of those lost man-days. Skin infections 

were highest among personnel doing dirty work in 

damp surroundings.28

Tropical Operations

Skin disease not treated adequately can result in 

hospitalization. This was noted especially during 

the Vietnam War: from 1965 to 1971,36 skin diseases, 

infectious diseases, and ill-defined symptoms were 

the most common causes for admission of US Marines 

to hospitals. In that report, Palinkas and Coben36

gave a rate of hospitalization per 1,000 person-years 

for “diseases of the skin and subcutaneous tissue” 
260

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

under the category of “other.” Skin disease accounted 

for 7% of all first-time sick call visits at the battalion 

aid station and clearing company. The authors did 

not identify the number of follow-up visits or patients 

referred for specialty care.40 Most dermatologists were 

assigned as general medical officers to hospitals or 

clearing stations during this conflict. While assigned 

to a clearing station, Pehr and Kornfield41 reported 

seeing 81 patients for skin disease. Eczematous dermatitis was the major reason service members sought 

healthcare in the field. Hepburn42 reported on the British dermatology experience in the Persian Gulf War. 

During a 6-month period, he evaluated 95 patients 

for dermatology complaints: 34 required admission, 

and 5 were evacuated permanently from theater. Infections were the most common reason for referral. In 

addition to protection from solar radiation, clothing 

can protect against cuts, abrasions, and bites, which 

might become infected. Eczema accounted for nearly 

one third of the dermatology consultations.42 The 

brief duration of the war, low humidity, and combat 

operations during the winter months (and, as noted 

previously, possibly with less insect activity than in 

the summer months) minimized the number of skin 

as 47.2 for Marines in Vietnam versus 15.6 for nonVietnam status. That striking difference, and an 

overall increase in disease and nonbattle injury, was 

probably the result of a combination of combat and 

exposure to climate and other environmental factors. 

During this time,37,38 malaria and skin disease were 

the leading causes of hospital admissions among 

military personnel in Vietnam. During a 1-month 

experience in jungle operations in Panama, English 

and Fano-Schultz39 reported that more than 50% of 

sick calls were because of skin disease. Bacterial and 

fungal infections accounted for more than half of the 

reported skin diseases.39

Desert Operations

Available reports do not identify skin disease as 

a major cause of lost man-hours during Operation 

Desert Shield (the deployment phase of the Persian Gulf 

War) and Operation Desert Storm (the combat phase of 

the Persian Gulf War). Wasserman and colleagues40

reported sick call visits for the 3rd Armored Cavalry 

Regiment for a 19-week period during Operation Desert Shield. The greatest percentage of visits was listed 

EXHIBIT 9-7

PREVENTION OF HAND DERMATITIS IN DEPLOYED SERVICE MEMBERS

Hand dermatitis is common in professionals who do wet work, or who handle raw foods, detergents, or solvents. 

To prevent these problems, individuals should do the following:

	 •	 Protect hands from soaps, detergents, and wet work by wearing waterproof, heavy-duty gloves. Vinyl gloves

work better than rubber gloves. Allergies to rubber can occur. An alternative option is to wear cotton or vinyl 

liners inside the rubber gloves. Gloves should be kept in work areas, their use encouraged, and they should 

not contain any holes. 

	 •	 Wear work gloves when doing dirty work. Clean hands are less likely to spread infections.

	 •	 Wear vinyl or nitrile gloves (with a liner) when working with solvents (eg, turpentine, gasoline, paints, polishes, or paint thinner).

	 •	 Use cool water and a small amount of mild soap to wash hands. (Ivory soap is not recommended.) Dry

hands gently. Lipid-free skin cleansers (such as Cetaphil or Aquanil) can be applied to the skin and wiped 

off. Hands will feel greasy if too much cleanser is used. Cold cream can also remove grease and oil from the 

hands instead of the waterless hand cleaners.*

	 •	 Wear cotton or leather gloves during cold weather to reduce skin water loss and chapping. Treat skin chapping of the hands with frequent applications of a skin lubricant (eg, Lubriderm or Moisturel), especially after 

wetting the hands. Very dry hands can be managed during cold weather deployment by wetting the hands; 

applying Vaseline, white petrolatum, or Crisco at night; and covering them with a pair of gloves or socks. 

During the day, frequent applications of a skin lubricant should follow for normal maintenance.

*Brand names: Ivory (soap), Procter & Gamble Company (Cincinnati, Ohio); Cetaphil, Galderma Laboratories (Fort Worth, Tex); 

Aquanil, Person & Covey, Inc (Glendale, Calif); Lubriderm, Johnson & Johnson Consumer Companies, Inc (New Brunswick, NJ); 

Moisturel Therapeutic Lotion, Dillon Distributors (Kenilworth, NJ); Vaseline, Unilever House (London, United Kingdom); Crisco, 

J. M. Smucker Company (Orrville, Ohio). 

Data source: Adapted with permission from a patient care handout used by the Dermatology Service, Wilford Hall Medical Center, 

Fort Sam Houston, Texas.
261

Protection of the Skin

infections among military personnel. Skin conditions 

sensitive to an environment of high solar radiation 

and low humidity accounted for a larger number of 

dermatology consultations. In the April 2005 issue of 

Medical Surveillance Monthly Report,

43 covering 2000 to 

2004—which includes the early stages of Operation 

Enduring Freedom—the relative diagnosis of hospitalization for dermatological diseases increased 

from 12th in 2000 to 10th in 2004 for US armed forces. 

During deployment to Iraq, a higher number of cases 

of cutaneous leishmaniasis was seen in personnel returning from Iraq than was seen after the Persian Gulf 

War (1990–1991). This might result from the longer 

time these military units spend in theater and problems with the availability of protective mosquito nets 

(Figure 9-13). Thus, a portion of this increase might be 

caused by changes in reporting procedures.22 However, as noted previously,22 a rapid increase began for 

US Army personnel in 2002. The reported rates were 

nearly flat from 1999 to 2002, with rapid increases for 

US Army personnel and much smaller increases for 

other service members (Figure 9-14). 

Cold Weather Operations

Corbett and Benson44 presented an overview of 

cold weather dermatology issues. Two reports described skin disease during cold weather operations 

in Bosnia. Croft and colleagues3 reported a 100% 

survey of two company-size units that operated there. 

One of the companies stationed at a dam site reported 

an outbreak of skin rashes allegedly from exposure 

to water contaminated with human remains. Members of both units were living in fixed facilities with 

running water. Skin diseases were reported in 14% 

of the study unit and in 21% of the control unit, with 

the most common diseases being infections, eczema, 

and acne. During a health survey of British troops in 

Bosnia, from December 1995 to April 1996, Smith and 

Croft45 noted that skin diseases accounted for 12.7% of 

all primary care consultations. Dry skin and chapped 

lips were common cold weather problems.45 Habek 

et al46 reported the sick call activities of the 105th 

Croatian Army Medical Brigade from 1991 to 1992. 

Of 4,220 reported patient visits:

	 •	 skin disease was the fourth leading cause of

these visits,

	 •	 skin infections and dermatitis were the major

causes of the sick call visits, and

	 •	 scabies accounted for 1% of the total visits.

In addition, this unit provided care to the refugees, as 

well as to its army.

Fig. 9-13. During World War II, troops slept under mosquito netting.

Painting: Courtesy of the Army Art Collection, US Army Center of Military History, Washington, DC.

SKIN DISEASE AND MEDICAL PLANNING

The effect of skin disease on military personnel/

military deployment is largely unappreciated by 

medical operational planners. Yet, skin diseases occur 

quite frequently, and—as in other minor, nonbattle 

injuries—military personnel can become rapidly disabled. Compounding the effects from skin disease is 

the inability of healthcare providers without specialty 

training to recognize and manage skin disease. A large 

expenditure of patient and healthcare provider time 

and medical supplies is often used in search of the correct diagnosis.47 With proper care, affected personnel 

are a source of valuable, recycled manpower during 
262

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine

deployment. Skin disease can also cause morale problems in affected individuals and in other personnel 

in the unit. With sufficient operational planning for 

proper care and protection of the skin, the cost of treating skin disease in deployed personnel can be reduced.

Schissel and Wilde48 reviewed past deployments 

and the cost savings of intratheater dermatology 

support to deployed units. They reported savings in 

preventing lost workdays and in reducing funds from 

having had 12 periodic dermatology missions to Bosnia. In addition, they demonstrated the advantages of 

having a dermatologist in theater. If, however, a dermatologist is not available in theater, a “teledermatology” 

consultation is an alternate method of delivering this 

needed healthcare. (The Internet has become more 

available to all deployed units and healthcare personnel, even in austere environments.) Teledermatology 

consulting involves a formal setup—arranged through 

the unit’s information management officers and the 

Army Medical Department (AMEDD)—that allows 

personal data and images to be transmitted over a secure system. These consultations are normally handled 

by a group of military dermatologists from the Army’s 

teledermatology project. Another method involves a 

healthcare worker e-mailing a dermatologist with a 

description of the skin disease. However, this type of 

consultation might take longer to answer and is usually 

not over a secure system. 

Fig. 9-14. Clinical diagnoses/reports of leishmaniasis at US military medical treatment facilities and estimated leishmaniasis

infection incidence rates among US service members in Operation Enduring Freedom/Operation Iraqi Freedom, by month,

January 2003–December 2006. After an initial increase, the incidence of leishmaniasis has decreased significantly.

Illustration: Adapted with permission from Lay JC. Leishmaniasis among U.S. Armed Forces, January 2003–November 

2004. Med Surv Monthly Rep. 2004;10:1–5 (Fig. 1, p. 3). Courtesy of the US Army Center for Health Promotion and Preventive 

Medicine (CHPPM), Aberdeen Proving Ground, Maryland (now the US Army Public Health Command [PHC]).

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Clinically Significant Infections Per 1,000 Person-years

22.0

20.0

18.0

16.0

14.0

12.0

10.0

8.0

6.0

4.0

2.0

0.0

140

130

120

110

100

90

80

70

60

50

40

30

20

10

0

Errors Diagnosed/Reported

JanAprJulOctJanAprJulOctJanAprJulOctJanAprJulOct

Clinical Diagnoses/Reports

Infection Rate

2000 2004 2005

SUMMARY

The skin is a complex organ and is affected by internal and external factors. Awareness of external factors 

that degrade the integrity and function of the skin is 

important for commanders and medical staff, because 

they can modify working and living environments that 

promote skin disease. It is imperative that medical 
263

Protection of the Skin

officers become familiar with the recognition and treatment of common skin diseases. Before deployment, 

medical staff need to evaluate and seek consultation 

for personnel with any long-standing skin disease. 

These actions can reduce the number of medical evacuations from the theater and the expense of deploying 

replacement personnel. In addition, knowledge of 

drug and skin disease interaction is important for the 

deploying medical officer. Commanders must ensure 

that personnel keep their skin clean, dry, and well 

Acknowledgment

This chapter was authored by Dr Keller more than a decade ago and has since undergone several extensive 

revisions to fit the focus of this book.

lubricated. Through the guidance of their medical 

staff, commanders should promote the effort to limit 

UVR exposure. With these efforts, acute and long-term 

skin disease can be reduced in service members during training, deployment, and beyond. The Internet 

provides valuable dermatology support to deploying 

healthcare workers. In the future, this tool will be of 

increasing value to healthcare workers and service 

members in promoting a more active partnership in 

the overall health of the military force.

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