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Skin disease in United Nations peacekeepers in Lebanon
  1. Zhou Zhou,
  2. T Liu and
  3. Z Zhang
  1. Department of Dermatology, Chengdu Military General Hospital, Chengdu, China
  1. Correspondence to Dr Zhongkui Zhang, Department of Dermatology, Chengdu Military General Hospital. No. 270, Rongdu Avenue, Jinniu District, Chengdu, Sichuan Province 610083, China; 44202648{at}qq.com

Abstract

Objectives Skin disease is one of the major components of health problems for soldiers either during war or peacetime. Despite increased numbers and scale of military missions, dermatological survey is limited. The aim of this study was to outline the dermatological profile in international peacekeepers in Lebanon and to explore the features of disease pattern.

Methods The dermatological records of peacekeepers visiting a Chinese Level 2 hospital during a 7-year period were retrospectively assessed. Comparisons with previous reports of skin disease in military personnel were performed.

Results A total of 1658 patients (91% men, with a mean age of 32 years) were included. More than half of them were Asian (62%). Dermatitis and eczema (27%) was the leading category. Tinea pedis (13%), lichen simplex chronicus (9%), unspecified dermatitis (8%), verruca vulgaris (7%) and alopecia areata (5%) were the top five complaints. Dermatitis and eczematous eruptions appeared to be the most common condition in troops deployed in the Middle East, whereas fungal infection was highly prevalent in tropical regions. Additionally, a remarkably high rate of alopecia areata was noted in two studies including ours.

Conclusions Environment, group living, occupational activities and work-related stress act as initiating and/or aggravating factors in the development and/or spread of some conditions. The knowledge of disease profile empowers doctors to enforce preventive measures and prepare for treatment modalities. In particular, the underlying psychological component in lichen simplex chronicus and alopecia areata should be addressed appropriately.

  • dermatitis
  • military personnel
  • military medicine
  • skin diseases

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Key messages

  • Dermatitis and eczema was the leading category of skin disease in international peacekeepers serving in Lebanon.

  • Cutaneous infections such as tinea pedis and verruca vulgaris were common complaints for military personnel, which can be prevented with appropriate measures.

  • Psychological consultation and behavioural intervention are necessary for patients with psychodermatological disorders (e.g. lichen simplex chronicus and alopecia areata).

Introduction

Dermatological disease is one of the major components of health problems for military personnel either during war or peacetime.1–3 It is especially evident in war or war-like settings where troops are deployed in an unfamiliar and often harsh environment.4–8 Although cutaneous conditions cause low morbidity or mortality, even relatively minor insults, like tinea pedis or hand eczema, may make a soldier unfit for duty.

There are currently 16 peacekeeping missions directed by the United Nations and despite increased number and scale of the operations, dermatological survey of peacekeepers is limited.7 ,8 The knowledge of the disease profile would enable healthcare providers to make targeted plans for protection, prevention and treatment.

United Nations Interim Force in Lebanon (UNIFIL) was established in 1978, and according to the latest data, UNIFIL's force consists of a total 10 410 peacekeepers from 37 countries; troop rotations of each contributing country take place every 3–12 months. The Chinese Level 2 hospital was founded in April 2007 and is responsible for military personnel in the Sector East of UNIFIL and the surrounding region. In general, soldiers are first screened by primary care providers at a Level 1 hospital; if there are diagnostic or therapeutic difficulties, patients are transferred for further evaluation—occasionally, patients come without referral. The purpose of this study is to describe the distribution of skin diseases in deployed international peacekeepers in the Sector East of UNIFIL based on data of seven consecutive years.

Methods

A retrospective study was conducted for all dermatological visits at the Chinese Level 2 hospital in the Sector East of UNIFIL, South Lebanon, between April 2007 and September 2014. The data were recorded in an electronic medical system. All the diagnoses were made by qualified dermatologists based on the history, clinical presentations and physical examination. Laboratory workups such as complete blood count, hepatitis B test and syphilis test were performed when indicated. Histological investigation was not available. Information on diagnosis, age, gender and nationality were collected from all outpatients and inpatients. Patients with return visits were counted only once. The diagnoses were categorised according to the International Classification of Diseases (10th version). The Medical Section, Division of Mission Support of UNIFIL approved the study.

Statistical analysis was performed using GraphPad Prism (V.5.0, GraphPad Software). The rate of each condition was reported in percentage proportion. The collected data were further compared with published reports.

Results

A total of 1658 patients were evaluated during the period reviewed, more than half of them were Asian (n=1030, 62%) and details of the nationalities are shown in Table 1. There were 91% men (n=1517) and 9% women (n=141) with the mean age being 32 years (range 20–60 years).

Table 1

Patients grouped by nationality

The detailed range of diagnoses is listed in Table 2. According to the medical records, the majority of the skin lesions occurred after their service in Lebanon. Dermatitis and eczema (n=457, 27%) was the leading category with further breakdown (Table 3). Alopecia areata (AA, n=82, 5%) was the predominate type of skin appendage disorders, followed by acne (n=68, 4%) and folliculitis (n=51, 3%). Papulosquamous disorders included psoriasis (n=34, 2%) and pityriasis rosea (n=25, 1%). Sexually transmitted disease (STD) mainly included condyloma acuminata (n=25, 1%). In terms of disease entity, the top five complaints were tinea pedis (n=211, 13%), lichen simplex chronicus (LSC, n=141, 9%), unspecified dermatitis (n=132, 8%), verruca vulgaris (n=119, 7%) and AA (5%).

Table 2

Frequencies of diagnoses by category

Table 3

Breakdown of dermatitis and eczema

Comparison of diagnosis with published military data is presented in Table 4. Dermatitis and eczematous eruptions represented the leading disease category in troops deployed in the Middle East (Lebanon and Iraq, 27% and 18%, respectively), whereas fungal infection was the most common disorder in tropical regions (Singapore and East Timor, 28% and 23%, respectively). Acne was most frequently seen in male soldiers with a relatively young age (Turkey and Korea, 15.7% and 35.7%, respectively), whereas viral wart was a constant problem (Lebanon, Turkey, Iraq, East Timor and Korea, 8%, 5.7%, 3%, 6% and 4.7%, respectively). The rate of alopecia was remarkably higher in our study (5%) than in other surveys (Iraq, Singapore and Korea, 1%, 0.2% and 0.9%, respectively), but comparable with the Turkish study (5.5%). Pruritus was specified in three studies (Lebanon, Turkey and Iraq, 4%, 0.3% and 2%, respectively).

Table 4

Comparison with data from published reports

Discussion

Dermatitis and eczema was the leading disease category in an international peacekeeping forces serving in Lebanon; specifically, tinea pedis, LSC, unspecified dermatitis, verruca vulgaris and AA were the most common complaints requiring medical attention. The prevalence of LSC, AA and pruritus was remarkably high. An underlying psychological component can contribute to the onset and/or aggravation of these conditions, highlighting the importance of psychological consultation and behavioural intervention.

This study is one of the largest surveys dedicated to dermatological conditions among military personnel, in addition, the 7-year uninterrupted study period allows for evaluation of seasonal conditions such as sunburn and xerosis cutis, which may be missed in short-term investigations. However, the study is limited in several ways. First, a referral bias exists as self-limited, transient or minor conditions may not be referred. Although the actual incidence cannot be determined, this study provides representative data of the spectrum of skin disorder in the military population on active service. Second, the disease pattern may be influenced by a variety of factors such as genetics and climate, which makes direct comparison between published reports difficult. We compared data from studies conducted either with similar environment or with similar ethnic group to identify a possible feature or predisposition. Lastly, we use anamnesis as the data source, so the quality of the data depends on the extent of documentation recorded by different dermatologists.

Similar to previous reports about troops deployed in the Middle East,1 ,4–6 dermatitis and eczematous eruptions represent the primary disease group. In contrast, dermatophytosis was the most common condition in tropical areas such as Vietnam, East Timor and Singapore.1 ,3 ,7 ,9 South-western and South-eastern Asia is equally hot, but the former is much drier. The skin's protective barrier function can be damaged by dryness since the water-holding capacity of the skin drops when the level of humidity decreases in the open-air conditions.10 An impaired skin barrier function is considered to be a basis for the development of dermatitis and eczema, a typical example of this is xerosis cutis. Like our study, this condition was almost exclusively present during winter when the weather was windy and cold.6 ,8 ,11

Superficial fungal infection was especially rampant in tropical areas where high ambient humidity favours the growth of dermatophytes.1 ,7 ,9 Poorly ventilated footwear, occupational activities, limited hygiene facilities, communal bathing and laundering facilities are all contributing factors.12 As this study shows, tinea pedis appeared to be the most prevalent complaint from soldiers.7 ,11 ,13 A clinical point prevalence of 60.1% and a mycological point prevalence of 27.3% were reported in Israeli soldiers.13 The setting of the military training, male gender and the period of military service were risk factors for tinea pedis.12–14

The second most common disease was LSC, which was not specified in prior reports; its old terminology neurodermatitis may make it simply referred to as dermatitis. LSC is one of the so-called mystery rashes which may require evacuations,5 which implies underdiagnosis at primary care level. Emotional tensions in susceptible subjects may play a key role in the initiation and persistence of LSC lesions by inducing a pruritic sensation, leading to scratching that can become self-perpetuating.15 People with greater a tendency to pain avoidance, greater dependency on other peoples’ desires and more conforming and dutiful were more prone to have LSC.16 These traits are not uncommon in armed forces because strict discipline and rigid hierarchy are distinguishing characteristics of army life.17

Besides this study, a high prevalence of AA was noted in a Turkish study.11 It showed a significantly higher rate of AA in a military group compared with their civilian counterparts.11 AA has been considered as a psychodermatological disorder.18 Stressful life events in the 6 months before onset and psychiatric disorders such as anxiety, personality disorders, depression and paranoid disorders are associated with AA.19–21 It should be noted that peacekeeping missions are not always peaceful; predeployment anxiety, environmental adaptation, homesickness and witnessing injuries or death are common stressors.22 ,23 Separation from family and friends, sorting out problems at home, risk of vehicle accidents, health concerns and behaviour of others were reported by more than half of peacekeepers deployed to Bougainville and East Timor.24 A recent study reported that 24% of the military personnel with AA were referred to a psychiatry clinic and 16% of them were initiated on antidepressant treatment.11

Some conditions may improve or be less likely to occur if appropriate measures are taken. For example, emollient is an easy and effective solution for dry and eczematous skin. Enforcement of hand hygiene, the addition of small quantities of disinfection agents in water, check of feet for signs of mechanical injury are essential preventative measures against infectious diseases, especially tinea pedis and verruca vulgaris.

For patients with psychodermatological disorders, doctors should try to identify the potential psychological component in a given case as without this broader perspective, the vicious cycle cannot be broken. Effective management involves an integral approach more than medication. Talking about the problem in plain language, communicating in a reassuring way, conducting behavioural intervention, addressing negative emotions and scheduling follow-up are practical strategies. Early recognition and prompt attention may avoid serious consequences. Referral to a specialist or evacuation should be initiated when necessary. It is noteworthy that STDs are another source of emotional distress. Anogenital warts, which was the primary reason for this type of visit in this and the Iraqi study,6 negatively influenced the quality of life in Dutch soldiers causing shame, frustration and even depression.25

Conclusions

Military personnel either deployed abroad or training domestically are subject to a variety of skin diseases due to environmental and occupational factors. Certain skin condition can be a visible manifestation of a mental problem. In addition to conventional therapy, psychological consultation and behavioural intervention are necessary for patient with psychodermatological disorders.

Acknowledgments

The authors would like to thank Major Yang Li from the Medical Section, Division of Mission Support of UNIFIL for assistance in gaining permission to access the data.

Reference

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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