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