Civilian dermatologists need to be aware of psoriasis’ effect on military eligibility

Jack is a 24-year-old patient with psoriasis you are meeting for the first time.

He has had psoriasis for 2 years with plaques on his elbows, dorsal hands and scalp, involving about 3% of his body surface area. He has tried and failed numerous topical medications and is frustrated. He mentions that his psoriasis developed a few years after he enlisted in the Army and that he remains on active duty. He is getting married soon and would love to be clear for his wedding as his fiancée wants pictures of them holding hands and she does not want his patches showing.

According to the International Psoriasis Council (full disclosure, I am on its board of directors), he is a candidate for systemic treatment as he has failed topical therapy. You have a sample of an IL-23 biologic and explain to Jack that you recommend it for him, it is highly effective and safe, and it requires infrequent dosing, and some patients even experience remission. There is one side effect that you forget to mention: It might jeopardize his career in the military. Wait, what?

In this issue of Healio Psoriatic Disease, we focus on the impact of psoriasis on military service, planned to coincide with Memorial Day as a way to honor those who have died in the performance of their military duties while serving in the United States Armed Forces. Our goal is to educate the civilian dermatology community about the implications psoriasis has for U.S. military service.

Psoriasis and psoriatic arthritis are medically disqualifying conditions for entrance into the U.S. military. Therefore, when delivering patient care, it is important to know the whole patient, including their ambitions and their work, particularly given the implications of psoriasis on future or current military service. The 15-year-old adolescent girl from a family with a history of distinguished military service with new-onset mild plaque psoriasis may be devastated by such a diagnosis. Similarly, an active-duty member, like Jack, who develops psoriasis while in the military needs to think carefully about treatment options as many treatments for psoriatic disease that are used routinely, especially biologics, could inhibit those who are enlisted from continuing to serve.

As civilian dermatologists, we need to be aware that our most effective treatments, biologics, may have a serious side effect, rendering an otherwise healthy soldier non-deployable. The military is cautious about the impact of chronic psoriasis as it has a well-documented history of having to airlift service members out of combat zones due to psoriasis flares. One famous story recounts how Rear Adm. William F. “Bull” Halsey, Pacific commander in World War II, was forced to the sidelines because of a severe case of psoriasis during the Battle of Midway. Adm. Raymond Ames Spruance, who had no previous combat experience, took over and engineered a daring victory, ultimately having two Navy vessels named after him.

We owe a debt of gratitude to those who serve in the military, particularly our dermatology colleagues who play a key role in maintaining military readiness. Roughly 20% of military personnel seek medical care for skin conditions while deployed, with psoriasis accounting for 2.1% of consultations. Given the ever-changing geopolitical landscape, along with the rapid evolution of treatments for psoriasis, it is our duty as civilian dermatologists to maintain our awareness of these complex issues so that our decisions do not unnecessarily affect those, like Jack, who bravely volunteer to serve our country in the military.

References:

Gelman AB, et al. Mil Med. 2015;doi:10.7205/MILMED-D-14-00240.

Rasmussen FN. Baltimore-born admiral gained fame in the Battle of Midway. www.baltimoresun.com/news/bs-xpm-2007-06-02-0706020087-story.html. Published June 2, 2007.