Psoriatic disease, biologic treatment can disqualify many from military service

Psoriasis and psoriatic arthritis remain medically disqualifying conditions for entrance into the U.S. military, and many treatments for psoriatic disease could inhibit those who are enlisted from continuing to serve.

Therefore, anyone looking to enlist, as well as the dermatologists and rheumatologists who treat them, should take this into consideration when determining treatment options.

The Department of Defense’s Medical Standards for Appointment, Enlistment, or Induction into the Military Services lists “history of psoriasis excluding non-recurrent childhood guttate psoriasis” under skin and soft tissue conditions that preclude an individual from service.

“There are many skin conditions and other medical conditions that can severely affect someone’s ability to deploy, join the military or stay in the military, and psoriatic disease is one of them,” U.S. Air Force Lt. Col. Justin P. Bandino, MD, associate professor and program director for the SAUSHEC dermatology residency program in San Antonio and president of the Association of Military Dermatologists, said. “Entry standards are required to be quite stringent.”

Risks in the field

The reasons behind these standards vary but ultimately come down to cost and safety.

Millions of dollars are spent to train service members in a variety of capacities, and if that person can no longer complete their duty, those funds have been wasted. But safety is an even bigger concern.

“We don’t want to waste millions of taxpayer dollars, but it’s also based on the concern for that individual’s life and the lives of others,” Bandino said.

While psoriasis or psoriatic arthritis could be mild, ultimately not having a great effect on any individual, there is always a chance that the condition could disrupt deployment missions, leaving a hole in the team and putting both the individual affected and the rest of the company at risk.

“When you’re deployed, you’re often in very austere environments,” Navy CDR Josephine C. Nguyen, MD, MHCDS, department head of dermatology at Naval Hospital Bremerton in Washington and 2020-2021 Department of Health and Human Services White House Fellow, said. “Those conditions, as well as stress, are known triggers to psoriasis, as is wearing heavy gear that can irritate the skin.”

Psoriasis can often be completely controlled in a regular environment, but the physical and emotional stress of deployment can cause dangerous flare-ups.

Many deployment environments include hot climates, which can be extremely arid or humid. Service members are also often in full tactical gear, including heavy helmets and protective garments that can irritate the skin and cause a flare-up of psoriasis symptoms.

A 2015 study published in Military Medicine found soldiers with psoriasis, which made up 2.1% of military dermatologic cases, had a high likelihood of being evacuated from theater.

“If someone gets an exacerbation of their psoriasis and they can’t do their job, that results in a gap of having a really critical member on a mission,” Nguyen said.

“Any loss of personnel in a deployed environment is a risk to all members of that unit,” LTC Sunghun Cho, MD, dermatology consultant to the Army Surgeon General and assistant professor, department of dermatology, Uniformed Services University of the Health Sciences in Maryland, said. “If a service member gets medevaced out, that’s something that’s fairly significant not just in terms of cost, but you’re leaving a hole in that person’s unit.”

Retention standards

While a diagnosis of psoriatic disease can render an individual ineligible for entrance into the service, a diagnosis later in their career can also have an impact, albeit not necessarily one as severe.

According to DoD retention standards, a service member can be disqualified for future service if they have psoriasis or parapsoriasis that is uncontrolled or requires immunomodulating or immunosuppressant medication or light therapy, or if they have psoriatic arthritis.

“The medical board or physical evaluation board will determine if you’re still capable of performing your duty,” U.S. Air Force Reserve Col. Chad M. Hivnor, MD, chief of dermatology at South Texas Veterans Health Care System and clinical associate professor at Uniformed Services University of the Health Sciences, said. “Trends vary, but right now we want a lean, mean fighting force where everyone can deploy at any point in time. Having anyone who is still active duty that cannot deploy takes away the overall efficacy of the fighting force in general.”

Retention standards are generally less strict than entrance standards, and service members will undergo evaluations of their condition to determine if they are able to complete their job, if they need to be moved to a different duty or if they are no longer able to serve.

“Nowadays with psoriasis, many members who are well controlled are still allowed to stay in the military,” Bandino said. “For us as dermatologists, we play a role in this. We are evaluating patients and providing input to the medical evaluation board.”

Treatment’s effect on service

Those with psoriasis or psoriatic arthritis, along with the dermatologists and rheumatologists who treat them, should understand how treatment options can affect their ability.

“When looking at medical conditions in the military, there are two goals: to make sure a patient is appropriately treated and to make sure we can fulfill military missions,” U.S. Air Force Lt. Col. Emily B. Wong, MD, dermatology consultant to the Air Force Surgeon General and associate professor at Uniformed Services University of the Health Sciences, said. “It can be very challenging if someone has psoriasis that is more than mild and needs systemic treatment.”

A 2016 article published in Cutis described pros and cons of multiple psoriasis treatments for military service members, concluding that any systemic treatment should be monitored closely and that military dermatologists should choose treatments that allow their patients to continue carrying out their missions.

Methotrexate, often cited as the gold standard of psoriasis care, is “easy to store, transport and administer,” according to the study authors. However, quarterly lab monitoring makes it a less desirable option. Similar concerns arise for cyclosporine, which can only be used for a limited time and also requires quarterly lab monitoring and monthly blood pressure checks.

Biologic treatments, which are extremely effective, can be a hinderance to those in the field. They require refrigeration and regular injections, which are usually not available in deployment settings.

In addition to the physical requirements for storage, biologics are immunosuppressant medications, which can put the service member at risk for further complications.

“These are things that we consider as nondeployable,” Nguyen said. “If they need to be on biologics, it creates an extra burden and limits their readiness to go immediately on deployment.”

Apremilast, an oral medication that is easier to store and does not require lab monitoring, is a good option but can be less efficacious than other treatment options.

“It can control psoriasis well, and military members can take it when deployed, so it’s great to have that and keep it in our back pocket as military dermatologists,” Bandino said.

Clinician awareness

For clinicians who treat patients with psoriasis or psoriatic arthritis who are looking to enlist or remain in the military, these treatment options should be carefully evaluated before decisions are made.

“We physicians want civilian dermatologists to be aware that active-duty members, when they’re considering treatment options, should not automatically go to biologics because it affects their ability to deploy. They should think about the whole arsenal of medications,” Nguyen said.

“Many dermatologists move patients onto biologics when they do not respond well to topicals or light therapy,” Cho said. “If you’re considering someone for military service, then apremilast might a good medication to try before biologics as it is not disqualifying for service.”

Both patients and clinicians should be aware of the process and enlistment standards as well, according to Bandino.

While psoriasis is a medically disqualifying condition, waivers can be obtained, and those treating patients who want to enter the military should be knowledgeable about that process.

“These standards exist, and it can be frustrating for civilian dermatologists,” Bandino said. “It’s good to understand the process can be bureaucratic and slow in terms of evaluations and pursuing waivers, but they are out there.”

Future developments

The ability for patients with psoriasis to serve in the military more readily in the future will be determined by medical advancements that allow for those individuals to be symptom free for longer periods of time with fewer caveats to treatment.

“We need a medication that’s as effective as the biologics but doesn’t suppress the immune system and doesn’t require refrigeration or monitoring every few months,” Nguyen said.

As developments continue in the field, a medication that does not require constant refrigeration will be paramount.

“There have been a lot of new developments in the treatment of psoriasis recently and I’m hopeful that this will continue. It would be ideal if we can find a medication even more specific for psoriasis that is not a systemic immunosuppressant,” Cho said.

The safety of every service member is ultimately what is most important and the reason for such medical disqualifications.

“In the big picture, when people are in the fight, they’ve got to be on,” Hivnor said. “You have to be on your game at all times, and you can’t be distracted. At the end of the day, we all have to realize there are certain restrictions to serve in the military, and that’s not to be mean. It’s to save the efficacy and effectiveness of what we do.”

References:

DOD Instruction 6130.03. Medical Standards for the Appointment, Enlistment, or Induction into the Military Services.

DOD Instruction 6130.03, Volume 2. Medical Standards for Military Service: Retention.

Evans T, et al. Cutis. 2016;98(6):370-373.

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

For more information:

Justin P. Bandino, MD, can be reached at 59 MDSP/SGMF, 1100 Wilford Hall Loop, Building 4554, JBSA Lackland, TX 78236; email: justin.p.bandino.mil@mail.mil.

Sunghun Cho, MD, can be reached at the Department of Dermatology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814; email: sunghun.cho.mil@mail.mil.

Chad M. Hivnor, MD, FAAD, can be reached at 59 MDSP/SGMF, 1100 Wilford Hall Loop, Building 4554, JBSA Lackland, TX 78236; email: chad.hivnor@va.gov.

Josephine C. Nguyen, MD, MHCDS, can be reached at email: jonguyen99@gmail.com.

Emily B. Wong, MD, can be reached at 59 MDSP/SGMF, 1100 Wilford Hall Loop, Building 4554, JBSA Lackland, TX 78236; email: emily.b.wong.mil@mail.mil.