Treatment advancements merit updates to dermatological disqualifiers in the military
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Key takeaways:
- Currently, psoriasis and atopic dermatitis are disqualifiers for military entry and barriers for retention.
- Advancements in biologics and immunomodulators may bring pause to these restrictions.
Due to medical advancements, researchers are calling for an update to the U.S. Department of Defense’s policies restricting individuals with psoriasis and atopic dermatitis from joining and remaining in the military, according to a study.
Psoriasis and AD are chronic dermatologic diseases that are currently disqualifying for entrance into the U.S. military.
“When not adequately controlled, these conditions can flare - especially in stressful environments like in the deployment setting or with wear of equipment such as body armor or combat helmet,” 2nd Lt. Samantha Williamson, MSC, a student at F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences and one of the study’s investigators, told Healio. “Additionally, it can really impact their ability to do their job which in turn may negatively impact their unit’s ability to successfully fulfill a mission.”
Because of these complications, the U.S. Department of Defense’s (DoD’s) policy states that individuals with any history of psoriasis or those who have had eczema in the last 36 months that cannot be controlled by over-the-counter corticosteroid creams or moisturizers cannot enter the military.
“Flares that cannot be controlled with topical steroids can become at risk for infection, which is at the very least uncomfortable for the service member,” Williamson added. “It’s also very expensive to medevac someone or move someone because their condition isn’t able to be controlled in that environment.”
According to the DoD’s policy, individuals that develop psoriasis or atopic dermatitis after joining the military may be deemed non-deployable if they cannot wear the required gear or perform tasks without their disease flaring. If these members require immunomodulators or biologics to control their disease, they must undergo a medical evaluation to determine their fitness for duty.
According to the study authors, this has presented challenges for both recruitment and retention of military personnel.
“Eczema is on the rise among the general population and dermatologic issues are one of the primary recruitment limitations,” MAJ Alexandra Rosenberg, MD, MPhil, a dermatologist at the William Beaumont Army Medical Center, told Healio. “And as far as retention goes, becoming non-deployable for a lot of service members essentially is a career-ending situation.”
“Recruitment numbers are declining,” ESN Alexius Russell, MSC, a student at F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, added. “In this study, we are encouraging the military to take a second look at some of these newer biologics and immunomodulators and evaluate their potential use. They have specific targets, do not necessarily make individuals immunosuppressed in a significant way, and can keep their dermatological condition at a point where they can still continue their career in the military.”
Psoriasis
According to the study, the current medical insurance for active-duty military is Tricare and the preferred biologic for the treatment of psoriasis that is covered by Tricare is adalimumab. The authors describe that while adalimumab is standard of care, many advances have been made since its debut in 2008.
As a result, the two medications that the researchers recommend for military personnel with psoriasis are risankizumab (Skyrizi, AbbVie) and deucravacitinib (Sotyktu, Bristol Myers Squibb).
According to a meta-analysis referenced by the authors that compared all the biologics used to treat plaque psoriasis, risankizumab proved to be the most effective in the short- and long-term. With a 12-week dosing interval and an ability to maintain control of disease for up to 36 weeks, risankizumab’s long-interval dosing schedule can be advantageous for military personnel on deployment.
Risankizumab, like all biologics, must be refrigerated which could potentially pose a problem for service members. However, the authors state that, for the most part, this could be accommodated.
“I can’t speak for the entirety of the military, but in my experience as a deployed provider, there are cold supply chains in place - to store vaccines for examples - even at smaller medical facilities such as a battalion aid station,” COL Sunghun Cho, MD, vice chair of education at the Department of Dermatology in the Uniformed Services University of the Health Sciences, told Healio. “For those in more remote locations, if there’s an opportunity for them to get the medication even on an intermittent basis, I think it could work out.”
As far as deucravacitinib goes, the authors recommend that it be made a first-line oral option, especially for those on deployment, as it is safer and more effective than adalimumab.
“While not quite as efficacious as risankizumab, it is certainly more convenient and still more effective than adalimumab, which is the standard of care,” Cho added.
Atopic dermatitis
The authors recommend dupilumab as the preferred systemic treatment for AD. According to the study, dupilumab is the best option for military members with AD in both the garrison and deployment settings because it offers a convenient subcutaneous injection route of administration that can be spaced out.
“Dupilumab is supposed to be administered every 2 weeks,” Rosenberg said, “but there is evidence that it can be efficacious for actually significantly longer than that.”
Dupilumab has also demonstrated a favorable safety profile which minimizes the risk for adverse events in military members during deployment.
Hope for the future
As the dermatology field continues to advance, the authors hope that the DoD will reevaluate guidelines to accommodate those who want to serve their country and those who are currently serving with psoriasis and eczema.
“We are seeing biologics and immunomodulators as more standard treatments for tough diseases in the civilian population and they’re quite effective,” Cho said. “So, why not entertain these for our military personnel as well?”
“We are often undertreating service members because they want to maintain their military career,” Rosenberg added. “So, being able to adequately treat service members with these medications and not have it be career ending would be a great advance.”