‘Serve those who have served us’: Veterans suffer dermatologic health disparities

Key takeaways:

• Veterans are more likely to have skin cancer and psoriasis than nonveterans.
• U.S. Veterans Affairs has shown to offer premium dermatology care to veterans with shorter wait times than the private sector.

Veterans continue to experience worse health outcomes than the general population.

“There are some environmental exposures that may trigger dermatological disease — agent orange exposure is associated with acne, burn pit exposure with increased risk for head and neck cancer and sun exposure with skin cancer,” Robert Dellavalle, MD, PhD, MSPH, professor and chair of dermatology at University of Minnesota Medical School and dermatology national executive program director for the U.S. Department of Veterans Affairs (VA), told Healio.

These health disparities among veterans persist despite group characteristics as well.

“Veterans are more likely than civilians to report a history of skin cancer as well as psoriasis, even after adjustment for demographic factors,” Rebecca I. Hartman, MD, MPH, FAAD, assistant professor of dermatology at Harvard Medical School and chief of the dermatology section at VA Boston Healthcare System, said in an interview.

While veterans are at risk for the diseases Dellavalle and Hartman listed, among others, it’s skin cancer that has prevailed as the predominate threat to this population.

Skin cancer

According to the American Cancer Society, skin cancer is the most commonly diagnosed cancer in the U.S., with invasive melanoma being the deadliest form. Although it only accounts for 1% of cases in the American population, invasive melanoma cases and deaths are expected to climb to 100,640 this year.

Men who are aged 50 years or older have a higher rate of invasive melanoma vs. women in the same age group, according to the American Academy of Dermatology Association. The academy posits that this may be caused by higher exposure to ultraviolet radiation, due to historically male-oriented recreational activities and occupations — one of which is enrollment in the military.

“Veterans face unique occupational exposures, including ultraviolet radiation, ionizing radiation from flight and chemical exposures that may increase their risk of skin cancer,” Hartman explained.

In a 2024 study published in JAMA Dermatology, Rezaei et al found that veterans are 1.72 times and 2.27 times more likely to have a history of skin cancer and melanoma, respectively, compared with nonveterans.

Also, in a press release from the AAD, researchers found that soldiers stationed in countries located near the equator, where the UV levels are higher, are at a higher risk for sunburn which can lead to skin cancer down the road. These researchers further found that Iraq War veterans infrequently used sun protection despite 75% of them working outside more than 6 hours a day. On top of that, 40% of the veterans stated they were unaware of the risks for skin cancer or how to implement sun protection measures.

According to a 2021 study conducted by the U.S. AirForce, fighter pilots and those who work around fighter jets are 24% more likely to be diagnosed with melanoma than their non-flying peers due to their exposure to ionizing radiation from flying at high altitudes. They are also 25% more likely to be diagnosed with melanoma compared with civilians.

“Additionally, our own research has found that veterans are more likely to be diagnosed with advanced melanoma than civilians,” Hartman said, referring to her 2022 study, published in the Journal of the American Academy of Dermatology, which found that veterans were 17.5% more likely to present with stage 3 melanoma and 13% more likely to receive an initial diagnosis of stage 4 compared with civilians.

Other diseases

While skin cancer dominates the health disparities experienced by veterans, other dermatological conditions affect this population as well.

According to the study by Rezaei et al, veterans also had a higher prevalence of psoriasis diagnoses vs. nonveterans (4.5% vs. 2.9%; P = .002). They were also faced with significantly higher odds of receiving a psoriasis diagnosis compared with nonveterans (OR = 1.61; 95% CI, 1.05-2.46).

Another study published in 2013 in the World Journal of Clinical Cases by Chong found that the top five skin diseases among veterans were fungal infections, eczema/dermatitis, insect bite reactions, bacterial infections and acne, most of which can be traced to working conditions such as environmental extremes (ie, humidity and heat), heavy uniforms, increased rates of sweating, exposure to irritants such as face camouflage, stress and other factors.

Diagnoses such as psoriasis or eczema can deem a service member non-deployable if they cannot wear the required gear or perform tasks without their disease flaring, according to Department of Defense policy as published by Russell et al in Military Medicine in 2024. As a result, military members may hide their disease in an effort to keep their careers, which may ultimately exacerbate their condition as they enter veteran status.

Treatment and service options

When it comes to treating skin cancer in veterans, prevention is always the optimal approach.

“It is important for clinicians to be aware that veterans face increased risk of skin cancer, and sun protection should be encouraged in this high-risk population,” Hartman said.

In the event that a veteran does have skin cancer, or any other skin condition, the VA is the best resource for appointments, treatments and individualized care.

In fact, a 2019 JAMA Network Open study by Penn et al found that the wait time for a VA appointment was, on average, 12 days shorter than for a private sector appointment (P < .001), with dermatology being named as one of the specialties with the shortest wait times in the VA (mean, 15.6 vs. 32.6 days; P < .001).

“The VA has been shown to provide the highest quality care for veterans, so I recommend veterans choose the VA for their care, when possible,” Dellavalle told Healio.

According to Dellavalle, the VA has been purposing to increase its dermatology offerings to veterans with the VA implementing teledermatology appointments to cater to rural veterans.

“Almost 90% of VA clinics have some access to dermatology services either on site or via teledermatology,” he said. “Physician assistants, nurse practitioners and information and communication technologies are also being used to increase access to dermatology services in the VA.”

According to Hartman, the VA formulary can also prescribe sunscreen to veterans — a fact that may be worth mentioning to veterans who may be unaware.

While veterans appear to be well served by the dermatology community, more work can always be done to mitigate the occupational threat of skin cancer for this population.

“Additional veteran-specific studies are needed to understand risk factors in this population and to create optimal targeted prevention and treatment strategies,” Hartman said. “That way, we can better serve those who have served us.”

Reference:

• Cancer Facts & Figures 2024. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2024/2024-cancer-facts-and-figures-acs.pdf. Published 2024. Accessed Nov. 26, 2024.
• Cancers Strike US Fighter Pilots, Crews at Higher Rates, Air Force Finds. https://www.defenseone.com/threats/2021/10/cancers-strike-us-fighter-pilots-crews-higher-rates-air-force-finds/186324/. Updated Oct. 24, 2021. Accessed Dec. 3, 2024.
• Chang MS. J Am Acad Dermatol. 2022;doi:10.1016/j.jaad.2022.02.063.
• Chong WS. World J Clin Cases. 2013;doi:10.12998/wjcc.v1.i7.208.
• Military members more at risk for melanoma. https://www.aad.org/news/military-more-risk-melanoma. Published March 8, 2024. Accessed Dec. 3, 2024.
• Penn M, et al. JAMA Netw Open. 2019; doi:10.1001/jamanetworkopen.2018.7096.
• Rezaei SJ, et al. JAMA Dermatol. 2024;doi:10.1001/jamadermatol.2024.3043.
• Russell A, et al. Mil Med. 2024;doi:10.1093/milmed/usae139.
• Skin Cancer. https://www.aad.org/media/stats-skin-cancer. Accessed Dec. 3, 2024.