Sunghun Cho, MD

Pseudofolliculitis barbae (PFB)(also referred to as razor bumps) is a skin disease of the face and neck caused by shaving and remains prevalent in the US Military. As the sharpened ends of curly hair strands penetrate back into the epidermis, they can trigger inflammatory reactions, leading to papules and pustules as well as hyperpigmentation and scarring.¹ Although anyone with thick curly hair can develop PFB, Black individuals are disproportionately affected, with 45% to 83% reporting PFB symptoms compared with 18% of White individuals.² In this article, we review the treatments and current policies on PFB in the military.

Treatment Options

Shaving Guidelines—Daily shaving remains the grooming standard for US service members who are encouraged to follow prescribed grooming techniques to prevent mild cases of PFB, defined as having “few, scattered papules with scant hair growth of the beard area,” according to the technical bulletin of the US Army, which provides the most detailed guidelines among the branches.³ The bulletin recommends hydrating the face with warm water, followed by a preshave lotion and shaving with a single pass superiorly to inferiorly. Following shaving, postrazor hydration lotion is recommended. Single-bladed razors are preferred, as there is less trauma to existing PFB and less potential for hair retraction under the epidermis, though multibladed razors can be used with adequate preshave and postrazor hydration.⁴ Shaving can be undertaken in the evening to ensure adequate time for preshave preparation and postshave hydration. Waterless shaving uses waterless soaps or lotions containing α-hydroxy acid just prior to shaving in lieu of preshaving and postshaving procedures.⁴

Topical Medications—For PFB cases that are recalcitrant to management by changes in shaving, topical retinoids are commonly prescribed, as they reduce follicular hyperkeratosis that may lead to PFB.⁵ The Army medical bulletin recommends a pea-sized amount of tretinoin cream or gel 0.025%, 0.05%, or 0.1% for moderate cases, defined as “heavier beard growth, more scattered papules, no evidence of pustules or denudation.”³ Adapalene cream 0.1% may be used instead of tretinoin for sensitive skin. Oral doxycycline or topical benzoyl peroxide–clindamycin may be added for secondary bacterial skin infections. Clinical trials have demonstrated that combination benzoyl peroxide–clindamycin significantly reduces papules and pustules in up to 63% of patients with PFB (P<.029).⁶ Azelaic acid can be prescribed for prominent postinflammatory hyperpigmentation. The bulletin also suggests depilatories such as barium sulfide to obtund the hair ends and make them less likely to re-enter the skin surface, though it notes low compliance rates due to strong sulfur odor, messy application, and irritation and reactions to ingredients in the preparations.⁴

Shaving Waivers and Laser Hair Removal—The definitive treatment of PFB is to not shave, and a shaving waiver or laser hair removal (LHR) are the best options for severe PFB or PFB refractory to other treatments. A shaving waiver (or shaving profile) allows for growth of up to 0.25 inches of facial hair with maintenance of the length using clippers. The shaving profile typically is issued by the referring primary care manager (PCM) but also can be recommended by a dermatologist. Each military branch implements different regulations on shaving profiles, which complicates care delivery at joint-service military treatment facilities (MTFs). The Table provides guidelines that govern the management of PFB by the US Army, Air Force, Navy, and Marine Corps. The issuance and duration of shaving waivers vary by service.

Laser hair removal therapy uses high-wavelength lasers that largely bypass the melanocyte-containing basal layer and selectively target hair follicles located deeper in the skin, which results in precise hair reduction with relative sparing of the epidermis.¹⁶ Clinical trials at military clinics have demonstrated that treatments with the 1064-nm long-pulse Nd:YAG laser generally are safe and effective in impeding hair growth in Fitzpatrick skin types IV, V, and VI.¹⁷ This laser, along with the Alexandrite 755-nm long-pulse laser for Fitzpatrick skin types I to III, is widely available and used for LHR at MTFs that house dermatologists. Eflornithine cream 13.9%, which is approved by the US Food and Drug Administration to treat hirsutism, can be used as monotherapy for treatment of PFB and has a synergistic depilatory effect in PFB patients when used in conjunction with LHR.^18,19 Laser hair removal treatments can induce a permanent change in facial hair density and pattern of growth. Side effects and complications of LHR include discomfort during treatment and, in rare instances, blistering and dyspigmentation of the skin as well as paradoxical hair growth.¹⁷

TRICARE, the uniformed health care program, covers LHR in the civilian sector if the following criteria are met: candidates must work in an environment that may require breathing protection, and they must have failed conservative therapy; an MTF dermatologist must evaluate each case and attempt LHR at an MTF to limit outside referrals; and the MTF dermatologist must process each outside referral claim to completion and ensure that the LHR is rendered by a civilian dermatologist and is consistent with branch-specific policies.²⁰

Service Policies on PFB

Army—The Army technical bulletin breaks down the treatment of PFB based on mild, moderate, and severe conditions.³ For mild conditions, a trial of shaving every 2 or 3 days until resolution is recommended. For moderate PFB, topical tretinoin as well as shaving every 2 to 3 days is recommended. For severe conditions, temporary beard growth with issuance of a temporary shaving profile up to 90 days is authorized.³

The technical bulletin also allows a permanent shaving profile for soldiers who demonstrate a severe adverse reaction to treatment or progression of the disease despite a trial of all these methods.³ The regulation stipulates that 0.125 to 0.25 inches of beard growth usually is sufficient to prevent PFB. Patients on profiles must be re-evaluated by a PCM or a dermatologist at least once a year.³

Air Force—Air Force Instruction 44-102 delegates PFB treatment and management strategies to each individual MTF, which allows for decentralized management of PFB, resulting in treatment protocols that can differ from one MTF to another.⁷ Since 2020, waivers have been valid for 5 years regardless of deployment or permanent change of station location. Previously, shaving profiles required annual renewals.⁷ Special duties, such as Honor Guard, Thunderbirds, Special Warfare Mission Support, recruiters, and the Air Force Band, often follow the professional appearance standards more strictly. Until recently, the Honor Guard used to reassign those with long-term medical shaving waivers but now allows airmen with shaving profiles to serve with exceptions (eg, shaving before ceremonies).²¹

Navy—BUPERS (Bureau of Naval Personnel) Instruction 1000.22C divides PFB severity into 2 categories.⁸ For mild to moderate PFB cases, topical tretinoin and adapalene are recommended, along with improved shaving hygiene practices. As an alternative to topical steroids, topical eflornithine monotherapy can be used twice daily for 60 days. For moderate to severe PFB cases, continued grooming modifications and LHR at military clinics with dermatologic services are expected.⁸

Naval administrative memorandum NAVADMIN 064/22 (released in 2022) no longer requires sailors with a shaving “chit,” or shaving waiver, to fully grow out their beards.⁹ Sailors may now outline or edge their beards as long as doing so does not trigger a skin irritation or outbreak. Furthermore, sailors are no longer required to carry a physical copy of their shaving chit at all times. Laser hair removal for sailors with PFB is now considered optional, whereas sailors with severe PFB were previously expected to receive LHR.⁹

Marine Corps—The Marine Corps endorses a 4-phase treatment algorithm (Table). As of January 2022, permanent shaving chits are authorized. Marines no longer need to carry physical copies of their chits at all times and cannot be separated from service because of PFB.¹⁰ New updates explicitly state that medical officers, not the commanding officers, now have final authority for granting shaving chits.¹¹

Final Thoughts

The Army provides the most detailed bulletin, which defines the clinical features and treatments expected for each stage of PFB. All 4 service branches permit temporary profiles, albeit for different lengths of time. However, only the Army and the Marine Corps currently authorize permanent shaving waivers if all treatments mentioned in their respective bulletins have failed.

The Air Force has adopted the most decentralized approach, in which each MTF is responsible for implementing its own treatment protocols and definitions. Air Force regulations now authorize a 5-year shaving profile for medical reasons, including PFB. The Air Force also has spearheaded efforts to create more inclusive policies. A study of 10,000 active-duty male Air Force members conducted by Air Force physicians found that shaving waivers were associated with longer times to promotion. Although self-identified race was not independently linked to longer promotion times, more Black service members were affected because of a higher prevalence of PFB and shaving profiles.²²

The Navy has outlined the most specific timeline for therapy for PFB. The regulations allow a 60-day temporary shaving chit that expires on the day of the appointment with the dermatologist or PCM. Although sailors were previously mandated to fully grow out their beards without modifications during the 60-day shaving chit period, Navy leadership recently overturned these requirements. However, permanent shaving chits are still not authorized in the Navy.

Service members are trying to destigmatize shaving profiles and facial hair in our military. A Facebook group called DoD Beard Action Initiative has more than 17,000 members and was created in 2021 to compile testimonies and data regarding the effects of PFB on airmen.²³ Soldiers also have petitioned for growing beards in the garrison environment with more than 100,000 signatures, citing that North Atlantic Treaty Organization allied nations permit beard growth in their respective ranks.²⁴ A Sikh marine captain recently won a lawsuit against the US Department of the Navy to maintain a beard with a turban in uniform on religious grounds.²⁵

The clean-shaven look remains standard across the military, not only for uniformity of appearance but also for safety concerns. The Naval Safety Center’s ALSAFE report concluded that any facial hair impedes a tight fit of gas masks, which can be lethal in chemical warfare. However, the report did not explore how different hair lengths would affect the seal of gas masks.²⁶ It remains unknown how 0.25 inch of facial hair, the maximum hair length authorized for most PFB patients, affects the seal. Department of Defense occupational health researchers currently are assessing how each specific facial hair length diminishes the effectiveness of gas masks.²⁷

Furthermore, the COVID-19 pandemic has led to frequent N95 respirator wear in the military. It is likely that growing a long beard disrupts the fitting of N95 respirators and could endanger service members, especially in clinical settings. However, one study confirmed that 0.125 inch of facial hair still results in 98% effectiveness in filtering particles for the respirator wearers.²⁸ Although unverified, it is surmisable that 0.25 inch of facial hair will likely not render all respirators useless. However, current Occupational Safety and Health Administration guidelines require fit tests to be conducted only on clean-shaven faces.²⁹ Effectively, service members with facial hair cannot be fit-tested for N95 respirators.

More research is needed to optimize treatment protocols and regulations for PFB in our military. As long as the current grooming standards remain in place, treatment of PFB will be a controversial topic. Guidelines will need to be continuously updated to balance the needs of our service members and to minimize risk to unit safety and mission success. Department of Defense Instruction 6130.03, Volume 1, revised in late 2022, now no longer designates PFB as a condition that disqualifies a candidate from entering service in any military branch.³⁰ The Department of Defense is demonstrating active research and adoption of policies regarding PFB that will benefit our service members.

Pseudofolliculitis barbae (PFB)(also referred to as razor bumps) is a skin disease of the face and neck caused by shaving and remains prevalent in the US Military. As the sharpened ends of curly hair strands penetrate back into the epidermis, they can trigger inflammatory reactions, leading to papules and pustules as well as hyperpigmentation and scarring.¹ Although anyone with thick curly hair can develop PFB, Black individuals are disproportionately affected, with 45% to 83% reporting PFB symptoms compared with 18% of White individuals.² In this article, we review the treatments and current policies on PFB in the military.

Treatment Options

Shaving Guidelines—Daily shaving remains the grooming standard for US service members who are encouraged to follow prescribed grooming techniques to prevent mild cases of PFB, defined as having “few, scattered papules with scant hair growth of the beard area,” according to the technical bulletin of the US Army, which provides the most detailed guidelines among the branches.³ The bulletin recommends hydrating the face with warm water, followed by a preshave lotion and shaving with a single pass superiorly to inferiorly. Following shaving, postrazor hydration lotion is recommended. Single-bladed razors are preferred, as there is less trauma to existing PFB and less potential for hair retraction under the epidermis, though multibladed razors can be used with adequate preshave and postrazor hydration.⁴ Shaving can be undertaken in the evening to ensure adequate time for preshave preparation and postshave hydration. Waterless shaving uses waterless soaps or lotions containing α-hydroxy acid just prior to shaving in lieu of preshaving and postshaving procedures.⁴

Topical Medications—For PFB cases that are recalcitrant to management by changes in shaving, topical retinoids are commonly prescribed, as they reduce follicular hyperkeratosis that may lead to PFB.⁵ The Army medical bulletin recommends a pea-sized amount of tretinoin cream or gel 0.025%, 0.05%, or 0.1% for moderate cases, defined as “heavier beard growth, more scattered papules, no evidence of pustules or denudation.”³ Adapalene cream 0.1% may be used instead of tretinoin for sensitive skin. Oral doxycycline or topical benzoyl peroxide–clindamycin may be added for secondary bacterial skin infections. Clinical trials have demonstrated that combination benzoyl peroxide–clindamycin significantly reduces papules and pustules in up to 63% of patients with PFB (P<.029).⁶ Azelaic acid can be prescribed for prominent postinflammatory hyperpigmentation. The bulletin also suggests depilatories such as barium sulfide to obtund the hair ends and make them less likely to re-enter the skin surface, though it notes low compliance rates due to strong sulfur odor, messy application, and irritation and reactions to ingredients in the preparations.⁴

Shaving Waivers and Laser Hair Removal—The definitive treatment of PFB is to not shave, and a shaving waiver or laser hair removal (LHR) are the best options for severe PFB or PFB refractory to other treatments. A shaving waiver (or shaving profile) allows for growth of up to 0.25 inches of facial hair with maintenance of the length using clippers. The shaving profile typically is issued by the referring primary care manager (PCM) but also can be recommended by a dermatologist. Each military branch implements different regulations on shaving profiles, which complicates care delivery at joint-service military treatment facilities (MTFs). The Table provides guidelines that govern the management of PFB by the US Army, Air Force, Navy, and Marine Corps. The issuance and duration of shaving waivers vary by service.

Laser hair removal therapy uses high-wavelength lasers that largely bypass the melanocyte-containing basal layer and selectively target hair follicles located deeper in the skin, which results in precise hair reduction with relative sparing of the epidermis.¹⁶ Clinical trials at military clinics have demonstrated that treatments with the 1064-nm long-pulse Nd:YAG laser generally are safe and effective in impeding hair growth in Fitzpatrick skin types IV, V, and VI.¹⁷ This laser, along with the Alexandrite 755-nm long-pulse laser for Fitzpatrick skin types I to III, is widely available and used for LHR at MTFs that house dermatologists. Eflornithine cream 13.9%, which is approved by the US Food and Drug Administration to treat hirsutism, can be used as monotherapy for treatment of PFB and has a synergistic depilatory effect in PFB patients when used in conjunction with LHR.^18,19 Laser hair removal treatments can induce a permanent change in facial hair density and pattern of growth. Side effects and complications of LHR include discomfort during treatment and, in rare instances, blistering and dyspigmentation of the skin as well as paradoxical hair growth.¹⁷

TRICARE, the uniformed health care program, covers LHR in the civilian sector if the following criteria are met: candidates must work in an environment that may require breathing protection, and they must have failed conservative therapy; an MTF dermatologist must evaluate each case and attempt LHR at an MTF to limit outside referrals; and the MTF dermatologist must process each outside referral claim to completion and ensure that the LHR is rendered by a civilian dermatologist and is consistent with branch-specific policies.²⁰

Service Policies on PFB

Army—The Army technical bulletin breaks down the treatment of PFB based on mild, moderate, and severe conditions.³ For mild conditions, a trial of shaving every 2 or 3 days until resolution is recommended. For moderate PFB, topical tretinoin as well as shaving every 2 to 3 days is recommended. For severe conditions, temporary beard growth with issuance of a temporary shaving profile up to 90 days is authorized.³

The technical bulletin also allows a permanent shaving profile for soldiers who demonstrate a severe adverse reaction to treatment or progression of the disease despite a trial of all these methods.³ The regulation stipulates that 0.125 to 0.25 inches of beard growth usually is sufficient to prevent PFB. Patients on profiles must be re-evaluated by a PCM or a dermatologist at least once a year.³

Air Force—Air Force Instruction 44-102 delegates PFB treatment and management strategies to each individual MTF, which allows for decentralized management of PFB, resulting in treatment protocols that can differ from one MTF to another.⁷ Since 2020, waivers have been valid for 5 years regardless of deployment or permanent change of station location. Previously, shaving profiles required annual renewals.⁷ Special duties, such as Honor Guard, Thunderbirds, Special Warfare Mission Support, recruiters, and the Air Force Band, often follow the professional appearance standards more strictly. Until recently, the Honor Guard used to reassign those with long-term medical shaving waivers but now allows airmen with shaving profiles to serve with exceptions (eg, shaving before ceremonies).²¹

Navy—BUPERS (Bureau of Naval Personnel) Instruction 1000.22C divides PFB severity into 2 categories.⁸ For mild to moderate PFB cases, topical tretinoin and adapalene are recommended, along with improved shaving hygiene practices. As an alternative to topical steroids, topical eflornithine monotherapy can be used twice daily for 60 days. For moderate to severe PFB cases, continued grooming modifications and LHR at military clinics with dermatologic services are expected.⁸

Naval administrative memorandum NAVADMIN 064/22 (released in 2022) no longer requires sailors with a shaving “chit,” or shaving waiver, to fully grow out their beards.⁹ Sailors may now outline or edge their beards as long as doing so does not trigger a skin irritation or outbreak. Furthermore, sailors are no longer required to carry a physical copy of their shaving chit at all times. Laser hair removal for sailors with PFB is now considered optional, whereas sailors with severe PFB were previously expected to receive LHR.⁹

Marine Corps—The Marine Corps endorses a 4-phase treatment algorithm (Table). As of January 2022, permanent shaving chits are authorized. Marines no longer need to carry physical copies of their chits at all times and cannot be separated from service because of PFB.¹⁰ New updates explicitly state that medical officers, not the commanding officers, now have final authority for granting shaving chits.¹¹

Final Thoughts

The Army provides the most detailed bulletin, which defines the clinical features and treatments expected for each stage of PFB. All 4 service branches permit temporary profiles, albeit for different lengths of time. However, only the Army and the Marine Corps currently authorize permanent shaving waivers if all treatments mentioned in their respective bulletins have failed.

The Air Force has adopted the most decentralized approach, in which each MTF is responsible for implementing its own treatment protocols and definitions. Air Force regulations now authorize a 5-year shaving profile for medical reasons, including PFB. The Air Force also has spearheaded efforts to create more inclusive policies. A study of 10,000 active-duty male Air Force members conducted by Air Force physicians found that shaving waivers were associated with longer times to promotion. Although self-identified race was not independently linked to longer promotion times, more Black service members were affected because of a higher prevalence of PFB and shaving profiles.²²

The Navy has outlined the most specific timeline for therapy for PFB. The regulations allow a 60-day temporary shaving chit that expires on the day of the appointment with the dermatologist or PCM. Although sailors were previously mandated to fully grow out their beards without modifications during the 60-day shaving chit period, Navy leadership recently overturned these requirements. However, permanent shaving chits are still not authorized in the Navy.

Service members are trying to destigmatize shaving profiles and facial hair in our military. A Facebook group called DoD Beard Action Initiative has more than 17,000 members and was created in 2021 to compile testimonies and data regarding the effects of PFB on airmen.²³ Soldiers also have petitioned for growing beards in the garrison environment with more than 100,000 signatures, citing that North Atlantic Treaty Organization allied nations permit beard growth in their respective ranks.²⁴ A Sikh marine captain recently won a lawsuit against the US Department of the Navy to maintain a beard with a turban in uniform on religious grounds.²⁵

The clean-shaven look remains standard across the military, not only for uniformity of appearance but also for safety concerns. The Naval Safety Center’s ALSAFE report concluded that any facial hair impedes a tight fit of gas masks, which can be lethal in chemical warfare. However, the report did not explore how different hair lengths would affect the seal of gas masks.²⁶ It remains unknown how 0.25 inch of facial hair, the maximum hair length authorized for most PFB patients, affects the seal. Department of Defense occupational health researchers currently are assessing how each specific facial hair length diminishes the effectiveness of gas masks.²⁷

Furthermore, the COVID-19 pandemic has led to frequent N95 respirator wear in the military. It is likely that growing a long beard disrupts the fitting of N95 respirators and could endanger service members, especially in clinical settings. However, one study confirmed that 0.125 inch of facial hair still results in 98% effectiveness in filtering particles for the respirator wearers.²⁸ Although unverified, it is surmisable that 0.25 inch of facial hair will likely not render all respirators useless. However, current Occupational Safety and Health Administration guidelines require fit tests to be conducted only on clean-shaven faces.²⁹ Effectively, service members with facial hair cannot be fit-tested for N95 respirators.

More research is needed to optimize treatment protocols and regulations for PFB in our military. As long as the current grooming standards remain in place, treatment of PFB will be a controversial topic. Guidelines will need to be continuously updated to balance the needs of our service members and to minimize risk to unit safety and mission success. Department of Defense Instruction 6130.03, Volume 1, revised in late 2022, now no longer designates PFB as a condition that disqualifies a candidate from entering service in any military branch.³⁰ The Department of Defense is demonstrating active research and adoption of policies regarding PFB that will benefit our service members.

Pseudofolliculitis barbae (PFB)(also referred to as razor bumps) is a skin disease of the face and neck caused by shaving and remains prevalent in the US Military. As the sharpened ends of curly hair strands penetrate back into the epidermis, they can trigger inflammatory reactions, leading to papules and pustules as well as hyperpigmentation and scarring.¹ Although anyone with thick curly hair can develop PFB, Black individuals are disproportionately affected, with 45% to 83% reporting PFB symptoms compared with 18% of White individuals.² In this article, we review the treatments and current policies on PFB in the military.

Treatment Options

Shaving Guidelines—Daily shaving remains the grooming standard for US service members who are encouraged to follow prescribed grooming techniques to prevent mild cases of PFB, defined as having “few, scattered papules with scant hair growth of the beard area,” according to the technical bulletin of the US Army, which provides the most detailed guidelines among the branches.³ The bulletin recommends hydrating the face with warm water, followed by a preshave lotion and shaving with a single pass superiorly to inferiorly. Following shaving, postrazor hydration lotion is recommended. Single-bladed razors are preferred, as there is less trauma to existing PFB and less potential for hair retraction under the epidermis, though multibladed razors can be used with adequate preshave and postrazor hydration.⁴ Shaving can be undertaken in the evening to ensure adequate time for preshave preparation and postshave hydration. Waterless shaving uses waterless soaps or lotions containing α-hydroxy acid just prior to shaving in lieu of preshaving and postshaving procedures.⁴

Topical Medications—For PFB cases that are recalcitrant to management by changes in shaving, topical retinoids are commonly prescribed, as they reduce follicular hyperkeratosis that may lead to PFB.⁵ The Army medical bulletin recommends a pea-sized amount of tretinoin cream or gel 0.025%, 0.05%, or 0.1% for moderate cases, defined as “heavier beard growth, more scattered papules, no evidence of pustules or denudation.”³ Adapalene cream 0.1% may be used instead of tretinoin for sensitive skin. Oral doxycycline or topical benzoyl peroxide–clindamycin may be added for secondary bacterial skin infections. Clinical trials have demonstrated that combination benzoyl peroxide–clindamycin significantly reduces papules and pustules in up to 63% of patients with PFB (P<.029).⁶ Azelaic acid can be prescribed for prominent postinflammatory hyperpigmentation. The bulletin also suggests depilatories such as barium sulfide to obtund the hair ends and make them less likely to re-enter the skin surface, though it notes low compliance rates due to strong sulfur odor, messy application, and irritation and reactions to ingredients in the preparations.⁴

Shaving Waivers and Laser Hair Removal—The definitive treatment of PFB is to not shave, and a shaving waiver or laser hair removal (LHR) are the best options for severe PFB or PFB refractory to other treatments. A shaving waiver (or shaving profile) allows for growth of up to 0.25 inches of facial hair with maintenance of the length using clippers. The shaving profile typically is issued by the referring primary care manager (PCM) but also can be recommended by a dermatologist. Each military branch implements different regulations on shaving profiles, which complicates care delivery at joint-service military treatment facilities (MTFs). The Table provides guidelines that govern the management of PFB by the US Army, Air Force, Navy, and Marine Corps. The issuance and duration of shaving waivers vary by service.

Laser hair removal therapy uses high-wavelength lasers that largely bypass the melanocyte-containing basal layer and selectively target hair follicles located deeper in the skin, which results in precise hair reduction with relative sparing of the epidermis.¹⁶ Clinical trials at military clinics have demonstrated that treatments with the 1064-nm long-pulse Nd:YAG laser generally are safe and effective in impeding hair growth in Fitzpatrick skin types IV, V, and VI.¹⁷ This laser, along with the Alexandrite 755-nm long-pulse laser for Fitzpatrick skin types I to III, is widely available and used for LHR at MTFs that house dermatologists. Eflornithine cream 13.9%, which is approved by the US Food and Drug Administration to treat hirsutism, can be used as monotherapy for treatment of PFB and has a synergistic depilatory effect in PFB patients when used in conjunction with LHR.^18,19 Laser hair removal treatments can induce a permanent change in facial hair density and pattern of growth. Side effects and complications of LHR include discomfort during treatment and, in rare instances, blistering and dyspigmentation of the skin as well as paradoxical hair growth.¹⁷

TRICARE, the uniformed health care program, covers LHR in the civilian sector if the following criteria are met: candidates must work in an environment that may require breathing protection, and they must have failed conservative therapy; an MTF dermatologist must evaluate each case and attempt LHR at an MTF to limit outside referrals; and the MTF dermatologist must process each outside referral claim to completion and ensure that the LHR is rendered by a civilian dermatologist and is consistent with branch-specific policies.²⁰

Service Policies on PFB

Army—The Army technical bulletin breaks down the treatment of PFB based on mild, moderate, and severe conditions.³ For mild conditions, a trial of shaving every 2 or 3 days until resolution is recommended. For moderate PFB, topical tretinoin as well as shaving every 2 to 3 days is recommended. For severe conditions, temporary beard growth with issuance of a temporary shaving profile up to 90 days is authorized.³

The technical bulletin also allows a permanent shaving profile for soldiers who demonstrate a severe adverse reaction to treatment or progression of the disease despite a trial of all these methods.³ The regulation stipulates that 0.125 to 0.25 inches of beard growth usually is sufficient to prevent PFB. Patients on profiles must be re-evaluated by a PCM or a dermatologist at least once a year.³

Air Force—Air Force Instruction 44-102 delegates PFB treatment and management strategies to each individual MTF, which allows for decentralized management of PFB, resulting in treatment protocols that can differ from one MTF to another.⁷ Since 2020, waivers have been valid for 5 years regardless of deployment or permanent change of station location. Previously, shaving profiles required annual renewals.⁷ Special duties, such as Honor Guard, Thunderbirds, Special Warfare Mission Support, recruiters, and the Air Force Band, often follow the professional appearance standards more strictly. Until recently, the Honor Guard used to reassign those with long-term medical shaving waivers but now allows airmen with shaving profiles to serve with exceptions (eg, shaving before ceremonies).²¹

Navy—BUPERS (Bureau of Naval Personnel) Instruction 1000.22C divides PFB severity into 2 categories.⁸ For mild to moderate PFB cases, topical tretinoin and adapalene are recommended, along with improved shaving hygiene practices. As an alternative to topical steroids, topical eflornithine monotherapy can be used twice daily for 60 days. For moderate to severe PFB cases, continued grooming modifications and LHR at military clinics with dermatologic services are expected.⁸

Naval administrative memorandum NAVADMIN 064/22 (released in 2022) no longer requires sailors with a shaving “chit,” or shaving waiver, to fully grow out their beards.⁹ Sailors may now outline or edge their beards as long as doing so does not trigger a skin irritation or outbreak. Furthermore, sailors are no longer required to carry a physical copy of their shaving chit at all times. Laser hair removal for sailors with PFB is now considered optional, whereas sailors with severe PFB were previously expected to receive LHR.⁹

Marine Corps—The Marine Corps endorses a 4-phase treatment algorithm (Table). As of January 2022, permanent shaving chits are authorized. Marines no longer need to carry physical copies of their chits at all times and cannot be separated from service because of PFB.¹⁰ New updates explicitly state that medical officers, not the commanding officers, now have final authority for granting shaving chits.¹¹

Final Thoughts

The Army provides the most detailed bulletin, which defines the clinical features and treatments expected for each stage of PFB. All 4 service branches permit temporary profiles, albeit for different lengths of time. However, only the Army and the Marine Corps currently authorize permanent shaving waivers if all treatments mentioned in their respective bulletins have failed.

The Air Force has adopted the most decentralized approach, in which each MTF is responsible for implementing its own treatment protocols and definitions. Air Force regulations now authorize a 5-year shaving profile for medical reasons, including PFB. The Air Force also has spearheaded efforts to create more inclusive policies. A study of 10,000 active-duty male Air Force members conducted by Air Force physicians found that shaving waivers were associated with longer times to promotion. Although self-identified race was not independently linked to longer promotion times, more Black service members were affected because of a higher prevalence of PFB and shaving profiles.²²

The Navy has outlined the most specific timeline for therapy for PFB. The regulations allow a 60-day temporary shaving chit that expires on the day of the appointment with the dermatologist or PCM. Although sailors were previously mandated to fully grow out their beards without modifications during the 60-day shaving chit period, Navy leadership recently overturned these requirements. However, permanent shaving chits are still not authorized in the Navy.

Service members are trying to destigmatize shaving profiles and facial hair in our military. A Facebook group called DoD Beard Action Initiative has more than 17,000 members and was created in 2021 to compile testimonies and data regarding the effects of PFB on airmen.²³ Soldiers also have petitioned for growing beards in the garrison environment with more than 100,000 signatures, citing that North Atlantic Treaty Organization allied nations permit beard growth in their respective ranks.²⁴ A Sikh marine captain recently won a lawsuit against the US Department of the Navy to maintain a beard with a turban in uniform on religious grounds.²⁵

The clean-shaven look remains standard across the military, not only for uniformity of appearance but also for safety concerns. The Naval Safety Center’s ALSAFE report concluded that any facial hair impedes a tight fit of gas masks, which can be lethal in chemical warfare. However, the report did not explore how different hair lengths would affect the seal of gas masks.²⁶ It remains unknown how 0.25 inch of facial hair, the maximum hair length authorized for most PFB patients, affects the seal. Department of Defense occupational health researchers currently are assessing how each specific facial hair length diminishes the effectiveness of gas masks.²⁷

Furthermore, the COVID-19 pandemic has led to frequent N95 respirator wear in the military. It is likely that growing a long beard disrupts the fitting of N95 respirators and could endanger service members, especially in clinical settings. However, one study confirmed that 0.125 inch of facial hair still results in 98% effectiveness in filtering particles for the respirator wearers.²⁸ Although unverified, it is surmisable that 0.25 inch of facial hair will likely not render all respirators useless. However, current Occupational Safety and Health Administration guidelines require fit tests to be conducted only on clean-shaven faces.²⁹ Effectively, service members with facial hair cannot be fit-tested for N95 respirators.

More research is needed to optimize treatment protocols and regulations for PFB in our military. As long as the current grooming standards remain in place, treatment of PFB will be a controversial topic. Guidelines will need to be continuously updated to balance the needs of our service members and to minimize risk to unit safety and mission success. Department of Defense Instruction 6130.03, Volume 1, revised in late 2022, now no longer designates PFB as a condition that disqualifies a candidate from entering service in any military branch.³⁰ The Department of Defense is demonstrating active research and adoption of policies regarding PFB that will benefit our service members.

To the Editor:

Neutrophilic dermatosis of the dorsal hand (NDDH) is an uncommon reactive neutrophilic dermatosis that presents as a painful, enlarging, ulcerative nodule. It often is misdiagnosed and initially treated as an infection. Similar to other neutrophilic dermatoses, it is associated with underlying infections, inflammatory conditions, and malignancies. Neutrophilic dermatosis of the dorsal hand is considered a subset of Sweet syndrome (SS); we highlight similarities and differences between NDDH and SS, reporting the case of a 66-year-old man without systemic symptoms who developed NDDH on the right hand.

A 66-year-old man presented with a progressively enlarging, painful, ulcerative, 2-cm nodule on the right hand following mechanical trauma 2 weeks prior (Figure 1). He was afebrile with no remarkable medical history. Laboratory evaluation revealed an erythrocyte sedimentation rate (ESR) of 20 mm/h (reference range, 0-10 mm/h) and C-reactive protein (CRP) level of 3.52 mg/dL (reference range, 0-0.5 mg/dL) without leukocytosis; both were not remarkably elevated when adjusted for age.^1,2 The clinical differential diagnosis was broad and included pyoderma with evolving cellulitis, neutrophilic dermatosis, atypical mycobacterial infection, subcutaneous or deep fungal infection, squamous cell carcinoma, cutaneous lymphoma, and metastasis. Due to the rapid development of the lesion, initial treatment focused on a bacterial infection, but there was no improvement on antibiotics and wound cultures were negative. The ulcerative nodule was biopsied, and histopathology demonstrated abundant neutrophilic inflammation, endothelial swelling, and leukocytoclasis without microorganisms (Figure 2). Tissue cultures for bacteria, fungi, and atypical mycobacteria were negative. A diagnosis of NDDH was made based on clinical and histologic findings. The wound improved with a 3-week course of oral prednisone.

Neutrophilic dermatosis of the dorsal hand is a subset of reactive neutrophilic dermatoses, which includes SS (acute febrile neutrophilic dermatosis) and pyoderma gangrenosum. It is described as a localized variant of SS, with similar associated underlying inflammatory, neoplastic conditions and laboratory findings.³ However, NDDH has characteristic features that differ from classic SS. Neutrophilic dermatosis of the dorsal hand typically presents as painful papules, pustules, or ulcers that progress to become larger ulcers, plaques, and nodules. The clinical appearance may more closely resemble pyoderma gangrenosum or atypical SS, with ulceration frequently present. Pathergy also may be demonstrated in NDDH, similar to our patient. The average age of presentation for NDDH is 60 years, which is older than the average age for SS or pyoderma gangrenosum.³ Similar to other neutrophilic dermatoses, NDDH responds well to oral steroids or steroid-sparing immunosuppressants such as dapsone, colchicine, azathioprine, or tetracycline antibiotics.⁴

The criteria for SS are well established^5,6 and may be used for the diagnosis of NDDH, taking into account the localization of lesions to the dorsal aspect of the hands. The diagnostic criteria for SS include fulfillment of both major and at least 2 of 4 minor criteria. The 2 major criteria include rapid presentation of skin lesions and neutrophilic dermal infiltrate on biopsy. Minor criteria are defined as the following: (1) preceding nonspecific respiratory or gastrointestinal tract infection, inflammatory conditions, underlying malignancy, or pregnancy; (2) fever; (3) excellent response to steroids; and (4) 3 of the 4 of the following laboratory abnormalities: elevated CRP, ESR, leukocytosis, or left shift in complete blood cell count. Our patient met both major criteria and only 1 minor criterion—excellent response to systemic corticosteroids. Nofal et al⁷ advocated for revised diagnostic criteria for SS, with one suggestion utilizing only the 2 major criteria being necessary for diagnosis. Given that serum inflammatory markers may not be as elevated in NDDH compared to SS,^3,7,8 meeting the major criteria alone may be a better way to diagnose NDDH, as in our patient.

Our patient presented with an expanding ulcerating nodule on the hand that elicited a wide list of differential diagnoses to include infections and neoplasms. Rapid development, localization to the dorsal aspect of the hand, and treatment resistance to antibiotics may help the clinician consider a diagnosis of NDDH, which should be confirmed by a biopsy. Similar to other neutrophilic dermatoses, an underlying malignancy or inflammatory condition should be sought out. Neutrophilic dermatosis of the dorsal hand responds well to systemic steroids, though recurrences may occur.

To the Editor:

Neutrophilic dermatosis of the dorsal hand (NDDH) is an uncommon reactive neutrophilic dermatosis that presents as a painful, enlarging, ulcerative nodule. It often is misdiagnosed and initially treated as an infection. Similar to other neutrophilic dermatoses, it is associated with underlying infections, inflammatory conditions, and malignancies. Neutrophilic dermatosis of the dorsal hand is considered a subset of Sweet syndrome (SS); we highlight similarities and differences between NDDH and SS, reporting the case of a 66-year-old man without systemic symptoms who developed NDDH on the right hand.

A 66-year-old man presented with a progressively enlarging, painful, ulcerative, 2-cm nodule on the right hand following mechanical trauma 2 weeks prior (Figure 1). He was afebrile with no remarkable medical history. Laboratory evaluation revealed an erythrocyte sedimentation rate (ESR) of 20 mm/h (reference range, 0-10 mm/h) and C-reactive protein (CRP) level of 3.52 mg/dL (reference range, 0-0.5 mg/dL) without leukocytosis; both were not remarkably elevated when adjusted for age.^1,2 The clinical differential diagnosis was broad and included pyoderma with evolving cellulitis, neutrophilic dermatosis, atypical mycobacterial infection, subcutaneous or deep fungal infection, squamous cell carcinoma, cutaneous lymphoma, and metastasis. Due to the rapid development of the lesion, initial treatment focused on a bacterial infection, but there was no improvement on antibiotics and wound cultures were negative. The ulcerative nodule was biopsied, and histopathology demonstrated abundant neutrophilic inflammation, endothelial swelling, and leukocytoclasis without microorganisms (Figure 2). Tissue cultures for bacteria, fungi, and atypical mycobacteria were negative. A diagnosis of NDDH was made based on clinical and histologic findings. The wound improved with a 3-week course of oral prednisone.

Neutrophilic dermatosis of the dorsal hand is a subset of reactive neutrophilic dermatoses, which includes SS (acute febrile neutrophilic dermatosis) and pyoderma gangrenosum. It is described as a localized variant of SS, with similar associated underlying inflammatory, neoplastic conditions and laboratory findings.³ However, NDDH has characteristic features that differ from classic SS. Neutrophilic dermatosis of the dorsal hand typically presents as painful papules, pustules, or ulcers that progress to become larger ulcers, plaques, and nodules. The clinical appearance may more closely resemble pyoderma gangrenosum or atypical SS, with ulceration frequently present. Pathergy also may be demonstrated in NDDH, similar to our patient. The average age of presentation for NDDH is 60 years, which is older than the average age for SS or pyoderma gangrenosum.³ Similar to other neutrophilic dermatoses, NDDH responds well to oral steroids or steroid-sparing immunosuppressants such as dapsone, colchicine, azathioprine, or tetracycline antibiotics.⁴

The criteria for SS are well established^5,6 and may be used for the diagnosis of NDDH, taking into account the localization of lesions to the dorsal aspect of the hands. The diagnostic criteria for SS include fulfillment of both major and at least 2 of 4 minor criteria. The 2 major criteria include rapid presentation of skin lesions and neutrophilic dermal infiltrate on biopsy. Minor criteria are defined as the following: (1) preceding nonspecific respiratory or gastrointestinal tract infection, inflammatory conditions, underlying malignancy, or pregnancy; (2) fever; (3) excellent response to steroids; and (4) 3 of the 4 of the following laboratory abnormalities: elevated CRP, ESR, leukocytosis, or left shift in complete blood cell count. Our patient met both major criteria and only 1 minor criterion—excellent response to systemic corticosteroids. Nofal et al⁷ advocated for revised diagnostic criteria for SS, with one suggestion utilizing only the 2 major criteria being necessary for diagnosis. Given that serum inflammatory markers may not be as elevated in NDDH compared to SS,^3,7,8 meeting the major criteria alone may be a better way to diagnose NDDH, as in our patient.

Our patient presented with an expanding ulcerating nodule on the hand that elicited a wide list of differential diagnoses to include infections and neoplasms. Rapid development, localization to the dorsal aspect of the hand, and treatment resistance to antibiotics may help the clinician consider a diagnosis of NDDH, which should be confirmed by a biopsy. Similar to other neutrophilic dermatoses, an underlying malignancy or inflammatory condition should be sought out. Neutrophilic dermatosis of the dorsal hand responds well to systemic steroids, though recurrences may occur.

To the Editor:

Neutrophilic dermatosis of the dorsal hand (NDDH) is an uncommon reactive neutrophilic dermatosis that presents as a painful, enlarging, ulcerative nodule. It often is misdiagnosed and initially treated as an infection. Similar to other neutrophilic dermatoses, it is associated with underlying infections, inflammatory conditions, and malignancies. Neutrophilic dermatosis of the dorsal hand is considered a subset of Sweet syndrome (SS); we highlight similarities and differences between NDDH and SS, reporting the case of a 66-year-old man without systemic symptoms who developed NDDH on the right hand.

A 66-year-old man presented with a progressively enlarging, painful, ulcerative, 2-cm nodule on the right hand following mechanical trauma 2 weeks prior (Figure 1). He was afebrile with no remarkable medical history. Laboratory evaluation revealed an erythrocyte sedimentation rate (ESR) of 20 mm/h (reference range, 0-10 mm/h) and C-reactive protein (CRP) level of 3.52 mg/dL (reference range, 0-0.5 mg/dL) without leukocytosis; both were not remarkably elevated when adjusted for age.^1,2 The clinical differential diagnosis was broad and included pyoderma with evolving cellulitis, neutrophilic dermatosis, atypical mycobacterial infection, subcutaneous or deep fungal infection, squamous cell carcinoma, cutaneous lymphoma, and metastasis. Due to the rapid development of the lesion, initial treatment focused on a bacterial infection, but there was no improvement on antibiotics and wound cultures were negative. The ulcerative nodule was biopsied, and histopathology demonstrated abundant neutrophilic inflammation, endothelial swelling, and leukocytoclasis without microorganisms (Figure 2). Tissue cultures for bacteria, fungi, and atypical mycobacteria were negative. A diagnosis of NDDH was made based on clinical and histologic findings. The wound improved with a 3-week course of oral prednisone.

Neutrophilic dermatosis of the dorsal hand is a subset of reactive neutrophilic dermatoses, which includes SS (acute febrile neutrophilic dermatosis) and pyoderma gangrenosum. It is described as a localized variant of SS, with similar associated underlying inflammatory, neoplastic conditions and laboratory findings.³ However, NDDH has characteristic features that differ from classic SS. Neutrophilic dermatosis of the dorsal hand typically presents as painful papules, pustules, or ulcers that progress to become larger ulcers, plaques, and nodules. The clinical appearance may more closely resemble pyoderma gangrenosum or atypical SS, with ulceration frequently present. Pathergy also may be demonstrated in NDDH, similar to our patient. The average age of presentation for NDDH is 60 years, which is older than the average age for SS or pyoderma gangrenosum.³ Similar to other neutrophilic dermatoses, NDDH responds well to oral steroids or steroid-sparing immunosuppressants such as dapsone, colchicine, azathioprine, or tetracycline antibiotics.⁴

The criteria for SS are well established^5,6 and may be used for the diagnosis of NDDH, taking into account the localization of lesions to the dorsal aspect of the hands. The diagnostic criteria for SS include fulfillment of both major and at least 2 of 4 minor criteria. The 2 major criteria include rapid presentation of skin lesions and neutrophilic dermal infiltrate on biopsy. Minor criteria are defined as the following: (1) preceding nonspecific respiratory or gastrointestinal tract infection, inflammatory conditions, underlying malignancy, or pregnancy; (2) fever; (3) excellent response to steroids; and (4) 3 of the 4 of the following laboratory abnormalities: elevated CRP, ESR, leukocytosis, or left shift in complete blood cell count. Our patient met both major criteria and only 1 minor criterion—excellent response to systemic corticosteroids. Nofal et al⁷ advocated for revised diagnostic criteria for SS, with one suggestion utilizing only the 2 major criteria being necessary for diagnosis. Given that serum inflammatory markers may not be as elevated in NDDH compared to SS,^3,7,8 meeting the major criteria alone may be a better way to diagnose NDDH, as in our patient.

Our patient presented with an expanding ulcerating nodule on the hand that elicited a wide list of differential diagnoses to include infections and neoplasms. Rapid development, localization to the dorsal aspect of the hand, and treatment resistance to antibiotics may help the clinician consider a diagnosis of NDDH, which should be confirmed by a biopsy. Similar to other neutrophilic dermatoses, an underlying malignancy or inflammatory condition should be sought out. Neutrophilic dermatosis of the dorsal hand responds well to systemic steroids, though recurrences may occur.

Medical education has seen major changes over the last decade. The allotted time for preclinical education has decreased from 24 months to 18 months or less at most institutions, with an increased focus on content associated with health care delivery and health system science.^1,2 Many schools now include at least some blended learning with online delivery of preclinical education.³ On the other hand, the clinical portion of medical education has remained largely unchanged prior to the COVID-19 pandemic, with the apprenticeship framework allowing the experienced physician to observe, mentor, and pass on practical knowledge so that the apprentice can one day gain independence after demonstrating adequate proficiency.⁴

With respect to dermatology education, skin disorders are in the top 5 reported reasons for visits to primary care⁵; however, a 2009 survey found that only 0.24% to 0.30% of medical schools’ curricula are spent on dermatology.⁶ Moreover, one institution found that fourth-year medical students received an average of 46.6% on a 15-item quiz designed to assess the ability to diagnose and treat common dermatologic conditions, and within that same cohort, 87.6% of students felt that they received inadequate training in dermatology during medical school.⁷

COVID-19 caused an unprecedented paradigm shift when medical schools throughout the country, including our own, canceled clinical rotations at the end of March 2020 to protect students and control the spread of infection. To enable clinical and preclinical learning to continue, institutions around the globe turned to either online learning or participation in telehealth as a substitute for clinical rotations.^8-10 At the Uniformed Services University of the Health Sciences (Bethesda, Maryland), one of the many online clinical courses offered included a distance learning (DL) dermatology course. Herein, we describe the results of a prospective study evaluating short-term information recall and comprehension as well as students’ confidence in their ability to apply course objectives over 3 months of an online DL dermatology course.

Methods

Between April and July 2020, 14 students at the Uniformed Services University of the Health Sciences (Table 1) enrolled in 1 of 3 four-week DL dermatology classes. The students independently completed the Basic Dermatology Curriculum, a set of online modules with demonstrated efficacy from the American Academy of Dermatology, over 4 weeks.¹¹ Additionally, students were instructed to review an hour of clinical dermatology images daily from online dermatology atlases and e-books accessed through our medical school’s virtual library. Optional Free Open Access Meducation resources also were provided. The course syllabus provided the students with clear expectations, links to the resources, and a recommended daily schedule.

An online video conferencing platform was utilized for an orientation session and 4 subsequent weekly 1.5-hour virtual meetings. The weekly DL meetings focused on a discussion of clinical images pertinent to the American Academy of Dermatology modules covered for the week. These interactive analytic sessions were referred to as Clinpic sessions. With instructor guidance, the students learned to describe images, and they provided differential diagnoses, workup, and treatments for various skin diseases. The virtual meetings included supplemental lectures detailing the use of teledermatology and laser therapy in the Military Health System and a journal review on the cutaneous manifestations of COVID-19.

A 40-question, image-based pretest and posttest utilized during clinical rotations evaluated knowledge recall and comprehension. A precourse and postcourse survey using a 5-point Likert scale (1=not confident; 5=extremely confident) assessed students’ confidence levels across course objectives: general knowledge of dermatology, working knowledge of teledermatology, ability to accurately describe skin lesions, generate sound differential diagnoses, and formulate a reasonable treatment plan. Statistical analysis was performed using free online statistical software at statskingdom.com.¹²

Results

All 14 student enrollees completed the precourse and postcourse tests and surveys. Pretest and posttest scores followed a normal distribution and therefore met criteria for utilization of a parametric test. The precourse test average of 67% (range, 40%–90%) improved to 84% postcourse (range, 70%–98%; P<.001; 95% CI, 11-23 by paired t test). Not surprisingly, the 2 students who had completed a dermatology rotation had higher average pretest and posttest scores (pretest, 87%; posttest, 94%). Students’ confidence with the course objectives were mostly at the somewhat confident level on the 5-point Likert scale precourse survey. By the end of the course, student survey responses increased to confident and very confident levels, corresponding to an overall improvement of 1.3 points (P<.001 by paired t test)(Table 2) when the mean of the survey results was aggregated across every question. Instructor evaluation of student performance mirrored student assessments.

The DL dermatology course succeeded in helping the enrolled students attain course objectives and offered a reasonable solution when in-person interaction was restricted. The students in the DL course made notable improvements in their dermatology knowledge and improved their communication, diagnosis, and management skills. Although a blended dermatology curriculum with e-learning combined with clinical experience has been shown to increase knowledge acquisition,^13,14 our results suggest that an online-only program also can increase comprehension as well as students’ confidence in their abilities.

A major challenge for the DL course was the lack of opportunity to perform common dermatology procedures. The addition of a hands-on skin procedure module would have been a great supplement to the course but was not possible due to social distancing guidelines during the COVID-19 pandemic. The small sample size and voluntary enrollment were limitations to this study.

Conclusion

Although the traditional dermatology rotation remains the gold standard for clinical instruction, a well-organized DL teaching environment allowed for a more controlled learning experience with a broader coverage of topics to include potentially greater exposure to rare skin disorders not typically encountered in everyday practice. A DL dermatology course may serve as an enduring curriculum for those who wish to learn dermatology more broadly and are not interested in performing skin procedures or direct patient exposure (eg, those pursuing non–primary care specialties, pathology, or radiology). It also may be attractive to students who have had a prior clinical dermatology rotation and desire a different learning experience with a wide coverage of topics.

Acknowledgments—The authors thank Thomas Darling, MD, PhD (Bethesda, Maryland), for coining the term Clinpic and providing critical feedback throughout the course. The authors also thank Sorana Raiciulescu, MS (Bethesda, Maryland), for assistance with the statistical analysis.

Medical education has seen major changes over the last decade. The allotted time for preclinical education has decreased from 24 months to 18 months or less at most institutions, with an increased focus on content associated with health care delivery and health system science.^1,2 Many schools now include at least some blended learning with online delivery of preclinical education.³ On the other hand, the clinical portion of medical education has remained largely unchanged prior to the COVID-19 pandemic, with the apprenticeship framework allowing the experienced physician to observe, mentor, and pass on practical knowledge so that the apprentice can one day gain independence after demonstrating adequate proficiency.⁴

With respect to dermatology education, skin disorders are in the top 5 reported reasons for visits to primary care⁵; however, a 2009 survey found that only 0.24% to 0.30% of medical schools’ curricula are spent on dermatology.⁶ Moreover, one institution found that fourth-year medical students received an average of 46.6% on a 15-item quiz designed to assess the ability to diagnose and treat common dermatologic conditions, and within that same cohort, 87.6% of students felt that they received inadequate training in dermatology during medical school.⁷

COVID-19 caused an unprecedented paradigm shift when medical schools throughout the country, including our own, canceled clinical rotations at the end of March 2020 to protect students and control the spread of infection. To enable clinical and preclinical learning to continue, institutions around the globe turned to either online learning or participation in telehealth as a substitute for clinical rotations.^8-10 At the Uniformed Services University of the Health Sciences (Bethesda, Maryland), one of the many online clinical courses offered included a distance learning (DL) dermatology course. Herein, we describe the results of a prospective study evaluating short-term information recall and comprehension as well as students’ confidence in their ability to apply course objectives over 3 months of an online DL dermatology course.

Methods

Between April and July 2020, 14 students at the Uniformed Services University of the Health Sciences (Table 1) enrolled in 1 of 3 four-week DL dermatology classes. The students independently completed the Basic Dermatology Curriculum, a set of online modules with demonstrated efficacy from the American Academy of Dermatology, over 4 weeks.¹¹ Additionally, students were instructed to review an hour of clinical dermatology images daily from online dermatology atlases and e-books accessed through our medical school’s virtual library. Optional Free Open Access Meducation resources also were provided. The course syllabus provided the students with clear expectations, links to the resources, and a recommended daily schedule.

An online video conferencing platform was utilized for an orientation session and 4 subsequent weekly 1.5-hour virtual meetings. The weekly DL meetings focused on a discussion of clinical images pertinent to the American Academy of Dermatology modules covered for the week. These interactive analytic sessions were referred to as Clinpic sessions. With instructor guidance, the students learned to describe images, and they provided differential diagnoses, workup, and treatments for various skin diseases. The virtual meetings included supplemental lectures detailing the use of teledermatology and laser therapy in the Military Health System and a journal review on the cutaneous manifestations of COVID-19.

A 40-question, image-based pretest and posttest utilized during clinical rotations evaluated knowledge recall and comprehension. A precourse and postcourse survey using a 5-point Likert scale (1=not confident; 5=extremely confident) assessed students’ confidence levels across course objectives: general knowledge of dermatology, working knowledge of teledermatology, ability to accurately describe skin lesions, generate sound differential diagnoses, and formulate a reasonable treatment plan. Statistical analysis was performed using free online statistical software at statskingdom.com.¹²

Results

All 14 student enrollees completed the precourse and postcourse tests and surveys. Pretest and posttest scores followed a normal distribution and therefore met criteria for utilization of a parametric test. The precourse test average of 67% (range, 40%–90%) improved to 84% postcourse (range, 70%–98%; P<.001; 95% CI, 11-23 by paired t test). Not surprisingly, the 2 students who had completed a dermatology rotation had higher average pretest and posttest scores (pretest, 87%; posttest, 94%). Students’ confidence with the course objectives were mostly at the somewhat confident level on the 5-point Likert scale precourse survey. By the end of the course, student survey responses increased to confident and very confident levels, corresponding to an overall improvement of 1.3 points (P<.001 by paired t test)(Table 2) when the mean of the survey results was aggregated across every question. Instructor evaluation of student performance mirrored student assessments.

The DL dermatology course succeeded in helping the enrolled students attain course objectives and offered a reasonable solution when in-person interaction was restricted. The students in the DL course made notable improvements in their dermatology knowledge and improved their communication, diagnosis, and management skills. Although a blended dermatology curriculum with e-learning combined with clinical experience has been shown to increase knowledge acquisition,^13,14 our results suggest that an online-only program also can increase comprehension as well as students’ confidence in their abilities.

A major challenge for the DL course was the lack of opportunity to perform common dermatology procedures. The addition of a hands-on skin procedure module would have been a great supplement to the course but was not possible due to social distancing guidelines during the COVID-19 pandemic. The small sample size and voluntary enrollment were limitations to this study.

Conclusion

Although the traditional dermatology rotation remains the gold standard for clinical instruction, a well-organized DL teaching environment allowed for a more controlled learning experience with a broader coverage of topics to include potentially greater exposure to rare skin disorders not typically encountered in everyday practice. A DL dermatology course may serve as an enduring curriculum for those who wish to learn dermatology more broadly and are not interested in performing skin procedures or direct patient exposure (eg, those pursuing non–primary care specialties, pathology, or radiology). It also may be attractive to students who have had a prior clinical dermatology rotation and desire a different learning experience with a wide coverage of topics.

Acknowledgments—The authors thank Thomas Darling, MD, PhD (Bethesda, Maryland), for coining the term Clinpic and providing critical feedback throughout the course. The authors also thank Sorana Raiciulescu, MS (Bethesda, Maryland), for assistance with the statistical analysis.

Medical education has seen major changes over the last decade. The allotted time for preclinical education has decreased from 24 months to 18 months or less at most institutions, with an increased focus on content associated with health care delivery and health system science.^1,2 Many schools now include at least some blended learning with online delivery of preclinical education.³ On the other hand, the clinical portion of medical education has remained largely unchanged prior to the COVID-19 pandemic, with the apprenticeship framework allowing the experienced physician to observe, mentor, and pass on practical knowledge so that the apprentice can one day gain independence after demonstrating adequate proficiency.⁴

With respect to dermatology education, skin disorders are in the top 5 reported reasons for visits to primary care⁵; however, a 2009 survey found that only 0.24% to 0.30% of medical schools’ curricula are spent on dermatology.⁶ Moreover, one institution found that fourth-year medical students received an average of 46.6% on a 15-item quiz designed to assess the ability to diagnose and treat common dermatologic conditions, and within that same cohort, 87.6% of students felt that they received inadequate training in dermatology during medical school.⁷

COVID-19 caused an unprecedented paradigm shift when medical schools throughout the country, including our own, canceled clinical rotations at the end of March 2020 to protect students and control the spread of infection. To enable clinical and preclinical learning to continue, institutions around the globe turned to either online learning or participation in telehealth as a substitute for clinical rotations.^8-10 At the Uniformed Services University of the Health Sciences (Bethesda, Maryland), one of the many online clinical courses offered included a distance learning (DL) dermatology course. Herein, we describe the results of a prospective study evaluating short-term information recall and comprehension as well as students’ confidence in their ability to apply course objectives over 3 months of an online DL dermatology course.

Methods

Between April and July 2020, 14 students at the Uniformed Services University of the Health Sciences (Table 1) enrolled in 1 of 3 four-week DL dermatology classes. The students independently completed the Basic Dermatology Curriculum, a set of online modules with demonstrated efficacy from the American Academy of Dermatology, over 4 weeks.¹¹ Additionally, students were instructed to review an hour of clinical dermatology images daily from online dermatology atlases and e-books accessed through our medical school’s virtual library. Optional Free Open Access Meducation resources also were provided. The course syllabus provided the students with clear expectations, links to the resources, and a recommended daily schedule.

An online video conferencing platform was utilized for an orientation session and 4 subsequent weekly 1.5-hour virtual meetings. The weekly DL meetings focused on a discussion of clinical images pertinent to the American Academy of Dermatology modules covered for the week. These interactive analytic sessions were referred to as Clinpic sessions. With instructor guidance, the students learned to describe images, and they provided differential diagnoses, workup, and treatments for various skin diseases. The virtual meetings included supplemental lectures detailing the use of teledermatology and laser therapy in the Military Health System and a journal review on the cutaneous manifestations of COVID-19.

A 40-question, image-based pretest and posttest utilized during clinical rotations evaluated knowledge recall and comprehension. A precourse and postcourse survey using a 5-point Likert scale (1=not confident; 5=extremely confident) assessed students’ confidence levels across course objectives: general knowledge of dermatology, working knowledge of teledermatology, ability to accurately describe skin lesions, generate sound differential diagnoses, and formulate a reasonable treatment plan. Statistical analysis was performed using free online statistical software at statskingdom.com.¹²

Results

All 14 student enrollees completed the precourse and postcourse tests and surveys. Pretest and posttest scores followed a normal distribution and therefore met criteria for utilization of a parametric test. The precourse test average of 67% (range, 40%–90%) improved to 84% postcourse (range, 70%–98%; P<.001; 95% CI, 11-23 by paired t test). Not surprisingly, the 2 students who had completed a dermatology rotation had higher average pretest and posttest scores (pretest, 87%; posttest, 94%). Students’ confidence with the course objectives were mostly at the somewhat confident level on the 5-point Likert scale precourse survey. By the end of the course, student survey responses increased to confident and very confident levels, corresponding to an overall improvement of 1.3 points (P<.001 by paired t test)(Table 2) when the mean of the survey results was aggregated across every question. Instructor evaluation of student performance mirrored student assessments.

The DL dermatology course succeeded in helping the enrolled students attain course objectives and offered a reasonable solution when in-person interaction was restricted. The students in the DL course made notable improvements in their dermatology knowledge and improved their communication, diagnosis, and management skills. Although a blended dermatology curriculum with e-learning combined with clinical experience has been shown to increase knowledge acquisition,^13,14 our results suggest that an online-only program also can increase comprehension as well as students’ confidence in their abilities.

A major challenge for the DL course was the lack of opportunity to perform common dermatology procedures. The addition of a hands-on skin procedure module would have been a great supplement to the course but was not possible due to social distancing guidelines during the COVID-19 pandemic. The small sample size and voluntary enrollment were limitations to this study.

Conclusion

Although the traditional dermatology rotation remains the gold standard for clinical instruction, a well-organized DL teaching environment allowed for a more controlled learning experience with a broader coverage of topics to include potentially greater exposure to rare skin disorders not typically encountered in everyday practice. A DL dermatology course may serve as an enduring curriculum for those who wish to learn dermatology more broadly and are not interested in performing skin procedures or direct patient exposure (eg, those pursuing non–primary care specialties, pathology, or radiology). It also may be attractive to students who have had a prior clinical dermatology rotation and desire a different learning experience with a wide coverage of topics.

Acknowledgments—The authors thank Thomas Darling, MD, PhD (Bethesda, Maryland), for coining the term Clinpic and providing critical feedback throughout the course. The authors also thank Sorana Raiciulescu, MS (Bethesda, Maryland), for assistance with the statistical analysis.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.

The National Defense Authorization Act for Fiscal Year 2017¹ has changed military medicine, including substantial reduction in military medical personnel as positions are converted to combat functions. As a result, there will be fewer military dermatologists, which means many US soldiers, sailors, airmen, and marines will seek medical care outside of military treatment facilities. This article highlights some unique treatment considerations in this patient population for our civilian dermatology colleagues.

Medical Readiness

In 2015, General Joseph F. Dunford Jr, 19th Chairman of the Joint Chiefs of Staff, made readiness his top priority for the US Armed Forces.² Readiness refers to service members’ ability to deploy to locations across the globe and perform their military duties with little advanced notice, which requires personnel to be medically prepared at all times to leave home and perform their duties in locations with limited medical support.

Medical readiness is maintaining a unit that is medically able to perform its military function both at home and in a deployed environment. Military members’ medical readiness status is carefully tracked and determined via annual physical, dental, hearing, and vision examinations, as well as human immunodeficiency virus status and immunizations. The readiness status of the unit (ie, the number of troops ready to deploy at any given time) is available to commanders at all levels at any time. Each military branch has tracking systems that allow commanders to know when a member is past due for an examination or if a member’s medical status has changed, making them nondeployable. When a member is nondeployable, it affects the unit’s ability to perform its mission and degrades its readiness. If readiness is suboptimal, the military cannot deploy and complete its missions, which is why readiness is a top priority. The primary function of military medicine is to support the medical readiness of the force.

Deployment Eligibility

A unique aspect of military medicine that can be foreign to civilian physicians is the unit commanders’ authority to request and receive information on military members’ medical conditions as they relate to readiness. Under most circumstances, an individual’s medical information is his/her private information; however, that is not always the case in the military. If a member’s medical status changes and he/she becomes nondeployable, by regulation the commander can be privy to pertinent aspects of that member’s medical condition as it affects unit readiness, including the diagnosis, treatment plan, and prognosis. Commanders need this information to aid in the member’s recovery, ensure training does not impact his/her care, and identify possible need of replacement.

Published accession guidelines are used to determine medical eligibility for service.³ These instructions are organized by major organ systems and broad disease categories. They provide guidance on medically disqualifying conditions. The Table outlines those conditions that apply to the skin.³ Individual military branches may have additional regulations with guidance on medically disqualifying conditions that are job specific. Additional regulations also are available based on an area of military operation that can be more restrictive and specific to those locations.⁴

Readiness and Patient Care

Importantly, readiness should not be seen as a roadblock to appropriate patient care. Patients should receive treatment that is appropriate for their medical condition. Much of the difficulty within military medicine is understanding and communicating how the natural disease history, prognosis, and treatment of their respective medical conditions will impact members’ service.

In some cases, the condition and/or treatment is incompatible with military service. Consider the following scenario: A 23-year-old active-duty soldier with a history of psoriasis developed widespread disease of 1 year’s duration and was referred to a civilian dermatologist due to nonavailability of a military dermatologist. After topical and light-based therapies failed, he was started on ustekinumab, which cleared the psoriasis. He wanted to continue on ustekinumab due to its good efficacy, but his unit was set to deploy in the coming year, and the drug made him medically nondeployable due to its immunosuppressive nature.

This real-life example was a difficult case to disposition. The service member was unsure if he could perform his military duties and deploy without continuing treatment with ustekinumab. His prior dermatology notes were requested to better assess the severity of his baseline disease, followed by a candid discussion between the military dermatologist and the patient about treatment options and their respective ramifications to his military career. One option included continuing ustekinumab, which would initiate an MEB evaluation and likely result in separation. Another option was UV therapy, which would not prompt an MEB evaluation but would not be available in deployed environments. Apremilast was offered as a third treatment option and could be used in place of UV therapy during deployment along with topical medications. This patient opted to continue treatment with ustekinumab, resulting in MEB review and separation from military service.

Dermatology Treatment Considerations

Civilian dermatologists should be aware of specific considerations when treating active US service members with common cutaneous diagnoses such as acne, atopic dermatitis (AD), psoriasis, dissecting cellulitis of the scalp (DCS), and lupus erythematosus (LE). This discussion is not meant to be all-inclusive but provides information and examples related to common treatment challenges in this patient population.

Acne
Acne is common in the active-duty military population. Typically, acne should be treated per recommended guidelines based on type and severity.⁸ Medical evaluation board review is warranted in cases of severe acne that is unresponsive to treatment and interferes with a service member’s performance.^5,6 Unique situations in the active-duty military population include the following:

• Use of minocycline. Aircrew members have unique restrictions on many medications,⁶ including minocycline, which is restricted in this population due to vestibular side effects. Doxycycline is an acceptable alternative for aircrew members; however, even this medication may require a ground trial to ensure there are no idiosyncratic effects.

• Use of isotretinoin, which is not permitted in aircrew members, submariners, or divers. If they take this medication, they will be temporarily removed from duty for the duration of treatment and for a period of time after completion (1–3 months, depending on service). Isotretinoin also is not used during deployment due to potential side effects, the need for laboratory monitoring, and iPLEDGE system requirements.

Atopic Dermatitis
A history of AD after the 12th birthday is considered a disqualifying condition with regard to military service,³ though mild and well-controlled disease can easily be overlooked during entrance physical examinations. Members frequently present with eczema flares following field training exercises where they are outdoors for many hours and have been exposed to grass or other environmental triggers while wearing military gear that is heavy and occlusive, which is further exacerbated by being unable to bathe or care for their skin as they would at home.

Separation from the military is considered when AD is moderate to severe, is unresponsive to treatment, and/or interferes with performance of duty. Severity often can be evaluated based on the impact of AD on performance of duties in addition to clinical appearance. A pilot who is distracted by itching presents a potentially dangerous situation. A soldier whose AD flares every time he/she goes to the field, requiring him/her to return home early to control symptoms, can be considered moderate to severe due to lack of ability to do his/her job away from home base.

Response to treatment is more often where trouble lies for military members with AD, as patients are only permitted to take emollients, preferred cleansers, and topical medications to field training exercises and deployments. UV therapy is used to control disease in the military population but is not an option in deployed environments. Classic immunosuppressants (eg, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine) may result in a good response to treatment; however, due to their side-effect profiles, need for laboratory monitoring, and immunosuppressive nature, long-term use of those medications will result in a nondeployable status. Dupilumab does not appear to have the immunosuppressive effects of other biologics; however, the medication requires refrigeration,⁹ which currently precludes its use in the deployed environment, as it would be difficult to ensure supply and storage in remote areas.

Service members with a history of AD are exempt from the smallpox vaccine due to concerns about eczema vaccinatum.¹⁰

Psoriasis
Psoriasis is another dermatologic condition that does not meet military admission standards,³ and mild undiagnosed cases may be overlooked during the entrance physical examination. Because psoriasis commonly affects young adults, it may manifest in service members after entering service. If psoriasis is extensive or refractory to treatment, an MEB evaluation may be required.^5,6 Widespread psoriasis can result in considerable discomfort when wearing body armor and other military gear. Severe localized disease can have duty implications; service members with treatment-resistant scalp psoriasis or pustular psoriasis of the feet may have difficulty wearing helmets or military boots, respectively.

Most service members with limited psoriasis vulgaris can be managed with topical steroids and steroid-sparing agents such as calcipotriene. Some service members opt not to aggressively treat their psoriasis if it is limited in nature and not symptomatic.

When discussing systemic treatments beyond light therapy in those with refractory disease, apremilast can be a good first-line treatment option.¹¹ It is an oral medication, has minimal monitoring requirements, and lacks immunosuppressive side effects; therefore, it does not adversely impact deployability. If patients do not improve in 4 months with apremilast, biologics should then be considered; however, biologics have service implications, the most important being inability to deploy while taking the medication. In rare circumstances, military dermatologists may discuss utilizing biologic therapy only in the nondeployed setting. In these cases, service members are counseled that biologic therapy will be discontinued if they deploy in the future and treatment will be sustained with topicals and/or apremilast through the deployment. The treatment plan also should be communicated to the patient’s primary care provider to ensure that he/she is in agreement.

Dissecting Cellulitis of the Scalp
Dissecting cellulitis of the scalp may result in separation if the condition is unresponsive to treatment and/or interferes with satisfactory performance of duty.⁵ In addition to causing considerable pain, this condition can prevent service members from wearing combat helmets, which limits their ability to train and deploy. One of the authors (S.C.) has had more service members undergo an MEB evaluation for DCS than any of the other conditions mentioned.

Topical tretinoin and topical antibiotics can be used in conjunction with either doxycycline or minocycline to treat DCS, with the addition of intralesional corticosteroids for painful nodules. Fluctuant lesions are treated with incision and drainage. If there is inadequate response to treatment after 2 to 3 months, oral clindamycin and rifampin can be tried for 3 months. As an alternative measure or if the condition is refractory to oral clindamycin and rifampin, isotretinoin can then be used. One of the authors (S.C.) typically recommends a temporary no-helmet profile to the patient’s primary care provider until his/her next dermatology appointment. If the patient still has substantial disease despite these treatment options, it is recommended that the patient be issued a permanent profile for no helmet wear, which will prompt an MEB evaluation. Although tumor necrosis factor α inhibitors can work well in patients with DCS, the use of biologics is not conducive to continued service.

Lupus Erythematosus
A history of LE is disqualifying from military service. Patients who develop LE while on active duty will be referred for MEB evaluation if their disease is unresponsive to treatment and/or interferes with the satisfactory performance of duty.^5,6 In general, connective tissue diseases have an array of physical implications that can affect military service, including photosensitivity, joint inflammation, and internal organ involvement. Similar to the other dermatologic conditions described, treatment of connective tissue diseases also can present challenges to continued military service. Considerations in the case of LE that are unique to military service members include the following:

• Sun exposure. Most military service members are required to work outside in all manners of conditions, which include hot, sunny, humid, and/or dry climates. Often physicians might counsel sun-sensitive patients with LE to avoid being outside during daylight hours, limit window exposure at work, and avoid daytime driving when possible; however, these recommendations are not possible for many, if not most, service members.

• Immunosuppressive therapies are incompatible with military deployment; therefore, prescribing methotrexate, cyclosporine, mycophenolate mofetil, rituximab, or belimumab for treatment of LE would prompt an MEB evaluation if the treatment is necessary to control the disease.

Final Thoughts

The recent changes to military medicine are needed to meet our country’s defense requirements and will ultimately result in civilian specialists playing a larger role in the care of our military population. This article highlights unique factors civilian dermatologists must consider when treating active-duty military patients to ensure they remain deployable during treatment.