an overview of the assessment and management of

J Royal Naval Medical Service 2014, Vol 100.3
244
Eczema and dermatitis in the afloat
population: an overview of the
assessment and management of the
common erythematous skin conditions
encountered in adults deployed on
afloat platforms
Surg Lt Cdr A Lundie, Surg Cdr M Turner
Abstract
Skin conditions constitute a large proportion of the workload of deployed medical staff. Dermatology is an area where
pattern recognition is key, and making a diagnosis can sometimes be difficult for deployed medical staff, who may have
limited experience of dermatology. This article provides a structure to assess patients presenting with skin rashes, as well
as a summary of the key features and management of common types of dermatitis that may be encountered when deployed
afloat: atopic eczema; irritant contact dermatitis; pompholyx; scabies and plaque psoriasis.
Introduction
Skin conditions constitute a large proportion of the
workload of deployed medical staff, with 20% of clinical
presentations (n=83) during the author’s (AL) 2012
deployment to the Central Arabian Gulf being classified as
dermatological disease (1).
Dermatitis is defined as an inflammation of the skin,
and although the underlying pathological trigger for the
inflammation differs in the different types of dermatitis, all
types result in an activation of the skin’s immune pathways
resulting in inflammatory infiltration of the epidermis and
epidermal spongiosis (intracellular oedema) (2,3). These
conditions are often referred to as ‘eczema’, and this can
often cause confusion as to whether the term is being used to
describe the collective group of inflammatory skin conditions
or the specific condition of atopic eczema. Therefore, for
the purpose of this article, the term ‘dermatitis’ will be
used to describe the collective group of inflammatory skin
conditions. Although the underlying pathological trigger
may differ (allergen, irritant or infection), the common
histopathological features common to the different types
of dermatitis result in very similar clinical features, i.e.
variants of an erythematous maculopapular rash. This can
make establishing an accurate diagnosis difficult.
Management of dermatitis is best approached with an
understanding of the natural progression of the disease.
Figure 1 illustrates how an initial pathological trigger leads
to an inflammatory response within the skin (4).
Figure 1: The ‘Itch and Scratch Cycle’. A simplified illustration
of how dermatitis can be triggered and result in a perpetuating
cycle of worsening symptoms. Adapted from National Eczema
Association (4).
This infiltration of the skin with inflammatory mediators
can cause the initial symptoms of inflammation, erythema
and pruritis. The pruritis inevitably leads to scratching
and excoriation, even in the most astute patients (it can
often become an unconscious or even nocturnal habit).
Excoriation leads to further skin damage, which in turn
triggers further inflammation and the cycle continues.
The concept of the ‘Itch and Scratch cycle’ should be
communicated to patients early in a management plan. This
will make the patient mindful of the fact that excoriation
245
will worsen pruritis and encourage the correct use of
treatments (such as emollients) to ease pruritis.
Environmental factors can also have a role to play in
triggering or worsening pruritis. Humidity or exercise can
result in increased perspiration which can trigger ‘prickly
heat’ symptoms. Emotional stress can lead to anger,
frustration and embarrassment, which causes skin flushing
and pruritis (4). Management of dermatitis usually involves
targeting one or many of the stages in this cycle. For
example, emollients improve the skin’s barrier function and
reduce skin damage as well as easing pruritis, whilst topical
steroids suppress the release of inflammatory mediators.
A management plan that takes a holistic approach and
considers the multiple factors that contribute to the disease
progression is likely to be more successful than focusing on
just one aspect.
The aim of this article is to provide a framework for making
Clinical
focus mainly on the inflammatory causes of dermatitis;
readers should consult the article by Tanzer et al in a
previous issue of this journal for a review of infective
conditions (5).
Diagnosis
Both MBR and GDMO training focus on clinical history
as an important area when formulating a diagnosis; this
principle also applies in dermatology. A common pitfall
in clinical practice is to focus immediately on the clinical
appearance of the rash, at times at the expense of a thorough
clinical history. This results in a less structured approach that
may in turn lead to inaccurate diagnosis. The SOCRATES
mnemonic is commonly used as a structure to follow when
assessing a patient presenting with pain (6). It is the author’s
opinion that this mnemonic can be easily adapted to structure
a dermatological history and ensure both that key aspects
of the history are not omitted (6,7), and also that a patient
measure of severity is included (Box 1) (8).
Site – Consider all the skin and scalp as well as mucous membranes. Is there a specific distribution? Is the rash only in
sweaty or sun exposed areas? Is the rash limited to flexural or extensor surfaces?
Onset – Is this an acute presentation or an ongoing chronic problem? Have they had rashes like this before? Is this an
exacerbation of a pre-existing skin condition?
Character – The symptoms experienced by the patient: Does it itch? Is it sore or tender to touch? Does it bleed or is
there any discharge?
Radiation – The development of the rash. Where did they notice the rash first and how has it spread across the body?
Did it initially appear in one or multiple locations?
Associated Symptoms – Is the patient well? Do they have a fever, lethargy or malaise? Do they have any pain elsewhere
(e.g. in joints) that appeared at the same time as the rash? Do they have any other medical problems or past medical
history?
Timing – When did the rash appear and what was the patient doing prior to its appearance? Occupational history is
important: consider whether the patient is a Marine Engineer who has been working in a hot engine room or a chef
who has been regularly hand washing or using cleaning fluids. Did they eat something unusual or come into contact
with anything new? Do they ever get this rash when there are at home or on leave? Are they under increased emotional
stress?
Exacerbating/Relieving Factors – Has the patient noticed that anything makes the rash worse or better, e.g. temperature
changes, salt water or sun exposure? Are they known to be allergic or hypersensitive to anything? Have they tried any
creams or medications before for this rash?
Severity – The patient is asked to score the effect the rash is having both functionally and occupationally. Either score
out of 10 or consider using a scoring system such as the Patient Oriented Eczema Measure (8).
Box 1: The SOCRATES mnemonic for a dermatological history (Adapted from Kernicki JG (6) & Borton C (7)).
an accurate diagnosis, outlining the key features of common
dermatitis presentations on a deployed platform, as well as
providing some guidance on how a General Duties Medical
Officer (GDMO) or Medical Branch Rating (MBR) could
approach the management in the deployed context within
the limitations of the Medical Equipment Table for Service
Afloat (METSA). The METSA governs the pharmaceutical
repertoire on an afloat platform, providing a limited
range, but adequate supply, of topical preparations to treat
commonly encountered skin conditions. This article will
Once a history has been taken, the clinician will hopefully
have established a list of differential diagnoses that can
be explored by clinical examination. First, observe the
distribution, symmetry and colour of the rash. Symmetrical
rashes tend to suggest endogenous disease (originating
from within the body), such as psoriasis or atopic eczema,
whereas exogenous rashes, such as tinea, are more likely
to be asymmetrical (9). The morphology of the individual
lesions should be noted, in particular: colour; shape;
elevation; edge (distinct or ill defined); and the presence of
J Royal Naval Medical Service 2014, Vol 100.3
any crusting or scale. Excoriation or infection may alter the
appearance of the rash. Gently palpate the skin to assess the
texture and thickness of the lesions, whether there is any
tenderness and whether the colour will blanch with pressure.
Gently scratching the skin may cause scale to become
more apparent. Significant crusting should be carefully
removed to allow for assessment of the skin underneath (9).
Describing the lesion using the nomenclature defined in
Box 2 may help with consolidation of examination findings
and facilitate record keeping or discussion of findings with
a senior colleague (9,10).
Macule – Flat circumscribed area of change in skin
colour (not raised) less than 1.5cm in diameter.
Patch – As above but >1.5cm in diameter.
Papule – small circumscribed elevation of the skin
(<5mm diameter).
Plaque – flat topped palpable lesion (a gathering of
papules >5mm diameter) or an area of skin thickening.
Nodule – Solid circumscribed elevation of the skin
whose greater part is beneath the skin surface (more
felt than seen).
Vesicle – collection of clear fluid (diameter < 5mm).
Bulla – collection of clear fluid (diameter > 5mm.
Pustule – collection of pus
Box 2: Terminology for use when describing skin lesions (9,10).
Atopic eczema
80 % of cases of atopic eczema first present under the
age of five years and, therefore, it is unlikely that the first
presentation of this condition will occur on a deployed
platform (11). Thorough exploration of past medical history
is imperative before making this diagnosis (Box 3).
The specific pathological trigger for atopic eczema is not
The rash must be itchy and fulfill at least 3 of the
following criteria:
• History of itchiness in the skin creases (bends
of the elbows or behind the knees)
• Visible eczema in the skin creases (flexural
eczema)
• History of asthma or hay fever
• Initial onset under the age of 2 years
• A tendency towards dry skin
If these criteria are not fulfilled other differential
diagnoses should be considered.
Box 3: The diagnostic criteria for atopic eczema (11).
fully understood. However, it is thought to have genetic
influences leading to immune dysfunction, combined with
environmental influences. Eczema has shown degrees of
concordance in twin studies and eczema and other atopic
disorders (e.g. asthma and hay fever) have shown clustering
246
in families. Current theories regarding the genetics and
immune mechanisms behind atopic eczema are summarized
at the reference (12). Figure 2 demonstrates the classical
flexural distribution of atopic eczema.
Figure 2: Atopic eczema on flexural aspect of the arm.
(DermNetNZ).
Guidance for initial management is to avoid any obvious
environmental precipitants, irritants to the skin, or
substances that compromise the skin’s barrier properties.
Low humidity, central heating and air-conditioning can
dry the skin, affecting its barrier function and causing
pruritis. Heat and high humidity can increase perspiration
and pruritis. Coarse clothing or washing powders used to
launder clothes can irritate the skin of some individuals.
Avoidance of the climate, air conditioning or the washing
powder used on clothing can be difficult on a deployed
platform (although some platforms may have the facility
to launder clothes separately using personal washing
powder). The second line intervention is to maintain the
barrier function of the skin by regular use of emollients
and by avoiding shampoos and shower gels that dry and
irritate the skin. One of the irritants found in many soaps,
shampoos and shower gels is Sodium Lauryl Sulphate
(SLS), which is also contained in Aqueous Cream. Use
of products containing SLS (including Aqueous Cream)
should be avoided in all patients suffering from dry skin
conditions (13). SLS-free emollients can also be used
Quantities of emollients recommended for generalised eczema
600g / week for an adult
250 - 500g / week for a child
Suitable weekly quantities of emollients for specific
areas of the body
Scalp 100g
Face 30g
Both hands 50g
Trunk 400g
Both arms or legs 200g
Groins & genitalia 25g
Box 4: Emollient prescription quantity guide (11).
247
for washing in the place of shower gels (E45® Cream
or Dermol® 500). The ideal frequency for application of
emollients is every four hours, or at least three times a day;
under-use of emollients is the usual reason for eczema not
remaining under control (11). Patients should, therefore, be
encouraged to integrate a skin care regimen into their daily
routine. The quantity guide found in Box 4 will facilitate in
the prescription of sufficient emollients and may assist the
clinician in monitoring compliance.
Emollients will also help ease pruritis, but if they are
not sufficient an antihistamine could be considered (e.g.
Loratadine or Chlorphenamine). Care should be taken when
prescribing sedating antihistamines (e.g. Chlorphenamine)
if the patient is likely to be operating heavy machinery
or watch-keeping. Prescribing a sedating antihistamine
to take at night can reduce this risk, but always consider
the operational tempo and the roles that the individual will
fulfill at both action and emergency stations. If regular
emollient use is not sufficient, topical steroids can be used
in short courses to manage an acute exacerbation of the
condition. Most platforms carry a mild potency steroid
cream (hydrocortisone 1%) and a potent steroid cream
(betamethasone valerate 0.1%) or ointment. In most cases
the mild potency agent should be sufficient, used sparingly
once or twice daily until the eczema has resolved. In more
severe cases a potent steroid cream may be required,
but this should usually be limited to a three- to five-day
course, and sensitive areas, such as the face, should be
avoided (14). Book of Reference (BR) 1991 contains useful
advice on emollients and steroids that can be provided to
patients (15). As previously discussed, it is important to
take a holistic approach to management of dermatitis and
therefore incorporate strategies to manage scratching and
excoriation into the management plan. Encourage the
patient to become actively aware of scratching and try to
break the cycle. Keeping occupied with structured daily
activity, keeping fingernails cut short, moisturising instead
of scratching and, if unable to resist scratching, using the
back of the nails to limit excoriation will all help. Increased
emotional stress can also precipitate scratching. It is therefore
important for the clinician to explore this with the patient and
facilitate the development of coping strategies (4).
Irritant contact dermatitis
Presenting in a similar fashion to atopic eczema, irritant
contact dermatitis is caused by single or repeated exposures
to a substance that irritates the skin. At a basic level water
can be an irritant if the exposure is repetitive, and this type
of dermatitis is often seen in chefs or healthcare workers
who wash their hands on a regular basis or immerse their
hands in water for long periods of time (16). Irritants range
from mild, where repeated exposure causes symptoms,
to more severe irritants, where a single exposure may be
sufficient to cause symptoms. The management of severe
Clinical
irritants on afloat platforms will be governed by Control
of Substances Hazardous to Health (COSHH) regulations;
personal protective equipment (PPE) should be worn to
prevent skin contact (16). It is, therefore, more likely that it
will be prolonged exposure to milder irritants that will cause
symptoms for deployed personnel. Initially the skin will
become dry, followed by mild pruritis, soreness, erythema
and cracking of the skin, as demonstrated in Figure 3.
Figure 3: Irritant contact dermatitis (DermNetNZ).
Unfortunately, from these initial stages the skin’s natural
barrier is broken down, making it more susceptible to the
irritant and causing a vicious cycle of increasing damage
(17). Optimum treatment is preventing exposure to the
irritant. However, if the irritant is water or soaps, this
can be challenging. The clinician should advise patients
to ensure that hands are well rinsed of soap residue after
washing and thoroughly dried, paying special attention to
the web spaces between the fingers. SLS-free emollients
(E45® Cream or Dermol® 500) can also be used instead
of soaps for hand washing. Emollients used regularly will
create a protective barrier and preserve the integrity of the
skin (17). Rubber or Nitrile gloves could also be worn when
washing up, working in the galley or cleaning. However,
prolonged wear may also irritate the skin further. Cotton
gloves worn underneath may help to mitigate this. If the
dermatitis becomes severe the individual may benefit from
modification of their duties to allow the skin to heal. A short
course of a steroid cream can also be used to suppress some
of the inflammation and improve symptoms, but should be
used with caution if there is evidence of cracking of the
skin, as suppression of the immune response may delay
wound healing (18).
Pompholyx
Also known as dyshydrotic dermatitis or dyshydrotic
eczema, pompholyx is characterized by an itchy vesicular
reaction on the hands, fingers and soles of the feet. Its
aetiology is unknown, and although it is thought to be
J Royal Naval Medical Service 2014, Vol 100.3
associated with excessive sweating, there is no histological
evidence to support this. Despite this, 40% of patients
with pompholyx also suffer from hyperhidrosis (excessive
sweating), and the condition is more common in the spring
and summer and in warmer climates. It can be acute,
chronic or recurrent, and affects the hands in 80% of cases.
It classically presents symmetrically with symptoms of
itching and burning on the hands, feet or both, followed
after several hours by an eruption of tiny vesicles initially
on the lateral aspect of fingers, as shown in Figure 4, then
on palms and soles (19).
248
valerate 0.1%) can control itching in the vesicular phase
when the blisters are developing, but after the vesicles have
dried emollients may be useful to prevent the skin from
cracking. Large blisters can be drained aseptically (19).
Scabies
Scabies can be common on ships and submarines owing
to close living conditions. The condition is caused by a
parasitic infestation with Sarcoptes scabiei mites, which
burrow under the skin to lay eggs. Burrows are usually
Figure 4: Pompholyx vesicles on the hands and feet (DermNetNZ).
Later in the disease progression, the vesicles will burst,
occasionally with some development of scale and
lichenification. Pompholyx usually requires no active
treatment and will usually resolve spontaneously after three
to four weeks. However, if the itching is severe, treatment
may be requested. Potent steroid cream (betamethasone
Figure 6: Pustular erythema on the hand as a result of scabies
(DermNetNZ).
located on the wrists or between the finger webbing, and
appear as fine, dark or silvery lines 4-10mm long, as shown
in Figure 5.
Figure 5: A classic burrow in scabies (DermNetNZ).
Around two to four weeks after infestation, a blotchy red
rash (Figure 6) and widespread itching can occur (sooner
249
Clinical
if the patient has had scabies before). This is owing to
an allergic reaction to the mites’ saliva, faeces or eggs.
Because of the delay in development of the rash, a patient
can be contagious for some time before they present
with symptoms. Therefore, if one person is diagnosed
as having scabies, all close contacts (i.e. the whole mess
deck) should be treated. Treatment is with an insecticide
(usually Permethrin cream), while simultaneously washing
all clothes, towels and bedding at a temperature of >50
degrees C. If washing facilities are limited an alternative is
to seal clothing and bedding in plastic bags for at least 72
hours to allow the mites to die. The itch can be severe so
the clinician may wish to consider providing patients with
other treatment, such as Crotamiton 10% cream (Eurax),
Hydrocortisone 1% cream or antihistamine tablets to
provide symptomatic relief (20).
well demarcated, red/pink lesions (plaques) with overlying
white scale that can be accentuated by gentle scraping (21).
Plaque psoriasis
Like eczema, psoriasis is an endogenous condition that
incorporates both a strong genetic basis (30% have
a family history), along with environmental triggers.
However, unlike eczema, it has an established T-cell
mediated autoimmune aetiology, and is uncommon in
children, usually first presenting before the age of 35. The
commonest form of psoriasis is plaque psoriasis which
accounts for 90% of psoriasis presentations. Other forms of
psoriasis will not be covered in this article. Sunlight usually
reduces the severity of psoriasis, with symptoms worsening
in the winter and improving in summer; however, in a
small minority, strong sunlight and sunburn can exacerbate
Nail changes are often seen as pitting and onycholysis
(separation of the nail from the nail bed) or yellow-red
discoloration of the nail bed (the ‘oil drop’ sign) (Figure 8).
The Psoriasis Area and Severity index (PASI) can be used
to score the severity of the psoriasis (22). If the psoriasis as
severe (>10% skin involvement), or if there is any evidence
of systemic involvement, such as fever or malaise, urgent
input should be sought from a base port general practitioner
(GP). Treatment is similar to that of atopic eczema, and
emollients should be used regularly to reduce itch and
scale and preserve skin integrity. In addition to this,
potent steroid creams (beclomethasone valerate 0.1%) and
Vitamin D analogues (calcipotriol cream) can be applied
once daily (one in the morning, one in the evening) for up
to two weeks as initial treatment. Calcipotriol cream can be
continued as long term therapy provided that local irritation
does not occur. As with atopic eczema, ensure that a holistic
approach is taken by addressing triggers and breaking
the itch and scratch cycle. If patients fail to respond to
treatment, advice from base port GPs or secondary care
should be sought (21).
Figure 7: Plaque psoriasis affecting the extensor surface of the
arm (DermNetNZ).
symptoms. Psychological stress may also play a role as
in triggering the condition, as can smoking and alcohol.
There are several drug triggers, with non steroidal antiinflammatories (NSAIDS), antimalarials and antibiotics
(Doxycycline and Penicillin) being the main ones of
most relevance to the afloat population. Finally, trauma
and infection to the skin can cause the development and
spread of psoriasis. As demonstrated in Figure 7, patients
will typically present with symmetrical, occasionally itchy,
Figure 8: Pitting and onycholysis when psoriasis affects the
nails (DermNetNZ).
Secondary infection
Whenever the surface integrity of the skin is broken down
by dermatitis an important immune barrier is breached.
Therefore, there is a chance that opportunistic infections
can develop. Bacteria can develop on the surface of the
skin causing golden crusting, sometimes with vesicles
and pustules, or can spread below the skin surface and
cause cellulitis. When assessing all the skin conditions
listed above, the clinician should consider whether there
are any signs of secondary infection (the skin feeling hot
to touch, looking exceptionally red and angry, or being
tender to palpate). This is of particular importance when
considering the use of steroid creams, which can worsen
any infections that are present. This is particularly relevant
in tinea infections (a common differential diagnosis to
J Royal Naval Medical Service 2014, Vol 100.3
consider when assessing dermatitis), which are discussed
in detail, along with other infective skin conditions, in an
article recently published in this journal (5).
Special occupational considerations
When prescribing any medication it is important to consider
the specific occupation of the individual concerned.
Fortunately dermatological preparations are typically free of
significant side effects and their use will not usually restrict
personnel from their duties. Paraffin-based treatments (e.g.
white soft paraffin and some ointments) are flammable
and when in contact with clothing or dressings are easily
ignited by a naked flame. The risk will be greater when
these preparations are applied to large areas of the body
(23). Clinicians should be mindful of this when prescribing
these products to personnel in fire-fighting roles or those
who might come into contact with naked flames (e.g. chefs).
Divers should be made aware that dry suit seals perish
quickly if emollients and oils (including most sun creams
and insect repellents) are applied to them. Care should be
250
taken to ensure that dry suit seals are thoroughly cleaned
after use to minimize damage (24). When prescribing for
aircrew, Air Publication (AP) 1269 should be consulted.
Of specific relevance to this article, the only approved
antihistamine for aircrew use is Loratadine (25).
Conclusion
This article provides a basis for the assessment and
management of the common forms of dermatitis
encountered on board afloat platforms. Although written
with the deployed Royal Navy clinician in mind, many of the
concepts also apply to general practice as a whole. Deployed
medical staff may have limited experience of dermatology,
but it is hoped that this article may inspire confidence in
making an accurate diagnosis and commencing treatment.
In cases that are not so clear, the structure provided for
history and examination should provide the information
required to allow a base port medical practitioner to assist
remotely.
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Acknowledgements
The authors are grateful to DermNetNZ.org for permission to reproduce the images used in this article.
Authors
Surgeon Lieutenant Commander AJ Lundie MB BS RN
General Practice Specialty Training Registrar
[email protected]
Surgeon Commander MJ Turner MB BS, MRCS, MRCGP, Dip Derm, Dip Occ Med, Dip Av Med RN
General Practitioner
Department of Community Psychiatry
RAF Brize Norton, Carterton, Oxfordshire
Clinical