Clinical Practice Guideline

for

DERMATITIS

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: Dermatitis is a generic term that describes inflammatory conditions of the skin, and can have an acute or chronic course, and is commonly applied to adult onset cases of “eczema.”  Two major categories include atopic dermatitis (AD) and contact dermatitis (CD).  This guideline will consider them all as “dermatitis” and discuss unique characteristics only as relevant to waiver consideration. 

 

Atopic dermatitis (AD), also known as eczema or atopic eczema, is a chronic relapsing skin condition characterized by intense itching, dry skin, and inflammation. AD is one of the most common skin diseases worldwide, with prevalence up to 30%.  About half of the cases are diagnosed in the first year of life and about 85% by age 5.  AD develops as a result of a complex interrelationship of environmental, immunologic, genetic, and pharmacologic factors and may be exacerbated by infection, psychologic stress, seasonal/climate changes, irritants, and allergens. The disease often moderates with age, but patients carry life-long skin sensitivity to irritants, and predisposition to occupational skin disease.  The scratched itchy skin, caused by AD develops eczema (a physical finding); in other words, it is the itch that rashes.  AD is often perceived as a minor condition, with patients, however, studies have shown that AD has a greater effect on quality of life than other common skin diseases, such as psoriasis. There is no complete cure for AD, so medical treatment focuses on avoidance of triggers, skin hydration, and reduction of skin inflammation.

 

CD is a delayed-type reaction to an exogenous substance that serves to “trigger” a skin reaction.  Irritant contact dermatitis (ICD) represents about 80% of all contact-related dermatoses and results from non-immunologic physical or chemical damage to the skin and can occur in any individual.  Allergic contact dermatitis (ACD) is an immune system reaction that only affects those with a genetic predisposition who have exposure to certain substances.  Nickel as a component of the metal in jewelry is a classic example of a triggering substance for ACD.

 

Diagnosis:  History and physical exam are often all that is required to make these diagnoses.  AD is diagnosed based on a constellation of clinical findings, mainly pruritus, facial/extensor involvement in infants/children, flexural lichenification in adults, chronic/relapsing dermatitis, and personal/family history of atopic disease.  The diagnosis of allergic contact dermatitis can be confirmed by patch testing.  Confirmatory tests for the diagnosis of irritant contact dermatitis are not available, but patch testing can be used to rule out allergic contact dermatitis.

 

Clinical Risk:  AD is often intensely pruritic and acutely characterized by erythematous papules with excoriation, vesicles, and exudate, with later scaling and thickened plaques, and chronic disease manifesting with lichenification and fibrotic papules.  The disease is exacerbated by dry climates and affected individuals may have an increased susceptibility to contact irritants.  Complications include ocular problems (eyelid dermatitis, chronic blepharitis, disabling atopic keratoconjunctivitis, vernal conjunctivitis, intense pruritus, keratoconus, cataracts), recurrent skin infections, hand dermatitis (aggravated by wet work), and potentially life-threatening exfoliative dermatitis.  AD is frequently associated with allergic rhinitis and/or asthma.  ACD may be acute or chronic, correlating with allergen exposure, and is intensely pruritic with similar skin findings as described for AD.  ICD is correlated with exposure to offending agents, and may cause a stinging or burning sensation initially followed by induration, blisters, erythema, or chapping in acute stages; it can also progress to the chronic findings listed above.

 

Treatment:  Treatment of dermatitis requires a systematic, multi-pronged approach that incorporates careful skin cleaning and hydration, elimination of flare factors and potentially medical therapy.  Individualized skin care is essential in dermatitis patients.  Careful use of emollients to manage dry skin and soaps to prevent infection without triggering worsening flare-ups is a key part of prevention and over-the-counter treatment.  Eliminating exposure to a triggering factor or material may not be possible due to the difficulty in determining the factor or removing from a patient’s life.  Many believe that AD and ACD are caused by unknown triggers in the environment.  If prevention or OTC treatment fails, therapy is mainly with topical or systemic prescription corticosteroid and other immuno-modifying medications, antihistamines, and possibly ultraviolet light therapy.  New agents include anti-inflammatory agents such as pimecrolimus (Elidel®) and tacrolimus (Protopic®), which act as immunosuppressants by inhibiting calcineurin, a calcium- activated phosphatase.  Pimecrolimus (Elidel) was recently approved for aircrew use.

 

Table 1 – Characteristics of atopic dermatitis (AD), irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD)

 

 

Characteristics

Atopic Dermatitis

Irritant Contact Dermatitis

Allergic Contact Dermatitis

Identifiable, controllable trigger

No

Yes

Yes

Patch test confirms diagnosis

No

No

Yes

Genetic contribution

Yes

No

Yes

Percent of contact derm cases

N/A

80%

20%

Environmental, psychological or seasonal variation

Yes

No

Possibly

 

Aeromedical Concerns: Aeromedical concerns include the risk of in-flight distraction/reduced performance as well as disease progression and medical treatment incompatibility due to the military aviation environment.  Discomfort from pruritus or pain can be significant and the resulting distraction may jeopardize flight safety or optimal performance.  AD is associated with allergic rhinitis and asthma and aircrew require a thorough evaluation of those conditions for compatibility with flying duty.  Complications from AD involving the eyes can occur and keratoconus (elongation and protrusion of the corneal surface) is believed to be more common in the atopic patients.  Affected skin in areas where there is constant pressure or rubbing from aviation equipment (helmet, gloves, mask, harnesses, and seat) may cause additional performance decrement and disease progression.  Use of systemic corticosteroids, high potency topical steroids, and antihistamines may cause side effects that would jeopardize flight safety.  In the short term, ultraviolet light therapy has side effects that include nausea, dizziness, headache, and photosensitivity.  Long term side effects include pruritus, skin damage, and increased skin cancer risk.  UV therapy may require several treatments per week, and could be unavailable in a deployed setting, and may require excessive time lost from flying duty.  If the trigger or flare factors cannot be identified and avoided, there is a potential for recurrence that may be incompatible with worldwide qualification and/or flying duties.

 

Medical Work-up: Evaluation for dermatitis should include a complete history of all skin conditions, description and treatment of all skin conditions, current medications and level of effectiveness and a consultation report from a dermatologist.  If the case is allergic in nature, a discussion of presence or absence of asthma and allergic rhinitis symptoms needs to be annotated.

 

Aeromedical Disposition:

 

Air Force: Flyers that are asymptomatic with minimal potential for flare-ups and those controlled with topical therapy for areas not interfering with aviation equipment can expect a waiver.  Those with severe symptoms or triggers that cannot be avoided may be considered for waiver.  Please review AFI 48-123 for applicable information and consult the current Official Approved Aircrew Medications Quick Reference List available online to ensure the most accurate information.

 

Army: A current or history of atopic dermatitis or eczema after the 9th birthday is disqualifying; as is a current or history of contact dermatitis especially if it involves materials used in any type of required personal protective equipment.  The primary aeromedical concern is the distraction pruritus represents, and to a lesser extent the possible interference with the proper wear of equipment.  For aircrew, mild to moderate atopic dermatitis is not considered disqualifying if the condition is controlled with the use of topical treatments to include tacrolimus ointment and mild steroids ointments (desonide and triamcinolone).  Moderate to severe atopic dermatitis requiring the need for moderate or high potency steroid ointments or oral medications is disqualifying and requires a waiver for continued aviation service.  Any history of atopic dermatitis requiring anything more than an occasional use of low potency steroids is disqualifying for flight applicants and requires an exception to policy (waiver).  A thorough dermatology evaluation is required in all waiver cases and lack of interference with ALSE gear must be documented.

 

Navy: Symptom severity and the requirement for therapy will determine the aeromedical disposition.  Patients controlled on topical therapy over small areas and patients who are asymptomatic on stable doses of loratadine (Claritin) OR fexofenadine (Allegra) may be considered for waiver.  An initial seven day grounding period is required for loratadine and fexofenadine to document no adverse effects.  A one time separate waiver submission is required for loratadine or fexofenadine.

 

INFORMATION REQUIRED:

1.     Allergy/immunology consultation to rule out asthma or hay fever

2.     Dermatology consult (when clinically indicated)

3.     Detailed full-body skin exam

4.     Details of current treatment

5.     Documentation of the ability to wear flight gear and achieve mask seal (if applicable)

 

Civilian: Much the same disposition as is done by the USAF will apply to the FAA.  Topical steroids are acceptable but as in many other medical conditions, if an equivalent dose of oral prednisone requiring over 20 mg, certification will not be allowed.  There is no contraindication to the use of steroids used topically. Sedating antihistamines are unacceptable. 

 

Waiver Experience:

 

Air Force: Review of AIMWTS produced a total of 81 aviators submitted for a waiver for eczema, atopic dermatitis, chronic dermatitis and 66 (82%) received a waiver.  The majority of the denied waivers was for initial qualification or established aircrew with multiple medical conditions. 

 

Army: The Aeromedical Epidemiological Data Repository (AEDR) catalogs all Army flight physicals since 1960.  There have been approximately 160,000 individual aircrew entered in this database.  During this period of time, there were 24 requests for waiver of this condition, 9 in initial applicants and 15 in pilots.  Only 1 was denied waiver which was in the case of an applicant.  Since this is usually a self-limited disease, the incidence is much higher than indicated, but they did not warrant aeromedical summaries and are not included in these figures. 

 

Navy: Not available at this time.

 

Civilian: Statistical data is not currently maintained on these conditions. 

 

ICD9 Code for Dermatitis

691

Atopic Dermatitis

692

Contact Dermatitis and other eczema

 

 

References:

 

Belsito DV.  Occupational contact dermatitis:  Etiology, prevalence, and resultant impairment/disability.  Journal American Academy of Dermatology.  2005; 53(2):303-313.

 

Rayman RB, Hastings JD, et al.  Clinical Aviation Medicine, 4th ed.  Professional Publishing Group.  New York; 2006:  294.

 

Habif TF.  Chapter 3 – Eczema and Hand Dermatitis.  Clinical Dermatology:  A Color Guide to Diagnosis and Therapy, 4th ed.  Philadelphia:  Mosby; 2004. 

 

Mark B, Slavin R.  Allergic Contact Dermatitis.  Med Clin N Am.  2006; 90:  169-185.

 

 

Prepared by Drs. Rawson Wood and Karen Fox

11/10/10