Analysis of cases managed by dermatological service in the Chinese peacekeeping level 1+ medical treatment facility in Lebanon, 2018-2019.

INTRODUCTION: To accomplish the peacekeeping mission in Lebanon, China has deployed a level 1+ (CHN L1+) medical treatment facility (MTF) as per the new memorandum. The aim of this study was to review and analyse the skin diseases managed by Chinese dermatological service so as to gain the latest prevalence of different types of skin diseases in this mission area.
METHODS: All patients assessed and treated by the dermatological service of CHN L1+ MTF from January 2018 to May 2019 were included. A comparative analysis was made between this study and data published by other peacekeeping medical facilities.
RESULTS: A total of 549 patients were included (87.4% men, with an average age of 35 years old), consisting of 399 military personnel and 150 civilians. Dermatitis and eczema (27.1%) were the most common category of skin diseases, followed by cutaneous mycoses (13.3%) and disorders of skin appendages (10.6%). Among these categories, unspecified dermatitis (9.3%), acne vulgaris (6.6%), tinea corporis (5.3%), folliculitis (5.1%) and tinea pedis (4.7%) were the top five most common reasons for dermatological consultation.
CONCLUSIONS: To get a clearer understanding of the disease-type profile in this mission area was beneficial for peacekeeping doctors to make more accurate diagnosis, as well as to prepare more comprehensive medicines during the predeployment period. As dermatological service was lacking in basic medical troops, we would recommend the use of telemedicine to promote dermatological consultations when a specialist was not deployed. © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Dermatitis and eczema were the most common category of skin diseases in this study, while unspecified dermatitis, contact dermatitis and eczematous dermatitis were the leading types of this category.

Tinea corporis was the primary type of cutaneous mycoses while acne vulgaris was the dominant type of disorders of skin appendages.

Dermatological service was lacking in basic military medical treatment facilities, and teledermatology might be a solution for this.

Introduction

United Nations Interim Forces in Lebanon (UNIFIL) has been deployed since 1978, and around 10 200 peacekeepers from 43 troop-contributing countries were conducting peacekeeping operations in this mission area.1 China has been contributing peacekeepers to UNIFIL since 2006. As per the new memorandum, since May 2016, China sent 30 military medical staff to the mission area in Lebanon every year who were based at the level 1+ (CHN L1+) medical treatment facility (MTF) in Sector East of UNIFIL.2 Besides military personnel, many civilians (including local staff, local civilians and international civilians) were also working in this mission area. The medical service of military force and civilians was supported mainly by contingents’ level 1 MTFs and two level 1+ MTFs, namely UNIFIL Hospital in the headquarter of UNIFIL and CHN L1+ in Sector East. In addition to the primary healthcare supplied by level 1 MTF, level 1+ MTF has more modules such as primary dental care, basic laboratory facilities, forward surgical team, and so on. For the purpose of providing better service for the UNIFIL, China also sent a military dermatologist and a traditional Chinese medicine doctor to CHN L1+ MTF. To meet the dermatological demands of other sectors and supply humanitarian assistance to nearby locals, alternate consultations were arranged occasionally in the headquarter, nearby villages and schools. The patients who consulted in these places were also included in this study.

Historically, dermatological conditions have caused significant influence on deployed service personnel. Although skin disease has a low mortality, it contributes to a relatively large percentage of morbidity, significantly influencing the efficiency of the troops.3 For instance, during World War II, in the South Pacific theatre, skin diseases accounted for approximately 75% of all US soldiers seeking dispensary care and 20% of hospital admissions,4 whereas in the Vietnam War, skin diseases accounted for 7.4% of all admissions and 12.2% of outpatient visits in the US troops.5 Generally, military personnel were initially screened by contingents’ level 1 MTF, followed by referral to level 1+ MTF according to the severity of diseases. Besides the military MTF, several civilian level 3 medical facilities in Tyre and Beirut that have cooperative relationships with UNIFIL could accept the referral. As only the CHN L1+ MTF was manned with a military dermatologist, physicians in contingents’ level 1 MTF were inclined to transfer patients with cutaneous disorders to our facility. As rotation periods vary from 3 months to 1 year among different contingents, the incidence of some diseases we analysed might face some bias because some new rotation physicians might not choose referral as they were more experienced or due to some other reasons.

This study was aimed at investigating the latest prevalence of skin diseases among military personnel and civilians in this mission area. Therefore, the results of this study might guide other United Nations (UN) MTFs to supply better dermatological service, and the pharmacists would benefit from these data to prepare more comprehensive types of medicines in predeployment period.

Methods

A retrospective study based on electronic hospital records was conducted for all presentations to the dermatology department at the CHN L1+ in the Sector East of UNIFIL, Lebanon, during the period between January 2018 and May 2019. The medical data were kept in the facility’s internal database. Detailed data including nationality, gender, age, diagnosis, duration of diseases, registration time and treatment methods were extracted, while no private information was revealed. Military troops and military police were classified as military personnel, while local civilians, international civilians, local staff and nearby locals who received humanitarian assistance were classified as civilians. Meanwhile, some major data concerning prevalence of dermatological disorders published by other peacekeeping MTFs were used for comparison. Research conducted in mission areas such as Lebanon, Sudan and East Timor were included (table 1). The category of skin diseases was determined according to the 10th version of International Classification of Diseases.

Table 1

Comparison with data published by other peacekeeping medical facilities

	Lebanon	Lebanon7	Lebanon8	Sudan9	Sudan10	East Timor11	Cambodia8
Location	Middle East	Middle East	Middle East	Africa	Africa	South-eastern Asia	South-eastern Asia
Climate	Mediterranean	Mediterranean	Mediterranean	Savannah	Savannah	Tropical rainforest	Tropical rainforest
Period studied	January 2018 to May 2019	April 2007 to September 2014	June 1992 to July 2001	March 2014 to February 2015	January 2010 to January 2011	September 1999 to February 2000	March 1992 to September 1993
Patients, n	549	1658	160	542	438	193	278
Mean age	35	32		30.5	34
Percentage of men (%)	87.4	91		77.3	93.2	100
Disease category (%)
Dermatitis and eczema	27.1	27	44.4	38.7	21.9*	16.1†	8.6
Cutaneous mycoses	13.8	15	16.2	22.5	10	23.3	78.5
Bacterial skin infection	9.3	3	10			15.5	7.9
Viral skin disease	7.5	11	11.9	3.5	6.8	17.1
Acne vulgaris	6.6	4		10.7	6.6	1
Benign neoplasm	5.1	5	11.9	3.3		1
Urticaria	4.6	3		5.3	3.4	0
STD	1.8	2		1.6		0
Alopecia	2.9	5		4	2.7	0
Disorders of pigmentation	2.7	1		8.7‡		0

*Lichen simplex chronicus (7.1%), asteatotic eczema (2.7%), seborrhoeic eczema (2.5%) and unspecified dermatitis (9.6%) were added together.

†Contact dermatitis (9.3%), seborrhoeic dermatitis (1.6%) and non-specific dermatitis (5.2%) were added together.

‡Melasma (6.2%) and dermatosis papulosa nigra (2.5%) were added together.

STD, sexually transmitted disease.

Results

During the period of study, a total of 549 cases consisting of 399 military personnel and 150 civilians were referred to the dermatological service (figure 1), including 87.4% men (n=480) and 12.6% women (n=69), with a mean age of 35 years (range 13–48 years).

Figure 1

Identity of patients managed by dermatological service.

Among the 17 categories we established, dermatitis and eczema were the most common category (n=149, 27.1%), followed by cutaneous mycoses (n=73, 13.3%) and disorders of skin appendages (n=58, 10.6%). In the dermatitis and eczema category, unspecified dermatitis (n=51, 9.3%), contact dermatitis (n=36, 6.6%) and eczematous dermatitis (n=28, 5.1%) were the leading types. Tinea corporis (n=29, 5.3%) was the primary type of cutaneous mycoses, while acne vulgaris (n=36, 6.6%) was the dominant type of disorders of skin appendages. The top 10 dermatology disease categories were shown in table 2 and figure 2.

Table 2

Frequencies of diagnoses by category

Diagnosis	Patients, n (%)
Dermatitis and eczema	149 (27.1)
Cutaneous mycoses*	73 (13.3)
Disorders of skin appendages†	58 (10.6)
Bacterial skin infection‡	51 (9.3)
Viral skin disease	41 (7.5)
Benign neoplasm	28 (5.1)
Urticaria	28 (5.1)
Burn	19 (3.5)
Corns and callosities	18 (3.3)
Disorders of pigmentation	15 (2.7)
Insect bites	12 (2.2)
Papulosquamous disorders	11 (2.0)
Sexually transmitted disease	10 (1.8)
Radiation-related disorders	10 (1.8)
Keloid and scar	3 (0.5)
Others	23 (4.2)
Total	549 (100)

*Cutaneous mycoses included tinea corporis (n=29, 5.3%), tinea pedis (n=26, 4.7%) and tinea versicolor (n=14, 2.6%).

†Acne vulgaris (n=36, 6.6%) was the dominant type of disorders of skin appendages.

‡Bacterial folliculitis (n=28, 5.1%) was the leading type in bacterial skin infection.

Figure 2

Top 10 categories.

In terms of specific diagnoses, unspecified dermatitis (n=51, 9.3%), acne vulgaris (n=36, 6.6%), tinea corporis (n=29, 5.3%), folliculitis (n=28, 5.1%) and tinea pedis (n=26, 4.7%) were the top five most common reasons for dermatological consultation.

No medical evacuation caused by skin diseases was conducted during this period. Eight of 549 civilians who consulted for skin cancer were suggested to receive biopsy in level 3 hospital in Beirut, and one patient among them was diagnosed with squamous cell carcinoma.

Eleven patients (n=11, 2%) diagnosed with lipoma were given surgery under local anaesthesia. Only two patients required admission to hospital during this period.

Discussion

Regardless of the mission type, warfare or peacekeeping troop, the incidence of dermatitis and eczema is high across multiple kinds of climates. Actually, the incidence of eczematous conditions will increase after deployment, due to reasons like psychological stress increase and climate maladjustment. During the mission period, consistent contact with chemicals, oil, uniforms, and others may trigger the eczematous condition, causing high incidence of irritant contact dermatitis and allergic contact dermatitis.6

Dermatitis and eczema were the most common category, followed by fungal infection and acne diseases. In comparison with research published by other peacekeeping facilities, dermatitis and eczema were the leading category managed by peacekeeping facilities in Lebanon (27.1% in 2018–2019 period, 27% in 2007–2014 period,7 44.4% in 1992–2001 period,8 respectively) and in Sudan (21.9% in 2010–2011 period,9 38.7% in 2014–2015 period,10 respectively), while in mission area of tropical rainforest climate, cutaneous mycoses were the leading cause (78.5% in Cambodia,8 23.3% in East Timor).11 Acne vulgaris is also a common disease in military mission areas, especially in young males (average age=25 years, men=75% in our study). The incidence of acne vulgaris was relatively high in long-term study over 1-year period (6.6%, 4% in two Lebanon studies, respectively, and 10.7%, 6.6% in two African studies), while 1% in 6-month East Timor study.11 While in comparison with the other two studies in Lebanon,7 8 incidences of viral skin disease (7.5% vs 11%, 11.9%, respectively) and alopecia (2.9% vs 5%) in the present study were remarkably lower than the former data.7

Superficial fungal infection was the second most common reason for consultation in the present study. Thereinto, tinea corporis (5.3%) was the most prevalent complaint in this study, followed by tinea pedis (4.7%). Hot and humid environment decreased the level of personal hygiene. Tropical environment was also to blame, as the incidence of cutaneous mycoses was extremely high in Cambodia8 (78.5%), a country with tropical rainforest climate. When the skin is injured or the individual’s immunity decreases due to fatigue, anxiety, lack of sleep, and others, superficial non-pathogenic bacteria may become the opportunistic pathogen. A relatively high prevalence of bacterial infection was also found in the present study, with the majority being scalp folliculitis (5.1%) in military personnel, which was supposed to be induced by long-time wearing of helmets during petrol.12 Acne vulgaris (6.6%) was common. Patients usually complained an exacerbation of acne vulgaris after deployment. The possible reason might be the stressful psychological status. Meanwhile, acne on the face will certainly affect the confidence and mental status, as depression caused by acne is not rare. Therefore, psychological problems affecting the peacekeepers should also be highlighted.13 14

As dermatological service is not always available in lower level MTF, we highlighted the importance of teledermatology. Smart mobile terminals equipped with powerful applications such as ‘Haodaifu’ have spread at an amazing pace throughout China, and people lacking high-level medical care could access consultations supplied by top specialists through these telemedical service.15 US army has developed a platform named Army Knowledge Online, which is characterised by the store-and-forward method and can supply best medical service to overseas deployed soldiers.16 17 Even the common social network applications like WeChat and WhatsApp can be used for teledermatology service. A research conducted by a Korean team showed that for the diagnosis of common skin diseases, the correct rate of online diagnosis was similar to face-to-face consultation.18 Lacking dermatological service is common in UN medical facilities, and making efficient use of teledermatology can handle this problem well. For example, professional platforms like mobile applications could be developed for better medical care for military personnel and civilians working in UN mission areas.

This study had some limitations, too. First, as our facility was located in the Sector East, we mainly focused on the service for personnel in this area. Cooperative research with the UNIFIL Hospital in Sector West could be conducted in the future to get more comprehensive data. Second, the scale of the study we conducted was limited, causing existence of some bias.

Conclusions

Pharmacists should prepare more targeted types of medicine during preparation period, so some referrals merely for prescription could decrease. Dermatological service was lacking in basic military MTFs, and teledermatology might be a solution for this. Moreover, professional telemedicine platforms could be developed for better medical care for military personnel and civilians working in UN mission areas.