Medical Research: What is the background for this study? What are the main findings?
Dr. Patterson: The utilization of Agent Orange (AO) and other herbicides by the United States during the Vietnam War was controversial at the time and remains a prominent topic of scrutiny even today due to the potential long-term health effects facing exposed military and civilian personnel. The Institute of Medicine (IOM) in accordance with the National Academy of Sciences publishes a semi-annual review of the scientific and medical data regarding the resultant medical effects of Agent Orange and other organochlorine chemical exposures, however, skin diseases are no longer comprehensively assessed.
This represents an important practice gap, as in our experience, we had encountered a significant number of patients inquiring whether their cutaneous ailment could be the result of Agent Orange exposure. Our goal was to perform a systematic review of the literature and produce a practical summary of the current evidence regarding cutaneous manifestations of organochlorine exposures that could be utilized by military and non-military dermatologists alike when responding to questions related to prior Agent Orange contact.
After examining the literature, there appears to be an increased risk for chloracne, porphyria cutanea tarda, cutaneous lymphoma, and soft-tissue sarcomas including dermatofibrosarcoma protuberans and leiomyosarcomas in organochlorine-exposed patients. Some evidence exists for a possible increased incidence of melanomas, non-melanoma skin cancers, milia, eczema, dyschromias, dysesthesias, and rashes not otherwise specified, but the data is not conclusive. Even less support exists for an association with psoriasis, seborrheic dermatitis, neurodermatitis, and hypertrichosis
Medical Research: What should clinicians and patients take away from your report?
Dr. Patterson: Age-appropriate patients who are given a diagnosis of porphyria cutanea tarda, cutaneous lymphomas, and soft-tissue sarcomas should be screened for industrial exposure or prior military service with subsequent Veterans Affairs referral for disability assessment based on Agent Orange-exposure status. When approached regarding a skin condition without an established association, physicians can reassure patients that it is unlikely that their condition is associated with Agent Orange while still encouraging veterans to see their local VA environmental health coordinator for official registration and evaluation if concerns persist. Providing support for veteran patients in light of potential underlying social and psychological needs remains paramount for any provider in these situations. Further information regarding herbicide use in the Vietnam War, the Agent Orange exposure registry, recognized disease associations, and disability claim procedures can be found on the U.S. Department of Veterans Affairs website under the Public Health section.
Additionally, while Agent Orange certainly serves as one of the more high profile organochlorine encounters, many large-scale occupational accidents and industrial exposures have occurred. Dermatologists should be cognizant of the potential development of these associated symptoms and conditions in their patients (particularly those involved with herbicide and pesticide manufacturing, paper mills, incineration/combustion, and metallurgy) and inquire regarding possible occupational hazards when appropriate.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Patterson: Ultimately, an ideal next step for assessing dermatologic morbidity and mortality related to these organochlorine exposures would involve gathering a significant number of subjects via utilization of existing VA or military-centered databases and performing a case-control study with specific emphasis on skin diseases in the veteran population with skin disease assessment performed by dermatologists, not by self-report or by less rigorously trained physicians. This is an important problem with most of the skin disease research that has been published associated with organochlorines. Additional opportunities also exist in the civilian realm for further inquiries into the toxicity, mechanism of disease, and epidemiologic trends associated with dioxins and other organochlorines by examining the long-term health outcomes for patients involved with some of the prominent mass industrial accidents where quantifying degree of exposure is more feasible.
Andrew T. Patterson, Benjamin H. Kaffenberger, Richard A. Keller, Dirk M. Elston
Publication stage: In Press Corrected Proof
Journal of the American Academy of Dermatology
Andrew T. Patterson, MD (2015). Agent Orange May Raise Risk Of Several Skin Conditions and Cancers