Skin Cancer and Other Dermatologic Conditions Among US Veterans

Key Points

Question

What are the prevalence and odds of skin cancer history and other dermatologic conditions (dermatitis/eczema/inflamed rash and psoriasis) among US veterans compared with nonveterans?

Findings

In this cross-sectional study of 61 307 participants (54 554 nonveterans and 6753 veterans) from the National Health and Nutrition Examination Survey, veterans were found to have higher odds of having a skin cancer history compared with nonveterans.

Meaning

The findings of this study suggest that an understanding of the prevalence of various dermatologic conditions among veterans can help inform public health measures aimed at improving prevention in this patient population.

Abstract

Importance

US veterans may be at an increased risk of developing various dermatologic conditions compared with nonveterans.

Objectives

To compare the prevalence and the odds of dermatologic conditions (eg, skin cancers, dermatitis/eczema/rash, psoriasis) between veterans and nonveterans.

Design, Setting, and Participants

This population-based cross-sectional study leveraged nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Three questionnaires (demographics, medical conditions, and dermatology) were merged from 1999-2018 for analysis. Participants were nonveterans and veterans from NHANES data. Data were analyzed from August 2023 to April 2024.

Main Outcomes and Measures

The prevalence and odds ratios (ORs) comparing veterans and nonveterans were examined for various dermatologic conditions, including self-reported skin cancer history (any skin cancer, melanoma, nonmelanoma and unknown subtypes), dermatitis/eczema/inflamed rash, and psoriasis.

Results

In a total of 61 307 participants (54 554 nonveterans and 6753 veterans), there was a higher prevalence of any skin cancer history among US veterans compared with nonveterans (9.0% vs 2.9%; P < .001) as well as a higher prevalence of melanoma history (2.2% vs 0.6%; P < .001). Adjusted for demographic factors, veterans had higher odds of any skin cancer history (OR, 1.72; 95% CI, 1.23-2.40) and higher odds of a melanoma history (OR, 2.27; 95% CI, 1.17-4.39) compared with nonveterans. Veterans had a higher prevalence of a psoriasis diagnosis compared with nonveterans (4.5% vs 2.9%; P = .002) and a 61% higher odds of a psoriasis diagnosis (OR, 1.61; 95% CI, 1.05-2.46) compared with nonveterans.

Conclusions and Relevance

This cross-sectional study found that veterans have higher prevalence and odds of various dermatologic conditions compared with nonveterans. Efforts aimed at improving health care quality among veterans must investigate the underlying causes of worsened skin health in this population.

This cross-sectional study assesses the prevalence and likelihood of various dermatologic conditions and skin cancer risk factors among US veterans compared with nonveterans.

Introduction

In 2021, there were 16.5 million veterans who had served in the US Armed Forces, nearly 50% of whom were aged 65 years and older.¹ Veterans experience unique challenges during and after military service, which are associated with greater morbidity across many diseases compared with the general US population.² Previous studies have reported elevated risks for mental health conditions such as posttraumatic stress disorder, depression, and substance use disorders.³ As of 2021, more than 4 million veterans had a service-related disability, with 1.9 million having a disability rating of 70% or above (ie, most severely disabled rating).^4,5 In particular, veterans routinely incur extreme sun exposure and lack photoprotection during active military service.⁶ Melanoma in veterans has been found to be diagnosed at later stages and is associated with poorer survival rates compared with a comparison cohort in a national sample.⁷ Therefore, understanding how various skin health conditions present in this specific population is important.

While the literature has reported melanoma risk among veterans,⁷ very few large studies to our knowledge have used a single data source to compare veterans and nonveterans, which limits comparisons that can be made between the 2 groups. To address this gap, our study uses the National Health and Nutrition Examination Survey (NHANES) across 2 decades (1999 to 2018) to investigate the prevalence and likelihood of various dermatologic conditions (skin cancer, psoriasis, and eczema/dermatitis/inflamed rash) and skin cancer risk factors data available in NHANES among veterans compared with nonveterans. We hypothesize higher prevalence and odds of having various dermatologic conditions in veterans.

Methods

This study used nationally representative cross-sectional NHANES data from 2 decades (1999-2018). NHANES is administered to the general US population that is not institutionalized or an active member of the military by the Centers for Disease Control and Prevention every 2 years.⁸ The NHANES data used multistage sampling design, including stratification, and applied sample weights to be nationally representative.⁹ All NHANES survey sets received ethical approval from the National Center for Health Statistics Institutional Review Board/Ethical Review Board.¹⁰ The Stanford institutional review board waived ethical review of this study as deidentified and publicly available NHANES data are considered not as human participant research. Stata version 17.0 (StataCorp LLC) was used for the analysis. Statistical significance was determined at P < .01, P < .05, and P < .10 (2-sided). The study used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Further details are provided in eMethods in Supplement 1.

Results

Demographic characteristics of a total of 61 307 participants are presented in Table 1 (54 554 nonveterans and 6753 veterans).

Table 1. Demographic Characteristics of Veterans vs Nonveterans, National Health and Nutrition Examination Survey 1999-2018.

Demographic variable	Category %		P value
	Nonveteran	Veteran
Age range, y
No.	54 554	6753
0-19	5.74	0.24	<.001
20-39	38.12	14.86
40-59	35.75	34.04
60-79	16.97	40.44
≥80	3.43	10.43
Gender
Female	57.24	7.26	<.001
Male	42.76	92.74
Race and ethnicitya
Mexican Americanb	9.13	2.61	<.001
Other Hispanic	6.08	2.54
Non-Hispanic White	65.78	80.42
Non-Hispanic Black	11.55	10.52
Other race-including multiracialc	7.46	3.91
Dataset cohort
1999-2000	8.38	11.27	<.001
2001-2002	9.33	12.15
2003-2004	9.30	11.22
2005-2006	9.52	10.96
2007-2008	9.96	9.52
2009-2010	10.11	9.84
2011-2012	10.46	8.92
2013-2014	10.74	8.80
2015-2016	10.92	8.81
2017-2018	11.28	8.50
Annual household income level, $
<$20 000	16.58	11.58	<.001
≥$20 000	83.42	88.42
Educational attainment level
< 9th Grade	6.24	3.06	<.001
≥9th Grade	93.76	96.94
Skin reactivity (burn/tan)
No.	32 207	2559
Get a severe sunburn with blisters	2.53	2.50	.83
A severe sunburn for a few days with peeling	10.65	11.36
Mildly burned with some tanning	30.58	30.66
Turning darker without a sunburn	20.35	21.17
Nothing would happen in half an hour	35.13	33.65
Other	0.78	0.66

^a Self-reported categories according to classifications in National Health and Nutrition Examination Survey.

^b Disaggregated from National Health and Nutrition Examination Survey classification “Other Hispanic.”

^c No further breakdown of classification is available.

Prevalence and Likelihood of Having Skin Cancer

The prevalence of self-reported skin cancer history was higher for veterans compared with nonveterans across all skin cancer subtypes (Table 2). Among the 54 991 participants who answered medical condition questions on their cancer history (48 278 nonveterans and 6713 veterans), 9.0% of veterans and 2.9% of nonveterans reported having had any subtype of skin cancer (P < .001). The prevalence of melanoma history was 2.2% vs 0.6% (P < .001), nonmelanoma skin cancer history was 5.1% vs 1.6% (P < .001), and skin cancer of unknown subtype was 2.2% vs 0.8% (P < .001) in veterans vs nonveterans, respectively. When analyzing skin cancer history across age groups, prevalence was greater for veterans in all age categories above 20-39 years, with the gap in prevalence between veterans and nonveterans widening as age increased (Figure).

Table 2. Skin Condition History and Sun-Related Behaviors Among Veterans Compared With Nonveterans, NHANES 1999-2018^a.

Variableb	Prevalence (95% CI)		P value	OR or RRR (95% CI)
	Nonveteran	Veteran		Unadjusted	Adjustedc
Skin cancer historyd
Any skin cancer
Yes	2.94 (2.72-3.19)	9.00 (8.00-10.11)	<.001	OR: 3.26 (2.81-3.79)e	OR: 1.72 (1.23-2.40)e
Melanoma
Yes	0.618 (.52-74)	2.18 (1.70-2.79)	<.001	OR: 3.58 (2.63-4.88)e	OR: 2.27 (1.17-4.39)f
Nonmelanoma
Yes	1.63 (1.48-1.80)	5.07 (4.34-5.91)	<.001	OR: 3.22 (2.67-3.89)e	OR: 1.80 (1.17-2.78)e
Unknown skin cancer subtype
Yes	0.75 (.65-88)	2.17 (1.80-2.61)	<.001	OR: 2.91 (2.28-3.73)e	OR: 1.32 (.63-2.75)
Psoriasisg
Psoriasis diagnosis
Yes	2.88 (2.58-3.20)	4.51 (3.48-5.84)	.002	OR: 1.60 (1.18-2.15)e	OR: 1.61 (1.05-2.46)f
Eczema/dermatitis/inflamed rashh
Any part of body
Yes	13.61 (12.86-14.39)	15.38 (12.82-18.34)	.16	OR: 1.15 (0.95-1.41)	OR: 1.18 (0.93-1.51)
Arms
Yes	4.81 (4.22-5.49)	5.57 (4.11-7.53)	.36	OR: 1.17 (0.84-1.63)	OR: 1.40 (1.00-1.96)i
Torso
Yes	3.29 (2.83-3.81)	4.63 (3.51-6.10)	.02	OR: 1.43 (1.06-1.93)f	OR: 1.40 (0.95-2.07)i
Sun reactivity
Sunburn/tan after half hour in sunj
Get a severe sunburn with blisters	2.53 (2.29-2.78)	2.50 (1.78-3.49)	.83	RRR: 1.03 (0.72-1.48)	RRR: 1.45 (0.94-2.25)i
A severe sunburn for a few days with peeling	10.65 (10.14-11.18)	11.36 (9.75-13.20)		RRR: 1.11 (0.93-1.33)	RRR: 1.44 (1.18-1.76)e
Mildly burned with some tanning	30.58 (29.67-31.50)	30.66 (28.23-33.20)		RRR: 1.05 (0.92-1.19)	RRR: 1.18 (1.02-1.38)f
Turning darker without a sunburn	20.35 (19.68-21.03)	21.17 (18.85-23.69)		RRR: 1.09 (0.92-1.28)	RRR: 1.22 (1.03-1.46)f
Other	0.78 (0.65-0.92)	0.66 (.37-1.20)		RRR: 0.89 (0.48-1.67)	RRR: 1.33 (0.71-2.52)
Nothing would happen in half an hour	35.13 (34.06-36.21)	33.65 (31.25-36.13)		1 [Reference]	1 [Reference]
Sun-related behaviorsk
Outdoors during work day (9 am-5 pm)l
No	31.50 (30.24-32.80)	22.33 (19.34-25.64)	<.001	OR: 1.62 (1.39-1.87)e	OR: 1.22 (1.04-1.43)f,m
≤4 h	56.20 (54.50-57.89)	59.03 (55.04-62.91)
>4 h	12.29 (11.10-13.59)	18.64 (15.72-21.95)

Abbreviations: NHANES, National Health and Nutrition Examination Survey; OR, odds ratio; RRR, relative risk ratio.

^a Logistic regressions were used to assess the likelihood of dermatologic disease history, after controlling for demographic covariates. Veteran status was associated with a higher odds of skin cancer history across skin cancer subcategories; eczema/dermatitis/red, inflamed rash on the arms and torso; and a diagnosis of psoriasis. Ordered, multinomial and regular logistic regressions were used to assess sun-related behaviors. Veteran status was not associated with a difference in frequency in using sunscreen, staying in the shade, or wearing long sleeves, but it was associated with a tendency to sunburn/tan after adjusting for demographic factors.

^b Time frames for each variable are provided in eMethods in Supplement 1. Questions are included in eMethods in Supplement 1.

^c Adjusted for gender, age, race and ethnicity, NHANES dataset cohort, income, race and ethnicity–income interaction term and sun reactivity (burn/tan).

^d For skin cancer history, nonveteran n = 48 278 and veteran n = 6713.

^e P < .01.

^f P < .05.

^g For psoriasis, nonveteran n = 23 142 and veteran n = 2361.

^h For eczema/dermatitis/inflamed rash, nonveteran n = 11 080 and veteran n = 1299.

ⁱ P < .10.

^j For sunburn/tan after half hour in sun, nonveteran n = 32 207 and veteran n = 2559.

^k Additional sun behavior variables provided in eTable 2 in Supplement 1.

^l For outdoors during work day, nonveteran n = 15 704 and veteran n = 896.

^m Adjusted for gender, age, race/ethnicity, NHANES dataset cohort, income, and race/ethnicity-income interaction term.

Figure. Prevalence of Skin Cancer History by Veteran Status Across Age Groups.

Whiskers indicate 95% CIs.

Table 2 reports the odds of having various dermatologic conditions in veterans compared with nonveterans. After adjusting for all covariates, veteran status was associated with higher odds of having a skin cancer history across all skin cancer subtypes except for unknown subtypes; any skin cancer (odds ratio [OR], 1.72; 95% CI, 1.23-2.40), melanoma (OR, 2.27; 95% CI, 1.17-4.39), and nonmelanoma skin cancer (OR, 1.80; 95% CI, 1.17-2.78; P < .10) compared with nonveteran status.

Other Dermatologic Conditions

Veterans had higher odds of having a psoriasis diagnosis compared with nonveterans (OR, 1.61; 95% CI, 1.05-2.46). Veterans did not have an increased odds of having eczema/dermatitis/inflamed rash in the past 30 days anywhere on the body compared with nonveterans, but they did have a statistically significant increased odds when localized to the arms (OR, 1.40; 95% CI, 1.00-1.96; P < .10) or torso (OR, 1.40; 95% CI, 0.95-2.07; P < .10) (Table 2).

Sun-Related Behaviors

Veteran status was positively associated with being outdoors on a work day (OR, 1.22; 95% CI, 1.04-2.25) but not with frequency of sunscreen use, staying in the shade, or wearing long sleeve shirts outdoors on a sunny day. Veteran status was associated with a 44% to 45% increased risk of severe sunburn after half an hour in the sun even after adjusting for demographic factors.

Discussion

Our study of 61 307 participants across 2 decades of NHANES data found that US veterans had a higher odds of being diagnosed with skin cancer, with the odds of having had melanoma being the greatest among the 3 skin cancer subcategories.

The benefits of sunlight exposure must be balanced with the harms of prolonged UV radiation, such as increased susceptibility to skin cancer.¹¹ In 2014, the US Surgeon General’s Call to Action to Prevent Skin Cancer recommended sun protective behaviors to avoid UV radiation, but noted that federal agencies and national health care organizations do not have a standardized messaging on sunscreen use.¹² In light of the association of sunscreen use and decreased skin cancer¹³ and the documented risk of skin cancers among veterans,⁶ directed photoprotection messaging for veterans with lighter skin tones can enhance uptake and improve health outcomes among this population.

Public health measures can mitigate modifiable skin condition risks affecting this patient population. Strategies to reduce skin exposure to UV radiation should be strongly considered for primary prevention in occupational settings, including for active military personnel. Improved adherence to primary preventive measures, such as physical protection with UV protective clothing or topical protection with sunscreen, among military personnel could reduce the risk of skin cancer development later in life. Improved education, counseling, and policies that reduce UV radiation exposure can aid in primary prevention.¹⁴

Strengths and Limitations

Our study has several strengths. It is the first study, to our knowledge, to characterize the skin health of veterans across 2 decades of NHANES data. By utilizing a single data source with harmonized variables across veteran and nonveteran cohorts, we are able to more easily make direct comparisons between these 2 populations. Though previous studies have analyzed skin cancer among veterans, they have been limited to smaller sample sizes or relied on data from multiple data sources. Furthermore, NHANES’ sampling design enables our findings to be nationally representative, which strengthens their generalizability.

There are also several limitations to our study, and areas that merit further investigation. First, while skin cancer risk is assessed across 2 decades (1999-2018), other dermatologic conditions are only available for a subset of this timeframe and limited to psoriasis and eczema/dermatitis/inflamed rash. Second, the interpretation of self-reported data on diagnosis warrants caution. Third, the predominance of males in the veteran population, with older white males highly represented, could also skew findings and introduce sampling bias. Future investigations should examine dermatologic conditions among active military personnel and could also explore any differences in prevalence of conditions based on time after service.

Conclusions

Our study used NHANES to assess skin health among veterans compared with nonveterans. Our findings contribute to evidence indicating greater risk of skin cancers among veterans using a single, population-based data source. Public health measures seeking to address veteran health care differences could emphasize primary preventive strategies to mitigate risk and early detection of dermatologic conditions through regular skin examinations.

Supplement 1.

eMethods. Data, Design, and NHANES Questions

eTable 1. Number of Veterans Included in Each NHANES Cohort

eTable 2. Additional Sun-Related Behaviors Among Veterans

eFigure. Prevalence of Skin Cancer History With 95% CI by Veteran Status Across Two Decades (NHANES 1999-2018)

Supplement 2.

Data Sharing Statement