Kathleen R. Krivda, MD

Tinea versicolor (TV) is a common, chronic, and recurrent superficial fungal infection caused by Malassezia species, most commonly Malassezia furfur (M. furfur)—a dimorphic fungus that is a part of the normal skin flora and resides in the stratum corneum.¹ TV manifests as hypopigmented, hyperpigmented, or erythematous macules and patches with scaling, typically found on the trunk and proximal upper extremities. The condition is most common among young to middle-aged individuals exposed to high temperatures and humidity.¹

While many cases respond to topical antifungal treatment, application can be cumbersome, particularly in large areas that are difficult to reach. An efficient and cost effective in-office treatment option could alleviate patient burden and improve satisfaction. This article presents a case of TV successfully treated with an in-office salicylic acid (SA) 30% peel, an uncommon application of this medication.

Case Presentation

An 18-year-old female active-duty US Army service member with a history of acne vulgaris presented to a dermatology clinic with a mildly pruritic rash that had been present for several weeks. An examination revealed hyperpigmented macules and patches with overlying fine scales across the patient’s back and bilateral arms (Figures 1 and 2). She reported no history of similar lesions. The patient had recently completed a military basic training course during which she wore a uniform jacket and trousers daily in hot and humid conditions. A skin scraping was obtained. Microscopic examination with potassium hydroxide preparation revealed hyphae and spores, consistent with TV.

The diagnosis of TV and treatment options (topical ketoconazole 2% shampoo, topical terbinafine, or oral fluconazole) were discussed with the patient. Due to military training-related constraints, residence in the barracks, and personal preference, the patient felt unable to regularly apply topical medications to the entirety of the affected area and preferred to avoid oral medication. The decision was made to pursue in-clinic treatment with a SA 30% peel. The affected areas (back and bilateral arms) were thoroughly cleansed and prepped with alcohol. SA 30% in hydroethanolic solution was applied evenly to the affected area. The patient was observed for pseudofrosting, a precipitation of SA crystals that indicates peel completion (Figure 3). The peel was left in place, as it is self-neutralizing, and the patient was instructed to shower that same day with a gentle cleanser. This procedure was repeated 10 days later. Both treatments were well tolerated, with only a transient burning sensation reported during the application. At 3-week follow-up, the patient presented with complete resolution of her arm lesions and significant improvement of the back lesions (Figures 4 and 5). She also reported improvement in the acne vulgaris on her back.

Discussion

SA 30% is a lipid-soluble hydroxybenzoic acid with comedolytic and desmolytic qualities. This results in the disruption of epidermal cell cohesion and promotes exfoliation.² Lipophilic properties allow SA to penetrate sebaceous glands and disrupt sebum production, making it particularly effective in seborrheic conditions such as acne. This mechanism may have increased therapeutic effect in this case.³ Additionally, as a salicylate, SA possesses anti-inflammatory properties, though this effect is most pronounced at lower concentrations. SA 30% is considered a superficial peel, as the depth of chemexfoliation is limited to the epidermis.³ A modified SA preparation is a safe and effective treatment for moderate-to-severe acne vulgaris. The apparent pseudofrost during application is due to precipitated SA, rather than the precipitation of dermal proteins seen in deeper peels, such as trichloroacetic acid.² Unlike glycolic or pyruvic acid peels, SA does not require neutralization.

SA is cost-effective and has been used safely in all skin types to treat various epidermal conditions, including acne vulgaris, melasma, photodamage, freckles, lentigines and postinflammatory hyperpigmentation (PIH).² Mild adverse effects occur in about 15% to 30% of patients and include prolonged erythema, intense exfoliation, dryness, crusting, and pigmentary dyschromias. Rare adverse effects include systemic toxicity (salicylism) and hypoglycemia. Contraindications to SA 30% peels include history of allergy to salicylates, active bacterial or viral infection, dermatitis in the treatment area, pregnancy, and skin malignancy.²

Chemical peels are typically used with caution in patients with skin of color due to a higher risk of PIH. However, SA 30% has been shown to be safe and effective in these populations.⁴ A study by Grimes found that 88% of patients with Fitzpatrick skin types V and VI experienced significant improvement in PIH, melasma, or enlarged pores with minimal to no adverse effects.⁴ Subsequent larger studies have reinforced these findings. In a study involving 250 patients with Fitzpatrick skin types IV and V, no patients experienced PIH, confirming the safety of SA in darker skin tones. This is likely due to the superficial nature of the peel, which does not affect the basal layer of the epidermis where melanocytes reside, reducing the risk of pigmentary complications. Additionally, SA peels are self-neutralizing, unlike glycolic or trichloroacetic acid peels, which require manual neutralization and carry a higher risk of PIH if not neutralized properly.⁵

SA has been as shown to be a moderately successful treatment for PIH. The Grimes study found that 4 of 5 patients with Fitzpatrick skin types IV and V saw a 75% improvement in PIH after SA peels.⁴ Davis et al found a nonsignificant trend toward skin lightening in Korean adults treated for acne and PIH, with significant decreases in erythema and improvements in greasiness, dryness, and scaliness.⁶ Importantly, the risk of PIH following TV is higher in patients with skin of color.⁷ SA may be effective in treating TV and PIH, offering a multifactorial approach by addressing both conditions while posing a low risk for causing PIH.⁸

TV and other Malassezia spp infections are common concerns in dermatology and primary care, with Malassezia-associated superficial mycoses (eg, dandruff, pityriasis versicolor, and folliculitis) affecting up to 50% of the population worldwide.⁹ Despite this, there has been little recent advancement in antifungal treatments. Ketoconazole, terbinafine, and fluconazole have been in use since the 1980s and 1990s.⁸ Most antifungal drugs target ergosterol, a component of the fungal cell wall.¹⁰ Additionally, Malassezia spp have been increasingly reported to cause invasive infections in immunocompromised patients.¹¹ Given the rise in antifungal resistance, the judicious use of antifungals and implementation of novel treatment strategies is essential.

While SA lacks intrinsic antifungal properties, different combinations (Whitfield ointment consisting of 3% SA and 6% benzoic acid; 2% sulfur and 2% SA) have been effective in the treatment of TV.¹ It is theorized that the effectiveness of SA against TV is due to its ability to exfoliate and acidify the stratum corneum, the natural habitat of M. furfur.

SA also reduces sebum production by downregulating sebocyte lipogenesis via the sterol regulatory element-binding protein-1 pathway and suppressing the nuclear factor κB (NF-κB) pathway, a key pathway in inflammation.¹² These mechanisms make SA an effective acne treatment. Additionally, M. furfur is a lipid-dependent yeast, thus the decreased lipogenesis by sebocytes may be beneficial in treating TV as well.¹² A study of 25 patients with TV in India found that 88% achieved clinical and microbiological cure after 4 once-weekly treatments of a SA 30% peel.⁸

In a study of deployed military personnel, fungal infections affected about 11% of participants.¹³ Contributing factors to the development of fungal infections included excessive sweating, humid conditions, and limited access to hygiene facilities. In such settings, traditional antifungal therapies may be less effective or challenging to adhere to, making alternative treatments more desirable. SA peels could offer a practical solution in these circumstances, as they are easily applied in the clinic, require no neutralization or downtime, and do not require the patient to apply medications between visits.

In this case, the patient demonstrated significant improvement with 2 SA peels, with noted improvement in her acne. SA 30% peel was highlighted as a useful treatment option for patients with TV who struggle with topical medication adherence; furthermore, it may be particularly beneficial for patients with concomitant acne.

Conclusions

This case demonstrates the successful use of in-office SA 30% peel as a treatment for TV. The rapid improvement and resolution of lesions with minimal adverse effects suggest that SA peel may serve as a valuable alternative for patients with extensive disease in difficult-to-reach affected areas, or those who are dissatisfied with traditional therapies. Additionally, the concurrent improvement of the patient’s back acne underscores the dual therapeutic potential of this treatment. Given the ease of application, cost effectiveness, and favorable safety profile, SA 30% peel is a viable option in the management of TV, especially in cases where topical or oral antifungals are impractical. Further studies could help establish standardized protocols and assess long-term outcomes of this treatment modality.

Tinea versicolor (TV) is a common, chronic, and recurrent superficial fungal infection caused by Malassezia species, most commonly Malassezia furfur (M. furfur)—a dimorphic fungus that is a part of the normal skin flora and resides in the stratum corneum.¹ TV manifests as hypopigmented, hyperpigmented, or erythematous macules and patches with scaling, typically found on the trunk and proximal upper extremities. The condition is most common among young to middle-aged individuals exposed to high temperatures and humidity.¹

While many cases respond to topical antifungal treatment, application can be cumbersome, particularly in large areas that are difficult to reach. An efficient and cost effective in-office treatment option could alleviate patient burden and improve satisfaction. This article presents a case of TV successfully treated with an in-office salicylic acid (SA) 30% peel, an uncommon application of this medication.

Case Presentation

An 18-year-old female active-duty US Army service member with a history of acne vulgaris presented to a dermatology clinic with a mildly pruritic rash that had been present for several weeks. An examination revealed hyperpigmented macules and patches with overlying fine scales across the patient’s back and bilateral arms (Figures 1 and 2). She reported no history of similar lesions. The patient had recently completed a military basic training course during which she wore a uniform jacket and trousers daily in hot and humid conditions. A skin scraping was obtained. Microscopic examination with potassium hydroxide preparation revealed hyphae and spores, consistent with TV.

The diagnosis of TV and treatment options (topical ketoconazole 2% shampoo, topical terbinafine, or oral fluconazole) were discussed with the patient. Due to military training-related constraints, residence in the barracks, and personal preference, the patient felt unable to regularly apply topical medications to the entirety of the affected area and preferred to avoid oral medication. The decision was made to pursue in-clinic treatment with a SA 30% peel. The affected areas (back and bilateral arms) were thoroughly cleansed and prepped with alcohol. SA 30% in hydroethanolic solution was applied evenly to the affected area. The patient was observed for pseudofrosting, a precipitation of SA crystals that indicates peel completion (Figure 3). The peel was left in place, as it is self-neutralizing, and the patient was instructed to shower that same day with a gentle cleanser. This procedure was repeated 10 days later. Both treatments were well tolerated, with only a transient burning sensation reported during the application. At 3-week follow-up, the patient presented with complete resolution of her arm lesions and significant improvement of the back lesions (Figures 4 and 5). She also reported improvement in the acne vulgaris on her back.

Discussion

SA 30% is a lipid-soluble hydroxybenzoic acid with comedolytic and desmolytic qualities. This results in the disruption of epidermal cell cohesion and promotes exfoliation.² Lipophilic properties allow SA to penetrate sebaceous glands and disrupt sebum production, making it particularly effective in seborrheic conditions such as acne. This mechanism may have increased therapeutic effect in this case.³ Additionally, as a salicylate, SA possesses anti-inflammatory properties, though this effect is most pronounced at lower concentrations. SA 30% is considered a superficial peel, as the depth of chemexfoliation is limited to the epidermis.³ A modified SA preparation is a safe and effective treatment for moderate-to-severe acne vulgaris. The apparent pseudofrost during application is due to precipitated SA, rather than the precipitation of dermal proteins seen in deeper peels, such as trichloroacetic acid.² Unlike glycolic or pyruvic acid peels, SA does not require neutralization.

SA is cost-effective and has been used safely in all skin types to treat various epidermal conditions, including acne vulgaris, melasma, photodamage, freckles, lentigines and postinflammatory hyperpigmentation (PIH).² Mild adverse effects occur in about 15% to 30% of patients and include prolonged erythema, intense exfoliation, dryness, crusting, and pigmentary dyschromias. Rare adverse effects include systemic toxicity (salicylism) and hypoglycemia. Contraindications to SA 30% peels include history of allergy to salicylates, active bacterial or viral infection, dermatitis in the treatment area, pregnancy, and skin malignancy.²

Chemical peels are typically used with caution in patients with skin of color due to a higher risk of PIH. However, SA 30% has been shown to be safe and effective in these populations.⁴ A study by Grimes found that 88% of patients with Fitzpatrick skin types V and VI experienced significant improvement in PIH, melasma, or enlarged pores with minimal to no adverse effects.⁴ Subsequent larger studies have reinforced these findings. In a study involving 250 patients with Fitzpatrick skin types IV and V, no patients experienced PIH, confirming the safety of SA in darker skin tones. This is likely due to the superficial nature of the peel, which does not affect the basal layer of the epidermis where melanocytes reside, reducing the risk of pigmentary complications. Additionally, SA peels are self-neutralizing, unlike glycolic or trichloroacetic acid peels, which require manual neutralization and carry a higher risk of PIH if not neutralized properly.⁵

SA has been as shown to be a moderately successful treatment for PIH. The Grimes study found that 4 of 5 patients with Fitzpatrick skin types IV and V saw a 75% improvement in PIH after SA peels.⁴ Davis et al found a nonsignificant trend toward skin lightening in Korean adults treated for acne and PIH, with significant decreases in erythema and improvements in greasiness, dryness, and scaliness.⁶ Importantly, the risk of PIH following TV is higher in patients with skin of color.⁷ SA may be effective in treating TV and PIH, offering a multifactorial approach by addressing both conditions while posing a low risk for causing PIH.⁸

TV and other Malassezia spp infections are common concerns in dermatology and primary care, with Malassezia-associated superficial mycoses (eg, dandruff, pityriasis versicolor, and folliculitis) affecting up to 50% of the population worldwide.⁹ Despite this, there has been little recent advancement in antifungal treatments. Ketoconazole, terbinafine, and fluconazole have been in use since the 1980s and 1990s.⁸ Most antifungal drugs target ergosterol, a component of the fungal cell wall.¹⁰ Additionally, Malassezia spp have been increasingly reported to cause invasive infections in immunocompromised patients.¹¹ Given the rise in antifungal resistance, the judicious use of antifungals and implementation of novel treatment strategies is essential.

While SA lacks intrinsic antifungal properties, different combinations (Whitfield ointment consisting of 3% SA and 6% benzoic acid; 2% sulfur and 2% SA) have been effective in the treatment of TV.¹ It is theorized that the effectiveness of SA against TV is due to its ability to exfoliate and acidify the stratum corneum, the natural habitat of M. furfur.

SA also reduces sebum production by downregulating sebocyte lipogenesis via the sterol regulatory element-binding protein-1 pathway and suppressing the nuclear factor κB (NF-κB) pathway, a key pathway in inflammation.¹² These mechanisms make SA an effective acne treatment. Additionally, M. furfur is a lipid-dependent yeast, thus the decreased lipogenesis by sebocytes may be beneficial in treating TV as well.¹² A study of 25 patients with TV in India found that 88% achieved clinical and microbiological cure after 4 once-weekly treatments of a SA 30% peel.⁸

In a study of deployed military personnel, fungal infections affected about 11% of participants.¹³ Contributing factors to the development of fungal infections included excessive sweating, humid conditions, and limited access to hygiene facilities. In such settings, traditional antifungal therapies may be less effective or challenging to adhere to, making alternative treatments more desirable. SA peels could offer a practical solution in these circumstances, as they are easily applied in the clinic, require no neutralization or downtime, and do not require the patient to apply medications between visits.

In this case, the patient demonstrated significant improvement with 2 SA peels, with noted improvement in her acne. SA 30% peel was highlighted as a useful treatment option for patients with TV who struggle with topical medication adherence; furthermore, it may be particularly beneficial for patients with concomitant acne.

Conclusions

This case demonstrates the successful use of in-office SA 30% peel as a treatment for TV. The rapid improvement and resolution of lesions with minimal adverse effects suggest that SA peel may serve as a valuable alternative for patients with extensive disease in difficult-to-reach affected areas, or those who are dissatisfied with traditional therapies. Additionally, the concurrent improvement of the patient’s back acne underscores the dual therapeutic potential of this treatment. Given the ease of application, cost effectiveness, and favorable safety profile, SA 30% peel is a viable option in the management of TV, especially in cases where topical or oral antifungals are impractical. Further studies could help establish standardized protocols and assess long-term outcomes of this treatment modality.

Tinea versicolor (TV) is a common, chronic, and recurrent superficial fungal infection caused by Malassezia species, most commonly Malassezia furfur (M. furfur)—a dimorphic fungus that is a part of the normal skin flora and resides in the stratum corneum.¹ TV manifests as hypopigmented, hyperpigmented, or erythematous macules and patches with scaling, typically found on the trunk and proximal upper extremities. The condition is most common among young to middle-aged individuals exposed to high temperatures and humidity.¹

While many cases respond to topical antifungal treatment, application can be cumbersome, particularly in large areas that are difficult to reach. An efficient and cost effective in-office treatment option could alleviate patient burden and improve satisfaction. This article presents a case of TV successfully treated with an in-office salicylic acid (SA) 30% peel, an uncommon application of this medication.

Case Presentation

An 18-year-old female active-duty US Army service member with a history of acne vulgaris presented to a dermatology clinic with a mildly pruritic rash that had been present for several weeks. An examination revealed hyperpigmented macules and patches with overlying fine scales across the patient’s back and bilateral arms (Figures 1 and 2). She reported no history of similar lesions. The patient had recently completed a military basic training course during which she wore a uniform jacket and trousers daily in hot and humid conditions. A skin scraping was obtained. Microscopic examination with potassium hydroxide preparation revealed hyphae and spores, consistent with TV.

The diagnosis of TV and treatment options (topical ketoconazole 2% shampoo, topical terbinafine, or oral fluconazole) were discussed with the patient. Due to military training-related constraints, residence in the barracks, and personal preference, the patient felt unable to regularly apply topical medications to the entirety of the affected area and preferred to avoid oral medication. The decision was made to pursue in-clinic treatment with a SA 30% peel. The affected areas (back and bilateral arms) were thoroughly cleansed and prepped with alcohol. SA 30% in hydroethanolic solution was applied evenly to the affected area. The patient was observed for pseudofrosting, a precipitation of SA crystals that indicates peel completion (Figure 3). The peel was left in place, as it is self-neutralizing, and the patient was instructed to shower that same day with a gentle cleanser. This procedure was repeated 10 days later. Both treatments were well tolerated, with only a transient burning sensation reported during the application. At 3-week follow-up, the patient presented with complete resolution of her arm lesions and significant improvement of the back lesions (Figures 4 and 5). She also reported improvement in the acne vulgaris on her back.

Discussion

SA 30% is a lipid-soluble hydroxybenzoic acid with comedolytic and desmolytic qualities. This results in the disruption of epidermal cell cohesion and promotes exfoliation.² Lipophilic properties allow SA to penetrate sebaceous glands and disrupt sebum production, making it particularly effective in seborrheic conditions such as acne. This mechanism may have increased therapeutic effect in this case.³ Additionally, as a salicylate, SA possesses anti-inflammatory properties, though this effect is most pronounced at lower concentrations. SA 30% is considered a superficial peel, as the depth of chemexfoliation is limited to the epidermis.³ A modified SA preparation is a safe and effective treatment for moderate-to-severe acne vulgaris. The apparent pseudofrost during application is due to precipitated SA, rather than the precipitation of dermal proteins seen in deeper peels, such as trichloroacetic acid.² Unlike glycolic or pyruvic acid peels, SA does not require neutralization.

SA is cost-effective and has been used safely in all skin types to treat various epidermal conditions, including acne vulgaris, melasma, photodamage, freckles, lentigines and postinflammatory hyperpigmentation (PIH).² Mild adverse effects occur in about 15% to 30% of patients and include prolonged erythema, intense exfoliation, dryness, crusting, and pigmentary dyschromias. Rare adverse effects include systemic toxicity (salicylism) and hypoglycemia. Contraindications to SA 30% peels include history of allergy to salicylates, active bacterial or viral infection, dermatitis in the treatment area, pregnancy, and skin malignancy.²

Chemical peels are typically used with caution in patients with skin of color due to a higher risk of PIH. However, SA 30% has been shown to be safe and effective in these populations.⁴ A study by Grimes found that 88% of patients with Fitzpatrick skin types V and VI experienced significant improvement in PIH, melasma, or enlarged pores with minimal to no adverse effects.⁴ Subsequent larger studies have reinforced these findings. In a study involving 250 patients with Fitzpatrick skin types IV and V, no patients experienced PIH, confirming the safety of SA in darker skin tones. This is likely due to the superficial nature of the peel, which does not affect the basal layer of the epidermis where melanocytes reside, reducing the risk of pigmentary complications. Additionally, SA peels are self-neutralizing, unlike glycolic or trichloroacetic acid peels, which require manual neutralization and carry a higher risk of PIH if not neutralized properly.⁵

SA has been as shown to be a moderately successful treatment for PIH. The Grimes study found that 4 of 5 patients with Fitzpatrick skin types IV and V saw a 75% improvement in PIH after SA peels.⁴ Davis et al found a nonsignificant trend toward skin lightening in Korean adults treated for acne and PIH, with significant decreases in erythema and improvements in greasiness, dryness, and scaliness.⁶ Importantly, the risk of PIH following TV is higher in patients with skin of color.⁷ SA may be effective in treating TV and PIH, offering a multifactorial approach by addressing both conditions while posing a low risk for causing PIH.⁸

TV and other Malassezia spp infections are common concerns in dermatology and primary care, with Malassezia-associated superficial mycoses (eg, dandruff, pityriasis versicolor, and folliculitis) affecting up to 50% of the population worldwide.⁹ Despite this, there has been little recent advancement in antifungal treatments. Ketoconazole, terbinafine, and fluconazole have been in use since the 1980s and 1990s.⁸ Most antifungal drugs target ergosterol, a component of the fungal cell wall.¹⁰ Additionally, Malassezia spp have been increasingly reported to cause invasive infections in immunocompromised patients.¹¹ Given the rise in antifungal resistance, the judicious use of antifungals and implementation of novel treatment strategies is essential.

While SA lacks intrinsic antifungal properties, different combinations (Whitfield ointment consisting of 3% SA and 6% benzoic acid; 2% sulfur and 2% SA) have been effective in the treatment of TV.¹ It is theorized that the effectiveness of SA against TV is due to its ability to exfoliate and acidify the stratum corneum, the natural habitat of M. furfur.

SA also reduces sebum production by downregulating sebocyte lipogenesis via the sterol regulatory element-binding protein-1 pathway and suppressing the nuclear factor κB (NF-κB) pathway, a key pathway in inflammation.¹² These mechanisms make SA an effective acne treatment. Additionally, M. furfur is a lipid-dependent yeast, thus the decreased lipogenesis by sebocytes may be beneficial in treating TV as well.¹² A study of 25 patients with TV in India found that 88% achieved clinical and microbiological cure after 4 once-weekly treatments of a SA 30% peel.⁸

In a study of deployed military personnel, fungal infections affected about 11% of participants.¹³ Contributing factors to the development of fungal infections included excessive sweating, humid conditions, and limited access to hygiene facilities. In such settings, traditional antifungal therapies may be less effective or challenging to adhere to, making alternative treatments more desirable. SA peels could offer a practical solution in these circumstances, as they are easily applied in the clinic, require no neutralization or downtime, and do not require the patient to apply medications between visits.

In this case, the patient demonstrated significant improvement with 2 SA peels, with noted improvement in her acne. SA 30% peel was highlighted as a useful treatment option for patients with TV who struggle with topical medication adherence; furthermore, it may be particularly beneficial for patients with concomitant acne.

Conclusions

This case demonstrates the successful use of in-office SA 30% peel as a treatment for TV. The rapid improvement and resolution of lesions with minimal adverse effects suggest that SA peel may serve as a valuable alternative for patients with extensive disease in difficult-to-reach affected areas, or those who are dissatisfied with traditional therapies. Additionally, the concurrent improvement of the patient’s back acne underscores the dual therapeutic potential of this treatment. Given the ease of application, cost effectiveness, and favorable safety profile, SA 30% peel is a viable option in the management of TV, especially in cases where topical or oral antifungals are impractical. Further studies could help establish standardized protocols and assess long-term outcomes of this treatment modality.

This retrospective observational study investigates skin cancer prevalence and care patterns within the Military Health System (MHS) from 2017 to 2022. Utilizing the MHS Management Analysis and Reporting Tool (most commonly called M2), we analyzed more than 5 million patient encounters and documented skin cancer prevalence in the MHS beneficiary population utilizing available demographic data. Notable findings included an increased prevalence of skin cancer in the military population compared with the civilian population, a substantial decline in direct care (DC) visits at military treatment facilities compared with civilian purchased care (PC) visits, and a decreased total number of visits during COVID-19 restrictions.

The Military Health System (MHS) is a worldwide health care delivery system that serves 9.6 million beneficiaries, including military service members, retirees, and their families.¹ Its mission is 2-fold: provide a medically ready force, and provide a medical benefit in keeping with the service and sacrifice of active-duty personnel, military retirees, and their families. For fiscal year (FY) 2022, active-duty service members and their families comprised 16.7% and 19.9% of beneficiaries, respectively, while retired service members and their families comprised 27% and 32% of beneficiaries, respectively.

The MHS operates under the authority of the Department of Defense (DoD) and is supported by an annual budget of approximately $50 billion.¹ Health care provision within the MHS is managed by TRICARE regional networks.² Within these networks, MHS beneficiaries may receive health care in 2 categories: direct care (DC) and purchased care (PC). Direct care is rendered in military treatment facilities by military or civilian providers contracted by the DoD, and PC is administered by civilian providers at civilian health care facilities within the TRICARE network, which is comprised of individual providers, clinics, and hospitals that have agreed to accept TRICARE beneficiaries.¹ Purchased care is fee-for-service and paid for by the MHS. Of note, the MHS differs from the Veterans Affairs health care system in that the MHS through DC and PC sees only active-duty service members, active-duty dependents, retirees, and retirees’ dependents (primarily spouses), whereas Veterans Affairs sees only veterans (not necessarily retirees) discharged from military service with compensable medical conditions or disabilities.

Skin cancer presents a notable concern for the US Military, as the risk for skin cancer is thought to be higher than in the general population.^3,4 This elevated risk is attributed to numerous factors inherent to active-duty service, including time spent in tropical environments, increased exposure to UV radiation, time spent at high altitudes, and decreased rates of sun-protective behaviors.³ Although numerous studies have explored the mechanisms that contribute to service members’ increased skin cancer risk, there are few (if any) that discuss the burden of skin cancer on the MHS and where its beneficiaries receive their skin cancer care. This study evaluated the burden of skin cancer within the MHS, as demonstrated by the period prevalence of skin cancer among its beneficiaries and the number and distribution of patient visits for skin cancer across both DC and PC from 2017 to 2022.

Methods

Data Collection—This retrospective observational study was designed to describe trends in outpatient visits with a skin cancer diagnosis and annual prevalence of skin cancer types in the MHS. Data are from all MHS beneficiaries who were eligible or enrolled in the analysis year. Our data source was the MHS Management Analysis and Reporting Tool (most commonly called M2), a query tool that contains the current and most recent 5 full FYs of Defense Health Agency corporate health care data including aggregated FY and calendar-year counts of MHS beneficiaries from 2017 to 2022 using encounter and claims data tables from both DC and PC. Data in M2 are coded using a pseudo-person identification number, and queries performed for this study were limited to de-identified visit and patient counts.

Skin cancer diagnoses were defined by relevant International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes recorded from outpatient visits in DC and PC. The M2 database was queried to find aggregate counts of visits and unique MHS beneficiaries with one or more diagnoses of a skin cancer type of interest (defined by relevant ICD-10-CM code) over the study period stratified by year and by patient demographic characteristics. Skin cancer types by ICD-10-CM code group included basal cell carcinoma (BCC), squamous cell carcinoma (SCC), malignant melanoma (MM), and other (including Merkel cell carcinoma and sebaceous carcinoma). Demographic strata included age, sex, military status (active duty, dependents of active duty, retired, or all others), sponsor military rank, and sponsor branch (army, air force, marine corps, or navy). Visit counts included diagnoses from any ICD position (for encounters that contained multiple ICD codes) to describe the total volume of care that addressed a diagnosed skin cancer. Counts of unique patients in prevalence analyses included relevant diagnoses in the primary ICD position only to increase the specificity of prevalence estimates.

Data Analysis—Descriptive analyses included the total number of outpatient visits with a skin cancer diagnosis in DC and PC over the study period, with percentages of total visits by year and by demographic strata. Separate analyses estimated annual prevalences of skin cancer types in the MHS by study year and within 2022 by demographic strata. Numerators in prevalence analyses were defined as the number of unique individuals with one or more relevant ICD codes in the analysis year. Denominators were defined as the total number of MHS beneficiaries in the analysis year and resulting period prevalences reported. Observed prevalences were qualitatively described, and trends were compared with prevalences in nonmilitary populations reported in the literature.

Ethics—This study was conducted as part of a study using secondary analyses of de-identified data from the M2 database. The study was reviewed and approved by the Walter Reed National Military Medical Center institutional review board.

Results

Encounter data were analyzed from a total of 5,374,348 visits between DC and PC over the study period for each cancer type of interest. Figures 1 and 2 show temporal trends in DC visits compared with PC visits in each beneficiary category. The percentage of total DC visits subsequently declined each year throughout the study period, with percentage decreases from 2017 to 2022 of 1.45% or 8200 fewer visits for MM, 3.41% or 7280 fewer visits for BCC, and 2.26% or 3673 fewer visits for SCC.

When stratified by beneficiary category, this trend remained consistent among dependents and retirees, with the most notable annual percentage decrease from 2019 to 2020. A higher proportion of younger adults and active-duty beneficiaries was seen in DC relative to PC, in which most visits were among retirees and others (primarily dependents of retirees, survivors, and Guard/Reserve on active duty, as well as inactive Guard/Reserve). No linear trends over time were apparent for active duty in DC and for dependents and retirees in PC. eTable 1 summarizes the demographic characteristics of MHS beneficiaries being seen in DC and PC over the study period for each cancer type of interest.

The Table shows the period prevalence of skin cancer diagnoses within the MHS beneficiary population from 2017 to 2022. These data were further analyzed by MM, BCC, and SCC (eTable 2) and demographics of interest for the year 2022. By beneficiary category, the period prevalence of MM was 0.08% in active duty, 0.06% in dependents, 0.48% in others, and 1.10% in retirees; the period prevalence of BCC was 0.12% in active duty, 0.07% in dependents, 0.91% in others, and 2.50% in retirees; and the period prevalence of SCC was 0.02% in active duty, 0.01% in dependents, 0.63% in others, and 1.87% in retirees. By sponsor branch, the period prevalence of MM was 0.35% in the army, 0.62% in the air force, 0.35% in the marine corps, and 0.65% in the navy; the period prevalence of BCC was 0.74% in the army, 1.30% in the air force, 0.74% in the marine corps, and 1.36% in the navy; and the period prevalence of SCC was 0.52% in the army, 0.92% in the air force, 0.51% in the marine corps, and 0.97% in the navy.

Comment

This study aimed to provide insight into the burden of skin cancer within the MHS beneficiary population and to identify temporal trends in where these beneficiaries receive their care. We examined patient encounter data from more than 9.6 million MHS beneficiaries.

The utilization of ICD codes from patient encounters to estimate the prevalence of nonmelanoma skin cancer (NMSC) has demonstrated a high positive predictive value. In one study, NMSC cases were confirmed in 96.5% of ICD code–identified patients.⁵ We presented an extensive collection of epidemiologic data on BCC and SCC, which posed unique challenges for tracking, as they are not reported to or monitored by cancer registries such as the Surveillance, Epidemiology, and End Results (SEER) Program.⁶

MHS Compared to the US Population—A study using the Global Burden of Disease 2019 database revealed an increasing trend in the incidence and prevalence of NMSC and melanoma since 1990. The same study found the period prevalence in 2019 of MM, SCC, and BCC in the general US population to be 0.13%, 0.31%, and 0.05%, respectively.⁷ In contrast, among MHS beneficiaries, we observed a higher prevalence in the same year, with figures of 0.66% for MM, 0.72% for SCC, and 1.02% for BCC. According to the SEER database, the period prevalence of MM within the general US population in 2020 was 0.4%.⁸ That same year, we identified a higher period prevalence of MM—0.54%—within the MHS beneficiary population. Specifically, within the MHS retiree population, the prevalence in 2022 was double that of the general MHS population, with a rate of 1.10%, underscoring the importance of skin cancer screening in older, at-risk adult populations. Prior studies similarly found increased rates of skin cancer within the military beneficiary population. Further studies are needed to compare age-adjusted rates in the MHS vs US population.^9-11

COVID-19 Trends—Our data showed an overall decreasing prevalence of skin cancer in the MHS from 2019 to 2021. We suspect that the apparent decrease in skin cancer prevalence may be attributed to underdiagnosis from COVID-19 pandemic restrictions. During that time, many dermatology clinics at military treatment facilities underwent temporary closures, and some dermatologists were sent on nondermatologic utilization tours. Likewise, a US multi-institutional study described declining rates of new melanomas from 2020 to 2021, with an increased proportion of patient presentations with advanced melanoma, suggesting an underdiagnosis of melanoma cases during pandemic restrictions. That study also noted an increased rate of patient-identified melanomas and a decreased rate of provider-identified melanomas during that time.¹² Contributing factors may include excess hospital demand, increased patient complexity and acute care needs, and long outpatient clinic backlogs during this time.¹³Financial Burden—Over our 5-year study period, there were 5,374,348 patient encounters addressing skin cancer, both in DC and PC (Figures 1 and 2; eTable 1). In 2016 to 2018, the average annual cost of treating skin cancer in the US civilian, noninstitutionalized population was $1243 for NMSC (BCC and SCC) and $2430 for melanoma.⁶ Using this metric, the estimated total cost of care rendered in the MHS in 2018 for NMSC and melanoma was $202,510,803 and $156,516,300, respectively.

Trends in DC vs PC—In the years examined, we found a notable decrease in the number of beneficiaries receiving treatment for MM, BCC, and SCC in DC. Simultaneously, there has been an increase in the number of beneficiaries receiving PC for BCC and SCC, though this trend was not apparent for MM.

Our data provided interesting insights into the percentage of PC compared with DC offered within the MHS. Importantly, our findings suggested that the majority of skin cancer in active-duty service members is managed with DC within the military treatment facility setting (61% DC management over the period analyzed). This finding was true across all years of data analyzed, suggesting that the COVID-19 pandemic did not result in a quantifiable shift in care of skin cancer within the active-duty component to outside providers. One of the critical roles of dermatologists in the MHS is to diagnose and treat skin cancer, and our study suggested that the current global manning and staffing for MHS dermatologists may not be sufficient to meet the burden of skin cancers encountered within our active-duty troops, as only 61% are managed with DC. In particular, service members in more austere and/or overseas locations may not have ready access to a dermatologist.

The burden of skin cancer shifts dramatically when analyzing care of all other populations included in these data, including dependents of active-duty service members, retirees, and the category of “other” (ie, principally dependents of retirees). Within these populations, the rate of DC falls to 30%, with 70% of active-duty dependent care being deferred to network. The findings are even more noticeable for retirees and others within these 2 cohorts in all types of skin cancer analyzed, where DC only accounted for 5.2% of those skin cancers encountered and managed across TRICARE-eligible beneficiaries. For MM, BCC, and SCC, percentages of DC were 5.4%, 5.8%, and 3.5%, respectively. Although it is interesting to note the lower percentage of SCC managed via DC, our data did not allow for extrapolation as to why more SCC cases may be deferred to network. The shift to PC may align with DoD initiatives to increase the private sector’s involvement in military medicine and transition to civilianizing the MHS.¹⁴ In the end, the findings are remarkable, with approximately 95% of skin cancer care and management provided overall via PC.

These findings differ from previously published data regarding DC and PC from other specialty areas. Results from an analysis of DC vs PC for plastic surgery for the entire MHS from 2016 to 2019 found 83.2% of cases were deferred to network.¹⁵ A similar publication in the orthopedics literature examined TRICARE claims for patients who underwent total hip or knee arthroplasties between 2006 and 2019 and found 84.6% of cases were referred for PC. Notably, the authors utilized generalized linear models for cost analysis and found that DC was more expensive than PC, though this likely was a result of higher rates of hospital readmission within DC cases.¹⁶ Lastly, an article on the DC vs PC disposition of MHS patients with breast cancer from 2003 to 2008 found 46% of cases managed with DC vs 26.% with PC and 27.8% receiving a combination. In this case, the authors found a reduced cost associated with DC vs PC.¹⁷

Little additional literature exists regarding the costs of DC vs PC. An article published in 2016 designed to assess costs of DC vs PC showed that almost all military treatment facilities have higher costs than their private sector counterparts, with a few exceptions.¹⁸ This does not assess the costs of specific procedures, however, and only the overall cost to maintain a treatment facility. Importantly, this study was based on data from FY 2014 and has not been updated to reflect complex changes within the MHS system and the private health care system. Indeed, a US Government Accountability Office FY 2023 study highlighted staffing and efficiency issues within this transition to civilian medicine; subsequently, the 2024 President’s Budget suspended all planned clinical medical military end strength divestitures, underscoring the potential ineffectiveness of a civilianized MHS at meeting the health care needs of its beneficiaries.^19,20 Future research on a national scale will be necessary to see if there is a reversal of this trend to PC and if doing so has any impact on access to DC for active-duty troops or active-duty dependents.

In addition to PC vs DC trends, we also can get a sense of the impact of the COVID pandemic restrictions on access to DC vs PC by assessing the change in rates seen in the data from the pre-COVID years (2017-2019) to the “post-COVID” years (2020-2022) included. Overall, rates of DC decreased uniformly from their already low percentages. In our study, rates of DC decreased from 5.8% in 2019 to 4.8% in 2022 for MM, from 6.6% to 4.3% for BCC, and from 4.2% to 2.9% for SCC. Although these changes seem small at first, they represent a 30.6% overall decrease in DC for BCC and an overall decrease of 55.4% in DC for SCC. Although our data do not allow us to extrapolate the real cost of this reduction across a nationwide health care system and more than 5 million care encounters, the financial and personal (ie, lost man-hours) costs of this decrease in DC likely are substantial.

In addition to costs, qualitative aspects that contribute to the burden of skin cancer include treatment-related morbidity, such as scarring, pain, and time spent away from family, work, and hobbies, as well as overall patient satisfaction with the quality of care they receive.²¹ Future work is critical to assess the real cost of this immense burden of PC for the treatment and management of skin cancers within the DoD beneficiary population.

Limitations—This study is limited by its observational nature. Given the mechanism of our data collection, we may have underestimated disease prevalence, as not all patients are seen for their diagnosis annually. Furthermore, reported demographic strata (eg, age, sex) were limited to those available and valid in the M2 reporting system. Finally, our study only collected data from those service members or former service members seen within the MHS and does not reflect any care rendered to those who are no longer active duty but did not officially retire from the military (ie, nonretired service members receiving care in the Veterans Affairs system for skin cancer).

Conclusion

We describe the annual burden of care for skin cancer in the MHS beneficiary population. Noteworthy findings observed were an overall decrease in beneficiaries being treated for skin cancer through DC; a decreasing annual prevalence of skin cancer diagnosis between 2019 and 2021, which may represent underdiagnosis or decreased follow-up in the setting of the COVID-19 pandemic; and a higher rate of skin cancer in the military beneficiary population compared to the civilian population.

This retrospective observational study investigates skin cancer prevalence and care patterns within the Military Health System (MHS) from 2017 to 2022. Utilizing the MHS Management Analysis and Reporting Tool (most commonly called M2), we analyzed more than 5 million patient encounters and documented skin cancer prevalence in the MHS beneficiary population utilizing available demographic data. Notable findings included an increased prevalence of skin cancer in the military population compared with the civilian population, a substantial decline in direct care (DC) visits at military treatment facilities compared with civilian purchased care (PC) visits, and a decreased total number of visits during COVID-19 restrictions.

The Military Health System (MHS) is a worldwide health care delivery system that serves 9.6 million beneficiaries, including military service members, retirees, and their families.¹ Its mission is 2-fold: provide a medically ready force, and provide a medical benefit in keeping with the service and sacrifice of active-duty personnel, military retirees, and their families. For fiscal year (FY) 2022, active-duty service members and their families comprised 16.7% and 19.9% of beneficiaries, respectively, while retired service members and their families comprised 27% and 32% of beneficiaries, respectively.

The MHS operates under the authority of the Department of Defense (DoD) and is supported by an annual budget of approximately $50 billion.¹ Health care provision within the MHS is managed by TRICARE regional networks.² Within these networks, MHS beneficiaries may receive health care in 2 categories: direct care (DC) and purchased care (PC). Direct care is rendered in military treatment facilities by military or civilian providers contracted by the DoD, and PC is administered by civilian providers at civilian health care facilities within the TRICARE network, which is comprised of individual providers, clinics, and hospitals that have agreed to accept TRICARE beneficiaries.¹ Purchased care is fee-for-service and paid for by the MHS. Of note, the MHS differs from the Veterans Affairs health care system in that the MHS through DC and PC sees only active-duty service members, active-duty dependents, retirees, and retirees’ dependents (primarily spouses), whereas Veterans Affairs sees only veterans (not necessarily retirees) discharged from military service with compensable medical conditions or disabilities.

Skin cancer presents a notable concern for the US Military, as the risk for skin cancer is thought to be higher than in the general population.^3,4 This elevated risk is attributed to numerous factors inherent to active-duty service, including time spent in tropical environments, increased exposure to UV radiation, time spent at high altitudes, and decreased rates of sun-protective behaviors.³ Although numerous studies have explored the mechanisms that contribute to service members’ increased skin cancer risk, there are few (if any) that discuss the burden of skin cancer on the MHS and where its beneficiaries receive their skin cancer care. This study evaluated the burden of skin cancer within the MHS, as demonstrated by the period prevalence of skin cancer among its beneficiaries and the number and distribution of patient visits for skin cancer across both DC and PC from 2017 to 2022.

Methods

Data Collection—This retrospective observational study was designed to describe trends in outpatient visits with a skin cancer diagnosis and annual prevalence of skin cancer types in the MHS. Data are from all MHS beneficiaries who were eligible or enrolled in the analysis year. Our data source was the MHS Management Analysis and Reporting Tool (most commonly called M2), a query tool that contains the current and most recent 5 full FYs of Defense Health Agency corporate health care data including aggregated FY and calendar-year counts of MHS beneficiaries from 2017 to 2022 using encounter and claims data tables from both DC and PC. Data in M2 are coded using a pseudo-person identification number, and queries performed for this study were limited to de-identified visit and patient counts.

Skin cancer diagnoses were defined by relevant International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes recorded from outpatient visits in DC and PC. The M2 database was queried to find aggregate counts of visits and unique MHS beneficiaries with one or more diagnoses of a skin cancer type of interest (defined by relevant ICD-10-CM code) over the study period stratified by year and by patient demographic characteristics. Skin cancer types by ICD-10-CM code group included basal cell carcinoma (BCC), squamous cell carcinoma (SCC), malignant melanoma (MM), and other (including Merkel cell carcinoma and sebaceous carcinoma). Demographic strata included age, sex, military status (active duty, dependents of active duty, retired, or all others), sponsor military rank, and sponsor branch (army, air force, marine corps, or navy). Visit counts included diagnoses from any ICD position (for encounters that contained multiple ICD codes) to describe the total volume of care that addressed a diagnosed skin cancer. Counts of unique patients in prevalence analyses included relevant diagnoses in the primary ICD position only to increase the specificity of prevalence estimates.

Data Analysis—Descriptive analyses included the total number of outpatient visits with a skin cancer diagnosis in DC and PC over the study period, with percentages of total visits by year and by demographic strata. Separate analyses estimated annual prevalences of skin cancer types in the MHS by study year and within 2022 by demographic strata. Numerators in prevalence analyses were defined as the number of unique individuals with one or more relevant ICD codes in the analysis year. Denominators were defined as the total number of MHS beneficiaries in the analysis year and resulting period prevalences reported. Observed prevalences were qualitatively described, and trends were compared with prevalences in nonmilitary populations reported in the literature.

Ethics—This study was conducted as part of a study using secondary analyses of de-identified data from the M2 database. The study was reviewed and approved by the Walter Reed National Military Medical Center institutional review board.

Results

Encounter data were analyzed from a total of 5,374,348 visits between DC and PC over the study period for each cancer type of interest. Figures 1 and 2 show temporal trends in DC visits compared with PC visits in each beneficiary category. The percentage of total DC visits subsequently declined each year throughout the study period, with percentage decreases from 2017 to 2022 of 1.45% or 8200 fewer visits for MM, 3.41% or 7280 fewer visits for BCC, and 2.26% or 3673 fewer visits for SCC.

When stratified by beneficiary category, this trend remained consistent among dependents and retirees, with the most notable annual percentage decrease from 2019 to 2020. A higher proportion of younger adults and active-duty beneficiaries was seen in DC relative to PC, in which most visits were among retirees and others (primarily dependents of retirees, survivors, and Guard/Reserve on active duty, as well as inactive Guard/Reserve). No linear trends over time were apparent for active duty in DC and for dependents and retirees in PC. eTable 1 summarizes the demographic characteristics of MHS beneficiaries being seen in DC and PC over the study period for each cancer type of interest.

The Table shows the period prevalence of skin cancer diagnoses within the MHS beneficiary population from 2017 to 2022. These data were further analyzed by MM, BCC, and SCC (eTable 2) and demographics of interest for the year 2022. By beneficiary category, the period prevalence of MM was 0.08% in active duty, 0.06% in dependents, 0.48% in others, and 1.10% in retirees; the period prevalence of BCC was 0.12% in active duty, 0.07% in dependents, 0.91% in others, and 2.50% in retirees; and the period prevalence of SCC was 0.02% in active duty, 0.01% in dependents, 0.63% in others, and 1.87% in retirees. By sponsor branch, the period prevalence of MM was 0.35% in the army, 0.62% in the air force, 0.35% in the marine corps, and 0.65% in the navy; the period prevalence of BCC was 0.74% in the army, 1.30% in the air force, 0.74% in the marine corps, and 1.36% in the navy; and the period prevalence of SCC was 0.52% in the army, 0.92% in the air force, 0.51% in the marine corps, and 0.97% in the navy.

Comment

This study aimed to provide insight into the burden of skin cancer within the MHS beneficiary population and to identify temporal trends in where these beneficiaries receive their care. We examined patient encounter data from more than 9.6 million MHS beneficiaries.

The utilization of ICD codes from patient encounters to estimate the prevalence of nonmelanoma skin cancer (NMSC) has demonstrated a high positive predictive value. In one study, NMSC cases were confirmed in 96.5% of ICD code–identified patients.⁵ We presented an extensive collection of epidemiologic data on BCC and SCC, which posed unique challenges for tracking, as they are not reported to or monitored by cancer registries such as the Surveillance, Epidemiology, and End Results (SEER) Program.⁶

MHS Compared to the US Population—A study using the Global Burden of Disease 2019 database revealed an increasing trend in the incidence and prevalence of NMSC and melanoma since 1990. The same study found the period prevalence in 2019 of MM, SCC, and BCC in the general US population to be 0.13%, 0.31%, and 0.05%, respectively.⁷ In contrast, among MHS beneficiaries, we observed a higher prevalence in the same year, with figures of 0.66% for MM, 0.72% for SCC, and 1.02% for BCC. According to the SEER database, the period prevalence of MM within the general US population in 2020 was 0.4%.⁸ That same year, we identified a higher period prevalence of MM—0.54%—within the MHS beneficiary population. Specifically, within the MHS retiree population, the prevalence in 2022 was double that of the general MHS population, with a rate of 1.10%, underscoring the importance of skin cancer screening in older, at-risk adult populations. Prior studies similarly found increased rates of skin cancer within the military beneficiary population. Further studies are needed to compare age-adjusted rates in the MHS vs US population.^9-11

COVID-19 Trends—Our data showed an overall decreasing prevalence of skin cancer in the MHS from 2019 to 2021. We suspect that the apparent decrease in skin cancer prevalence may be attributed to underdiagnosis from COVID-19 pandemic restrictions. During that time, many dermatology clinics at military treatment facilities underwent temporary closures, and some dermatologists were sent on nondermatologic utilization tours. Likewise, a US multi-institutional study described declining rates of new melanomas from 2020 to 2021, with an increased proportion of patient presentations with advanced melanoma, suggesting an underdiagnosis of melanoma cases during pandemic restrictions. That study also noted an increased rate of patient-identified melanomas and a decreased rate of provider-identified melanomas during that time.¹² Contributing factors may include excess hospital demand, increased patient complexity and acute care needs, and long outpatient clinic backlogs during this time.¹³Financial Burden—Over our 5-year study period, there were 5,374,348 patient encounters addressing skin cancer, both in DC and PC (Figures 1 and 2; eTable 1). In 2016 to 2018, the average annual cost of treating skin cancer in the US civilian, noninstitutionalized population was $1243 for NMSC (BCC and SCC) and $2430 for melanoma.⁶ Using this metric, the estimated total cost of care rendered in the MHS in 2018 for NMSC and melanoma was $202,510,803 and $156,516,300, respectively.

Trends in DC vs PC—In the years examined, we found a notable decrease in the number of beneficiaries receiving treatment for MM, BCC, and SCC in DC. Simultaneously, there has been an increase in the number of beneficiaries receiving PC for BCC and SCC, though this trend was not apparent for MM.

Our data provided interesting insights into the percentage of PC compared with DC offered within the MHS. Importantly, our findings suggested that the majority of skin cancer in active-duty service members is managed with DC within the military treatment facility setting (61% DC management over the period analyzed). This finding was true across all years of data analyzed, suggesting that the COVID-19 pandemic did not result in a quantifiable shift in care of skin cancer within the active-duty component to outside providers. One of the critical roles of dermatologists in the MHS is to diagnose and treat skin cancer, and our study suggested that the current global manning and staffing for MHS dermatologists may not be sufficient to meet the burden of skin cancers encountered within our active-duty troops, as only 61% are managed with DC. In particular, service members in more austere and/or overseas locations may not have ready access to a dermatologist.

The burden of skin cancer shifts dramatically when analyzing care of all other populations included in these data, including dependents of active-duty service members, retirees, and the category of “other” (ie, principally dependents of retirees). Within these populations, the rate of DC falls to 30%, with 70% of active-duty dependent care being deferred to network. The findings are even more noticeable for retirees and others within these 2 cohorts in all types of skin cancer analyzed, where DC only accounted for 5.2% of those skin cancers encountered and managed across TRICARE-eligible beneficiaries. For MM, BCC, and SCC, percentages of DC were 5.4%, 5.8%, and 3.5%, respectively. Although it is interesting to note the lower percentage of SCC managed via DC, our data did not allow for extrapolation as to why more SCC cases may be deferred to network. The shift to PC may align with DoD initiatives to increase the private sector’s involvement in military medicine and transition to civilianizing the MHS.¹⁴ In the end, the findings are remarkable, with approximately 95% of skin cancer care and management provided overall via PC.

These findings differ from previously published data regarding DC and PC from other specialty areas. Results from an analysis of DC vs PC for plastic surgery for the entire MHS from 2016 to 2019 found 83.2% of cases were deferred to network.¹⁵ A similar publication in the orthopedics literature examined TRICARE claims for patients who underwent total hip or knee arthroplasties between 2006 and 2019 and found 84.6% of cases were referred for PC. Notably, the authors utilized generalized linear models for cost analysis and found that DC was more expensive than PC, though this likely was a result of higher rates of hospital readmission within DC cases.¹⁶ Lastly, an article on the DC vs PC disposition of MHS patients with breast cancer from 2003 to 2008 found 46% of cases managed with DC vs 26.% with PC and 27.8% receiving a combination. In this case, the authors found a reduced cost associated with DC vs PC.¹⁷

Little additional literature exists regarding the costs of DC vs PC. An article published in 2016 designed to assess costs of DC vs PC showed that almost all military treatment facilities have higher costs than their private sector counterparts, with a few exceptions.¹⁸ This does not assess the costs of specific procedures, however, and only the overall cost to maintain a treatment facility. Importantly, this study was based on data from FY 2014 and has not been updated to reflect complex changes within the MHS system and the private health care system. Indeed, a US Government Accountability Office FY 2023 study highlighted staffing and efficiency issues within this transition to civilian medicine; subsequently, the 2024 President’s Budget suspended all planned clinical medical military end strength divestitures, underscoring the potential ineffectiveness of a civilianized MHS at meeting the health care needs of its beneficiaries.^19,20 Future research on a national scale will be necessary to see if there is a reversal of this trend to PC and if doing so has any impact on access to DC for active-duty troops or active-duty dependents.

In addition to PC vs DC trends, we also can get a sense of the impact of the COVID pandemic restrictions on access to DC vs PC by assessing the change in rates seen in the data from the pre-COVID years (2017-2019) to the “post-COVID” years (2020-2022) included. Overall, rates of DC decreased uniformly from their already low percentages. In our study, rates of DC decreased from 5.8% in 2019 to 4.8% in 2022 for MM, from 6.6% to 4.3% for BCC, and from 4.2% to 2.9% for SCC. Although these changes seem small at first, they represent a 30.6% overall decrease in DC for BCC and an overall decrease of 55.4% in DC for SCC. Although our data do not allow us to extrapolate the real cost of this reduction across a nationwide health care system and more than 5 million care encounters, the financial and personal (ie, lost man-hours) costs of this decrease in DC likely are substantial.

In addition to costs, qualitative aspects that contribute to the burden of skin cancer include treatment-related morbidity, such as scarring, pain, and time spent away from family, work, and hobbies, as well as overall patient satisfaction with the quality of care they receive.²¹ Future work is critical to assess the real cost of this immense burden of PC for the treatment and management of skin cancers within the DoD beneficiary population.

Limitations—This study is limited by its observational nature. Given the mechanism of our data collection, we may have underestimated disease prevalence, as not all patients are seen for their diagnosis annually. Furthermore, reported demographic strata (eg, age, sex) were limited to those available and valid in the M2 reporting system. Finally, our study only collected data from those service members or former service members seen within the MHS and does not reflect any care rendered to those who are no longer active duty but did not officially retire from the military (ie, nonretired service members receiving care in the Veterans Affairs system for skin cancer).

Conclusion

We describe the annual burden of care for skin cancer in the MHS beneficiary population. Noteworthy findings observed were an overall decrease in beneficiaries being treated for skin cancer through DC; a decreasing annual prevalence of skin cancer diagnosis between 2019 and 2021, which may represent underdiagnosis or decreased follow-up in the setting of the COVID-19 pandemic; and a higher rate of skin cancer in the military beneficiary population compared to the civilian population.

This retrospective observational study investigates skin cancer prevalence and care patterns within the Military Health System (MHS) from 2017 to 2022. Utilizing the MHS Management Analysis and Reporting Tool (most commonly called M2), we analyzed more than 5 million patient encounters and documented skin cancer prevalence in the MHS beneficiary population utilizing available demographic data. Notable findings included an increased prevalence of skin cancer in the military population compared with the civilian population, a substantial decline in direct care (DC) visits at military treatment facilities compared with civilian purchased care (PC) visits, and a decreased total number of visits during COVID-19 restrictions.

The Military Health System (MHS) is a worldwide health care delivery system that serves 9.6 million beneficiaries, including military service members, retirees, and their families.¹ Its mission is 2-fold: provide a medically ready force, and provide a medical benefit in keeping with the service and sacrifice of active-duty personnel, military retirees, and their families. For fiscal year (FY) 2022, active-duty service members and their families comprised 16.7% and 19.9% of beneficiaries, respectively, while retired service members and their families comprised 27% and 32% of beneficiaries, respectively.

The MHS operates under the authority of the Department of Defense (DoD) and is supported by an annual budget of approximately $50 billion.¹ Health care provision within the MHS is managed by TRICARE regional networks.² Within these networks, MHS beneficiaries may receive health care in 2 categories: direct care (DC) and purchased care (PC). Direct care is rendered in military treatment facilities by military or civilian providers contracted by the DoD, and PC is administered by civilian providers at civilian health care facilities within the TRICARE network, which is comprised of individual providers, clinics, and hospitals that have agreed to accept TRICARE beneficiaries.¹ Purchased care is fee-for-service and paid for by the MHS. Of note, the MHS differs from the Veterans Affairs health care system in that the MHS through DC and PC sees only active-duty service members, active-duty dependents, retirees, and retirees’ dependents (primarily spouses), whereas Veterans Affairs sees only veterans (not necessarily retirees) discharged from military service with compensable medical conditions or disabilities.

Skin cancer presents a notable concern for the US Military, as the risk for skin cancer is thought to be higher than in the general population.^3,4 This elevated risk is attributed to numerous factors inherent to active-duty service, including time spent in tropical environments, increased exposure to UV radiation, time spent at high altitudes, and decreased rates of sun-protective behaviors.³ Although numerous studies have explored the mechanisms that contribute to service members’ increased skin cancer risk, there are few (if any) that discuss the burden of skin cancer on the MHS and where its beneficiaries receive their skin cancer care. This study evaluated the burden of skin cancer within the MHS, as demonstrated by the period prevalence of skin cancer among its beneficiaries and the number and distribution of patient visits for skin cancer across both DC and PC from 2017 to 2022.

Methods

Data Collection—This retrospective observational study was designed to describe trends in outpatient visits with a skin cancer diagnosis and annual prevalence of skin cancer types in the MHS. Data are from all MHS beneficiaries who were eligible or enrolled in the analysis year. Our data source was the MHS Management Analysis and Reporting Tool (most commonly called M2), a query tool that contains the current and most recent 5 full FYs of Defense Health Agency corporate health care data including aggregated FY and calendar-year counts of MHS beneficiaries from 2017 to 2022 using encounter and claims data tables from both DC and PC. Data in M2 are coded using a pseudo-person identification number, and queries performed for this study were limited to de-identified visit and patient counts.

Skin cancer diagnoses were defined by relevant International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes recorded from outpatient visits in DC and PC. The M2 database was queried to find aggregate counts of visits and unique MHS beneficiaries with one or more diagnoses of a skin cancer type of interest (defined by relevant ICD-10-CM code) over the study period stratified by year and by patient demographic characteristics. Skin cancer types by ICD-10-CM code group included basal cell carcinoma (BCC), squamous cell carcinoma (SCC), malignant melanoma (MM), and other (including Merkel cell carcinoma and sebaceous carcinoma). Demographic strata included age, sex, military status (active duty, dependents of active duty, retired, or all others), sponsor military rank, and sponsor branch (army, air force, marine corps, or navy). Visit counts included diagnoses from any ICD position (for encounters that contained multiple ICD codes) to describe the total volume of care that addressed a diagnosed skin cancer. Counts of unique patients in prevalence analyses included relevant diagnoses in the primary ICD position only to increase the specificity of prevalence estimates.

Data Analysis—Descriptive analyses included the total number of outpatient visits with a skin cancer diagnosis in DC and PC over the study period, with percentages of total visits by year and by demographic strata. Separate analyses estimated annual prevalences of skin cancer types in the MHS by study year and within 2022 by demographic strata. Numerators in prevalence analyses were defined as the number of unique individuals with one or more relevant ICD codes in the analysis year. Denominators were defined as the total number of MHS beneficiaries in the analysis year and resulting period prevalences reported. Observed prevalences were qualitatively described, and trends were compared with prevalences in nonmilitary populations reported in the literature.

Ethics—This study was conducted as part of a study using secondary analyses of de-identified data from the M2 database. The study was reviewed and approved by the Walter Reed National Military Medical Center institutional review board.

Results

Encounter data were analyzed from a total of 5,374,348 visits between DC and PC over the study period for each cancer type of interest. Figures 1 and 2 show temporal trends in DC visits compared with PC visits in each beneficiary category. The percentage of total DC visits subsequently declined each year throughout the study period, with percentage decreases from 2017 to 2022 of 1.45% or 8200 fewer visits for MM, 3.41% or 7280 fewer visits for BCC, and 2.26% or 3673 fewer visits for SCC.

When stratified by beneficiary category, this trend remained consistent among dependents and retirees, with the most notable annual percentage decrease from 2019 to 2020. A higher proportion of younger adults and active-duty beneficiaries was seen in DC relative to PC, in which most visits were among retirees and others (primarily dependents of retirees, survivors, and Guard/Reserve on active duty, as well as inactive Guard/Reserve). No linear trends over time were apparent for active duty in DC and for dependents and retirees in PC. eTable 1 summarizes the demographic characteristics of MHS beneficiaries being seen in DC and PC over the study period for each cancer type of interest.

The Table shows the period prevalence of skin cancer diagnoses within the MHS beneficiary population from 2017 to 2022. These data were further analyzed by MM, BCC, and SCC (eTable 2) and demographics of interest for the year 2022. By beneficiary category, the period prevalence of MM was 0.08% in active duty, 0.06% in dependents, 0.48% in others, and 1.10% in retirees; the period prevalence of BCC was 0.12% in active duty, 0.07% in dependents, 0.91% in others, and 2.50% in retirees; and the period prevalence of SCC was 0.02% in active duty, 0.01% in dependents, 0.63% in others, and 1.87% in retirees. By sponsor branch, the period prevalence of MM was 0.35% in the army, 0.62% in the air force, 0.35% in the marine corps, and 0.65% in the navy; the period prevalence of BCC was 0.74% in the army, 1.30% in the air force, 0.74% in the marine corps, and 1.36% in the navy; and the period prevalence of SCC was 0.52% in the army, 0.92% in the air force, 0.51% in the marine corps, and 0.97% in the navy.

Comment

This study aimed to provide insight into the burden of skin cancer within the MHS beneficiary population and to identify temporal trends in where these beneficiaries receive their care. We examined patient encounter data from more than 9.6 million MHS beneficiaries.

The utilization of ICD codes from patient encounters to estimate the prevalence of nonmelanoma skin cancer (NMSC) has demonstrated a high positive predictive value. In one study, NMSC cases were confirmed in 96.5% of ICD code–identified patients.⁵ We presented an extensive collection of epidemiologic data on BCC and SCC, which posed unique challenges for tracking, as they are not reported to or monitored by cancer registries such as the Surveillance, Epidemiology, and End Results (SEER) Program.⁶

MHS Compared to the US Population—A study using the Global Burden of Disease 2019 database revealed an increasing trend in the incidence and prevalence of NMSC and melanoma since 1990. The same study found the period prevalence in 2019 of MM, SCC, and BCC in the general US population to be 0.13%, 0.31%, and 0.05%, respectively.⁷ In contrast, among MHS beneficiaries, we observed a higher prevalence in the same year, with figures of 0.66% for MM, 0.72% for SCC, and 1.02% for BCC. According to the SEER database, the period prevalence of MM within the general US population in 2020 was 0.4%.⁸ That same year, we identified a higher period prevalence of MM—0.54%—within the MHS beneficiary population. Specifically, within the MHS retiree population, the prevalence in 2022 was double that of the general MHS population, with a rate of 1.10%, underscoring the importance of skin cancer screening in older, at-risk adult populations. Prior studies similarly found increased rates of skin cancer within the military beneficiary population. Further studies are needed to compare age-adjusted rates in the MHS vs US population.^9-11

COVID-19 Trends—Our data showed an overall decreasing prevalence of skin cancer in the MHS from 2019 to 2021. We suspect that the apparent decrease in skin cancer prevalence may be attributed to underdiagnosis from COVID-19 pandemic restrictions. During that time, many dermatology clinics at military treatment facilities underwent temporary closures, and some dermatologists were sent on nondermatologic utilization tours. Likewise, a US multi-institutional study described declining rates of new melanomas from 2020 to 2021, with an increased proportion of patient presentations with advanced melanoma, suggesting an underdiagnosis of melanoma cases during pandemic restrictions. That study also noted an increased rate of patient-identified melanomas and a decreased rate of provider-identified melanomas during that time.¹² Contributing factors may include excess hospital demand, increased patient complexity and acute care needs, and long outpatient clinic backlogs during this time.¹³Financial Burden—Over our 5-year study period, there were 5,374,348 patient encounters addressing skin cancer, both in DC and PC (Figures 1 and 2; eTable 1). In 2016 to 2018, the average annual cost of treating skin cancer in the US civilian, noninstitutionalized population was $1243 for NMSC (BCC and SCC) and $2430 for melanoma.⁶ Using this metric, the estimated total cost of care rendered in the MHS in 2018 for NMSC and melanoma was $202,510,803 and $156,516,300, respectively.

Trends in DC vs PC—In the years examined, we found a notable decrease in the number of beneficiaries receiving treatment for MM, BCC, and SCC in DC. Simultaneously, there has been an increase in the number of beneficiaries receiving PC for BCC and SCC, though this trend was not apparent for MM.

Our data provided interesting insights into the percentage of PC compared with DC offered within the MHS. Importantly, our findings suggested that the majority of skin cancer in active-duty service members is managed with DC within the military treatment facility setting (61% DC management over the period analyzed). This finding was true across all years of data analyzed, suggesting that the COVID-19 pandemic did not result in a quantifiable shift in care of skin cancer within the active-duty component to outside providers. One of the critical roles of dermatologists in the MHS is to diagnose and treat skin cancer, and our study suggested that the current global manning and staffing for MHS dermatologists may not be sufficient to meet the burden of skin cancers encountered within our active-duty troops, as only 61% are managed with DC. In particular, service members in more austere and/or overseas locations may not have ready access to a dermatologist.

The burden of skin cancer shifts dramatically when analyzing care of all other populations included in these data, including dependents of active-duty service members, retirees, and the category of “other” (ie, principally dependents of retirees). Within these populations, the rate of DC falls to 30%, with 70% of active-duty dependent care being deferred to network. The findings are even more noticeable for retirees and others within these 2 cohorts in all types of skin cancer analyzed, where DC only accounted for 5.2% of those skin cancers encountered and managed across TRICARE-eligible beneficiaries. For MM, BCC, and SCC, percentages of DC were 5.4%, 5.8%, and 3.5%, respectively. Although it is interesting to note the lower percentage of SCC managed via DC, our data did not allow for extrapolation as to why more SCC cases may be deferred to network. The shift to PC may align with DoD initiatives to increase the private sector’s involvement in military medicine and transition to civilianizing the MHS.¹⁴ In the end, the findings are remarkable, with approximately 95% of skin cancer care and management provided overall via PC.

These findings differ from previously published data regarding DC and PC from other specialty areas. Results from an analysis of DC vs PC for plastic surgery for the entire MHS from 2016 to 2019 found 83.2% of cases were deferred to network.¹⁵ A similar publication in the orthopedics literature examined TRICARE claims for patients who underwent total hip or knee arthroplasties between 2006 and 2019 and found 84.6% of cases were referred for PC. Notably, the authors utilized generalized linear models for cost analysis and found that DC was more expensive than PC, though this likely was a result of higher rates of hospital readmission within DC cases.¹⁶ Lastly, an article on the DC vs PC disposition of MHS patients with breast cancer from 2003 to 2008 found 46% of cases managed with DC vs 26.% with PC and 27.8% receiving a combination. In this case, the authors found a reduced cost associated with DC vs PC.¹⁷

Little additional literature exists regarding the costs of DC vs PC. An article published in 2016 designed to assess costs of DC vs PC showed that almost all military treatment facilities have higher costs than their private sector counterparts, with a few exceptions.¹⁸ This does not assess the costs of specific procedures, however, and only the overall cost to maintain a treatment facility. Importantly, this study was based on data from FY 2014 and has not been updated to reflect complex changes within the MHS system and the private health care system. Indeed, a US Government Accountability Office FY 2023 study highlighted staffing and efficiency issues within this transition to civilian medicine; subsequently, the 2024 President’s Budget suspended all planned clinical medical military end strength divestitures, underscoring the potential ineffectiveness of a civilianized MHS at meeting the health care needs of its beneficiaries.^19,20 Future research on a national scale will be necessary to see if there is a reversal of this trend to PC and if doing so has any impact on access to DC for active-duty troops or active-duty dependents.

In addition to PC vs DC trends, we also can get a sense of the impact of the COVID pandemic restrictions on access to DC vs PC by assessing the change in rates seen in the data from the pre-COVID years (2017-2019) to the “post-COVID” years (2020-2022) included. Overall, rates of DC decreased uniformly from their already low percentages. In our study, rates of DC decreased from 5.8% in 2019 to 4.8% in 2022 for MM, from 6.6% to 4.3% for BCC, and from 4.2% to 2.9% for SCC. Although these changes seem small at first, they represent a 30.6% overall decrease in DC for BCC and an overall decrease of 55.4% in DC for SCC. Although our data do not allow us to extrapolate the real cost of this reduction across a nationwide health care system and more than 5 million care encounters, the financial and personal (ie, lost man-hours) costs of this decrease in DC likely are substantial.

In addition to costs, qualitative aspects that contribute to the burden of skin cancer include treatment-related morbidity, such as scarring, pain, and time spent away from family, work, and hobbies, as well as overall patient satisfaction with the quality of care they receive.²¹ Future work is critical to assess the real cost of this immense burden of PC for the treatment and management of skin cancers within the DoD beneficiary population.

Limitations—This study is limited by its observational nature. Given the mechanism of our data collection, we may have underestimated disease prevalence, as not all patients are seen for their diagnosis annually. Furthermore, reported demographic strata (eg, age, sex) were limited to those available and valid in the M2 reporting system. Finally, our study only collected data from those service members or former service members seen within the MHS and does not reflect any care rendered to those who are no longer active duty but did not officially retire from the military (ie, nonretired service members receiving care in the Veterans Affairs system for skin cancer).

Conclusion

We describe the annual burden of care for skin cancer in the MHS beneficiary population. Noteworthy findings observed were an overall decrease in beneficiaries being treated for skin cancer through DC; a decreasing annual prevalence of skin cancer diagnosis between 2019 and 2021, which may represent underdiagnosis or decreased follow-up in the setting of the COVID-19 pandemic; and a higher rate of skin cancer in the military beneficiary population compared to the civilian population.