Diagnostic Assessment — Hidradenitis Suppurativa
Example 1 of 1 · fictitious patient (Veteran DI)
Diagnostic Assessment
Hidradenitis Suppurativa
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran DI, date of birth 19 August 1988, Australian Army, Military Police (later Corporal), enlisted 15 January 2007, medically discharged 04 June 2021. Operational service: Solomon Islands, 12 March 2009 to 30 August 2009 (non-warlike); Afghanistan, 01 February 2012 to 15 September 2012 (warlike); Iraq, 20 January 2016 to 25 August 2016 (warlike).
Occupational History
As a military police member the veteran conducted security patrols, close protection, detainee handling and entry control, wearing body armour, a load-carrying vest and a duty belt with a pistol, radio and restraints for shifts of 10 to 12 hours. The armour and webbing sat tightly against the axillae, chest and groin, and in tropical and desert climates her uniform was soaked with sweat for most of every shift.
Military police are exposed to heat, humidity and sustained friction and occlusion of the skin under equipment, irregular shift work, limited facilities for washing and changing on operations, and confrontational and traumatic incidents. Smoking was common and accepted among members on shift work and on deployment in the period.
Members with skin disease of the axillae and groin on operations often cannot rest the affected skin, because armour, webbing and weapons must be worn on every tasking, and dermatological care, biological therapies and wound care supplies are not available at deployed medical facilities.
History
Veteran DI, a military police member in the Australian Army, developed hidradenitis suppurativa in the axillae and groin on 10 June 2012 during warlike service in Afghanistan, after years of smoking, obesity, polycystic ovary syndrome with insulin resistance and progestogen implant use, and months of heat, sweating and friction under body armour. The condition worsened to Hurley stage III in July 2016 during warlike service in Iraq.
Timeline
- 22 Apr 2010 — A gynaecologist diagnosed polycystic ovary syndrome with irregular menses, hirsutism, a raised free androgen index and polycystic ovaries on ultrasound. An etonogestrel contraceptive implant was inserted on 06 May 2010 for menstrual suppression, at the request of her unit before field exercises and deployments, and was replaced every three years. She was smoking about 20 cigarettes a day. "PCOS, etonogestrel implant inserted"
- 14 Nov 2011 — At her pre-deployment medical, an oral glucose tolerance test showed impaired glucose tolerance with a two-hour glucose of 9.6 mmol/L and fasting insulin of 24 mU/L, consistent with insulin resistance related to polycystic ovary syndrome. Weight 86 kg, height 1.66 m, BMI 31.2. The skin examination was normal, with no axillary or groin lesions. "insulin resistance, BMI 31.2, skin normal"
- 10 Jun 2012 — During warlike service in Afghanistan, after four months of daily patrols in body armour in temperatures up to 45 degrees, she developed painful deep nodules in both axillae and the right groin. The nodules were tender, slow to resolve and recurred in the same sites. The Regimental Medical Officer recorded recurrent deep painful nodules without fever and prescribed flucloxacillin, with no improvement. "recurrent axillary and groin nodules"
- 18 Jul 2012 — At review in Afghanistan she reported five episodes of painful nodules in the axillae and groin since June, two of which had discharged. Double-ended comedones were noted in both axillae. She was advised to reduce friction, but was required to continue wearing body armour on all patrols. "double-ended comedones, recurrent abscesses"
- 22 Nov 2012 — A dermatologist diagnosed hidradenitis suppurativa, Hurley stage I in both axillae and the right groin, based on typical lesions at typical sites with recurrence more than twice in six months. Skin swabs grew no pathogenic organism. Doxycycline, topical clindamycin and smoking cessation advice were given. "hidradenitis suppurativa, Hurley I"
- 15 May 2016 — During her warlike service in Iraq a dermatologist, reviewing photographs at a telehealth consultation, recorded progression to Hurley stage II in both axillae, with early tunnels and recurrent abscesses every two to three weeks despite doxycycline and clindamycin. Adalimumab was recommended, but it could not be started or monitored in theatre, and a request to modify her body armour or duties was not actioned. She continued 12-hour armoured shifts. "Hurley II, adalimumab recommended"
- 30 Jul 2016 — On warlike service in Iraq, after six months of 12-hour shifts in body armour in extreme heat, she presented to the role 2 facility with a large discharging abscess in the left axilla and interconnected draining tracts in both axillae and the groin. Incision and drainage was performed. BMI 36.4. She was still smoking 20 cigarettes a day. The deployed medical officer recorded Hurley stage III disease. "Hurley III, sinus tracts, I and D"
- 12 Oct 2016 — A dermatologist confirmed worsening to Hurley stage III in both axillae and Hurley stage II in the groin, with a modified Sartorius score of 78, up from 18 in 2012, and a DLQI of 24. Ultrasound showed interconnected fluid-filled tunnels. Adalimumab, recommended in May 2016 before deployment, was finally approved and started. "worsened HS, Sartorius 78"
- 05 Mar 2018 — Wide local excision of the left axillary disease was performed by a plastic surgeon, with healing by secondary intention. She remained on adalimumab and was medically downgraded because she could not wear body armour. "axillary excision, cannot wear armour"
Symptoms
At onset the veteran had recurrent painful, deep, tender nodules in both axillae and the right groin that lasted one to two weeks, some of which discharged pus and blood, with double-ended comedones, aggravated by sweating and the rubbing of her body armour and webbing. The lesions recurred in the same places despite antibiotics.
She now has persistent draining tunnels and scarring in both axillae and the groin, with daily pain, odour and soiling of clothing, flares every few weeks and restricted arm movement from scarring. She cannot wear tight clothing or carry a backpack, avoids swimming and intimacy, and reports low mood related to the condition.
Imaging
- 22 Nov 2012 — Ultrasound of axillae and groin: "Multiple hypoechoic dermal nodules up to 12 mm in both axillae and the right groin with widened hair follicles. No fistulous tracts."
- 12 Oct 2016 — Ultrasound of axillae and groin: "Multiple interconnected fluid-filled tunnels in both axillae up to 45 mm in length, a 22 mm collection in the left axilla, and two tunnels in the right groin. Marked progression since 2012."
Onset Date
The most likely date of onset of this condition is 10 Jun 2012.
At that date the veteran was on warlike service in Afghanistan as a military police member, patrolling daily in body armour and webbing in temperatures up to 45 degrees. She had smoked about 20 cigarettes a day for several years, had a BMI above 30, polycystic ovary syndrome with insulin resistance, and an etonogestrel implant in place.
This date is appropriate because her pre-deployment medical on 14 November 2011 recorded normal skin with no axillary or groin lesions, and she first presented with the nodules on 10 June 2012, the day they appeared. It falls within uninterrupted full-time service and within the deployment.
For the smoking factor, by onset she had smoked about 15 cigarettes a day from 2006 and about 20 a day from 2009, a total of more than five pack-years before 10 Jun 2012. For the friction and occlusion factor, the six months before onset run from 10 Dec 2011 to 10 Jun 2012; she wore body armour and webbing on pre-deployment training and on daily patrols in Afghanistan throughout. For the heat and humidity factor, the six months before onset include her deployment in Afghanistan from 01 Feb 2012 to 10 Jun 2012, more than four months of daily work in extreme heat. For the contraceptive factor, the three months before onset run from 10 Mar 2012 to 10 Jun 2012, during which the etonogestrel implant inserted in 2010 remained in place. For the shaving factor, the same six months from 10 Dec 2011 to 10 Jun 2012 were filled by shaving of both axillae and the groin at least four times a week to meet field hygiene requirements. Obesity, polycystic ovary syndrome and insulin resistance were present at onset.
For the worsening factors, the period after onset runs from 10 Jun 2012 to the documented worsening on 30 Jul 2016. The one month before the worsening runs from 30 Jun 2016 to 30 Jul 2016, within six months of daily armoured shifts in Iraq. She was smoking 20 cigarettes a day and her BMI was 36.4 at the time of the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Hidradenitis Suppurativa (ICD-10-AM L73.2), Hurley stage III in both axillae and stage II in the groin. No Statement of Principles has been determined for hidradenitis suppurativa.
Hidradenitis suppurativa is a chronic inflammatory disease of the hair follicles in skin folds, mainly the armpits, groin, buttocks and under the breasts. Blockage and rupture of hair follicles triggers deep, painful nodules and abscesses that recur in the same places and, over time, form draining tunnels under the skin and scarring. Smoking and obesity are the strongest recognised risk factors, and androgen excess, insulin resistance, progestogen-only contraceptives, friction, occlusion, heat and sweating contribute to onset and flares.
The veteran's condition began on 10 June 2012 on warlike service in Afghanistan, after months of patrols in body armour in extreme heat, in a woman who smoked heavily and had obesity, polycystic ovary syndrome and an etonogestrel implant. It was diagnosed on 22 November 2012 and worsened to Hurley stage III in Iraq in July 2016.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
10 June 2012.
When did the veteran first present to a health / medical provider for this condition?
10 June 2012.
When was the condition confirmed / formally diagnosed?
22 November 2012.
When did the veteran first present to you (or your practice) for this condition?
11 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by a dermatologist on 22 November 2012 using the accepted clinical criteria for hidradenitis suppurativa: typical lesions (deep painful nodules, abscesses and double-ended comedones), at typical sites (both axillae and the groin), with chronicity and recurrence (more than two episodes in six months). Skin swabs excluded a primary bacterial infection, and the failure of standard antibiotics and the double-ended comedones distinguish the condition from simple boils.
The disease was staged as Hurley stage I in 2012, with abscesses but no tunnels or scarring, and ultrasound showed dermal nodules and widened follicles. The worsening was documented on 30 July 2016 and confirmed by the dermatologist on 12 October 2016, with interconnected tunnels on ultrasound, Hurley stage III disease and a rise in the modified Sartorius score from 18 to 78.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for hidradenitis suppurativa, so the Statements of Principles do not limit the factors that can be considered. The claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, applied to the veteran's service. The recognised causes below are drawn from the dermatological literature and are set out in Statement of Principles style.
Legislation: the clinical onset of this condition was on 10 June 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The condition began on warlike service in Afghanistan in 2012 and worsened on warlike service in Iraq in 2016. For conditions with Statements of Principles, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service, and the same beneficial approach is applied here.
Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of hidradenitis suppurativa; — MET
- The veteran smoked about 15 cigarettes a day from 2006 and about 20 a day from 2009, when her smoking increased during non-warlike service in the Solomon Islands and on shift work, as recorded on 22 April 2010. By onset on 10 June 2012 she had smoked more than five pack-years. Nicotine promotes follicular plugging and inflammation.
Cause 2: being obese at the time of the clinical onset of hidradenitis suppurativa; — MET
- The veteran's BMI was 31.2 on 14 November 2011 and remained above 30 to onset. The weight gain followed irregular shift work, field rations and polycystic ovary syndrome. Obesity deepens skin folds and increases friction, sweating and hormonal drive to the follicles.
Cause 3: having repeated friction and occlusion of the skin of the affected region for at least the six months before the clinical onset of hidradenitis suppurativa; — MET
- Throughout the six months before onset, from 10 December 2011 to 10 June 2012, the veteran wore body armour, a load-carrying vest and a duty belt for 10 to 12 hours a shift on pre-deployment training and on daily patrols in Afghanistan. The armour and webbing rubbed and occluded both axillae and the groin, the sites where the disease began.
Cause 4: working in a hot environment with heavy sweating of the affected region for at least one month within the six months before the clinical onset of hidradenitis suppurativa; — MET
- From 01 February 2012 to onset on 10 June 2012, on warlike service in Afghanistan, the veteran patrolled daily in temperatures up to 45 degrees in body armour, with her uniform soaked in sweat for most of each shift and limited facilities to wash or change. This exceeded four months within the six months before onset.
Cause 5: having polycystic ovary syndrome or another hyperandrogenic state at the time of the clinical onset of hidradenitis suppurativa; — MET
- A gynaecologist diagnosed polycystic ovary syndrome on 22 April 2010, with hirsutism, a raised free androgen index and polycystic ovaries on ultrasound, and the condition was present at onset. Androgens stimulate the follicular changes that underlie hidradenitis suppurativa.
Cause 6: having insulin resistance, impaired glucose tolerance or diabetes mellitus at the time of the clinical onset of hidradenitis suppurativa; — MET
- An oral glucose tolerance test on 14 November 2011 showed impaired glucose tolerance with a two-hour glucose of 9.6 mmol/L and a raised fasting insulin of 24 mU/L. The insulin resistance was present at onset and was worsened by irregular meals and shift work in service.
Cause 7: taking a progestogen-only contraceptive agent for at least the three months before the clinical onset of hidradenitis suppurativa; — MET
- An etonogestrel implant was inserted on 06 May 2010 for menstrual suppression at the request of her unit before field exercises and deployments, and it remained in place throughout the three months before onset, from 10 March 2012 to 10 June 2012. Progestogens with androgenic activity are associated with the onset and flares of hidradenitis suppurativa.
Cause 8: having depilation or shaving trauma to the skin of the affected region on at least three days per week for at least the six months before the clinical onset of hidradenitis suppurativa; — MET
- To meet field hygiene standards and limit odour under armour in the absence of regular showers, the veteran shaved both axillae and the bikini line at least four times a week, recorded by the Regimental Medical Officer on 18 July 2012 with folliculitis and razor abrasions, throughout the six months before onset.
Worsening factors
Worsening 1: smoking at least 10 cigarettes per day, or the equivalent thereof in other tobacco products, at the time of the clinical worsening of hidradenitis suppurativa; — MET
- The veteran was smoking 20 cigarettes a day on warlike service in Iraq, recorded on 30 July 2016 at the time of the worsening. Her attempts to stop in 2013 and 2015 failed during periods of shift work and deployment stress.
Worsening 2: having a Body Mass Index of 35 or greater at the time of the clinical worsening of hidradenitis suppurativa; — MET
- The veteran's BMI was 36.4 on 30 July 2016 at the time of the worsening. The additional weight gain since 2012 followed reduced exercise from painful axillary and groin lesions, shift work and polycystic ovary syndrome.
Worsening 3: having repeated friction and occlusion of the skin of the affected region in a hot environment for at least one month before the clinical worsening of hidradenitis suppurativa; — MET
- From 20 January 2016 to the worsening on 30 July 2016 on warlike service in Iraq the veteran wore body armour and webbing for 12-hour shifts in extreme heat, with continuous friction, occlusion and sweating of both axillae and the groin, covering the one month before the worsening from 30 June 2016 to 30 July 2016.
Worsening 4: inability to obtain appropriate clinical management for hidradenitis suppurativa. — MET
- In May 2016 a dermatologist recommended adalimumab for progressive disease, but the veteran was deployed to Iraq from January 2016, where no dermatologist or biological therapy was available, and she was required to continue wearing body armour. Treatment could not begin until 12 October 2016, by which time the disease had progressed to Hurley stage III with tunnels. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The hidradenitis suppurativa is a sequela of the veteran's service-related obesity, polycystic ovary syndrome treatment with an etonogestrel implant provided for operational menstrual suppression, and smoking established in service. Axillary scarring with restricted shoulder movement, chronic pain and an adjustment disorder with depressed mood are sequelae of the hidradenitis suppurativa.
Unintended Consequence
Met. The hidradenitis suppurativa is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the etonogestrel contraceptive implant inserted at the request of her unit for menstrual suppression on field exercises and deployments, which has androgenic progestogen activity (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. Adalimumab recommended by a dermatologist in May 2016 could not be started while the veteran was on warlike service in Iraq, where no dermatologist or biological therapy was available, and she was required to keep wearing body armour despite active disease. The disease progressed from Hurley stage II to stage III, and the modified Sartorius score rose to 78. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent recommended treatment amount to an inability to obtain appropriate clinical management. The lack of any modification of her equipment or duties after diagnosis in 2012 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 22 Apr 2010, Gynaecology consultation and pelvic ultrasound report, Gynaecologist
- 06 May 2010, Procedure record, Medical Officer, Garrison health centre
- 14 Nov 2011, Pre-deployment medical and glucose tolerance test, Medical Officer
- 10 Jun 2012, Deployed health record, Regimental Medical Officer, Afghanistan
- 18 Jul 2012, Deployed health record, Regimental Medical Officer, Afghanistan
- 22 Nov 2012, Dermatology consultation and ultrasound report, Dermatologist
- 15 May 2016, Telehealth dermatology consultation, Dermatologist
- 30 Jul 2016, Role 2 facility record, Medical Officer, Iraq
- 12 Oct 2016, Dermatology consultation and ultrasound report, Dermatologist
- 05 Mar 2018, Operation report, Plastic surgeon
- Medical-scientific literature on the causes of hidradenitis suppurativa (no Statement of Principles determined)
