Diagnostic Assessment — Left Infraorbital Region - Actinic Keratosis
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Left Infraorbital Region - Actinic Keratosis
SOP Codes: Solar Keratosis - No. 80 of 2021 (Balance of Probabilities), Solar Keratosis - No. 79 of 2021 (Reasonable Hypothesis)
ADF History
The veteran, Airfield Defence Guard (ADG), enlisted 29 July 1993, currently serving.
Occupational History
As an Airfield Defence Guard in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards including prolonged exposure to sunlight (UV radiation), environmental exposures to dust and particulates, physical stressors from manual handling, noise exposure from weapons firing and aircraft operations, and chemical exposures. Health Surveillance Questionnaires consistently note exposure to sun, including proximity to flight lines and weapons range activities. Environmental exposures during deployments included significant sun exposure, particularly during deployments to tropical and near-tropical regions.
History
The veteran an Airfield Defence Guard in the RAAF, developed actinic keratosis on his left infraorbital region, which was diagnosed and treated by a dermatologist in July 2018. This condition likely developed due to cumulative sun exposure throughout his military service.
Timeline
- 29 Jul 1993. The veteran enlisted in the Royal Australian Air Force as an Airfield Defence Guard. This occupation would involve significant outdoor activities with exposure to solar ultraviolet radiation throughout his career.
- 31 Jun 1999. Annual Health Assessment noted "The use of weapons and exposure to the sun" as part of his work area description, indicating ongoing occupational sun exposure.
- Jun 2000 – Nov 2000. Deployed to an overseas area of operations (an overseas area of operations) under an operational deployment. This deployment would have involved significant solar exposure in a high UV environment.
- Sep 2006 – Jan 2007. Deployed to an overseas area of operations under an operational deployment. The Post Deployment Health Screen noted daily exposure to environmental factors including dust in Kabul, AMAB and KAF.
- Apr 2018 – May 2018. Deployed to Papua New Guinea under Operation Kimba. This tropical location would have exposed him to intense solar radiation.
- 25 May 2016. Reviewed by the treating doctor Lau, Dermatologist. The report stated: "He has a very mild actinic keratosis on the left infraorbital region which I have treated with cryotherapy." This represents the formal diagnosis and initial treatment of the condition.
Symptoms
At the time of diagnosis, the veteran had a visible lesion on his left infraorbital region that was clinically identified as an actinic keratosis by a dermatologist. The specific symptoms were not extensively detailed, but actinic keratoses typically present as rough, scaly patches on sun-exposed skin. They can be red, tan, pink, or flesh-colored and may cause itching, burning, or tenderness. The medical record describes his lesion as "very mild," suggesting it was likely in an early stage of development.
The condition was treated with cryotherapy, which is a standard first-line treatment for actinic keratosis. No follow-up for this specific condition was noted in the records, suggesting successful initial treatment. However, given the nature of actinic keratosis as a condition related to cumulative sun damage, the veteran remains at risk for developing additional lesions in sun-exposed areas.
Imaging
- 25 May 2016. "He has a very mild actinic keratosis on the left infraorbital region which I have treated with cryotherapy." No specific imaging studies were noted for this condition, as actinic keratosis is typically diagnosed through clinical examination by a dermatologist.
1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Actinic Keratosis (also known as Solar Keratosis) of the left infraorbital region. The applicable DVA SOP codes are Solar Keratosis - No. 79 of 2021 (Reasonable Hypothesis) and Solar Keratosis - No. 80 of 2021 (Balance of Probabilities). The ICD-10 code is L57.0.
Actinic keratosis is a cutaneous lesion characterized by the local proliferation of atypical (dysplastic) epidermal keratinocytes. It is a premalignant condition that develops on skin chronically exposed to ultraviolet radiation from the sun or artificial sources. These lesions typically present as single or multiple rough erythematous plaques that occur on sun-damaged skin, though the clinical appearance can be highly variable.
Actinic keratoses are considered precancerous lesions that can potentially progress to squamous cell carcinoma if left untreated, though many remain stable or may even regress spontaneously. Risk factors include cumulative sun exposure, fair skin, advanced age, and immunosuppression. Treatment options include cryotherapy (as was performed in this case), topical medications, photodynamic therapy, or surgical removal.
2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The exact onset date of symptoms is not explicitly stated in the medical records. Actinic keratosis typically develops gradually over years of sun exposure, often without noticeable symptoms in early stages. The first documented identification of this condition was during the dermatology review on 25 May 2016. Given the cumulative nature of sun damage leading to actinic keratosis, the lesion likely developed gradually over years prior to diagnosis, with symptoms potentially emerging months before medical attention was sought.
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to the treating doctor Lau, Dermatologist, on 25 May 2016, when the actinic keratosis on his left infraorbital region was diagnosed and treated with cryotherapy. There is no documentation of prior presentations specifically for this condition.
When was the condition confirmed / formally diagnosed? The condition was formally diagnosed on 25 May 2016 by the treating doctor Lau, Dermatologist. The diagnosis was made through clinical examination, which is the standard diagnostic approach for actinic keratosis. Immediate treatment with cryotherapy was provided at the same appointment.
When did the veteran first present to you (or your practice) for this condition? 16 November 2017
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of actinic keratosis on the left infraorbital region was confirmed through clinical examination by the treating doctor Lau, Dermatologist, on 25 May 2016. The dermatologist identified the lesion as "a very mild actinic keratosis on the left infraorbital region" based on its clinical appearance. Actinic keratosis is primarily diagnosed through visual inspection by a qualified dermatologist, and no additional investigations such as biopsy were documented as necessary in this case due to the characteristic clinical presentation. The condition was promptly treated with cryotherapy during the same appointment, which is a standard first-line treatment for actinic keratosis.
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.
having sunlight exposure to unprotected skin at the affected site for a cumulative period of at least 4,500 hours while in a tropical area, or having equivalent sunlight exposure in other latitude zones, before the clinical onset of solar keratosisMET
- The veteran has served in the RAAF as an Airfield Defence Guard since 29 July 1993, with multiple deployments to high UV regions. Based on a comprehensive calculation in his medical records, his total outdoor hours are estimated at 36,000 hours over his 25-year service period (calculated as 6 hours outside per day, 5 days per week, 48 weeks per year). These hours have been weighted according to the latitude zones where he served. His predominant posting at the RAAF base (approximately 22.58 years, latitude 27.6° South, weighting factor 0.75) accounts for most of his service, contributing about 24,386 weighted hours. His deployments to various locations added approximately 2,010 weighted hours, including: an overseas area of operations operations (an overseas area of operations, an overseas area of operations) with a weighting factor of 0.75; tropical deployments to Papua New Guinea, Vanuatu, Guam, Ethiopia, and the an overseas area of operations with a weighting factor of 1.0; and other postings such as the base and the base city with weighting factors of 0.5. His total weighted sunlight exposure is calculated at approximately 26,396 hours, far exceeding the 4,500 hours required for the Balance of Probabilities SOP.
having sunburn as specified: (a) on at least 5 occasions: (i) before the age of 20 years; and (ii) at least 5 years before the clinical onset of solar keratosis; and (b) where the clinical onset of solar keratosis has occurred before the age of 50 years NOT MET
- While the veteran likely experienced sun exposure throughout his service, there is no specific documentation of sunburn events meeting these specific criteria. Additionally, his diagnosis occurred at age 42, but there is no documentation of the required sunburn history before age 20.
being a prisoner of war of overseas before the clinical onset of solar keratosis NOT MET
- The veteran was not a prisoner of war of overseas.
having exposure of the affected region to welding light, while arc-welding metal without skin protection, for a cumulative period of at least 12,000 hours before the clinical onset of solar keratosis NOT MET
- There is no documentation of extensive arc-welding exposure in the veteran occupational history.
undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of solar keratosisNOT MET
- There is no history of organ or tissue transplantation in the veteran medical records.
having PUVA therapy involving the affected site where: (a) the first PUVA treatment commenced at least 5 years before the clinical onset of solar keratosis; and (b) at least 25 PUVA treatments were administered before the clinical onset of solar keratosis NOT MET
- There is no documentation of PUVA therapy in the veteran medical records.
taking hydroxyurea or voriconazole for at least the 3 months before the clinical onset of solar keratosis NOT MET
- There is no documentation of hydroxyurea or voriconazole use in the veteran medication history.
inability to obtain appropriate clinical management for solar keratosis NOT MET
- The veteran received prompt treatment (cryotherapy) by a dermatologist when the actinic keratosis was identified. There is no evidence of barriers to accessing appropriate clinical management.
Sequelae
There are no identified sequelae of the actinic keratosis at this time. However, it should be noted that individuals with a history of actinic keratosis are at higher risk of developing additional solar keratoses and other sun-related skin conditions, including skin cancers such as squamous cell carcinoma.
Unintended Consequence
There is no evidence that this condition resulted from an unintended consequence of medical management. The actinic keratosis is attributable to cumulative sun exposure rather than as a complication of any medical treatment.
Inability to Attain Appropriate Medical Management
There is no evidence of an inability to attain appropriate medical management for this condition. When the actinic keratosis was identified, the veteran received prompt and appropriate treatment (cryotherapy) by a specialist dermatologist. There were no apparent barriers to healthcare access for this condition.
The % contribution of the causes is 100% and significant
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
