Diagnostic Assessment — Lower Lip - Actinic Cheilitis
Example 1 of 1 · fictitious patient (Veteran DJ)
Diagnostic Assessment
Lower Lip - Actinic Cheilitis
BOP Code: 80 of 2021 (Solar Keratosis)
RH Code: 79 of 2021 (Solar Keratosis)
ADF History
Veteran DJ, date of birth 08 November 1922, Australian Army, Infantry Soldier (Second Australian Imperial Force) and later Craftsman Metalsmith (Warrant Officer Class 2), enlisted 20 June 1941, discharged 12 March 1946; re-enlisted in the Australian Regular Army 02 February 1948, discharged 30 June 1973. Operational service: Malaya and Singapore, 15 August 1941 to 15 February 1942; prisoner of war of Japan, 15 February 1942 to 15 September 1945, including the Burma-Thailand Railway from October 1942; Korea, 10 April 1952 to 27 July 1953; Malaya (Malayan Emergency), 12 October 1957 to 30 September 1959; South Vietnam, 05 May 1966 to 20 May 1967.
Occupational History
As an infantry soldier in Malaya in 1941 and then as a prisoner of war, the veteran worked outdoors in the tropics for most daylight hours, without hats, shirts or any sun protection, cutting rail cuttings and laying track on the Burma-Thailand Railway. Prisoners were given no protection from the sun and suffered repeated sunburn, malnutrition and tropical disease.
As a craftsman metalsmith in the post-war Regular Army he arc-welded vehicle bodies, trailers, bridging and field equipment in workshops and in the open, in Australia and on operations in Korea, Malaya and South Vietnam. Field workshops of the period commonly used hand-held shields or goggles rather than full-face helmets, leaving the lower face exposed to ultraviolet light from the arc, and much field welding was done outdoors in tropical sun.
History
Veteran DJ, an infantry soldier who was a prisoner of war of Japan and later a Regular Army metalsmith, developed actinic cheilitis of the lower lip on 12 March 1971, at the age of 48, after years of tropical sun exposure on operational and peacetime service, repeated sunburn as a young prisoner, about 16,000 hours of arc-welding without face protection, a kidney transplant, psoralen and ultraviolet A therapy and hydroxyurea treatment. The condition worsened to severe dysplasia, confirmed on biopsy on 18 September 1972, after specialist care was delayed during a remote posting.
Timeline
- 15 Feb 1942 — At the age of 19 the veteran became a prisoner of war of Japan at the fall of Singapore, having served in Malaya with an infantry battalion since August 1941, where he was sunburnt on the face and lips on at least three occasions during jungle and beach defence training. In mid-1942 he was sent to work parties in Singapore and then, from October 1942, to the Burma-Thailand Railway. The camp medical officer's later report records repeated blistering sunburn of the face, lips and back among his work party in 1942. "POW of Japan, repeated sunburn"
- 15 Sep 1945 — The veteran was liberated after three and a half years as a prisoner of war, working outdoors on the railway and in Thailand for 10 to 12 hours a day, unclothed above the waist and without a hat for most of that time. His repatriation medical examination recorded malnutrition, malaria, tropical ulcers and weathered, sun-damaged facial skin. "liberated, sun-damaged facial skin"
- 11 Jan 1965 — A dermatologist at a military hospital commenced oral methoxsalen with ultraviolet A lamp treatment for widespread plaque psoriasis, given two to three times a week with the face, including the lips, unshielded. Treatment continued in courses until 1970, with 142 treatments recorded by March 1971. His records note about 16,000 hours of arc-welding as a metalsmith since 1948, using goggles or a hand shield without face protection. "psoralen UVA commenced, face unshielded"
- 22 Apr 1969 — The veteran underwent kidney transplantation for end-stage renal failure from analgesic nephropathy, caused by years of phenacetin-containing powders taken for chronic back pain from service injuries. He was maintained on azathioprine and prednisolone. Because of his transplant, methotrexate could not be used for his psoriasis. "renal transplant, azathioprine, prednisolone"
- 10 Sep 1970 — A dermatologist commenced hydroxyurea 1 gram daily for severe psoriasis unresponsive to topical treatment and psoralen ultraviolet therapy. The periodic health examination on 02 November 1970 recorded normal lips with no scaling, crusting or ulceration. "hydroxyurea 1 g daily commenced"
- 22 Mar 1971 — The veteran presented to the unit medical officer with ten days of a persistently dry, scaly and rough lower lip that did not heal with lip balm, beginning on 12 March 1971. Examination showed diffuse scaling of the lower lip vermilion with loss of definition of the border between the lip and skin, and small adherent white patches. He was referred to a dermatologist. "scaly lower lip, blurred vermilion"
- 14 Apr 1971 — A dermatologist performed a punch biopsy of the lower lip, which showed actinic cheilitis with atypical keratinocytes in the lower epidermis (mild to moderate dysplasia) and solar elastosis. Cryotherapy and review in three months were planned, but the veteran was posted to a remote northern Australian base on 01 June 1971, where no dermatologist was available. "biopsy actinic cheilitis, dysplasia"
- 18 Sep 1972 — After 15 months without specialist review, the veteran returned with a thickened, hyperkeratotic plaque on the left side of the lower lip and a small erosion. Biopsy showed actinic cheilitis with severe dysplasia, without invasion. A vermilionectomy was performed on 06 November 1972. "severe dysplasia, vermilionectomy planned"
Symptoms
At onset the veteran had a persistently dry, rough and scaly lower lip with a burning feeling in the sun, adherent white patches and blurring of the edge between the lip and the skin, which did not heal with lip balm. Over the following months the lip cracked and crusted intermittently, particularly after time outdoors.
By September 1972 he had a thickened, hard patch on the left lower lip with a recurring erosion that bled easily. After vermilionectomy he has had recurrent scaly patches of the lower lip requiring cryotherapy and topical treatment, tightness of the lip and altered sensation, and he is under regular skin surveillance because of his high risk of lip cancer.
Imaging
No imaging is required to establish this diagnosis.
Onset Date
The most likely date of onset of this condition is 12 Mar 1971.
At that date the veteran was serving full time in the Australian Regular Army as a Warrant Officer metalsmith supervising a workshop in Australia, at the age of 48. He was taking hydroxyurea for psoriasis and azathioprine after his kidney transplant, and he had received psoralen ultraviolet A therapy since 1965. On that day he noticed a dry, scaly lower lip that persisted.
This date is appropriate because his periodic health examination of 02 Nov 1970 recorded normal lips, and he presented on 22 Mar 1971 with ten days of persistent scaling and loss of the vermilion border, with the diagnosis confirmed on biopsy on 14 Apr 1971. The onset occurred before the age of 50, which fell on 08 Nov 1972.
For the sunlight factors, the cumulative tropical sun exposure accrued from August 1941 to 1945 in Malaya, Singapore and Thailand, and in tropical postings and operations from 1948 to 1967, well before onset. For the sunburn factor, the sunburn had to occur before the age of 20, that is before 08 Nov 1942, and at least five years before onset, that is before 12 Mar 1966; his sunburns in Malaya in 1941 and as a prisoner of war in 1942 fall within both limits. He was a prisoner of war of Japan from 15 Feb 1942 to 15 Sep 1945. The arc-welding exposure accrued from 1948 to 1970. The kidney transplant took place on 22 Apr 1969. The first psoralen ultraviolet A treatment, on 11 Jan 1965, was more than five years before onset, and 142 treatments had been given before onset. For the hydroxyurea factor, the three months before onset run from 12 Dec 1970 to 12 Mar 1971, during which he took hydroxyurea 1 gram daily, having started on 10 Sep 1970.
For the worsening, the period after onset runs from 12 Mar 1971 to the documented worsening on 18 Sep 1972. From his posting on 01 Jun 1971 he could not obtain the planned cryotherapy and dermatology review for 15 months, and the dysplasia progressed from mild to moderate to severe over that time.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Lower Lip - Actinic Cheilitis (ICD-10-AM L56.8), solar keratosis of the lower lip vermilion, under the Statements of Principles concerning solar keratosis, Balance of Probabilities No. 80 of 2021 and Reasonable Hypothesis No. 79 of 2021.
Actinic cheilitis is the form of solar keratosis that affects the lip, almost always the lower lip, which receives the most direct sunlight. Cumulative ultraviolet radiation damages the keratinocytes of the lip, which proliferate with atypical (dysplastic) features. It presents as persistent dryness, scaling, rough white patches, cracking and blurring of the border between the red lip and the skin. Its importance is that it is a precursor of squamous cell carcinoma of the lip, which carries a higher risk of spread than skin squamous cell carcinoma elsewhere. Risk is greatly increased by long outdoor exposure in the tropics, sunburn in youth, artificial ultraviolet sources such as welding arcs and psoralen ultraviolet A therapy, and immunosuppression after organ transplantation.
The condition began on 12 March 1971 after decades of ultraviolet exposure on operational and peacetime service, including as a prisoner of war of Japan, and after a kidney transplant and photosensitising treatments, and it worsened to severe dysplasia by September 1972 when specialist care was not available.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
12 March 1971.
When did the veteran first present to a health / medical provider for this condition?
22 March 1971.
When was the condition confirmed / formally diagnosed?
14 April 1971.
When did the veteran first present to you (or your practice) for this condition?
10 September 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by punch biopsy of the lower lip on 14 April 1971, which showed proliferation of atypical keratinocytes in the lower epidermis with mild to moderate dysplasia and solar elastosis. This meets the Statement of Principles definition of solar keratosis: a cutaneous lesion characterised by the local proliferation of atypical (dysplastic) epidermal keratinocytes, related to ultraviolet light exposure. The clinical findings were typical of actinic cheilitis: diffuse scaling of the lower lip, adherent white patches and loss of definition of the vermilion border.
The worsening was confirmed by a second biopsy on 18 September 1972, which showed severe dysplasia without invasion, and the surgical specimen from the vermilionectomy of 06 November 1972 confirmed extensive actinic cheilitis with severe dysplasia across the lower lip. Imaging is not required for this diagnosis.
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.
Legislation: the clinical onset of this condition was on 12 March 1971, before 1 July 2004. The veteran had operational service in Malaya and Singapore in 1941 and 1942, as a prisoner of war of Japan from 1942 to 1945, and in Korea, the Malayan Emergency and South Vietnam, and the factors relied on arose substantially from that service. This is therefore a claim under the Veterans' Entitlements Act 1986, under which the Statements of Principles apply. The Reasonable Hypothesis instrument applies to his operational service. The Balance of Probabilities instrument applies to his other eligible war service and peacetime service in Australia; his peacetime Regular Army service before 7 December 1972 is also covered by the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA), under which the Statements of Principles do not bind but every factor has been analysed.
Each factor must be related to the person's relevant 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.
Balance of Probabilities — Statement of Principles concerning Solar Keratosis, No. 80 of 2021
Causative factors
Factor 9(1): 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 keratosis; — MET
- During peacetime Regular Army service the veteran was posted to workshops in tropical northern Queensland from February 1948 to March 1952 and from October 1959 to April 1966, where he worked outdoors on vehicle recovery and field welding for about four hours a day on most working days, in an open-necked shirt with a slouch hat or beret that did not shade the lower lip. This amounts to more than 7,000 hours of tropical sun exposure to the unprotected lower lip in peacetime alone, all before onset on 12 March 1971.
Factor 9(2): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of solar keratosis; — MET
- The veteran underwent kidney transplantation on 22 April 1969, about two years before onset, for end-stage renal failure from analgesic nephropathy caused by phenacetin-containing powders taken for chronic back pain from service injuries. He was maintained on azathioprine and prednisolone, and the immunosuppression reduced his skin's ability to repair ultraviolet damage.
Factor 9(3): 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 50 PUVA treatments were administered before the clinical onset of solar keratosis; — MET
- Oral methoxsalen with ultraviolet A lamp treatment for psoriasis began at a military hospital on 11 January 1965, more than six years before onset, and was given with the face and lips unshielded. By March 1971 he had received 142 treatments. The treatment was provided by Defence medical services during his peacetime service.
Factor 9(4): taking hydroxyurea or voriconazole for at least the 3 months before the clinical onset of solar keratosis; — MET
- The veteran took hydroxyurea 1 gram daily from 10 September 1970, prescribed by a Defence-funded dermatologist for severe psoriasis because methotrexate could not be used after his transplant. He took it continuously throughout the three months before onset, from 12 December 1970 to 12 March 1971.
Worsening factors
Factor 9(5): inability to obtain appropriate clinical management for solar keratosis. — MET
- After the biopsy of 14 April 1971 confirmed actinic cheilitis with dysplasia, cryotherapy and review in three months were planned. On 01 June 1971 the veteran was posted to a remote northern Australian base with no dermatology service, and he did not obtain review or treatment for 15 months. By 18 September 1972 the lesion had progressed to a hyperkeratotic plaque with severe dysplasia requiring vermilionectomy. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management that materially contributed to the worsening.
Reasonable Hypothesis — Statement of Principles concerning Solar Keratosis, No. 79 of 2021
Causative factors
Factor 9(1): having sunlight exposure to unprotected skin at the affected site for a cumulative period of at least 2,250 hours while in a tropical area, or having equivalent sunlight exposure in other latitude zones, before the clinical onset of solar keratosis; — MET
- As a prisoner of war of Japan from 15 February 1942 to 15 September 1945, including on the Burma-Thailand Railway from October 1942, the veteran worked outdoors in the tropics for 10 to 12 hours a day without a hat or any protection of the face and lips, amounting to well over 9,000 hours of tropical sun exposure. Further exposure followed on operational service in Malaya in 1941, the Malayan Emergency from 1957 to 1959 and South Vietnam from 1966 to 1967. All of this preceded onset on 12 March 1971.
Factor 9(2): 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; — MET
- The veteran was born on 08 November 1922. On operational service in Malaya from August 1941 he was sunburnt on the face and lips on at least three occasions, and as a prisoner of war from February 1942 he had repeated blistering sunburn of the face, lips and back in work parties in 1942, all before he turned 20 on 08 November 1942. These five or more episodes occurred almost 30 years before onset, and the clinical onset on 12 March 1971 occurred at the age of 48, before the age of 50.
Factor 9(3): being a prisoner of war of Japan before the clinical onset of solar keratosis; — MET
- The veteran was captured at the fall of Singapore on 15 February 1942 and was a prisoner of war of Japan until his liberation on 15 September 1945, including forced labour on the Burma-Thailand Railway. This was 26 years before the onset of actinic cheilitis on 12 March 1971.
Factor 9(4): 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; — MET
- As a Regular Army metalsmith from 1948 to 1970 the veteran arc-welded for an average of about four to five hours a working day, including in field workshops on operational service in Korea from 1952 to 1953, the Malayan Emergency from 1957 to 1959 and South Vietnam from 1966 to 1967, using goggles or a hand-held shield that left the lower face and lips exposed. His service records estimate about 16,000 hours of welding before onset on 12 March 1971.
Factor 9(5): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of solar keratosis; — MET
- The veteran's kidney transplant on 22 April 1969, before onset, was required for analgesic nephropathy from long-term analgesic powders taken for back pain from injuries that included a spinal injury sustained on the Burma-Thailand Railway as a prisoner of war. He remained on azathioprine and prednisolone up to onset.
Factor 9(6): 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; — MET
- Psoralen ultraviolet A therapy to the whole body, including the unshielded lips, began on 11 January 1965, more than six years before onset, and 142 treatments were given before onset on 12 March 1971. The psoriasis being treated had first appeared after his return from operational service in Korea in 1953.
Factor 9(7): taking hydroxyurea or voriconazole for at least the 3 months before the clinical onset of solar keratosis; — MET
- The veteran took hydroxyurea 1 gram daily continuously from 10 September 1970, throughout the three months before onset from 12 December 1970 to 12 March 1971, for severe psoriasis that had begun after his operational service in Korea.
Worsening factors
Factor 9(8): inability to obtain appropriate clinical management for solar keratosis. — MET
- After diagnosis the veteran was posted on 01 June 1971 to a remote northern base with no dermatologist, and the planned cryotherapy and review were not provided for 15 months. The dysplasia progressed to severe on biopsy on 18 September 1972 and required vermilionectomy. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management, and his susceptibility to rapid progression arose from the immense ultraviolet damage accrued on operational service, including as a prisoner of war of Japan.
The % contribution of the causes is 100% and significant.
Sequelae
The actinic cheilitis has required a vermilionectomy, leaving tightness of the lower lip, reduced lip bulk and altered sensation, and the veteran has had recurrent dysplastic patches of the lip requiring cryotherapy and topical treatment. Actinic cheilitis carries a recognised risk of progression to squamous cell carcinoma of the lip, which would be a sequela of the accepted condition and may be claimed in its own right.
Unintended Consequence
Met. The psoralen ultraviolet A therapy given at a military hospital from 1965 with the lips unshielded, the hydroxyurea prescribed from 1970, and the azathioprine immunosuppression after his transplant all increased the ultraviolet damage to his lip and are unintended consequences of treatment provided by the Commonwealth while he was serving (section 6A of the DRCA and the equivalent provisions of the Veterans' Entitlements Act 1986).
Inability to Attain Appropriate Medical Management
MET. After actinic cheilitis with dysplasia was confirmed on biopsy on 14 April 1971, the veteran was posted on 01 June 1971 to a remote northern Australian base with no dermatology service, and the planned cryotherapy and three-monthly review were not provided for 15 months. During that time the lesion progressed from mild to moderate to severe dysplasia, documented on biopsy on 18 September 1972, and required vermilionectomy. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his service prevented him from obtaining the treatment that was clinically appropriate, and that inability materially contributed to the worsening of his actinic cheilitis.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 31 Dec 1942, Camp medical officer's report, prisoner of war work party, Burma-Thailand Railway
- 15 Sep 1945, Repatriation medical examination, Medical Officer
- 11 Jan 1965, Dermatology treatment record, psoralen ultraviolet A therapy, Dermatologist, Military hospital
- 22 Apr 1969, Hospital admission and transplant operation report, Transplant surgeon and Renal physician
- 10 Sep 1970, Dermatology consultation, Dermatologist
- 02 Nov 1970, Periodic health examination, Medical Officer
- 22 Mar 1971, Outpatient health record and referral, Unit Medical Officer
- 14 Apr 1971, Dermatology consultation and histopathology report, Dermatologist and Pathologist
- 18 Sep 1972, Dermatology consultation and histopathology report, Dermatologist and Pathologist
- 06 Nov 1972, Operation report, vermilionectomy, Plastic surgeon
- Statement of Principles concerning Solar Keratosis (Balance of Probabilities) No. 80 of 2021, Repatriation Medical Authority
- Statement of Principles concerning Solar Keratosis (Reasonable Hypothesis) No. 79 of 2021, Repatriation Medical Authority
