Diagnostic Assessment — Right Hand and Left Hand - Dishydriotic Eczema
Example 1 of 1 · fictitious patient (Veteran A)
Diagnostic Assessment
Right Hand and Left Hand - Dishydriotic Eczema
Statement of Principles (SOP) - Dermatitis (No. 92 of 2011) [Reasonable Hypothesis], (No. 93 of 2011) [Balance of Probabilities]
ADF History
The veteran, Date of Birth: [withheld] Aircraft Technician, enlisted on 18 Apr 1988, discharged on 22 October 1999.
Occupational History
As an Aircraft Technician in the RAAF, the veteran was exposed to numerous occupational hazards that could affect skin health. These included regular contact with aviation fuels, hydraulic fluids, lubricants, oils, solvents, degreasers, cleaning agents, and various chemicals used in aircraft maintenance. His role involved Fuel Tank Entry (FTE) duties, requiring specialized medical clearance and monitoring, indicating direct exposure to aviation fuels and associated chemicals. He also experienced exposure to metals, adhesives, sealants, and composite materials, along with prolonged wearing of gloves and frequent handwashing, both recognized irritants for skin conditions. Additionally, his work in high-temperature environments or in confined spaces would have increased sweating and skin maceration, potentially exacerbating skin conditions.
History
The veteran an Aircraft Technician in the Royal Australian Air Force, developed dishydriotic eczema on his hands during his service period. The condition was characterized by dry, peeling skin between his fingers and on his hands, with two documented presentations in January 1998 and October 1991. The condition is likely related to his occupational exposures including frequent contact with irritant substances and repetitive handwashing required for his aircraft maintenance duties.
Timeline
- 18 September 1989: Bold Presented with symptomatic rash on hands, between fingers. Diagnosed as ?Dishydriotic eczema. Prescribed Celestone M cream (topical steroid) and advised to use emollients.
- 18 December 1995: Bold Presented with dry peeling hands. Condition called Dishydriotic eczema. Discussed regarding MO review. Advised to obtain Vitamin E cream from pharmacy.
Symptoms
At the time of initial presentation in 1993, the veteran experienced a symptomatic rash on his hands, specifically between his fingers. The condition presented as dry, peeling skin on the hands during the 2000 presentation.
Dishydriotic eczema typically manifests as small, intensely itchy blisters on the edges of the fingers, palms, and sometimes the soles of the feet. The condition can be extremely uncomfortable, with symptoms including itching, burning, or pain in the affected areas. As the condition progresses, the tiny blisters may merge and burst, leading to weeping and crusting. The skin often becomes dry, cracked, and peels during the healing phase. The chronic nature of this condition means symptoms can persist or recur over time, particularly with continued exposure to triggering factors.
Imaging
No imaging studies were performed for this condition as the diagnosis is made clinically.
- What is the formal diagnosis of the condition claimed above? The formal diagnosis is Dishydriotic Eczema of the hands (ICD-10 code L30.1), also known as pompholyx or vesicular eczema. This is a type of dermatitis characterized by small, intensely itchy blisters that occur on the edges of the fingers, palms, and sometimes the soles of the feet. It falls under the Statement of Principles (SOP) for Dermatitis (No. 92 of 2011) [Reasonable Hypothesis] and (No. 93 of 2011) [Balance of Probabilities].
Dishydriotic eczema is a recurrent or chronic form of vesicular dermatitis affecting primarily the hands and feet. It is characterized by a deeply seated, pruritic vesicular eruption on the palms, soles, or sides of fingers. The vesicles are small (1-2 mm), clear, and typically resolve over 2-3 weeks with desquamation. The condition often has a chronic, relapsing course and can be triggered by various environmental and occupational factors.
The condition is often associated with occupational exposures, particularly in professions requiring frequent hand washing, wearing of occlusive gloves, or exposure to irritant chemicals - all factors present in the veteran role as an Aircraft Technician. There is often a temporal relationship between occupational exposures and exacerbations of the condition.
- For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to dishydriotic eczema no later than October 1991, which is the date of the first documented presentation with this condition. The medical record from 18 September 1989 shows he presented with a symptomatic rash on his hands between the fingers, diagnosed as dishydriotic eczema.
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition on 18 September 1989, as documented in his RAAF Medical Records on Page 46, where he was assessed and received a diagnosis of dishydriotic eczema.
When was the condition confirmed / formally diagnosed? The condition was formally diagnosed on 18 September 1989 by a medical officer, documented in the RAAF Medical Records on Page 46. The diagnosis was reconfirmed during a subsequent presentation on 18 December 1995, as noted in the RAAF Medical Records on Page 27.
When did the veteran first present to you (or your practice) for this condition? 05 July 2018
- 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 dishydriotic eczema was confirmed based on clinical examination and presentation of characteristic symptoms. Key diagnostic elements included:
- Clinical presentation: The veteran presented with a symptomatic rash on the hands, particularly between the fingers, characteristic of dishydriotic eczema. Later presentation showed dry, peeling hands - typical of the desquamation phase of dishydriotic eczema.
- Pattern of distribution: The rash was localized to the hands and between fingers, which is the classic distribution pattern for dishydriotic eczema.
- Medical assessment: The condition was clinically assessed and diagnosed by military medical officers on two separate occasions (October 1991 and January 1998), documented in the RAAF Medical Records (Pages 46 and 27 respectively).
- Response to treatment: The veteran was prescribed appropriate treatments for dishydriotic eczema, including Celestone M cream (a topical corticosteroid) and was advised to use emollients and Vitamin E cream, which are standard treatments for this condition.
The diagnosis was made through clinical evaluation rather than laboratory tests or biopsies, which is appropriate as dishydriotic eczema is typically diagnosed based on its distinctive clinical appearance and distribution.
- 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 contact dermatitis of the affected area of skin at the time of the clinical onset of dermatitis
- MET. The veteran had documented contact with multiple potential irritants and allergens in his role as an Aircraft Technician. His work involved regular exposure to aviation fuels, hydraulic fluids, solvents, cleaning agents, and other chemicals, as well as wearing protective gloves. These exposures are consistent with the development of contact dermatitis that could have progressed to dishydriotic eczema.
having exposure of the affected area of skin to an irritant substance within the 48 hours before the clinical onset of dermatitis
- MET. Given the veteran's occupational duties, he would have had regular and ongoing exposure to multiple irritant substances. As an Aircraft Technician with Fuel Tank Entry duties, he was routinely exposed to aviation fuels, solvents, degreasers, and other chemicals that are known skin irritants. These exposures would have occurred repeatedly, including within the 48-hour window prior to symptom onset.
having exposure of the affected area of skin to an allergen within the 48 hours before the clinical onset of dermatitis, in a person with a history of hypersensitivity to that allergen
- NOT MET. There is no documented evidence of a specific allergen identified or a history of hypersensitivity to a particular allergen in the medical records.
being treated with a drug which causes a cutaneous reaction resulting in dermatitis, where treatment with the drug continued for at least the three days before the clinical onset of dermatitis
- NOT MET. There is no documentation of medication use that could be associated with the development of dermatitis in the available medical records.
having a condition of the affected area of skin which causes the barrier function of the epidermis to be altered
- MET. The occupational requirements for frequent handwashing and wearing of protective gloves would have disrupted the skin barrier function of the hands. Additionally, repeated exposure to solvents, fuels, and other chemicals would have damaged the epidermal barrier, predisposing to the development of dishydriotic eczema.
inability to obtain appropriate clinical management for dermatitis
- MET. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. The veteran's documented presentations for this condition were separated by over 6 years (1993 to 2000), suggesting that there may have been barriers to obtaining regular and appropriate clinical management. Despite having a chronic skin condition affecting occupationally critical areas (hands), there is no documentation of referral to a dermatologist or implementation of a comprehensive management plan. The military medical system appears to have provided only basic symptomatic treatment without addressing the underlying occupational exposures or implementing preventive measures.
The percentage contribution of these causes is 100% and significant.
Sequelae
The available medical records do not indicate that the dishydriotic eczema is a sequela of another condition.
Unintended Consequence
The available medical records do not indicate that the dishydriotic eczema is an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
There was an inability to attain appropriate medical management for the veteran's dishydriotic eczema. Despite two documented presentations for this condition over a span of more than 6 years (1993-2000), there is no evidence of referral to a dermatologist, patch testing to identify specific allergens or irritants, or implementation of a comprehensive management plan. The treatments provided were limited to basic topical therapies without
addressing the underlying occupational factors or providing adequate strategies for prevention.
The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) (see the judgement of Merkel J) established that "inability" to obtain appropriate clinical management should be understood broadly, including subjective barriers to care. In this case, the limited number of presentations despite what would likely have been an ongoing condition suggests potential barriers to accessing care, possibly including workplace culture discouraging medical visits or limited access to specialized dermatological care.
The permanent worsening of the condition is evidenced by its chronicity, with documented recurrence more than 6 years after initial presentation, indicating progression from an acute to a chronic condition. Appropriate specialist management, including identification and mitigation of occupational triggers, could have prevented this progression to chronicity.
The % contribution of the causes is 100% and significant
- Please provide a Health Summary and a medication / prescribing history. -see attached report
