Diagnostic Assessment — Right Temple Inferior - Solar Keratosis
Example 1 of 1 · fictitious patient (Veteran C)
Diagnostic Assessment
Right Temple Inferior - Solar Keratosis
Balance of Probabilities SOP No. 80 of 2021 Reasonable Hypothesis SOP No. 79 of 2021
ADF History
The veteran, Communications and Information Systems Controller (CISCON), 28 July 1986, 22 Mar 2003.
Occupational History
As a Communications and Information Systems Controller in the Royal Australian Air Force, the veteran was exposed to significant occupational hazards including prolonged ultraviolet radiation exposure during deployments and field operations. His role required outdoor activities for tactical communications setup, equipment installation, and maintenance in various geographical locations including tropical and desert environments. During deployments to an overseas deployment and the an overseas area of operations, he would have experienced intense solar radiation exposure while performing duties that required extended periods outdoors without adequate sun protection, particularly during the early 2000s when sun protection awareness was less comprehensive than current standards.
History
The veteran a CISCON in the RAAF, developed solar keratosis on his right temple inferior as a result of cumulative ultraviolet radiation exposure during his military service, particularly during deployments to high UV environments in an overseas deployment and the an overseas area of operations.
Timeline
- 21 Feb 2016: The veteran underwent surgical excision of multiple temple lesions including the right temple inferior, with the procedure performed under local anaesthesia as part of comprehensive skin cancer management. The cream-colored scaly macule was excised with clear surgical margins marked for accurate pathological assessment. Post-operative care included antibiotic ointment and oral antibiotics with scheduled follow-up care.
- 31 Feb 2016: Pathology examination confirmed solar keratosis in the right temple inferior specimen, measuring 9x7 mm and showing clear margins with no residual malignancy. The lesion was identified as a pre-malignant change resulting from chronic ultraviolet exposure, with the pathologist noting solar keratosis alongside a central dermal scar and confirming complete excision. The diagnosis established the condition as a direct consequence of cumulative sun damage.
Symptoms
At the time of diagnosis, the right temple inferior solar keratosis presented as an asymptomatic cream-colored scaly macule that was identified during comprehensive skin examination. The lesion caused no specific symptoms such as pain, itching, or functional impairment, being discovered as part of routine skin cancer surveillance.
From current assessment, the condition has been successfully treated with complete excision showing clear margins. The patient requires ongoing dermatological surveillance due to his history of multiple skin lesions and significant occupational UV exposure during military service.
Imaging
31 Feb 2016: Pathology confirmed solar keratosis in the right temple inferior, clear of margins, with a central dermal scar and no residual basal cell carcinoma.
1. What is the formal diagnosis of the condition claimed above?
Solar keratosis of the right temple inferior, DVA SOP Balance of Probabilities No. 80 of 2021 and Reasonable Hypothesis No. 79 of 2021, ICD-10 code L57.0.
Solar keratosis, also known as actinic keratosis, is a cutaneous lesion characterized by the local proliferation of atypical (dysplastic) epidermal keratinocytes. It represents a pre-malignant condition that develops as a result of chronic ultraviolet radiation exposure, predominantly affecting sun-exposed areas of the skin in fair-skinned individuals. The lesions typically present as rough, scaly, erythematous plaques on sun-damaged skin, though clinical appearance can be highly variable. Solar keratoses may regress spontaneously, remain stable, or undergo malignant transformation into invasive squamous cell carcinoma. The condition represents field cancerization, where sun-damaged skin adjacent to localized lesions also shows dysplastic changes. Treatment involves destruction or excision of lesions, with ongoing surveillance required due to the risk of new lesion development and potential malignant transformation.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The solar keratosis was asymptomatic and first identified during surgical intervention in March 2019, though the lesion likely developed gradually over years prior to clinical detection.
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented for surgical management of the solar keratosis on 21 February 2016 to a surgeon who performed the excision as part of comprehensive temple lesion management.
When was the condition confirmed / formally diagnosed?
The condition was formally diagnosed on 31 February 2016 through histopathological examination by a pathologist who confirmed solar keratosis with clear margins following surgical excision.
When did the veteran first present to you (or your practice) for this condition?
21 January 2015.
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 was confirmed through histopathological examination following surgical excision. The key finding was a cream-colored scaly macule identified during clinical examination, leading to surgical excision on 21 February 2016. Pathology examination on 31 February 2016 definitively confirmed solar keratosis, measuring 9x7 mm with clear surgical margins. The pathologist identified characteristic features of solar keratosis including dysplastic epidermal keratinocytes consistent with chronic UV damage. The excision showed complete removal with no residual malignancy.
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 keratosis(Balance of Probabilities factor):
MET - the veteran's service from 1992 to 2009 involved significant UV exposure during deployments to an overseas deployment (8.6°S latitude, tropical area) in 1997 and the an overseas area of operations (approximately 25-35°S) in 2008, combined with regular duties in the state (27.6°S) and other locations. Calculating equivalent sunlight exposure using latitude weighting factors: tropical area exposure (weighting 1.0), 23°27'S to 35°S exposure (weighting 0.75), and >35°S exposure (weighting 0.5). Assuming 6 hours outdoor exposure, 5 days per week, 48 weeks per year across his 17-year service period, with appropriate latitude weightings, total equivalent exposure significantly exceeds 4,500 hours. His CISCON role required field communications setup, equipment installation, and outdoor operational duties during deployments.
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(Reasonable Hypothesis factor):
MET - As detailed above, the veteran's cumulative UV exposure well exceeds the 2,250-hour threshold required under the Reasonable Hypothesis standard, with significant exposure during an overseas deployment deployment in tropical latitudes and extensive service in the state and an overseas area of operations deployments.
Having sunburn as specified on at least 5 occasions before the age of 20 years and at least 5 years before the clinical onset of solar keratosis, where the clinical onset has occurred before the age of 50 years (Reasonable Hypothesis factor):
NOT MET - No documented history of specified sunburn episodes before age 20, and the clinical onset occurred after age 50 (diagnosed at age 47 but likely present earlier).
Being a prisoner of war of overseas before the clinical onset of solar keratosis (Reasonable Hypothesis factor):
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 (Reasonable Hypothesis factor):
NOT MET - No evidence of welding exposure in his CISCON role.
Undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of solar keratosis:
NOT MET - No history of organ or tissue transplantation.
Having PUVA therapy involving the affected site where the first PUVA treatment commenced at least 5 years before the clinical onset and at least 25-50 PUVA treatments were administered:
NOT MET - No history of PUVA therapy.
Taking hydroxyurea or voriconazole for at least 3 months before the clinical onset:
NOT MET - No documented use of these medications.
Inability to obtain appropriate clinical management for solar keratosis:
MET - The condition was not diagnosed until 2022, despite years of likely presence. Given the occupational UV exposure and multiple skin lesions, earlier dermatological surveillance and diagnosis could have been implemented. The delay between potential lesion development and formal diagnosis constitutes inability to obtain appropriate preventive clinical management, resulting in permanent establishment of the lesion requiring surgical intervention.
Sequelae
Solar keratosis is not a sequela of another condition but rather a primary condition resulting from UV exposure.
Unintended Consequence
The condition is not an unintended consequence of ADF medical treatment, as no medical procedures or medications contributed to its development.
Inability to Attain Appropriate Medical Management
The inability to attain appropriate medical management factor is MET. The Full Federal Court in Brew v Repatriation Commission (19 July 1990) enlarges on the meaning of "inability" as the lack of ability to get treatment in both objective and subjective senses, including barriers that prevent seeking appropriate care.
The condition was not diagnosed until 2022 despite the veteran's extensive occupational UV exposure and high-risk profile for skin lesions. Given his deployment history to high UV environments and occupational exposure as a CISCON requiring outdoor duties, appropriate clinical management would have included regular dermatological surveillance from early in his service or shortly after deployment. The absence of preventive skin screening and early detection represents an inability to obtain appropriate clinical management.
This inability to obtain appropriate clinical management caused permanent worsening by allowing the solar keratosis to fully develop and become established, requiring surgical intervention rather than early preventive treatment or lifestyle modifications that could have prevented lesion formation.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
