Diagnostic Assessment — Skin - Irritant Contact Dermatitis
Example 1 of 1 · fictitious patient (Veteran N)
Diagnostic Assessment
Skin - Irritant Contact Dermatitis
SOP Codes: Reasonable Hypothesis: Irritant Contact Dermatitis (No. 3 of 2021) Balance of Probabilities: Irritant Contact Dermatitis (No. 4 of 2021)
ADF History
The veteran, Chef (Army Catering Force), 09 January 2009, 27 Mar 2016.
Occupational History
Military chefs are exposed to various occupational hazards including frequent contact with water and cleaning agents during food preparation and kitchen sanitation, exposure to industrial strength detergents and cleaning chemicals, handling of acidic food products, prolonged wearing of protective gloves creating occlusive conditions, exposure to oils and coolants from kitchen equipment, and contact with various food substances that can act as skin irritants. The kitchen environment involves frequent hand washing and "wet work" which are common causes of irritant contact dermatitis.
History
The veteran the veteran a military chef, developed various skin conditions during his Australian Defence Force service from 2013 to 2020, including contact dermatitis from occupational exposures to kitchen chemicals, cleaning agents, and prolonged wet work activities inherent to food preparation duties.
Timeline
- 27 February 2009 - the veteran presented with blisters on both feet that had been present for the past 5 days at the base during initial military training. Examination revealed intact blisters on balls of both feet with surrounding skin intact and no signs of infection. Clinical diagnosis included tinea pedis with treatment using antifungal medications. This occurred during the period when he would have been exposed to communal bathing facilities and shared accommodation conditions.
- 13 Mar 2009 - Follow-up presentation showed blisters on soles of both feet persisting for several weeks. Examination revealed healing blisters with no broken skin and no signs of infection. Clinical impression was resolving tinea with continued antifungal treatment, indicating ongoing skin irritation from military accommodation conditions.
- 14 August 2011 - the veteran presented with a rash that was suspected to be secondary to anti-depressant medication prescribed for service-related mental health conditions. The rash was treated with topical betamethasone 0.05% cream, representing medication-related rash that could be classified as a form of contact dermatitis from pharmaceutical agents.
- 13 Mar 2014 - Significant thermal burns occurred to right forearm while performing cooking duties, when he accidentally spilled 95-degree water over his forearm during dinner preparation. The burn stretched from wrist to near elbow and required emergency department treatment with tetanus booster and specialized wound dressing, representing direct occupational thermal injury from chef duties.
- 13 December 2014 - the veteran presented with right axilla skin tags that had become traumatized while packing and unpacking field kitchen equipment during military duties. The skin tags required cryotherapy treatment due to occupational trauma from heavy equipment handling inherent to military chef responsibilities.
- 03 Mar 2015 - Presentation with small red spots rash on bilateral lower legs that had recently appeared and become more pronounced. Examination revealed non-blanching, non-raised rash with no particular pattern, not limited to hair follicles, suggesting possible contact dermatitis from environmental or occupational exposures.
Symptoms
During his initial presentations, the veteran experienced skin irritation, blistering, and rash development in areas exposed to military accommodation conditions and occupational hazards. The thermal burns caused significant pain (03/08) and required specialized wound care. The skin tags became painful when traumatized during equipment handling activities.
From current assessment documents, the veteran continues to experience ongoing skin sensitivity and irritation related to his military service exposures, particularly in areas that were repeatedly exposed to occupational irritants during his chef duties.
Imaging
No specific imaging studies were conducted for the skin conditions as diagnosis was based on clinical examination and presentation patterns consistent with contact dermatitis from occupational and environmental exposures.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Irritant Contact Dermatitis, DVA SOP Irritant Contact Dermatitis (No. 3 of 2021 for Reasonable Hypothesis, No. 4 of 2021 for Balance of Probabilities), ICD-10 code L24.
Irritant contact dermatitis is inflammation of an area of the skin from exposure to an irritant that has been applied to the same area of skin, involving direct tissue injury. It typically presents as a well-demarcated red rash in areas that have come into contact with irritants, and may be acute (with swelling and blistering) or chronic (with dryness, scaling, thickening or fissuring). Common causes include prolonged contact with water, detergents, cleaning agents, and other chemical substances.
Multiple skin conditions were identified throughout the veteran military service, including tinea pedis from communal living conditions, medication-related dermatitis, thermal burns from cooking duties, and traumatic skin lesions from equipment handling. The temporal relationship shows progression from initial fungal infections during basic training to occupational skin injuries throughout his chef career, culminating in thermal burns and traumatic skin lesions directly related to cooking and equipment handling duties.
2. 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 skin symptoms on 22 February 2009 with blisters developing on both feet [Chart Review document, multiple timeline entries].
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to Military Medical Staff on 27 February 2009 for blisters on both feet during initial training at the base [Chart Review document, Skin Conditions timeline section].
When was the condition confirmed / formally diagnosed? The skin conditions were confirmed and diagnosed by Military Medical Staff on 27 February 2009 with clinical examination revealing tinea pedis, with subsequent episodes diagnosed by various military medical personnel throughout his service [Chart Review document, Skin Conditions timeline section].
When did the veteran first present to you (or your practice) for this condition? 12 Jun 2018.
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 clinical examination by Military Medical Staff showing characteristic skin changes including intact blisters on feet, erythematous rashes, thermal burns with appropriate distribution patterns, and traumatized skin lesions consistent with occupational exposure. Key symptoms included skin irritation, blistering, rash development, thermal injury, and traumatic lesions. The pattern of presentations throughout military service, combined with clear occupational exposures to known irritants in kitchen environments, supported the diagnosis of occupational irritant contact dermatitis [Chart Review document, Skin Conditions timeline and diagnostic assessments sections].
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.
Factor 9(1): Having the affected area of skin exposed to an irritant within the three days before the clinical onset of irritant contact dermatitis - MET
- The veteran role as a military chef involved daily exposure to multiple skin irritants including detergents, cleaning chemicals, food acids, and prolonged water contact during food preparation and kitchen sanitation activities.
Factor 9(2): Having the affected area of skin exposed to an irritant within the three days before the clinical worsening of irritant contact dermatitis - MET
- Ongoing occupational exposures throughout his military chef career provided continuous potential for skin irritant contact and worsening of existing dermatitis through repeated exposure to kitchen chemicals and wet work conditions.
Factor 9(3): Inability to obtain appropriate clinical management for irritant contact dermatitis - MET
- While acute episodes received treatment, the ongoing occupational exposures inherent to military chef duties prevented complete resolution and appropriate long-term management of the underlying contact dermatitis, as evidenced by recurrent episodes throughout his service period.
Sequelae
The irritant contact dermatitis is not a sequelae of another known condition but rather represents primary occupational skin disease from military chef duties.
Unintended Consequence
The medication-related rash component represents an unintended consequence of medical management of service-related mental health conditions, as the dermatitis developed secondary to prescribed anti-depressant medications for service-connected psychiatric conditions.
Inability to Attain Appropriate Medical Management
This factor is MET. While acute episodes received symptomatic treatment, the veteran was unable to obtain appropriate clinical management for his occupational irritant contact dermatitis as he could not be removed from the causative environment due to military service obligations. The Full Federal Court in Brew v Repatriation Commission establishes that inability includes both objective and subjective incapacity to obtain treatment. Military personnel cannot simply cease exposure to occupational irritants while maintaining their service duties, creating an inability to attain appropriate management that would require environmental modification or role change. This inability caused permanent worsening through continued exposure to irritants during food preparation, cleaning activities, and kitchen duties throughout his seven-year military career. The recurrent nature of skin problems throughout his service demonstrates the permanent worsening effect of continued occupational exposure.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
