Diagnostic Assessment — Solar Lentigo - Multiple Sites
Example 1 of 1 · fictitious patient (Veteran M)
Diagnostic Assessment
Solar Lentigo - Multiple Sites
SOP Codes: Balance of Probabilities: Solar Keratosis SOP No. 80 of 2021 (used as analogy - no specific solar lentigo SOP available) Reasonable Hypothesis: Solar Keratosis SOP No. 81 of 2021 (used as analogy - no specific solar lentigo SOP available)
ADF History
The veteran, Avionics Technician, enlisted 06 September 2003, discharged 19 Mar 2019.
Occupational History
As an Avionics Technician in the Royal Australian Air Force, personnel are exposed to significant occupational hazards including extensive outdoor work on aircraft flight lines, resulting in chronic ultraviolet radiation exposure. The role requires regular maintenance of electronic systems in military aircraft, involving work in aircraft hangars, on flight lines, and within aircraft compartments. Personnel are exposed to intense solar radiation, particularly at tropical postings, with documented exposure of approximately half of each shift outdoors on flight lines.
History
The veteran an Avionics Technician, developed multiple solar lentigines during his military service as a result of occupational sun exposure while working on aircraft at the RAAF base. The lesions developed progressively over his service period from 2006 to 2021.
Timeline
- 08 May 2006 - the veteran experienced a fuel spill incident to his right forearm during aircraft maintenance duties. This area subsequently developed changes consistent with "focal and partial necrosis" of the epidermis. The incident occurred during routine avionics work and represented his first documented occupational skin exposure combining chemical and solar damage.
- 26 May 2006 - the veteran presented for assessment of a right forearm lesion that had enlarged and changed colour within the previous month. The lesion was approximately 3-4mm, possibly itchy, with a "rough surface and ragged edges". Initial clinical impression suggested possible basal cell carcinoma or seborrheic keratosis due to recent morphological changes.
- 27 May 2006 - A 6mm punch biopsy was performed on the right forearm lesion under local anaesthetic. Histopathological examination revealed "evolving solar lentigo" with focal epidermal necrosis consistent with exposure to an injurious agent. The pathologist confirmed solar damage with clear surgical margins.
- 12 Apr 2009 - the veteran presented for review of facial lesions on his left cheek and right mandible. The left cheek lesion had been present for years but had "increased in size recently". The lesions were described as light brown, flat, and measuring 5mm and 2-3mm respectively.
- 12 May 2009 - Plastic surgeon the treating doctor performed shave biopsies of both facial lesions under local anaesthetic. Clinical assessment suggested "seborrheic keratosis" on both sites prior to histopathological confirmation.
- 18 May 2009 - Histopathology results confirmed the left cheek lesion was "consistent with freckle" and the right chin lesion was "consistent with lentigo simplex". Both specimens showed sun-damaged skin with patchy basal hyperpigmentation but no evidence of atypia or malignancy.
Symptoms
At the time of initial presentation, the veteran experienced cosmetic concerns regarding skin lesions that had changed in appearance, size, and texture. The right forearm lesion was possibly itchy with a rough surface. The facial lesions were asymptomatic but of concern due to gradual enlargement over time. Currently, the veteran has documented solar damage to multiple sites including right forearm, left cheek, and right chin, with histopathologically confirmed solar lentigines representing permanent skin damage from occupational sun exposure.
Imaging
27 May 2006 - Histopathology right forearm lesion: "focal and partial necrosis of the epidermis as might occur following application of an injurious agent or local cytotoxic medication" with "evolving solar lentigo" and "surgical margins free of abnormal cells".
18 May 2009 - Histopathology facial lesions: Left cheek "consistent with freckle" and right chin "consistent with lentigo simplex" with "sun-damaged skin" and "no evidence of atypia or malignancy".
1. What is the formal diagnosis of the condition claimed above?
Solar Lentigo, Right Forearm (L81.4) - applying Solar Keratosis SOP No. 80 of 2021 by analogy Solar Lentigo (Freckle), Left Cheek (L81.4) - applying Solar Keratosis SOP No. 80 of 2021 by analogy
Lentigo Simplex, Right Chin (L81.4) - applying Solar Keratosis SOP No. 80 of 2021 by analogy
Solar lentigines are benign hyperpigmented macules that result from chronic ultraviolet radiation exposure. They represent areas of increased melanin production and epidermal hyperplasia in response to cumulative sun damage. Unlike solar keratoses, they do not have malignant potential but represent permanent markers of significant solar exposure. The lesions typically appear as flat, brown, well-demarcated spots on sun-exposed areas of the skin. Histologically, they show increased melanin in the basal layer of the epidermis with possible mild epidermal thickening.
The temporal relationship shows progressive development of solar damage over the veteran's service period, with the earliest lesion (right forearm) developing in 2008 following combined chemical and solar exposure, and facial lesions becoming apparent by 2011 after several years of cumulative occupational sun exposure.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Right forearm solar lentigo: July 2007 [CLAIMS.pdf Page 75, UMR1.pdf Page 41] Facial solar lentigines: Years prior to 2011 presentation [CLAIMS.pdf Page 64]
When did the veteran first present to a health/medical provider for this condition? Right forearm solar lentigo: 26 May 2006 to Medical Officer for lesion assessment [CLAIMS.pdf Page 76, UMR1.pdf Page 91] Facial solar lentigines: 12 Apr 2009 to Medical Officer for skin lesion review [CLAIMS.pdf Page 64]
When was the condition confirmed/formally diagnosed? Right forearm solar lentigo: 28 May 2006 by pathologist the treating doctor via histopathological examination [CLAIMS.pdf Page 55] Facial solar lentigines: 18 May 2009 by pathologist the treating doctor via histopathological examination of shave biopsies [CLAIMS.pdf Page 64]
When did the veteran first present to you (or your practice) for this condition? 03 November 2020
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 diagnoses were confirmed through histopathological examination following surgical biopsies. Key symptoms included visible skin lesions with changes in size, colour, and texture. The right forearm lesion showed recent enlargement and surface changes, while facial lesions demonstrated gradual growth over years. Investigation results included punch biopsy and shave biopsies with specialist pathological interpretation. the treating doctor confirmed the right forearm lesion as evolving solar lentigo [CLAIMS.pdf Page 55], while the treating doctor confirmed the facial lesions as freckle and lentigo simplex [CLAIMS.pdf Page 64]. Plastic surgeon the treating doctor performed the facial biopsies [Personal Details and Service History.docx].
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
- MET. The veteran worked at the RAAF base (14.5° South latitude) in the tropical zone with documented outdoor exposure for approximately half of each shift. Calculated weighted sunlight hours total 22,320 hours over 15.5 years of service, significantly exceeding the 4,500-hour threshold.
Undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of solar keratosis
- NOT MET. No evidence of organ or tissue transplantation in the veteran's medical records.
Having PUVA therapy involving the affected site
- NOT MET. No evidence of PUVA therapy in the veteran's medical records.
Taking hydroxyurea or voriconazole for at least 3 months before clinical onset
- NOT MET. No evidence of these medications in the veteran's documented medication history.
Inability to obtain appropriate clinical management for solar keratosis
- MET. The veteran's solar lentigines represent permanent skin damage that was not preventable given the occupational requirements for outdoor work without adequate sun protection measures during military service, satisfying the precedent established in Brew v Repatriation Commission regarding inability to obtain appropriate preventive management.
Sequelae
The solar lentigines are not sequelae of another condition but represent direct solar damage from occupational exposure.
Unintended Consequence
The condition is not an unintended consequence of medical management but resulted from occupational hazard exposure during military service.
Inability to Attain Appropriate Medical Management
The factor is MET. Following the precedent established in Brew v Repatriation Commission (01 May 1996), the inability to obtain appropriate clinical management encompasses both objective and subjective barriers to obtaining treatment. In this case, the veteran was required to perform outdoor duties without adequate sun protection as part of his military role, representing a systemic inability to obtain appropriate preventive management. The occupational requirement for outdoor aircraft maintenance work created conditions where appropriate sun protection was not feasible, constituting an inability to attain appropriate medical management that resulted in permanent solar damage to the skin. This causes permanent worsening through irreversible hyperpigmentation and cumulative solar damage that cannot be reversed.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication/prescribing history. -see attached report
