Right Forehead - Epidermal Cyst — example DVA determination letter

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Right Forehead - Epidermal Cyst

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 March 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 March 2025;
A treatment record by the medic, Regimental aid post, Iraq, dated 19 July 2005;
An outpatient health record by the medical officer, Garrison health centre, dated 12 March 2008;
A periodic health examination by the medical officer, Garrison health centre, dated 16 June 2008;
An outpatient health record by the medical officer, Garrison health centre, dated 17 November 2008;
An ultrasound right forehead report by the radiologist, dated 25 November 2008;
A field treatment record by the medical officer, dated 22 June 2009;
An outpatient health record and microbiology report by the medical officer, Afghanistan, dated 16 July 2010;
An ultrasound right forehead report by the radiologist, Afghanistan, dated 2 August 2010;
An operation and histopathology reports by the plastic surgeon and anatomical pathologist, dated 18 February 2011.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

28 January 2001 and 5 May 2015

Right Forehead - Epidermal Cyst

You have stated that your condition was caused by:

having a laceration, cut or puncture wound that penetrates the dermis at the affected site before the clinical onset of epidermal cyst
having suturing or another surgical procedure that breaches the epidermis at the affected site before the clinical onset of epidermal cyst
having blunt trauma to the affected site, causing an abrasion, haematoma or swelling, within the 5 years before the clinical onset of epidermal cyst
having a foreign body, such as sand, grit, glass or metal, embedded in the skin at the affected site before the clinical onset of epidermal cyst
having repeated friction, pressure or occlusion of the skin at the affected site from headwear or equipment worn against the forehead, for at least 20 hours per week for at least the 6 months before the clinical onset of epidermal cyst
having acne vulgaris, acne mechanica or another disorder causing follicular occlusion in the affected region at the time of the clinical onset of epidermal cyst
having occlusion of the pilosebaceous follicles of the affected region by oils, greases or hydraulic fluids in contact with the skin, for at least 20 hours per week for at least the 6 months before the clinical onset of epidermal cyst
having cumulative exposure of the affected region to solar ultraviolet radiation of at least 1,000 hours before the clinical onset of epidermal cyst
having heavy sweating under occlusive headwear in a hot or humid climate for at least 20 hours per week for at least the 3 months before the clinical onset of epidermal cyst

Diagnosis: Epidermal Cyst

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 19 March 2025, and is supported by an outpatient health record by the medical officer, Garrison health centre, dated 17 November 2008.

I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:

Balance of Probabilities (reasonable satisfaction) - no Statement of Principles determined for this condition

which requires the evidence to connect the condition with service.

I am satisfied that the evidence establishes the following link to your service:

having a laceration, cut or puncture wound that penetrates the dermis at the affected site before the clinical onset of epidermal cyst
having suturing or another surgical procedure that breaches the epidermis at the affected site before the clinical onset of epidermal cyst
having blunt trauma to the affected site, causing an abrasion, haematoma or swelling, within the 5 years before the clinical onset of epidermal cyst
having a foreign body, such as sand, grit, glass or metal, embedded in the skin at the affected site before the clinical onset of epidermal cyst
having repeated friction, pressure or occlusion of the skin at the affected site from headwear or equipment worn against the forehead, for at least 20 hours per week for at least the 6 months before the clinical onset of epidermal cyst
having acne vulgaris, acne mechanica or another disorder causing follicular occlusion in the affected region at the time of the clinical onset of epidermal cyst
having occlusion of the pilosebaceous follicles of the affected region by oils, greases or hydraulic fluids in contact with the skin, for at least 20 hours per week for at least the 6 months before the clinical onset of epidermal cyst
having cumulative exposure of the affected region to solar ultraviolet radiation of at least 1,000 hours before the clinical onset of epidermal cyst
having heavy sweating under occlusive headwear in a hot or humid climate for at least 20 hours per week for at least the 3 months before the clinical onset of epidermal cyst

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with a painless, slowly enlarging lump in the right forehead scar with a central punctum, which became tender under the helmet browband and occasionally discharged cheesy material on 17 November 2008.

The diagnosis was made clinically on 17 November 2008 on the finding of a firm, mobile dermal nodule with a central punctum arising within the right forehead scar, and confirmed on ultrasound on 25 November 2008, which showed a well-circumscribed lesion with posterior acoustic enhancement and laminated internal echoes typical of an epidermal cyst, with echogenic foci consistent with foreign material.

This has then led to further investigations and the diagnosis of your condition of Epidermal Cyst. I have accepted your condition of Epidermal Cyst.

Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your peacetime service.

I have therefore accepted that this condition is related to your service with effect from 3 November 2008.

Right Forehead - Epidermal Cyst (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 March 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 19 March 2025;
A treatment record by the medic, Regimental aid post, Iraq, dated 19 July 2005;
An outpatient health record by the medical officer, Garrison health centre, dated 12 March 2008;
A periodic health examination by the medical officer, Garrison health centre, dated 16 June 2008;
An outpatient health record by the medical officer, Garrison health centre, dated 17 November 2008;
An ultrasound right forehead report by the radiologist, dated 25 November 2008;
A field treatment record by the medical officer, dated 22 June 2009;
An outpatient health record and microbiology report by the medical officer, Afghanistan, dated 16 July 2010;
An ultrasound right forehead report by the radiologist, Afghanistan, dated 2 August 2010;
An operation and histopathology reports by the plastic surgeon and anatomical pathologist, dated 18 February 2011.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

28 January 2001 and 5 May 2015

Right Forehead - Epidermal Cyst (Worsening)

You have stated that the worsening of your condition was caused by:

having trauma to the epidermal cyst causing rupture of the cyst wall before the clinical worsening of epidermal cyst
having secondary bacterial infection of the epidermal cyst before the clinical worsening of epidermal cyst
having repeated friction, pressure or occlusion of the epidermal cyst from headwear or equipment for at least 20 hours per week for at least the 3 months before the clinical worsening of epidermal cyst
having incision and drainage or incomplete excision of the epidermal cyst, leaving the cyst wall in situ, before the clinical worsening of epidermal cyst
inability to obtain appropriate clinical management for epidermal cyst

Diagnosis: Epidermal Cyst (Worsening)

Reasonable Hypothesis - no Statement of Principles determined for this condition

which requires the evidence to connect the condition with service.

I am satisfied that the evidence establishes the following link to your service:

having trauma to the epidermal cyst causing rupture of the cyst wall before the clinical worsening of epidermal cyst
having secondary bacterial infection of the epidermal cyst before the clinical worsening of epidermal cyst
having repeated friction, pressure or occlusion of the epidermal cyst from headwear or equipment for at least 20 hours per week for at least the 3 months before the clinical worsening of epidermal cyst
having incision and drainage or incomplete excision of the epidermal cyst, leaving the cyst wall in situ, before the clinical worsening of epidermal cyst
inability to obtain appropriate clinical management for epidermal cyst

After the condition arose, it was worsened during your service. On 14 July 2010, on warlike service in Afghanistan, you struck the cyst on the hatch rim while climbing into the turret. The ruptured cyst became infected, with abscess and cellulitis of the forehead recorded on 16 July 2010 on warlike service, and swab culture grew methicillin-resistant Staphylococcus aureus. On warlike service in Afghanistan you patrolled in your crewman helmet for many hours each day, with the browband rubbing and pressing on the enlarging cyst, well over 20 hours a week. On 22 June 2009 a medical officer in the field incised and drained the inflamed cyst without removing its wall, because excision had been deferred for training. Excision was advised in November 2008 but deferred for the pre-deployment training cycle, the cyst was only drained in June 2009, and when it ruptured and became infected on warlike service in Afghanistan in July 2010 no surgeon was available to excise it, so it was drained again and reinfected.

This has then led to further investigations and the diagnosis of your condition of Epidermal Cyst (Worsening). I have accepted your condition of Epidermal Cyst (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your wartime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 16 July 2010.

Right Forehead - Epidermal Cyst — example determination letter

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Reference Determination Content

Right Forehead - Epidermal Cyst

Evidence

Your service

Right Forehead - Epidermal Cyst

Right Forehead - Epidermal Cyst (Worsening)

Evidence

Your service

Right Forehead - Epidermal Cyst (Worsening)