Reference Determination Content
Suggested draft · fictitious patient
Skin - Medication Induced Rash
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 18 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 June 2025;
- An outpatient health record by the medical officer, Army training centre health facility, dated 14 September 2010;
- A role 2 consultation and serology report by the medical officer, Afghanistan, dated 24 April 2012;
- A role 2 consultation by the medical officer, Afghanistan, dated 1 May 2012;
- A wound swab microbiology report by the pathologist, dated 5 May 2012;
- A consultation and biochemistry report by the medical officer, Afghanistan, dated 12 May 2012;
- A patrol base treatment record by the medic, Afghanistan, dated 22 May 2012;
- A role 3 hospital admission record by the medical officer, Afghanistan, dated 26 May 2012;
- A dermatology consultation and patch test report by the dermatologist, dated 21 January 2013;
- A hospital admission and discharge summary by the medical officer, Iraq, dated 16 March 2017;
- A clinical assessment by the general practitioner, dated 18 June 2025.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 July 2009 and 18 November 2021
Skin - Medication Induced Rash
You have stated that your condition was caused by:
- taking a sulfonamide antibiotic, including trimethoprim-sulfamethoxazole, within the 3 weeks before the clinical onset of drug eruption
- taking an aminopenicillin, including amoxicillin or amoxicillin-clavulanate, within the 3 weeks before the clinical onset of drug eruption
- taking a non-steroidal anti-inflammatory drug for at least the 7 days before the clinical onset of drug eruption
- taking a photosensitising drug, including doxycycline, together with exposure of the skin to solar ultraviolet radiation for at least 4 hours per day, for at least 2 weeks within the 4 weeks before the clinical onset of drug eruption
- having an acute viral infection, including Epstein-Barr virus, cytomegalovirus or human herpesvirus 6 infection, at the time of commencing the drug implicated in the drug eruption
- having had a cutaneous adverse reaction to the same drug or a cross-reacting drug before the clinical onset of drug eruption
- taking at least 3 systemic medicines concurrently within the 3 weeks before the clinical onset of drug eruption
- having reduced renal clearance of the implicated drug, including from dehydration or acute kidney injury, within the 3 weeks before the clinical onset of drug eruption
Diagnosis: Medication Induced Rash
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 18 June 2025, and is supported by a role 3 hospital admission record by the medical officer, Afghanistan, dated 26 May 2012.
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:
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:
- taking a sulfonamide antibiotic, including trimethoprim-sulfamethoxazole, within the 3 weeks before the clinical onset of drug eruption
- taking an aminopenicillin, including amoxicillin or amoxicillin-clavulanate, within the 3 weeks before the clinical onset of drug eruption
- taking a non-steroidal anti-inflammatory drug for at least the 7 days before the clinical onset of drug eruption
- taking a photosensitising drug, including doxycycline, together with exposure of the skin to solar ultraviolet radiation for at least 4 hours per day, for at least 2 weeks within the 4 weeks before the clinical onset of drug eruption
- having an acute viral infection, including Epstein-Barr virus, cytomegalovirus or human herpesvirus 6 infection, at the time of commencing the drug implicated in the drug eruption
- having had a cutaneous adverse reaction to the same drug or a cross-reacting drug before the clinical onset of drug eruption
- taking at least 3 systemic medicines concurrently within the 3 weeks before the clinical onset of drug eruption
- having reduced renal clearance of the implicated drug, including from dehydration or acute kidney injury, within the 3 weeks before the clinical onset of drug eruption
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 an intensely itchy red rash that began on the chest and back and spread over two days to the arms and thighs, with burning in the sun-exposed skin of the forearms and neck and poor sleep from itch on 22 May 2012.
The diagnosis was made clinically by a medical officer at the role 3 hospital on 26 May 2012 and confirmed by a dermatologist on 21 January 2013. The rash was a symmetrical, pruritic, erythematous maculopapular eruption that started on the trunk 14 days after co-trimoxazole was commenced, with peripheral eosinophilia, and it resolved within four weeks of stopping the drug. There was no blistering, skin detachment or mucosal involvement, excluding Stevens-Johnson syndrome and toxic epidermal necrolysis, and viral exanthem was considered and excluded by the drug timing and the recurrence on rechallenge.
This has then led to further investigations and the diagnosis of your condition of Medication Induced Rash. I have accepted your condition of Medication Induced Rash.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 22 May 2012.
Skin - Medication Induced Rash (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 18 June 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 18 June 2025;
- An outpatient health record by the medical officer, Army training centre health facility, dated 14 September 2010;
- A role 2 consultation and serology report by the medical officer, Afghanistan, dated 24 April 2012;
- A role 2 consultation by the medical officer, Afghanistan, dated 1 May 2012;
- A wound swab microbiology report by the pathologist, dated 5 May 2012;
- A consultation and biochemistry report by the medical officer, Afghanistan, dated 12 May 2012;
- A patrol base treatment record by the medic, Afghanistan, dated 22 May 2012;
- A role 3 hospital admission record by the medical officer, Afghanistan, dated 26 May 2012;
- A dermatology consultation and patch test report by the dermatologist, dated 21 January 2013;
- A hospital admission and discharge summary by the medical officer, Iraq, dated 16 March 2017;
- A clinical assessment by the general practitioner, dated 18 June 2025.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 July 2009 and 18 November 2021
Skin - Medication Induced Rash (Worsening)
You have stated that the worsening of your condition was caused by:
- continuing to take the implicated drug after the clinical onset of drug eruption and before the clinical worsening of drug eruption
- being re-exposed to the implicated drug or a cross-reacting drug after the clinical onset of drug eruption and before the clinical worsening of drug eruption
- exposure of the affected skin to heat with heavy sweating, occlusion or solar ultraviolet radiation for at least 4 hours per day in the week before the clinical worsening of drug eruption
- inability to obtain appropriate clinical management for drug eruption
Diagnosis: Medication Induced Rash (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 18 June 2025, and is supported by a role 3 hospital admission record by the medical officer, Afghanistan, dated 26 May 2012.
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:
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:
- continuing to take the implicated drug after the clinical onset of drug eruption and before the clinical worsening of drug eruption
- being re-exposed to the implicated drug or a cross-reacting drug after the clinical onset of drug eruption and before the clinical worsening of drug eruption
- exposure of the affected skin to heat with heavy sweating, occlusion or solar ultraviolet radiation for at least 4 hours per day in the week before the clinical worsening of drug eruption
- inability to obtain appropriate clinical management for drug eruption
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 an intensely itchy red rash that began on the chest and back and spread over two days to the arms and thighs, with burning in the sun-exposed skin of the forearms and neck and poor sleep from itch on 22 May 2012.
The diagnosis was made clinically by a medical officer at the role 3 hospital on 26 May 2012 and confirmed by a dermatologist on 21 January 2013. The rash was a symmetrical, pruritic, erythematous maculopapular eruption that started on the trunk 14 days after co-trimoxazole was commenced, with peripheral eosinophilia, and it resolved within four weeks of stopping the drug. There was no blistering, skin detachment or mucosal involvement, excluding Stevens-Johnson syndrome and toxic epidermal necrolysis, and viral exanthem was considered and excluded by the drug timing and the recurrence on rechallenge.
After the condition arose, it was worsened during your service. After the eruption appeared on 22 May 2012 the patrol base medic, on radio advice, told you to continue co-trimoxazole because no medical officer could review you for four days. On 14 March 2017, on warlike service in Iraq, co-trimoxazole was prescribed for cellulitis of the left hand at a coalition clinic whose deployed record did not show your documented sulfonamide allergy. In the week before the first worsening, 19 to 26 May 2012, you completed two patrols of eight to ten hours in temperatures above 40 degrees Celsius in body armour, with heavy sweating and friction over the inflamed trunk and direct sun on your forearms and neck. When the eruption appeared on 22 May 2012 no medical officer could examine you for four days because of your location at a patrol base, and the culprit drug was continued in that time.
This has then led to further investigations and the diagnosis of your condition of Medication Induced Rash (Worsening). I have accepted your condition of Medication Induced Rash (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 26 May 2012.
