Dr. Hurst - Independent Medical Opinion

Independent medical opinion

I will summarize my initial letter which was sent following review of this man's DVA file in regards to treatment of his acne by UV light therapy, and then answer your specific questions from your October 3, 2012 1etter.

This gentleman did develop acne prior to enlistment and it is his contention that it was not a major concern but treatment was offered/ordered through the military. Topical agents had been prescribed but I see no record of oral antibiotics, suchas tetracycline, being given. I saw one note of Vitamin A 50,000 international units given for 30 days. This was a forerunner to the new standard of care Accutane. Normally vitamin A would be given for a minimum of 4 months and often at least 6 months.

He states that UV light was recommended and he was ordered to attend these sessions. There was no improvement so the sessions were increased in both frequency and duration. He remembers a smell emanating from his skin during the longer treatments. I believe there is agreement that this gentleman did receive well over 180 treatments over 18 months.

Since 1996 there has been an increasing number of precancerous lesions, (Actinic keratoses) requiring treatment with cryotherapy and cancerous lesions (basal cell carcinomas) requiring excision. I understand this outcome of his UV treatment for acne has been compensated. Since 2008 he is noticing extreme aging of his skin with yellow bumps that have been called solar elastosis by his dermatologist. This is causing him great concern. He is requesting review for compensation as he finds the appearance very disturbing since it reminds him of the damage done and the likelihood of ongoing need to treat precancerous and cancerous lesions. As well he is voicing concerns that rather than relatively minor skin cancers he could develop malignant melanoma, which could be fatal.

I met this gentleman November 21, 2012 to review his recollection of events and gave him a full skin exam. This has allowed me to fill in many of the missing details from the file.

I believe he attended UV treatment at the Fort Osborne Barracks. The duration of the treatments was increased well beyond 10 minutes [he states up to 40 minutes] a number of times a month. He describes a simple UV box of which 2 small doors were opened and the face would be exposed [I have seen one of these machines and his description is accurate]. I was even treated by one of these machines in the late 1960s and the physician would open the small doors for between 1-3 min. In the past, I have spoken to one of the older dermatologists who remembers some cases requiring up to 6 minutes exposure but seldom was this given more than twice a month.

**Although UV treatment was conventional treatment in the mid 1960s, it was usually used as adjuvant treatment with oral medication such as tetracycline / vitamin A, rather than sole therapy. Therefore I believe that his prolonged duration and multiple treatments each month for many months was not in accordance with the standard of care, at the time.

Your next set of questions relate to whether he has solar elastosis. I will start with a preamble to point out the differences between aging and photo aging of skin. Aging skin leads to reduced thickness of all 3 layers, that is the epidermis, dermis and subcutaneous fat with some decrease and pigmentation leading to lax pale skin. There is some decrease of Langerhans' cells which reduces the immune function of the skin. Whereas photoaging has areas of atrophy and adjacent hypertrophy causing roughness with associated decreased / increased pigmentation creating mottling. This is interspersed with yellow papules of ineffective elastin tissue and a dramatic reduction in Langerhans cells which make the area prone to development of precancerous and cancerous lesions.

His exam showed only aging skin on the torso/limbs suggesting over the years he has not been a person to expose himself to the sun on a frequent basis. However the face showed dramatic combination of sagging skin with yellow papules and areas of hyper and hypopigmentation on the sides of the neck, cheeks, nose and forehead with sparing of the submental skin [as will occur from exposure to light, from an external source]. This would be my understanding of solar elastosis / photo damage. **As I do not see similar changes on the torso or limbs I believe this was likely caused by UV damage from his repetitive long duration treatment for acne.

In conclusion it is my opinion that his repetitive prolonged exposure to UV light given for his acne treatment on the face has caused this gentleman to develop solar elastosis which is a constant reminder of what may occur in the future.