Statement of Principles

concerning

PSORIASIS
(Reasonable Hypothesis)

(No. 13 of 2021)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 24 December 2020

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning psoriasis (Reasonable Hypothesis) (No. 13 of 2021).

2               Commencement

              This instrument commences on 25 January 2021.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning psoriasis No. 31 of 2012 (Federal Register of Legislation No. F2012L00938) made under subsections 196B(2) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about psoriasis and death from psoriasis.

Meaning of psoriasis

(2)          For the purposes of this Statement of Principles, psoriasis means a chronic inflammatory skin disorder characterised by keratinocyte hyperproliferation that results in erythematous plaques, patches and papules.

Note: Morphological variants of psoriasis include the common plaque type, as well as flexural, erythrodermic, pustular (including impetigo herpetiformis) and guttate forms.

(3)          While psoriasis attracts ICD‑10‑AM code L40.0, L40.1, L40.2, L40.4, L40.8, L40.9 or L40, in applying this Statement of Principles the meaning of psoriasis is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from psoriasis

(5)          For the purposes of this Statement of Principles, psoriasis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's psoriasis.

Note: terminal event is defined in the Schedule 1 - Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that psoriasis and death from psoriasis can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting psoriasis or death from psoriasis with the circumstances of a person's relevant service:

(1)          having an injury to the skin of the affected site or developing a lesion of the affected site within the 30 days before the clinical onset of psoriasis;

(2)          taking a drug from the specified list of drugs for at least the seven days before the clinical onset of psoriasis;

Note: specified list of drugs is defined in the Schedule 1 - Dictionary.

(3)          taking a drug which is associated in the individual with:

(a)          the development of psoriasis during drug therapy; and

(b)           the improvement of psoriasis within two months of discontinuing or tapering drug therapy;

where taking the drug continued for at least the seven days before the clinical onset of psoriasis;

(4)          withdrawing from tumour necrosis factor-α inhibitor treatment in the six months before the clinical onset of psoriasis;

(5)          withdrawing from systemic glucocorticoids, moderate potency topical glucocorticoids or high potency topical glucocorticoids in the 30 days before the clinical onset of psoriasis;

Note: moderate potency topical glucocorticoids and high potency topical glucocorticoids are defined in the Schedule 1 - Dictionary.

(6)          consuming an average of at least 200 grams of alcohol per week for at least the one year before the clinical onset of psoriasis;

Note: Alcohol consumption is calculated utilising the Australian Standard of ten grams of alcohol per standard alcoholic drink.

(7)          experiencing a category 1A stressor within the six months before the clinical onset of psoriasis;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(8)          experiencing a category 1B stressor within the six months before the clinical onset of psoriasis;

Note: category 1B stressor is defined in the Schedule 1 - Dictionary.

(9)          experiencing a category 2 stressor within the six months before the clinical onset of psoriasis;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

Note 2: category 2 stressor is defined in the Schedule 1 - Dictionary.

(10)      having a Streptococcus pyogenes infection of the pharynx, tonsils or skin within the 30 days before the clinical onset of psoriasis;

(11)      having infection with human immunodeficiency virus before the clinical onset of psoriasis;

(12)      having smoked at least five pack-years of tobacco products before the clinical onset of psoriasis;

Note: pack-year of tobacco products is defined in the Schedule 1 - Dictionary.

(13)      being exposed to second-hand smoke for at least 5,000 hours before the clinical onset of psoriasis;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(14)      being overweight or obese for at least five years before the clinical onset of psoriasis;

Note: being overweight or obese is defined in the Schedule 1 - Dictionary.

(15)      for impetigo herpetiformis only, being pregnant within the six weeks before the clinical onset of impetigo herpetiformis;

Note: impetigo herpetiformis is defined in the Schedule 1 - Dictionary.

(16)      having an injury to the skin of the affected site or developing a lesion of the affected site within the 30 days before the clinical worsening of psoriasis;

(17)      taking a drug from the specified list of drugs for at least the seven days before the clinical worsening of psoriasis;

Note: specified list of drugs is defined in the Schedule 1 - Dictionary.

(18)      taking a drug which is associated in the individual with:

(a)           the worsening of psoriasis during drug therapy; and

(b)           the improvement of psoriasis within two months of discontinuing or tapering drug therapy;

where taking the drug continued for at least the seven days before the clinical worsening of psoriasis;

(19)      withdrawing from tumour necrosis factor-α inhibitor treatment in the six months before the clinical worsening of psoriasis;

(20)      withdrawing from systemic glucocorticoids, moderate potency topical glucocorticoids or high potency topical glucocorticoids in the 30 days before the clinical worsening of psoriasis;

Note: moderate potency topical glucocorticoids and high potency topical glucocorticoids are defined in the Schedule 1 - Dictionary.

(21)      consuming an average of at least 200 grams of alcohol per week for at least the one year before the clinical worsening of psoriasis;

Note: Alcohol consumption is calculated utilising the Australian Standard of ten grams of alcohol per standard alcoholic drink.

(22)      experiencing a category 1A stressor within the six months before the clinical worsening of psoriasis;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(23)      experiencing a category 1B stressor within the six months before the clinical worsening of psoriasis;

Note: category 1B stressor is defined in the Schedule 1 - Dictionary.

(24)      experiencing a category 2 stressor within the six months before the clinical worsening of psoriasis;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

Note 2: category 2 stressor is defined in the Schedule 1 - Dictionary.

(25)      having a Streptococcus pyogenes infection of the pharynx, tonsils or skin within the 30 days before the clinical worsening of psoriasis;

(26)      having infection with human immunodeficiency virus before the clinical worsening of psoriasis;

(27)      having smoked at least five pack-years of tobacco products before the clinical worsening of psoriasis;

Note: pack-year of tobacco products is defined in the Schedule 1 - Dictionary.

(28)      being exposed to second-hand smoke for at least 5,000 hours before the clinical worsening of psoriasis;

Note: being exposed to second-hand smoke is defined in the Schedule 1 - Dictionary.

(29)      being overweight or obese for at least five years before the clinical worsening of psoriasis;

Note: being overweight or obese is defined in the Schedule 1 - Dictionary.

(30)      inability to obtain appropriate clinical management for psoriasis.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 9(16) to 9(30) apply only to material contribution to, or aggravation of, psoriasis where the person's psoriasis was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                               being exposed to second-hand smoke means being in an enclosed space and inhaling smoke from burning tobacco products or smoke that has been exhaled by another person who is smoking.

                               being overweight or obese means having a Body Mass Index (BMI) of 25 or greater.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               biologic agent means a therapeutic product which is derived from living organisms or which contains components of living organisms.

Note: Examples of biologic agents used for the treatment of cancer and autoimmune disease include interferons, monoclonal antibodies, tumour necrosis factor-α inhibitors, tyrosine kinase inhibitors and vascular endothelial growth factor antagonists.

                               BMI means W/H2 where:

(a)          W is the person's weight in kilograms; and

(b)          H is the person's height in metres.

                               category 1A stressor means one of the following severe traumatic events:

(a)          experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)          being threatened with a weapon, being held captive, being kidnapped or being tortured.

                               category 1B stressor means one of the following severe traumatic events:

(a)          killing or maiming a person;

(b)          being an eyewitness to a person being killed or critically injured;

(c)          being an eyewitness to atrocities inflicted on another person;

(d)          participating in the clearance of a corpse or a critically injured casualty; or

(e)          viewing a corpse or a critically injured casualty as an eyewitness.

Note: corpse and eyewitness are also defined in the Schedule 1 - Dictionary.

                               category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing distress, concern or worry:

(a)          being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;

(b)          experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation or divorce;

(c)          having concerns in the work or school environment including ongoing disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment;

(d)          experiencing serious legal issues including being detained or held in custody, ongoing involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;

(e)          having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property or bankruptcy;

(f)           having a family member or significant other experience a major deterioration in their health; or

(g)          being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.

Note: significant other is also defined in the Schedule 1 - Dictionary.

                               corpse means the human remains or body parts of one or more persons who have met a violent or horrific death.

Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents.  Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

                               eyewitness means a person who observes an incident first hand and can give direct evidence of it.  This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                               high potency topical glucocorticoids means:

(a)          betamethasone dipropionate 0.05%;

(b)          betamethasone valerate 0.1%;

(c)          clobetasol 0.05%;

(d)          methylprednisolone 0.1%;

(e)          mometasone 0.1%; or

(f)           another topical glucocorticoid of equivalent potency.

                               impetigo herpetiformis means a pustular skin condition of pregnancy, characterised by the presence of widespread tiny superficial pustules in a herpetiform pattern on erythematosquamous plaques, and often associated with constitutional symptoms.

                               moderate potency topical glucocorticoids means:

(a)          betamethasone valerate 0.02% and 0.05%;

(b)          clobetasone 0.05%;

(c)          desonide 0.05%;

(d)          triamcinolone 0.02%; or

(e)          another topical glucocorticoid of equivalent potency.

                                MRCA means the Military Rehabilitation and Compensation Act 2004.

                               pack-year of tobacco products means:

(a)          20 cigarettes per day for a period of one calendar year; or

(b)          7,300 cigarettes in a period of one calendar year; or

(c)          7,300 grams of smoking tobacco by weight, either in cigarettes, pipe tobacco or cigars, or a combination of same, in a period of one calendar year.

                               psoriasis—see subsection 7(2).

                               relevant service means:

(a)          operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)          hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)          warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                               specified list of drugs means:

(a)          angiotensin-converting enzyme inhibitors;

(b)          apixaban;

(c)          beta-blockers;

(d)          biologic agents for the treatment of cancer and autoimmune disease;

(e)          bupropion;

(f)           chloroquine;

(g)          docetaxel;

(h)          hydroxychloroquine;

(i)            itraconazole;

(j)            lithium;

(k)          mefloquine;

(l)            primaquine;

(m)        quinacrine (mepacrine or Atebrin);

(n)          terbinafine; or

(o)          tetracyclines.

Note: biologic agent is also defined in the Schedule 1 - Dictionary.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               VEA means the Veterans' Entitlements Act 1986.