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The skin

AMA5 Chapter 8 (p 173) applies to the assessment of permanent impairment of the skin, subject to the modifications set out below. Before undertaking an impairment assessment, users of the Guidelines must be familiar with:

  • the Introduction in the Guidelines
  • chapters 1 and 2 of AMA5
  • the appropriate chapter(s) of the Guidelines for the body system they are assessing
  • the appropriate chapter(s) of AMA5 for the body system they are assessing.

The Guidelines take precedence over AMA5.

Introduction

14.1 AMA5 Chapter 8 (pp 173–90) refers to skin diseases generally rather than work related skin diseases alone. This chapter has been adopted for measuring impairment of the skin system, with the following variations.

14.2 Disfigurement, scars and skin grafts may be assessed as causing significant permanent impairment when the skin condition causes limitation in the performance of activities of daily living (ADL).

14.3 For cases of facial disfigurement, refer to Table 6.1 in Chapter 6 of in the Guidelines.

14.4 AMA5 Table 8-2 (p 178) provides the method of classification of impairment due to skin disorders. Three components – signs and symptoms of skin disorders, limitations in ADL and requirements for treatment – define five classes of permanent impairment. The assessing specialist should derive a specific percentage impairment within the range for the class that best describes the clinical status of the claimant.

14.5 The skin is regarded as a single organ and all non-facial scarring is measured together as one overall impairment, rather than assessing individual scars separately and combining the results.

14.6 A scar may be present and rated as 0% WPI.

Note that uncomplicated scars for standard surgical procedures do not, of themselves, rate an impairment.

14.7 The table for the evaluation of minor skin impairment (TEMSKI) (see Table 14.1 below) is an extension of Table 8-2 in AMA5. The TEMSKI divides class 1 of permanent impairment (0–9%) due to skin disorders into five categories of impairment. The TEMSKI may be used by trained assessors (who are not trained in the skin body system), for determining impairment from 0–4% in the class 1 category, that has been caused by minor scarring following surgery. Impairment greater than 4% must be assessed by a specialist who has undertaken the requisite training in the assessment of the skin body system.

14.8 The TEMSKI is to be used in accordance with the principle of ‘best fit’. The assessor must be satisfied that the criteria within the chosen category of impairment best reflect the skin disorder being assessed. If the skin disorder does not meet all of the criteria within the impairment category, the assessor must provide detailed reasons as to why this category has been chosen over other categories.

14.9 Where there is a range of values in the TEMSKI categories, the assessor should use clinical judgement to determine the exact impairment value.

14.10 The case examples provided in AMA5 Chapter 8 do not, in most cases, relate to permanent impairment that results from a work-related injury. The following NSW examples are provided for information.

14.11 Work-related case study examples 14.1–14.6 are included below, in addition to AMA5 examples 8.1–8.22 (pp 178–87).

Table 14.1: Table for the evaluation of minor skin impairment (TEMSKI)

Criteria0% WPI1% WPI2% WPI3-4% WPI5-9% WPI*

Description of the scar(s) and/or skin conditions(s)
(shape, texture, colour)

Claimant is not conscious or barely conscious of the scar(s) or skin condition.

Good colour match with surrounding skin, and the scar(s) or skin condition is barely distinguishable.

Claimant is unable to easily locate the scar(s) or skin condition.

No trophic changes.

Any staple or suture marks are barely visible.

Claimant is conscious of the scar(s) or skin condition.

Some parts of the scar(s) or skin condition colour contrast with the surrounding skin as a result of pigmentary or other changes.

Claimant is able to locate the scar(s) or skin condition.

Minimal trophic changes.

Any staple or suture marks are visible.

Claimant is conscious of the scar(s) or skin condition.

Noticeable colour contrast of scar(s) or skin condition with surrounding skin as a result of pigmentary or other changes.

Claimant is able to easily locate the scar(s) or condition.

Trophic changes evident to touch.

Any staple or suture marks are clearly visible.

Claimant is conscious of the scar(s) or skin condition.

Easily identifiable colour contrast of scar(s) or skin condition with surrounding skin as a result of pigmentary or other changes.

Claimant is able to easily locate the scar(s) or skin condition.

Trophic changes evident to touch.

Any staple or suture marks are clearly visible.

Claimant is conscious of the scar(s) or skin condition.

Distinct colour contrast of scar(s) or skin condition with surrounding skin as a result of pigmentary or other changes.

Claimant is able to easily locate the scar(s) or skin condition.

Trophic changes are visible.

Any staple or suture marks are clearly visible.

Location

Anatomic location of the scar(s) or skin condition not clearly visible with usual clothing/hairstyle.

Anatomic location of the scar(s) or skin condition not usually visible with usual clothing/hairstyle.

Anatomic location of the scar(s) or skin condition is usually visible with usual clothing/hairstyle.

Anatomic location of the scar(s) or skin condition is visible with usual clothing/hairstyle.

Anatomic location of the scar(s) or skin condition is usually and clearly visible with usual clothing/hairstyle.

Contour

No contour defect.

Minor contour defect.

Contour defect visible.

Contour defect easily visible.

Contour defect easily visible.

ADL/treatment

No effect on any ADL.

No treatment, or intermittent treatment only, required.

Negligible effect on any ADL.

No treatment, or intermittent treatment only, required.

Minor limitation in the performance of few ADL.

No treatment, or intermittent treatment only, required.

Minor limitation in the performance of few ADL and exposure to chemical or physical agents (eg sunlight, heat, cold etc) may temporarily increase limitation.

No treatment, or intermittent treatment only, required.

Limitation in the performance of few ADL (including restriction in grooming or dressing) and exposure to chemical or physical agents (eg sunlight, heat, cold etc) may temporarily increase limitation or restriction.

No treatment, or intermittent treatment only, required.

Adherence to underlying structures

No adherence.

No adherence.

No adherence.

Some adherence.

Some adherence.

This table uses the principle of 'best fit'. You should assess the impairment to the whole skin system against each criteria and then determine which impairment category best fits (or describes) the impairment. Refer to 14.8 regarding application of this table.

Examples

Example 14.1: Cumulative irritant dermatitis

Subject42-year-old man
HistorySpray painter working on ships in dry dock. Not required to prepare surface but required to mix paints (including epoxy and polyurethane) with ‘thinners’ (solvents) and spray metal ships’ surface. At end of each session, required to clean equipment with solvent. Not supplied with gloves or other personal protective equipment until after onset of symptoms. Gradual increase in severity in spite of commencing to wear gloves. Off work two months leading to clearance, but frequent recurrence, especially if the subject attempted prolonged work wearing latex or PVC gloves or wet work without gloves.
CurrentReturned to dry duties only at work. Mostly clear of dermatitis, but flares.
Physical examinationVaries between no abnormality detected to mild dermatitis of the dorsum of hands.
InvestigationsPatch test standard + epoxy + isocyanates (polyurethanes) - no reactions
Impairment0%
CommentNo interference with ADL.

Example 14.2: Allergic contact dermatitis to hair dye

Subject30-year-old woman
HistoryHairdresser 15 years, with six-month history of hand dermatitis, increasing despite beginning to wear latex gloves after onset. Dermatitis settled to very mild after four weeks off work, but not clear. As the condition flared whenever the subject returned to hairdressing, she ceased and is now a computer operator.
CurrentMild continuing dermatitis of the hands, which flares when doing wet work (without gloves) or when wearing latex or PVC gloves. Has three young children and impossible to avoid wet work.
InvestigationPatch test standard + hairdressing series - possible reaction to paraphenylene diamine.
Impairment5%
CommentAble to carry out ADL with difficulty, therefore limited performance of some ADL.

Example 14.3: Cement dermatitis due to chromate in cement

Subject43-year-old man
HistoryConcreter since age 16. Eighteen-month history of increasing hand dermatitis, eventually on dorsal and palmar surface of hands and fingers. Off work, and treatment led to limited improvement only.
Physical examinationFissured skin, hyperkeratotic chronic dermatitis.
InvestigationPatch test - positive reaction to dichromate.
CurrentIntractable, chronic, fissured dermatitis.
Impairment12%
CommentUnable to obtain any employment because has chronic dermatitis, and is on disability support pension. Difficulty gripping items, including steering wheel, hammer and other tools. Unable to do any wet work (eg painting). Former home handyman, now calls in tradesman to do any repairs and maintenance. Limited performance in some ADL.

Example 14.4: Latex contact uritcaria/angioedema with cross reactions

Subject40-year-old female nurse
HistorySix-month history of itchy hands minutes after applying latex gloves at work. Later swelling and redness associated with itchy hands and wrists, and subsequently widespread urticaria. One week off led to immediate clearance. On return to work wearing PVC gloves, developed anaphylaxis on first day back.
Physical examinationNo abnormality detected or generalised urticaria/angioedema.
InvestigationLatex radioallergosorbent test, strong response.
CurrentThe subject experiences urticaria and mild anaphylaxis if she enters a hospital, some supermarkets or other stores (especially if latex items are stocked), at children’s parties, or in other situations where balloons are present, or on inadvertent contact with latex items, including sporting goods handles, some clothing and many shoes (latex-based glues). Also has restricted diet (must avoid bananas, avocados and kiwi fruit).
Impairment17%
CommentSevere limitation in some ADL in spite of intermittent activity.

Example 14.5: Non-melanoma skin cancer

Subject53-year-old married man
HistoryRoad worker since 17 years of age. Has had a basal cell carcinoma on the left forehead, squamous cell carcinoma on the right forehead (graft), basal cell carcinoma on the left ear (wedge resection) and squamous cell carcinoma on the lower lip (wedge resection) excised since 45 years of age. No history of loco-regional recurrences. Multiple actinic keratoses treated with cryotherapy or Efudix over 20 years (forearms, dorsum of hands, head and neck).
CurrentNew lesion right preauricular area. Concerned over appearance - 'I look a mess'.
Physical examinationMultiple actinic keratoses forearms, dorsum of hands, head and neck. Five millimetre diameter nodular basal cell carcinoma right preauricular area; hypertrophic red scar, 3cm length, left forehead; 2cm-diameter graft site (hypopigmented with 2mm contour deformity) right temple; non-hypertrophic scar left lower lip (vermilion) with slight step deformity; and non-hypertrophic pale wedge resection scar left pinna, leading to 30% reduction in size of the pinna. Graft sites taken from right post-auricular area. No regional lymphadenopathy.
Impairment rating6%
CommentRefer to Table 6.1 (facial disfigurement) in Chapter 6.

Example 14.6: Non-melanoma skin cancer

Subject35-year-old single female professional surf life saver
HistoryOccupational outdoor exposure since 19 years of age. Basal cell carcinoma on tip of nose excised three years ago with full thickness graft following failed intralesional interferon treatment.
CurrentPoor self-esteem because of cosmetic result of surgery.
Physical examinationOne-centimetre diameter graft site on the tip of nose (hypopigmented with 2mm depth contour deformity, cartilage not involved). Graft site taken from right post-aricular area.
Impairment10%
CommentRefer to Table 6.1 (facial disfigurement) in Chapter 6.