Citation Nr: 0007563 Decision Date: 03/21/00 Archive Date: 03/28/00 DOCKET NO. 98-12 727 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an increased evaluation for hidradenitis suppurativa, post-operative, recurrent, generalized sebaceous cysts, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Hinton, Associate Counsel INTRODUCTION The veteran served on active duty from November 1976 to August 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (RO), which denied the benefit sought on appeal. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable determination of the veteran's claim has been obtained. 2. The veteran's hidradenitis suppurativa, post-operative, recurrent, generalized sebaceous cysts disorder is manifested by numerous active cysts and residual scars, with periodic and varying involvement including areas of the jaw, neck, left axilla, back, chest, gluteal and perianal areas, and scrotum; with ulceration and nervous manifestations. CONCLUSION OF LAW The criteria for an evaluation of 50 percent for hidradenitis suppurativa, post-operative, recurrent, generalized sebaceous cysts have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code 7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is plausible and, thus, well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation for a service-connected disability is a well-grounded claim). The Board is also satisfied that all relevant facts have been properly developed and no further assistance is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The veteran has been provided a recent VA examination to evaluate his service- connected skin disorder, and various treatment records have been obtained. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the veteran's service medical records as well as all other evidence of record pertaining to the history of his service-connected skin disability. The Board has found nothing in the historical record which would lead it to conclude that the current evidence of record is not adequate for rating purposes. Under the laws administered by VA, disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider the history of the veteran's injury, as well as the current clinical manifestations of its residuals and the overall effect that the disability has on the earning capacity of the veteran. See 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). As there is no diagnostic code specific for the veteran's skin disorder, the veteran is rated by analogy under the diagnostic code for eczema, 38 C.F.R. § 4.118, Diagnostic Code 7806. This diagnostic code was selected because the veteran's skin disorder causes a similar functional affliction, it has similar symptomatology, and the anatomical locations are similar. 38 C.F.R. § 4.20. Under this code provision, a 30 percent evaluation is contemplated where there is evidence of constant exudation or itching, extensive lesions, or marked disfigurement. A 50 percent evaluation is warranted where there is ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or where the condition is exceptionally repugnant. See 38 C.F.R. § 4.118, Diagnostic Code 7806. Recent private and VA clinical records show that the veteran has received periodic treatment in the 1990's for symptoms associated with his service connected skin disability. Treatment records prior to September 1998 show that he has been treated for various related conditions, including multiple cysts, abscesses, and infections involving various parts of his body, including the neck, back, buttocks, groin and right leg. An October 1997 VA progress note shows that the veteran was seen at that time for hidradenitis of the perianal area. Examination showed infection that at that time was clearing up, with no appreciable drainage. During a VA psychological evaluation in October 1997, the veteran reported complaints of anxiety resulting from not being able to hold a job due to the painful cysts. He reported that he had a general anxiety and felt extremely uncomfortable around groups of people. He reported that when at the supermarket, he would begin to feel nervous and then mad when waiting in line. The veteran reported having a lot of distress coping with his hidradenitis. The veteran reported having been in jail for fighting, and never having steady employment. On examination, the veteran's mood was dysphoric, especially when explaining his discomfort with his medical condition. The report concluded with a summary that the veteran presented with anxiety and an inability to sleep; and had problems with recurrent cysts, which he believed prevented him from working and was the source of his anxiety. The diagnosis included generalized anxiety disorder, and recurrent hidradenitis. VA clinic progress notes show that in February 1998, the examiner made findings of hidradenitis of the skin with one lesion in the nape of the neck and one in the gluteal cleft. In March 1998, the veteran was seen for complaints about his nerves. Objective findings included that he seemed anxious and concerned about himself and his situation; and that he felt that he needed medication to overcome his discomfort due to anxiety and to help him sleep. During the most recent examination for skin diseases, by VA in September 1998, the veteran reported a history of sebaceous cysts on his face and chest since 1976. He gave a further history of infection and drainage of cysts in the region of both jaws; left axilla; and in the gluteal area, which he reported was diagnosed as hidradenitis suppurativa. He complained of recurrence of abscess in the perianal area, for which he was scheduled to have surgery later in September 1998. He complained that due to the abscess, he had pain in the region of the gluteal and perianal areas, which sometimes caused difficulty in walking. On examination of the face, the veteran manifested two small (4-6 mm) cysts in the region of the right jaw, which were indurated. No pus was oozing from this. In the region of the right jaw, the veteran manifested a 4 cm horizontal scar, which was well healed, superficial and nontender. In the region of the left jaw, the veteran manifested a 3 cm horizontal scar, which was superficial and nontender; and an isolated small cyst. On examination of the chest, the anterior chest wall evidenced several deep pitted scar residuals of resolved cysts. In the region of the left axilla, there were two scars, one measured about 4 cm and the other measured 1.5 cm; both of which were superficial and nontender. No cysts were evidenced on palpation of both axilla. In the scrotum, there were two to three cysts. One was oozing pus when pressure was applied. In the region of the gluteal area, in the left cleft and in the perianal area, there was induration. In the right perianal area, there was induration and erythema; no pus was oozing from the abscess, and it was tender to palpation. The claims file contains pertinent color photographs noted in the examination report. The report contains diagnoses of sebaceous cysts of the face and scrotum; and history of hidradenitis suppurativa, perianal area. VA medical treatment records show that the veteran received subsequent treatment in late September 1998, when he underwent excision of perirectal hidradenitis in treatment for a diagnosis of perirectal hidradenitis suppurativa. A January 1999 interim progress note shows that he was seen at that time in follow up to the September 1998 surgery. At that time, the examiner observed that the face and neck, as well as the back showed many scattered large open comedones, with underlying cysts. The groin area showed scarring with few cysts. The buttocks showed a large scar with one area of erosion. The assessment at that time was hidradenitis suppurativa. During a May 1999 hearing, the veteran testified regarding his skin disability. He described the various symptoms, periodicity of the symptoms and locations affected. He described the treatment, including surgeries. He testified that he currently was wearing a pad due to present drainage around the anus. He described the affect on his life, including that he could not hold a job due to the continuous irritation and moisture; and that the cysts sometimes prevent him from walking. After reviewing the record, the Board is of the opinion that, given the totality of the medical evidence, manifestations of the veteran's service-connected hidradenitis suppurativa, post-operative, recurrent, generalized sebaceous cyst more nearly approximate the criteria for a 50 percent evaluation for that disability than a 30 percent evaluation. 38 C.F.R. 4.7 (1999). This is particularly the case given the extent and severity of the veteran's recently-documented dermatologic condition. Under such circumstances, a 50 percent evaluation for service-connected skin disability is in order. In this regard, the Board notes that the clinical record has consistently shown findings of hidradenitis suppurativa, with recurrent active cysts and residual scars involving the jaw, neck, left axilla, back, chest gluteal and perianal areas, and scrotum. On examination in September 1998, there were sebaceous cysts of the face and scrotum. There were indurated cysts on the face; deep pitted scars on the chest; cysts on the scrotum, one of which was oozing pus; and cyst, induration and erythema involving the perianal area. Although no pus was oozing from the perianal area abscess, it was tender to palpation. Since that examination, the veteran has undergone surgery for excision of perirectal hidradenitis later in September 1998. The most recent clinical evidence shows that the veteran had many scattered, large open comedones, with underlying cysts. The groin manifested scarring with cysts; and the buttocks manifested a large scar with an area of erosion. Other clinical evidence of record is consistent with these overall findings and show that he takes medication for related pain. The veteran has asserted that he manifests anxiety and nervousness over his skin disability. The record shows treatment for nervousness, diagnosed as an anxiety disorder. The veteran has consistently related his nervous manifestations to the pain from the recurrent cysts that has resulted in an inability to work due to the pain symptoms. Under the rating schedule, 38 C.F.R. § 4.118, Diagnostic Code 7806 (1999) provides for a maximum 50 percent rating when the skin condition is productive of ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or is exceptionally repugnant. In applying the pertinent criteria to the facts of this case, the Board finds that the veteran's disability picture due to his service-connected skin disability more nearly approximate the criteria for a 50 percent evaluation for that disability than a 30 percent evaluation. 38 C.F.R. 4.7 (1999). In this regard, the Board has considered the veteran's complaints of related nervous manifestations along with the associated diagnosis of anxiety disorder. The Board has considered the evidence indicating painful symptoms in multiple areas including the perirectal region, with recent surgical treatment required; as well as the clinical diagnosis in 1995 indicating ulceration associated with a perianal soft tissue infection. The Board has considered the documented continuous nature of the active disease process involving cysts and other related skin conditions, and credible assertions that the veteran is unable to walk or sit at times due to his disorder, which in turn affects his employment and causes nervous manifestations. Lastly, while no examiner has described the manifestations of the veteran's skin disorder as exceptionally repugnant, in making this decision, the Board has considered both the included photographs of affected areas showing manifestations, and the criteria required under Diagnostic Code 7806 for an evaluation of 50 percent. In summary, the Board finds on review that the clinical evidence of record, as noted above, indicates that there is evidence of current manifestations reflective of the criteria for a 50 percent rating under Diagnostic Code 7806. On that basis, the Board finds that an increased rating pursuant to Diagnostic Code 7806 is warranted for the veteran's skin disability. The Board notes that the 50 percent evaluation assigned in this decision is the maximum available under Diagnostic Code 7806 for the veteran's service-connected skin disorder. The Board also finds that no other potentially applicable diagnostic code affords the veteran a higher evaluation for his skin disorder. In particular, the Board has considered whether a higher evaluation is warranted for the veteran's scars under Diagnostic Codes 7803 and 7804. However, 10 percent is the maximum rating assigned for scars under both of these code provisions. See 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804 (1999). ORDER A 50 percent evaluation for hidradenitis suppurativa, post- operative, recurrent, generalized sebaceous cysts is granted subject to the laws and regulations governing the award of monetary benefits. F. JUDGE FLOWERS Member, Board of Veterans' Appeals