Citation Nr: 0019761 Decision Date: 07/27/00 Archive Date: 08/02/00 DOCKET NO. 98-08 730A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for seborrheic dermatitis of the face and scalp. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. L. Rippel, Counsel INTRODUCTION The veteran had active service from April 1994 to December 1996. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which granted service connection for seborrheic dermatitis of the face and scalp, and assigned a 10 percent evaluation, effective as of December 1996. The veteran disagreed with the assignment of the 10 percent evaluation, arguing that this condition warranted a higher evaluation. In May 1999, the Board remanded the matter to the RO for additional development. To the extent possible, that development has been accomplished, and the matter is again before the Board. As noted in the Board remand, the rating decision on appeal also denied the veteran's claim for service connection for bilateral ankle and knee pain. The veteran filed a notice of disagreement with respect to that decision, and the RO issued a statement of the case. During his hearing before the RO in June 1998, however, the veteran withdrew his appeal with respect that these issues. Therefore, these claims are not before the Board for appellate review. See 38 C.F.R. § 20.204 (1999). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran's seborrheic dermatitis of the face and scalp is manifested by no more than exfoliation, exudation or itching involving an exposed surface or extensive area without constant exudation or itching, extensive lesions or marked disfigurement. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 10 percent for seborrheic dermatitis of the face and scalp have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.118, Diagnostic Code 7899-7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran claims that his service-connected seborrheic dermatitis of the face and scalp is more severely disabling than currently evaluated. The veteran has disagreed with the characterization of his condition as controlled by medication. He maintains that the condition is uncontrollable and productive of constant itching. Disability ratings are determined by applying the criteria set forth in the 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 (West 1991); 38 C.F.R. § 4.1 (1999). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14. In August 1997, the RO rendered a favorable decision on the veteran's claim, and assigned a 10 percent rating for seborrheic dermatitis of the face and scalp, effective from December 1996. The veteran filed a notice of disagreement with respect to the 10 percent evaluation, and this appeal ensued. As this is a claim of disagreement with the initial rating assigned following a grant of service connection, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staging." See Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a), which gives rise to the VA's duty to assist. See Fenderson, 12 Vet. App. at 127. Under these circumstances, the VA must attempt to obtain all such medical evidence as is necessary to evaluate the severity of the veteran's disability from the effective date of service connection through the present. Fenderson, 12 Vet. App. at 125-127, citing Goss v. Brown, 9 Vet. App. 109, 114 (1996); Floyd v. Brown, 9 Vet. App. 88, 98 (1996); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also 38 C.F.R. § 4.2 (ratings to be assigned "in the light of the whole recorded history.") The Board finds that all relevant evidence has been obtained and that no further duty is required under the provisions of 38 U.S.C.A. § 5107. As noted, the veteran was awarded a 10 percent schedular evaluation for his seborrheic dermatitis. He maintains that constant itching makes the recurring face and scalp rash productive of open sores on a routine basis. The Board has considered the veteran's argument as well as the other evidence of record, and, for the following reasons, concludes that the veteran's skin condition is appropriately rated at 10 percent. Service medical records show that the veteran had chronic skin problems on the face beginning in December 1994 and continuing through the rest of his service. At his August 1997 VA examination, the veteran reported that he used Ketoconazole cream on his face daily, Ketoconazole shampoo two to three times per week, and hydrocortisone as needed. Examination revealed the skin to be smooth and oily. There were raised, reddish, macular areas of seborrheic dermatitis starting at the scalp in the anterior portion of the hairline, all across his hairline and into the left side of the hairline over the temple area moving halfway to the back, almost to the crown. All along the right side of the scalp, above the right ear and along the hairline into the hair to the back of the head on the right side was the same macular, slightly elevated erythematous dermatitis. There was involvement including flaky skin on the posterior aspect of the right ear and face across the eyebrows, the bridge of the nose and along both sides of the nose. There was no discharge. The examiner described the rash as "just erythematous with some flakiness seen." The diagnosis was seborrheic dermatitis of the face and scalp not disfiguring at present. The veteran submitted photographs of the affected areas in January 1998. These show some lesions in his scalp area which he revealed by parting his hair with his hands. Although visible when the hair was parted, the lesions were generally covered by the veteran's hair. The veteran offered testimony at a hearing before an RO hearing officer in June 1998. He testified to severe exacerbations and explained that the VA examination had not been conducted while the rash was at its peak. He stated that, at its peak, the rash would force him to scratch his scalp repeatedly. He stated that the condition was productive of pus and drainage. At those times, he used the prescription soap and showered to wash his hair two or three times per day. No residual scarring was observed or alleged. Records received pursuant to the Board's May 1999 remand consist of VA outpatient records and a portion of his VA pharmacy record. The veteran received five refills for his creams and shampoo from September 1998 to June 1999. In July 1997 he sought treatment for his dry face rash of one year's duration. The rash would reportedly start dry and pruritic, then feel like it was burning and then scab over. The examiner noted a red, scaly two to three centimeter rash beneath each nostril, a red, slightly elevated rash on the upper side of the forehead, and a red scaly rash on the scalp. Also noted was dandruff. The assessment was seborrheic dermatitis. The treatment plan included mild soap, anti-dandruff shampoo, facial creams to moisturize face and referral to dermatology clinic. Subsequent dermatology clinic examination of July 1997 revealed greasy scaling on the scalp and central face and scaling of the fingers. The veteran was prescribed medication and he was to follow up as needed. The next dermatology clinic record is dated in September 1998. At that time, the examiner described the veteran's seborrheic dermatitis as well-controlled with Nizoral. Examination of the face revealed bilateral nasolacrimal fold scaling. Hand eczema, characterized by mild scaling, was also noted at that time. The veteran was instructed to continue use of his facial and scalp medication creams. The veteran was afforded an additional VA examination for dermatology conditions in March 2000. The veteran reported that he was still treating his condition with Nizoral cream and shampoo daily. The veteran reported two to three exacerbations per month. Cold weather, smoke exposure or change in weather could precipitate an exacerbation. The last flare-up was reportedly one week before the examination. Examination revealed a small amount of scaling and erythema about the eyebrows. No scalp lesions were noted. There was a small area of mild scaling (0.5 cm) just above the left lip and beard line. No other areas appeared infected and no other areas of exacerbation were reported. There was no evidence of constant itching on examination. The lesions were described by the examiner as non-extensive and non- disfiguring. The examiner also noted that there was no evidence of exudation on examination. The assessment was seborrheic dermatitis. The veteran's seborrheic dermatitis of the face and scalp is an unlisted skin condition rated by analogy under Diagnostic Code 7806 pertaining to eczema. 38 C.F.R. §§ 4.27, 4.118, Diagnostic Code 7806 (1999). Eczema which is productive of slight, if any, exfoliation, exudation or itching on a nonexposed or small area, is rated as noncompensable, while eczema producing exfoliation, exudation or itching, if involving an exposed surface or extensive area, warrants a 10 percent rating. Eczema with constant exudation or itching, extensive lesions or marked disfigurement warrants a 30 percent rating, while eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or which is exceptionally repugnant warrants a 50 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7806. The record is replete with reference to the fact that the veteran's seborrheic dermatitis is at present a nondisfiguring condition. Both the photographs submitted by the veteran and the observations in the medical examination records are in accord in this regard. Further, the condition causes no current functional limitation. Moreover, the veteran's skin condition was characterized in the March 2000 VA examination as productive of only mild scaling and erythema. That the examiner found no evidence of constant itching further supports the conclusion that manifestations of this skin condition are appropriately contemplated by the current evaluation. The Board does not doubt the veteran's assertions that the rash can be characterized as involving itching. However, based on the several examinations of record, the Board notes that the veteran's condition has not been observed to be productive of constant itching or exudation. Moreover, while there is evidence that the skin condition at issue has been productive of exfoliation, that symptomatology is contemplated by the currently assigned 10 percent evaluation. Neither the photographic evidence nor the examination reports suggest the presence of extensive lesions. Thus, although the veteran's contentions regarding more severe manifestations of the rash have been considered, they are found to be without support in the medical evidence and thus of less probative value than the remaining evidence suggesting more moderate symptoms. Overall, the record affords no basis for an evaluation in excess of 10 percent for seborrheic dermatitis of the face and scalp at any relevant time. Additional diagnostic codes have been considered. However, in the absence of evidence of other significant findings or symptomatology, there is no basis for assignment of an evaluation in excess of the currently assigned evaluation under any other code provision. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim for an initial evaluation in excess of 10 percent for seborrheic dermatitis of the face and scalp. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Further, there has been no showing that the veteran's disability has caused marked interference with employment, necessitated frequent periods of hospitalization, or otherwise renders impracticable the application of the regular schedular standards. Although the veteran indicated in written statements that his condition is severe, examiners during the pendency of this appeal have not observed any appreciable manifestations of the condition to the degree asserted by the veteran. Moreover, there is no indication that the condition has in any way impaired the veteran in the performance of an occupation. The veteran testified that he told his most recent employer merely that he had a condition similar to dandruff. Thus, the Board concludes that this disability has not markedly interfered with any particular job. Under these circumstances, further consideration of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1); see also Bagwell v. Brown, 9 Vet. App. 237 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial evaluation in excess of 10 percent for seborrheic dermatitis of the face and scalp is denied. S. L. KENNEDY Member, Board of Veterans' Appeals