Citation Nr: 0307835 Decision Date: 04/24/03 Archive Date: 04/30/03 DOCKET NO. 02-07 079 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to a rating in excess of 30 percent for fungus infection, to include furunculitis. 2. Entitlement to a rating in excess of 10 percent for scarring of the head, face, and neck. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Hal Smith INTRODUCTION The veteran served on active duty from May 1952 to May 1956 and from August 1957 to September 1959. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2001 rating decision of the Regional Office (RO) in Los Angeles, California. The RO denied entitlement to increased evaluations for fungus infection to include furunculosis and scarring of the head, face, and neck. FINDINGS OF FACT 1. VA has made reasonable efforts to assist the veteran in obtaining information and evidence necessary to substantiate his claims. 2. The veteran's fungus infection, to include furunculitis, is not productive of ulceration, extensive exfoliation, or crusting with systemic or nervous manifestations, or an exceptionally repugnant condition. Nor is this disorder productive of more than 40 percent of the entire body or more than 40 percent of exposed areas affected. Constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs have not been required during the past 12 month period. 3. The veteran's scarring of the head, face, and neck is not productive of severe disfigurement, especially a marked deformity of the eyelids, lips, or auricles, or marked color contrast. Nor is there visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears, (auricles), cheeks, lips), or; with two or three characteristics of disfigurement . CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for fungus infection, to include furunculitis, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.20, 4.118 Diagnostic Codes (DCs) 7813, 7806 (prior to and subsequent to Aug. 30, 2002). 2. The criteria for a rating in excess of 10 percent for scarring of the head, face, and neck have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.118, DC 7800 (prior to and subsequent to Aug. 30, 2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service medical records (SMRs) dated in January 1954 show that the veteran was treated for cellulitis without lymphangitis of the scrotum. In May 1954, he was treated for lymphadenitis, bilateral inguinal. SMRs dated in December 1955 and January 1956 reveal that the veteran had folliculitis of the left face and cheek. In March 1956, he was treated for dermatophytosis (athlete's foot), fungus infection of both feet, and cellulitis without lymphangitis of the left foot. The veteran was afforded a VA examination in August 1976, during which he reported that he had had athlete's feet since 1953. The problems with the skin of the feet occurred several times per year, and the skin over his entire body became covered with purulent pustules which then left scarring. Treatment was with antibiotics and Hydrocortisone cream. Multiple skin biopsies reportedly revealed fungal infection. The pertinent diagnoses were lymphadenitis of the inguinal region, bilaterally, by history, not present on examination; cellulitis with lymphangitis of the left foot, not present on examination; tinea pedis; and probable tinea versicolor of the body, recurrent. In September 1976 the RO granted entitlement to service connection for fungus infection, probably tinea versicolor and pedis, evaluated as noncompensable under DC 7813. The RO also found that residuals of cellulitis of the scrotum and left foot as well as residuals of lymphadenitis, bilateral, inguinal regions were not shown on examination and were not service-connected. VA outpatient treatment records dated in July 1990 show that the veteran had a history of chronic folliculitis involving his entire body, with the greatest involvement around the left axilla and left arm. Physical examination revealed the left axilla and forearm with folliculitis. There was a scaling rash in the intertriginous areas with a base of erythema. The assessment was chronic folliculitis under fair control with Hydrocortisone cream. In September 1990, the veteran complained of rash on the feet and underarms. Objective examination showed vesicles around the toes and fingers; and follicular nodules and pustules on the face. The assessments were dyshidrosis and probable hidradenitis. The veteran was treated at a VA emergency room in November 1990 with a chief complaint of fungus over the whole body. There was a rash on the face. Follow-up examination was conducted in December 1990 for tinea pedis/folliculitis. Physical examination showed scaling of the feet. The assessments were tinea pedis and nummular eczema. VA outpatient treatment records dated in February 1991 show that the veteran had scales on the soles and webs of the toes of his feet. There were inflamed papules on his face with diffuse erythema, especially of the medial face. Examination of the body revealed inflamed follicular papules. In November 1991, the veteran had a few papules on his face. His feet had no scales but there was maceration on the plantar metacarpals and toe webs, with mild erythema. VA outpatient treatment records dated in July 1992 show that the veteran requested medication renewal for chronic dermatitis. An August 1992 follow-up examination revealed erythema of the cheeks and erythematous papules and pustules in the axilla and abdomen. Both feet had scaling between the toes. It was recommended that the veteran decrease the Hydrocortisone medication in order to address the rosacea. The other assessments included folliculitis and tinea pedis. In September 1992, physical examination showed a few pustules on the cheeks and neck and cystic lesion in the axilla. Mild scaling on the soles of both feet was demonstrated. In December 1992 there was erythema on the cheeks and a telangiectatic papule on the left cheek; a furuncle on the left jaw; and scaling of both feet, left greater than right. In November 1993 the RO granted a 10 percent rating for fungus infection, probable tinea versicolor and pedis under DC 7813. The RO explained that the increase was on the basis that the service-connected skin disability was recurrent and involved an extensive area. VA outpatient treatment records dated in August 1993 indicate that the veteran had follicular papules and pustules under the axillae, ingrown. The feet were white, scaling and hypertrophic. In December 1993, there was erythema of the face and scaling of the feet. VA outpatient dermatology records of January 1994 indicate that the veteran had an inflamed pustule of the face and scattered pustules on his back. The feet were macerated and scaly in between the toes. The veteran was afforded a VA examination for rating purposes in May 1994. He reported that since 1974 he had had boils all over his body and tinea pedis, left greater than right. Subjective complaints included pain from the boils, unsightliness of the residual scars from the boils, and itchiness and scaling of the feet. Objective findings included hyperpigmented skin in the axillary region bilaterally as well as the groin region, secondary to scarring from skin lesions. Hyperpigmented scarring was also observed on both forearms and the back. Scaling between the toes, especially on the left foot, was noted, consistent with tinea pedis. The examiner also noted that the pustular lesions occurred primarily on the upper torso, with the greatest concentration in the axillary areas and the groin; there were occasional appearances on the face and extremities. No nervous manifestations were noted. The diagnoses were tinea pedis, bilaterally, with the left greater than right and chronic furunculosis (original diagnosis of tinea versicolor was incorrect). In the July 1994 statement of the case, the RO explained that a 30 percent rating was not warranted for the service- connected fungus infection since extensive lesions or marked disfigurement were not shown (DC 7806). VA dermatology clinic records dated in January 1995 show that the veteran had multiple erythematous cysts on the upper thighs and scarring under his arms. There was no evidence of folliculitis. The impressions were hidradenitis; no folliculitis; tinea pedis; and lichen simplex chronicus. At a hearing at the RO in January 1995, the veteran testified that his skin problems affected his scrotum, between his legs, his armpits and the back of his neck. Hearing transcript (Tr.) 1. He stated that the dark boils over his body constituted marked disfigurement. Tr. at 4. He testified that he required medication over his body on a daily basis. Tr. at 8. Following the hearing, the hearing officer resolved doubt in the veteran's favor and granted service connection for hidradenitis, lichen simplex (variously diagnosed as cellulitis and furunculitis). The RO implemented the decision in a subsequent rating action. A noncompensable evaluation was assigned for furunculitis, scrotum, left foot, armpits, and back of the neck, under DC 7899-7806. VA dermatology clinic records dated in June 1995 show that the veteran was seen for dyshidrosis eczema and hidradenitis suppurativa. There were multiple erythematous papules and pustules of both armpits and erythematous scaly vesicles on both soles and toe webs. There also were nail changes. The assessments were folliculitis and tinea pedis versus dyshidrotic eczema. In September 1995 there were seen scaly plaques with deep-seated vesicles on the plantar surfaces. There were a few follicular papules on the chest and axillae. The examiner noted that the veteran used Hydrocortisone cream all over his body, and discussed the side effects of hypertension, bone necrosis, peptic ulcer disease and skin atrophy. The veteran submitted 2 color photographs of the left axilla in March 1996. The area above the armpit was reddened and a boil or scar was within the redness. On the reverse side of the picture it was noted that the photograph was taken in May 1995. VA outpatient treatment records dated in March 1996 show that the veteran was treated for skin follow-up care. A surgical pathology report at that time revealed benign hyperkeratotic squamous papillomas, consistent with dermatosis papulosa nigra or acrochordons (face and neck skin lesions) and slight papillomatosis and hyperpigmentation of the epidermis, without neoplasm (left forearm). In August 1996, physical examination revealed hyperpigmented maculo-papular lesions of both axilla and the groin. The veteran was afforded a VA examination in November 1996. His subjective complaints included itching in the groin, axillae and buttocks; inflammation of the skin and nose areas; a deformed left toenail; and left lower extremity itching. Physical examination revealed intact, dry skin that was slightly hyperpigmented of the anterior lower extremities. There was very slight excoriation of the extremities. Skin of the medial upper arms and the right and left lateral chest was hyperpigmented, flat and atrophied. Skin of the scrotum, both medial thighs and the perianal area was erythematous. There was one pustule on the medial left thigh. There were a few 1-millimeter (mm) raised nodular lesions on the fingers and palms. On the left foot, there were 2 red, raised 0.5-mm papules on the extensive surfaces of the left 3rd toe and 1 similar lesion on the left 4th toe. The left 3rd toenail was frayed, but otherwise normal. There were 4 hyperpigmented nevi, 4-7 mm in diameter on the back. There were 2 raised, erythematous papules on the back over the scapula and 5 raised, erythematous papules on the left side of the chest, 2 or 3 on the right side of the chest, 1 on the abdomen, and 2 on the right shoulder. The diagnoses were tinea cruris; tinea pedis; lichen simplex, lower extremities; benign nevi on the back; folliculitis; atrophy of the skin of the upper arms and lateral chest; and dishydrotic eczema of the hand. Color photographs and slides of the areas affected by the skin disorder were associated with the claims file. An October 1997 examination report indicates that the veteran had longstanding folliculitis of the groin area and armpits for which he was on medication and Hydrocortisone lotion once a day for years. He had not used the medications for one week before the examination in order to show how severe the skin disorder was. He complained of increased itching and burning. On physical examination, there were bilateral striae of the armpits with no reddening. There were striae, erythema and fine wrinkling of the skin with purple-red coloration in the bilateral groin skin. There was dark redness of the veteran's facial cheeks and posterior auricular area. Three non-pustular hyperpigmented papules of the right groin were noted. The assessment was chronic folliculitis and mild hidradenitis, most likely aggravated or caused by steroid overuse. The groin and axillae showed evidence of steroid atrophy. No overt infectious activity was shown. The veteran was symptomatic with chronic itching and soreness. The recommendation was for the veteran to wean down from use of Hydrocortisone cream over a one-month period. The veteran was afforded a dermatologic examination on behalf of VA in July 1998. The examiner noted that since service, he had been subject to scaling, peeling and occasionally a fine blistering eruption on the soles and sides of his feet and between his toes. Various treatments over the years had helped control or minimize this eruption but not cure it. On examination, there were macular and a few depressed pigmented scars in the subaxillary sides of the chest. Similar lesions were present in both inguinocrural folds. Those findings were consistent with hidradenitis suppurativa. It was noted that the soles and sides of the feet as well as the interdigital areas were all scaly and peeling. Several toenails on each foot had thickening, yellowish-gray discoloration. Those findings supported a diagnosis of dermatophytosis and onychomycosis. Both conditions were considered to be in a relatively inactive phase of chronicity. The examiner also took 3 photographs which showed the side of the veteran's torso, his left foot and his thigh. VA outpatient treatment records dated in December 1999 show that the veteran was treated for hidradenitis. It was noted that he used a 1% hydrocortisone lotion daily. He complained of a flare-up in the groin and inner thighs despite his current regimen. The flare-ups were described as seasonal, with moderate to severe itching. Physical examination of the groin showed multiple cystic lesions along the inner thighs bilaterally and scrotal skin and perianally with associated erythema. The pertinent assessment was hidradenitis, chronic. The veteran was to continue his current regimen of medication and lotion. In January 2000 the Board determined that service connection for fungus infection, variously diagnosed as tinea pedic, folliculitis, hidradenitis, and lichen simplex, rated as 10 percent, and furunculitis of the scrotum, left foot, armpits, and back of neck, rated 0 percent, should be combined. An increased rating of 30 percent was granted, and the disorder was recharacterized as shown on the title page of this decision. Additionally, service connection was established for scarring of the head, face, and neck, and a separate 10 percent rating was assigned. VA outpatient treatment records added to the record subsequent to the Board's January 2000 decision show that in December 1999, the veteran complained of flare-ups of hydradenitis supporitava in the groin and inner thighs. He described the flare-ups as being seasonable with moderate to severe itching. He also complained of a single war-like lesion on the right face for the past 3 weeks. He reported no discomfort, and noted that his flare-ups were seasonal in nature. On examination there were multiple cystic lesions along the inner thighs, bilaterally, and scrotal skin and perianally with associated erythema. There was a single verrucous growth on the right face lateral to the mouth. The assessment was hydradenitis supporitava and cerruca vulgaris on the right face. The veteran was continued on hydrocortisone lotion and oral tetracycline. In August 2001, the veteran reported a problem with frequent outbreaks of folliculitis of the scalp and neck area, and also of the groin and buttocks. On VA examination the veteran reported that his condition of skin boils had come and gone over the years. His medications included hydrocortisone and tetracycline, which he used every day. He felt that these medications had kept his condition under control. He saw a private physician to have the boils lanced when they occurred. His symptoms included a rash and itching. Objective findings on examination included scattered hyperpigmented macular rashes over both armpits, residuals from healed furuncles as well as hyperpigmented macular rashes over the groin area, bilaterally. Scabs were noted as residuals of healed furuncles. There were a couple of active furuncles over the buttocks containing pus. The skin was warm and dry. The diagnosis was furunculitis of the scrotum, left foot, armpits, buttocks, back, and neck. The veteran said that over the years his condition had resulted in scarring formation over the head, face, and neck. His symptoms included itching, burning, and boils. He had not received treatment for his scars. On examination there was an active furuncle measuring 0.5 x 0.5 cm. on the occipital area. The skin was warm and dry. The examiner noted residuals of healed furuncles over the face, neck and head with mild disfigurement. In January 2002, the veteran requested treatment for hydradenitis of the suprapubic, perineal, and axillary regions. On examination there were multiple hyperpigmented papules on the back and maculopapular lesions on the acilla, inguinal area, and perineum. Later that month he requested treatment for a right groin boil. The examiner noted a 2 cm. raised erythematosus papule with firm nodule in the right groin. He also requested treatment for folliculitis of the scalp. He was using topical erythromycin for treatment. On examination, there were multiple hyperpigmented papules with stalks around the neck. Later that month, the veteran reported that the two boils on his scalp had healed, and he was doing well with skin tags which were excised on his last visit. He reported no further problems with the wart frozen on the left occipital scalp. Photographs submitted by the veteran in January 2002 reflect an active abdomen furuncle. Criteria Disability evaluations are based upon the average impairment of earning capacity as determined by the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2002). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole-recorded history, including service medical records. 38 C.F.R. §§ 4.2, 4.41 (2002). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2002); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. 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 (2002). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (2002). Prior to August 30, 2002, dermatophytosis was rated analogous to scars, disfigurement, etc., on the extent of constitutional symptoms, physical impairment. 38 C.F.R. § 4.119, DC 7813. By history and currently, the veteran's skin disability has been evaluated under DC 7806. Upon reviewing the veteran's symptoms, the Board finds that rating by analogy to the aforementioned code is both possible and appropriate under 38 C.F.R. § 4.20. Under the old criteria, DC 7806 provided that eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area warranted a 10 percent evaluation; eczema with constant exudation or itching, extensive lesions, or marked disfigurement warranted a 30 percent evaluation; and eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or which is exceptionally repugnant warranted a 50 percent evaluated. Under the new criteria, DC 7813 defines dermatophytosis as ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris). The provision provides that the disability is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC) 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. DC 7806 now provides a noncompensable rating for dermatitis or eczema over less than 5 percent of the entire body or less than 5 percent of the exposed area affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating requires dermatitis or eczema of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires dermatitis or eczema of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires dermatitis or eczema over more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Prior to August 30, 2002, disfiguring scars of the head, face, and neck (DC 7800) resulted in a noncompensable rating when slight. Moderate; disfiguring resulted in a 10 percent rating. For a 30 percent evaluation, disfiguring scars of the head, face, and neck had to be severe, especially if producing a marked and unsightly deformity of the eyelids, lips, or auri8cles. For a 50 percent rating, there had to be complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement. Under the new criteria, DC 7800 calls for a 10 percent rating with one characteristic of disfigurement. With visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, a 30 percent rating is warranted. With visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears, (auricle), cheeks, lips), or; with four or five characteristics of disfigurement, a 50 percent rating is warranted. With visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, an 80 percent rating is warranted. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2002). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West Supp 2002). Analysis Preliminary Matter: Duty to Assist The Board initially notes that there has been a significant change in the law during the pendency of this appeal. On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. 106-475, § 7(b), 114 Stat. 2096, 2099-2100 (2000), 38 U.S.C.A. § 5107 note (Effective and Applicability Provisions). Among other things, this law eliminates the concept of a well-grounded claim and supersedes the decision of the United States Court of Appeals for Veterans Claims (CAVC) in Morton v. West, 12 Vet. App. 477 (1999), withdrawn sub nom. Morton v. Gober, 14 Vet. App. 174 (2000) (per curiam order), which held that VA cannot assist in the development of a claim that is not well grounded. This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA, or filed before the date of enactment and not yet final as of that date. VCAA, Pub. L. No. 106-475, § 7(b), 114 Stat. 2096, 2099-2100 (2000). 38 U.S.C.A. § 5107 note (Effective and Applicability Provisions); see generally Holliday v. Principi, 14 Vet. App. 280 (2001); see also Karnas v. Derwinski, 1 Vet. App. 308 (1991). On August 29, 2001, the final regulations implementing the VCAA were published in the Federal Register. The portion of these regulations pertaining to the duty to notify and the duty to assist are also effective as of the date of the enactment of the VCAA, November 9, 2000. 66 Fed. Reg. 45, 620, 45, 630-45, 632 (August 29, 2001) (to be codified at 38 C.F.R. § 3.159). Where the law and regulations change while a case is pending, the version more favorable to the appellant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). The Board is of the opinion that the new duty to assist law has expanded VA's duty to assist (e.g., by providing specific and expanded provisions pertaining to the duty to notify), and is therefore more favorable to the veteran. Therefore, the amended duty to assist law applies. Id. In the case at hand, the Board is satisfied that the duty to notify and the duty to assist have been met under the new law. The duty to notify has been satisfied as the veteran has been provided with notice of the VCAA and what is required to substantiate his claim. Specifically, by letter dated in April 2001 the RO advised the veteran to submit additional evidence in support of his claim. He was advised that he could submit it himself or sufficiently identify such evidence, and if private in nature, complete a VA Form 21- 4242(s) so that VA could obtain it for him. Such notice sufficiently notified the veteran of what evidence could be obtained by whom and advised him of his responsibilities if he wanted such evidence to be obtained by VA. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Further, it is noted that a preliminary review of the record shows that VA has made reasonable efforts to obtain evidence necessary to substantiate the veteran's claim. The Board notes that a variety of extensive records have been associated with the claims folder including SMRs, postservice private and VA treatment and/or examination reports. The evidence of record provides a complete basis for addressing the merits of the veteran's claim as cited above at this time. Therefore, the duty to assist has been satisfied in this case. 38 U.S.C.A. § 5103A (West Supp. 2002); see also 66 Fed. Reg. 45,620, 45,630 (August 29, 2001) (to be codified at 38 C.F.R. § 3.159). In its many correspondences the RO has informed the veteran of the evidence he should obtain and which evidence it would retrieve as specified. The RO has in fact augmented the evidentiary record in accordance with the veteran's directives. See Quartuccio, supra. The RO, through its issuance of an April 2002 statement of the case, provide the criteria of the new law and indicated that it had considered his claim under such criteria. That is, he was provided with notice of the enactment of the VCAA of 2000, the regulations pertaining to the disability at issue, a rationale of the denial, and he was notified of his appellate rights. 38 U.S.C.A. § 5103 (West Supp. 2002); 38 C.F.R. § 3.159. As noted above, the RO has considered the veteran's claim under the new law. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to his claim is required to comply with the duty to assist him as mandated by 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2002). Having determined that the duty to assist has been satisfied, the Board turns to an evaluation of the veteran's claim on the merits. Increased Evaluation Fungus Infection, to Include Furunculitis The rating criteria for a rating in excess of 30 percent have not been met under either the old or amended criteria. The evidence fails to show that the veteran's clinical disability picture is productive of eczema with ulceration, or extensive exfoliation or crusting, and systemic or nervous manifestations, or that his skin disorder is exceptionally repugnant. (Old criteria in effect prior to August 30, 2002.) Nor does the evidence show that the veteran's fungus infection is productive of dermatitis or eczema of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; that systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. (New criteria in effect since August 30, 2002.) As the record demonstrates, this condition is manifested primarily by moderate to severe itching. There are seasonal flare-ups of symptoms, but the veteran's fungus infection is adequately compensated by the 30 percent rating in effect, under the old or new criteria. The clinical manifestations meeting the criteria that would warrant a rating in excess of 30 percent are not demonstrated. Scarring of the Head, Face, and Neck. As to the service-connected scarring of the head, face, and neck, the evidence fails to show that the veteran's clinical disability picture is productive of severe disfigurement, or marked and unsightly deformity of the eyelids, lips, or auricles. (Old criteria in effect prior to Aug. 30, 3002.) Nor is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears, (auricles), cheeks, lips), or; with two or three characteristics of disfigurement demonstrated. (New criteria, in effect from Aug. 30, 2002.) The evidence shows active flare-ups of furuncles and papules. The veteran uses hydrocortisone lotion and tetracycline for treatment, and recent evidence reflects excision or freezing. These manifestations, however, do not meet the criteria for a rating in excess of 10 percent. A VA examiner has described facial scarring as mild. Specifically, the record does not reflect that the requisite criteria for assignment of the next higher rating have not been met. As to the fungus infection to include furunculosis and the scarring of the head, face, and neck, the Board notes that although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for increased evaluations. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Extraschedular Evaluation The CAVC has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996). The Board, however, is still obligated to seek all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law or regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the CAVC clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1), or from reaching such conclusion on its own. In the veteran's case at hand, the Board notes that the while RO provided and discussed the criteria for assignment of extraschedular evaluations, it did not grant entitlement to an increased evaluation for either disability at issue on that basis. The CAVC has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the VA Under Secretary for Benefits or the Director of the VA Compensation and Pension Service might consider unusual or exceptional. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board does not find that the veteran's disability picture has been rendered unusual or exceptional in nature as to warrant referral of his case to the Director or Under Secretary for review for consideration of extraschedular evaluations for the disabilities at issue for which an increased compensation benefits are sought on appeal. The current schedular criteria adequately compensate the veteran for the current nature and extent of severity of the disabilities at issue. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER Entitlement to a rating in excess of 30 percent for fungus infection, to include furunculitis, is denied. Entitlement to a rating in excess of 10 percent for scarring of the head, face, and neck, is denied. ____________________________________________ RONALD R. BOSCH Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.