Citation Nr: 0314610 Decision Date: 07/02/03 Archive Date: 07/10/03 DOCKET NO. 98-03 459 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for hidradenitis suppurativa. 2. Entitlement to a total disability rating based on individual unemployability (TDIU rating). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The veteran had active service from April 1981 to May 1984. This matter comes before the Board of Veterans' Appeals (Board) partly from a May 1998 RO decision which denied a claim for a TDIU rating. In April 1999, the Board remanded this issue for further development. A July 2002 RO decision denied service connection for hidradenitis suppurativa, and a subsequent RO decision also denied service connection for hidradenitis suppurativa secondary to service-connected residuals of an excision of a pilonidal cyst; the veteran appeals this service connection issue as well. In January 2003, the veteran requested a Board videoconference hearing, but he withdrew his request in February 2003. The present Board decision addresses the issue of service connection for hidradenitis suppurativa. The issue of entitlement to a TDIU rating is the subject of the remand at the end of the decision. FINDINGS OF FACT The veteran's hidradenitis suppurativa began during active service. CONCLUSION OF LAW Hidradenitis suppurativa was incurred in active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran served on active duty in the Army from April 1981 to May 1984. His service medical records indicate that he was treated for skin problems. A December 1982 treatment entry noted that the veteran was seen with complaints of a tender nodule in the groin area for the previous week. The examiner reported that there was a tender nodule in the pubic hair area with no penile lesions. The assessment was folliculitis. A May 1983 consultation report noted that the veteran complained of a long history of pain in the foreskin area during intercourse. It was reported that there was no active infection or rash and that a circumcision would be scheduled. A March 1984 treatment entry noted that the veteran complained of soreness between the buttocks and a cyst. The examiner reported that there was a small cyst with soreness. The veteran underwent drainage of the cyst and the assessment was a cyst. The March 1984 objective examination report included a notation that the veteran's skin was normal. The veteran underwent a VA general medical examination in July 1984. The examiner noted that the veteran's skin was normal. Private treatment records dated from August 1989 to January 1997 refer to treatment for disorders other than skin conditions. VA treatment records dated from July 1995 to February 1997 show that the veteran was treated for skin conditions. An April 1996 treatment record reported that the veteran had a pilonidal sinus of the back. It was noted that the veteran underwent excision of the pilonidal cyst and the final diagnosis was a pilonidal cyst. An October 1996 entry indicated that the veteran complained of inner thigh pain and that he reported that he was getting hard protrusions in the right groin at intervals. The examiner noted that there were several pustules along the right groin. A March 1997 VA respiratory examination report noted that the veteran underwent a pilonidal cyst removal in April 1996. The diagnoses did not refer to skin conditions. Private treatment records dated from April 1997 to February 1998 show that the veteran continued to receive treatment for several disorders. VA treatment records dated from April 1997 to March 1998 reflect treatment for disorders including hidradenitis suppurativa. An April 1997 entry noted that the veteran had hidradenitis in the groin area which was made worse with standing, walking, and heat. A May 1997 entry noted that the veteran had a history of hidradenitis. A March 1998 entry also related an impression of hidradenitis suppurativa. The veteran underwent a VA cardiovascular, respiratory, and dermatological, examination in March 1998. He reported that he had pilonidal cyst that was diagnosed in 1983. The veteran stated that he had a lot of discharge and pain and that he underwent surgical treatment. He indicated that a cyst recurred in 1996 and that he had to undergo surgery. The veteran also reported that he had been having a lot of complaints with his skin, especially in the groin area and under the armpits. He noted that he had noticed swelling in those areas with discharge and that he had been diagnosed with hidradenitis suppurativa. The examiner reported that there was hyperpigmentation in both axillae and in the groin with only one cystic to firm swelling area palpable in the right groin. The examiner stated that no discharge was noted. The diagnoses included history of pilonidal cyst with excision in 1980 and again in 1996. It was also noted that the veteran had been diagnosed with hidradenitis suppurativa. In April 1998, the RO granted service connection and a noncompensable rating for postoperative residuals of an excision of a pilonidal cyst. VA treatment records dated from April 1998 to March 1999 show that the veteran was treated for multiple disorders including skin conditions. An April 1998 treatment entry noted that the veteran had nine infected sites with furunculosis around the lower trunk and thighs including an infected pilonidal cyst. A July 1998 entry noted that the veteran had a history of hidradenitis deprevia. Private treatment records dated from October 1998 to May 1999 reflect that the veteran continued to receive treatment. A May 1999 entry related an assessment which included pilonidal cyst, furunculosis, and hidradenitis. An April 1999 Board decision increased the rating for the veteran's service-connected postoperative residuals of an excision of a pilonidal cyst from noncompensable (0 percent) to 10 percent. VA records dated from January 2000 to April 2000 reflect continued treatment. The veteran underwent a VA general medical examination in May 2000. He reported that in the military he had some cysts on the back of his neck, groin, and rectum. He stated that he was given antibiotics which did help sometimes. The veteran also noted that he had a pilonidal cyst in approximately 1982 which was later drained in March 1984. He indicated that the cysts on his skin had become worse since he left the service. The examiner reported that the veteran had some areas on the back of the neck that looked like they might have been pseudofolliculitis barbae. The examiner also noted that the veteran had some areas on the lower half of his abdomen which looked like they may have been infected in the past and that there were presently enormous pores left in the skin. It was noted that the veteran also had very dark, thickened skin in- between his legs and that there was no evidence of any present infection in such areas. The examiner indicated that the only scars were the discoloration and thickness in the skin between the veteran's thighs. There was no tissues loss, inflammation, edema, or keloid formation. The examiner reported that examination of the pilonidal cyst area showed a 2 and 1/2 inch scar and a deeper opening with an aperture which was approximately 3/8 of an inch. It was noted that there appeared to be slight crusting from drainage from the aperture. The diagnoses included icthyosis of the groin area (which could be healed hidradenitis suppurativum) and pilonidal cyst, status post multiple drainage and multiple surgical procedures, with persistent drainage. Private treatment records dated from June 2000 to October 2000 show treatment for skin disorders including hidradenitis suppurativa. VA treatment records dated from June 2000 to October 2001 show continued treatment. An April 2000 entry noted an assessment of chronic intermittent recurrent cutaneous soft tissue infections (abscesses, folliculitis, and furuncles) of unclear etiology and most likely associated with obesity and poor hygiene. The veteran underwent a dermatological examination in November 2002. It was noted that the claims folder had been reviewed, and the examiner discussed the veteran's medical history in detail. The examiner reported that there were multiple acrochordons on the veteran's neck, body, and legs. The examiner indicated that the veteran had pseudoacanthosis nigricans of the areas of friction such as his neck, underarms, and in the groin areas. There were old scars in the axillae, but no current draining lesions in those areas. The examiner noted that in the rub areas of the inner thighs, there were multiple old healed lesions with nodular scars present from his previous disease with no active lesions at present. The examiner indicated that the gluteal crease showed a pilonidal dimple and a scar from the veteran's previous treatments. It was reported that there was an area in the suprapubic area where the crease of the panus was showing evidence of prior disease with scarring and some inflammatory nodules. The examiner stated that the veteran also had mild tinea pedis. The diagnoses were old pilonidal cyst, postsurgical; hidradenitis suppurativa; mild tinea pedis; and morbid obesity, complicated by asthma, hypertension, and diabetes. The examiner commented that a pilonidal sinus was not directly related to hidradenitis suppurativa and that such was a developmental condition where there was retraction of the tissue in the gluteal crease. The examiner noted that many people had pilonidal sinuses and cysts who did not have hidradenitis suppurativa, so the two conditions were not directly related. It was reported that the lesions that were currently present were certainly compatible with hidradenitis suppurativa because those lesions typically arose where the apocrine sweat glands were located. The examiner indicated that the only entry that would establish the possibility for service connection for hidradenitis would be in December 1982. The examiner noted that, unfortunately, there was very little information in that note other than to describe the location of the tender nodule being in he pubic area. It was reported that the note in March 1984, which indicated that the veteran had a cyst, would pretty much establish service connection for a pilonidal. The examiner remarked that hidradenitis was not caused by or secondary to the service- connected pilonidal cyst. However, the examiner stated that if it was assumed that the author of the December 1982 note was correct, such may have been the beginning of hidradenitis suppurativa, which had been complicated by the veteran's morbid obesity and the constant friction and rubbing of his skin in the apposed surfaces. II. Analysis Through correspondence, the rating decision, the statement of the case, and the supplemental statement of the case, the veteran has been informed of the evidence necessary to substantiate his claim. Identified relevant medical records have been obtained, and a VA examinations have been provided. The Board finds that the notice and duty to assist provisions of the law have been satisfied. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Service connection may be granted for a disability due to a disease or injury which was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131; 38 C.F.R. § 3.303. Secondary service connection may be granted for a disability which is proximately due to or the result of an established service-connected condition. 38 C.F.R. § 3.310. Secondary service connection may be found when an established service- connected condition aggravates a non-service-connected disability. When there is such aggravation of a non-service- connected disability, which is proximately due to or the result of a service-connected condition, the veteran will be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet.App. 439 (1995). The veteran's service medical records from his April 1981 to May 1984 active duty, show that in December 1982 he was seen with complaints of a tender nodule in the pubic hair area with no penile lesions. The assessment was folliculitis. Additionally, a March 1984 treatment entry noted that the veteran complained of soreness and a cyst between the buttocks. The veteran underwent drainage of the cyst and the assessment referred a cyst. The Board notes that the veteran is already service-connected for postoperative residuals of an excision of a pilonidal cyst. Post-service medical records indicate that the veteran was treated for variously diagnosed skin conditions. An October 1996 VA treatment entry, years after the veteran's separation from service, noted that he had several pustules along the right groin. The first medical evidence of hidradenitis suppurativa was in April 1997. A March 1998 VA cardiovascular, respiratory, and dermatological examination report related diagnoses including hidradenitis suppurativa and a May 2000 VA general medical examination report noted diagnoses which included icthyosis of the groin area (which could be healed hidradenitis suppurativum). At the November 2002 VA dermatological examination, the examiner reviewed the claims folder. Diagnoses, at that time, included hidradenitis suppurativa. The examiner commented that the only entry that would establish the possibility for service connection for hidradenitis was the December 1982 entry (noted above), but that there was very little information in that note other than to describe the location of a tender nodule in the pubic area. The examiner stated that if it was assumed that the author of the December 1982 note was correct, such might have been the beginning of the veteran's hidradenitis suppurativa. After reviewing all the evidence, including the recent VA examination opinion which is favorable to the veteran, the Board finds that the veteran's current hidradenitis suppurativa began during his active duty. The condition was incurred in service, and service connection is warranted. As the Board has granted service connection on a direct basis, it need not address secondary service connection in this matter. The benefit-of-the-doubt rule has been applied in making this decision. 38 U.S.C.A. § 5107(b). ORDER Service connection for hidradenitis suppurativa is granted. REMAND The remaining issue on appeal is entitlement to a TDIU rating based on service-connected disabilities. As discussed above, the Board has granted service connection for hidradenitis suppurativa. Therefore, this case must be remanded to the RO so that it may establish a percentage disability rating for hidradenitis suppurativa and then reevaluate the TDIU claim The Board also notes that at the November 2002 VA dermatological examination, it was noted that the veteran was receiving disability benefits from the Social Security Administration (SSA). The veteran has also reported that he was receiving such benefits in statements on appeal, including a statement dated in May 1999. As the SSA records may be relevant to the veteran's claim, they should be obtained. See Murincsak v. Derwinski, 2 Vet.App. 363 (1992). Accordingly, the case is remanded for the following: 1. The RO should contact the SSA and obtain copies of all medical and other records considered by that agency in awarding disability benefits, as well as copies of all related SSA decisions. 2. The RO should establish a percentage disability rating for the service- connected hidradenitis suppurativa. 3. Thereafter, the RO should review the claim for entitlement to a TDIU rating. If the claim is denied, the RO should issue a supplemental statement of the case to the veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ L. W. TOBIN 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.