Citation Nr: 1101657 Decision Date: 01/14/11 Archive Date: 01/20/11 DOCKET NO. 06-10 981A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating greater than 10 percent for hidradenitis suppurativa , left axillary, with residual scarring and cysts. 2. Entitlement to a rating greater than 10 percent for hidradenitis suppurativa , right axillary, with residual scarring and cysts. 3. Entitlement to a rating greater than 10 percent for hidradenitis suppurativa , right perineal area, with residual scarring and cysts. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S.K.C. Boyce, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1987 to December 1987 and from November 1989 to October 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which denied entitlement to a rating in excess of 10 percent for hidradenitis suppurativa . In February 2009, the RO issued a second rating decision that assigned three separate 10 percent disability ratings for the Veteran's service-connected hidradenitis suppurativa under an alternate diagnostic code for a combined disability rating of 30 percent. FINDING OF FACT The Veteran's service-connected hidradenitis suppurativa requires near-constant systemic treatment with antibiotics. CONCLUSION OF LAW The criteria for a 60 percent disability rating for service- connected hidradenitis suppurativa have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, Diagnostic Codes 7806, 7820 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 and Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir., 2004). An RO letter dated in December 2004 informed the Veteran of all three elements required by 38 C.F.R. § 3.159(b), as stated above. Regarding the duty to assist, the RO has obtained the Veteran's service records, VA treatment records, and private treatment records. The Veteran was provided with VA examinations in December 2004 and December 2008. The Veteran's representative contends that the Veteran should be afforded an additional examination because the most recent examination is more than two years old and the Veteran's skin disorder "seems to be an ever changing condition." When the record does not adequately reveal the current state of a Veteran's disability, the fulfillment of the statutory duty to assist by the Department of Veterans Affairs (VA) requires a thorough and contemporaneous medical examination. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). VA must schedule a reexamination where the evidence indicates that there has been a material change in a disability or that the current rating may be incorrect. 38 C.F.R. § 3.327. The Court of Appeals for Veteran's Claims (Court) has held that an examination that is nearly two years old is too remote to be contemporaneous where the appellant submitted evidence that the disability had worsened. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). However, mere passage of time does not trigger VA's duty to provide an additional medical examination unless there is an allegation of deficiency in the record. Palczewski, 21 Vet. App. at 182-83. Here, the Veteran's representative does not allege that her condition has worsened; rather, the allegation is that the Veteran's condition is variable and subject to intermittent flare-ups. However, there is a substantial amount of evidence in the record demonstrating the frequency and severity of these flare-ups, there is no evidence showing that the Veteran's condition has increased in severity since the December 2008 VA examination, and the Veteran has not alleged that her condition has worsened. Neither the Veteran nor her representative allege that the examination was inadequate, and the December 2008 VA examiner thoroughly reviewed the Veteran's medical history and conducted a skin examination. As such, VA's duty to provide a thorough and contemporaneous medical examination has been met. The duty to assist has been satisfied as there is no reasonable possibility that any further assistance to the Veteran by VA would serve any useful purpose. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); Canlas v. Nicholson, 21 Vet. App. 312 (2007); Forcier v. Nicholson, 19 Vet. App. 414 (2006); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that there is no basis for a remand when no benefit would flow to the Veteran). Therefore, because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Increased Rating Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Although the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection 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). A recent decision of the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. Consequently, the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so, although the Board may not ignore such distinctions where they appear in the medical record. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam); see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may only consider independent medical evidence in support of its findings and may not substitute its own medical opinion). The Veteran was initially granted service connection for a scar under the left arm, residuals of cyst removal, in a March 1997 rating decision. She was assigned a noncompensable disability rating under 38 C.F.R. § 4.118, Diagnostic Code 7805, effective October 20, 1996. In June 2000, the Veteran filed a claim seeking service connection for a bacterial infection that caused painful cysts and boils. In June 2000, the RO informed the Veteran that she already been granted service connection for residuals of cyst removal and interpreted her claim as a claim for an increased rating for her service-connected skin condition. In October 2000, the RO issued a rating decision characterizing the Veteran's disability as recurrent hidradenitis suppurativa, status post-multiple cyst excisions with axillary scarring, and increased her rating to 10 percent under 38 C.F.R. § 4.118, Diagnostic Code 7806. In November 2004, the Veteran submitted another claim for an increased rating for her service-connected hidradenitis suppurativa, claiming that her symptoms had worsened such that a higher evaluation was warranted. In a February 2005 rating decision, the RO denied her claim for a higher rating. Subsequently, in February 2009, the RO issued the three separate 10 percent ratings listed on the title page of this decision under Diagnostic Code 7804, resulting in a combined rating of 30 percent due to the application of the regulations concerning the calculation of a bilateral factor. See 38 C.F.R. § 4.26. The Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. The Board must explain in its decision the diagnostic code under which the claim is evaluated, and explain any inconsistencies that result from shifting diagnostic codes throughout the adjudication process in order to avoid confusion as to the standards and criteria used to evaluate the claim. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Where an evaluation of a specific disability is reduced, but the amount of compensation is not reduced because of a simultaneous increase in the evaluation of one or more other disabilities, the regulations pertaining to reductions under 3.105(3) do not apply. See Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007); VAOPGCPREC 71-91 (Nov. 7, 1991). Furthermore, in general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings and then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." See 38 U.S.C.A. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The Board also notes that the Veteran initially filed her claim for an increased rating for hidradenitis suppurativa in November 2004, and that the schedular criteria by which skin disabilities are rated were revised, effective October 23, 2008, during the pendency of her appeal. See 73 Fed. Reg. 54710 (October 23, 2008); see also 38 C.F.R. § 4.118, DCs 7800 to 7805 (2010). However, because the amended regulations apply only to claims received by VA on or after October 23, 2008, that version of the scar regulations will not be applied here. See id. Under 38 C.F.R. § 4.118, Diagnostic Code 7820, infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal and parasitic diseases) are rated as disfigurement of the head, face, or neck (DC 7800); scars (DC 7801, 7802, 7803, 7804, or 7805; or dermatitis (DC 7806), depending on the predominant disability. Diagnostic Codes 7800 through 7803 are not applicable in this case as the Veteran's hidradenitis suppurativa , as discussed below, does not affect her head, face, or neck; and any resulting scars are not deep, do not cause limited motion; are not 144 square inches or greater, and are not unstable. The Veteran's disability is currently rated under Diagnostic Code 7804. Under 38 C.F.R. § 4.118, DC 7804, a 10 percent rating is available for superficial scars that are painful on examination. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7804, Note (1). Initially, the Veteran's disability was rated under Diagnostic Code 7805. Under 7805, scars are to be rated on the limitation of function of the affected part. The Veteran's disability has also been previously rated by analogy to 38 C.F.R. § 4.118, Diagnostic Code 7806, which is used to rate dermatitis and eczema. Under Diagnostic Code 7806, a 60 percent rating is assigned for dermatitis or eczema when more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or when systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. At the time the Veteran filed her claim for an increased rating for her service-connected hidradenitis suppurativa in November 2004, she submitted statements from her fiancé and mother that detailed both her symptoms and the effect that her disease has on her life. Her fiancé asserted that the Veteran had a cyst the size of a golf ball in each underarm, which caused her severe pain and prevented her from sleeping or lowering her arms to her sides, impairing her ability to dress. He asserted that after her cysts were surgically removed, she required continuing post- surgical care, pain medication, and antibiotics. The Veteran missed a week of work following the surgery. The Veteran's fiancé describes this incident as the most severe incident the Veteran experienced that he had witnessed to that date, although there had been others. The Veteran's mother asserted that the Veteran had undergone 10 surgeries to remove cysts from her underarms, and that these episodes worsened over time. At the time of her statement, the episodes were occurring once every three months instead of once or twice a year. The Veteran's mother also asserted that her daughter's condition was active during her December 2004 VA examination. In December 2004, the VA examiner was asked to evaluate the Veteran for scars and skin diseases. The Veteran provided a history of her disease. She explained that her skin lesions presented in an episodic fashion both historically and currently, and that she had experienced abscesses of the right and left underarms every year since her discharge from service. She asserted that the abscess formations were intermittent, but not progressive. The examination notes indicate that the Veteran was not taking any medication, including antibiotics, at the time of the examination. She reported that her last abscess began three weeks prior, that it had burst approximately two weeks prior, and that she currently had a dry sterile dressing on the abscess site. She also indicated the presence of a second abscess inferior to the first which was still in the early phase of formation. The Veteran indicated that both of these sites were painful. She also reported having missed 15 days of work over the last 12 months due to the abscesses and complications. The Veteran also asserted that she had residual scar formation from the she abscesses experienced in the military. She recalled eleven cysts that were lanced during her active service, six on the left and five on the right. The residual scars were asymptomatic, except for one scar in the left axillary region which was moderately tender but stable. This scar measured 2 centimeters by 1.5 centimeters. It was not attached to the underlying tissue, was not inflamed, and did not cause any limitation of function. There was no keloid formation, ulceration, breakdown of the skin, or induration. Upon examination, the Veteran's body was void of any dermatosis in any place other than the right and left axillary region. There was no acne, chloracne, alopecia, or hyperhidrosis. The left axilla was unremarkable for active lesions. There was a well-healed 5.5 centimeter scar in the mid-axial area that measured 3 to 4 millimeters in width. The lateral aspect of the scar was elevated, and the elevated portion was tender to palpitation. The right axilla was remarkable for a 1.5 centimeter elliptical wound with a maximum width of 5 millimeters. There was scant amount of greenish discharge from the wound. The wound was seen to be in the healing phase of the abscess scenario described by the Veteran. There was another area inferior to the wound that measured 2 centimeters by 1 centimeter and was somewhat raised and significantly tender. There was also a well-healed scar measuring 2 centimeters by 1.5 centimeters on the superior aspect of the right axilla that was mildly tender to palpitation. In October 2005, the Veteran submitted private treatment records, dating from May 2003 to December 2004, along with a statement asserting that, contrary to the RO's February 2005 decision and the conclusion reached by the December 2004 VA examiner, she had been taking antibiotics as prescribed by her doctor, but they have not been effective at alleviating her symptoms. She attributed the discrepancy to a misunderstanding between her and the examiner regarding the medical history she provided at the time of the examination. This assertion is supported by her private treatment records, which show that the Veteran was taking antibiotics to treat an abscess that has been present for five days in May 2003 and that she was prescribed antibiotics for an additional outbreak in December 2004. The private medical records submitted by the Veteran also show that she had cysts removed in May 2003 and June 2003, and that, at that time, she had a prior history of six to eight past procedures to excise and drain the abscesses. A referral letter from December 2004 shows that the Veteran consulted with another private physician about the possibility of surgical intervention. At that time, the Veteran had an abscess in the left axilla that spontaneously drained the day before. Upon examination, she showed obvious bilateral axillary hidradenitis and a small abscess that spontaneously drained on the left side. There were multiple old sinus tracts on the left side. On the right side, she had a recent opened tract which was closing. The Veteran reported continuing treatment with antibiotics and was not interested in pursuing surgical intervention at that time. Her primary physician's notes from the same date show that the Veteran complained of moderately severe swelling with pain under both arms with redness and tenderness without drainage. The symptoms had started two weeks prior and were worsening. The notes also indicated that the Veteran had recurrent cysts in the past, beginning during her active military service. No alleviating factors were noted. The Veteran reported using warm compresses to treat the cysts. Upon examination, she had a 2 centimeter area of induration in the right axilla with surrounding erythema and some fluctulance in the center. The notes indicate that the Veteran would need a surgeon to drain the cysts as they were too large to treat in the office. As noted above, an antibiotic was prescribed. Additional private treatment records were received in August 2009. The records dated prior to May 2008 are consistent with the records already received. In May 2008, the Veteran first complained of blistered and painful lesions in the genital area lasting about one week per episode. Examination showed small open lesions on the upper thighs bilaterally. The Veteran was tested for herpes and the preliminary and final results received in June 2008 were negative. At that time the Veteran was still experiencing boil-like lesions to the groin area. In December 2008 the Veteran was provided with a second VA examination. The examiner described the course of her hidradenitis suppurativa as intermittent with recurrent cysts that occasionally drain on their own. The examiner also found that the Veteran's hidradenitis suppurativa was treated with antibiotics and by draining the cysts, and noted that this systemic treatment was near constant over the last 12 months. The Veteran reported symptomatic sites of the right and left axilla and the perineal area, with symptoms recurring monthly. The growths tended to increase in size from a papule to a cyst about the size of a half-dollar. She asserted that they were always tender but increased in painfulness as the cysts enlarged. They were also noted to cause pain with motion. Upon examination, the examiner determined that no exposed areas were affected, and that the total body area affected was less than five percent. Two half inch scars were found in the right axilla, tender to palpitation and erythemous, and one half inch scar was found in the left axilla, tender to palpitation. The Veteran also had a papule present in the left axilla. On the right side of the perineal area, the Veteran had two quarter-inch scars, mildly tender to palpitation and an open lesion with purulent exudates. The open lesion was erythemous and severely tender. The Veteran described it as a papule that has just "popped." The examiner also diagnosed the Veteran with eczema. The Veteran stated that she began to have a rash on her left calf over the past six months. Since then, it has increased in size and become chronic. The condition is treated with over the counter soaps and lotions. In December 2008, the Veteran's private physician asserted in a statement that the Veteran still suffers from hidradenitis suppurativa with recurrent abscesses in multiple locations. In the same month, the Veteran also submitted a statement regarding the effects of her disability on her employment and her paperwork regarding requested under the Family Medical and Leave Act (FMLA) for her condition. She also submitted a statement from her husband testifying to the pain experienced by the Veteran, the degree of assistance required by the Veteran (e.g. help dressing due to limited arm movement), and the progression of her disease. Specifically, he asserted that the Veteran's condition had spread from her underarms to her groin area. This statement is supported by additional medical evidence submitted by the Veteran showing the appearance of blistered, painful lesions in the external genital area, as well as the VA examiner's findings. The Veteran also submitted a treatise describing the nature of her conditions and its manifestations. Private treatment records from December 2008 show that the Veteran had a follow-up appointment. The diagnoses provided include hidradenitis and dermatitis. The notes show that the Veteran complained of recurrent abscesses in the axiallae only in the past, but now, in recent months, has begun having symptoms in the groin area and also that she complained of discoloration around the left ankle with mild dryness and itching. Treatment notes from July 2009 show that the Veteran had no new rashes at that time. It was noted that her hidradenitis suppurativa mainly affected her groin area. The Board finds that the lay statements of record from the Veteran, her mother, and her husband are credible as they are consistent with the medical evidence of record. Furthermore, all three lay witnesses are competent to testify to the Veteran's pain or, in the case of her husband and mother, her reports of pain; her apparent physical limitations; the frequency of her symptoms; and whether she was prescribed and/or observed to be taking antibiotics. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). Under 38 C.F.R. § 4.118, Diagnostic Code 7806, the Veteran is entitled to a 60 percent rating if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. According to the Veteran's treatment records from May 2003, she was being treated with antibiotics at that time. Both the Veteran and her husband submitted statements attesting to that fact. While the December 2004 VA examiner noted that the Veteran was not taking antibiotics, the Veteran submitting a subsequent statement clarifying her conversation with the VA examiner. In the statement, she asserted that she had become immune to certain antibiotics prescribed by her doctor such that they provided no relief, but that her physician continued to prescribe them in hopes that one would prove effective. This statement is supposed by the private treatment records submitted by the Veteran showing treatment with antibiotics dated from the same time period as the December 2004 VA examination. At the December 2008 VA examination, the examiner noted that the Veteran treated her hidradenitis suppurativa with antibiotics on a monthly basis, that the duration of use over the last 12 months was near-constant, and that the type of treatment was systemic. The Board notes that Diagnostic Code 7806 does not require that the Veteran receive corticosteroids or other immunosuppressive drugs exclusively, but, rather, that the precise language of the regulation indicates that the systemic treatment required must only be similar to the examples provided: corticosteroids or other immunosuppressive drugs. This is shown by the use of the phrase "such as," which renders the conditions listed examples of systemic treatment as opposed to a conclusive list. As such, resolving any doubt in favor of the Veteran, the Board finds that constant systemic therapy has been required over the previous 12 month period such that the Veteran is entitled to a 60 percent rating for her service-connected hidradenitis suppurativa . This is the maximum rating allowable under this Diagnostic Code. Furthermore, the Board finds that the Veteran's symptoms have most closely approximated the symptoms described under the criteria for a 60 percent rating under Diagnostic Code 7806 throughout the appellate period, such that is not necessary to "stage" the Veteran's rating. See Hart, 21 Vet. App. at 509- 10. Therefore, although the evidence of record shows that the Veteran's symptoms became more severe in May 2008 when her skin condition began to affect an additional area of the body, she was nevertheless entitled to the highest rating allowable under Diagnostic Code 7806 before that time. The Board has considered the applicability of Diagnostic Codes 7804 and 7805, but 7804 allows a maximum disability rating of 30 percent only, such that applying this code would not lead to a higher rating for the Veteran. Diagnostic Code 7805 directs the Board to apply an appropriate diagnostic code to disabling effects not considered by Diagnostic Codes 7800-7804, which is precisely what the Board has done in applying Diagnostic Code 7806, such that there would be no difference in result by applying Diagnostic Code 7805 over 7806. The Board has also considered whether the Veteran is entitled to a higher rating under DC 7828, which rates acne. Under DC 7828, a 10 percent rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or deep acne other than on the face and neck; and a 30 percent rating is assigned for deep acne affecting 40 percent or more of the face and neck. 38 C.F.R. § 4.119, DC 7828. However, a rating in excess of 30 percent is not available under DC 7828 such that the application of this code could not result in a higher evaluation for the Veteran. Lastly, the Board finds that the Veteran is not entitled to a separate rating under any of the alternative codes discussed as this would violate the rule against pyramiding. Esteban, 6 Vet. App. at 260. The Board finds that all the codes considered are significantly concerned with the degree of cosmetic impairment suffered by the Veteran, as evidenced by the considerable effort taken to require a precise determination regarding the size of any skin disfigurement and the extra consideration given to any skin disfigurement of the face. See 38 C.F.R. § 4.114 Diagnostic Codes 7804, 7806, 7828; See Esteban, 6 Vet. App. at 260 (holding that separate ratings may only be awarded where none of the symptomatology for one ratable conditions is duplicative or overlapping with another ratable condition); see also Perry v. Nicholson, 23 Vet. App. 502 (2007) (memorandum decision). The overlapping symptomatology evidenced in these Diagnostic Codes is also demonstrated by the language of Diagnostic Codes 7806 and 7828, which grant VA the option rating the skin disability under the rating codes for scars, depending on the predominant disability. Id. Furthermore, Diagnostic Code 7820 also directs VA to rate infections of the skin not listed elsewhere as disfigurement of the head face or neck, scars, or dermatitis, such that the plain language of the regulation acknowledges that all of the statutes indicated compensate the Veteran for the same manifestation of the same disability. Therefore, the Veteran is not entitled to separate disability ratings for scars where her condition is rated under Diagnostic Codes 7820 and 7806. The rating schedule represents as far as is practicable the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's hidradenitis suppurativa are not shown to cause any impairment that is not already contemplated by the rating criteria. Although the Veteran has shown that she has missed work due to her condition, Diagnostic Code 7806 contemplates the type of continuous therapy and disfigurement that can significantly interfere with daily life, including periods of missed work. Therefore, the Board finds that the rating criteria reasonably describe her disability and referral for consideration of an extraschedular rating is not warranted in this case. ORDER Entitlement to a disability rating of 60 percent, but not higher, for service-connected hidradenitis suppurativa is granted, subject to the statutes and regulations governing the payment of monetary benefits. ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs