Citation Nr: 1110574 Decision Date: 03/16/11 Archive Date: 03/30/11 DOCKET NO. 08-16 793 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a skin condition. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Vavrina, Counsel INTRODUCTION The Veteran served on active duty from May 1953 to January 1955. This matter came to the Board of Veterans' Appeals (Board) initially on appeal from a September 2007 rating decision in which the RO reopened the Veteran's claim for service connection for a skin condition and then denied the claim on the merits. In November 2009, the Board determined that new and material evidence had been received and reopened the Veteran's claim for service connection for a skin condition, remanding the issue back for additional development and de novo adjudication. The case is now before the Board for further appellate consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Although the Veteran has been diagnosed with folliculitis and statis dermatitis, there is no competent medical evidence showing that any skin condition had its onset in service or within one year after his discharge from active duty or is otherwise related to service; the only probative medical evidence of record is against the Veteran's claim. CONCLUSION OF LAW The criteria for service connection for a skin condition have not been met. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and 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. See 73 Fed. Reg. 23,353-356 (Apr. 30, 2008). VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. Collectively, letters dated in July 2007 and April 2010 provided notice to the Veteran regarding what information and evidence was needed to substantiate his claim for service connection, as well as what information and evidence must be submitted by the Veteran, what information and evidence would be obtained by VA, and how a disability rating and an effective date is established consistent with the holdings in Pelegrini and Dingess. After the Veteran and his representative were afforded opportunity to respond to the notice identified above, the January 2011 supplemental statement of the case (SSOC) reflects readjudication of the service-connection claim on appeal. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters decided on appeal. Pertinent medical evidence associated with the claims file consists of available private and VA medical records, and an October 2010 VA examination report. Also of record and considered in connection with the appeal are various articles and written statements provided by the Veteran and his representative, on his behalf. The Board's November 2009 remand acknowledged that the Veteran's service treatment records are unavailable and are presumed destroyed by a fire at the National Personnel Records Center (NPRC) in 1973, but instructed VA to make another attempt to locate them and to obtain the Veteran's Official Military Personnel File (OMPF) and associate such records with the claims file. In an April 2010 response, the NPRC indicated that there were no service treatment records or Surgeon General Office (SGO) records and supplied the Veteran's OMPF, which has been associated with the record. The Board observes that, where records are unavailable, "VA has no duty to seek to obtain that which does not exist." Counts v. Brown, 6 Vet. App. 473, 477 (1994); Porter v. Brown, 5 Vet. App. 233, 237 (1993). In response to an April 2010 letter asking the Veteran to identify healthcare providers who have treated him for a skin condition, the Veteran only identified the Durham VA Medical Center (VAMC), indicating that he had no additional evidence. Additional VA medical records have been associated with the record. The AMC issued an SSOC in January 2011. Given the foregoing, the Board finds that VA has substantially complied with the Board's prior remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). Under these circumstances, the Board concludes that the Veteran has been accorded ample opportunity to present evidence and argument in support of the matter decided on appeal. II. Analysis Initially, as noted above, information received from the NPRC indicates that the Veteran's service treatment records and SGO records are not available due to possible destruction during a fire at the NPRC, in St. Louis, Missouri, in July 1973. The Board is aware that in such situations, it has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis has been undertaken with the heightened obligation set forth in O'Hare in mind. Service connection will be granted if it is shown that a veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as scleroderma, which are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran has never been diagnosed with scleroderma; therefore presumptive service connection is not for consideration in this case. When a veteran seeks service connection for a disability, due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which he served, his military records, and all pertinent medical and lay evidence. 38 C.F.R. § 3.303(a). Although the Veteran served during the Korean War period, he did not serve in combat, so the provisions of 38 U.S.C.A. § 1154(b) (West 2002) do not apply. After a full review of the record, including the medical evidence and statements made by the Veteran and his representative on his behalf, the Board finds that service connection for a skin condition is not warranted. During the pendency of this appeal, the Veteran was diagnosed with folliculitis and statis dermatitis upon VA skin examination in October 2010. In McClain v. Nicholson, 21 Vet. App. 319, 323 (2007), the U. S. Court of Appeals for Veterans Claims (Court) held that a Board finding that veteran had disability "at some point during the processing of his claim," satisfied service connection requirement for manifestation of current disability. Therefore, the Board will assume for argument's sake that the Veteran has a skin condition. Thus, the question now is whether there is sufficient evidence of a nexus to service. During a July 2004 Decision Review Officer (DRO) hearing, the Veteran testified that about February 1954, he initially had warts on his arm that swelled up and for which he was given shots of penicillin. Then a month later he got warts on his hands and he had them burned off. The Veteran stated that the doctor told him to keep his hands out of water for 24 hours, but his sergeant made him wash windows in about 30 degrees below zero degree weather and he felt that the tingling and numbness in his hands is related to this. He testified that, between 1956 and 1980, he broke out in scabs and that they operated on his back; that he had four done by a private doctor and then a couple of them taken off by VA, two of which were frozen off and one of which was shaved off, but the Veteran did not know what kind of lesions they were. The Veteran also stated that he complained of breaking out in scabs on his scalp and that his VA healthcare provider recommended that he wash his hair with a special kind of shampoo. More recently, he indicated that he has been given medication, a lotion, for an itch. The Veteran testified that records for the private doctor who had treated him between 1956 and 1980 are no longer available. In a June 2007 statement, a former comrade indicated that the Veteran had a severe rash on his neck and scalp in the winter of 1954 when he was stationed in Alaska and that, when asked about this condition, the Veteran stated that he had been seen by a doctor and had been given a penicillin shot. The Veteran's service personnel records confirm that he served as a stevedore and had been stationed in Alaska. In a January 1979 DD Form 293, Application for Review of Discharge or Dismissal from the Armed Forces of the United States, the Veteran stated that, when he first joined the Army, he was proud of his uniform and happy to be a soldier. But, while stationed in Alaska, he became disenchanted with service life mainly due to the depressing conditions at Whittier, Alaska. He added: Working conditions were frequently bad due to the climate. There was very little to do in the way of entertainment during off duty hours. Living conditions were unruly and crowded. Also, [his] superiors didn't seem to care about the way men were treated. The Veteran gave as an example the incident about the removal of a number of warts on his right hand at the base hospital and his first sergeant putting him to work washing windows in freezing temperatures. He does not allege and his service records confirm that he did not serve in combat or overseas during his entire period of service. A November 1995 VA ultrasound of the scrotum revealed a tiny left epididymal cyst. In December 1995, the Veteran was treated at the VAMC for complaints of cysts on his back, reporting that he had had two excised before but they had returned. In addition, he had a new one which bothered him when lying in bed. On examination, he had two sebaceous cysts on the mid-back and one on the right shoulder that were removed on December 15, 1995. The diagnosis on the pathology report was epidermal inclusion cyst. In May 1999, the Veteran was seen in the VA dermatology clinic for a 0.8-cm round epidermal inclusion cyst on his trunk, which was removed via shave biopsy. The diagnosis on the pathology report was epidermoid cyst. During a November 2005 VA dermatology consult, the Veteran presented for evaluation of a rash. He reported that he first developed the rash about six years ago, which he believed was temporally related to his enrollment in a shingles vaccine trial. Individual lesions started as whiteheads, then turn into red bumps that resolve in three months, often leaving behind brown discoloration. Lesions were painful but did not itch. He denied trying any medications for his condition. The Veteran had no other skin complaints and no personal or family history of skin cancer. He also had no family history of dermatological conditions or cutaneous malignancies. His scalp, face, neck, chest, back, abdomen, upper and lower extremities, hands, buttocks, genitalia, and nails were examined. Erythematous papulopustular eruption, most concentrated on bilateral medial thighs, but also with scattered lesions involving back, chest, abdomen and arms, were found. Several brown, hyperpigmented macules and papules consistent with post-inflammatory hyperpigmentation were found, particularly on thighs. There also was an erythematous papule on the left shoulder overlying the medial clavicle/neck area with overlying stuck-on, brown verrucous papule and a brown, warty papule having a "stuck-on" appearance on the mid-back. The assessment was folliculitis that was unrelated to prior shingles vaccine or history of lupus anticoagulant. He was give Benzac wash to use with daily shower. The left shoulder lesion was suspected to be an acneiform lesion adjacent to a seborrheic keratosis. During a January 2005 VA primary care visit, the Veteran still had a rash on the lower leg. He reported being seen in 2005 by dermatology and treated for folliculitis and was to return in three months but an appointment was never scheduled. At an April 2010 VA dermatology consult for complaints of itchy spots on back and arms, the spots consisted of red bumps that occasionally have pus bumps that have been present for years. The Veteran used Dove in the shower and in the past had used doxycycline. In addition, he complained of itchy shins with discoloration that had been present since October 2009 following a flu vaccination shot. He was using Gold Bond cream to moisturize the area. The Veteran reported swelling in his ankles and having worn compression stocking only after being diagnosed with deep vein thrombosis (DVT), but he no longer wore the stockings. His scalp, face, neck, chest, back, abdomen, upper and lower extremities, hands, buttocks, genitalia, and nails were examined. The assessment was statis dermatitis of the lower extremities, recommended triamcinolone 0.1% cream daily to the affected areas. Not to be used on face, groin, or armpits. Recommended compression stockings. The Veteran was also diagnosed with folliculitis on the back and upper extremities, recommended clindamycin 1% lotion to apply daily and benzoyl peroxide 5% wash twice a week to the upper extremities and back. Ammonium lactate 12% lotion daily all over the body following showering was recommended daily for pruritus, mild generalized. At an October 2010 VA skin examination, the Veteran was found to have folliculitis and stasis dermatitis. He reported that his folliculitis had been present for many years and that it was constant and was manifested by dry, pruritic and scaling lesions. It was treated with a 5% benzoyl peroxide wash used twice a week. The Veteran indicated that he had received treatment with clindamycin 1% lotion in the past year for folliculitis. An April 2010 VA treatment note revealed that the Veteran complained of itchy shins with skin discoloration that had been present since October 2009 following a flu vaccination. He was using Gold Bond cream to moisturize the area. The Veteran also reported swelling in his ankles and having worn compression stocking only after being diagnosed with DVT, but he no longer wore stockings. He denied a personal or family history of skin cancer. The condition was progressive and was manifested by dry, pruritic skin on the lower extremities, especially his shins. The diagnosis was stasis dermatitis which was treated with 0.1% cream and 20-30mmHG of mercury, triamcinolone and compression stockings. He was not treated with either a corticosteroid or an immunosuppressive for either condition. On examination, folliculitis affected less than 5 percent of exposed areas and greater than 40 percent of total body area. The Veteran's folliculitis was manifested by many scattered, erythematous maculopapular lesions approximately 0.5 to 0.3 cm. in diameter, many with "heads" which were pus centered. On the face, the right jaw line and a few were found on the chin. Also lesions were scattered mainly on the arms and the back and in a "T" pattern on the chest, with a few at the groin area. The Veteran's stasis dermatitis was found on the lower extremities with areas of hyperpigmentation, hair loss, and tibial plaques without skin breakdown. It covered zero percent of exposed area and 15 percent of total body area. The Veteran claimed that he handled chemicals removed from shipboard and that at least some of the chemicals were DDT. He reported fluid exposures as well as breathing in chemicals which were very strong and sometimes he felt sick breathing this material and sometimes to the point of throwing up. After reviewing the claims file and the remand, the examiner opined that there is little doubt that the Veteran's stasis dermatitis is related to his nonservice-connected coronary heart condition, which includes congestive heart failure, coronary artery disease as well as DVT in the lower extremities. There is no indication that this skin condition is military related. With regard to the Veteran's folliculitis, review of the claims file did not add any more information than that already stated. The examiner noted that there was an absence of outside physician notes which might elucidate the history of this condition further. VA medical records reveal that the Veteran was seen for inclusion cysts that were removed. There is no indication of other skin conditions recorded. When seen in 2005, it was explained that the Veteran's folliculitis was unrelated to prior shingles vaccine or to his history of lupus anticoagulant. The examiner indicated that she had reviewed his reported history of exposure to DDT and other chemicals but could not find sufficient evidence to state that the Veteran's folliculitis was caused by such. Having reviewed all materials available to include the medical literature concerning chemical exposure to include DDT, the examiner could not state that the Veteran's skin conditions to include past history of inclusion cyst(s), folliculitis or stasis dermatitis were caused by military service, to include possible injury incurred as a result of handling toxins or other military service related issues without resorting to mere speculation. Here, the Veteran's representative argues that, in light of the October 2010 VA examiner's opinion, the Veteran should be given the benefit of the doubt and his claim should be granted. The Board disagrees. In Jones v. Shinseki, 23 Vet. App. 382 (2010), the Court held that an examination is not inadequate merely because the examiner states that he or she cannot reach a conclusion without resort to speculation citing to Roberts v. West, 13 Vet. App. 185, 189 (1999). In general, the Court held that it must be clear on the record that the inability to opine on questions of diagnosis and etiology is not the first impression of an uninformed examiner, but rather an assessment arrived at after all due diligence in seeking relevant medical information that may have a bearing on the requested opinion. Jones, 23 Vet. App. at 390. Therefore, it must be clear, from either the examiner's statements or the Board decision, that the examiner did indeed consider "all procurable and assembled data." Here, the VA examiner indicated that she had reviewed all materials available to her from the Veteran's claims file to include his VAMC medical records as well as the medical literature concerning chemical exposure to include DDT, and she specifically discussed his DRO hearing testimony. In compliance with VA's duty to assist, the Veteran was asked on multiple occasions to support his claim with relevant information. In a July 2007 VCAA notice letter, he was asked to submit evidence verifying exposure to chemicals while on active duty or showing treatment for a skin condition while on active duty; to provide the dates of medical treatment during service and to provide the name and exact location of the dispensary, hospital, or other facility where he received treatment for this condition; to provide his rank and the organization at the time of treatment; to provide statements from persons who knew him when he was in service and knew of any disability he had while on active duty; to provide records and statements from service medical personnel; to provide employment physical examinations; to provide medical evidence from hospitals, clinics, and private physicians since military service; to provide pharmacy prescription records; and to provide insurance examination reports. The Veteran was requested to send any medical reports he had or, alternatively, to complete and return the attached VA Form 21-4142, Authorization and Consent to Release Information, for each healthcare provider, to authorize release of information from any doctors and/or hospitals concerning any treatment he received. If he had received treatment at a VA facility, he should furnish the date(s) and place(s). He was also asked to provide copies of any evidence or information in his possession that he thought would support his claim. If the RO did not receive the information or evidence within 60 days, VA would decide his claim based only on the evidence received and any VA examination or medical opinions. In response, the Veteran indicated that he had been treated at the Durham VAMC, submitted a buddy statement and a signed but otherwise blank VA Form 21-4142. The RO associated VA treatment records with the claims file; and reopened the claim and issued a denial on the merits in September 2007, to which the Veteran disagreed. In May 2008, the RO issued a statement of the case (SOC), finding that even though the Veteran had provided lay evidence of a skin condition during active duty, there was no evidence showing that a current skin condition incurred 49 years following service discharge was caused by an acute and transitory skin condition during military service. Previously, in a January 2005 rating decision, denying service connection for a skin condition, the RO noted that no evidence had been submitted verifying the Veteran's claimed exposure to chemicals while on active duty or showing treatment for a skin condition while on active duty. Although the Veteran testified that he had been treated privately between 1956 and 1980, he admitted that there were no private records available. In the April 2010 VCAA letter, VA again asked the Veteran to submit any military records in his possession and to send VA any medical reports he had, to include medical records from private healthcare providers not already associated with the record. Also, he was asked to identify the private doctor that treated his skin condition, which he alluded to at the July 2004 DRO hearing and, if he wanted VA to obtain them, to complete and return the attached VA Form 21-4142 to authorize release of information from any doctors and/or hospitals concerning any treatment he received. When asked again to identify healthcare providers who had treated him for a skin condition, in April 2010, the Veteran identified the Durham VAMC and indicated that he had no more evidence to provide. Prior to the issuance of the SSOC in January 2010, available VA treatment records were associated with the claims file, which failed to show any complaints of a skin condition prior to December 1995. Except for his own testimony and statements and a buddy statement dated in June 2007, the Veteran has not provided any lay statements or medical evidence with regard to any skin condition or identified any alternative sources of medical evidence with signed authorizations for release of such information. The duty to assist is not a one-way street and a claimant seeking help cannot passively wait for it in those circumstances where he or she may or should have information that is essential in obtaining putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In the absence of the Veteran's cooperation with VA's resolute and repeated efforts to obtain any available pertinent information relevant to his claim, the Board is forced to conclude that the October 2010 VA examiner's assessment was arrived after all due diligence in seeking relevant medical information that might have a bearing on the requested opinion and that such opinion was based on "all procurable and assembled data." Jones, 23 Vet. App. at 389. As the Court noted, in Jones, while VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. Notwithstanding the duty to assist, it remains the claimant's responsibility to submit evidence to support his claim. Id. at 391. Based on the Veteran's history, physical examination, the DRO hearing testimony, the articles provided on chemical exposure and the claims file, the October 2010 VA examiner noted that the Veteran claimed that he handled chemicals removed from shipboard and that at least some of the chemicals were DDT. He reported fluid exposures as well as breathing in chemicals which were very strong and sometimes he felt sick breathing this material and sometimes to the point of throwing up. After reviewing the claims file and the remand, the examiner opined that there is little doubt that the Veteran's stasis dermatitis is related to his nonservice-connected coronary heart condition, which includes congestive heart failure, coronary artery disease as well as DVT in the lower extremities. There is no indication that this skin condition is military related. With regard to the Veteran's folliculitis, review of the claims file did not add any more information than that already stated. The examiner noted that there was an absence of outside physician notes which might elucidate the history of this condition further. VA medical records reveal that the Veteran first was seen for inclusion cysts that were removed in 1995 and 1999. There is no indication of other skin conditions recorded. When seen in 2005, it was explained that the Veteran's folliculitis was unrelated to prior shingles vaccine or to his history of lupus anticoagulant. The examiner indicated that she had reviewed his reported history of exposure to DDT and other chemicals but could not find sufficient evidence to state that the Veteran's folliculitis was caused by such. Having reviewed all materials available to include the medical literature concerning chemical exposure to include DDT, the examiner could not state that the Veteran's skin conditions to include past history of inclusion cyst(s), folliculitis or stasis dermatitis were caused by military service, to include possible injury incurred as a result of handling toxins or other military service related issues without resorting to mere speculation. The Veteran gave a history of having chronic skin conditions since active military duty. Although the Veteran testified that he received treatment for skin conditions between 1956 and 1980, he has not provided any objective evidence of such treatment during those years. In this regard, the Veteran claims that such private treatment records no longer exist. When seen by VA in December 1995, the Veteran reported that he had had two cysts excised on his back before but they had returned. The next time the Veteran was treated for a cyst was in May 1999. It was not until November 2005 that the Veteran was evaluated for a skin rash, which he reported first developed about six years ago, as a result of a shingles vaccine trial or, alternatively, related to lupus anticoagulant. Following an examination, the VA examiner assured the Veteran that his skin conditions were not the related to prior shingles vaccine or history of lupus anticoagulant. At that time, the Veteran reported onset only six years earlier. The next time the Veteran was seen for a skin condition was not until April 2010. The examiner indicated that she had reviewed his reported history of exposure to DDT and other chemicals but could not find sufficient evidence to state that the Veteran's folliculitis was caused by such. Having reviewed all materials available to include the medical literature concerning chemical exposure to include DDT, the examiner could not state that the Veteran's skin conditions to include past history of inclusion cyst(s), folliculitis or stasis dermatitis were caused by military service, to include possible injury incurred as a result of handling toxins or other military service related issues without resorting to mere speculation. The Board finds that the examiner has done all that reasonably should be done to become informed about the instant claim and that the examiner's inability to render the requested opinion is adequately explained by the examiner's and the Board's own review of the evidence. Here, the totality of the evidence fails to show that a chronic skin condition was incurred in service or that scleroderma was diagnosed and manifested to a compensable degree within one year after the Veteran's separation from service. The Board acknowledges that the Veteran apparently had warts removed while stationed in Alaska, according to his statements and that of a buddy; however, there is no evidence showing that such condition was chronic. The Veteran has reported a continuity of symptoms, but these statements must be weighed against the other evidence of record, including the lack of any objective evidence of treatment pertaining to a skin condition after the Veteran's separation from active duty until December 1995. Although the Veteran continued to be treated by VA, he was next seen for skin problems in May 1999. It was not until November 2005 that the Veteran was evaluated for a skin rash, which he reported first developed about six years ago, as a result of a shingles vaccine trial or, alternatively, related to lupus anticoagulant. (Emphasis added.). Thus, the Board does not find his statements as to chronicity credible. In addition, while the Veteran has been diagnosed with folliculitis, the absence of any clinical evidence for decades after service weighs the evidence against a finding that the Veteran's current skin condition other than stasis dermatitis was present in service or in the year immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The medical evidence of record shows the first diagnosis of a cyst in 1995, more than 40 years after the Veteran was discharged from service in January 1955. Although he claims treatment by a private doctor, none was identified and no complete authorization for release of information was provided by the Veteran. While the Veteran has provided testimony, articles on chemical exposure, and various statements attempting to link one of his current skin conditions to service, as a lay person he is not competent to provide an opinion concerning medical causation. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Veteran is competent to report observable symptomatology, such as a skin rash or warts, but his opinion as to the cause of those symptoms simply cannot be accepted as both competent and credible evidence here based on the totality of the record. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Additionally, the Board finds that the articles relating to chemical exposure lack probative weight because they do not specifically address the Veteran, to include his medical history documented in the claims file or the lack of actual proof of claimed exposure. In a long line of cases, the Court has consistently held that medical treatise evidence that is generic and inconclusive as to the specific facts in a case was insufficient to establish causal link. See, e.g., Mattern v. West, 12 Vet. App. 222 (1999). The Board concludes that the only probative medical evidence of record, the October 2010 VA examiner's opinion correctly weighs against the Veteran's report of a continuity of symptoms. As the Court stated, in Jones, there are limits to even the most current medical knowledge. And in cases like this one, no medical expert can assess the likelihood that a condition was due to an in-service event, because information that could only have been collected in service, or soon thereafter, is missing, or the time for obtaining other information has passed. The valid application of current medical knowledge can yield multiple possible etiologies with none more likely than not the cause of a claimant's disability, such that a physician can only speculate as to the cause of a claimant's disability or condition. Here, the examiner indicated that the etiology of the Veteran's status dermatitis is clearly related to his nonservice-connected coronary heart disease and DVT of the lower extremities. But she could not state that the Veteran's skin conditions to include past history of inclusion cyst(s), folliculitis or stasis dermatitis were caused by military service, to include possible injury incurred as a result of handling toxins or other military service related issues without resorting to mere speculation. This is particularly so here where the Veteran's claimed exposure to chemicals has not been verified. Thus, the Board finds that it would be inappropriate for VA to demand a conclusive opinion from the October 2010 examiner whose evaluation of the "procurable and assembled" information prevents the rendering of such an opinion. See Jones, 23 Vet. App. at 390. An examination is not inadequate merely because the examiner states she cannot reach a conclusion without resort to speculation. In Jones, the Court rejected the assertion that VA is bound to proceed through multiple iterations of medical opinions until it declares no further examinations would assist the claimant. Here, the October 2010 examiner's assessment is inherent in a finding that the duty to assist has been fulfilled. See id. at 390 (citing Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009)). Thus, in the absence of any evidence showing treatment for a skin condition prior to December 1995, and of a probative medical opinion linking any skin condition to service, the preponderance of the evidence is against the claim and it must be denied. ORDER Entitlement to service connection for a skin condition is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs