Citation Nr: 1139552 Decision Date: 10/25/11 Archive Date: 11/07/11 DOCKET NO. 93-07 273 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to a disability rating greater than 10 percent prior to November 20, 2008 and a disability rating greater than 30 percent beginning November 20, 2008 for neurodermatitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran had active service from July 1974 to July 1977. This appeal came to the Board of Veterans' Appeals (Board) from May 1991 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania which continued a 10 percent disability rating for neurodermatitis. The Veteran disagreed with this decision and perfected an appeal. In January 2004 the Board denied the Veteran's claim for a disability rating greater than 10 percent for the Veteran's neurodermatitis. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In December 2006, the Court issued a memorandum decision setting aside the Board's denial. In February 2008 the Board remanded the claim for compliance with the Court's December 2006 memorandum decision. Subsequently, by rating decision dated in April 2009 the RO increased the Veteran's disability rating for neurodermatitis from 10 percent to 30 percent effective November 20, 2008, the date of the most recent VA examination. However, the Veteran's appeal for a higher rating both before and after November 20, 2008 remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In a February 2009 report of contact the Veteran raised the issue of entitlement to increased dependency compensation due to his son's continued enrollment at a university. Subsequently, in July 2011 the Veteran's representative submitted a private psychiatric examination report wherein an examiner diagnosed the Veteran with major depressive disorder secondary to his service-connected right knee and skin disorders. In July 2011 correspondence the Veteran's representative indicated that this psychiatric examination report was being submitted in support of the claim filed by the Veteran in July 2010 which, the Board notes does not appear to be in the claims file. While these issues have been raised by the record, they have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to November 20, 2008, the Veteran's neurodermatitis was manifested primarily by small papules on the palms and wrists of both hands with toe web involvement of both feet, and scarring of the face; symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck are not found; nor is exfoliation, exudation or constant itching of an exposed or extensive area found, and less than 5 percent of the entire body is affected and the condition does not require treatment with intermittent systemic therapy. 2. Beginning November 20, 2008, the Veteran's neurodermatitis has been manifested primarily by acne pits on the Veteran's bilateral cheeks with a two centimeter cyst on the right cheek, scattered lichenified papules on the bilateral dorsal hands and on his scrotum along with interdigital xerosis of the bilateral hands with small papules on the right webspace and flesh-colored papules on the dorsum of the bilateral hands, slightly linchified and hyperpigmented skin on the surface of the scrotum, and hypopigmented macules and patches on his bilateral shins consistent with post-inflammatory hyperpigmentation. Symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck are not found; nor is exfoliation, exudation or constant itching of an exposed or extensive area found. The skin manifestations involve between 3 to 20 percent of total body surface area and the condition does not require treatment with intermittent systemic therapy. CONCLUSIONS OF LAW 1. Prior to November 20, 2008 the criteria for an initial disability rating greater than 10 percent for neurodermatitis were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.7, 4.118, Codes 7800, 7806, effective prior to and as of August 30, 2002. 2. Beginning November 20, 2008 the criteria for a disability rating greater than 30 percent for neurodermatitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.7, 4.118, Codes 7800, 7806, effective prior to and as of August 30, 2002. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises out of the Veteran's claim that his service-connected neurodermatitis is more disabling than evaluated both prior to and beginning November 20, 2008. Factual Background Service treatment records show that the Veteran was treated for skin problems on several occasions during military service. In May 1975 he was seen for dermatitis of the hands and in July 1975 he was seen for a skin eruption on the face diagnosed as acne. In February 1977 lichen simplex was diagnosed. The Veteran submitted a claim for service connection for a skin disorder in June 1979. By rating decision dated in November 1979 the RO granted service connection for lichen simplex of the hands and face and assigned a 10 percent disability rating effective from June 5, 1979, the date of the Veteran's claim. By rating decision dated in September 1981 the RO increased the evaluation for the skin disorder, reclassified as neurodermatitis, from 10 to 30 percent. The 30 percent evaluation was effective from January 8, 1981, the date of the Veteran's claim for an increased rating. Subsequently, by rating decision dated in October 1982 the RO reduced the evaluation for the neurodermatitis from 20 to 10 percent. The 10 percent evaluation was effective from February 1, 1983. This 10 percent rating was confirmed by a Board decision in December 1984 and several subsequent rating decisions. In October 1990 the Veteran filed the current claim on appeal. He underwent a VA dermatology consultation in April 1991. His face was pitted with scars and acneform papules. There were no pustules. There was eczematous dermatitis on the right ear and crust on the nose. The impressions were acne and eczema. He was prescribed Cleocin, Retin-A, Eucerin cream, and Lubriderm. By rating decision dated in May 1991 the RO continued a 10 percent rating for the Veteran's neurodermatitis. Thereafter the Veteran disagreed with the decision and perfected this appeal. The Veteran underwent a VA dermatology consultation in September 1991. There were ice-pick scars and lesions on the face and hyperpigmentation on the hands. The diagnoses were acne and post inflammatory hyperpigmentation and scarring. The Veteran testified at a hearing in September 1991. His testimony was to the effect that he had diffuse skin problems and scarring that warranted the assignment of a higher evaluation for his skin condition. On VA examination in October 1991 the Veteran complained of constant itching on his hands, face, and arm. He complained of rashes erupting on his nose, ears, and side of mouth and indicated that it was difficult to shave. A November 1992 VA dermatology consultation showed scaling and hyperpigmentation of both hands, ears, nose, right eyebrow, and groin since 1976. A VA outpatient report shows that the Veteran was seen in August 1993. There were a few papules on his face. There were lichenification and slight scales on the hands. The assessments were seborrheic dermatitis, acne, and eczema. He was prescribed topical agents. The Veteran underwent a VA skin examination in November 1995. At that time he complained of cystic acne for 20 years, treated in the past with Retin A, tetracycline, and benzoyl peroxide, as well as other topical solutions. He reported that he mainly had scarring now but that it flared from time to time. In addition, on his dorsal wrists and palms he complained of a vesticular rash, bilaterally, of an on for 20 years. He had used topical ointments on it but did not know what types. He washed his hands 12 to 15 times per day and reported that they were occasionally pruritic. He had no personal or family history of atopy. He reported having a history of lichen planus on his hands. He complained of a groin rash which was itchy and had been present for about 20 years. On physical examination there was a three by one centimeter red plaque with pinpoint vesicles on the left wrist and a one by one centimeter plaque on the right wrist. His hands were normal. There was a lichenified, slightly scaly scrotum and pubic region. There were ice-pick facial scars without obvious nodules or cysts. The diagnosis was eczema, lichen simplex chronicus, and acne. A VA outpatient report shows that the Veteran was seen in March 1996. There were scaly plaques and papules along the sides of his fingers and palms. There was a rash on his buttocks. There were ice-pick acne scars on his face. There was mild scaling on the scalp. The impressions were acne, seborrheic dermatitis, dyshidrosis, and xerosis. The Veteran underwent a VA skin examination in February 2003. At that time he reported a 20 year history of a rash on his feet, hands, and groin. He reported that this was biopsied in the early 1990s as lichen planus, although this record was reportedly not found on the chart. The rash had been intermittent, non-progressive, and pruritic. He also had a report of acne since the age of 15 with deep pustules and cysts on the temples of his face and axilla bilaterally. He had been treated with Retin-A and oral Tetracycline. At the time of the examination he was not using any topical or oral treatments. In the past, he had used multiple creams and ointments, but the only name he could remember was Absorbase for his hands. He thought he may have used a topical steroid in the past on his hands to use under gloves at night. His most recent breakout lasted six months. He described them as water blisters on his palms and on all sides of his fingers, which he breaks and they are itchy at times. He had no side effects to his treatment, which was currently none. There were no local symptoms such as fever or weight loss. On physical examination he had multiple small papules with plaques on his central palms and wrists, bilaterally. There was some toe web involvement of both feet. The skin manifestations involved less than 10 percent of the hands in terms of surface area, less than five percent of his feet, and approximately one percent of total body surface. There were no active lesions on his face. There were multiple deep pitting scars on his cheek along the beard line. The scrapings of his hand and wrist lesions were negative for mites to suggest scabies. The diagnostic impressions were dyshidrotic eczema and acne with post acne scarring. In April 2003, the examiner who conducted the February 2003 VA examination prepared an addendum to the report of that examination that noted the Veteran's file was reviewed and that he had no exudation, no marked disfigurement, no extensive lesions, no ulceration or extensive exfoliation or crusting, no systemic or nervous manifestations, and no exceptional repugnance. Itching was present. The examiner noted that the scarring on the Veteran's face was not severe and did not produce marked or unsightly deformity. The examiner noted that the facial scarring did not produce exceptional repugnant deformity of one side of the face or bilaterally repugnant disfigurement. As above, in January 2004 the Board denied a disability rating greater than 10 percent for the Veteran's skin disorder. Thereafter, the Veteran appealed this decision to the Court. In December 2006, the Court issued a memorandum decision setting aside the Board's denial. Specifically, the Court noted that the January 2004 Board decision mistakenly indicated that there was "no itching" in the April 2003 VA examination addendum when, in fact, the examiner wrote "itching is present." Inasmuch as "itching constant" was a criterion for a 30 percent disability rating for the Veteran's skin disorder prior to an August 30, 2002 regulation change concerning the skin, the Court set aside the Board's decision denying an increased disability rating for the Veteran's skin disorder. In February 2008 the Board remanded the claim for compliance with the Court's December 2006 memorandum decision. Specifically, the Board found that a VA examination was necessary to determine whether the Veteran's itching was "constant, intermittent, periodic, etc." in order to properly assess whether his skin disorder met the schedular requirements for a 30 percent disability rating prior to November 20, 2008. Pursuant to the February 2008 Board remand the Veteran was afforded a VA skin examination in November 2008. At that time the Veteran reported a 30 year history of skin problems including itchy, dry, and oily skin on his scrotum, hands, face, and legs. He reported that his symptoms were particularly bad on his hands and that washing his hands in hot water irritated them. He reported that his skin problems in general were worse in warmer weather. The Veteran had tried many different topical treatments for skin conditions though he did not remember exactly what, however, the Veteran had been seen in dermatology at a VA clinic in December 2004 and February 2007 during which times he was treated with Clobetasol topically twice a day for flares and with Dermacerin moisturizer to use as often as possible. He was also instructed to switch to Dove soap. They had diagnosed him with eczematous hand dermatitis. The Veteran also reported that he had a history of acne since he was 15 years old. He reported deep pustules and cysts on his face and he reported that he had been treated with topical Erythromycin and topical Tretinoin in 0.1 percent daily, the Erythromycin in the morning and though he does not remember exactly how often he has supposed to take but they were Doxy 100 mg (milligram) tablets. The Veteran reported that he had not taken anything topically or orally in the past 12 months. The examiner noted that during a 2003 VA examination the Veteran reported that the itching related to his eczema had been getting worse but the examiner pointed out that the Veteran had not used any treatments in the past 12 months. On physical examination, there were acne pits on the Veteran's bilateral cheeks; however, there was no evidence of any active inflammation. There were scattered lichenified papules on the Veteran's bilateral dorsal hands and on his scrotum and there were hypopigmented macules and patches on his bilateral shins consistent with post-inflammatory hyperpigmentation. Approximately 10 percent of the exposed area was affected and 20 percent of the entire body was affected. There was no scarring and no disfigurement. There was acne but no chloracne. There were no diagnostic or clinical tests included and no color photos were included in the report. The diagnoses were 1) lichen simplex chronicus associated with the Veteran scratching his hands and legs and 2) acne (although the examiner indicated that she was supposed to focus on the skin disorder previously diagnosed as neurodermatitis which was now diagnosed as lichen simplex chronicus related to the scratching and itching cycle.) The Veteran was reportedly working delivering mail and he reported that his skin disorder of the hands was irritated by the gloves that he had to wear for his job, however, he reported that his skin disorder did not have any effect on his ability to do activities of daily living, although he stated that he must bathe in cooler water to prevent irritation. With regard to core indicators, the diagnosis was stated precisely and was justified. The requested medical opinion was properly stated and the attending physician agreed with this note and diagnosis. In an addendum to the November 2008 VA examination report the examiner wrote that she wanted to clarify that she was asked about the degree of itching which the Veteran reported. According to the examiner the Veteran reported that his itching was intermittent but certainly much worse during the warmer months and exacerbated by washing his skin with warm or hot water and, also, as far as the diagnosis which she was lichen simplex chronicus, this was related to an itch-scratch cycle which can also be called neurodermatitis. Subsequently, by rating decision dated in April 2009 the RO increased the Veteran's disability rating for neurodermatitis from 10 percent to 30 percent effective November 20, 2008, the date of the most recent VA examination. The increased rating was due to the November 2008 VA examiner's report that 20 percent of the Veteran's entire body area was affected by the skin disorder. The Veteran was afforded another VA examination in January 2010, specifically so that photos could be obtained. During this examination the examiner wrote that the Veteran's three-volume claims file was reviewed. The examiner noted that she was specifically requested to include photos of the Veteran's skin disorder so she indicated that she was limiting her examination to this. She wrote that the Veteran's skin examination showed some ice pick pitting of the bilateral cheeks. There was a two cm (centimeter) cyst on the right cheek. He had interdigital xerosis of bilateral hands, with small papules of the right webspace. There were small, flesh-colored papules on the dorsum of the bilateral hands. There was slightly lichenified, hyperpigmented skin on the surface of the scrotum. There were no scrotal papules or pustules and there was no intertrigo. Approximately a total of 5 percent of exposed areas were affected, 3 percent of the entire body was affected. There was no scarring and the Veteran's acne was not active. No diagnostic or clinical tests were done. The examiner noted two diagnoses: 1) dyshidrotic eczema of the hands, and 2) acne - pitting with one cyst. Color photos were taken and associated with the Veteran's medical records. A review of the record shows that various color photographs of the Veteran's face, groin area, hands, and other body parts were taken at some of the above-noted VA examinations. In the Board's opinion, these photographs do not show skin manifestations of marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. A request for an increased rating is to be reviewed in light of the entire relevant medical history. See generally 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The regulations for the evaluation of disabilities of the skin were amended twice during the course of this appeal, first effective August 30, 2002 (67 Fed. Reg. 49590 -49599 (July 31, 2002) and 67 Fed. Reg. 58448 -58449 (Sept. 16, 2002)) and again on September 23, 2008, when VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. The most recent amendments are only effective for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran has not requested such consideration. Accordingly, in this case the Board is required to review both the pre- and post-August 30, 2002, rating criteria to determine the proper evaluation for the Veteran's skin disorder. If it is determined that the new criteria is more favorable, the new criteria may not be applied for the period prior to the revision. See VAOPGCPREC 3-2000 (April 10, 2000). As limited by 38 U.S.C.A. § 5110(g) (West 2002), the effective date of any increase assigned under the amended version of the rating schedule can be no earlier than the effective date of the regulation. Prior to August 30, 2002, skin disorders were rated under 38 C.F.R. § 4.118, Diagnostic Codes (DCs) 7800-7806. Under DC 7806, a 10 percent rating was warranted for eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent rating was provided for eczema with exudation or itching constant, extensive lesions, or marked disfigurement. Eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant warranted a 50 percent rating. 38 C.F.R. § 4.118, DC 7806 (effective prior to August 30, 2002). Scars, other than of the head, face, or neck and which were not the result of burns, were to be rated under DCs 7803 to 7805. Under DC 7803, a 10 percent evaluation was assignable for scars, superficial, poorly nourished, with repeated ulceration. 38 C.F.R. § 4.118, DC 7803 (prior to August 30, 2002). Beginning August 30, 2002, disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of 3 or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 6 or more characteristics of disfigurement will be rated 80 percent. Such disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 4 or 5 characteristics of disfigurement will be rated 50 percent. Such disfigurement with 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 will be rated 30 percent. Such disfigurement with one characteristic of disfigurement a 10 percent rating will be assigned. Note (1):The 8 characteristics of disfigurement, for purposes of evaluation under 38 C.F.R. § 4.118, are: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2): Rate tissue loss of the auricle under DC 6207 (loss of auricle) and anatomical loss of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate. Note (3): Take into consideration unretouched color photographs when evaluating under these criteria. 38 C.F.R. § 4.118, DC 7800, effective as of August 30, 2002. Beginning August 30, 2002, dermatitis or eczema with 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 warrants a 60 percent rating. With 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 30 percent evaluation will be assigned. With 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 10 percent rating will be assigned. With less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period a zero percent rating will be assigned. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, Code 7806, effective as of August 30, 2002. Analysis There are two periods of time at issue here: prior to November 20, 2008, when the Veteran's neurodermatitis was evaluated as 10 percent disabling; and November 20, 2008 to the present, while the Veteran's neurodermatitis was evaluated as 30 percent disabling. The Board will consider the proper evaluation to be assigned for both time periods. See Hart, 21 Vet. App. at 505. a. Prior to November 20, 2008 After a review of all the evidence with emphasis on the report of the Veteran's February 2003 VA skin examination, the Board finds that, prior to November 20, 2008, the Veteran's skin disorder was manifested primarily by small papules on the palms and wrists of both hands with toe web involvement of both feet, and scarring of the face. The skin manifestations involved approximately one percent of total body surface. These symptoms support the assignment of a 10 percent rating for the skin disorder under DC 7800, effective prior to or as of August 30, 2002. The examiner who conducted the February 2003 VA examination of the Veteran's skin reviewed the evidence in the claims file and prepared an addendum dated in April 2003 that notes the Veteran had no exudation, no marked disfigurement, no extensive lesions, no ulceration or extensive exfoliation or crusting, no systemic or nervous manifestations, and no exceptional repugnance. The examiner noted that the scarring on the Veteran's face was not severe and did not produce marked or unsightly deformity. The examiner noted that the facial scarring did not produce exceptional repugnant deformity of one side of the face or bilaterally repugnant disfigurement. Nor do the color photographs of the Veteran's face, groin area, hands, and other body parts reveal skin manifestations of marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck. The Board finds that the evidence does not show symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck. Nor does the evidence show exfoliation, exudation or constant itching of an exposed or extensive area, and the evidence reveals that less than 5 percent of the entire body is affected and that the condition does not require treatment with intermittent systemic therapy. While the Veteran complained of "constant" itching on his hands, face, and arm during the October 1991 VA examination and the February 2003 VA examination report shows that itching was present, the November 2008 VA examiner clarified that the itching was "intermittent". Hence, the evidence does not support the assignment of rating in excess of 10 percent for the Veteran's skin disorder prior to November 20, 2008 under either the pre or post-August 30, 2002 criteria. b. Beginning November 20, 2008 After a review of all the evidence with emphasis on the report of the Veteran's November 2008 and January 2010 VA skin examinations, the Board finds that, beginning November 20, 2008, the Veteran's skin disorder has been manifested primarily by acne pits on the Veteran's bilateral cheeks with a two centimeter cyst on the right cheek, scattered lichenified papules on the Veteran's bilateral dorsal hands and on his scrotum along with interdigital xerosis of the bilateral hands with small papules on the right webspace and flesh-colored papules on the dorsum of the bilateral hands, slightly linchified and hyperpigmented skin on the surface of the scrotum, and hypopigmented macules and patches on his bilateral shins consistent with post-inflammatory hyperpigmentation. The skin manifestations involve between 3 to 20 percent of total body surface area. These symptoms support the assignment of a 30 percent rating for the skin disorder under DC 7800, effective prior to or as of August 30, 2002. As above, during the November 2008 VA examination 20 percent of the entire body was affected and there was no scarring and no disfigurement. Furthermore, the Veteran denied the use of topical or oral medication for his skin during the past 12 months. As above, while the Veteran complained of itching the examiner indicated that the itching was "intermittent." The January 2010 VA examiner indicated that there was no scarring and that approximately 3 percent of the Veteran's body was affected. As above, to warrant a higher rating under the post-August 30, 2002 rating criteria for dermatitis or eczema there must be 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. To warrant a higher rating under the post-August 30, 2002 rating criteria for scars there must be disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 4 or 5 characteristics of disfigurement. The Board notes that there is a significant discrepancy between the reported total area affected by the Veteran's skin disorder, 20 percent in the November 2008 VA examination and 3 percent in the January 2010 VA examination report. While the January 2010 VA examination report shows a significant improvement in the Veteran's skin disorder which does not meet the requirements for a 30 percent disability rating, the Board will not disturb the 30 percent rating already awarded. Statements and testimony from the Veteran are to the effect that he has diffuse skin problems and scarring that warrant the assignment of higher evaluations for his skin disorder both prior to and beginning November 20, 2008. While the objective medical evidence corroborates his statements to the extent that he has diffuse skin problems with scarring, it does not corroborate his assertion that those manifestations support the assignment of a higher rating or the assignment of another separate compensable evaluation for the skin disorder. In sum, there is no support for assignment of increased ratings for the Veteran's skin disorder over any portion of the rating period on appeal. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Consideration As to whether the record raises the matter of referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1), the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology. As was noted in the November 2008 VA examination report, the Veteran is employed delivering the mail and, while the gloves that he wears for his employment irritate his hands, he reported that his skin disorder does not have any effect on his ability to do activities of daily living. The competent medical evidence of record shows that his skin disorder is primarily manifested by intermittent itching. The applicable diagnostic codes used to rate the Veteran's disability provide for ratings based on such complaints. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Thun v. Peake, 22 Vet. App. 111 (2008). Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Substantially compliant notice was sent in May 2001, March 2002, March 2008 and May 2008 letters and the claim was readjudicated in May 2009, April 2010, and March 2011 supplemental statements of the case. Mayfield, 444 F.3d at 1333. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant adequate physical examinations, obtained medical opinions as to the severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board although he declined to do so. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. ORDER A disability rating greater than 10 percent prior to November 20, 2008 for neurodermatitis is denied. A disability rating greater than 30 percent beginning November 20, 2008 for neurodermatitis is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs