Citation Nr: 1500667 Decision Date: 01/07/15 Archive Date: 01/13/15 DOCKET NO. 10-36 248 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for ulcerative colitis, to include as secondary to a service-connected skin disability. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD L. Zobrist, Associate Counsel INTRODUCTION The Veteran had a period of active duty service from April 2, 1976, to March 10, 1980, that has been characterized as Honorable service; and a period of service from March 11, 1980 to November 1980 that has been considered to be of a character that precludes certain VA benefits. He had additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO). Following the submission of additional evidence, an August 2009 rating decision continued the denial of the Veteran's claim. In December 2013, the case was remanded by another Veterans Law Judge for additional development; it has been reassigned to the undersigned for the purpose of this decision. FINDING OF FACT The Veteran's ulcerative colitis is reasonably shown to be related to his service-connected follicular occlusion triad, to include hidradenitis suppurativa and acne. CONCLUSION OF LAW Service connection for ulcerative colitis is warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. However, given the favorable disposition of the Veteran's claim, further discussion of the VCAA regarding this matter is not necessary. It is not in dispute that the Veteran developed ulcerative colitis subsequent to treatment with Accutane, as competent (medical) evidence of record documents the use of Accutane to treat his service-connected skin disability and the subsequent diagnosis and treatment of ulcerative colitis. What remains for consideration is whether his ulcerative colitis is, as alleged, caused or aggravated by medication (to specifically include Accutane) taken to treat his service-connected follicular occlusion triad, to include hidradenitis suppurativa and acne. Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 U.S.C.A. § 3.310(a). Establishing service connection on a secondary basis requires evidence of (1) a current chronic disability for which service connection is sought; (2) an already service-connected disability; and (3) that the disability for which service connection is sought was either (a) caused or (b) aggravated by the already service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). In this regard, there is both positive and negative evidence. The positive evidence includes a June 2010 VA medical examination report in which the examiner stated that, although the timeline between treatment with Accutane and the development of ulcerative colitis is not clear, "Accutane is known to cause ulcerative colitis." [The Board notes that the June 2010 examiner provided a negative nexus opinion. However, this was due to the examiner's understanding that the Veteran was not specifically service connected for hidradenitis suppurativa, the condition for which the Veteran stated that he took Accutane. As the Veteran's service-connected skin disability has been recharacterized to include hidradenitis suppurativa (see August 2013 SSOC), the Board finds that, read as a whole, the June 2010 VA medical examination report is probative evidence in support of the Veteran's claim.] The negative evidence includes a June 2013 VA examiner's opinion that "[t]he current literature does not clearly support a relationship between Accutane use and the development of . . . ulcerative colitis" (emphasis added). The examiner cited six recent studies, at least one of which found a "possible causal association" between treatment with Accutane and the development of ulcerative colitis. Based on the contradiction between the June 2010 and June 2013 VA medical opinions, the Board remanded the matter for an additional VA examination. The July 2014 VA examiner provided a negative nexus opinion, stating that there was "no conclusive data on the correlation of Accutane and development of ulcerative colitis" (emphasis added). However, the examiner cited to two case studies noting, in general, a small increased risk in developing ulcerative colitis after taking Accutane. [There is also a negative December 2008 VA medical opinion. However, that opinion is limited to consideration of a nexus between ulcerative colitis and antibiotics, and is thus not relevant to consideration of a nexus involving Accutane.] The law provides that when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding the etiology of a disability, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. Here, there is a positive (June 2010) VA nexus opinion and two purportedly negative VA opinions (June 2013 and July 2014) that, nonetheless, cite to medical studies supporting a link between Accutane use and the later development of ulcerative colitis. Furthermore, the Board notes that the negative opinions were based on the lack of clarity regarding a possible nexus, not on the basis that sound medical science is against such a finding. Accordingly, resolving all doubt in favor of the Veteran, the Board concludes that the evidence is at least in equipoise as to a finding that his ulcerative colitis is secondary to treatment received for his service-connected skin disability. Thus, service connection for ulcerative colitis is warranted. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for ulcerative colitis is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs