Citation Nr: 1543351	
Decision Date: 10/08/15    Archive Date: 10/13/15

DOCKET NO.  02-06 121	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Atlanta, Georgia


THE ISSUE

Entitlement to a rating higher than 10 percent for pseudofolliculitis barbae.


REPRESENTATION

Appellant represented by:	Georgia Department of Veterans Services


ATTORNEY FOR THE BOARD

K. M. Georgiev, Associate Counsel


INTRODUCTION

The Veteran served on active duty from June 1979 to June 1982 in the United States Marine Corps.

By a rating decision dated July 1999, service connection for pseudofolliculitis barbae was granted.  The Veteran claimed an increased rating in November 2000.  This appeal to the Board Veterans' Appeals (Board/BVA) is from an August 2001
decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied the claim on appeal.

In November 2006 the Board issued a decision confirming the RO's August 2001
denial of a rating higher than 10 percent for the pseudofolliculitis barbae.  As well, the Board denied service connection for seborrheic dermatitis and acne vulgaris, including as secondary to the service connected pseudofolliculitis barbae, and determined the RO had not committed clear and unmistakable error (CUE) in a prior July 1999 decision assigning an initial 10 percent rating for the pseudofolliculitis barbae.

The Veteran appealed the Board's November 2006 decision to the U.S. Court of
Appeals for Veterans Claims (Court/CAVC).  In a March 2008 Memorandum
Decision, the Court affirmed the Board's decision denying service connection for
seborrheic dermatitis and acne vulgaris including as secondary to the service connected pseudofolliculitis barbae, also agreed the RO had not committed CUE
in the July 1999 decision assigning an initial 10 percent rating for the
pseudofolliculitis barbae, but vacated and remanded the claim for a rating higher
than 10 percent for the pseudofolliculitis barbae for further development and
readjudication consistent with the Memorandum Decision.

In October 2008 and May 2010 the Board in turn remanded this claim for the
required further development.  The Board subsequently again denied this claim in
April 2012 and the Veteran again appealed the Board's decision to the Court.  In November 2012 the Court granted a joint motion, again vacating the Board's
decision denying this claim and again remanding this claim to the Board for action
consistent with the terms of the joint motion.

In March 2013 the Board again denied this claim and the Veteran again appealed
the Board's decision to the Court.  In December 2013 the Court granted another
joint motion, again vacating the Board's decision denying this claim and again
remanding this claim to the Board for action consistent with the terms of the
joint motion.  

To assist in complying with the Court's December 2013 Order, the Board again remanded this claim in May 2014 and January 2015 for further development.  This matter is again before the Board.  The Board finds compliance with the remand instructions.  See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999).

As indicated in the prior Board opinions, during the course of this appeal the Veteran requested a hearing to testify in support of his claim.  After the
Board scheduled his hearing, he failed to report for it and did not provide a good-cause explanation for his absence, and did not request to have his hearing rescheduled.  The Board thus deemed his hearing request withdrawn.  See 38 C.F.R. § 20.704(d) (2014).

The Board notes that additional evidence was submitted by the Veteran after the RO's latest Supplemental Statement of the Case.  As the Veteran submitted a waiver of RO review of the additional evidence, the Board proceeds with the case.

Although the Veteran has submitted evidence of a medical disability, and made a claim for a higher rating, he has not submitted evidence of unemployability, or claimed to be unemployable due to his service-connected skin disability; therefore, the question of entitlement to a total disability rating based on individual unemployability has not been raised.  See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001).

The Board has reviewed the Veteran's Virtual VA and Veteran's Benefits Management System paperless claims processing systems to ensure a total review of the evidence.


FINDINGS OF FACT

1.  The Veteran's pseudofolliculitis barbae has manifested throughout the appeals period as extensive lesions and disfiguring hyperpigmentation.  Treatment has included systemic medication, antibiotics and an antihistamine required for a total duration of six weeks or more, but not constantly.

2.  There is no evidence the Veteran's pseudofolliculitis barbae has manifested as ulceration or extensive exfoliation or crusting, systemic or nervous manifestation or exceptional repugnance, complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement, nor visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement.  There is no indication that there is 40 percent of the entire body or more than 40 percent of exposed areas affected, or that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required.


CONCLUSIONS OF LAW

1.  The criteria for a disability rating of 30 percent for the Veteran's service-connected pseudofolliculitis barbae are met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.118, Diagnostic Codes 7800-7806 (2014).

2.  The criteria for a disability rating in excess of 30 percent for the Veteran's service-connected pseudofolliculitis barbae are not met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.118, Diagnostic Codes 7800-7806 (2014).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Board has thoroughly reviewed all the evidence in the Veteran's claims file.  Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but is not required to discuss each piece of evidence).  The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims.  The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran).

Veterans Claims Assistance Act of 2000 (VCAA)

In regard to the Veteran's claims for entitlement to an increased rating in excess of 10 percent for pseudofolliculitis barbae, because service connection, an initial rating, and an effective date have been assigned, the notice requirements of the VCAA, 38 U.S.C.A. § 5103(a) (West 2014) have been met.  Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007).  

The Board also concludes VA's duty to assist has been satisfied.  The Veteran's service treatment records and VA medical records are in the Veteran's claim file.  Private medical records identified by the Veteran have been obtained, to the extent possible.  The Veteran has not referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim.

The Court has also held that VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one.  See Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  Where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2014).

In this case, several VA examinations have been conducted.  The Board finds the examination reports to be thorough and complete and sufficient upon which to base a decision with regard to these claims.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).  These examinations, along with the remaining evidence of record, contain sufficient findings to rate the Veteran's service-connected disabilities under the appropriate diagnostic criteria.   

As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless.  See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).

Legal Criteria for Increased Rating

Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity.  38 U.S.C.A. § 1155 (West 2014).  Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2014).  The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations.  38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2014).  VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion.  Schafrath, 1 Vet. App. at 589.

The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability.  Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994).  Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  There is no evidence to support the finding of a staged rating in this case.

If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7 (2014).  

The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity."  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.  The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes.  Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993).

Increased Rating for Pseudofolliculitis Barbae

During the pendency of this appeal, the criteria for rating skin disorders were
revised effective August 30, 2002.  See 67 Fed. Reg. 49,590 (2002).  Either the old
or the new rating criteria may be used, whichever are more favorable to the Veteran,
but the new criteria only may be applied prospectively from their effective date.  See 38 USCA § 5110(g), 38 C.F.R. § 3.114, Kuzma v. Principi, 341 F.3d 1327
(Fed. Cir. 2003), VAOPGCPREC 3-2000.  

Further amendment was made to certain criteria for rating the skin, effective October 2008.  See 73 Fed. Reg. 54,708 (2008) (codified at 38 C.F.R. § 4.118, DCs 7800 to 7805 (2014)).  However, the amended regulations effective October 2008 are only applicable to claims received on or after October 23, 2008, or if the Veteran requests review under the clarified criteria, which is not the case in the current claim.  See 73 Fed. Reg. 54708 (2008).  As such, the Board will not consider these regulations in this case.

Pseudofolliculitis barbae is not listed in 38 C.F.R § 4.118, which contains the
diagnostic codes applicable to the rating of skin disorders.  When an unlisted
disorder is encountered it will be permissible to rate under a closely related disease
or injury in which not only the functions affected, but also the anatomical
localization and symptomatology are closely analogous.  Conjectural analogies will
be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis,
or for those not fully supported by clinical and laboratory findings, nor will ratings
assigned to organic diseases and injuries be assigned by analogy to conditions of
functional origin.  38 C.F.R. § 4.20.

The RO has rated the Veteran's pseudofolliculitis barbae as 10 percent disabling
since December 1998, initially under Diagnostic Code 7806 pertaining to dermatitis
or eczema, and more recently by a June 2006 decision, under Diagnostic Code 7813-7800, pertaining to dermatophytosis (ringworm of the beard area, i.e., tinea barbae).  38 C.F.R § 4.118 Diagnostic Code (DC) 7806, 7813-7800.  Under DC 7813, dermatophytosis is rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801-7805) or dermatitis (DC 7806), depending upon the predominant disability.  The Veteran filed a claim for a higher rating in November 2000, contending this condition is more disabling than the current evaluation contemplates.  

Pseudofolliculitis is defined as erythematous follicular papules or, less commonly
pustules resulting from close shaving of very curly hair.  Stedman's Medical
Dictionary, 27th ed. at 1470.  Dermatitis is inflammation of the skin.  Id., at 479. 
Eczema is the generic term for inflammatory conditions of the skin, particularly
with vesiculation in the acute stage, typically erythematous edematous, papular,
and crusting."  Id., at 566.  As the symptoms of pseudofolliculitis are similar to
those of eczema, and include disfigurement of the face and neck rating the
Veteran's pseudofolliculitis barbae under DC 7806 is permissible.  See Butts v.
Brown, 5 Vet App 532, 539 (1993) (holding that the Board's choice of DC should
be upheld if supported by explanation and evidence).  See also Pernorzo v.
Derwznskz, 2 Vet App 625, 629 (1992) (indicating that any change in DC must be
specifically explained).

The Board notes that the Veteran has other skin disorders that have not been service
connected, namely acne and seborrheic dermatitis.  Evidence received after prior Board denials suggests there may be overlapping symptomatology, and as such, one condition cannot be wholly differentiated from the other.  When it is not possible to separate the effects of the service-connected condition and the non-service-connected condition, VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, dictate that such signs and symptoms be attributed to the service-connected condition.  61 Fed.Reg. 52698 (Oct. 8, 1996); see also Mittleider v. West, 11 Vet. App. 181, 182 (1998).

There is nothing in the rating criteria to suggest that systemic antibiotic therapy is insufficient to warrant a rating under Diagnostic Code 7806.  See Brown v. Shinseki, 2012 WL 738725 at *3 (March 8, 2012, Vet. App.) (non-precedential) (holding in the context of an appeal concerning the use of systemic antibiotics for a skin disorder that that the use of the phrase "such as" in Diagnostic Code 7806 "is an ambiguously worded regulation that might be interpreted to apply to 'systemic therapy' that is other than immunosuppressive in nature.").

Criteria Effective Prior to August 30, 2002

Prior to August 30, 2002, under the former version of DC 7806, a 10 percent rating was warranted for eczema with exfoliation, exudation, or itching involving an exposed surface or extensive area.  A 30 percent rating was assigned for eczema with constant exudation or itching, extensive lesions, or marked disfigurement.  To warrant a 50 percent rating, ulceration or extensive exfoliation or crusting, and systemic or nervous manifestation or exceptional repugnance needed to be shown.  See 38 C F R § 4 118, DC 7806 (2001).

Code 7800 provided a 30 percent rating where disfiguring scars on the head, face, or neck were severe, especially if producing a marked and unsightly deformity of the eyelids, lips, or auricles.  A higher 50 percent rating was available where there was complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement.

Code 7801 described third degree burn scars.  Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion.  Code 7803 provides a 10 percent rating for superficial unstable scars.  As these codes are inapplicable to the Veteran's claim, the Board will not further discuss these rating criteria.

Throughout the appeal period, Code 7805 has provided that scars can be rated on limitation of function of the affected part.  As the Veteran's skin condition has not caused any limited function of a body part, the Board also will not further discuss these criteria.

Criteria Effective from August 30, 2002

Code 7806 revisions provide that a 10 percent rating is warranted for dermatitis or eczema 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 if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks during the last 12-month period.  A higher 30 percent rating is assigned for dermatitis or eczema that involves 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 60 percent rating is warranted with more than 40 percent of the entire body or more than 40 percent of exposed areas affected or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period.  38 C F R §4.118, DC 7806 (2003).

DC 7806 also allows for ratings under DCs 7800 through 7805.  However, other
than DC 7800, disfigurement of the head, face, or neck, the other DCs either apply to scars other than on the head, face, and neck, or do not provide for a rating higher than 10 percent.  Further discussion of them is not necessary since they will not provide the Veteran with a higher rating.

Revised Code 7800 provides for a 10 percent rating for one characteristic of
disfigurement, a higher 30 percent rating where there is disfigurement of the head, face, or neck 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.  A 50 percent rating is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement.

Note (1) provides that the 8 characteristics of disfigurement are: Scar is 5 or more inches (13 or more cm.) in length; scar is at least one-quarter inch (0.6 cm.) wide at the widest part; surface contour of scar is elevated or depressed on palpation; scar is adherent to underlying tissue; skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); or skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.).  Under note (3) the adjudicator is to take into consideration unretouched color photographs when evaluating under these criteria.

Under DC 7813, dermatophytosis is rated as disfigurement of the head, face, or
neck (DC 7800), scars (DCs 7801-7805) or dermatitis (DC 7806), depending upon the predominant disability.

Facts

Private and VA post-service outpatient treatment records since dated from 1999 to
present show continuing treatment for pseudofolliculitis barbae.  

In March 1982, the Veteran was shown with a moderately severe amount of papules on the chin, neck, and cheeks; some papules were infected.  Diagnosis was moderately severe pseudofolliculitis barbae.

In January 1999, the Veteran was diagnosed with pseudofolliculitis barbae with post- inflammatory hyperpigmentation.  Pseudofollicular papules with hyperpigmented macules on the neck were noted.

During an April 2001 VA authorized private dermatological examination the
Veteran indicated that he suffered from inflammation and bumps on his face which
had become worse.  His treatment consisted of special topical medications, which
he stated improved his symptoms, but he still considered his condition to be
disfiguring.  Physical examination noted that the skin was diffusely hyperpigmented
in the distribution of the beard.  Multiple small (0.1 cm) papules, and a few small
pustules at the base of the hair shaft were noted as well as round keloid nodules
(0.10-0.2 cm) in the submandibular area.  There were no adhesions or tissue loss.  
The diagnosis was pseudofolliculitis barbae.  

January and August 2004, October and November 2005 VA and private treatment records reflect that the Veteran was treated with protopic and hydrocortisone cream.  
Hydrocortisone cream is a topical corticosteroid used as an anti-inflammatory and anti-pruritic agent and Protopic is the brand name for tacrolimus a topical immunosuppressant.    See Drugs.com at http://www.drugs.com/cdi/hydrocortisone-cream.html; www.drugs.com/protopic.html.

During a November 2005 VA examination, the Veteran complained of mild
tenderness of the pseudofolliculitis barbae lesions.  Physical examination showed
that the beard area had no erythematous papules or pustules and few
hyperpigmented minimally elevated papules were centered about the hair follicles. 
There was no scarring or disfigurement and less than two percent of the entire body
was affected.  Color photographs taken at that time were consistent with the above
description.  The diagnosis was pseudofolliculitis barbae.

An October 2005 treatment record noted few hyperpigmented minimally elevated papules centered around hair follicules.

A January 2006 VA treatment record shows the Veteran reported occasional
pustules, mostly erythematous papules.  He said he experienced great improvement
of his pseudofolliculitis barbae with the use of a prescription topical cream.

Private medical records from S.F.C., M.D., dated from 2007 to 2009 reflect
ongoing treatment for pseudofolliculitis barbae of the face and front of the neck
only, with only topical medication.  In December 2007 the Veteran had follicular
papules and hyperpigmented macules on his face and neck, with none on the rest of
his body.  The physician advised the Veteran that therapy was aimed at reducing the
inflammation from curled hairs growing back into the skin, through topical
corticosteroids and anti-inflammatory antibiotics, the best therapy is manually
removing the ingrown hair and growing a beard.  In February 2008, his follicular
papules and hyperpigmented macules were improved on the face and neck with
none on the rest of his body.  In January 2009 he reported that his spots and bumps
were overall better, and he liked Epiceram.  On examination, there were fewer
follicular papules and persistent hyperpigmented patches on his neck, chin and
lower cheeks, with none on the rest of his body.

During a March 2010 VA examination, the Veteran complained of pruritic bumps in the beard region of his face and neck and said the lesions had been persistent.  He reported occasional episodes of bleeding from the lesions with scratching or shaving.  He said he shaved every three days and used a special electric razor which did not shave close to the skin.  He saw a dermatologist every two months for this condition.  He used Benzashave cream while shaving and used Tretinx cream twice daily, Topicort cream once daily, and Hydroquinone twice daily for the pseudofolliculitis barbae without any improvement in the lesions.  He said the medications temporarily relieved the pruritus.  Topicort is the brand name for desoximetasone, a topical steroid used to reduce inflammation redness and swelling.  He said his medications were adjusted every two to three months as most of the medications had been ineffective.  He noted scarring on his face due to these lesions.  He worked at the U.S. Postal Service as a mail handler, and his job did not require him to shave.  He was concerned about the cosmetic appearance of his face due to the scarring.

On objective physical examination, there were multiple hyperpigmented papular
lesions surrounding the hair follicles, involving the beard region of the neck, chin
and lower cheeks, and hyperpigmented macular patches/scarring noted on the beard
region of the anterior neck, chin and lower cheeks.  There were no pustules.  The
lesions involved approximately 1.5 percent of the total body surface area, and the
lesions involved approximately 10 percent of the exposed areas.  The examiner
indicated the Veteran had had recurring and persistent lesions over the last several
years involving the beard regions of his neck, chin and lower cheeks.  He had not
received any systemic therapy for the pseudofolliculitis barbae and was currently on
topical medications without significant improvement in symptoms.

By letter dated in April 2010, the Veteran's private physician, S.F.C., M.D.,
indicated the Veteran had been seen in his dermatology clinic for pseudofolliculitis
barbae and scarring/hyperpigmentation.  He had involvement of the cheeks, chin
and neck, and extensive hyperpigmented scars on the above areas.

A February 2011 private medical record from V.T.P., M.D., reflects that the
Veteran presented with a history of acne keloidalis on the face.  On examination
there was pustular inflammation of the hair follicles on the neck and face.  Medication was prescribed, including Monodox caplets, Brevoxyl creamy wash, Atarax tablets (an antihistamine) by mouth as needed for itching, and pds cream.  Treatment notes in question reflect that 60 capsules of 100 mg Monodox were prescribed with one refill to be taken 1 PO QD indicative of one capsule by mouth per day (See Dermatology Notes dated February 15, 2011).  Monodox is the brand name for doxycycline monohydrate an antibacterial used to prevent infections.  See Drugs.com, http://www.drugs.com/pro/monodoxhtm.  25 mg of Atarax was prescribed at 30 tablets with one refill.  These medications were continued: T sal and gel shampoos, locoid lipo samples, Benzashave medicated shaving cream, sunscreen, and Epiduo samples.  Dr. P. noted that the Veteran's history and physical examination pointed toward the diagnosis of folliculitis, an inflammatory hair follicle condition which often resolves with systemic and/or topical antibiotics.

An April 2013 private treatment record noted a prescription of 60 pills of Monodox, taken orally one time daily, with one refill.  Symptoms were noted as multiple erythematous follicular papules and pustules on the jaw and chin, and multiple erythematous plaques with moist scale on the forehead and scalp.

A July 2013 private treatment record noted a rash eruption and itching on the face and scalp.  

The Veteran appeared for a VA examination in July 2014.  The examiner noted diagnoses of pseudofolliculitis barbae, acne, and seborrheic dermatitis.  The examiner found no scarring or disfigurement.  Visible skin conditions covered less than 5 percent of total body area and less than 5 percent of exposed area.  The affected area is less than 39 square inches and abnormal texture and hyperpigmentation cover an area less than 39 square centimeters.  The examiner characterized the Veteran's pseudofolliculitis barbae as mild and mainly hyperpigmentation.  The examiner found acne which affects less than 40 percent of the face and neck.  The examiner specified that the Veteran was treated with Monodox in 2011 which is an antibiotic which treats acne vulgaris.  The examiner explained that antibiotic is not a treatment for pseudofolliculitis.

The examiner noted that the Veteran reports pruritus which is an indication for Atarax, but both Monodox and Atarax are not corticosteroids or immunosuppressant drugs.  The examiner stated that the Veteran has not been treated with either corticosteroids or immunosuppressant drugs for
pseudofolliculitis.  His record indicates use of topical corticosteroid but not as treatment for pseudofolliculitis.

A November 2014 private treatment record noted pseudofolliculitis barbae with multiple erythematous folliculocentric papules and pustules with post inflammatory hyperpigmentation on the entire beard area and anterior neck.  Treatment was noted to continue taking oral Doxycline at 100mg QD, once daily for 30 days, as well as applying Cleocin lotion and BenzEfoam daily.

A November 2014 skin disability benefits questionnaire was submitted by the Veteran's treating physician, F.H., who indicated the Veteran had been a patient for 14 years for the treatment of chronic pseudofolliculitis barbae which itches and discolors the face, jaws, chin and neck, and includes papules, pustules, and sometimes nodules.  The examiner noted the Veteran was treated over the past twelve months with Atarax for itching due to pseudofolliculitis and Doxycycline of 100 mg for pseudofolliculitis at a "constant/ near constant" basis.  The examiner further noted the Veteran is treated with Cleocin, Atrapro, Benzafoam, and Klingman's formula at a "constant/ near constant" basis for pseudofolliculitis and itching.  The examiner indicated that the Veteran's pseudofolliculitis covered less than 5 percent of total body area and 20 to 40 percent of exposed area.  The examiner indicated the Veteran does not suffer from acne, chloracne, vitiligo, alopecia, or hyperhidrosis.

January 2015 private treatment records note the Veteran was prescribed Doxycline 200 mg delayed release medication, started on January 2015.

In March 2015, the Veteran appeared for an additional VA examination, in part to reconcile possibly contradictory opinions in the July 2014 and November 2014 examinations.  The examiner again noted diagnoses of pseudofolliculitis barbae, acne, and seborrheic dermatitis, as well as earlier diagnoses of asteatotic eczema, acne keloidalis, and verruca vulgaris.  The Veteran described flare-ups; his last flare-up was four months ago, and in response his Doxycline dosage was increased from 100 to 200 mg for the past 5 months.  He has noticed after antibiotic use, his flare-ups will return.  He shaves every three days, after which he experiences facial soreness, bleeding skin and pimps that ooze.  The examiner noted that pseudofolliculitis and acne cause scarring and disfigurement of head, face, and neck.  The examiner specified that the Veteran was taking Atarax, an antihistamine, until November 2014, for 6 weeks or more, but not constantly.  The examiner noted that upon reviewing pictures from the July 2014 examination, the examiner found no exacerbation of any facial/neck skin condition.  The examiner found at the time of the examination the Veteran's skin condition affects zero percent of his total body area and zero percent exposed area.

The examiner explained that FDA approved prescriptive medications/treatments are Benzashave, hydrocortisone cream, antibiotics (Tetracycline) and tretinoin for severe razor bumps but also has an indication for Acne Vulgaris.  The examiner noted that the Veteran reported using Atarax until November 2014 for itching,
Doxycycline 100mg twice daily, Cleocin Gel, Atrapro Gel and Betamethasone
Valerate Lotion 0.1%.  The examiner clarified that this medication can be used for all skin disorders of Acne Vulgaris, pseudofolliculitis barbae, seborrheic dermatitis, except for the Betamethasone Lotion.  The examiner explained that the prescriptions for Doxycycline 100mg or Monodox 100mg were prescribed in November 2014 for 30 days, July 2013 and April 2013 for 60 days each, and the medical records does not show these are an on-going daily medication, only during flare-ups.

The examiner stated that it was impossible to differentiate pseudofolliculitis barbae from other diagnosed skin conditions without examining the Veteran during a flare-up.  The examiner explained that at this time the Veteran has two intermingling skin
Disorders of Acne Vulgaris and pseudofolliculitis barbae; the Doxycycline can be used for both but the Tretinoin is predominantly used for Acne Vulgaris but can be used for severe pseudofolliculitis barbae.

An April 2015 private treatment notes that the Veteran presents with folliculitis, but has been on Benzepro foam and Doxycline 200 mg delayed release medication which has yielded great improvement.

Analysis

The Board finds an increase of 30 percent evaluation warranted for the duration of the appeals period.

In March 1982, medical evidence shows a moderately severe amount of papules on the chin, neck, and cheeks; some papules were infected.  In January 1999, the Veteran was diagnosed with pseudofolliculitis barbae with post- inflammatory hyperpigmentation.  

Giving the Veteran the benefit of the doubt, the Board finds this evidence points to "extensive lesions," warranting a 30 percent rating under the former version of DC 7806.  Further, post- inflammatory hyperpigmentation supports significant disfigurement, which warrants a 30 percent rating under DC 7800.

Subsequent medical records support that the Veteran was prescribed topical creams which improved his symptoms.

In December 2007 the Veteran had follicular papules and hyperpigmented macules on his face and neck, with none on the rest of his body.  The physician advised the Veteran that therapy was aimed at reducing the inflammation from curled hairs growing back into the skin, through topical corticosteroids and anti-inflammatory antibiotics.

A February 2011 private medical record reflects that the Veteran presented with pustular inflammation of the hair follicles on the neck and face.  Medication was prescribed, including Monodox caplets, Brevoxyl creamy wash, Atarax tablets (an antihistamine) by mouth as needed for itching, and pds cream.  Treatment notes in question reflect that 60 capsules of 100 mg Monodox were prescribed with one refill to be taken 1 PO QD indicative of one capsule by mouth per day.  25 mg of Atarax was prescribed at 30 tablets with one refill.  Thus the medical record reflects that the appellant was prescribed a systemic antibiotic, Monodox, as well as system drug Atarax for a period of six weeks or more during a 12-month period.  Code 7806 revisions effective August 30, 2002 provide that a higher 30 percent rating is assigned for dermatitis or eczema that involves 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.  There is nothing in the rating criteria to suggest that systemic antibiotic therapy is insufficient to warrant a rating under Diagnostic Code 7806.  See Brown v. Shinseki, 2012 WL 738725 at *3 (March 8, 2012, Vet. App.) (non-precedential) (holding in the context of an appeal concerning the use of systemic antibiotics for a skin disorder that that the use of the phrase "such as" in Diagnostic Code 7806 "is an ambiguously worded regulation that might be interpreted to apply to 'systemic therapy' that is other than immunosuppressive in nature.").

Similarly, an April 2013 private treatment record noted a prescription of 60 pills of Monodox, taken orally one time daily, with one refill.  Symptoms were noted as multiple erythematous follicular papules and pustules on the jaw and chin, and multiple erythematous plaques with moist scale on the forehead and scalp.

A November 2014 private treatment record noted pseudofolliculitis barbae with multiple erythematous folliculocentric papules and pustules with post inflammatory hyperpigmentation on the entire beard area and anterior neck.  Treatment was noted in part to continue taking oral Doxycline at 100mg QD, once daily for 30 days.

January 2015 private treatment records note the Veteran was prescribed Doxycline 200 mg delayed release medication, started on January 2015.

The Board notes that questions have persisted as to whether the Veteran's systemic treatment was for his pseudofolliculitis barbae, as opposed to non-service connected conditions such as acne and seborrheic dermatitis.  In answering these questions, and giving the Veteran the benefit of the doubt, the Board weighs most heavily the March 2015 VA examiner's opinion, as that examiner reviewed the entire record including conflicting prior opinions.  The March 2015 examiner stated that all systemic medication prescribed could be used to treat pseudofolliculitis barbae.

The Board finds a rating higher than 30 percent is not warranted for the duration of the appeals period.  Under the former version of DC 7806, there is no evidence of ulceration or extensive exfoliation or crusting, and systemic or nervous manifestation or exceptional repugnance to warrant a 50 percent rating.  Under DC 7800, there is no indication of complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement, nor visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement, for a 50 percent rating. 

Under DC 7806 revisions, there is no indication that there is 40 percent of the entire body or more than 40 percent of exposed areas affected, for a 60 percent rating.  There is also no evidence of constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period.  In support, the Board notes the March 2015 examiner's opinion which stated that the medical record does not show the systemic medication is an on-going daily medication, but rather prescribed only during flare-ups.

Accordingly, the preponderance of the evidence is for a rating of 30 percent, but no more, for the Veteran's service-connected pseudofolliculitis barbae.  This decision is in accordance with giving the Veteran the benefit of the doubt.  Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990); 38 C.F.R. § 3.102.

Extraschedular Evaluation

The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1) , for exceptional cases where scheduler evaluations are found to be inadequate.  See Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating.  First, the Board must first 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 Board must determine whether the Veteran's 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 Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating.

With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disabilities is inadequate.  A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology.  In regard to the Veteran's pseudofolliculitis barbae, the Veteran reported having suffered itching, pustules that would bleed or drain on close shaving and post-inflammatory hyperpigmentation he perceived disfiguring, symptoms appropriately contemplated under a 30 percent rating.  

There is no evidence in the medical records of an exceptional or unusual clinical picture.  The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted.


ORDER

A rating of 30 percent, but no higher, for pseudofolliculitis barbae is granted.




____________________________________________
MICHAEL LANE
Veterans Law Judge, Board of Veterans' Appeals





Department of Veterans Affairs