Citation Nr: 1616384 Decision Date: 04/25/16 Archive Date: 05/04/16 DOCKET NO. 08-12 966A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for tinea pedis, to include as secondary to service-connected disability. 2. Entitlement to service connection for ingrown toenails, to include as secondary to service-connected disability. 3. Entitlement to an initial rating greater than 10 percent for eczema. REPRESENTATION Appellant represented by: Robert Chisholm, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Rutkin, Counsel INTRODUCTION The Veteran served on active duty from November 1994 to November 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case is currently under the jurisdiction of the RO in Nashville, Tennessee. The Board remanded these claims for further development in March 2010, September 2011, August 2013, and June 2015. The Veteran testified at a hearing before the undersigned in May 2009. A transcript is of record. The initial rating of eczema is addressed in the REMAND portion of the decision below and is REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. Manifestations of tinea pedis during the pendency of this claim did not result from disease or injury incurred in or aggravated by active service, and were not caused or aggravated by service-connected eczema or pes planus (flat feet). 2. Manifestations of an ingrown toenail condition during the pendency of this claim did not result from disease or injury incurred in or aggravated by active service, and were not caused or aggravated by service-connected eczema or pes planus. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinea pedis are not satisfied. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 2. The criteria for entitlement to service connection for ingrown toenails are not satisfied. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Due Process VA's duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) have been satisfied. See 38 U.S.C.A §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2015). Letters dated in February 2007, March 2007, August 2008, and November 2013 provided all notice required under the VCAA. They notified the Veteran of the elements of service connection on both a direct and secondary basis, the types of evidence that could support the claims, and the allocation of responsibilities between the Veteran and VA for obtaining relevant records and other evidence on her behalf. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b). The letters were followed by adequate time for the Veteran to submit information and evidence before initial adjudication or readjudication of these claims. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2007) (VCAA notice must generally be provided prior to the initial rating decision); but see Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (a timing delay in VCAA notice is harmless if followed by readjudication of the claim after the claimant has had an appropriate time to respond); accord Prickett v. Nicholson, 20 Vet. App. 370 (2006). Concerning the duty to assist, the Veteran's service treatment records and VA treatment records have been associated with the claims file. See 38 C.F.R. § 3.159(c). She has not identified any other records or evidence he wished to submit or have VA obtain. VA examinations were performed in March 2007, May 2010, January 2012, and August 2014. See 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2015). The examination reports reflect review of the claims file and consideration of the Veteran's medical history, and set forth the findings made on examination. Medical opinions regarding the service connection claims were provided in August 2014 which are supported by clear and logically sound rationales linking the data to the conclusions reached, and are sufficient to be weighed against any contrary opinions. Accordingly, the examination reports and medical opinions are adequate to make a fully informed decision. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (an adequate opinion must support its conclusion with an analysis that can be weighed against contrary opinions); Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion); see also 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). In sum, the Veteran has had a meaningful opportunity to participate effectively in the processing of these claims, and no prejudicial error has been committed in discharging VA's duties to notify and assist. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009); Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011); Vogan v. Shinseki, 24 Vet. App. 159, 163 (2010). The Board remanded these claims in March 2010, September 2011, August 2013, and June 2015 with instructions to obtain additional records, to request the Veteran to identify any pertinent records, to provide her with adequate VCAA notice, and to arrange for new VA examinations and opinions responsive to the Board's directives. All of these actions have been accomplished. Accordingly, the Board finds there has been substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (only substantial rather than strict compliance with the Board's remand directives is required under Stegall). The Veteran testified at a hearing before the undersigned in May 2009. Under 38 C.F.R. § 3.103(c)(2) (2015), the hearing officer has the responsibility to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the hearing officer has two duties under § 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id. at 496-97. At the hearing, the Veteran had an opportunity to provide testimony in support of the claims, facilitated by questioning from the undersigned and the representative of record. The Veteran did not raise any new issues at the hearing apart from the issue of secondary service connection for tinea pedis and ingrown toenails, which has since been developed including via VA examination and opinion. Further, there is no indication that any outstanding evidence might exist that would provide additional support for the claims. See id. Moreover, the Board undertook additional development after the hearing was conducted, including arranging for VA examinations and opinions to address the outstanding issues of whether ingrown toenails or tinea pedis were related to manifestations of these conditions during service or secondary to service-connected eczema of the feet or pes planus. See id. at 498-99 (finding that any deficiencies in discharging the hearing officer's duties under § 3.103(c)(2) were rendered harmless by otherwise developing the record). Given this development, in addition to the Veteran's testimony at the hearing and the evidence in the claims file, the "clarity and completeness of the hearing record [is] intact" and there is no prejudicial error concerning the hearing officer's duties under § 3.103(c)(2). See Bryant, 23 Vet. App. at 498 (holding that the rule of prejudicial error applies to the hearing officer's duties); see also Sanders, 556 U.S. at 407, 410. II. Service connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "medical nexus" between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303(a). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection entails "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. VA will not find that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). The Board must assess the credibility and weight of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Tinea Pedis The Veteran seeks entitlement to service connection for tinea pedis. Specifically, she states that she has current manifestations of tinea pedis related to the tinea pedis diagnosed in service, and that it has been present ever since service. For the following reasons, the Board finds that service connection is not established. Service treatment records reflect peeling skin in the webspaces of the left foot in December 1994. The assessment included tinea pedis. In July 1996, the Veteran presented to the dermatology clinic with scaling between her toes and dystrophic toenails. The assessment was tinea pedis with onychomycosis. During treatment in January 1997, the Veteran's tinea pedis was described as well-controlled. In September 1997, the Veteran was diagnosed with onychomycosis and was given Diflucan. The Veteran returned for follow-up of onychomycosis in March 1998, and reported excellent results with Diflucan. The pertinent assessment was onychomycosis resolved with Diflucan. Clinical evaluation of the feet and skin was normal on periodic examination in May 2001 and the Veteran denied foot trouble or skin diseases in her Report of Medical History at that time. In her August 2006 Report of Medical History at separation, the Veteran denied skin diseases; however, she reported foot trouble, specifically, large blisters. The examiner commented that the Veteran had blisters on her feet after climbing Mount Fuji in August 2006. It was noted that she had recovered and this condition was not considered disabling. On separation examination in August 2006, clinical evaluation of the skin was normal. Clinical evaluation of the feet was abnormal, with a notation of pes planus, but no noted abnormalities of the skin. During a March 2007 VA examination, the Veteran reported the onset of dermatophytosis of the toe nails and feet in the mid-1990s. She described an intermittent course of interdigital peeling, itching, and cracking of the skin, treated with over-the-counter antifungal creams. She also described an intermittent course of fungus of the bilateral toe nails, although there was no nail fungus at the time of examination. There was no tinea pedis or onychomycosis on examination. The pertinent diagnoses were tinea pedis bilateral feet, resolved, and onychomycosis bilateral toe nails, resolved. The Veteran presented to the Jacksonville VA outpatient clinic (OPC) in October 2007 with a pruritic rash on the bottom of her feet. The assessment included tinea pedis. On VA foot examination in May 2010 there was no skin abnormality of either foot. However, a VA skin examination report from the same date noted dryness and peeling with a few reddish papules on the plantar aspect of the left foot. The right foot was clear. The assessment was eczema of the bilateral feet. A July 2011 VA treatment record includes an assessment of peeling at the plantar feet, most consistent with fungal versus dyshidrotic eczema, with the latter diagnosed by a dermatologist in May 2009. During VA dermatological treatment in August 2011, the Veteran described irritation of her feet which started in service with wearing boots. The assessment was dyshidrotic eczema, aggravated by trauma from scrubbing and strong soap. The Veteran's skin was described as normal during treatment at the VA podiatry clinic in September 2011, March 2012, and November 2012. A November 2011 VA dermatology note reflects that the Veteran gave a history of a rash on her feet for a long duration, although she had had a good response to topical medications and the rash was clear. The assessment was tinea pedis, resolved. On VA skin examination in January 2012, the Veteran reported that her skin condition started on a ship in November 2004 because she was always working and could not take off her boots. She indicated that her symptoms of peeling, itching, and small pustules had been continuous since. She stated that she had been using Terbinafine HCL for tinea pedis constantly or nearly constantly since August 2011. The diagnoses were eczema of the feet and no objective evidence of tinea pedis on examination. In the August 2014 VA examination report, the examiner opined that it was less likely than not that the Veteran's tinea pedis was incurred in active service. The examiner explained that tinea pedis is a condition which is treatable and usually resolves with treatment. Available medical records revealed that the Veteran did have tinea pedis as well as toenail onychomycosis which was successfully treated. The examiner stated that with no documentation of recurrence in a short interval following treatment it was most likely that the mycosis involving the feet and nails resolved. Any recurrence after a significant interval of more than 6 months was much more likely a separate infection and not related to the tinea pedis which occurred in service. The examiner noted that treatment records showed that after the Veteran separated from service, she developed diabetes, and that diabetes placed her at increased risk for infections of the feet, including mycotic infections. It was therefore likely (the examiner wrote "unlikely," but in the context of the sentence and the overall opinion clearly meant likely) that any bouts of tinea pedis which the Veteran had since service separation were separate infections and unrelated to the tinea pedis which the Veteran had during military service. The examiner further noted that there was no documentation in the VA treatment records of any complaints or treatment of a skin condition of the feet, or ongoing therapy for a skin condition of the feet. The examiner observed that the Veteran was treated periodically with a steroid cream for apparent eczema, but that the records did not reflect ongoing treatment for tinea pedis. The examiner reiterated that the recurrence of tinea pedis after a prior manifestation has been cured is a separate episode of the condition. The examiner also stated that a substantial period of no documentation of the condition made it most likely that the Veteran's in-service tinea pedis had been cured. The Board here noted that not only is there an absence of documentation, but the service examination reports and March 2007 VA examination report show that the Veteran did not have tinea pedis at the time. With regard to secondary service connection, the examiner opined that flat feet and eczema do not cause tinea pedis nor predispose to tinea pedis. The examiner explained that tinea pedis is usually a mycotic infection and if that infection involves the nails it is diagnosed as onychomycosis. The Veteran's health records revealed that she was successfully treated for tinea pedis as well as onychomycosis. If the Veteran had recurrences of tinea pedis, it was much more likely than not that her diabetes was a major contributor, according to the examiner. The examiner concluded that there was no evidence that the Veteran's eczema of the feet or flat feet would cause or aggravate tinea pedis. Finally, the examiner noted that there were no signs of eczema, tinea pedis, or onychomycosis on examination. The preponderance of the evidence weighs against a relationship between any manifestations of tinea pedis during the pendency of this claim and the tinea pedis diagnosed in service. The May 2001 periodic examination, August 2006 separation examination, and March 2007 VA examination report all show that the manifestation tinea pedis during service in 1997 had fully resolved. While the Veteran is competent to state that she has had recurrent skin rashes since service, the above examination reports clearly show that prior manifestations of tinea pedis had resolved. The Board also notes that the recurrent skin rashes could be consistent with service-connected eczema. In any event, as explained by the August 2014 VA examiner, any subsequent manifestations of tinea pedis during the pendency of this claim were discrete episodes unrelated to the tinea pedis that occurred during service, which had completely resolved before separation. The examiner's opinion carries more weight than the Veteran's lay opinion, as the former represents the conclusion of a medical professional and is supported by a thorough explanation. The Veteran, by contrast, does not have similar medical expertise, and has not provided an explanation or supporting evidence, or accounted for the fact that the prior manifestation of tinea pedis had resolved. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the medical question at issue); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence"). Accordingly, there is no medical nexus between any current manifestations of tinea pedis and the tinea pedis that occurred during service. See Holton, 557 F.3d at 1366. Thus, service connection on a direct basis is not established. See id.; 38 C.F.R. § 3.303(a). With regard to secondary service connection, the August 2014 VA examiner explained that flat feet and eczema do not cause or aggravate tinea pedis. The examiner explained that tinea pedis is an unrelated condition and that diabetes was more likely a major contributor. The Board also finds no apparent reason why flat feet or eczema would cause tinea pedis or aggravate it beyond any medically established baseline, and the Veteran has not advanced any explanations or evidence in this regard. The examiner's opinion carries more weight on this issue than the Veteran's lay statements. See King, 700 F.3d at 1345; Madden, 125 F.3d at 1481. Moreover, and in the alternative, there is no evidence of functional impairment, symptoms, or worsening beyond any medically established baseline. Accordingly, secondary service connection is not established. See 38 C.F.R. § 3.310. In sum, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for tinea pedis is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Ingrown Toenails The Veteran seeks entitlement to service connection for ingrown toenails. Specifically, she states that she has current manifestations of ingrown toenails related to the ingrown toenails diagnosed in service, and that she has had a recurrent ingrown toenail condition ever since service. For the following reasons, the Board finds that service connection is not established. Service treatment records reflect that, in July 1996, the Veteran presented with swelling and tenderness of the lateral left great toenail. The assessment was ingrown toenail. Clinical evaluation of the feet was normal on periodic examination in May 2001 and the Veteran denied foot trouble in her Report of Medical History at that time. In November 2005, the Veteran received treatment for an ingrown toenail on the first digit of the right foot. In her August 2006 Report of Medical History at separation, the Veteran denied skin diseases; however, she reported foot trouble, specifically, large blisters. The examiner commented that the Veteran had blisters on her feet after climbing Mount Fuji in August 2006. It was noted that she had recovered and this condition was not considered disabling. On separation examination in August 2006, clinical evaluation of the skin was normal. Clinical evaluation of the feet was abnormal in that pes planus was noted. The March 2007 VA skin examination report reflects that the examiner found no nail conditions on examination. The examiner noted the Veteran's history of onychomycosis, but stated that it had resolved. A January 2008 VA treatment record reflects the Veteran's report of painful toenails since 2005, and a February 2008 VA treatment record reflects the Veteran's report of ingrown toenails since 2004. Examination revealed ingrown first toenails, bilaterally. The Veteran was scheduled for surgical correction. She presented for surgical correction later that month, at which time she complained of painful ingrown toenails of both great toes for several weeks and gave a history of many ingrown nails. The assessment was chronic ingrowing nails bilateral hallux medial borders. Phenol matrixectomy was performed. In the August 2014 VA examination report, the examiner opined that it was less likely than not that the Veteran's ingrown toenails were incurred in active service. The examiner explained that onychomycosis can cause ingrown toenails, but that the records in the file showed that the Veteran's in-service manifestation of onychomycosis had been cured. Thus, the examiner concluded that any additional episodes of onychomycosis constituted a separate mycotic infection which was not related to the previous infection, as the former infection was shown to have resolved. The examiner stated that recurrence of ingrown toenails after the removal of the toenails are separate episodes of the condition and due to factors occurring after such treatment such as possible additional onychomycosis infections and "appropriate nail care [sic]" (the examiner likely meant "inappropriate" nail care, in the context of the sentence and overall opinion). The examiner also noted that the Veteran did not have ingrown toenails on examination. With regard to secondary service connection, the examiner found that flat feet and eczema do not cause or aggravate ingrown toenails. The examiner provided the explanation above, stating that ingrown toenails may be related to other factors, such as onychomycosis. As there is no apparent basis for a relationship between flatfeet or eczema and ingrown toenails, either by way of causation or aggravation, further opinion is not warranted. The preponderance of the evidence weighs against a relationship between any manifestations of ingrown toenails during the pendency of this claim and the ingrown toenails that occurred during service. The May 2001 periodic examination, August 2006 separation examination, and March 2007 VA examination report all indicate that the Veteran did not have ingrown toenails when examined, and thus that the ingrown toenail condition during service had resolved. As explained by the August 2014 VA examiner, any subsequent manifestations of ingrown toenails during the pendency of this claim were separate episodes unrelated to the ingrown toenails that occurred during service, which had completely resolved before separation. The examiner noted that onychomycosis would be a cause of the ingrown toenails, but the STRs and post-service treatment records similarly show that the in-service onychomycosis had fully resolved with medication, and the August 2014 VA examiner explained that subsequent manifestations of onychomycosis would not be related to the in-service manifestations. The examiner's opinion carries more weight on this issue than the Veteran's lay statements, for the reasons discussed above with regard to tinea pedis. See King, 700 F.3d at 1345; Madden, 125 F.3d at 1481. Accordingly, there is no medical nexus between any current manifestations of ingrown toenails and the ingrown toenails that occurred during service. See Holton, 557 F.3d at 1366. Thus, service connection on a direct basis is not established. See id.; 38 C.F.R. § 3.303(a). With regard to secondary service connection, the August 2014 VA examiner found that flat feet and eczema do not cause or aggravate ingrown toenails. The examiner explained that ingrown toenails are an unrelated condition more likely due to subsequent episodes of onychomycosis or inappropriate nail care. The Veteran has not advanced any explanations or supporting evidence as to how eczema or flat feet could cause or aggravate an ingrown toenail condition. More weight is placed on the examiner's opinion than the Veteran's lay statements. Moreover, and in the alternative, there is no evidence of functional impairment, symptoms, or worsening beyond any medically established baseline. Accordingly, secondary service connection is not established. See 38 C.F.R. § 3.310. In sum, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for ingrown toenails is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for tinea pedis, to include as secondary to service-connected disability is denied. Entitlement to service connection for ingrown toenails, to include as secondary to service-connected disability is denied. REMAND While the Board sincerely regrets the delay, the appeal of the initial rating of the Veteran's service-connected eczema must be remanded again for further development to ensure it is afforded every due consideration in light of recent case law, and to aid the Board in making an informed decision. A new VA opinion is required to assess whether the Veteran's eczema requires treatment with topical corticosteroids. In this regard, the U.S. Court of Appeals for Veterans Claims (Court) recently held that topical corticosteroids constitute systemic therapy under Diagnostic Code (DC) 7806, which pertains to dermatitis or eczema, based on the plain language of the rating criteria, irrespective of whether topical corticosteroids are in fact considered to be systemic therapy from a medical standpoint. Johnson v. McDonald, 27 Vet. App. 497, 504 (2016); see 38 C.F.R. § 4.118 (2015). The record shows that the Veteran's eczema has been treated with topical corticosteroids during the pendency of this claim, but it is not evident whether this treatment is "required" and for what duration so as to meet the criteria for a higher rating based on the use of topical corticosteroids under Diagnostic Code 7806. See 38 C.F.R. § 4.118. Specifically, in the August 2014 VA examination report, the examiner noted that the Veteran stated she was using hydrocortisone ("HC") cream "left over from previous prescriptions." The examiner observed that there were no prescriptions for a skin condition documented in the available treatment records over the past eighteen months. However, the examiner checked the box in the questionnaire for constant or near-constant topical corticosteroids, specifying the HC 1% cream. Further, an August 2011 VA treatment record reflects that fluocinonide cream was prescribed "when needed" for irritation, and a January 2012 VA examination report states that the Veteran had been treated with topical corticosteroids in the past twelve months based on the prescription for fluocinonide cream. The examiner further stated that it was used for six weeks or more, but not constant or near-constant, without explaining the basis for this finding. Because the August 2014 VA examiner indicated that the Veteran used topical corticosteroids on a constant or near-constant basis, but did not specify whether they are actually required to treat the condition, and as this finding was apparently based on the Veteran's use of hydrocortisone left over from past but not current prescriptions, it is not clear to the Board whether the Veteran's eczema has in fact required topical corticosteroids, and for what duration (i.e. more or less than six weeks, or constant or near-constant). See 38 C.F.R. § 4.118, DC 7806; Johnson, 27 Vet. App. at 504. Similarly, the January 2012 VA examination report does not clarify the basis for the examiner's finding that topical corticosteroids were used for six weeks or more, but not constant or near-constant over the past 12-month period, or whether such was actually required. Thus, a new opinion must be obtained to clarify this issue. See 38 C.F.R. § 4.2 (2015) (providing, in pertinent part, that if a VA examination report does not contain sufficient detail, it is incumbent on the rating board to return the report as inadequate for evaluation purposes). Accordingly, the case is REMANDED for the following action: 1. Obtain a supplemental opinion as to whether the Veteran's service-connected eczema has required therapy with topical corticosteroids since January 2011, and for what duration for any given 12-month period (i.e. more or less than 6 weeks, or constant or near-constant). The entire claims file must be made available to the examiner for review. For purposes of rendering the opinion, the examiner is advised of the following: * In the August 2014 VA examination report, the examiner noted that the Veteran stated she was using hydrocortisone ("HC") cream "left over from previous prescriptions." The examiner observed that there were no prescriptions for a skin condition documented in the available treatment records over the past eighteen months. However, the examiner checked the box in the questionnaire for constant or near-constant topical corticosteroids, specifying the HC 1% cream. * An August 2011 VA dermatology record reflects that fluocinonide cream was prescribed "when needed" for irritation, and a January 2012 VA examination report states that the Veteran had been treated with topical corticosteroids in the past twelve months based on the prescription for fluocinonide cream. The examiner further stated that it was used for six weeks or more, but not constant or near-constant, without explaining why or whether this was actually required. * A February 2011 VA treatment record reflects that the Veteran was going to try hydrocortisone cream for suspected dishydrotic eczema. A list of prescription medications shows that she was prescribed hydrocortisone cream on this day. A complete explanation must be provided in support of the conclusion reached. The Board emphasizes that the examiner must clarify whether the use of topical corticosteroids has been actually required, not merely whether they have been used. 2. Then, review the opinion obtained to ensure it adequately responds to the above remand directives. If not, it must be returned to the examiner for corrective action. 3. Finally, after completing any other development that may be indicated, readjudicate the claim on the merits. If the benefits sought are not granted, the Veteran and her representative must be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the issues the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. All claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs