Citation NR: 9738327 Decision Date: 11/17/97 Archive Date: 12/02/97 DOCKET NO. 93-00 757 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an increased rating for a skin disease (hidradenitis suppurativa), currently rated 30 percent disabling. REPRESENTATION Appellant represented by: Georgia Department of Veterans Service WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert T. Jones, Counsel INTRODUCTION The veteran served on active duty from January 1968 to January 1988. This matter initially came to the Board of Veterans’ Appeals (Board) on appeal of a November 1991 rating decision by the Atlanta, Georgia, Regional Office (RO) Department of Veterans Affairs (VA), which denied the veteran’s claim for an increased rating for a skin disease (hidradenitis suppurativa), rated 30 percent disabling. In October 1994, the case was remanded by the Board for further development. This development has been completed, and the case was returned to the Board in October 1997. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his service-connected skin condition is systemic, causes nervousness, and covers exposed surfaces, with regularly occurring flare-ups requiring treatment. He asserts a higher rating is warranted for the service-connected skin condition. DECISION OF THE BOARD The Board, in accordance with 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran’s claims file. Based on its review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that a preponderance of the evidence is against the claim for a higher rating for a service-connected skin condition (hidradenitis suppurativa). FINDING OF FACT The veteran’s service-connected skin condition (hidradenitis suppurativa) is manifested by episodic flare-ups, primarily involving nonexposed areas; it produces no systemic or nervous manifestations, and it is not exceptionally repugnant. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for the veteran’s service-connected skin condition (hidradenitis suppurativa) have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.20, 4.27, 4.118, Code 7899-7806 (1996). REASONS AND BASES FOR FINDING AND CONCLUSION I. Factual Background The veteran served on active duty from January 1968 to January 1988. Service medical records show he underwent an excision of gluteal grease hidradenitis suppurativa in May 1987. The October 1987 service retirement examination noted recurrent furuncles of the buttocks. A May 1988 VA skin examination noted diagnoses including hidradenitis suppurativa with prepubic boils or furuncles involvement in the groin, intragluteal buttocks and perineum areas. In June 1988, the RO granted a 30 percent rating for the service-connected skin condition, effective from the veteran’s separation from service. The 30 percent evaluation has been continuously in effect since that time. In May 1991, the veteran filed a claim for an increased rating. April to July 1991 VA outpatient treatment records show that the veteran was treated for hidradenitis suppurativa, characterized as representing mild activity or severity. In April 1991, Susan C. Hurt, M.D., reported that she had seen the veteran in April 1991 for his history of hidradenitis suppurativa. Examination showed no active areas of hidradenitis but some mild residual scarring from previous activity. She stated the veteran’s hidradenitis had been quiescent for the past three years. She recommended the veteran for a trial employment with the Post Office. In February 1992, outpatient treatment records from Dr. Hurt were received; they showed the veteran had active hidradenitis suppurativa in January 1992, and this condition had cleared by February 1992. Records received from Dr. Hurt in July 1992 show the veteran had a small flare-up in May 1992. The veteran testified in support of his contentions at a hearing at the RO in February 1992. At the hearing he submitted a copy of a letter from the U. S. Postal Service to the effect that a review of the veteran’s medical records showed he was not medically qualified for a job as a mail processor because of his hidradenitis suppurativa. In May 1992, the veteran was seen at a VA medical facility for several lesions on his neck, right ear and thigh. The assessment was folliculitis. Additional records from Dr. Hurt show the veteran was seen for a flare-up of hidradenitis of the left groin in January 1993. In November 1993, Isaac Willis, M.D., reported that the veteran had a diagnosis of hidradenitis suppurativa with a secondary chronic infection. He stated that when the veteran was required to work in an environment which would cause perspiration or require prolonged sitting or repetitive irritating motions to the armpits, thighs, groin, or buttocks, he would have exacerbations of hidradenitis suppurativa in the affected areas. He reported the exacerbations were debilitating and getting worse with each subsequent flare-up. The veteran was seen at a Georgia Baptist Medical Center in December 1993 for a boil between his legs of a two-day duration. Medications were prescribed. In November 1994, F. Augustus Dozier, M.D., reported he had been seeing the veteran since April 1993 for severe hidradenitis and abscesses. He enclosed outpatient treatment records which show the veteran had a left posterior scrotal abscess in October 1994 and had an excision of a cyst of the right neck in November 1994. On a VA general medical examination in April 1995, the veteran reported that he had hidradenitis suppurativa which affected primarily his axillae, neck area, back and groin. He reported he would get boils around his groin, buttocks, under his arms and sometimes on his back and the side of his neck. Examination showed no lesions of hidradenitis suppurativa on the face, neck, axilla or groin. There were a few inflammatory papules on the back. On the buttocks, there was some inflammatory papules, but, actually, they were more like slightly pigmented, raised lesions with no inflammatory reaction. The examiner summarized the veteran did not have active hidradenitis suppurativa at the time of examination. There was no scarring of the axillae or perineum. The diagnoses included hidradenitis suppurativa, history of, presently in remission. No psychiatric disorder was found on an April 1995 VA psychiatric examination. On a May 1995 VA dermatology consultation, the veteran complained of problems with hidradenitis of the groin, buttocks and axilla since 1971. Examination showed a two- centimeter cyst and a one-centimeter nodule on the right inguinal crease. There were multiple cysts and pustules on the upper back, lower earlobes, face, chest, and lateral aspect of the neck. The assessment was hidradenitis suppurativa and acneiform lesions. The veteran was hospitalized at a VA medical center in March 1996 for treatment of depressive symptoms. During the admission, a dermatology evaluation showed hidradenitis in the axilla and groin. He was begun on medication and topical ointment with warm compresses and hot tub soaks. Psychotropic medication reduced his anxiety to the point the progression of the hidradenitis symptoms was halted. In June 1996, the skin condition was quiescent, with no active lesions. The June 1996 discharge diagnosis was major depressive episode and dysthymic disorder. Other conditions noted were hypertension, hidradenitis and a stable umbilical herniation. An August 1996 addendum to the discharge summary noted that the hidradenitis was a nervous manifestation and the veteran’s nervous condition (anxiety) was ameliorated with the medications. The doctor noted that while in the hospital the veteran had been in a “physically quiescent state," but had suffered significant emotional turmoil. It was noted that the hospital environment was climate controlled for heat and humidity and the veteran had not been involved in repetitive physical activities, but his hidradenitis still flared-up due to his nervous condition. An April 1997 VA dermatology examination noted that the veteran’s hidradenitis suppurativa had been quiescent at an April 1995 examination and was still in remission except for a few inflammatory papules, which were scattered throughout. There was a small indurated papule on the mid suprapubic area and a small raised area on the left retroauricular area without pustule formation. In fact, the latter lesion was subcutaneous and not visible. There was also a small pustule on the left lumbar area. There were no axillary lesions or other lesions in the crural or perineal areas. There were no facial lesions. It was the examiner’s impression that the hidradenitis suppurativa was well controlled and just minimally active. The diagnosis was chronic hidradenitis suppurativa, presently minimally active. Color photographs of the affected areas were enclosed with the examination report. An April 1997 compensation examination dealt with psychiatric aspects of the veteran’s condition. In July 1997 the examiner noted that the veteran’s service-connected skin condition was not caused by the psychiatric condition but the psychiatric condition could aggravate the skin condition. It was noted the veteran had a history of a major depressive episode which was not related to the skin disease. The diagnosis was major depression. II. Analysis The veteran’s claim for an increased rating for the service- connected skin condition is well grounded; that is, it is not inherently implausible. 38 U.S.C.A. § 5107(a). All relevant evidence has been obtained, no further assistance to the veteran is required to comply with the VA’s duty to assist. Id. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The veteran’s skin condition, hidradenitis suppurativa, is rated as analogous to eczema. 38 C.F.R. §§ 4.20, 4.27, 4.118, Code 7899-7806. A 30 percent evaluation is warranted for eczema with constant exudation or itching, extensive lesions or marked disfigurement. A 50 percent rating requires ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or when the condition is exceptionally repugnant. 38 C.F.R. § 4.118, Code 7806. The medical history reflects the veteran has had a number of episodes of abscesses, boils and cysts, mostly in the buttock and inguinal regions. However, except for occasional periods of activity, such as when the veteran was hospitalized in 1996, the service-connected hidradenitis suppurativa has been quiescent or at the most minimally active, as was the case at the 1997 VA skin examination. Even when active, the service- connected skin condition does not have ulceration, extensive exfoliation or crusting with systemic or nervous manifestations, nor is the condition exceptionally repugnant. Lesions, when they appear, are primarily on nonexposed areas. As noted in the medical records, including the 1997 VA psychiatric examination, the veteran’s nervous symptoms are not the product of the skin condition. The photographs and medical descriptions do not reflect an exceptionally repugnant skin disorder. The disability picture more nearly approximates the criteria for the present 30 percent rating, than the criteria for the next higher rating of 50 percent, and thus the lower rating of 30 percent is proper. 38 C.F.R. § 4.7. Inasmuch as the preponderance the evidence is against the claim for an evaluation in excess of 30 percent for the service-connected skin condition, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An increased rating for a service-connected skin condition (hidradenitis suppurativa) is denied. L. W. TOBIN Member, Board of Veterans’ Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. - 2 -