Citation Nr: 9832823 Decision Date: 11/04/98 Archive Date: 11/17/98 DOCKET NO. 90-42 948 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an increased evaluation for multiple sebaceous cysts of the face and scalp, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Virginia Department of Veterans Affairs ATTORNEY FOR THE BOARD M. L. Wright, Associate Counsel INTRODUCTION The veteran had active service from August 1978 to August 1981. This appeal arises from a November 1989 rating decision of the Roanoke, Virginia, Regional Office (RO). In this decision, the RO denied the veteran’s claim for an increased evaluation of his multiple sebaceous cysts of the face and scalp which was rated as 30 percent disabling. The veteran appealed this determination. The Board of Veterans’ Appeals (Board) remanded this case in October 1991 for further development of the medical evidence. The case was returned to the Board and again remanded in May 1995. The Board determined that a contemporaneous dermatology examination was needed. It was further found that the veteran had filed claims for secondary service connection for multiple disorders as a result of his service- connected skin disease. These secondary service connection claims were determined to be inextricably intertwined with the issue on appeal. By letter of June 1995, the RO contacted the veteran and requested that he clarify his claims for secondary service connection. He responded in April 1996 that he wished to claim secondary service connection for a psychiatric disorder and a joint disorder as a result of his service-connected skin disease. The RO denied these secondary service connection claims in a rating decision of November 1996. The veteran was notified of this decision in a letter dated that same month. He filed a notice of disagreement with the denial of secondary service connection for a psychiatric disorder in March 1997. The RO issued a statement of the case in April 1997 and a supplemental statement of the case in June 1997. The veteran failed to file a timely substantive appeal. Therefore, the veteran’s claims for secondary service connection are no longer in appellate status. The remand section of this decision contains a discussion about the veteran’s claim for a total disability evaluation for individual unemployability due to his service-connected skin disorder. CONTENTION OF APPELLANT ON APPEAL The veteran contends, in effect, that his service-connected skin disease is worse than currently evaluated. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), 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 in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence warrants a grant of an increased schedular evaluation of 50 percent and no more for his service-connected cysts of the face and scalp. FINDINGS OF FACT 1. The veteran’s service-connected skin disorder is manifested by ulceration, purulent discharge, marked disfiguring scars, and nervous manifestations. 2. The veteran’s service-connected skin disorder has not resulted in marked discoloration, color contrast, or a most repugnant or disfiguring condition. CONCLUSION OF LAW An increased evaluation to 50 percent disabling, but not more, is warranted for the veteran’s multiple sebaceous cysts of the face and scalp. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.14, Codes 7800, 7806, 7819 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background. By rating decision of September 1982, the RO granted the veteran’s claim for service connection for multiple sebaceous cysts. This disability was determined to be noncompensable under the U. S. Department of Veterans Affairs (VA) Schedule For Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code (Code) 7819. This award was made effective from August 1981. The noncompensable evaluation was confirmed in a rating decision of February 1983. In a rating decision of June 1986, the veteran was granted an increased evaluation to 10 percent disabling effective from March 1985 and the disorder was identified as multiple sebaceous cysts of the face and scalp. The 10 percent evaluation was confirmed in rating decisions of October 1986 and October 1987. By rating decision of May 1988, the RO again increased the evaluation of the veteran’s skin disability to 30 percent disabling effective from August 1987. In April 1989, the veteran filed a claim for an increased evaluation for his service-connected skin disorder. He claimed that he constantly had cysts on his face and neck that would drain, itch, flake, and peel. The veteran asserted that every time one of his cyst was lanced it would heal into a scar with lose of hair growth. He considered these scars to be disfiguring. VA outpatient records dated from October 1987 to April 1989 were incorporated into the claims file in June 1989. In March 1989, the veteran requested VA domiciliary care. He claimed that he had been forced to leave his last place of residence because his roommate could not tolerate his cyst that would burst and release a foul odor. The veteran alleged that he had not worked in the last eight months and prior to that period had only worked as a temporary laborer doing odd jobs. In April 1989, the medical clinic removed a recurring cyst or abscess from the veteran’s left occipital/parietal area. The consultation report noted that the veteran was followed for severe acne and dissecting cellulitis of scalp. He tended to get abscessed areas in his groin and scalp. The last cyst removed from the veteran had been approximately two months before. It was noted that the veteran’s abscesses usually stank and would develop a secondary infection after incision and drainage. The veteran was afforded a VA dermatology examination in July 1989. It was noted that the veteran had been followed by the VA dermatology clinic since 1987 for dissecting cellulitis of the scalp, acne valgus, and hidradenitis suppurativa. He complained of problems with cysts on his face and scalp. On examination, the scalp was found to have numerous nodules that drained purulent material and were associated with fibrosis and scarring. These nodules were located on the top of his scalp and in the bi-temporal area. There were numerous old scars, pustules, and nodules on the veteran’s face. The nodules were noted to actively drain purulent material, especially on the right lower jaw. These fluctuant nodules measured two by five centimeters (cm) and smaller. The veteran’s chest and back were clear with few papules, but did contain post-inflammatory residuals and open comedones. The right axilla was clear, but the left showed scarring that was sausage-shaped in appearance with no activity. Examination of the veteran’s scrotal area revealed sausage- shaped scars on the right scrotal sac. This area was not active on examination, but the veteran reported it had recently been so. Color photographs were attached to the examination report. The impression included dissecting cellulitis of the scalp; cystic acne vulgaris on the face, chest, and back; and hidradenitis suppurative on the left axilla and right scrotal sac. It was opined by the examiner that all of these disorders were chronic in nature with no possible cure, but medication sometimes controlled the process. By rating decision of November 1989, the RO determined that an evaluation in excess of 30 percent disabling was not warranted for the veteran’s service-connected skin disability. The veteran filed a notice of disagreement (NOD) with this decision in June 1990. He claimed that the drainage and odor from his service-connected cysts were so bad that employers refused to let him stay on the job. In his substantive appeal of August 1990, the veteran alleged that his service-connected skin disorder caused constant drainage and soreness. He also asserted that he had problems being around other people because of the smell and swelling that his cysts caused. The veteran’s representative filed a VA Form 1-646 in September 1990 in which it was argued that the color photographs taken at the VA examination in November 1989 showed that the veteran’s cysts had continuous drainage, crusting, ulceration, and were exceptionally repugnant. In an appellant’s brief submitted by the veteran’s representative in August 1991, it was contended that the severity of the veteran’s skin disability warranted at least a 50 percent evaluation. The Board issued a remand in October 1991 in order to obtain pertinent VA medical records. VA outpatient records dated from December 1990 to September 1991 were associated with the claims file in January 1992. These records noted treatment of the veteran’s skin disorders. Medical records from a VA medical center dated from April 1989 to October 1991 were incorporated into the claims file in June 1992. These records contained references to outpatient treatment for the veteran’s skin problems and a hospitalization in September and October 1991 for a collapsed lung. The RO again denied an increased evaluation for the veteran’s skin disability in a rating decision of June 1992. Associated with the veteran’s claim file in December 1992 were VA medical records dated from December 1990 to September 1992. A VA outpatient record of July 1991 noted that the veteran had small nodules on his scalp and axillary. An employment history was taken from the veteran on a medical record of February 1992. He claimed that he had given up his business as a barber because of the overhead associated with it and because of his growing drug and alcohol use. In April 1992, the veteran complained of draining cysts on his face and scalp that had gotten worse. Examination revealed two furuncles on the side of this neck and small nodules on his scalp. The diagnosis was facial furuncles and folliculitis. An operative report of July 1992 noted the veteran had been treated as an outpatient for cellulitis and had an infected cyst underneath his chin. This cyst was surgically removed and the veteran was released. In September 1992, the veteran complained of a cyst on the side of his neck and was diagnosed with questionable folliculitis with regional “hymphondenotis.” The RO again denied entitlement to an increased evaluation for the veteran’s skin disorder by rating decision of December 1992. In November 1993, the RO received a letter that the veteran had written to his congressional representative. He claimed that his service-connected skin disorder continued to exist and had resulted in the loss of employment. The veteran alleged that this disability had resulted in verbal abuse and his subsequent mental anguish. VA inpatient treatment records dated from June to July 1993 were incorporated into the claims file in November 1993. These records contain no description of treatment of the veteran’s skin disorder. By rating decision of August 1994, the RO again denied an increased evaluation for the veteran’s skin disorder. In November 1994, the RO incorporated into the claims file VA outpatient records dated from June 1993 to October 1994. The veteran complained of subaceous cysts on his scalp and under his left arm in May 1994. He claimed that these cysts had yellowish drainage that would smell. It was reported by the examiner that there were multiple scars with hair loss in the occipital area. The diagnosis was recurrent scalp folliculitis. In July 1994, the veteran complained of a two week history of a painful cyst on the right side of his head. He described purulent and smelling drainage coming from this cyst. An examination revealed recurrent cysts in the right occipital and left axillary areas. The impression was sebaceous cysts and dissecting cellulitis. The veteran had a mildly fluctuant cyst removed from his scalp in October 1994. His medical history was noted 10 years of multiple cysts and abscesses in his scalp. It was reported that that these cysts had resulted in multiple incision and irrigation with subsequent poor response to antibiotics. An examination of his skin revealed multiple cystic lesions of the scalp with evidence of purulent drainage. An operative note dated in November 1994 noted that three abscesses were removed from the right side of his scalp. The diagnosis was chronic hidradenitis with subcutaneous abscesses. Also received by the RO in November 1994 was a VA discharge summary for a period of hospitalization from June to July 1993. A physical examination revealed several sebaceous cysts on the scalp with severe scarring. In a rating decision of December 1994, the RO again denied the veteran’s claim for an increased evaluation for his service-connected skin disability. The Board issued another remand in this case in May 1995. The RO was instructed to develop secondary service connection claims resulting from the veteran’s skin disorder. It was also directed by the Board that the veteran’s recent treatment records be obtained and that he be given a contemporaneous VA dermatology examination. A letter from the veteran was received in July 1995. He claimed that his service-connected skin disorder was uncontrollable. It was the veteran’s contention that continual flare-ups of this disorder had interfered with his profession as a barber and with his family relations. He also alleged that his skin disorder had resulted in his own emotional problems. VA medical records dated from October 1993 to August 1995 were associated with the claims file in September 1995. An outpatient record of October 1993 reported that the veteran had a 2 cm cyst in the mandible area. The impression was sebaceous cyst. In November 1993, the veteran was found to have cystic acne and hidradenitis suppurativa. The veteran complained in June 1995 of recurrent cysts in his scalp and groin area. He claimed that these cyst would itch, drain fluid, and burst. The impression was folliculitis. A VA discharge summary for a period of hospitalization in October 1994 reported that the veteran had a skin rash with bumps of three months duration. He also had cysts on his head and the back of his neck. In a VA discharge summary for a period of domiciliary care from October to November 1994, a physical examination revealed cysts on the veteran’s head that had purulent drainage. The diagnoses included multiple cyst lesions of the scalp. A social history taken during a VA hospitalization in June 1995, noted that the veteran had difficulty sustaining a job because of his skin disorder. The veteran was hospitalized at a VA facility in August 1995 due to psychiatric problems. It was noted that the veteran had suffered with chronic depression since the 1980’s that had intensified in the last few months. The discharge summary reported: [The veteran] is particularly bothered by a recurrent fear of a maggot infestation. He described nightmares of large maggots. At times he has a sensation of bugs crawling on him and he feels that he is now obsessed with cleanliness. These symptoms had been subsequent to an incident in which maggots were found in an open lesion in his scalp. He had been homeless in the days prior to discovery of the maggots…He blames the loss of his job as a cosmetic/hair specialist on his skin condition. He also described a sense of paranoia, feeling as if others are all looking at his skin. The diagnoses included acne vulgaris. A VA dermatology examination was provided to the veteran in September 1995. He complained of cysts on his scalp for many years and acne on his face and axilla. The veteran reported a rash on his chest, back, and neck of one month’s duration. On examination, there was extensive scarring on the scalp in a sausage-like configuration. There was a purulent site on the left parietal and left occiput areas. The veteran’s face had extensive deep pitted scarring of the forehead and cheeks. There was numerous ingrown hear papules in the beard area. In the right beard area there was a firm mass. Verruca valgus was found on the left elbow. Examination of the axillae was negative. On the veteran’s back, chest, and neck was “hypopygmation.” Potassium hydroxide tests were positive for fungus. In October 1995, the veteran was given a VA psychiatric examination. The veteran described on examination his obsession and fear of maggots in his skin. The diagnosis was cocaine and alcohol dependence in partial remission. It was opined that there probably were no active depressive symptoms, and, if so, these were related to the veteran’s substance abuse. Delusional parasitosis was to be ruled out, but the examiner opined that these symptoms may be related to [illegible] or chronic cocaine dependence. The examiner also commented that it could be the result of malingering as the veteran had a history of consistent antisocial personality. By rating decision of December 1995, the RO denied an increased evaluation for the veteran’s service-connected skin disability. He was notified of this decision by letter of February 1996. The RO incorporated into the veteran’s claim file in December 1996 three VA discharge summaries for periods of hospitalization in May 1995, December 1995, and May 1996. The veteran was hospitalized in May 1995 for psychiatric complaints. His psychiatric complaints included a poor self- image due to his skin condition. He also claimed that he had been forced to give up his occupation as a barber because of his skin disorder. Physical examination found multiple cysts in the occipital area of the scalp. His discharge diagnoses included to rule out major depression and a mood disorder induced by substance abuse; and psychosis barbae. In December 1995, the veteran was again admitted for psychiatric complaints. The veteran claimed that at one time he had been a barber, but lost his shop after developing his skin disorder. He alleged that his customers thought he had developed HIV and feared to be around him. On examination, the veteran’s scalp had scaly lesions and was mildly tender. No discharge diagnosis was recorded. The hospitalization in May 1996 was in response to the veteran’s psychiatric complaints. These complaints included the feeling that maggots were crawling in and out of his veins. Physical examination revealed pustular lesions at two different sites in the scalp. There was also a possible cyst in the veteran’s scrotum area. The discharge diagnoses included substance induced mood disorder with psychotic features, polysubstance abuse, and removal of sebaceous cyst. A letter was received from the veteran in January 1997. He claimed that he had many hospitalizations in the last 10 years due to his skin disorder. The veteran alleged that this disorder had left him unemployed and emotionally disabled which in turn caused a hardship on his family. He asserted that his skin disorder had left his face permanently disfigured. In a written statement of November 1996, the veteran claimed that his skin disability had hindered his ability to make a productive living. He contended that the VA had not properly considered the impact his service- connected skin disability had on his employment. The veteran alleged that his VA physicians had told him that his chronic deep depression was due to his skin condition. It was reported by the veteran that he was to undergo surgery for his skin disorder in the coming week. The veteran submitted a written statement in March 1997 in which he claimed that he was constantly thinking and dreaming about his skin disorder. Multiple VA discharge summaries were associated with the claims file in June 1997 that described the veteran’s multiple hospitalizations between February and May 1997. These hospitalizations were the result of the veteran’s psychiatric and substance abuse complaints. In February 1997, the veteran claimed that finding maggots in his open wounds had triggered nightmares, flashbacks, hyperarousal, and mood swings. The discharge diagnoses included dysthymic disorder, polysubstance abuse, cellulitis, cystic acne, and hidradenitis suppurativa. A March 1997 discharge summary noted that the veteran had obtained full-time employment working the night shift at a shipyard. The veteran was readmitted a day later after visual hallucinations of maggots eating his skin and chasing him. He acknowledged that he had been using marijuana for the past 15 years and cocaine for the past five years. The veteran blamed his skin disorder for his emotional difficulties that had resulted in paranoia and isolation. The discharge diagnoses included dysthymia, alcohol and cocaine dependence, hidradenitis suppurativa, cystic acne, and a history of dissecting cellulitis. The discharge summaries from May 1997 are inconsistent about whether the veteran was unemployed or had maintained his employment with the shipyard. Physical examinations revealed that the veteran had lymphadenopathy secondary to acne lesions and hepatomegaly, chronic cystic acne vulgaris. The diagnoses included dysthymia, polysubstance dependence, hidradenitis suppurativa of the left axilla and groin, cystic acne vulgaris of the face, dissecting cellulitis of the scalp, keratosis pillaries of the buttocks, xerosis of the extremities and trunk, and tinea pedis with onychomycosis. A provisional diagnosis was also given for post-traumatic stress disorder (PTSD) secondary to a skin condition. The veteran was given another VA psychiatric examination in June 1997. It was noted that the veteran was unemployed and homeless. The veteran claimed that his skin disorder had gotten much worse over recent years. He asserted that at times his facial scars would drain and stink, and his face would become swollen. The veteran alleged that sometimes he has had to take two to three days off work in order to get the swelling to go down. He complained that his skin disability had caused him to become irritable, on edge, hopeless, and depressed. The veteran claimed that people would look at his skin funny and not want to be around him because of the smell. He alleged that in the past maggots had been found in the lesions in his face, armpits, and groin. Because of this, the veteran asserted that he now had nightmares of maggots coming out of his lesions and all over the floor around him. He claimed that he was bothered by seeing rice or anything else that resembled maggots. The veteran also reported that he heard voices telling him to kill himself and saw the faces of demons pushing out from solid walls to talk to him. The examiner noted that the veteran had previously received a provisional diagnosis for PTSD. The diagnoses were chronic undifferentiated schizophrenia, history of alcohol and cocaine dependence, hidradenitis suppurativa, and a history of dissecting cellulitis. The examiner opined that the veteran’s schizophrenia had not been previously diagnosed probably due to the fact that the positive symptoms are not nearly as prominent as the veteran’s negative symptoms. It was further determined by the examiner that this illness began in the veteran’s mid-to-late twenties. The RO sent a letter to the veteran in July 1997 requesting him to identify the health care provider who had conducted surgery he had claimed was done for his skin disorder in November 1996. He was asked to sign and submit the appropriate release forms so that these medical records could be obtained. The veteran was warned that if he did not complete and return the release forms within 60 days of the date of the letter, his claim could be disallowed. No response was received from the veteran. This evidence was received by the RO, but in September 1997 the veteran requested that it be returned to him. The RO complied with this request that same month. II. Applicable Criteria. Under the applicable criteria, 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 (West 1991); 38 C.F.R. Part 4 (1998). Separate diagnostic codes identify the various disabilities. The 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 conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2 (1998). Also, 38 C.F.R. § 4.10 (1998) provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person's ordinary activity. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 594. However, when entitlement to compensation has been established and an increase in disability rating is the issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The evaluation of the same disability or manifestations under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (1998). Rather, the veteran’s disability will be rated under the diagnostic code which allows the highest possible evaluation for the clinical findings shown on objective examination. When an unlisted condition is encountered, it will be permissible to rate this disability under a closely related disease or injury in which not only the functions affected, but 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 (1998). The following rating criteria are applicable to the current claim: Code 7800. Scars, disfiguring, head, face or neck: >Complete or exceptionally repugnant deformity of one side of face or marked or repugnant bilateral disfigurement; rate as 50 percent disabling. >Severe, especially if producing a marked and unsightly deformity of eyelids, lips, or auricles; rate as 30 percent disabling. * Note: When in addition to tissue loss and cicatrization there is marked discoloration, color contrast, or the like, the 50 percent rating under Code 7800 may be increased to 80 percent, the 30 percent to 50 percent, and the 10 percent to 30 percent. The most repugnant, disfiguring conditions, including scars and diseases of the skin, may be submitted for central office rating, with several unretouched photographs. Code 7806. Eczema: >With ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant; rate as 50 percent disabling. >With exudation or itching constant, extensive lesions, or marked disfigurement; rate as 30 percent disabling. Code 7819. New growths, benign, skin. >Rate as scars, disfigurement, etc. >Unless otherwise provided, rate codes 7807 through 7819 as for eczema, dependent upon location, extent, and repugnant or otherwise disabling character of manifestations. * Note: The most repugnant conditions may be submitted for central office rating with several unretouched photographs. Total disability ratings may be assigned without reference to Central Office in the most severe cases of pemphigus and dermatitis exfoliativa with constitutional symptoms. 38 C.F.R. Part 4 (1998). III. Analysis. The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is well-grounded if the claimant alleges that a disorder for which service connection has been granted has worsened. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this case, the veteran asserted that his service-connected skin disorder is worse than currently evaluated, and he has thus stated a well-grounded claim. Initially, the undersigned notes that the veteran claimed in November 1996 that additional medical records pertinent to his skin disorder were available. The RO requested information about this evidence in July 1997 and informed the veteran of the adverse action that could result due to his lack of cooperation. It is determined by the undersigned that the VA has satisfied all requirements to help the veteran develop this evidence and inform him of the possible adverse consequences. See Robinette v. Brown, 8 Vet. App. 69 (1995). Therefore, this claim is ready for appellate consideration. A review of the objective evidence indicates that the veteran has recurrent cysts and/or abscesses about his scalp, face, and neck. The most analogous rating criteria are found at Codes 7800 and 7806. These cysts have been noted to have purulent, odorous drainage. There are a number of incidents noted since 1990 of the veteran having these cysts surgically removed. An April 1989 examiner observed that these incisions tended to develop secondary infections. Severe fibrosis and extensive deep-pitted scarring has been noted on the veteran’s face and scalp. The veteran’s skin disorder has received diagnoses of dissecting cellulitis, folliculitis, acne valgus, and hidradenitis suppurativa. The VA dermatologist who examined the veteran in July 1989 commented that the veteran’s skin disorders could not be cured and only possibly alleviated with medication. He has been prescribed medication for these cysts, but it appears to have done little to alleviate their recurrence. Photographs of the veteran’s skin disorder have been taken at both of his VA dermatology examinations in July 1989 and September 1995. These photographs show extensive sausage- type scars on the veteran’s face and active, purulent cysts in his scalp and other parts of his body. The veteran has claimed that his cysts are uncontrollable and led to loss of employment and isolation within his community. He asserted that the sight and odor of his cysts makes people avoid him and led to his current psychiatric disability. The veteran also contends that it was his service-connected disability that led to the loss of his barber business and current unemployment. The undersigned finds that veteran has chronic cysts in his face, scalp, and neck that have left a marked and repugnant bilateral deformity. It is clear that this disability has resulted in nervous manifestations by the avoidance from others due to the ugly and odorous drainage from the veteran’s cysts. Therefore, the veteran has met the criteria for a 50 percent disability evaluation under either Codes 7800 or 7806. However, a higher evaluation is not warranted under either criteria. The photographs of the veteran’s face, scalp, and neck do not show marked color contrast or discoloration. In September 1995, a VA dermatologist noted that the veteran’s torso (an area of the body normally covered by clothing) revealed discoloration (hypopigmentation). However, the color photographs of the veteran’s face and neck do not indicate any significant discoloration to this part of his anatomy. Without such findings an evaluation of 80 percent disabling is not warranted under Code 7800. It is also determined that this case does not warrant referral for VA central office consideration. The residuals of the veteran’s skin disorder are not so repugnant or disfiguring as to render the rating criteria ineffectual. While it is granted that the veteran’s service-connected skin disorder has caused some industrial and social impairment, and has necessitated treatment during periods of hospitalization for other reasons, the preponderance of the evidence does not demonstrate that the disability picture in this case is exceptional, that is, where evaluations provided by the rating schedule are found to be inadequate. The evaluation noted in the rating code adequately provides for the level of disability incurred by the veteran’s service- connected skin disorder and referral to the VA’s central office for consideration of an extra-schedular evaluation is not warranted. ORDER An increased evaluation to 50 percent disabling for cysts of the face and scalp is granted, subject to the applicable criteria pertaining to the payment of monetary benefits. REMAND In a rating decision of December 1995, the RO denied the veteran’s claim for a total disability evaluation for individual unemployability as a result of his service- connected disabilities. The veteran was notified of this decision in a letter issued in February 1996. In a written statement received in November 1996, he contended that he was unable to obtain or keep a job due to his service-connected skin disorder. In a separate statement received in the same month, the veteran expressed his dissatisfaction with the RO’s decision and contended that he was entitled to an additional monetary award because his service-connected disability hindered him from making a “productive living.” The undersigned finds that the veteran filed a notice of disagreement in November 1996 with the RO’s denial of a total disability evaluation due to individual unemployability. See 38 C.F.R. § 20.201 (1998). The Court of Veterans Appeals (Court) held that when there has been an initial RO adjudication of a claim and a NOD has been filed as to its denial, thereby initiating the appellate process, the claimant is entitled to a statement of the case (SOC) regarding the denied issue. The RO’s failure to issue such an SOC is a procedural defect requiring remand. Godfrey v Brown, 7 Vet. App. 398, 408 (1995). Under the circumstance, the undersigned finds that the issue of entitlement to a total disability evaluation due to individual unemployability must be remanded to the RO for the preparation of a SOC. The RO should prepare a SOC on its denial of a total disability evaluation due to individual unemployability as a result of the veteran’s service-connected skin disorder. This SOC should be issued to the veteran and his representative and they should be informed of the veteran’s appellate rights. The appropriate time in which to respond to this SOC must be afforded the veteran. If a timely substantive appeal is properly filed, then the case must be referred to the Board for appellate consideration. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the RO's to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. The veteran need take no further action until he is informed. The purpose of this REMAND is to protect the veteran’s appellate rights. No inference should be drawn regarding the final disposition of the claim as a result of this action. N. R. ROBIN Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), 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 that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1998). - 2 -