Citation Nr: 9905305 Decision Date: 02/25/99 Archive Date: 03/03/99 DOCKET NO. 93-02 761 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an increased evaluation for hidradenitis suppurativa, currently evaluated as 30 percent disabling. 2. Entitlement to a total rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carolyn Wiggins, Counsel INTRODUCTION The veteran served on active duty for training from May 1969 to November 1969. This appeal arises from a August 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. In October 1994 the Board of Veterans' Appeals remanded the veteran's claims to the RO for further development. The requested development has been accomplished to the extent possible and the claims have been returned to the Board for appellate consideration. REMAND The veteran has reported that he received treatment at Michael Reese Hospital from October 1977 to March 1978; from October 1979 to January 1980; and from November 1980 to March 1981. He has submitted copies of various medical records which indicate that underwent surgery at this facility in January or February 1978 and that he had resection surgery of the perineal area in November 1980. A VA examination in December 1982 reflects that the veteran reported that he had had boils on his buttocks, underarms, the back of his neck, and the facial area. It was reported that the condition recurred four times a year. When the condition was active, he could not sit down or walk. He had three active facial abscesses. Examination revealed highly pitted areas of the face. He also had one to one and one half inch wide scars of the buttocks and perineum as a result of the excision of lesions. In February 1984 a VA dermatology examination reflects that the veteran reported that he had one to two boils every month that were painful and prevented him from working. He had the glands removed from both axillae and the anal region, but still had recurrences in these areas. In March 1984 the veteran had an abscess drained. He had a draining sinus in the right inferior auricular area where an abscess was drained two days previously. A VA dermatology examination performed in December 1984 reflects that the veteran stated that the lesions were forming more rapidly and causing severe pain. The pain left him bedridden and unable to walk or perform any work until they subsided or were surgically removed. The examiner noted a history of hidradenitis suppurative flare ups every one to two months. Physical examination revealed that the left groin had pustules forming. Both the gluteal cheeks had surgical scars. The post nuchal area and right lateral auricular areas were all involved and active. The axillae revealed scarring and chronic symptoms. The impression was severe debilitating hidradenitis suppurativa. A November 1985 VA dermatology examination found active lesions on the left buttock, with drainage. In February 1986 a VA dermatology examination found several painful nodules on the left axilla. VA records in July 1986 noted one tender lesion in the right groin. There were two cystic lesions on the face. VA records from July 1987 revealed dry areas of hyperpigmentation in the left axilla. There were two well healed scars. The groin had a moist region with a small nodule on the left aspect of the scrotum. It was tender to the touch. In the area of his anus he had numerous well healed scars. In August 1987 the veteran had inflammation in the rectal and groin area. For three weeks he had symptoms with a severe burning sensation. He had severe itching under his left armpit for three weeks. He had difficulty with sitting and walking. VA hospital records from August 1987 reveal that the veteran had a small fluctuant area of the left perirectal area. He had incision and drainage of two fluctuant areas with return of about one cubic centimeter of purulent material from each. A VA examination in September 1987 found chronic inflammatory changes and deep seated cysts in the groin and axillary area. There were surgical scars on the buttocks. There were areas of hyperpigmentation on the groin and axilla. The assessment was chronic debilitating, but not life threatening, dermatoses that required surgical excision for definitive treatment of hidradenitis suppurativa. A note from the veteran's VA physician dated in July 1988 stated that he should not sit or stand for prolonged periods. An examination of the veteran revealed a tender two centimeter in diameter nodule on the left buttock. The assessment was exacerbation of hidradenitis of the left buttock and eczema of the extremities that was now pruritic. VA dermatological examination in July 1989 revealed a nodule behind the right ear and nodules on the buttocks and left groin. Hospital reports from the VA in March and April 1990 noted an excision of hidradenitis of the left groin. Examination revealed tenderness, induration and draining of purulent exudate from a six centimeter in diameter area in the left groin. VA records of hospitalization from October and November 1990 reveal treatment for recurrent hidradenitis of the buttock. The veteran had a 2x2 centimeter fluctuant mass at the left anterior perineal area. A wide excision was performed. December 1990 VA records revealed healed surgical scars of the buttock and left groin. He was slightly boggy in the inner buttock. There was no erythema. The veteran jumped at slight touch, anywhere in a two centimeter area. The area behind the scrotum was now healed without drainage. VA records from January 1992 revealed a tender fluctuant nodule in the right inguinal region. In June 1992 the veteran reported a painful boil on the right buttock for three days. Examination revealed tenderness on the right buttock with no fluctuance. Needle aspirate was negative. At a July 1992 VA skin examination, the veteran reported a flare-up on the right and left buttocks. Objectively no pustules were found on the buttocks. There was a scarred intergluteal area. There were several papular lesions in the axilla. In January 1993 VA records revealed that the veteran had lesions on his face. The veteran denied systemic symptoms. The examiner diagnosed acne and hidradenitis suppurativa. The veteran was hospitalized for three days. VA records, two weeks after the veteran was discharged from the hospital, noted that he was doing better and the wound on his buttock was healed without fluctuance. A VA examination was performed in October 1994. The veteran reported that he was unable to sit for a time because of severe pain. His condition also aggravated him when he stood. The examiner noted no nervous manifestations of the skin disorder. The disorder affected the groin folds and perirectal area with diffuse linear inflamed scars. Some scars were not inflamed. He had linear hypertrophic plaques with inflamed scars. The scared red areas flared up four times a year. March 1995 VA records included complaints of very painful boils between the buttocks and under the left arm. He had difficulty sitting and was unsteady on his feet. He had a one centimeter tender nodule in the left axilla. It was aspirated with no pus. The right buttock was also tender with an area of fluctuance. In May 1996 a VA consult included a report of a large eight by one centimeter lesion on the medial aspect of the left arm without invasive infection. The veteran was scheduled for an excision. A VA history taken in June 1996 revealed a history of hidradenitis suppurative of the left axilla, groin and perineum. The veteran had presented for excision and skin grafting of the left axillary region. Other areas were quiescent. He denied recent fever cellulitis. An excision of the left axilla hidradenitis and coverage with a split thickness skin graft from the left thigh was performed. A VA examination was performed in May 1997. The veteran complained of pain and tenderness when the disease was active. He had undergone surgical treatment of the left axillae in August 1996 at the VA with a skin graft. He had surgery in the groin three times and in the buttock region nine times. Examination revealed a skin graft on the left upper arm adjacent to the left axilla. Color photograph were taken and are of record. A VA social and industrial survey completed in May 1997 reflects that the veteran reported that his only income consisted of his VA compensation of $475 per month. A vocational rehabilitation evaluation completed in September 1997 reflects that the veteran reported that he had been unemployed since 1977 and relied upon his VA benefits and Social Security benefits ($479.00 per month) for financial support. Thus, it appears that after the May 1997 social and industrial survey, the veteran began to receive Social Security benefits. If the benefits he receives from the Social Security Administration are based upon disability, the records utilized by this agency may contain information which would tend to support his claims for an increased rating for his skin disorder and for a total rating based on unemployability. The United States Court of Veterans Appeals (Court) has held that "[w]hen VA is put on notice prior to the issuance of a final decision of the possible existence of certain records and their relevance, the BVA must seek to obtain those records." Murincsak v. Derwinski, 2 Vet. App. 363, 373 (1992). The Court has also stated that "[a]s part of the Secretary's obligation to review a thorough and complete record, VA is required to obtain evidence from the Social Security Administration, including any decisions by the administrative law judge, and give that evidence appropriate consideration and weight." Id. at 372; see Collier v. Derwinski, 1 Vet. App. 413, 417 (1991); Hayes v. Brown, 9 Vet. App. 67, 74 (1996). Additionally, the veteran reports that he has flare-ups approximately every two months. Those flare ups have on occasion been noted to be debilitating. On many occasions the skin disorder results in difficulty sitting, standing or walking for prolonged periods. On numerous occasions the skin disorder was of such severity that the lesions had to be excised. The areas were of such size that on more than one occasion skin grafts were required after the lesions were excised. There is no question that on those occasions the skin disorder was of such severity that the veteran's movements and activities would be impaired. Nevertheless on many occasions the flare ups were not of such severity that surgery was required or that impairment in movement resulted. The veteran's hidradenitis suppurativa is currently rated as 30 percent disabling by analogy to eczema under Diagnostic Code 7899-7806. The next higher rating under Diagnostic Code 7806 requires ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptional repugnance. Inasmuch as the above cited evidence reflects involvement of various areas of the veteran's body, a medical determination as to whether or not the hidradenitis suppurative is productive of systemic manifestations would be helpful. Accordingly, the case is REMANDED for the following: 1. The RO should contact the veteran, and afford him the opportunity to present any additional evidence he believes is pertinent to the issue on appeal. The veteran should be requested to clarify whether or not he is receiving benefits from the Social Security Administration and if so, whether such benefits are based upon disability. A reasonable period of time should be afforded for the veteran to respond. 2. If the veteran indicates that he has been awarded Social Security disability benefits, or if he fails to reply, the RO should request from the Social Security Administration the records pertinent to any claim the veteran has filed for Social Security benefits, to include the medical records relied upon concerning that claim. The RO should document all efforts to obtain such documents, and associate all records received with the claims folder. 3. The RO should obtain records regarding the veteran's August 1996 skin graft at a VA hospital as well as up-to- date VA medical records for the veteran. 4. The RO should refer the records in this case to an appropriate medical specialist for an opinion as to whether or not the veteran's hidradenitis suppurative is productive of systemic manifestations. The medical specialist should be specifically requested to review the above historical summary of the veteran's condition and the color photographs taken in May 1997, in addition to the clinical data contained in the claims folder. 5. After completing any additional development deemed necessary, the RO should review the claims folder to insure that the above development has been completed. The RO should then readjudicate the issues on appeal in light of any additional evidence added to the records assembled for appellate review. If the benefit sought is not granted, the veteran should be furnished a Supplemental Statement of the Case and an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. The RO should ensure that the records returned to the Board include the Counseling/Evaluation Rehabilitation folder. By this remand, the Board intimates no opinion as to any final outcome warranted. 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 ROs 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. Gary L. Gick Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This 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).