Citation Nr: 9917098 Decision Date: 06/22/99 Archive Date: 06/29/99 DOCKET NO. 94-18 880 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an evaluation in excess of 30 percent for hidradenitis suppurativa (cystic acne). REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. S. Hughes, Associate Counsel INTRODUCTION The veteran served on active duty from June 1979 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which granted service connection for hidradenitis suppurativa; incorporated it with the previously service-connected scars, right and left side at waistline; and evaluated it as 10 percent disabling. In November 1996, the veteran presented argument at a personal hearing at the Los Angeles, California, RO. At this time, he withdrew his claim of entitlement to increased evaluations for cholesteatoma of the left ear, hearing loss of the left ear, and verruga peruana of the right index finger. Accordingly, these issues are not before the Board for appellate consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable resolution of the veteran's appeal has been obtained by the RO. 2. The veteran's disability due to skin disorder is not shown to be productive of a complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement; or eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptional repugnance. CONCLUSION OF LAW The schedular criteria for an evaluation in excess of 30 percent for hidradenitis suppurativa (cystic acne) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Codes 7800, 7806 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background By rating decision dated in February 1984, the RO granted service connection for scars, right and left side at waistline, and assigned a zero percent evaluation effective from May 1983. This determination was based on service medical records, which showed treatment for a boil at the right waist and removal of a raised and infected pustule at the iliac crest, and a January 1984 report of VA examination, which noted a well healed scar on the veteran's right side and an old scar over the iliac crest on the left side. Upon VA examination in March 1984, the veteran complained of acne on his neck. However, he did not undergo an examination of the skin at this time. In January 1992, the veteran requested that his "service connected disability claim" be reopened. This request was subsequently clarified by his accredited representative to show that he was requesting increased ratings for his service-connected disabilities. The RO denied the veteran's request for increased evaluations by a May 1992 Confirmed Rating Decision. The veteran disagreed with this determination in February 1993 and submitted a Medical Statement in Support of Claim from his private physician, V. Tangpraphaphorn, M.D. Dr. Tangpraphaphorn reported that he had treated the veteran for recurrent skin infections at the neck and dizziness on numerous occasions since March 1987. The diagnoses included skin abscesses of the neck. VA outpatient treatment records show that the veteran received treatment for a recurrent skin disorder. These records include an August 1992 treatment report which reflects that the veteran's complaints included sebaceous cyst in the left neck area. In October 1992, it was noted that cystic acne was present in the neck, left axilla, and right and left groin area and had not improved. In January 1993, the veteran sought treatment for a nodule at the left side of the neck which had been present for three days. It was noted that the veteran usually has nodules lanced and is given antibiotics. The diagnosis was cystic acne. Follow up examination showed that the veteran's cysts were still present at the left side of the neck, left axilla, and lower part of the back. He was treated for hidradenitis suppurativa in the neck, inguinal, and abdominal areas in April 1993, at which time he was referred to general surgery for surgical excision. Upon VA examination in September 1993, the veteran's complaints included skin tumors. No examination of his skin was performed at this time. In January 1994, the veteran submitted copies of private treatment records, dated in February 1986, which show that he was referred to W. A. Binder, M.D., for treatment of red itchy patches on his arms and legs which had been symptomatic for two months and a cyst at the posterior neck which had been present off and on for two years. Dr. Binder provided the following description of the veteran's skin disorder: Has a rather large patch of oozing dermatitis at the medial portion of the right leg. He additionally has numerous other areas of raised, scaling dermatitis which involved both legs as well as both arms. The area at the leg was the first area of involvement. This appears to be infectious eczema at this time. He also has some cystic areas of acne around the back of the neck. Some of these areas appear to be confluent. He has one large, rather notable area at the left posterior neck which is several inches long and curves around the back of the neck. He denies any other acne at this time. He has numerous comedones at the back of the neck as well. Dr. Binder's diagnosis was "compatible with an infectious eczema with cystic acneiform eruption around the neck." On his January 1994 Appeal to Board of Veterans' Appeals, VA Form 9, the veteran stated that he needed compensation for nodule tumors of the skin for which he was treated in service and which has continued to the present. In June 1995, the veteran submitted photographs of himself which he identified as having been taken in 1982. He claimed that these photographs showed that he had an inflammation of the left side of his neck at the collar line below his ear. The veteran recalled that this inflammation recurred frequently. In a December 1995 statement, the veteran recalled that he developed boil-like abscesses on his neck subsequent to a September 1982 automobile accident. The veteran also submitted statements from family members which recalled that he had an infection on his neck when he returned home from service. Additionally, similar statements from his friends reflect that the veteran has had a skin disorder on his neck since 1983, the year of his discharge from service. VA outpatient treatment records, dated from August 1992 to January 1996, reflect continued treatment for his skin complaints. These records include a May 1993 report from general surgery which notes that the veteran had a ten year history of hidradenitis at the neck and groin area. The assessment was recurrent, chronic hidradenitis. Multiple scars in the axilla, neck, flanks, and left groin area were noted upon follow-up examination in August 1993. In November 1993, it was noted that the veteran was doing well on his treatment of hidradenitis suppurativa. However, in January 1994, the veteran complained of a bloody abscess in the groin for one and one half weeks which was productive of green drainage, pain, and swelling. It was noted that similar clumps were present on the veteran's back and the left side of his neck. In May 1994 the veteran was treated for abscesses on the lower back and right buttock, the assessment was pilonidal cyst with infection and he was referred to surgery. The veteran was seen in surgery in July 1994, it was noted that he had been experiencing intermittently recurring pilonidal cysts since 1980, and surgery was recommended. However, the veteran refused such surgery and, in January 1995, reported that a cyst was also forming on the left side just below the waist. The veteran subsequently reported that the cyst had ruptured and was productive of a yellow purulent material. Treatment records show that the veteran has continued to seek treatment for his skin disorder. These records note multiple cystic lesions with extensive scarring and comedones on the neck, back, groin, axilla, and over the belt line. Treatment reports in December 1995 show that the veteran also developed an abscess above the knee which had "opened up and drained" and was manifested by swelling and tenderness. An October 1996 treatment report notes that the lesions on the veteran's neck, ear lobes, groin, and sacral area were mild to moderate. A September 1996 letter from Dr. Binder, which indicates that he is a specialist of diseases of the skin and skin cancer, states that the veteran has wide spread areas of chronic hidradenitis suppurativa on his neck, axilla, waist, groin, and inner thighs. Dr. Binder reported that the onset of this skin disorder was 13 years previously and commented that, although the veteran had scarred areas but was not particularly active at the time of examination, he "does need evaluation by a surgery team. Dermatology cannot handle this directly." Included with this letter were copies of private treatment records showing treatment for skin lesions from January 1985 to August 1992. During his November 1996 personal hearing, the veteran testified that his skin disorder recurs six or seven times in a six month to one year time period. He described an active period as the lesions swelling until they drain and start going down and indicated that these episodes recur every two weeks to one month. The veteran described a lesion on his neck as being particularly active. He reported that he had been prescribed antibiotics for a long time but eventually stopped taking them because they caused nausea, gas, and cramps. The veteran testified that, over the years, he has been forced to change his life style to keep his skin disorder under control. Upon consideration of the forgoing, by a December 1996 Hearing Officer Decision, the veteran was granted service connection for hidradenitis suppurativa (cystic acne), this disorder was combined with his previously service-connected scarring of the waistline, and an increased rating of 10 percent disabling was assigned. Thereafter, the veteran disagreed with the December 1996 rating decision, asserting that his service-connected skin disability was inadequately reflected in the 10 percent evaluation, and submitted VA outpatient treatment records in support of his claim. These medical records show that, in December 1996, the veteran sought treatment for an abscess on his right ear lobe which was swollen and tender and, in January 1997, he sought treatment for an abscess on his neck, left axilla, and the top of the buttock which was draining bloody puss. A June 1997 treatment record notes that the veteran's abscesses generally recurred once per month and he had no acute lesions at the time of examination. Upon VA examination in July 1997, the veteran complained of painful drainage of sinus, hip, and groin. Objective findings revealed multiple draining abscesses at the groin, buttock, and axillae. This examination report was accompanied by photographs of lesions on the veteran's body including his ear lobe, neck, armpit, thigh, and groin area. The diagnosis was hidradenitis suppurativa. The July 1997 examination was deemed inadequate for rating purposes because the examiner failed to describe the severity of the veteran's skin disorder. Accordingly, the veteran was reexamined in October 1997 and the examiner described his hidradenitis suppurativa as mild to moderate. Specifically, the examiner noted that there were multiple open comedones and few inflammatory cysts (less than four) predominantly involving the groin, medial thighs, and posterior aspect of his neck. It was also noted that both axilla involved a diffuse erythematous rash (sheet erythema) consistent with infectious antitrigo (candidiasis with superimposed streptococcal and/or staphylococcal over growth). A February 1998 VA examination report reflects that the veteran complained of itching and no pain on initial outbreak. Objective findings consisted of multiple cysts with pustules at the posterior neck and bilateral areas of the groin, buttocks, and scrotum. There was no associated nervous manifestation and no ulcerative lesions or crusting of the skin. The diagnosis was hidradenitis suppurativa. Upon consideration of the foregoing, by a December 1998 supplemental statement of the case, the veteran's hidradenitis suppurativa at the posterior neck, waistline, and groin was evaluated as 30 percent disabling. Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4 (1998). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1998). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1, 4.2 (1998), which require the evaluation of the complete medical history of the veteran's condition. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1998). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1998). The veteran's skin disorder has been rated by analogy to disfiguring head, face, or neck scars, due to a similarity in anatomical location and symptomatology. See 38 C.F.R. § 4.20. A 30 percent rating is for warranted for severe scars, especially if producing a marked and unsightly deformity of the eyelids, lips, or auricles. A 50 percent evaluation is warranted for scarring characterized by the complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement. When in addition to tissue loss and cicatrization there is marked discoloration, color contrast, or the like, the 50 percent evaluation may be increased to 80 percent, the 30 percent to 50 percent, and the 10 percent to 30 percent. The veteran may also be rated under 38 C.F.R. § 4.118, Diagnostic Code 7806, for eczema which provides a 30 percent evaluation for exudation or itching constant, extensive lesions, or marked disfigurement and a maximum schedular evaluation of 50 percent for ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. 38 C.F.R. § 4.118, Diagnostic Code 7806. When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1998). Analysis Initially, the Board finds that the veteran's claim for an evaluation in excess of 30 percent for the service-connected hidradenitis suppurativa is well grounded in accordance with 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance to the veteran is required in order to satisfy the VA's duty to assist him mandated by 38 U.S.C.A. § 5107(a). The recent medical evidence, which consists of VA examinations from 1997 and 1998, VA outpatient treatment records, and a September 1996 statement from Dr. Binder, show that the veteran's chronic hidradenitis suppurativa is manifested in widespread areas at the neck, axilla, waist, groin, and inner thighs by drainage, pain, swelling, and itching. Specifically, a June 1997 VA outpatient treatment report notes that the veteran had no acute lesions at the time of examination. In July 1997, a VA examiner described the veteran's hidradenitis suppurativa as mild to moderate and noted multiple open comedones as well as a few inflammatory cysts. In February 1998, a VA examiner noted itching and multiple cysts with pustules with no associated nervous manifestations, ulcerative lesions, or crusting of the skin. Additionally, in September 1996, Dr. Binder noted that the veteran had not been particularly active but had various scarred areas at the time of examination. He commented that dermatology could not handle the veteran's disorder directly and he required evaluation by a surgery team. The veteran testified at a personal hearing at the RO in November 1996, but no evidence was presented to show that his condition was worse than that which was described in subsequent VA examinations and outpatient treatment reports. Accordingly, upon consideration of the aforementioned medical evidence, the Board finds that the impairment associated with the veteran's hidradenitis suppurativa is adequately reflected by the 30 percent evaluation presently in effect. The manifestations and symptoms of hidradenitis suppurativa do not exceed the requirements for a 30 percent rating under either Code 7800 (severely disfiguring scars of the head, face or neck) or Code 7806 (a skin condition with constant exudation or itching, extensive lesions, or marked disfigurement). An evaluation in excess of 30 percent is not warranted under either of these codes, as there is no persuasive evidence that the veteran's hidradenitis suppurativa produces "marked or repugnant bilateral disfigurement" or is "exceptionally repugnant." The evidence is not approximately balanced; rather, the preponderance of the evidence is against the claim. Thus, the reasonable doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For the foregoing reasons, an increased rating for hidradenitis suppurativa must be denied. ORDER An evaluation in excess of 30 percent for hidradenitis suppurativa is denied. RONALD R. BOSCH Member, Board of Veterans' Appeals