Citation Nr: 9926154 Decision Date: 09/14/99 Archive Date: 09/21/99 DOCKET NO. 90-18 471 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for a psychiatric disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa. 2. Entitlement to service connection for a joint disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa. 3. Entitlement to service connection for a gastrointestinal disorder (claimed as ulcers), as secondary to service- connected acne conglobata and hidradenitis suppurativa. 4. Entitlement to an increased disability rating for service-connected acne conglobata and hidradenitis suppurativa, currently evaluated as 30 percent disabling. 5. Entitlement to a total rating for compensation purposes on the basis of individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran served on active duty from July 1968 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1988 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The December 1988 rating decision reduced the disability rating assigned for the veteran's service-connected acne conglobata from 30 percent to 10 percent disabling; denied entitlement to service connection for a psychiatric disorder, arthritis, and ulcers as secondary to service-connected acne conglobata; and denied entitlement to a TDIU. In November 1989, the RO granted entitlement to service connection for hidradenitis suppurativa, evaluated as 10 percent disabling, effective from February 1989. In an October 1991 rating decision, the RO recharacterized the veteran's service-connected skin disorder as acne conglobata and hidradenitis suppurativa and restored the 30 percent disability rating. The case was previously before the Board in January 1991 and August 1992, when it was remanded for examination of the veteran and further adjudication. The RO in Atlanta, Georgia, currently has jurisdiction over the veteran's claims. In August 1998 and June 1999, the Board requested medical opinions from independent medical experts (IMEs) in accordance with 38 C.F.R. §§ 3.328, 20.901(d) (1998). After the opinions were received at the Board, the appellant was provided a copy and 60 days to submit any additional evidence or argument in response to the opinions. 38 C.F.R. § 20.903 (1998). The veteran's representative responded in January and July 1999. The claims of entitlement to service connection for a psychiatric disorder on a secondary basis (on the merits) and to a TDIU are the subject of the remand immediately following this decision. FINDINGS OF FACT 1. In September 1984, the Board denied entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata. 2. In May 1993, on reconsideration of the veteran's case, the Board again denied entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa. The scope of the reconsideration was confined to the record available to the Board in September 1984. 3. Evidence received since September 1984 is so significant that it must be considered in order to fairly decide the merits of the claim. 4. The claim of entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa is plausible. 5. Sufficient evidence for an equitable disposition of the veteran's claim of entitlement to service connection for a joint disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa, has been obtained. 6. The veteran's claimed joint disorder was not caused or aggravated by his service-connected acne conglobata and hidradenitis suppurativa. 7. No medical evidence has been presented or secured establishing a relationship between the service-connected acne conglobata and hidradenitis suppurativa and any current gastrointestinal disorder. 8. The veteran's service-connected acne conglobata and hidradenitis suppurativa is manifested by periodic exacerbations and remissions, deformity, extensive areas of scarring, and draining lesions. CONCLUSIONS OF LAW 1. The Board's decision of May 1993 that denied entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa is final. 38 U.S.C.A. §§ 7103(a), (b)(3), 7104(a) and (b) (West 1991 & Supp. 1999); 38 C.F.R. § 20.1100 (1998). 2. Additional evidence received is new and material, and the veteran's claim of entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156 (1998). 3. The claim of entitlement to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The veteran is not entitled to service connection for a joint disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.310(a) (1998). 5. The claim of entitlement to service connection for a gastrointestinal disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa, is not well grounded and there is no statutory duty to assist the veteran in developing facts pertinent to this claim. 38 U.S.C.A. § 5107(a) (West 1991). 6. The criteria for a disability rating of 50 percent, and not higher, for service-connected acne conglobata and hidradenitis suppurativa have been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7806 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Psychiatric disorder A. Factual background The veteran's service medical records are negative for any complaints or findings of a psychiatric disorder. The veteran was diagnosed as having an inadequate personality with a history of multiple drug usage and periodic excessive drinking on psychological evaluation in March 1975. On psychiatric examination in July 1976, pertinent diagnoses included antisocial personality when intoxicated, dyssocial behavior and habitual excessive drinking. He was also diagnosed as having a history of polysubstance abuse with a superimposed behavior disorder in October 1978. The veteran was hospitalized from November 1981 to April 1982 following a head injury. A computed tomography (CT) scan showed blood and edema in the left temporal lobe. Pertinent diagnoses included substance abuse and post-concussion syndrome. He was again hospitalized in April 1982 and diagnosed as having poly-drug abuse (alcohol, amphetamines) and antisocial personality. The veteran was hospitalized from November 1982 to March 1983 due to psychiatric symptomatology. The examiner diagnosed a dysthymic disorder, alcohol abuse and a personality disorder, mixed type, with schizoid, paranoid and antisocial features. During hospitalization in July 1983, the veteran was diagnosed as having an unspecified personality disorder, as well as alcohol abuse. In July 1983, a registered nurse who had treated the veteran reported that his skin condition contributed to his emotional difficulties, namely, fear of people, poor self-image, depression and anxiety. The veteran testified at a personal hearing at the RO in July 1983. He stated that his psychiatric disorder was caused by his service-connected skin disorder. Specifically, he stated that his mental problems were caused by his inability to hold a job and by people making fun of him because of his skin condition. He was afraid to be around other people, resulting in depression, anxiety and paranoia. The veteran was afforded a VA psychiatric examination in August 1983. The examiner diagnosed an antisocial personality disorder; amphetamine abuse; amphetamine delusional disorder; continuous alcohol abuse; alcohol hallucinosis; cocaine abuse, course unknown; opioid abuse, course unknown; hallucinogen abuse, course unknown; continuous cannabis abuse; and continuous cannabis dependence. The examiner concluded that the veteran had no psychiatric symptoms that could not be fully accounted for by the foregoing diagnoses. The RO denied entitlement to service connection for a psychiatric disorder as secondary to a the veteran's service connected skin disorder in September 1983. The veteran appealed the RO's decision to the Board. In September 1984, the Board denied entitlement to service connection for an acquired psychiatric disorder, including as secondary to the veteran's service connected skin disorder. The Board found that the evidence did not indicate that the veteran's psychiatric disorder was etiologically related to his service-connected disability. Since September 1984, additional evidence has been received, as follows (in pertinent part): The veteran participated in a detoxification program due to continuous alcoholism in August 1984. He was again hospitalized in June 1985 for treatment for mixed substance abuse, continuous alcohol abuse and an antisocial personality disorder. The veteran was next hospitalized in May 1986, when he was diagnosed as having a substance abuse disorder and a borderline personality disorder. In August 1986, Lackey G. Moody, M.D. stated that the veteran had marked disfigurement due to his skin disorder with systemic and nervous manifestations. Additional diagnoses from 1986 to 1988 included major depression with suicidal ideation; a personality disorder; depression; avoidant personality disorder; narcotic abuse; and sedative abuse. A May 1987 psychological report indicated that the veteran's depression may be related to poor human relations and to perceived inadequacies in social skills. On VA dermatology examination in May 1989, the examiner stated that the association between the veteran's cutaneous condition and his psychiatric condition was unclear. The veteran was examined by VA in April 1991. The examiner diagnosed a dysthymic disorder and an intermittent explosive disorder. In October 1991, a VA psychologist reported that while it was difficult to verify in an absolute way, the veteran's presentation would support the conclusion that his physical condition at least exacerbated his feelings of social inadequacy. The psychologist further stated in February 1992 that the veteran suffered from a dysthymic disorder and a personality disorder, mixed type, with antisocial features. The veteran requested reconsideration of the September 1984 Board decision. In May 1993, the Board issued a decision which replaced the September 1984 Board decision. However, the scope of the reconsideration was confined to the record available to the Board in September 1984. The Board found that the veteran's psychiatric symptomatology was not etiologically related to his service-connected skin disorder. The veteran was hospitalized from March to April 1995. The examiner diagnosed chronic pain syndrome; depression, not otherwise specified; rule out organic mood secondary to long- term use of benzodiazepines and opiates and chronic pain; rule out major depressive episode; opiate dependence; benzodiazepine dependence/withdrawal; and cluster B traits, antisocial. The veteran sought treatment for substance abuse in April 1995. He was hospitalized and diagnosed as having polysubstance abuse and major depressive episodes secondary to substance abuse. The veteran was afforded a VA psychiatric examination in October 1996. Review of a September 1995 CT scan of the head disclosed an area of encephalomalacia in the left temporal lobe most likely related to old trauma. The examiner diagnosed (i) rule out dysthymic disorder versus major depression and (ii) impairment of cognitive functions related maybe to the head trauma and subsequently an area of infarct in the brain in the temporal lobe. The examiner stated that there had been articles about the relationship between skin disorders, especially psoriasis, in relationship with depression, so there was a possibility than any skin disorder which caused disfigurement could cause depression. The examiner further stated that, "Also, I just raised the question if depression can also be worse because of the infarct in the brain. The literature supports this theory, too, that strokes, like in this case, can cause depression. The other possibility is that this patient has been using, chronically abusing, opiates and benzodiazepines throughout the years, as they said on admission to the fourth floor, the possibility of organic mood related to the long-term use of these prescribed medications. Also, hepatitis B and hepatitis C that causes alot of pain and medical problems." The Board deemed that additional medical expertise was needed to render an equitable disposition in this case and in August 1998 requested an IME opinion. In January 1999, Cheryl A. Hemme, M.D., an assistant professor of clinical psychiatry at the University of Missouri Department of Psychiatry and Neurology provided an expert medical opinion in response to a specific Board request. The physician stated, in pertinent part: The patient presents a rather long and complicated history of substance abuse, mood disorder, personality disorder (which includes borderline personality disorder and antisocial personality disorder) as well as legal difficulties. In addition to his psychiatric difficulty he sustained a significant head injury which resulted in loss of consciousness for 5 days. As noted in the record his dysthymia may be related to his head injury and subsequent area of infarct in the temporal lobe. Skin disorders or any problem that causes disfigurement, especially of the face, can lead to low self esteem, feelings of inadequacy, etc. He describes his skin condition as disturbing and traumatic which may exacerbate his mood symptoms. Given his history it seems he has little social support and hasn't developed ways of dealing with his psychiatric and medical concerns. After review of the file, I offer the following opinions to the specific questions submitted by the Review Board: Question 1: What is the most likely etiology of the veteran's current psychiatric disorder, most recently diagnosed as a dysthymic disorder? The most likely etiology of his current diagnosis of dysthymia is his long history of substance abuse and his head trauma in September of 1995. It is clear from his record he has had several hospitalizations for alcohol abuse, mixed substance abuse, chronic abuse of opiates and benzodiazepines. Question 2: What is the likelihood that the veteran's current psychiatric disorder was caused by or resulted from the service-connected skin disorder? It is difficult to ascertain the exact causation for his dysthymia. Chronic illness can certainly precipitate a depressive episode in some people. He describes his skin condition and his physical appearance as his main problem yet given his substance history, benzodiazepine use and head injury, it is extremely difficult to extrapolate the role his skin condition plays in his dysthymia. It certainly may play a role as one function or as a stress which potentiates his dysthymia but is not the primary factor. Question 3: If the psychiatric disorder is more likely separate and distinct from the service- connected skin disorder than a manifestation or symptom of it, what is the likelihood that the psychiatric disorder is exacerbated or worsened by the service-connected skin disorder? Psychiatric disorders are clearly exacerbated by stress regardless of the etiology. If his perception of his skin condition causes him to feel rejected, hopeless, etc. it will exacerbate his low mood. However, the difficulty is in separating out the role that his medical and psychiatric illness really play in his circumstances. He has a diagnosis of Antisocial Personality Disorder as well as Borderline Personality Disorder which further complicates his history and brings up the issue of secondary gain for obtaining disability. In general, people with these diagnoses know how to manipulate a system to obtain what they need. Only a complete psychiatric evaluation by a psychiatrist and possibly testing (MMPI) would help distinguish the role his skin disorder plays in the diagnosis of dysthymia. Overall, it is likely that is [sic] skin disorder could exacerbate his underlying dysthymia but not a primary reason for his medical problems. B. Legal analysis Service connection may be established for a current disability on a "secondary" basis. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304(a), (b), (c), 3.310(a) (1998). Service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1998). Establishing service connection on a secondary basis requires evidence sufficient to 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. 38 C.F.R. § 3.310(a) (1998); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). In May 1993, the Board issued a decision which replaced the September 1984 Board decision, again denying entitlement to service connection for a psychiatric disorder on a secondary basis. Decisions of the Board are final. 38 U.S.C.A. §§ 7103(b)(3), 7104(a) (West Supp. 1999); 38 C.F.R. § 20.1100 (1998) ("A panel reconsidering a case . . . shall render its decision after reviewing the entire record before the Board. . . . The decision of the panel shall constitute the final decision of the Board."); VAOPGCPREC 70-91 (O.G.C. Prec. 70-91) ("[D]ecisions of the [Board] in which reconsideration is ordered are not final.") Where, as here, a final Board decision existed on a claim, i.e., in May 1993, that claim may not be thereafter reopened and allowed, and a claim based upon the same factual basis may not be considered by the Board. 38 U.S.C.A. § 7104(b). The exception is that, if new and material evidence is presented or secured with respect to the claim, the Secretary shall reopen the claim and review the former disposition. See 38 U.S.C.A. §§ 5108, 7104. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has specifically held that the Board may not consider a previously and finally disallowed claim unless new and material evidence is presented, and that before the Board may reopen such a claim, it must so find. See Barnett v. Brown, 83 F. 3d 1380, 1383 (Fed. Cir. 1996). In the case of Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998), the Federal Circuit held that in Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991), the United States Court of Appeals for Veterans Claims (formerly the U.S. Court of Veterans Appeals) (Court) impermissibly ignored the definition of "material evidence" adopted by VA under 38 C.F.R. § 3.156(a) as a reasonable interpretation of an otherwise ambiguous statutory term (found under 38 U.S.C. § 5108) and, without sufficient justification or explanation, rewrote the statute to incorporate the definition of materiality from an altogether different government benefits scheme. Pursuant to the holding in Hodge, the legal hurdle adopted in Colvin and related cases, see e.g. Sklar v. Brown, 5 Vet. App. 140, 145 (1993), Robinette v. Brown, 8 Vet. App. 69 (1995) and Evans v. Brown, 9 Vet. App. 273 (1996), that required reopening of claim on the basis of "a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome" of the case was declared invalid. Thus, the Federal Circuit held in Hodge that the legal standard that remains valid was that contemplated under 38 C.F.R. § 3.156(a) that requires that in order for new evidence to be material, the new evidence should "bear[ ] directly and substantially upon the specific matter under consideration . . . [and must be] so significant that it must be considered in order to fairly decide the merits of the claim." In Elkins v. West, 12 Vet. App. 209 (1999), the Court held that the two-step process set out in Manio, for reopening claims became a three-step process under the Federal Circuit's holding in Hodge, and is in effect a less restrictive standard based on the language of 38 C.F.R. § 3.156(a). The Court held in Elkins that now the Secretary must first determine whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, immediately upon reopening the claim, the Secretary must determine whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C. § 5107(a); and third, if the claim is well grounded, the Secretary may evaluate the merits after ensuring the duty to assist under 38 U.S.C. § 5107(b) has been fulfilled. The Court further added that the Federal Circuit in Hodge effectively "decoupled" the relationship between determinations of well-groundedness and of new and material evidence by overruling the reasonable-possibility-of-a- change-in-outcome prong established by Colvin. There is no duty to assist in the absence of a well-grounded claim. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) cert. denied, sub nom. Epps v. West, 118 S.Ct. 2348 (1998). See also Winters v. West, 12 Vet. App. 203 (1999). Accordingly, the Board will consider whether new and material evidence has been submitted in accord with the holding in Hodge, supra. There is no prejudice to the appellant in the Board's appellate consideration herein for several reasons: (1) the veteran was provided notice of the applicable law and regulations pertaining to new and material evidence, specifically 38 C.F.R. § 3.156; (2) the Board's review of the claim under the more flexible Hodge standard accords the appellant a less stringent "new and material" evidence threshold to overcome; and (3) the Board resolves this issue in the veteran's favor. Cf. Bernard v. Brown, 4 Vet. App. 384 (1993). In the May 1993 Board decision, the scope of the reconsideration was confined to the record available to the Board in September 1984. Thus, in reviewing the veteran's claim, the Board will review all evidence that has been received since September 1984 in determining whether new and material evidence has been submitted. In September 1984, the evidence consisted, in pertinent part, of post-service medical evidence of a psychiatric disorder; the veteran's lay statements that this condition was caused by his service-connected acne conglobata and hidradenitis suppurativa; and a July 1983 statement from a registered nurse to the effect that the veteran's skin condition contributed to his emotional difficulties, namely, fear of people, poor self-image, depression and anxiety. There was insufficient medical evidence relating any current psychiatric disorder to the service-connected disability. Therefore, in order to be material, there would have to be competent evidence showing a relationship between a current psychiatric disorder and the service-connected acne conglobata and hidradenitis suppurativa. Any "new" evidence would have to bear directly and substantially upon this matter and be so significant that it must be considered in order to fairly decide the merits of the claim. The evidence received subsequent to September 1984 is presumed credible for the purposes of reopening the appellant's claim unless it is inherently false or untrue, or it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1995); Justus v. Principi, 3 Vet. App. 510, 513 (1992). See also Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995). Turning to the evidence that has been received since September 1984, the veteran has provided, in pertinent part, an August 1986 statement from Lackey G. Moody, M.D. to the effect that the veteran had marked disfigurement due to his skin disorder with nervous manifestations; an October 1991 statement from a VA psychologist to the effect that the veteran's physical condition at least exacerbated his feelings of social inadequacy; an October 1996 statement by a VA examiner to the effect that there was a possibility than any skin disorder which caused disfigurement could cause depression; and the January 1999 IME opinion to the effect that it is likely that the veteran's skin disorder could exacerbate his underlying dysthymia. The Board finds that new and material evidence has been received. The additional evidence is clearly new as it was not of record in 1984. This new evidence is also material. It includes medical opinions indicating that the veteran's service-connected skin disorder either caused or aggravated a current psychiatric disorder. These statements are presumed credible for the purpose of reopening the veteran's claim since it is within the examiners' competence as a medical doctor, psychologist, etc., to render such opinions. The opinions bear directly and substantially upon the pertinent issue regarding this claim (i.e., did the veteran's service- connected skin disorder cause or aggravate a psychiatric disorder). See Colvin, 1 Vet. App. at 174 (material evidence is relevant to and probative of the issue at hand). Therefore, because the additional evidence is new and material in light of the applicable laws and regulations, the Board finds that the claim for service connection for a psychiatric disorder on a secondary basis is reopened. Having determined that the claim has been reopened, it must next be determined whether the reopened claim is well grounded. See Elkins v. West, 12 Vet. App. 209 (1999). Establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the disability is service connected; it requires evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible, i.e., meritorious on its own or capable of substantiation. See Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by a claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). For some factual issues, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Id. at 93. To establish a well-grounded claim for service connection for a disorder on a secondary basis, in addition to providing evidence of the existence of a current disability, the veteran must present medical evidence to render plausible a connection or relationship between the service-connected disorder and the new disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994). Truthfulness of the evidence is presumed in determining whether a claim is well-grounded. Id. at 504. Based upon the foregoing facts, the Board finds that the veteran's claim is well grounded, in that he has presented a plausible claim. There is medical evidence of a current psychiatric disorder and of a relationship between this disability and the veteran's service-connected acne conglobata and hidradenitis suppurativa. Having determined that the claim is well grounded, it appears that additional assistance is required in order to fulfill the duty to assist. 38 U.S.C.A. § 5107(a) (West 1991). Accordingly, the underlying issue of entitlement to service connection will be the subject of the remand that follows. II. Joint disorder A. Factual background In a November 1987 written statement, the veteran claimed entitlement to service connection for arthritis as secondary to his service-connected skin condition. He stated that arthritis was caused by loss of movement and swelling associated with his skin condition. He has provided excerpts from various medical texts indicating that joint disease can occur with hidradenitis suppurativa. As a background, the veteran was treated by Lackey G. Moody, M.D. beginning in January 1986 for cervical degenerative disc disease. In August 1986, Dr. Moody stated that the veteran had marked disfigurement due to his skin disorder with systemic and nervous manifestations. Treatment records dated from 1987 to 1988 from the Arkansas Department of Corrections reveal diagnoses of arthritis and bursitis of the shoulders and post traumatic arthritis of the hip. VA x-rays of the left shoulder in November 1988 revealed a slight superior migration of the humeral head which could represent a soft tissue disease such as capsulitis or tendonitis. The veteran was diagnosed as having myalgia of the shoulders in December 1988. X-rays of the shoulders in January 1989 were interpreted as showing mild arthritic changes. Degenerative joint disease of the lumbosacral spine was also diagnosed in February 1989. The veteran complained of shoulder, back, ankle, hip and knee pain in that same month. The examiner's impression was a connective tissue disorder of unknown etiology, affecting multiple joints. The veteran was afforded a VA examination in May 1989. He was diagnosed as having tendonitis of the shoulder and lumbar strain. The skin examiner also diagnosed evidence of follicular occlusion triad including severe acne (acne conglobata) and hidradenitis suppurativa. This examiner further concluded that the association between the cutaneous condition and the veteran's arthritis was unclear. The veteran testified at a personal hearing at the RO in April 1989. He stated that there was a correlation between his skin service-connected skin condition and his arthritis. September 1990 x-rays of the veteran's hands were interpreted as showing changes consistent with early rheumatoid arthritis. X-rays of the lumbar spine in the same month showed mild degenerative changes, but no changes characteristic of ankylosing spondylitis. October 1990 x-rays of the veteran's shoulder and knees were interpreted as negative. However, December 1990 x-rays of the right shoulder taken after a fall were interpreted as showing a subtle lucent line extending obliquely across the right acromion process which could represent an acromial fracture and mild degenerative changes of the right acromioclavicular joint. A January 1991 x-ray showed degenerative disc disease at C5-C6 and C6-C7. The veteran was re-examined by VA in April 1991. He complained of pain in his neck, shoulders, hands, wrists, low back, knees, feet and ankles. The examiner noted multiple joint symptoms with few objective findings. Rheumatoid factor was negative. The sedimentation rate was high. X- rays of the knees, hands, wrists and feet were negative. X- rays of the lumbosacral spine revealed minimal osteophytosis at L1-L2 and were otherwise negative. An x-ray of the cervical spine showed a mild degenerative change consisting of small anterior osteophytes at C4, C5 and C6. X-rays of the shoulders revealed left acromioclavicular joint degenerative changes; otherwise negative. Finally, x-rays of the ankles showed well-healed fractures of the left ankle with retained hardware in the medial and lateral malleolus, with no degenerative joint disease seen. The examiner stated that limitation of motion of the shoulders was related to scarring from the hidradenitis suppurativa and that the pain in the feet was due to metatarsalgia. The examiner further noted that the remainder of the joint complaints, diagnosed as polyarthralgias, were probably unrelated to the widespread skin condition. A bone scan conducted in September 1991 revealed faint labeling of the mid-segment of the eighth posterior rib, possibly related to old incompletely healed trauma; intense labeling of the right ankle with predominant involvement of the lateral malleolus also with involvement of the medial malleolus, consistent with severe arthropathy and/or possible recent trauma; and typical arthritis changes involving the knees and right acromioclavicular bursa. The veteran's treating physician, Jon A. Green, M.D. (of the University of California, Davis, School of Medicine, Department of Internal Medicine), stated in June 1993 that the published literature supports a relationship between chronic infectious processes and arthritis in general, as well as the specific chronic spondyloarthropathy. Dr. Green subsequently stated that he felt that the veteran had a disease complex which included hidradenitis, acne conglobata and non-deforming arthritis at a minimum, as well as aseptic necrosis of the femoral heads as either a consequence of the treatment of the acne [steroids] or as a component of the disease complex. He based this conclusion upon the fact that the veteran had documented episodes of hand swelling and joint pain consistent with an arthropathy, as well as a finding of aseptic necrosis of the hips on magnetic resonance imaging. It was Dr. Green's impression that the veteran did not drink alcohol, and there was no other recognized basis for aseptic necrosis of the femoral heads at a young age. A VA examiner in November 1993 diagnosed the veteran as having polyarthralgias without objective arthritis (peripheral). There were no x-rays or clinical suggestions of an inflammatory component. The examiner noted that hidradenitis and acne conglobata are known to associate with spondyloarthropathy and peripheral arthropathy. He further stated that, "Although it is very possible that this pt's arthropathy (peripheral arthralgias and DDD of spine) is assc with skin pathology, his rheumatic presentations are rather atypical." In December 1993, the same VA examiner noted that the arthritis associated with these skin disorders was known to be destructive and "spondyloarthropathy is inflammatory innature [sic] with syndesmophytes." The examiner further stated that the presentation of the veteran's rheumatic complaints was more limited to polyarthralgias without objective documentation of synovitis. "Negative x-rays (without signs of previous synovitis) 10-15 years after severe arthritis further mitigate against serious/severe arthritis and certainly no destruction is apparent. Spine pathology seemed more degenerative process than inflammatory spondylitis. The arthritis and spondylitis assc with HP and AC are not very common. Limited my experience in this type of case makes further difficulty in making the association." In January 1994, Dr. Green diagnosed the veteran as having hidradenitis suppurativa and questionable arthralgias/arthritis due to immune complex disease due to hidradenitis suppurativa. In December 1994, the veteran complained of swollen hands, a lump on the left forearm and chronic back pain. Dr. Green diagnosed arthritis questionably related to hidradenitis suppurativa, questionably related to cold weather. The veteran was afforded a VA examination in January 1995. X-rays of the hips and sacroiliac joints were negative. X- rays of the shoulders disclosed possible impingement syndrome. X-rays of the lumbosacral spine showed minimal degenerative joint disease. The examiner concluded that the veteran's arthritis was in no way related to his acne or hidradenitis suppurativa because he did not present with the seronegative spondylar arthropathy picture described in association with acne and hidradenitis suppurativa, nor with the acute fulminant, febrile polyarthritis seen in association with teenage acne vulgaris. The Board deemed that additional medical expertise was needed to render an equitable disposition in this case and in June 1999 requested an IME opinion. In July 1999, Daniel J. Stechschulte, M.D., a professor of medicine and director of the Division of Allergy, Clinical Immunology and Rheumatology at the University of Kansas Medical Center provided an expert medical opinion in response to a specific Board request. The physician stated, in pertinent part: I have reviewed the files of the above- referenced case. This 50 year old gentleman [. . .] is service-connected for hidradenitis suppurativa and acne conglobata. He has a chronic history of musculoskeletal complaints which involve the hands, shoulders[,] knees, neck and low back regions. He has a history of trauma in the past which may have contributed to some of his musculoskeletal complaints. The past history is positive for a history of "broken legs" in 1972 which was sustained when jumping off a building. In 1977, he underwent a splenectomy. By 1983, he has a chronic history (many years) of hidradenitis suppurativa and acne conglobata with remissions and exacerbation with multiple surgeries. It should be noted that he had vague musculoskeletal complaints of pain at least as early as 1968. Radiographic examination of his musculoskeletal system was documented in 1989 when he had evidence of a healed right tibial and fibial fracture. Films on September 27, 1990, were read as a subtle erosive change of the left ulnar styloid along with some subtle erosive changes in the second and third metatarsal heads. This was interpreted as suggestive of rheumatoid arthritis. Plain films of the right ankle in April of 1991 were reported as normal. In September of 1991, a bone scan revealed increased uptake in the right posterior 8th rib and increased uptake in the right lateral malleolus and minimal uptake in the medial malleolus. There was also some increased uptake in the bilateral knees and right shoulder. The axial skeleton was reported as normal and there was no mention of any evidence of uptake in the left ulnar styloid or metatarsal heads. In September of 1993, laboratory studies revealed a negative rheumatoid factor and ANA with an ESR of 21. In September an MRI of the back revealed mild posterior disk bulging at lumbar 1-5. An MRI of the femoral heads was interpreted as bilateral avascular necrosis. A physical exam in November revealed no joint findings and no SI joint tenderness. Another physical exam on December 7, 1993, did not detect any evidence of synovitis. On January 30, 1995, bilateral shoulder films revealed minimal spurring of the clavicles. Plain films of the hip were unremarkable and the SI joints were free of any osteitis or erosions. Lumbar films were interpreted as having minimal degenerative changes. A note is made of some limitation of motion of the right and left shoulder due to skin scaring [sic] on the axillary areas. A report by Dr. Scott Anderson on 1/30/95 was reported as mild impingement of the left shoulder, Heberden's node of the DIP joint and an essentially normal musculoskeletal exam. After reviewing the records, it is my opinion that the patient has: 1. Chronic musculoskeletal pain secondary to degenerative changes manifested by mild impingement of the shoulder capsule, degenerative changes in the axial skeleton and degenerative changes in the knees and ankles, probably associated with trauma or degenerative of the articular cartilages. There is no evidence of an active synovitis, osteitis, sacroiliitis or spondylitis. The radiographic findings as reported are consistent with the physical findings as reported and support a diagnosis of degenerative arthritis. It is well recognized that acne conglobata and hidradenitis suppurativa can be associated with an inflammatory synovitis, osteitis, sacroiliitis and spondylitis. This relationship is part of a syndrome of synovitis, acne, pustulosis, hyperostosis and osteitis, the acronym for which is the SAPHO syndrome. This individual does not have the musculoskeletal manifestations and, therefore, I would conclude that the current joint findings in this patient are not caused or resulting from the service- connected skin disorders. The diagnosis of avascular necrosis noted on MRI in October of 1993 is somewhat puzzling since the January of 1995 plain hip films did not demonstrate any abnormality. Although an MRI is clearly a more sensitive diagnostic test for avascular necrosis of the femoral heads, it would be expected that after 18+ months, this entity would also be seen on plain films. It is not clear from the records the extent and duration of steroid treatment for the patient's cutaneous conditions. It is well-recognized that corticosteroids contribute to avascular necrosis, but the records to not clearly make this diagnosis, nor is there documentation of the amount of steroids that this individual received. It is my opinion that steroid treatment for the skin disorder could contribute to avascular necrosis of the femoral heads, but it is not clear that this diagnosis can be made in this patient. 2. It is my opinion that the joint disorder is separate and distinct from the service-connected skin disorder. However, many joint symptoms, whether due to osteoarthritis or an inflammatory arthritis, may be exacerbated when the patient undergoes an infectious or inflammatory condition. The mechanism for this is not clear. It is my opinion that the patient's symptoms relating to the musculoskeletal system may be exacerbated by an infectious inflammatory skin disorder. As I mentioned above, high dose and prolonged corticosteroid treatment for a skin condition would be associated with an increased risk of avascular necrosis, but the latter diagnosis has not been established in this patient. B. Legal analysis The veteran's claim is found to be "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1997). All relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). As noted above, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1998). Establishing service connection on a secondary basis requires evidence sufficient to 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. 38 C.F.R. § 3.310(a) (1998). In Allen v. Brown, 7 Vet. App. 439, 448 (1995), the Court held that when aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Thus, service connection on a secondary basis may be granted under one of two conditions. The first is when the disorder is proximately due to or the result of a disorder of service origin. In that case, all symptomatology resultant from the secondary disorder will be considered in rating the disability. The second is when a service-connected disability aggravates a non-service-connected disability. In this case, the VA may only consider the degree of disability over and above the degree of disability prior to the aggravation. The veteran is service connected for acne conglobata and hidradenitis suppurativa. He also has a joint disorder(s), diagnosed as chronic musculoskeletal pain secondary to degenerative changes manifested by mild impingement of the shoulder capsule, degenerative changes in the axial skeleton and degenerative changes in the knees and ankles by the IME in July 1999. Based upon review of diagnostic testing, a diagnosis of avascular necrosis of the femoral head could not be made. The record includes some medical evidence favorable to the veteran's claim and some that is unfavorable. Therefore, the Board must assess the probative weight of this evidence in rendering a decision including analysis of the credibility and probative value of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, the Board may not base a decision on its own unsubstantiated medical conclusions, but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board must also assess the credibility and weight to be given to the medical evidence before it. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The evidence is no longer presumed to be credible once an analysis of the claim on the merits is undertaken. For the following reasons, the Board concludes that the preponderance of the evidence is against the claim for secondary service connection for a joint disorder because the medical evidence reflecting that the veteran's acne conglobata and hidradenitis suppurativa did not cause or aggravate a joint disorder is more persuasive and of greater weight than the medical evidence that is favorable to such a connection. Although Dr. Moody stated that the veteran's skin disorder had systemic and nervous manifestations in January 1986, he did not specifically render an opinion concerning causation of a joint disorder. His statement is ambiguous and has little probative value. Moreover, the medical excerpts provided by the veteran are general in nature and not specific to the facts of this case. The opinion of Dr. Green in June 1993, which is favorable to the veteran's claim, is inconclusive and must, therefore, be accorded less weight. While Dr. Green stated in June 1993 that the veteran had non-deforming arthritis as a result of his service-connected skin disorder, in December 1994 he diagnosed the veteran as having arthritis questionably related hidradenitis suppurativa, questionably related to cold weather. These inconsistencies in his statements render his opinion nonprobative. The initial opinion is unconvincing when viewed on conjunction with his subsequent statement. Moreover, it is clear that Dr. Green did not review the veteran's complete medical records in light of his statement that the veteran did not drink alcohol. The medical records are replete with evidence of alcohol abuse. Another opinion favorable to the veteran's claim was from the VA examiner in November 1993, who stated that although it is very possible that the veteran's arthropathy (peripheral arthralgias and DDD of spine) was associated with his skin pathology, his rheumatic presentations were rather atypical. However, in December 1993 this examiner appeared to reach a contrary conclusion. He further stated that his limited experience in this type of case made it difficult for him to render an opinion on causation. Where a physician is unable to provide a definite causal connection, the opinion on that issue constitutes "what may be characterized as 'non- evidence.'" See Perman v. Brown, 5 Vet. App. 237, 241 (1993). Other medical professionals have concluded that the veteran's joint disorder(s) was not caused by his service-connected acne conglobata and hidradenitis suppurativa. A VA examiner in April 1991 concluded that the veteran's joint complaints (other than limitation of motion of the shoulders, for which the veteran is already service connected), diagnosed as polyarthralgias, were probably unrelated to his service- connected skin condition. In January 1995, a VA examiner concluded that the veteran's arthritis was in no way related to his acne or hidradenitis suppurativa because he did not present with the seronegative spondylar arthropathy picture described in association with acne and hidradenitis suppurativa, nor with the acute fulminant, febrile polyarthritis seen in association with teenage acne vulgaris. The July 1999 IME opinion was, by far, the most extensive review of the medical evidence of record and the lengthiest documented opinion of record. The doctor stated that, "It is well recognized that acne conglobata and hidradenitis suppurativa can be associated with an inflammatory synovitis, osteitis, sacroiliitis and spondylitis. This relationship is part of a syndrome of synovitis, acne, pustulosis, hyperostosis and osteitis, the acronym for which is the SAPHO syndrome. This individual [the veteran] does not have the musculoskeletal manifestations and, therefore, I would conclude that the current joint findings in this patient are not caused or resulting from the service-connected skin disorders." This opinion was well reasoned, definitive and based on extensive review of the claims file. The IME is also a specialist in clinical immunology and rheumatology, a practitioner in a medical discipline which the Board believes is well qualified to address to etiology of the veteran's joint disorder(s). There is also one medical opinion of record concerning the issue of aggravation of the veteran's joint disorder(s) by the service-connected skin disorder. The IME stated that many joint symptoms, whether due to osteoarthritis or an inflammatory arthritis, may be exacerbated when the patient undergoes an infectious or inflammatory condition, but that the mechanism for this was not clear. The doctor then concluded that the veteran's symptoms relating to the musculoskeletal system may be exacerbated by an infectious inflammatory skin disorder. This opinion is inconclusive. The qualified language of this opinion means that it has limited value. The implication is that the veteran's joint disorder may or may not be exacerbated by his service- connected skin disorder. Moreover, the doctor indicated that he was unable to provide any rationale, as the mechanism for such a relationship was not clear. Standing alone, this opinion would be so speculative that it would fail to provide the medical evidence necessary to well ground the veteran's claim. See, e.g., Bloom v. West, 12 Vet. App. 185 (1999);); Obert v. Brown, 5 Vet. App. 30 (1993); but see Alemany v. Brown, 9 Vet. App. 518 (1996). The Board is cognizant of the fact that the veteran maintains that he has a joint disorder as a result of his service- connected skin disorder. However, the veteran is not competent to render such an opinion. There is no indication that he possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. See Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). For these reasons, the Board concludes that the evidence against the veteran's claim is more probative and of greater weight and, based on this evidence, finds as fact that the veteran's claimed joint disorder(s) was not caused or aggravated by his service-connected acne conglobata and hidradenitis suppurativa. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a joint disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. A reasonable doubt exists where there is an approximate balance of positive and negative evidence that does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (1998). It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. Id. It is not a means of reconciling actual conflict or a contradiction in the evidence. Id. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the relationship between the veteran's acne conglobata and hidradenitis suppurativa and his joint disorder. III. Gastrointestinal disorder, claimed as ulcers A. Factual background VA outpatient treatment records show that the veteran was first treated for gastrointestinal symptomatology in January 1978. He complained of left abdominal pain. Pertinent diagnoses included left lower quadrant pain with guaiac positive stool, etiology unclear, and history of red vomitus. The veteran was hospitalized at the VA Medical Center (VAMC) in Martinez, California, from August to September 1978 following a stab wound. He complained of left flank pain. A celiotomy was preformed at which time a splenic abscess and perisplenic abscess was found. The spleen and tip of the pancreas were removed. The assessment was status post- operative splenectomy secondary to stab wound. The veteran complained of severe pains in the epigastric area in October 1978. Pertinent diagnoses included chronic polydrug abuse, malingering due to chronic polydrug abuse, and status post traumatic splenectomy. The veteran was hospitalized at the VAMC in Palo Alto, California, from October 1978 to February 1979. He complained of epigastric pain. An upper gastrointestinal series (UGI) showed findings consistent with inflammatory changes of the duodenal sweep, consistent with pancreatitis status, status post stab wound and partial pancreatectomy. During VA hospitalization from November 1981 to April 1982, the veteran was diagnosed as having constipation. Sigmoidoscopy was negative. VA outpatient treatment records reflected complaints of right upper quadrant pain in April 1982. Pertinent diagnoses included right upper quadrant pain of questionable etiology and status post splenectomy due to stab wound to the spleen and liver. The veteran was awarded Social Security Administration (SSA) disability benefits in 1978 due, in part, due to status post splenectomy and partial removal of the pancreas. VA outpatient treatment records reflected complaints of right upper quadrant pain in March 1985. The examiner's assessment was right upper quadrant pain of questionable etiology. During hospitalization at Gray's Hospital in August 1986, the veteran was diagnosed as having acute duodenal ulcer disease. Medical records from the Arkansas Department of Corrections showed that he was treated for ulcers and gastritis in 1987 and 1988. In a November 1987 written statement, the veteran claimed entitlement to service connection for ulcers as secondary to his service-connected skin condition. He stated that ulcers were caused by his inability to hold work due to his service- connected disability. The veteran testified at a personal hearing at the RO in April 1989. He stated that his ulcers were caused by stress associated with his service-connected skin condition. The veteran was afforded a VA examination in May 1989. The dermatology examiner stated that the association between the veteran's cutaneous condition and his ulcer was unclear. On VA examination in April 1991, UGI series was unremarkable. There was a very subtle questionable area of irregularity in the tip of the bulb with some thickening, which may be normal versus possible mild residual scarring from prior peptic ulcer disease. The examiner diagnosed a history of peptic ulcer disease. The examiner concluded that it was unlikely that this condition was due to the veteran's skin condition. B. Legal analysis The laws and regulations concerning well grounded claims and service connection on a secondary basis were discussed above and will not be repeated. The veteran is currently diagnosed as having gastrointestinal disorders, including an ulcer. However, the record lacks evidence of a relationship between these current disorders and the service-connected acne conglobata and hidradenitis suppurativa. There are no medical opinions contained in any of the medical records relating any current gastrointestinal disorder to the service-connected disability. The August 1989 VA examiner's statement fails to establish any such connection. Moreover, a VA examiner ruled out any such relationship in an April 1991 opinion. The veteran lacks medical expertise and is not qualified to render an opinion regarding a causal relationship between any gastrointestinal disorder and the service-connected acne conglobata and hidradenitis suppurativa. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Without competent medical evidence establishing such a relationship, his claim for service connection on a secondary basis is not well grounded. See Jones, 7 Vet. App. at 137. Where a claimant refers to a specific source of evidence that could make his claim plausible, VA has a duty to inform him of the necessity to submit that evidence to complete his application for benefits. See Epps v. Brown, 9 Vet. App. 341, 344-45 (1996), aff'd Epps v. Gober, 126 F.3d. 1464, 1468 (Fed. Cir. 1997). The Board finds VA has no outstanding duty to inform the appellant of the necessity to submit certain evidence to complete his application for VA benefits. 38 U.S.C.A. § 5103(a) (West 1991). Nothing in the record suggests the existence of evidence that might well ground the veteran's claim for service connection for a gastrointestinal disorder on a secondary basis. Although the RO has not obtained the veteran's complete SSA records, there is no basis for speculating that such records would produce evidence necessary to well ground the veteran's claim for service connection on a secondary basis. Brewer v. West, 11 Vet. App. 228 (1998); see Grivois v. Brown, 6 Vet. App. 136, 139-40 (1994) (noting that "implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which . . . require adjudication."). Accordingly, the Board concludes that VA did not fail to meet its obligations with regard to the veteran's claim under 38 U.S.C.A. § 5103(a) (West 1991). IV. Rating for acne conglobata and hidradenitis suppurativa A. Factual background The veteran was originally granted entitlement to service connection for acne vulgaris by means of a September 1972 rating decision. The RO assigned a noncompensable disability evaluation, effective from August 1972. In December 1974, the RO assigned a 10 percent disability rating for this condition, effective from July 1974. In April 1978, the RO assigned a 30 percent disability rating for this condition, effective from February 1976. The 30 percent disability rating has remained in effect since that time. During hospitalization from October 1978 to February 1979, the veteran underwent excision of an old perirectal abscess and sinus tracts in the right buttocks and split thickness skin grafting to the right buttock. Review of the claims folder further reveals that the veteran was awarded SSA disability benefits in October 1978 due, in part, due to his service-connected skin disorder. More recently, the veteran sought reevaluation of the disability rating assigned for his service-connected skin disorder in November 1987. Medical records obtained in conjunction with his claim showed that he was hospitalized at Gray's Hospital where he was treated by Lackey Moody, M.D. in August 1986. There was a great deal of scar tissue over his neck and right hip and large, deformed, sebaceous-type lesions of the axilla, neck and hip. The examiner's impression was severe sebaceous disease and severe (marked) scarring of the neck, axilla and hips. In a August 1986 written statement, Dr. Moody stated that the veteran had severe seborrheic cystic dermatitis with recurrent infection and marked disfigurement with systemic and nervous manifestations. Dr. Moody further stated that the veteran was unable to work and obtain a substantially gainful occupation because of this condition. Medical records from the Arkansas Department of Corrections dated from 1987 to 1988 revealed treatment for severe sebaceous gland disease under the arms and in the groin with scarring. Cysts were also noted on the neck and hip. In May 1987, a diagnosis of severe cystic sebaceous disease with deformity and scarring under both arms was rendered. There was also a large scar of the right buttocks with complaints of chronic pain. No signs of infection were noted on examination in July 1988 but the veteran was treated prophylactically. The assessment was chronic hidradenitis suppurative of the axilla with a history of grafts on the buttocks and chronic recurring infections. There was also a mild malar rash and facial pitting. On VA examination in November 1988, the veteran gave a history of swelling in the axillary areas bilaterally as well as in the groin, perianal and neck areas. The examiner noted multiple healed sinuses in these areas, suggestive of minimally active hidradenitis suppurativa. The examiner stated that the degree of the disease was moderate and appeared to be minimally active at this time. Also associated with the claims folder are VA outpatient treatment records dated from 1986 to 1989. In November 1988, there were findings of erythema and nodular swelling in the veteran's right groin, perianal area and axilla. There was scarring in all areas and evidence of surgery and skin graft of the right buttocks. On dermatology consultation in December 1988, there were acne scars on the cheeks and neck and rosacea. There was scarring and contractures of the axilla and groin, without active drainage. In February 1989, ice pick scars on the veteran's face (especially cheeks) were noted. Scarring due to hidradenitis suppurative was present in the axilla. There was an erythematous firm nodule in the right axilla. The examiner's assessment was acne scars; hidradenitis suppurativa, active; acne rosacea. The veteran testified at a personal hearing at the RO in April 1989. He stated that women made fun of his skin condition. His skin condition (of the groin, neck, chest and armpits) reportedly itched and swelled as big as a tennis ball. It became tender, painful and red, and would then drain. These episodes occurred at least once a month and lasted from one to three weeks. He last worked as an electrician's helper in 1984, but stated that there were times that he could not go to work because of his skin condition. The veteran was afforded a VA examination in May 1989. Physical examination revealed a few active cysts on the back and shoulders with multiple pitted scar-like areas covering the back, shoulders and much of the face. There were extensive areas of scarring in both axillae with a few active draining sinuses. There was similar but less dramatic involvement in the groin area. The veteran was on medication for this condition. The examiner's impression was evidence of follicular occlusion triad including severe scarring cystic acne (acne conglobata) and hidradenitis suppurativa. The cutaneous condition was described as obviously severe. On VA examination in April 1991, the veteran reported that his skin condition involved his neck, armpits, anterior and posterior chest, buttocks and inguinal area. Examination of the skin showed extensive acne scarring on the face and anterior and posterior chest. There was a surgical incision over the right pectoralis major. There was extensive surgical scarring in the right axilla and moderate scarring in the left. There was a skin graft over the right buttock and scars in the right and left inguinal areas. The examiner diagnosed acne conglobata and hidradenitis suppurativa with scarring. Additional VA outpatient treatment records showed that the veteran was treated for a three millimeter draining ulcer of the right axilla in November 1991. There was a flocculent area about two to three inches with pain to palpation. There was a two by two inch painful area in the left axilla and a deep, flocculent area in the left buttocks. In February 1992, many acne scars, cysts and inflamed pustules were noted. In December 1992, there were hard, cord-like areas, painful to touch, in both axillae. In March 1993, there were cysts in the occipital area of both axillae, the groin and buttocks. Keloids were also in these areas. The veteran underwent incision and drainage of a left buttock abscess (8 centimeters by 10 centimeters) in May 1993. He walked with difficulty and was unable to sit or sleep. There was also a tender, large, indurated area over the right buttock, which was not ready for incision and drainage. In June 1993, there were several cysts and scarring of the veteran's face, neck, buttocks and armpits. A developing hidradenitis lesion was noted on the left axilla in August 1993. A two to three centimeter indurated lesion was thereafter noted, with continued tenderness at the site. In September 1993, nodes were noted in the axillae. A right axilla rash was noted in November 1993. The veteran complained of increased itching in November 1994. In December 1994, there were abscesses on the right and left buttocks. He underwent incision and drainage. Both lesions were draining freely. An open wound on the left buttock was noted one week later. An abscess of the right deltoid was noted in January 1995. The veteran underwent VA skin examination in January 1995. The examiner reviewed the claims file. The veteran reported that for the past 30 years he had extensive pustular drainage from the armpits, neck, back and buttocks. He underwent extensive surgery in these areas and had a skin graft to the right buttock. He was frequently on antibiotics. The examiner noted extensive scarring with depressed, adherent, nontender scars in the right axilla. There were similar scars in the left axilla, but less extensive. Examination of the posterior neck and upper back showed extensive pitting and scarring, without active pustular lesions. Examination of the buttocks showed extensive pustular lesions and surgical scars without active lesions. There was a skin graft over the right buttock. Photographs of the affected areas were included with the examination report. The examiner diagnosed acne conglobata and hidradenitis suppurativa, status post multiple surgeries. During VA hospitalization from March to April 1995, there were cystic acne scars over the veteran's face and back. There were also multiple, healed surgical scars, one on the right arm over the deltoid, another on the right buttocks, and a another over the right nipple, status post surgical removal of infected glands. The veteran was hospitalized at the Atlanta, Georgia, VAMC in January 1997. He gave a 20 to 25 year history of recurrent abscesses in the groin and buttocks. His present complaints included fever, chills and pain for the past two days. The examiner noted large abscesses with fluctuance and erythema, extremely tender, in the right and left cheeks. They were laterally over the lateral surfaces and away from the anorectal area. The veteran was placed on antibiotics and underwent incision and drainage with wide debridement. B. Legal analysis The veteran has presented a well-grounded claim for an increased disability evaluation for his service-connected skin disorder within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); cf. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (where veteran asserted that his condition had worsened since the last time his claim for an increased disability evaluation for a service-connected disorder had been considered by VA, he established a well-grounded claim for an increased rating). The veteran has been afforded VA examinations and a personal hearing and his treatment records have been associated with the file. The Board is satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78 (1990); Littke v. Derwinski, 1 Vet. App. 90 (1990). Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155 (West 1991). Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2 (1998). Nevertheless, past medical records do not take precedence over current findings in determining whether to increase a disability rating, although a rating specialist is directed to review the recorded history of disability to make a more accurate evaluation. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2 (1998), and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3 (1998). If there is a question as to which evaluation to apply to the veteran's disability, 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). Where the particular disability for which the veteran is service connected is not listed, it may be rated by analogy to a closely related disability in which not only the functions affected but also the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20 (1998). Therefore, the veteran's skin condition, acne conglobata and hidradenitis suppurativa, is currently evaluated under 38 C.F.R. § 4.118, Diagnostic Code 7806, pertaining to eczema. The criteria for rating the veteran's service-connected skin disorder provides that a 30 percent rating may be assigned with exudation or itching constant, extensive lesions, or marked disfigurement. The highest or 50 percent rating may be assigned with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. 38 C.F.R. § 4.118, Diagnostic Code 7806 (1998). Examining the medical and lay evidence relative to the severity of the veteran's acne conglobata and hidradenitis suppurativa in light of Diagnostic Code 7806, the Board finds that a relative balance has been reached with regard the merits of the veteran's claim for a rating greater than 30 percent. The evidence of record shows that the veteran's acne conglobata and hidradenitis suppurativa is subject to periodic exacerbations and remissions. The rating of the disability must account for the disorder at its most active phase. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992). The evidence of record can reasonably be interpreted as suggesting that a flare-up of the veteran's disorder at its most severe is of such significant severity as to constitute the ulceration and repugnancy that would warrant a 50 percent rating, which is the maximum schedular rating. The veteran's condition has been described as severe on more than one occasion and is accompanied by deformity, extensive areas of scarring, and draining lesions. He also required surgery, i.e., incision and drainage, on more than one occasion. The Board therefore finds that a state of relative equipoise has been reached in this case, and the benefit of the doubt rule is applicable. 38 C.F.R. §§ 3.102, 4.3, 4.7 (1998). ORDER New and material evidence having been submitted, the claim of entitlement to service connection for a psychiatric disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa, is reopened. Entitlement to service connection for a joint disorder, as secondary to service-connected acne conglobata and hidradenitis suppurativa, is denied. Having found the claim not well grounded, entitlement to service connection for a gastrointestinal disorder (claimed as ulcers), as secondary to service-connected acne conglobata and hidradenitis suppurativa, is denied. Entitlement to an a 50 percent disability rating, and not higher, for service-connected acne conglobata and hidradenitis suppurativa, is granted, subject to controlling regulations regarding the payment of monetary benefits. REMAND Entitlement to service connection for a psychiatric disorder on a secondary basis With respect to service connection for a psychiatric disorder as secondary to service-connected acne conglobata and hidradenitis suppurativa, the issue that was addressed by the RO was whether new and material evidence had been submitted to reopen the claim. It would be prejudicial to the veteran if the Board were to proceed to decide the question of service connection at this point, since the Board finds that additional evidentiary development is necessary for a fair decision in this case. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). There are potentially medical records that the RO should attempt to obtain concerning the veteran's claim. For example, he was awarded SSA disability benefits, in part because of a psychiatric disorder, in 1978. It is also likely that he has received additional treatment for a psychiatric disorder since 1995, the date of the most recent VA outpatient treatment records associated with the claims folder. Therefore, the RO should make arrangements to obtain these records on remand. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Littke v. Derwinski, 1 Vet. App. 90 (1990); Murphy v. Derwinski, 1 Vet. App. 78 (1990); see also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (VA records are constructively part of the record which must be considered). The January 1999 IME also stated that only a complete psychiatric evaluation by a psychiatrist and possibly testing, i.e., Minnesota Multiphasic Personality Inventory (MMPI), would help distinguish the role the veteran's skin disorder plays in the diagnosis of dysthymia. Therefore, on remand the veteran should be hospitalized for a period of inpatient observation and evaluation and for appropriate psychological testing in order to resolve this matter. Entitlement to a TDIU The veteran perfected an appeal of the December 1988 denial of entitlement to a TDIU. However, this issue was inadvertently dropped from the appeal. The veteran has not been provided a supplemental statement of the case on this issue, despite the receipt of additional evidence, since August 1989. Additional development is warranted in this regard. 38 C.F.R. § 19.31 (1998). As noted above, the veteran has reportedly applied for SSA benefits. Any SSA records, as well as any additional VA records, may prove pertinent to his claim for a TDIU. The veteran should also be afforded additional VA examination on remand for the purpose of determining what effect his service-connected acne conglobata, limitation of motion of the right shoulder, limitation of motion of the left shoulder, scar of the right axilla and scar of the left buttock, as opposed to his nonservice-connected disabilities, have on his ability to work. See Friscia v. Brown, 7 Vet. App. 294 (1994), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In Friscia, the Court specifically stated that, where the VA has merely offered its own opinion regarding whether a veteran is unemployable as a result of a service- connected disability, the VA has the duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disability has on his ability to work. Friscia at 297, citing 38 U.S.C.A. § 5107(a); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a); Beaty v. Brown, 6 Vet. App. 532, 538; and Obert v. Brown, 5 Vet. App. 30, 33 (1993). Accordingly, the case is hereby REMANDED to the RO for the following actions: 1. Request that the veteran provide a list of those who have treated him for any psychiatric disorder and his service- connected disabilities since 1995. Obtain all records of any treatment reported by the veteran that are not already in the claims file. The Board is particularly interested in any treatment received at VAMCs. On requesting records from private physicians, specify that actual treatment records, to include all diagnostic test results, as opposed to summaries, are requested. If any private treatment is reported and the records are not obtained, the veteran and his representative should be told of the negative results and of the veteran's ultimate responsibility to provide the records. 38 C.F.R. § 3.159 (1998). 2. Make the necessary arrangements to obtain a copy of any SSA decision denying or granting disability benefits to the veteran. Obtain all the records from the SSA that were used in considering the veteran's claim for disability benefits, including any reports of subsequent examinations or treatment. If these records are duplicates of those already on file, that fact should be annotated in the claims folder. Any other records should be associated with the claims folder. 3. Schedule the veteran for a period of inpatient observation and evaluation to assess his psychiatric disorder(s). The examiner should be provided a copy of this remand together with the veteran's entire claims folder, and the examiner is asked to indicate that he or she has reviewed the claims folder. All necessary tests, including an MMPI, should be conducted and the examiner should review the results of any testing prior to completion of the report(s). The examiner is asked to render diagnoses of all current psychiatric disorders the veteran has. All necessary tests in order to determine the correct diagnoses are to be done. If no such disorders are found, the examiner should so state. The examiner should furnish an opinion with respect to the following questions: a. What is the most likely etiology of the veteran's current psychiatric disorder(s)? b. What is the likelihood that the veteran's current psychiatric disorder(s) was caused by or resulted from the service-connected skin disorder? c. If the psychiatric disorder(s) is more likely separate and distinct from the service-connected skin disorder than a manifestation or symptom of it, what is the likelihood that the psychiatric disorder is exacerbated or worsened by the service-connected skin disorder? The examiner must provide a comprehensive report including complete rationales for all conclusions reached. If further testing or examination by other specialists is determined to be warranted in order to evaluate the condition in issue, such testing or examination is to be accomplished. 4. Afford the veteran a comprehensive VA examination for the purpose of determining what effect his service-connected physical disabilities have on his ability to work. The examiner should be provided a copy of this remand together with the veteran's entire claims folder, and the examiner is asked to indicate that he or she has reviewed the claims folder. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is specifically requested to express a medical opinion as to the degree of occupational impairment attributable to the veteran's service-connected acne conglobata, limitation of motion of the right shoulder, limitation of motion of the left shoulder, scar of the right axilla and scar of the left buttock, as opposed to his nonservice-connected disabilities. In particular, describe what types of employment activities would be limited because of the veteran's service-connected disabilities and whether any limitation on employment is likely to be permanent. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. If further testing or examination by other specialists is determined to be warranted in order to evaluate the residuals of the condition in issue, such testing or examination is to be accomplished. 5. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination reports. If the requested examinations do not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the reports must be returned for corrective action. 38 C.F.R. § 4.2 (1998); see also Stegall v. West, 11 Vet. App. 268 (1998). 6. Readjudicate the veteran's claims, with application of all appropriate laws and regulations and consideration of any additional information obtained as a result of this remand, including the VA examinations. If the decision with respect to the claims remains adverse to the veteran, he and his representative should be furnished a supplemental statement of the case and afforded a reasonable period of time within which to respond thereto. Then, the claims folder should be returned to the Board for further appellate consideration. The veteran need take no action until he is so informed. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this REMAND is to obtain additional information and to comply with all due process considerations. 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 Appeals for Veterans Claims 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. 1999) (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. J. SHERMAN ROBERTS Member, Board of Veterans' Appeals