Citation Nr: 0812589 Decision Date: 04/16/08 Archive Date: 05/01/08 DOCKET NO. 05-34 148 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for urticaria. 2. Entitlement to service connection for post-traumatic stress disorder (PTSD). 3. Entitlement to service connection for dry eye syndrome. 4. Entitlement to an initial disability rating higher than 10 percent for lumbar spondylosis. 5. Entitlement to an initial disability rating higher than 10 percent for a psychiatric disability, described as an adjustment disorder with mixed emotional features. 6. Entitlement to an initial disability rating higher than 10 percent for chronic left hip strain. 7. Entitlement to an initial compensable disability rating for dermatitis. 8. Entitlement to an initial compensable disability rating for allergies and chronic sinusitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The veteran served on active duty from January 1987 to January 1990, from October 1990 to May 1991, and from October 1997 to January 2004. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the United States Department of Veterans Affairs (VA) Regional Offices (ROs) in Winston- Salem, North Carolina, and Phoenix, Arizona. In an April 2004 rating decision, the Winston-Salem RO granted service connection for several disabilities, and assigned initial disability ratings of 10 percent for lumbar spondylosis, 10 percent for an adjustment disorder with mixed emotional features, 10 percent for chronic left hip strain, 0 percent for dermatitis, and 0 percent for allergies and chronic sinusitis. In a September 2006 rating decision, the Phoenix RO denied service connection for urticaria, PTSD, and dry eye syndrome. In October 2007, the veteran submitted a claim for a temporary total disability rating. In a December 2007 rating decision, the RO denied a temporary total disability rating. On December 19, 2007, the same date that the RO mailed the rating decision, the RO stamped as received additional evidence that the veteran submitted in support of his claim for a temporary total rating. It appears that the additional evidence may have been received after the rating decision was issued. The Board therefore refers the temporary total rating issue to the RO for appropriate action. The issues of service connection for PTSD and higher ratings for lumbar spondylosis and allergies and chronic sinusitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The veteran has had recurrent urticaria during and since service. 2. The veteran had dry eye syndrome during service that has continued after service. 3. Since separation from service in January 2004, the veteran's service-connected psychiatric disorder, described as an adjustment disorder with mixed emotional features, has been manifested by depression, anxiety, chronic sleep impairment, and irritability, which produce difficulty in occupational and social functioning. 4. Since January 2004, the veteran's chronic left hip strain been manifested by pain and some diminished endurance, producing no more than slight hip disability. 5. Since January 2004, the veteran's dermatitis has affected the back of his neck, including between 5 and 20 percent of his exposed areas. CONCLUSIONS OF LAW 1. Recurrent urticaria was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 2. Chronic dry eye syndrome was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. Since January 2004, the veteran's adjustment disorder with mixed emotional features has met the criteria for a 30 percent disability rating. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.10, 4.130, Diagnostic Code 9440 (2007). 4. Since January 2004, the veteran's chronic left hip strain has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253, 5255 (2007). 5. Since January 2004, the veteran's dermatitis has met the criteria for a 10 percent disability rating. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.7, 4.10, 4.118, Diagnostic Codes 7800, 7806 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. Urticaria The veteran contends that he had recurrent urticaria, or hives, during service, and has continued to have recurrent urticaria since service. VA established service connection for dermatitis, in response to the veteran's August 2003 claim for service connection for a rash on the head. The veteran asserts that his urticaria is a separate condition from that dermatitis. The veteran's service medical records show outpatient treatment for skin symptoms on multiple occasions between 1999 and 2003. In June 1999, the veteran reported a two week history of an intermittent rash on different areas, including the left wrist and hand and the face. The treating practitioner's impression was acute urticaria. In October 2001, the veteran was seen for a rash in both underarm areas. The treating practitioner's impression was contact dermatitis. In February 2002, the veteran was seen after having facial swelling and a rash on his abdomen, both of which had resolved with non-prescription allergy medication. In December 2002, after having a flu shot, the veteran developed a mild rash on his face and a burning sensation in the skin of his arms and low back. The treating practitioner's impression was allergic reaction. In January 2003, the veteran was seen for an itchy rash on his back, buttocks, and legs. The treating practitioner's impression was contact dermatitis. In February 2003, the veteran reported having intermittent urticaria. The treating practitioner's impression was recurrent urticaria. In July 2003, the veteran saw a dermatologist for bumps on his neck and scalp. The dermatologist's impression was dermatitis. On follow-up in September 2003, the dermatitis on the scalp had resolved. In a pre-discharge VA examination in August 2003, the veteran reported a rash on the back of his neck that had recurred about four times since September 2002. He stated that since about 1991 he had experienced recurrent outbreaks of hives on his wrists, underarms, trunk, and thighs. At the time of the examination, there was one erythematous papular lesion on the neck. The examiner's diagnosis was dermatitis. On VA examination in May 2005, the veteran reported a recurrent rash on the back of his neck since 2002, and recurrent outbreaks of hives since 1990. At the time of the examination, there were no active lesions on the back of the neck, and no hives. The examiner expressed the opinion that it was more likely than not that the veteran's hives were related to his time in service. The veteran had VA outpatient treatment for urticaria in 2005. In June 2006, the RO requested a VA skin examination. In July 2006, the VA dermatologist who examined the veteran in May 2005 stated that it was not necessary to examine the veteran again. The dermatologist stated that the May 2005 examination had indicated that the veteran had recurrent urticaria, also called hives, and that that disorder was service connected. In January 2008, the veteran had a Travel Board hearing at the RO before the undersigned Veterans Law Judge. The veteran reported that he had experienced hives during his 1997 to 2004 period of service, and that he continued to have outbreaks of hives. He stated that he took allergy medication to partially control the hives. He asserted that the hives appeared in different areas, and were a separate condition, from the dermatitis he had on the back of his head and neck. He indicated that the dermatitis was treated with a cream, and the hives were treated with an allergy medication in pill from. The veteran's statements and the medical records indicate that he had recurrent urticaria in service, and has continued to have that disorder since service. A VA dermatologist expressed the opinion that the current disorder is related to service. Treating practitioners have described the urticaria as a condition separate from the dermatitis for which service connection is already established. The evidence support service connection for urticaria. Dry Eye Syndrome The veteran reports that he had dry eye syndrome during service, and that the disorder has continued since service. The veteran's service medical records reflect that he reported a chronic irritation and burning sensation in both eyes on multiple occasions from 1997 to 2003. Several practitioners provided an impression of keratoconjunctivitis sicca, or dry eye syndrome. In the August 2003 VA examination, the veteran reported a history of dry eye syndrome. He stated that he currently felt burning and pressure in his eyes on a regular basis. The examiner observed no evidence of severe dry eye syndrome at the time of the examination. The examiner discussed options for dry eye treatment, and recommended follow-up. In records of VA outpatient of the veteran from 2005 to 2007, the lists of prescribed medications include artificial tears. In April 2006, the veteran had a Persian Gulf veteran registry examination. He reported that he continued to have a burning sensation in his eyes. The examiner's impression was dry eye syndrome. In the January 2008 hearing, the veteran reported that his dry eye syndrome had been diagnosed in about 1998. He stated that the symptoms were now chronic, such that he needed eye drops daily, and sometimes hourly. He indicated that he received VA treatment for the disorder. There is medical evidence and credible lay evidence that the veteran had dry eye syndrome during service, and has continued to have that disorder after service. The record supports, and the Board grants, service connection for dry eye syndrome. Rating Claims Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. An evaluation of the level of disability present also includes consideration of the veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on the functional abilities. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When evaluation of a musculoskeletal disability is based on limitation of motion, VA regulations provide, and the Court has emphasized, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). The veteran appealed the initial disability ratings that the RO assigned for a psychiatric disorder, chronic left hip strain, dermatitis, and allergies and chronic sinusitis. The Board will consider the evidence for the entire period since January 13, 2004, the effective date of the grant of service connection for those disabilities, and will consider whether staged ratings are warranted. VA may consider an extraschedular rating in cases that are exceptional, such that the standards of the rating schedule appear to be inadequate to evaluate a disability. 38 C.F.R. § 3.321(b)(1) (2007). Extraschedular ratings under 38 C.F.R. § 3.321(b)(1) are limited to cases in which there is an exceptional or unusual disability picture, with such related factors as marked interference with employment, or frequent periods of hospitalization, that makes it impractical to apply the regular standards of the rating schedule. The Board does not have the authority to assign, in the first instance, higher ratings on an extraschedular basis under 38 C.F.R. § 3.321(b)(1). When an extraschedular rating may be warranted, the Board must refer the case to designated VA officials. Bagwell v. Brown, 9 Vet. App. 377 (1996). Adjustment Disorder The RO describes the veteran's service-connected psychiatric disorder as an adjustment disorder with mixed emotional features. The RO assigned a 10 percent rating for that disorder under 38 C.F.R. § 4.130, Diagnostic Code 9440. The rating schedule includes a General Rating Formula for Mental Disorders for evaluating chronic adjustment disorder and other mental disorders. The rating criteria are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name .......................... 100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships ............................................. 70 percent Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships ........................... 50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) ..................................................... 30 percent Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication ............................. 10 percent A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication ................................ 0 percent In an August 2003 VA psychiatric examination, the veteran reported anxiety, depression, and problems with sleep. He stated that he had become increasingly frustrated and angry in reaction to events during his service. He indicated that he was very short tempered, and easily became upset with his wife and children. He reported that his service duties were as an electrician. He related that he worried that his depression and anxiety might distract him and lead to mistakes while working around dangerous high voltage equipment. He stated that he had problems getting along with supervisors and co-workers. The examiner observed that the veteran's speech and thought content were normal, and that he showed anxiety and tension, but not depression. The examiner's impression was adjustment disorder with mixed emotional features. The examiner assigned a Global Assessment of Functioning (GAF) score of 55. The claims file contains records of VA outpatient mental health treatment of the veteran from 2004 forward. In an August 2004 preventive health management visit, screening for PTSD was positive, while screening for depression was negative. In a preventive health management visit in December 2004, screening was positive for both PTSD and depression. In December 2004, the veteran reported that during service he had experienced problems with anger and difficulty getting along with others, and had had homicidal thoughts at that time. He reported having depression, nightmares, difficulty sleeping, and an exaggerated startle response. He indicated that he was not employed, but was taking college courses. The veteran was started on medication for depression. Outpatient mental health treatment notes from February 2005 reflect the veteran's reports of depression, anxiety, flashbacks, nightmares, irritability, and hyperalertness. He was on medication for depression. He stated that he was attending college full time, and hoped to get employment after finishing his studies. A treating psychiatrist listed a provisional diagnosis of PTSD, and assigned a GAF score of 50. In March 2005, the veteran had a hearing before an RO Decision Review Officer. He reported that his mental disorder was manifested by nervousness, sleep impairment, and dreams about experiences during service. He stated that he was on prescription medication for anxiety. He indicated that he was a full time student, and that he was able to handle his studies. On VA mental health examination in May 2005, the veteran reported having sleep impairment, nightmares, anger, hypervigilance and homicidal ideation. He stated that he was a full time college student. He indicated that he lived with his second wife, and that his children from his first marriage lived with him during the summers. The examiner found that the veteran was oriented, and showed no evidence of psychosis. The examiner indicated that the veteran's judgment was impaired, and that his memory and concentration were fair to good. The examiner stated the opinion that the veteran had a personality disorder. The examiner assigned a GAF score of 50. In VA mental health outpatient treatment in May 2005, the veteran reported that medication was helping with his mood and anxiety. He indicated that he saw a counselor at a Vet Center. He stated that he had finished a year of college courses with good grades. The treating psychiatrist listed a diagnosis of PTSD, with a GAF score of 55 to 60. VA treatment, with medication, for PTSD continued in 2006. In January 2006, the veteran reported that he startled easily at times, that he was hypervigilant, and that he avoided people and crowds. He stated that he had to force himself to concentrate. He indicated that he was still attending college full time. In June 2006, he reported having flashbacks. A treating psychiatrist found that the veteran's memory, insight, and judgment were intact. In an August 2006 VA mental health examination, the veteran reported ongoing depression and difficulty sleeping. He indicated that he was irritable, but kept his temper under control. He stated that he felt uncomfortable in crowded places. The veteran reported that he was still in school, and that he worked a part time job in the summer between semesters. He related that at home he helped with chores, and socialized with his family. The veteran was on medication for depression. The examiner noted that the veteran did not have a significant problem with inappropriate behavior. The veteran's speech, memory, and concentration were normal. There was no indication of delusions. The examiner listed a diagnosis of PTSD, and assigned a GAF score of 60. In VA outpatient mental health treatment in September 2006, the treating practitioner noted that the veteran's mood was mildly anxious. The examiner assigned a GAF score of 65. In May 2007, the veteran reported that he had stopped taking an antidepressant. He indicated that he was still a student, and that he had quit a part time job. He reported difficulty concentrating, an easy startle reaction, and some hypervigilance. The treating practitioner found that the veteran's mood was mildly anxious and mildly dysphoric. His speech and thought process were normal, and there were no psychotic symptoms. The practitioner reinstated the antidepressant, at a lower dose. The practitioner assigned a GAF score of 65. In the January 2008 hearing, the veteran reported that his adjustment disorder was manifested by anxiety and irritability that caused him difficulty with his studies ,and with his interaction with fellow students and with family members. Over most of the period since the veteran's separation from service in 2004, mental health practitioners have prescribed antidepressant medication to treat the veteran's psychiatric disorder, which those practitioners describe as an adjustment disorder or as PTSD. The veteran has had chronic sleep impairment, and ongoing symptoms of depression and anxiety. He reports difficulty concentrating. He has not reported panic attacks, and practitioners have not found him to have memory impairment. The veteran's occupation since separation from service has been as a student. He indicates that his psychiatric symptoms make it harder for perform in his studies, but that he has persevered and performed reasonably well. He reports feeling irritable toward others at school and at home, but usually managing to control his actions. Overall, the veteran's psychiatric symptoms appear to be more than mild or transient. The evidence indicates that his psychiatric disorder causes him difficulty in his studies and his social functioning, although it is not clear that there are periods when he is unable to perform the tasks associated with his coursework. The manifestations and effects of the veteran's psychiatric disorder appear to fall somewhere between the criteria for 10 percent and 30 percent ratings. Considering the level and persistence of the veteran's symptoms, the disability picture more nearly approximates the criteria for a 30 percent rating. Therefore, the Board will grant an increase to a 30 percent rating. The effects of the psychiatric disorder have been fairly similar over the period since separation from service, and therefore do not warrant staged ratings. The manifestations and effects of the veteran's psychiatric disorder do not necessitate referral of the rating of that disability to designated VA officials for consideration of an extraschedular rating. The veteran has not had frequent hospitalizations for his psychiatric disorder, and the evidence does not indicate that his psychiatric disorder markedly interferes with his pursuit of training or his potential for employment. Left Hip Strain The veteran reports that he injured his low back and left hip during service. He states that he has ongoing pain in his low back and left hip, and pain radiating down his left leg almost to the ankle. The RO established service connection for a back disability, described as lumbar spondylosis, and for chronic left hip strain. The veteran has appealed the 10 percent rating that the RO assigned for the left hip disability. The RO evaluates the veteran's left hip disability under 38 C.F.R. § 4.71a, Diagnostic Code 5255, as analogous to malunion of the femur. That code provides for ratings of hip disability of 10 percent if slight, 20 percent if moderate, and 30 percent if marked. The rating schedule also provides for evaluating hip disability based on limitation of motion. Compensable ratings may be assigned if extension is limited to 5 degrees, flexion is limited to 45 degrees, abduction is limited to 10 degrees, adduction is limited such that the person cannot cross his legs, or rotation is limited to toeing out to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5251-5253. In the August 2003 VA examination, the veteran reported that he had made parachute jumps during service, and had injured his low back and left hip in a jump in 1998. He stated that he had ongoing chronic left hip strain, with pain about twice a day, lasting about an hour each time. He indicated that the left hip disorder limited his endurance for prolonged standing or sitting. At the time of the examination, the left hip had normal ranges of motion, without pain. There was tenderness to palpation of that hip. The hip appeared normal on x-rays. The examiner's diagnosis was chronic left hip strain. VA outpatient treatment records from 2004 forward note chronic left hip pain among the veteran's disorders. In August 2004, a treating physician found that the veteran's left hip had a full range of motion, and full muscle strength. Notes from 2005 indicate that he was taking medication daily for pain in his low back and left hip. In the March 2005 RO hearing, the veteran reported constant low back pain, and pain in his left hip and down his left leg to his ankle. He stated that he wore a brace on his left knee. He reported that he had constant pain in his left hip, and that he took nonprescription medication daily for that and other musculoskeletal pain. He indicated that he could not squat completely without pain. He related that he had to sleep in a certain position to alleviate the pain. He reported that his left hip disability had worsened to the extent that he could no longer be very active, as he had been before. On VA examination in April 2005, the veteran reported chronic pain in his low back and left hip. The range of motion of both hips was to 10 degrees of extension, 145 degrees of flexion, 30 degrees of internal rotation, 50 degrees of external rotation, and 45 degrees of abduction, all without marked pain. At the left hip, the veteran was quite tender on deep pressure over the greater trochanter. The examiner stated that the veteran had moderate pain that would further reduce the function of his left hip, and that the left hip had lack of endurance following repetitive use. On VA examination in August 2006, the veteran reported ongoing pain in his left hip. He stated that he had weakness and giving way. He indicated that he always used a brace for walking. He related that his left hip pain limited him to standing for three to eight hours, with short rest periods, and to walking one to three miles. The examiner found that the veteran's gait was normal. The ranges of motion of the left hip were to 30 degrees of extension, 125 degrees of flexion, with pain from 100 degrees, 30 degrees of abduction, with pain from 20 degrees, 25 degrees of adduction, with the ability to cross the legs, and 60 degrees of external rotation. X-rays of the pelvis and left hip joint showed some bony demineralization, and minimally prominent superior acetebular lips bilaterally. In the January 2008 hearing, the veteran reported having constant pain in his left hip. He stated that his left hip pain decreased his walking ability, and made him unable to run or to squat. He indicated that he wore a brace because of his left hip disorder. The veteran reports ongoing pain in his left hip, and he relates that his left hip pain limits his endurance for prolonged walking, standing, or sitting. Examination reports indicate that, even with his limitations, the veteran can still walk more than a mile and stand or sit for several hours. The limitations on the veteran's activity as a result of his left hip disorder are more consistent with slight disability than moderate disability. Thus, the disability does not warrant a rating higher than the current 10 percent rating under Diagnostic Code 5255. The veteran's left hip does not have limitation of motion that would warrant a higher rating under Diagnostic Codes 5251 through 5253. The veteran's left hip disability has not had manifestations that would warrant a rating higher than 10 percent at any time since his separation from service in 2004. The Board therefore denies the appeal for a higher rating. The manifestations and effects of the veteran's chronic left hip strain do not necessitate referral of the rating of that disability to designated VA officials for consideration of an extraschedular rating. The veteran has not had frequent hospitalizations for his left hip disorder, and the evidence does not indicate that his left hip disorder markedly interferes with his pursuit of training or his potential for employment. Dermatitis The veteran has appealed the initial noncompensable rating that the RO assigned for dermatitis. Since separation from service, the veteran has reported that his dermatitis occurs over the back of his neck. The rating schedule provides the following criteria for evaluating dermatitis. More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period .................................... 60 percent 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period ......................................................... 30 percent At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period ................... 10 percent Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period ....................................................... 0 percent 38 C.F.R. § 4.118, Diagnostic Code 7806. Dermatitis may also be evaluated based on disfigurement of the head, face, or neck. Disfigurement of the head, face, or neck is rated compensably if there are scars of larger than certain specified sizes or with certain characteristics, if significant areas of skin have irregularities of color or texture, or if there is underlying soft tissue missing in a significant area. See 38 C.F.R. § 4.118, Diagnostic Code 7800. The veteran received treatment for skin disorders during service. Treating practitioners characterized rashes in the underarms, back, buttocks, and legs as contact dermatitis, and bumps on the neck and scalp as dermatitis. In the August 2003 pre-discharge VA examination, the veteran reported a rash on the back of his neck that had recurred about four times since September 2002. The examiner noted one erythematous papular lesion on the veteran's neck, and provided a diagnosis of dermatitis. In the March 2005 RO hearing, the veteran reported that he had a rash that occurred on the back of his neck every morning and lasted about two hours. He stated that the rash affected the entire back of his neck, from where his hair ended to the beginning of his back, extending to the left and the right. He indicated that he treated the rash with clear Caladryl in the morning, and with white calamine lotion when it flared up at night. Records of VA outpatient treatment in 2005 to 2007 reflect that the veteran was prescribed Ketoconazole cream to be applied topically. On VA examination in May 2005, the veteran reported a recurrent rash on the back of his neck since 2002. At the time of the examination, there were no active lesions on the back of the neck. On VA skin examination in August 2006, the veteran reported that a pruritic rash on the back of his neck had begun in 2002, and had been intermittent, with remissions, but more recently had become chronic. He stated that Ketaconazole cream once a day controlled the rash, but that he had flare- ups twice a month. He indicated that itching was constant, and that he had itching and tingling during flare-ups. The examiner noted exfoliation and mild erythema on the back of the head, from the occiput down to the C3 vertebra. The examiner found that the dermatitis affected more than 5 percent, but less than 20 percent, of exposed areas, and less than 5 percent of the total body area. In the January 2008 Travel Board hearing, the veteran reported that dermatitis affected the back of his neck. He stated that he applied a prescription cream to the area daily, and that this controlled the symptoms. He indicated that the symptoms were present year round, but were worse in the summer. Since separation from service, the veteran has reported a skin disorder affecting the back of his neck. In the August 2006 VA examination, the examiner's findings were consistent with the veteran's descriptions, and the examiner found that the dermatitis affected between 5 and 20 percent of the veteran's exposed areas. The percentage of the exposed area affected meets the criteria for a 10 percent rating under Diagnostic Code 7806; and the Board grants an increase of the initial rating to 10 percent. The dermatitis has not been shown to affect a larger area, nor to require systemic therapy such as corticosteroids or other immunosuppressive drugs, such as would warrant a rating higher than 10 percent. The manifestations and effects of the veteran's dermatitis do not necessitate referral of the rating of that disability to designated VA officials for consideration of an extraschedular rating. The veteran has not been hospitalized for his dermatitis, and the evidence does not indicate that his dermatitis markedly interferes with his pursuit of training or his potential for employment. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). VA must request that the claimant provide any evidence in the claimant's possession that pertains to a claim. 38 C.F.R. § 3.159. The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). In a claim for an increased rating, VA must inform the claimant of the criteria for a higher rating, including the consideration of relevant Diagnostic Codes. If the Diagnostic Code under which the disability is rated contains criteria, such as a specific measurement or test result, for a higher rating that would not be satisfied by a showing of worsening or increase in disability, VA must notify the claimant of that requirement. VA must notify the claimant, and give examples, of the types of medical and lay evidence that are relevant to an increased rating for the particular disability. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and once an error is identified as to any of the four notice elements, the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). With regard to the claims for increased ratings for lumbar spondylosis, an adjustment disorder with mixed emotional features, chronic left hip strain, dermatitis, and allergies and chronic sinusitis, the veteran is challenging the initial evaluations assigned following the grant of service connection. In cases where service connection has been granted, and an initial disability rating and effective date have been assigned, the service-connection claim has been more than substantiated, it has been proven; thereby rendering section 5103(a) notice no longer required, because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473. Because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify with regard to those claims has been satisfied. The RO provided the appellant pre-adjudication notice concerning the claims currently on appeal by letters issued in August 2003, August 2005, and May 2006. The combined notices substantially complied with the specificity requirements of Dingess, identifying the five elements of a service connection claim; Quartuccio, identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini, requesting the claimant to provide evidence in his or her possession that pertains to the claims. In an August 2005 statement of the case (SOC), the RO informed the veteran of the Diagnostic Codes and rating criteria relevant to rating lumbar spondylosis, an adjustment disorder, left hip strain, dermatitis, and allergies and chronic sinusitis. The rating criteria adequately notified the veteran what the evidence must show in order the to support higher ratings for those disabilities. While the required notices were completed after the initial adjudication, the veteran has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The veteran has not alleged any prejudice as a result of the untimely completion of notification, nor has any been shown. The claims were readjudicated in supplemental statements of the case (SSOCs) issued in September 2006, June 2007, and November 2007. VA has obtained service medical records, assisted the veteran in obtaining evidence, afforded the veteran physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the veteran the opportunity to give testimony before the Board. All known and available records relevant to the claims decided herein have been obtained and associated with the veteran's claims file; and the veteran has not contended otherwise. The Board concludes that VA has substantially complied with the notice and assistance requirements, and that the veteran is not prejudiced by a decision on those claims at this time. ORDER Entitlement to service connection for urticaria is granted. Entitlement to service connection for dry eye syndrome is granted. Entitlement to an initial disability rating of 30 percent for an adjustment disorder with mixed emotional features, is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. Entitlement to an initial or subsequent disability rating higher than 10 percent for chronic left hip strain is denied. Entitlement to an initial disability rating of 10 percent for dermatitis is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. REMAND The RO established service connection for a mental disorder, described as an adjustment disorder with mixed emotional features. The veteran notes that he has been diagnosed with PTSD. He asserts that service connection should be established for his PTSD, and that his service-connected mental disorder should be described as PTSD, rather than as an adjustment disorder. The veteran served in Southwest Asia in 1990 and 1991 and in Afghanistan in 2002. His duties were in fuel supply in Southwest Asia, and power equipment repair and maintenance in Afghanistan. He has reported having traumatic experiences during those assignments. VA mental health practitioners have diagnosed the veteran as having PTSD related to traumatic events during service that the veteran has reported. The claims file does not contain supporting evidence of the occurrence of the stressors that the veteran has reported. The veteran's statements and the assembled service records do not indicate that the veteran engaged in combat with the enemy. Therefore, service records are needed to corroborate the occurrence of the stressors that the veteran has reported. See Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The RO concluded that the veteran had not provided sufficiently detailed information to make it possible to request a search of military records to corroborate his reported stressors. The Board finds that some further steps are warranted, and will remand the issue for such action. The veteran has at least partially identified the units with which he served in Southwest Asia and in Afghanistan. The claims file contains some service personnel records for the veteran, but does not contain a DA Form 20 or other records documenting the full unit designations and the locations of those units during the veteran's service. The RO should request these records from the veteran's service department, the U. S. Army. Thereafter, the RO should make a request to U. S. Army and Joint Services Records Research Center (JSRRC) for stressor verification. The veteran has appealed the initial 10 percent rating that the RO assigned for his thoracolumbar back disability, which the RO describes as lumbar spondylosis. In the January 2008 hearing, the veteran stated that his back disability has worsened since the most recent VA examination of his back, in July 2007. The Board will remand the issue for a new examination, to determine the current manifestations of the back disability. Snuffer v. Gober, 10 Vet. App. 400 (1997). The veteran has appealed the initial noncompensable rating that the RO assigned for his service-connected allergies and chronic sinusitis. The criteria for evaluating chronic sinusitis include the frequency, or times per year, of incapacitating episodes of sinusitis, requiring prolonged antibiotic treatment, and of non-incapacitating episodes of sinusitis, manifested by headaches, pain, and purulent discharge or crusting. 38 C.F.R. § 4.97, Diagnostic Codes 6510-6514 (2007). In an August 2006 VA examination, and in the January 2008 Travel Board hearing, the veteran reported that he had intermittent sinus infections, that were accompanied by headaches. He stated that the infections occurred about monthly, with worse symptoms during cold weather. He indicated that VA practitioners treated the infections with antibiotics, usually for about three days. The claims file contains records of VA outpatient treatment of the veteran from 2003 through early June 2007. The assembled records do not show findings of sinus infection or treatment with antibiotics. The Board will remand the issue to obtain records of VA outpatient treatment of the veteran from June 2007 forward. Accordingly, the case is REMANDED for the following action: 1. Obtain records of all VA outpatient treatment of the veteran from June 1, 2007, through the present, and should associate those records with the claims file. 2. Contact the National Personnel Records Center (NPRC) and, if necessary, other appropriate sources of service department records, and request the veteran's complete service personnel records, including the DA Form 20, and any other records of the veteran's unit assignments during his service. 3. Contact the U. S. Army and Joint Services Records Research Center (JSRRC) a search for military records to corroborate stressors reported by the veteran. The specific settings and events that the veteran reports are as follows: A. In February 1991, the veteran's unit, the 348th Transp. Co., supported front line units in Kuwait, including at a location where there were bodies of dead Iraqi soldiers. B. In February or March 1991, soon after a scud missile attack in Saudi Arabia that killed a large number of U. S. servicemembers, the 348th Transp. Co. worked at or near the site of that attack. C. In March 1991, the 348th Transp. Co. operated at Logbase Bravo in Iraq, where there were bodies of dead Iraqi soldiers. D. Between January and September 2002, the 249th Eng. Bn. was in Kandahar, Afghanistan, where U.S. and coalition forces had a medical facility where wounded servicemembers were treated. 4. After completion of the foregoing, schedule the veteran for a VA psychiatric examination for the purpose of ascertaining whether PTSD found present is related to service. a. Prior to the examination, specify for the examiner the stressor or stressors that it is determined are established by the record, and the examiner must be instructed that only that/those event(s) may be considered for the purpose of determining whether the veteran was exposed to one or more stressors in service. b. The examiner should conduct the examination with consideration of the current diagnostic criteria for PTSD. The examination report should include a detailed account of all pathology present. Any further indicated special studies, including psychological studies, should be accomplished. c. If a diagnosis of PTSD is appropriate, the examiner should specify (1) whether each alleged stressor found to be established by the evidence of record was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiner. A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination 5. Schedule the veteran for a VA orthopedic examination to determine the current manifestations of his thoracolumbar spine disability. The veteran's claims file should be provided to the examiner for review. All relevant tests and studies should be undertaken, including range of motion testing. The examiner should indicate whether the veteran's thoracolumbar spine exhibits weakened movement, excess fatigability, or incoordination attributable to his service-connected disability. If possible, the examiner should express such manifestations in terms of the degree of additional range of motion lost or favorable or unfavorable ankylosis. The examiner should also express an opinion as to the degree to which pain could limit functional ability during flare-ups, or when the thoracolumbar spine is used repeatedly over a period of time. 6. Schedule the veteran for the an appropriate VA examination to determine the current nature and severity of the allergies and chronic sinusitis. The claims folder should be provided to the examiner for review. All indicated tests and studies, to include X-rays or other diagnostic procedures deemed necessary, should be conducted. The examiner should report the number and severity of episodes per year of sinusitis, including whether each episode is incapacitating, or requires antibiotic treatment, and, if so, the duration of the antibiotic therapy, and whether the sinusitis is characterized by headaches, pain, and purulent discharge or crusting. The rationale for all opinions expressed should also be provided. 7. After completion of the above, the RO should review the expanded record and determine if the claims that the Board has remanded can be granted. If any of those claims remains denied, the RO should issue a supplemental statement of the case and afford the veteran an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Board intimates no opinion as to the ultimate outcome of this case. The veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs