Citation Nr: 1019154 Decision Date: 05/24/10 Archive Date: 06/04/10 DOCKET NO. 07-15 349 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to an increased rating for pseudofolliculitis barbae (PFB) with cystic acne, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Nicole Klassen, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1970 to July 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied the above claim. In February 2008, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge. When this claim was initially before the Board in May 2008 and March 2009, it was remanded for further development. FINDINGS OF FACT 1. For the period of August 9, 2004, to May 25, 2009, the Veteran's PFB with cystic acne was manifested by one characteristic of disfigurement, did not affect more than 20 percent of his entire body or more than 20 percent of his exposed areas, did not require intermittent systematic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more during a twelve month period, and did not affect more than 40 percent of his face or neck. 2. Since May 26, 2009, the Veteran's PFB with cystic acne has been manifested by two characteristics of disfigurement, but has not affected more than 40 percent of his entire body or more than 40 percent of his exposed areas, and has not required constant or near-constant systematic therapy such as corticosteroids or other immunosuppressive drugs for a twelve month period. CONCLUSIONS OF LAW 1. For the period of August 9, 2004, to May 25, 2009, the criteria for a rating in excess of 10 percent for PFB with cystic acne were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.114, 4.118, Diagnostic Code (DCs) 7800, 7806, 7820, 7828 (2007). 2. Since May 26, 2009, the criteria for a 30 percent disability rating, but no more, for PFB with cystic acne have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.114, 4.118, DCs 7800, 7806, 7820, 7828 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir., 2004). An RO letter dated in September 2005 informed the Veteran of all three elements required by 38 C.F.R. § 3.159(b), as stated above. Additionally, letters outlining the specific rating criteria for an increased rating for PFB were provided to the Veteran in May 2008 and March 2009, before the claim was readjudicated in the November 2009 supplemental statement of the case. Regarding the duty to assist, the RO has obtained the Veteran's service and VA treatment records. There is no indication from the claims file that the Veteran has received private treatment for his PFB, and accordingly, no such records could be obtained. The Veteran has also been provided with three VA examinations and a hearing. Moreover, the Board is satisfied that the RO has substantially complied with the Board's April 2009 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that it directed the RO to obtain a complete copy of the Veteran's recent VA treatment records and schedule the Veteran for a VA dermatology examination. In this regard, the Board notes that all relevant records have been obtained, and in May 2009, the Veteran was afforded a VA dermatology examination that addressed the specific rating criteria for skin disorders. Accordingly, the duty to assist has been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Increased Rating The Veteran was initially granted service connection for PFB in August 1986 and was assigned a noncompensable disability rating under 38 C.F.R. § 4.118 DC 7806, effective July 28, 1986, the date of his claim. In September 1988, the Veteran submitted a claim for an increased rating, reporting that his skin condition was worse than it was currently rated, and in a January 1989 rating decision, the RO increased the rating assignment for the Veteran's PFB to 10 percent disabling under DC 7806, effective from May 9, 1988. In August 2005, the Veteran again submitted a claim for an increased rating for his skin condition, asserting that his PFB had worsened such that a higher rating is warranted. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Although the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). A recent decision of the United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. However, as discussed below, the record reflects that the Veteran's disability has remained constant with respect to the applicable schedular criteria. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The United States Court of Veterans Appeals (Court) held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). A. Factual History During VA treatment in October 2004, the Veteran sought treatment for a sore boil on his left cheek. The doctor treated him with a Kenalog injection, and noted that the Veteran's current treatment included taking daily tetracycline and using Retin-A and Cleocin-T. The doctor reported that the Veteran continued to have short-laid beard hair with pitted ice-pick scarring. The doctor also stated that the Veteran was essentially unchanged since his past examination except for a scar bound down papule with a cross, which was consistent with a history of folliculitis. In August 2005, the Veteran's medications were reviewed; the doctor renewed orders for clotrimazole and nystatin for 30 days, with no refills until his next appointment. The Veteran was afforded a VA examination in October 2005. At the outset, the examiner indicated that the Veteran's claims file was not available for review, but that he had reviewed the October 2004 VA treatment note. The Veteran reported that he had to use scissors to trim his beard due to exacerbations of his symptomatology, and that he was unable to have a close shaven face. He also reported that, in the past two years, a sebaceous cyst had developed from ingrown facial hair, which required incision and drainage (I&D) surgery. The examiner reported that the Veteran had at least three small raised nodules of less than 0.5 centimeters on the left side of his face, with a history of I&D on a pre-auricular area on the right cheek and two on the left cheek. The examiner went on to summarize the Veteran's current lesions of the face and neck, reporting that they were generalized in distribution and were of acne-form type, causing superficial cysts, discoloration (i.e., increased pigmentation), and scarring. The examiner stated that the Veteran had several scars, including a 2.75 by 0.1 centimeter vertical scar in the pre-auricular area on the right side, which was depressed, but not inflamed or discolored; and two semi-lunar shaped scars on the left cheek, which were slightly depressed, non-inflamed, and of normal skin tone. The examiner also stated that the Veteran had at least two palpable superficial nodules on the right cheek, and at least one on the right cheek, all of which were less than 0.5 centimeters round, and which caused increased pigmentation at the leading edge of his beard. The examiner reported that 2 percent of the Veteran's total body surface and 4.5 percent of his face was affected by his PFB. Finally, the examiner stated that the Veteran's PFB treatment included taking tetracycline orally on a daily basis, as well as using topical solutions, including Retin-A and Cleocin-T, on a daily basis. In April 2006, the Veteran was treated by the same doctor that treated him in October 2004. The doctor reported that since that time, the Veteran had developed intermittent chronic deep-seated pimples with occasional acne breakouts, and noted that the Veteran had been on tetracycline for sometime, which was not improving the condition. On examination, the Veteran had very oily facial skin, some areas of ice-pick scarring consistent with old acne, and two to three deep-seated pustules (almost cystic-type lesions) on his left and right cheeks consistent with cystic acne. The doctor went on to diagnose the Veteran with deep-seated cystic acne with an occasional papular component, prescribed him with doxycylcine twice daily, and told him to apply benzoyl peroxide lotion and Cleocin-T on a daily basis. In September 2006, the Veteran reported that he had two deep- seated nodules on the right side of his face in his beard area that had become inflamed and irritated. On examination, the Veteran had diffuse ice-pick scarring of the beard area with two deep-seated tender painful nodules - one on the right mid-cheek and one on the right jaw line - as well as a few pustules across his beard area. The doctor diagnosed the Veteran with PFB with inflammatory nodules, which he injected with Kenalog. The doctor also noted that if these nodules became recurrent and non-responsive to treatment, excision would be considered. The Veteran was advised to continue taking daily oral tetracycline and using Retin-A and benzoyl peroxide. In February 2007, the Veteran reported that he was not tolerating the tetracycline due to gastrointestinal side effects, but that he continued to use benzoyl peroxide and cleomycin topically. The Veteran reported some improvement, but indicated that he had two persistent nodules - one on his right upper cheek and one on his right mandible - that had been present for over a year and had been injected at his last treatment with only minimal improvement. An examination of the scalp, face, and neck revealed multiple pitted scars across the mid-face and an 11-millimeter mobile subcutaneous nodule on his right upper cheek, as well as an 8-millimeter subcutaneous nodule on his right upper cheek. The doctor diagnosed him with PFB with persistent nodules, which she stated were probably epidermal inclusion cysts resulting from ingrown hair. The doctor also scheduled him for an excision the following month, advised him to continue using topical treatment, including benzoyl peroxide and cleomycin, and to start using hydrocortisone cream immediately after shaving. On March 7, 2007, the Veteran underwent a shave biopsy of a cyst on his right mandibular line. The cyst, which had a hard central core, but no cyst wall, was excised and the lesion was injected with Kenalog. Later that month, on March 22, the Veteran sought treatment for enlargement of the cystic structure. The doctor noted that the Veteran had a subcutaneous nodule consistent with an epidermal inclusion cyst on the right mandibular line, and scheduled the Veteran for a cyst excision the following month. Four days later, on March 26, the Veteran again sought treatment for his cyst, reporting that it had enlarged and become painful. On examination, the doctor noted that the Veteran had a nodule that was enlarged and slightly erythematous. The doctor gave the Veteran a 14 day prescription of doxycycline. Subsequently, on March 30, 2007, the Veteran sought urgent VA treatment for the cyst, reporting that he began taking antibiotics four days earlier due to the cyst enlarging and becoming painful. The Veteran indicated that the size of the cyst had decreased over the past two days, but that he wanted to have it examined before the weekend. He also reported that he had been running a low grade fever for the past few days before the cyst started draining. The doctor noted that the Veteran had a subcutaneous nodule on his right lower jaw and was positive for right cervical adenopathy. The doctor noted that the Veteran was scheduled for an excision the following month and advised him to continue taking doxycycline and using the topical solutions. In October 2007, the Veteran sought treatment for routine follow-up of his PFB and nodular cystic acne of the lower face. The doctor noted that the Veteran was currently being treated with benzoyl peroxide and tretinoin cream, and had recently undergone epidermal inclusion cyst removal of a cyst on his temple with good results. Examination of the scalp, face, neck, and arms revealed a few inflammatory papules and nodules on his beard area including one on his right cheek that was 1.2 centimeters in size, well circumscribed, and with no current signs of infection that was consistent with an epidermal inclusion cyst. The doctor diagnosed him with PFB with an epidermal inclusion cyst on the right cheek, prescribed him with doxycycline, and recommended that he continue using benzoyl peroxide, tretinoin, and Cleocin-T. At his February 2008 Board hearing, the Veteran reported that he has flare-ups of his condition during which he has cysts and boils, and indicated that he had recently undergone I&D surgery in 2007 due to several ingrown hairs. He also reported that since the I&D surgery, he had experienced several episodes of boils and disfigurement on the left side of his face. The Veteran stated that he was currently receiving follow-treatment for his PFB approximately every six months, and reported that he develops a boil about every 60 to 90 days. Regarding treatment, the Veteran stated that he received occasional steroid shots, and was taking four medications, including Retin-A. During follow-up treatment in June 2008, the VA doctor noted that the Veteran was undergoing treatment for PFB and nodular cystic acne of the lower face, with two cysts previously resected. The doctor reported that the Veteran continued to take daily doxycycline and use benzoyl peroxide wash, as well as cleocin and Retin-A solution. The doctor also noted that the Veteran had a persistent lesion on his left malar cheek, which had been present for six to eight months and was not resolving. An examination of the scalp, face, neck, chest, back, abdomen, and arms, revealed an 8-millimeter papule with hyper-pigmentation on the left malar cheek, as well as pitted scarring. The doctor diagnosed the Veteran with PFB with an epidermal inclusion cyst of the left malar cheek, injected the cyst with Kenalog, advised the Veteran to continue his current topical regimen, and reduced his doxycycline dose. The doctor also informed him that he could discontinue his doxycycline use altogether in three months if he continued doing well; however, the following month, the Veteran called to report that the lesion on his left cheek seemed to be getting worse. The Veteran was afforded another VA examination in July 2008. At the outset, the examiner reported that he had reviewed the Veteran's claims file. The Veteran reported that his breakouts worsened when he shaved his face, causing tender bumps that swelled and drained, and which occasionally became infected and had to be excised and drained. The examiner reported that the Veteran was currently using topical therapies, including clindamycin and Retin-A, and was not able to close-shave. The examiner also noted that the Veteran had a persistent knot on his left cheek that has been treated with steroid injection without resolution. On examination, the Veteran had hyper-pigmentation and lichenfied papules on his neck and cheeks, multiple ice-pick and boxcar scars on his bilateral cheeks, large linear scars and angular scars on his cheeks, temples, and nose, as well as an indurated, hyper-pigmented papule on his left cheek with no express pus. Photographs from this examination have been associated with the claims file. The examiner diagnosed the Veteran with PFB and cystic acne with scarring, noting that these conditions affected approximately 5 percent of his exposed body surface and 5 percent of his total body area. The examiner went on to provide the opinion that these conditions were related to military service, noting that shaving during service would have exacerbated this condition and that the Veteran had experienced breakouts on his face since basic training. In August 2008, the Veteran sought treatment for removal of a palpable firm scar on the left cheek. The doctor noted that the Veteran had a history of acne with extensive scarring, and reported that, on examination, he had a papule that was 8-millimeters in size on his left cheek that was somewhat verucuous, firm, flat, and hyper-pigmented. The papule was removed by shave-excision. In an April 2009 statement, the Veteran's friend reported that the Veteran had experienced reoccurring facial problems such as a swollen jaw and irritation around the mustache area, and that the Veteran had complained about tenderness and inflammation of his cheeks, jaw, and mustache area. In May 2009, the Veteran was afforded a third VA dermatology examination. At the outset, the examiner reported that she had reviewed the Veteran's claims file. The examiner noted that the Veteran presented with symptoms including tenderness to palpation and intermittent drainage, especially from a large cyst on his right cheek. The Veteran reported that the scars on his face were intermittently irritating and itchy, and that his lesions caused infrequent sharp pain, especially the lesion on his right temple and the lesion on his right pre-auricular skin. On examination, the Veteran had five significant scars on his face. First, he had a linear scar, 0.3 by 1.8 centimeters in area with 1 by 1 centimeters of underlying tissue loss, which was hyper-pigmented, soft, and depressed. This scar was not tender to palpation, indurated, inflexible, inflamed, or significantly elevated. Second, he had a linear scar on his left temple, 0.1 by 1 centimeter, which was hyper-pigmented and soft. This scar was not adherent to the underlying tissue, indurated, inflexible, inflamed, elevated, depressed, or tender on palpation. There was also no tissue loss associated with this scar. Third, there was a 0.2 by 1.2 centimeter linear scar on his right cheek with 2 millimeters of depression, which was hyper-pigmented and soft, but was not adherent to the underlying tissue, indurated, inflexible, inflamed, or tender on palpation. There was also no tissue loss associated with this scar. Fourth, the Veteran had a 0.4 by 4.2 centimeters scar on the right pre-auricular skin with 1 millimeter of depression from the surrounding tissue, which was hyper-pigmented and soft. This scar was not adherent to the underlying tissue, indurated, inflexible, inflammation, or tender on palpation. There was no underlying tissue loss, but the examiner noted that it was slightly irregular in texture on palpation. Fifth, there was an irregular, stellate scar on the right temple that was 0.8 by 1.5 centimeters in size, and which was hyper-pigmented and soft. The scar was not adherent to the underlying tissue, indurated, or inflexible; had no underlying tissue loss; was not significantly elevated or depressed; and was not tender on palpation; however, the examiner noted that this scar was greater than 0.6 centimeters wide at it widest part and had an irregular surface on palpation. The examiner reported that 5 percent of the Veteran's total body surface area was affected by his PFB, and that 8 percent of his exposed surface area (i.e., his face and neck) was affected, and as such, 20 to 40 percent of the Veteran's body was not involved with his PFB. The examiner also reported that, over the past year, the Veteran's treatment included taking doxycycline orally, and using daily topical treatments, including Cleocin, benzyl peroxide, and tretinoin. In this regard, the examiner stated that the Veteran's skin condition did not require systemic therapy, such as use of corticosteroids or other immunosuppressive drugs, for a total duration of six weeks. The examiner went on to report that although collectively, the Veteran's scars were disfiguring, none of them was individually disfiguring. She also stated that there was no distortion or asymmetry of any of his features and no loss of function, but indicated that his facial scarring appeared to have progressed since the last examination. The examiner then stated that it was clear that the Veteran had an overlap between acne and PFB, and that the two were etiologically related to each other. Finally, she reported that the Veteran would continue to require ongoing oral therapy, as well as surgical therapy for the large epidermal inclusion cysts secondary to the persistent inflammation that he experienced. Finally, in December 2009, the Veteran's wife reported that she had watched her husband suffer from pain and swelling in his face three times a year or more, and stated that he had undergone surgery that had caused scarring. B. DC 7820-7806 At the outset, the Board notes that, the Veteran initially filed his claim for an increased rating for his PFB with cystic acne in August 2005, and that during the pendency of his appeal, the schedular criteria by which skin disabilities are rated were revised, effective October 23, 2008. See 73 Fed. Reg. 54710 (October 23, 2008); see also 38 C.F.R. § 4.118, DCs 7800 to 7805 (2009). However, because the amended regulations apply only to claims received by VA on or after October 23, 2008, that version of the scar regulations will not be applied here. See id. The Veteran's PFB has been assigned a 10 percent evaluation under 38 C.F.R. 4.118, DC 7820-7806. DC 7820 provides that infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal and parasitic diseases) are to be rated as disfigurement of the head, face, or neck under DC 7800; as a scar under DC 7801, 7802, 7803, 7804, or 7805; or as dermatitis or eczema under DC 7806, depending upon the predominant disability. In this case, DCs 7806, 7800, and 7804, are the only diagnostic codes applicable, as the affected part is the head, face, and neck; there are no unstable scars; and the condition does not cause limitation of motion of the affected part or any limitation of function. See 38 C.F.R. § 4.118 DCs 7801-7805. C. DC 7806 Under DC 7806, dermatitis or eczema is assigned a 10 percent rating where the condition affects 5 to 20 percent of the entire body or 5 to 20 percent of the exposed areas affected, or requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during a twelve month period; a 30 percent rating is assigned where the condition affects 20 to 40 percent of the entire body, or 20 to 40 percent of the exposed areas affected, or requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during a twelve month period; and a 60 percent rating is assigned where the condition affects more than 40 percent of the entire body, or more than 40 percent of the exposed areas affected, or requires constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs during a twelve month period. 38 C.F.R. § 4.118 DC 7806 (2007). Based on a thorough review of all of the evidence of record, the Board finds that the Veteran's PFB with cystic acne does not warrant a rating in excess of 10 percent under DC 7806. In this regard, the Board notes that at no point during the pendency of this appeal has the Veteran's PFB with cystic acne been noted to affect more than 20 percent of his entire body or more than 20 of the exposed areas affected. Rather, at his October 2005 VA examination, the examiner noted that the Veteran's PFB affected 2 percent of his total body surface and 4.5 percent of his face. Additionally, at his July 2008 VA examination, the examiner reported that the Veteran's PFB with cystic acne and scarring affected approximately 5 percent of his exposed body surface and 5 percent of his total body area. Finally, at his May 2009 VA examination, the examiner reported that 5 percent of the Veteran's total body surface area and 8 percent of his exposed surface area (i.e., his face and neck) was affected by his PFB, and specifically noted that 20 to 40 percent of the Veteran's body was not involved with his PFB. The evidence of record also fails to show that the Veteran's PFB with cystic acne has required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more. In this regard, the Board acknowledges that the Veteran has fairly consistently been prescribed oral medication, including doxycycline and tetracycline, throughout the duration of this appeal. Significantly, however, neither of these antibiotic medications are a corticosteroid or an immunosuppressive drug. The Board also acknowledges that, throughout the duration of this appeal, the Veteran has been treating his PFB and cystic acne with numerous topical solutions, including Clindamycin/Cleocin-T (an antibiotic cream), Tretinoin/Retin-A (an acid form of vitamin A), benzoyl peroxide, Clotrimazole (an antifungal cream), and Nystatin (another antifungal cream). Significantly, however, none of these topical medications or treatments is a corticosteroid or immunosuppressive drug. The Board notes that the Veteran was advised to begin using hydrocortisone cream (a corticosteroid hormone) after shaving in February 2007; however, this was a one time prescription and at no point since has the Veteran been advised to continue such use. As such, there is no indication that the February 2007 prescription was part of systemic corticosteroid therapy or that he was required to use this cream intermittently for a total duration of six weeks or more during a one year period. Finally, the Board acknowledges that the Veteran has received several Kenalog injections in problematic cysts, nodules, and pustules throughout the duration of this appeal, including injections in October 2004, September 2006, March 2007, and June 2008. In this regard, while the Board notes that Kenalog is a corticosteroid, it points out that such treatment not been performed intermittently for a total duration of six weeks or more. Rather, as the Veteran himself reported at his February 2008 hearing, such treatment has only been used occasionally on particularly resistant cysts, nodules, and pustules. Moreover, the Board points out that the May 2009 examiner specifically stated that that Veteran's PFB treatment has not required systemic therapy, such as use of corticosteroids or other immunosuppressive drugs, for total duration of six weeks. Accordingly, because the Veteran's PFB with cystic acne does not affect more than 20 percent of his entire body or more than 20 percent of the exposed areas affected, and has not required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, a rating in excess of 10 percent under DC 7806 is not warranted in this case. D. DC 7800 Under DC 7800, disfigurement of the head, face, or neck is assigned a 10 percent rating where there is one characteristic of disfigurement; a 30 percent rating when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement; a 50 percent rating when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement; and, an 80 percent rating when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, DC 7800 (2007). The eight characteristics of disfigurement for purposes of evaluation under § 4.118 are (1) a scar of 5 or more inches (13 or more cm.) in length; (2) a scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) the surface contour of a scar is elevated or depressed on palpation; (4) the scar is adherent to underlying tissue; (5) the skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) the skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) the underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); and (8) the skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118 DC 7800, Note (1) (2007). Based on a review of all of the evidence of record, the Board finds that the Veteran's PFB with cystic acne warrants a 30 percent rating, but no higher, effective May 26, 2009, under DC 7800. However, for the foregoing reasons, his condition does not warrant an evaluation in excess of 10 percent for the period from August 9, 2004, to May 25, 2009, under this diagnostic code. As noted above, a 10 percent rating under DC 7800 contemplates one characteristic of disfigurement; whereas a 30 percent rating contemplates two or three characteristics of disfigurement. Such characteristics include scars whose surface contour is elevated or depressed on palpation, and scars that are at least one-quarter inch (0.6 cm.) wide at their widest part. See 38 C.F.R. § 4.118, DC 7800, Note 1 (2007). The October 2005 VA examination report reveals that the Veteran had one characteristic of disfigurement at that time; specifically, the Veteran had three depressed scars, including one on the right side of his face that was 2.75 by 0.1 centimeters in size and two semi-lunar shaped scars on his left cheek. Although the examiner also noted that the Veteran had three palpable superficial acne-form nodules that were each less than 0.5 centimeters round that caused areas of hyper-pigmentation, because the area of such hyper- pigmentation caused by these three nodules did not exceed six square inches (39 sq. cm.), this is not considered a character of disfigurement. Similarly, the July 2008 examination report reveals that the Veteran had only one characteristic of disfigurement at that time; namely, multiple depressed scars, which were described as ice-pick scars. The examiner also noted that the Veteran had hyper-pigmented and lichenfied papules on his neck and cheeks; however, there is no indication that the area of hyper-pigmentation caused by these papules exceeded six square inches (39 sq. cm.). The examiner also noted that the Veteran had large linear scars and angular scars on his cheeks, temples, and nose; however, there is no indication from the examination report that any of these scars were 5 or more inches long (13 or more cm.), or at least one-quarter inch (0.6 cm.) wide at their widest part. Additionally, the examiner noted that the Veteran had an indurated, hyper- pigmented papule on his left cheek; however, there is no indication that the area of indurated skin resulting from this papule exceeded six square inches (39 sq. cm.). Finally, there is no indication from the July 2008 examination report that the Veteran had any scars that were adherent to the underlying tissue, or that he had any areas of skin with an abnormal texture (irregular, atrophic, shiny, scaly, etc.) or with missing underlying soft tissue exceeding six square inches (39 sq. cm.). It was not until his May 2009 VA examination that the Veteran was shown to have two characters of disfigurement; specifically, three scars whose surface contours are depressed, and one scar that is at least one-quarter inch (0.6 cm.) wide at its widest part. In this regard, the Board notes that the May 2009 VA examiner noted that the Veteran had a depressed linear scar that was 0.3 by 1.8 centimeters in area, a 0.2 by 1.2 centimeter linear scar with 2 millimeters of depression, a 0.4 by 4.2 centimeters scar with 1 millimeter of depression from the surrounding tissue; and an irregular, stellate scar on the right temple that was 0.8 by 1.5 centimeters in size and which is greater than 0.6 centimeters wide at it widest part. Accordingly, the evidence shows that the Veteran's PFB with cystic acne has been manifested by two characteristics of disfigurement since his May 26, 2009, VA examination, but not earlier, and as such, the Veteran has met the criteria for a 30 percent disability rating under DC 7800 rating from that date, forward. However, while the Veteran's symptomatology warrants a 30 percent rating from May 26, 2009, forward, his total disability picture does not rise to the severity required for a 50 percent rating. In this regard, the Board notes that, at his May 2009 examination, the Veteran was not noted to have any scars that are 5 or more inches long, adherent to underlying tissue, or indurated and inflexible, and was not noted to have any areas of hypo-pigmented skin. While the Veteran was noted to have five hyper-pigmented scars, which in total, cover an area of 17.46 centimeters (1.8 by 9.7 centimeters), because the area of hyper-pigmentation does not exceed six square inches (39 sq. cm.), this is not considered a character of disfigurement. Similarly, although the Veteran was noted to have a scar with 1 by 1 centimeter of underlying tissue loss, because the area of underlying soft tissue loss is less than six square inches (39 sq. cm.), this is not considered a character of disfigurement. Finally, while the Veteran does have a scar that is 1.2 centimeters in area (0.8 by 1.5 centimeters) with an irregular surface on palpation, because the area of this irregular scar does not exceed six square inches (39 sq. cm.), it is not considered a character of disfigurement. As such, the evidence of record fails to show that the Veteran has more than three characteristics of disfigurement. Moreover, at no point has the Veteran been noted to have palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features. See 38 C.F.R. § 4.119, DC 7800 (2007). Rather, he was specifically noted to have no distortion or asymmetry of any of his features at his May 2009 VA examination. Thus, a rating in excess of 30 percent under DC 7800 is not warranted in this case. E. DC 7804 As noted above, a Veteran can receive separate disability ratings for different problems or residuals of an injury as long as the separate ratings are not for the "same disability" or the "same manifestation" (i.e., the symptomatology for any one of the conditions is not duplicative of, or overlapping with, the symptomatology of the other conditions). See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Under 38 C.F.R. § 4.118, DC 7804 (2007), a 10 percent rating is available for superficial scars that are painful on examination. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7804, Note (1) (2008). In this regard, the Board acknowledges that, at his May 2009 VA examination, the Veteran reported that his lesions cause infrequent sharp pain, and during VA treatment, the he has reported that his nodules are tender and painful. See September 2006 and March 2007 VA treatment records. Significantly, however, at no point during this appeal have any of the Veteran's scars been noted to be painful on examination, and at his May 2009 examination, the examiner specifically noted that none of his scars were tender on palpation. Accordingly, a separate 10 percent rating under 38 C.F.R. § 4.118, DC 7804, is not warranted in this case. F. DC 7828 The Board has also considered whether the Veteran is entitled to a higher rating at any point during the pendency of this appeal under DC 7828, which rates acne. Under DC 7828, a 10 percent rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or deep acne other than on the face and neck; and a 30 percent rating is assigned for deep acne affecting 40 percent or more of the face and neck. 38 C.F.R. § 4.119, DC 7828 (2007). Significantly, a rating in excess of 30 percent is not available under DC 7828. See id. Based upon a full review of the record, the Board finds that the preponderance of the evidence is against entitlement to a disability rating in excess of 10 percent for the Veteran's PFB with cystic acne under DC 7828. In this regard, the Board acknowledges that the Veteran has undergone numerous treatments for deep inflamed nodules and pus-filled cysts throughout the duration of this appeal, including receiving several Kenalog injections, undergoing cyst excision, taking tetracycline and doxycycline, and using several topical creams. Significantly, however, at no point has the Veteran's PFB with cystic acne been reported to affect 40 percent or more of his face or neck. Rather, as discussed above, at his October 2005 VA examination, the examiner noted that the Veteran's PFB affected 4.5 percent of his face, and at his July 2008 VA examination, the examiner noted that the Veteran's PFB and cystic acne with scarring affected approximately 5 percent of his exposed body surface and 5 percent of his total body area. Finally, at his May 2009 VA examination, the examiner reported that 8 percent of his exposed surface area (i.e., his face and neck) was affected by his PFB. Accordingly, because the evidence fails to show that the Veteran's deep inflamed nodules and pus-filled cysts affect 40 percent or more of his face and neck, but rather, affect at most 8 percent of his face and neck, he is not entitled to a higher rating for his PFB with cystic acne under DC 7828. III. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2009). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b) (2009). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's PFB with cystic acne are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describe his disability. For these reasons, referral for consideration of an extraschedular rating is not warranted for this claim. ORDER Entitlement to a rating in excess of 10 percent for PFB with cystic acne from August 9, 2004, to May 25, 2009, is denied. Subject to the law and regulations governing payment of monetary benefits, effective May 26, 2009, a 30 percent rating for PFB with cystic acne is granted. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs