Citation Nr: 1032002 Decision Date: 08/25/10 Archive Date: 09/01/10 DOCKET NO. 07-11 962 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for eczematous dermatitis before December 11, 2009. 2. Entitlement to an initial disability rating in excess of 30 percent for eczematous dermatitis from December 11, 2009. REPRESENTATION Veteran represented by: AMVETS WITNESSES AT HEARING ON APPEAL The Veteran and her mother ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2004 to October 2004 and July 2005 to July 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Lincoln, Nebraska, Regional Office (RO) of the Department of Veterans Affairs (VA), which, inter alia, granted entitlement to service connection for eczematous dermatitis, assigning a noncompensable disability rating. The Veteran appealed the initial disability evaluation assigned. In April 2007, the RO assigned a 10 percent disability rating for eczematous dermatitis effective July 17, 2006. Moreover, a January 2010 rating decision found that the Veteran's service connected eczematous dermatitis disability worsened in symptomatology and granted her a 30 percent disability rating from December 11, 2009. The United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, the issue of entitlement to an increased initial evaluation remains on appeal. The Veteran testified before the undersigned Veterans Law Judge at a personal hearing conducted at the Lincoln, Nebraska, RO in July 2009. A copy of the hearing transcript is of record and has been reviewed. The Board also notes that the Veteran has submitted additional evidence with the appropriate waivers of agency of original jurisdiction consideration. See 38 C.F.R. § 20.1304 (2009). In August 2009, the Board remanded the Veteran's claim. The Appeals Management Center (AMC) continued the previous denial of the claim in a January 2010 supplemental statement of the case (SSOC). Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. FINDINGS OF FACT 1. Prior to February 1, 2008, the evidence of record shows that the Veteran's service-connected eczematous dermatitis involved 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, and systemic therapy to include corticosteroid injections required for a total duration of six weeks or more, but not constantly, during the past 12 month period. 2. From February 1, 2008 to December 10, 2009, the evidence of record does not show that the Veteran's service-connected eczematous dermatitis involved 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are 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. 3. From December 11, 2009, the evidence of record does not show that the Veteran's service-connected eczematous dermatitis involved more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 4. The evidence does not show that the Veteran's service- connected eczematous dermatitis is so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. The criteria for a 30 percent disability rating for the Veteran's service-connected eczematous dermatitis prior to February 1, 2008, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2009). 2. The criteria for a disability rating in excess of 10 percent for the Veteran's service-connected eczematous dermatitis from February 1, 2008 to December 10, 2009, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2009). 3. The criteria for a disability rating in excess of 30 percent for the Veteran's service-connected eczematous dermatitis from December 11, 2009, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2009). 4. Application of extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to an increased disability rating for her service-connected eczematous dermatitis. In the interest of clarity, the Board will discuss certain preliminary matters. The issue on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in August 2009, the Board remanded this claim and ordered either the agency of original jurisdiction (AOJ) or the AMC to schedule the Veteran for a VA examination for her service-connected eczematous dermatitis and associate a report of the examination with the Veteran's claims folder. The Veteran's claim was then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran was provided a VA examination with respect to her service-connected eczematous dermatitis. A report of the examination has been associated with the Veteran's claims folder. The Veteran's claim was readjudicated via the January 2010 SSOC. Accordingly, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). The VCAA alters the legal landscape in three distinct ways: standard of review, notice, and duty to assist. The Board will now address these concepts within the context of the circumstances presented in this case. Standard of review After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2009). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2009), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice, to include notice with respect to the effective-date element of the claim, by a letter mailed in September 2006, prior to the initial adjudication of her claim. In short, the record indicates the Veteran received appropriate notice pursuant to the VCAA. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate her claim. There is no reasonable possibility that further assistance would aid in substantiating the claim. The pertinent evidence of record includes the Veteran's statements, service treatment records, photographs, as well as VA and private treatment records. The Veteran was afforded VA examinations in December 2006 and December 2009. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed her claims folder, reviewed her past medical history, documented her current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's disability under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2009); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2009). The Veteran has been accorded the opportunity to present evidence and argument in support of her claim. She has retained the services of a representative. She was afforded a personal hearing in July 2009. Accordingly, the Board will proceed to a decision. Higher evaluation for Eczematous Dermatitis Pertinent legal criteria Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2009). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. 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 diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Veteran's skin disability is currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7806 [dermatitis or eczema] (2009). Diagnostic Code 7806 is deemed by the Board to be the most appropriate code, primarily because it pertains specifically to the disability at issue [eczematous dermatitis], but also because it provides specific guidance as to how symptoms of this disability are to be evaluated. The Board notes that the December 2009 VA examiner indicated that the Veteran had scattered lesions on her face and neck which wax and wane. The Board has considered rating the Veteran's skin disability under 38 C.F.R. § 4.118, Diagnostic Code 7800, which rates disfigurement of the head, face, or neck. However, rating the Veteran under Diagnostic Code 7800 would not be in the best interest of the Veteran, as these criteria require at least one characteristic of disfigurement [to include a scar 5 or more inches in length, a scar one quarter inch wide, a scar with elevated surface contour, underlying tissue adherence, hypo- or hyper-pigmentation, abnormal skin texture exceeding six square inches, missing underlying soft tissue, or inflexible skin exceeding six square inches]. The evidence does not show, nor has the Veteran contended that her current disability results in disfigurement of the head, face, or neck. See, e.g., the December 2009 VA examination report. In particular, the record does not reveal at least one of the characteristics of disfigurement. Accordingly, Diagnostic Code 7800 is not appropriate in this case. The Board can identify nothing in the evidence to suggest that a diagnostic code other than 7806 would be more appropriate, and the Veteran has not requested that another diagnostic code should be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 7806. The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective August 30, 2002 and again in October 2008. The October 2008 revisions are applicable to application for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed her claim in September 2006. Therefore, only the post-2002 and pre- October 2008 version of the schedular criteria, set out immediately below, is applicable. Diagnostic Code 7806 provides for the following levels of disability: A 30 percent disability rating is appropriate where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent disability rating is appropriate where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12- month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806, as amended by 67 Fed. Reg. 49596 (July 31, 2002). Staged ratings are currently in effect for the Veteran's eczematous dermatitis: the disability has been rated 10 percent disabling from July 17, 2006, the day after the Veteran was discharged from active duty service, to December 10, 2009, and 30 percent thereafter. Even so, VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). Period prior to December 11, 2009 In order to obtain a 30 percent disability rating under Diagnostic Code 7806, the Veteran would have to show that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected by the eczematous dermatitis, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. The criteria are disjunctive. See Johnson v. Brown, 7 Vet. App. 95 (1994) [only one disjunctive "or" requirement must be met in order for an increased rating to be assigned]. Compare Melson v. Derwinski, 1 Vet. App. 334 (1991) [use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met]. The Board finds that the competent and credible evidence from July 17, 2006 to January 31, 2008 reflects manifestations of eczematous dermatitis that more closely correspond to a 30 percent disability rating. Specifically, a private treatment letter dated in February 2007 from R.R., PA-C, documented the Veteran's treatment for her eczematous dermatitis from March 2006 to October 2006. In March 2006, the Veteran initially suffered from red, raised, dry scaly patches and plaques on the arms and legs with some involvement of the thorax. A punch biopsy was performed at that time, and she was diagnosed with eczematous dermatitis. She was prescribed photo therapy in addition to Hydroxyzine and Triamcinolone in Sarna lotion from May 2006 to September 2006. After that treatment failed to improve the Veteran's dermatitis symptomatology, she was prescribed to undergo a complete fragrance free regimen and to use certain detergent, conditioner, shampoo, and cleanser as well as discontinue any use of fabric softeners. Further, she was prescribed Zyrtec to be used in the morning, Tagamet three times a day, and Hydroxyzine at night. In September 2006, due to the continued presence of significant eczematous scaling of the entire upper and lower leg areas with some involvement of the face and arms, the Veteran was given intralesional injections of corticosteroids and Vanos cream. Although improvement was demonstrated after the use of corticosteroid injections, the Veteran still evidenced pink papules on both of her lower legs covering a body surface area of greater than five percent and was prescribed to continue the regimen of antihistamines and lotion. R.R. indicated that throughout the duration of the Veteran's treatment, the range of her eczematous flaring covered at least 20 percent of the body surface area to, at her last follow up treatment in October 31, 2006, slightly over five percent. The Veteran was afforded a VA examination in December 2006. She complained of a skin rash that began in December 2005 during her period of military service. She stated that the rash was constantly on her face and left arm, and that the rash was dry and itchy. She used antihistamines and lotion for treatment, although no improvement was demonstrated. Upon examination, the VA examiner noted a very small patch of dry skin over the Veteran's right cheek, and a small area over the left forearm. He did not indicate any disfiguration, drainage, discharge, or crusting. Notably, the VA examiner reported that the total body surface area affected was zero to five percent, with the area of the right face being zero to five percent affected. He diagnosed the Veteran with eczematous dermatitis involving the left forearm and right cheek. A subsequent VA treatment record dated in January 2007 documented the Veteran's use of topicort and Vanos cream for her eczematous dermatitis. Pertinently, a subsequent VA treatment record dated in March 2007 indicated that the Veteran used photo therapy and Kenalog injections. She was assessed with atopic dermatitis, and instructed to apply a protopic ointment and to take Hydroxyzine, tetracycline, and Kenalog injections. Later VA treatment records dated in November and December 2007 documented the Veteran's complaints of and treatment for sores on her arms, legs, chest, and axilla. She stated that the creams did not improve her skin condition, although she used steroids which demonstrated improvement. At the July 2009 Board hearing, the Veteran testified that the eczematous dermatitis caused itching over her entire body, to include her arms, legs, face, forehead, neck, and shoulders especially in winter or in humid weather. She stated that when she scratches the affected areas, there is some discharge of liquid and bleeding. Further, she used shampoo, conditioner, face wash, and laundry soap for treatment as well as ointments and corticosteroid cream. She reported that she had last received a corticosteroid injection or an oral steroid in January 2008. Additionally, she used light treatment once or twice a week for five minutes. Finally, she stated that she prefers to wear long sleeved clothing. As stated above, to warrant a 30 percent disability rating for eczematous dermatitis under Diagnostic Code 7806, the evidence must show 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. Crucially, R.R. indicated in the February 2007 private treatment letter that the Veteran's eczematous dermatitis covered at least 20 percent of her entire body, although the letter indicated that the coverage reduced to slightly over five percent by October 31, 2006. The December 2006 VA examination report similarly shows that the coverage reduced to between zero and five percent. About the same time as this decrease, in September 2006, the Veteran began to receive corticosteroid injection therapy. She stated at the July 2009 Board hearing that she took steroids "every other month," and her last steroid injection was in January 2008. During the December 2006 VA examination, the Veteran did not indicate that she was receiving corticosteroid injections. On the contrary, she only stated that she used Zyrtec and lotions for treatment. However, the January 2007 VA treatment record demonstrates that the Veteran's medication for her eczematous dermatitis included Kenalog injections. Further, in the March 2007 VA treatment record, she was instructed to treat her eczematous dermatitis with one cc of Kenalog 40. In the November 2007 VA treatment record, the Veteran stated that she used steroids for treatment. As such, the record demonstrates that the Veteran's eczematous dermatitis covered at least 20 percent of her body prior to October 31, 2006, when at that time the evidence demonstrated that the coverage was reduced to slightly over five percent. However, the evidence prior to February 2008 is consistent with the use of systemic therapy, specifically corticosteroid injections, but not constantly. After January 2008, the evidence of record is absent any indication that the Veteran's eczematous dermatitis specifically covered 20 to 40 percent of the entire body or that 20 to 40 percent of exposed areas were affected, or that she used systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during any 12 month period. The Board therefore finds that the Veteran is entitled to a 30 percent disability rating for service-connected eczematous dermatitis prior to February 1, 2008. A rating in excess of 30 percent is not warranted during this period. Specifically, there is no evidence at any time during this period that the Veteran's eczematous dermatitis covered more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during any 12-month period. With respect to the period from February 1, 2008, to December 11, 2009, the evidence does not show that the Veteran's skin condition affected more than 40 percent of the entire body or more than 40 percent of the exposed areas of her body. Furthermore, as set forth above, the Veteran has indicated that she received no steroidal injections during this period. Accordingly a rating in excess of 10 percent is not warranted from February 1, 2008, to December 11, 2009. Period from December 11, 2009 The Veteran was provided a VA examination in December 2009. She continued her complaints of itching, especially in the winter. Further, she avoids wearing clothing that exposes the lesions in order to avoid flare-ups. She stated that when the skin condition flares up, the lesions will erupt, become erythematous, and pruritic. If she scratches the lesions, they may bleed. However, she indicated the condition was stable as long as she uses steroid creams on a routine basis, avoids excessive itching, uses hypoallergenic products, and maintains photo therapy. The Veteran stated that her last steroid injection was more than one year prior to the examination. She used prescription topical steroid cream on a weekly basis for two to three days at a time, which reduced inflammation, itching, and redness of the lesions. However, use of the steroid cream results in burning and dryness of the affected skin. Consequently, she was not using the medication on a constant, daily basis. Over the past year, she used the topical steroid cream greater than a total of six weeks combined. She also continued the use of specialized soap, shampoo, and lotion for treatment as well as photo therapy twice a week for five minutes. Upon examination, VA examiner noted that eruptions of the primary skin lesions of the Veteran's legs will come and go. However, the condition constantly waxes and wanes on the legs, face, and neck. Further, the upper extremities demonstrate scattered lesions that were erythematous and mostly papular, affecting primarily the forearms, and to a lesser extent, the upper arms bilaterally. Moreover, the Veteran had more extensive lesions on the lower legs, including the erythematous papular lesions as well as larger patches and her neck and face demonstrated scattered lesions. Pertinently, the VA examiner noted that the Veteran's skin condition affected between 20 to 40 percent of the total surface area, most prominently in the bilateral lower legs, bilateral arms, neck, and face. As stated above, in order to obtain a 60 percent disability rating under Diagnostic Code 7806, the Veteran would have to show that more than 40 percent of the entire body, or more than 40 percent of exposed areas are affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board finds that the evidence does not show that entitlement to a 60 percent disability rating is warranted under Diagnostic Code 7806 during this time period. Crucially, there is no evidence which demonstrates that the Veteran's eczematous dermatitis covered more than 40 percent of the entire body or more than 40 percent of exposed areas are affected at any time during this time period. Moreover, the evidence of record does not reflect that the Veteran uses constant or near-constant systemic therapy such as corticosteroids or immunosuppressive drugs to treat her skin disability. Rather, the record indicates that the Veteran uses topical steroids. Pertinently, Diagnostic Code 7806 distinguishes between "topical therapy" and "systemic therapy." For example, if the skin disability affects less than 5 percent of the entire body or exposed areas, and no more than "topical" therapy is required, a noncompensable (zero percent) disability rating is assigned. However, if treatment of the skin condition requires "systemic" therapy, higher ratings are assigned depending on frequency of use. By its own language, Diagnostic Code 7806 [as well as identical Code 7816] indicates that skin disabilities treated by topical therapy are rated differently than those requiring non- topical, systemic therapy, depending on the disabilities' percentage of total body or affected part coverage. See Lacroix v. Peake, --- Vet. App. ---, 2008 WL 1883992 (2008) [indicating that the plain language of DC 7816 supports the argument that the appellant's use of topical steroids does not constitute constant systemic therapy]. The Board acknowledges that Lacroix is a non- precedential decision, but notes that a non- precedential decision may be cited "for any persuasiveness or reasoning it contains." See Bethea v. Derwinski, 252, 254 (1992). Concerning the Veteran's ultraviolet therapy, even if the Board were to concede that such constitutes "systemic" therapy, the evidence of record demonstrates that the Veteran uses ultraviolet therapy on average twice a week for five minutes. See the December 2009 VA examination report. Although the word "constant" is not defined in VA regulations, "constant" is generally defined as "not failing; remaining unaltered." See Malikow v. Nicholson, 2007 WL 415712 (Vet. App.) [citing Dorland's Illustrated Medical Dictionary, 28th ed. (1994)]. Indeed, the record does not reflect that the Veteran's intermittent ultraviolet light therapy constitutes constant or near-constant use of systemic therapy. Accordingly, there is no evidence that the Veteran's service- connected skin disability has required treatment through the use of constant or near-constant systemic therapy at any time during the appeal period. Therefore, an increased rating from 30 to 60 percent based on the type and frequency of use of the Veteran's skin medication is not warranted. Extraschedular consideration The Board has considered the question of whether an extraschedular rating may be appropriate for the Veteran's service-connected eczematous dermatitis. See Bagwell v. Brown, 9 Vet. App. 157 (1966). Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.21(b)(1) (2009). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first 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 level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's 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 Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The Veteran has not identified any factors which may be considered to be exceptional or unusual, and the Board has been similarly unsuccessful. The evidence of record indicates that the Veteran currently works for the Transportation Security Administration (TSA). See the July 2009 Board hearing transcript, page 3. The Board observes the Veteran's testimony that handling luggage exacerbates her eczematous dermatitis. Id. However, there is no indication that she has missed any work due to her eczematous dermatitis. Further, the Board notes that it has no reason to doubt that the Veteran's skin disability symptomatology adversely impacts her employability; however, this is specifically contemplated by the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. In addition, there is no evidence in the medical records of an exceptional or unusual clinical picture. The evidence of record is absent any indication of hospitalization for the service- connected eczematous dermatitis during the period under consideration. Further, the record does not demonstrate any other reason why an extraschedular rating should be assigned. Accordingly, the Board therefore has determined that referral of the case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. In granting the Veteran's claim in part and denying her claim in part for an increased rating, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the evidence of record does not show, and the Veteran has not asserted, that she is unemployable because of her service-connected eczematous dermatitis disability. On the contrary, she reported at the July 2009 Board hearing that she works for TSA. Accordingly, the issue of TDIU has not been raised in this case. ORDER Entitlement to a 30 percent disability rating for service- connected eczematous dermatitis prior to February 1, 2008 is granted, subject to the laws and regulations governing monetary awards. Entitlement to a disability rating in excess of 10 percent for service-connected eczematous dermatitis from February 1, 2008 to December 11, 2009 is denied. Entitlement to a disability rating in excess of 30 percent for service-connected eczematous dermatitis from December 11, 2009 is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs