Citation Nr: 1111449 Decision Date: 03/22/11 Archive Date: 04/05/11 DOCKET NO. 08-36 168 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a skin disability of the feet and toenails (characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant & his spouse ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from February 1948 to February 1955 and from April 1955 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. A Travel Board hearing was held at the RO in March 2010 before the undersigned Acting Veterans Law Judge and a copy of the hearing transcript has been added to the record. In June 2010, the Board remanded the Veteran's appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. In its June 2010 remand, the Board referred an increased rating claim for left foot stasis dermatitis to the RO for appropriate action. To date, however, the RO has not taken action on this claim. Therefore, the Board does not have jurisdiction over this claim and it is referred to the RO again for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The competent evidence shows that the Veteran's skin disability of the feet and toenails (characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis), which manifested first several decades after service separation, is not related to active service. CONCLUSION OF LAW A skin disability of the feet and toenails (characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis) was not incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in October 2006 and in June 2010, VA notified the appellant of the information and evidence needed to substantiate and complete his claim, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the appellant to submit medical evidence relating the claimed disability to active service and noted other types of evidence the Veteran could submit in support of his claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As will be explained below in greater detail, the evidence does not support granting service connection for a skin disability of the feet and toenails. Because the Veteran was fully informed of the evidence needed to substantiate his claim, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The claimant also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Additional notice of the five elements of a service-connection claim was provided in the October 2006 VCAA notice letter, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect to the timing of the notice, the Board points out that the Veterans Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the October 2006 VCAA notice letter was issued prior to the currently appealed rating decision issued in February 2007; thus, this notice was timely. Because the appellant's claim is being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the Board. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file. The Veteran has contended that he was treated by Luis R. Venegas, D.P.M., in Brownsville, Texas, for his claimed skin disability of the feet and toenails. In response to a request for the Veteran's medical records, however, this physician's office informed the RO in September 2010 that it had no records for the Veteran. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the claimant has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's act of service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran also has been provided with VA examinations which address the contended causal relationship between the claimed disability and active service. There is no competent evidence, other than the Veteran's statements, which indicates that a skin disability of the feet and toenails may be associated with service. The Veteran is not competent to testify as to etiology of this disability as it requires medical expertise to diagnose. The Board notes that, following a comprehensive physical examination of the Veteran in September 2010, the VA examiner concluded that it would be "mere speculation" to find a casual relationship between the Veteran's skin disability of the feet and toenails and active service. The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Court also has held that medical opinions using the "mere speculation" language, without more, generally are disfavored because they are inconclusive as to the origin of a disability. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). The Court has explained that opinions which contain the "mere speculation" language, without more, amount to 'nonevidence' neither for nor against the claim because service connection may not be based on speculation or remote possibility. See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The Court recently held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection). Before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, however, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Furthermore, VA must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is "based on sufficient facts or data." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear from either the examiner's statements or the Board's decision that the examiner has considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis. See Daves v. Nicholson, 21 Vet. App. 46 (2007). When the record leaves this issue in doubt, it is the Board's duty to remand for further development. The Board observes that a review of the VA examiner's September 2010 shows that he provided a clear basis for his opinion that he could not resolve the issue of the contended causal relationship between the Veteran's skin disability of the feet and toenails and active service without resorting to mere speculation. See Stefl, 21 Vet. App. at 124. He specifically found that, although the Veteran's available service treatment records referred repeatedly to left ankle dermatitis, there was no reference to any toenail fungal infection in those records. He also concluded that the available evidence was insufficient to render a medically-based opinion concerning the etiology of the Veteran's skin disability of the feet and toenails with any reasonable degree of confidence. The Board finds that this opinion was "based on sufficient facts or data" because the VA examiner reviewed the Veteran's entire claims file, including his service treatment records and post-service VA and private treatment records. See Nieves-Rodriguez, 22 Vet. App. at 302. It also is clear from a review of the September 2010 VA examination report that the VA examiner considered "all procurable and assembled data" (in this case, the Veteran's available service treatment records and post-service VA and private treatment records) prior to finding that he could not offer an opinion without resorting to mere speculation. See Daves, 21 Vet. App. at 46. Accordingly, the Board finds that the September 2010 VA examination report is competent medical evidence for VA compensation purposes. See 38 C.F.R. § 4.2 (2010). The Board also observes that, in its June 2010 remand, it cited Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), as support for the proposition that lay evidence may be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The Board finds in this case, however, that, although the Veteran is competent to identify a skin disability of the feet and toenails by describing the symptoms he allegedly experienced during active service (skin irritation while wearing combat boots in hot weather), he was not reporting a medical diagnosis contemporaneous to service. The Board noted in its June 2010 remand that the Veteran's contemporaneous service treatment records showed only that his left big toe was cleaned and dressed in December 1966 and no diagnosis of a skin disability of the feet and toenails was offered at that time (or at any time during active service). The VA examiner found in September 2010 that there was no diagnosis of a skin disability of the feet and toenails anywhere in the Veteran's available service treatment records. The Board observes in this regard that the Veteran's service treatment records cover approximately 21 years of active service between 1948 and 1969. Accordingly, the Board finds that, even applying Davidson, the Veteran's lay testimony alone does not establish an in-service diagnosis of a skin disability of the feet and toenails or support granting service connection for this disability. Id. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. The Veteran contends that he incurred a skin disability of the feet and toenails during active service. He specifically contends that he experienced skin irritation of the feet and toenails while wearing combat boots in hot weather during active service. He also contends that his in-service skin disability was treated with oral medications. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any 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). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a skin disability of the feet and toenails (characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis). Despite the Veteran's lay assertions and hearing testimony to the contrary, his service treatment records do not show that he was diagnosed as having a chronic skin disability of the feet and toenails at any time during his nearly 21 years of active service. These records show instead that, at the Veteran's enlistment physical examination in February 1948 at the beginning of his first period of active service, clinical evaluation of his skin was normal. These results were unchanged on periodic physical examination in February 1951. The Veteran was not treated for a skin disability of the feet and toenails during his first period of active service. At a separation physical examination in February 1955 at the end of his first period of active service, clinical evaluation of the Veteran's skin was normal. At an enlistment physical examination in April 1955 at the beginning of the Veteran's second period of active service, clinical evaluation of his skin was normal. He denied any relevant medical history. On an abbreviated medical evaluation in March 1958, no relevant clinical evaluation results were reported. The Veteran stated that there had been no changes in his health except for minor colds. On periodic physical examinations in January 1961 and in March 1964, clinical evaluation of the Veteran's was normal. He denied any relevant medical history. On outpatient treatment in December 1966, it was noted that the Veteran's left big toe had been treated and cleaned. He also had been given a 0.5 cc tetanus shot. On periodic physical examination in February 1968, the Veteran reported a history of skin diseases. Clinical evaluation showed a skin lesion on the left foot which the in-service examiner attributed to stasis dermatitis of the left foot. The in-service examiner also stated that this problem was under treatment at a dermatology clinic. At his final separation physical examination in August 1968, the Veteran denied that he had a medical history of skin diseases. He stated that he was in good health. The in-service examiner stated that the Veteran's current problems included stasis dermatitis of the left ankle. Clinical evaluation showed pigmentation on the outer aspect of the left ankle which the in-service examiner attributed to stasis dermatitis of the left foot. This examiner also stated that the Veteran's stasis dermatitis of the left foot had been treated and was not disqualifying. In a "Statement of Medical Condition" dated in January 1969 and signed by the Veteran, he reported that, since his separation physical examination, his medical condition had changed due to a "fungus on feet [which was] treated and currently cured." The post-service medical evidence shows that, on VA outpatient treatment in March 2008, the Veteran's complaints included stasis dermatitis of the left ankle. It was noted that the Veteran had reported for enrollment in to the VA health care system. He stated that, if he used his lotions regularly, his stasis dermatitis of the left ankle was not a problem. Physical examination of his feet showed intact skin with no calluses or lesions. The assessment included stasis dermatitis of the left ankle. Following VA outpatient treatment in September 2008, it was noted that the Veteran's stasis dermatitis of the left ankle was stable. On VA outpatient treatment in December 2009, the Veteran's complaints included onychomycosis. The post-service medical evidence also shows that the Veteran has received regular outpatient treatment for onychomycosis from a variety of private treating physicians. For example, in February 2003, he complained of painful, thick, deformed toenails of both feet on toes 1, 3, 4, and 5, pain and difficulty walking, and brittle, discolored, blackened, yellowed, ingrown, thickened, and long toenails. A history of mycotic nails was noted. The painful, thick, deformed toenails were located on toes 1, 3, 4, and 5 of both feet. Objective examination showed markedly thickened and ingrown nail plates of both feet at toes 1-5 without evidence of infection or cellulitis and asymptomatic corns and calluses without evidence of ulceration or underlying bone pathology. The assessment included onychomycosis toenails. The Veteran's mycotic nail plates 1-5 were debrided down to a healthy nail bed and subungual debris was curetted and removed from the nail beds. The Veteran also was prescribed Loprox cream 1%, 30 grams, to apply daily to nail beds and margins. The Veteran continued to receive private outpatient treatment for onychomycosis of the toenails of both feet throughout 2003, 2004, and 2005. For example, in May 2005, no relevant complaints were noted. Physical examination of the skin showed normal skin color, turgor, hydration, and temperature. There was hair growth to the feet. There also were no signs of cellulitis, drainage, ulcers, or other lesions. Physical examination of the nails showed they were mycotic from nail beds 1-5 bilaterally. The assessment included onychomycosis. In July 2005, the Veteran complained of painful mycotic nails. Physical examination of the skin showed normal skin color and turgor with no ulcerations, hyperkeratotic lesions, masses, or indurations. Physical examination of the nails showed positive mycotic infection and ingrown nails, especially on the bilateral hallux. There were no signs of cellulitis or other lesions. The assessment was onychomycosis and an ingrown toenail of the bilateral hallux. The Veteran's toenails 1-5 were debrided bilaterally to relieve the pain and pressure. He was started on Penlac solution to apply daily to affected areas. On private outpatient treatment with Gladys P. Bembo, D.P.M., in August 2007, the Veteran complained of having fungal nails for many years. He stated that his fungal nails began during active service "around 1950 and 1960." He also stated that he had been prescribed some anti-fungal medication during service but stopped taking it secondary to possible liver problems. He also reported that he had been seen by a private physician since the 1990's for this problem and had been using Keralac nail gel for about 1-11/2 years with no positive improvement of his fungal nails. A history of some stasis dermatitis was noted. Physical examination of the skin showed no open lesions, indurations, or masses. Physical examination of the nails showed short nails which were thickened, discolored, and crumbly, especially on both big toes. There was no cyanosis or petechia noted in the nails. The assessment was onychomycosis. In September 2007, no relevant complaints were noted. The Veteran reported that he had been using fungoid tincture on his nails since his prior visit in August 2007. Physical examination was unchanged. The assessment also was unchanged. The Veteran's toenails were debrided and he was given a prescription for Penlac nail lacquer. In June 2009, the Veteran's complaints included fungal nails. It was noted that he had been using ciclopirox 8% solution and Keralac nail gel. Physical examination of the skin showed some slight skin around the ankle area without ulcerations. Physical examination of the nails showed long, thickened, discolored, brittle nails with abundant subungual debris. The assessment included onychomycosis. In September 2009, no relevant complaints were noted. Physical examination of the skin showed some dry skin on the plantar aspect of the right heel and also on the plantar forefoot of the left foot. Physical examination of the nails showed long, thickened, discolored, brittle nails except for the right second toenail. The assessment included onychomycosis, currently treated with topical medication. The Veteran's nails were debrided. In December 2009, the Veteran complained of painful, thickened, discolored nails. He reported that he had been applying Keralac nail gel and had used fungoid tincture and Penlac "at one point." Physical examination of the skin showed no open lesions, masses, or induration, and slight dry skin on both feet. Physical examination of the nails showed slightly elongated, thickened, discolored, brittle nails X 10 with no clubbing or cyanosis. The assessment was onychomycosis and xerosis. The Veteran's nails were debrided X 10. He was advised to continue Keralac nail gel and Penlac for his nails. In March 2010, no relevant complaints were noted. The Veteran stated that he had been using Keralac nail gel and ciclopirox. Physical examination of the skin showed dry skin on the feet which was improved from the previous visit and no open lesions. Physical examination of the nails showed elongated, thickened, discolored, brittle nails X 10 especially nails 1,3, and 5 on the left and 1, 3-5 on the right. The assessment was onychomycosis, currently on topical medication, and xerosis which was improved. The Veteran's nails were debrided X 10. He was advised to continue Keralac nail gel and Penlac for his nails. Dr. Bembo stated in a March 2010 letter that the Veteran had been under her care since 2007 for onychomycosis and xerosis. She also stated that the Veteran had been on topical medication for the fungal infection since 2007. On VA examination in September 2010, the Veteran complained of bilateral toenail mycosis which had begun in 1959 while wearing combat boots in hot weather. The VA examiner reviewed the Veteran's claims file, including his service treatment records, VA outpatient treatment records, and private medical records. The Veteran stated that his bilateral toenail mycosis was constant and resulted in tender feet with increased walking. He reported taking clotrimazole 1% and ciclopirox 8% topically twice a day as needed in the previous 12 months. The VA examiner noted that neither of these medications were a corticosteroid or an immunosuppressive. Physical examination showed yellowing and thickening of all toenails except the second toenails bilaterally and the fifth toenail on the left foot. The VA examiner stated that he could not resolve whether the Veteran's bilateral toenail fungal infections were related to active service without resorting to mere speculation. His rationale was that, although the available service treatment records referred to left ankle dermatitis repeatedly, there appeared to be no reference to any toenail fungal infection. The Veteran insisted that the toenail fungal infection started in service and was treated in service with an oral medication. The VA examiner concluded that the available evidence was insufficient to render a medically-based opinion in this case with any reasonable degree of confidence. The diagnosis was bilateral toenail mycosis. The Board acknowledges the Veteran's assertion that his current skin disability of the feet and toenails began during active service. The competent evidence shows, however, that he was not diagnosed with a chronic skin disability of the feet and toenails (whether characterized as a chronic fungal disorder or onychomycosis) at any time during his nearly 21 years of active service. As the VA examiner stated in September 2010, the Veteran's available service treatment records do not show that he was diagnosed as having any toenail fungal infection during active service. These records also show that he was treated for stasis dermatitis of the left foot and left ankle during service. The Board notes that service connection already is in effect for stasis dermatitis of the left foot. The Board also notes that no diagnosis of a chronic skin disability of the feet and toenails (whether characterized as a chronic fungal disorder or onychomycosis) was offered at the Veteran's final separation physical examination in September 1968. The Board notes further that the in-service examiner stated at the Veteran's separation physical examination that his stasis dermatitis had been treated. It also was noted in January 1969, just prior to the Veteran's actual discharge from service, that his "foot fungus" (which appears to refer to his stasis dermatitis) had been "treated and currently cured." It appears that, following his service separation in January 1969, the Veteran first complained of a chronic skin disability of the feet and toenails in February 2003, or more than 34 years later. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran also did not report any relevant in-service history of an alleged chronic skin disability of the feet and toenails to the VA examiners who treated him between March 2008, when he enrolled in the VA health care system, and December 2009, when he first complained of onychomycosis on VA outpatient treatment. The remaining post-service evidence shows that, although the Veteran currently experiences a chronic skin disability of the feet and toenails (variously diagnosed as onychomycosis and bilateral toenail mycosis), it is not related to active service or any incident of such service. The Board observes that, although the Veteran has been seen frequently on outpatient treatment by multiple VA and private treating physicians, he has not reported consistently his alleged in-service history of a chronic skin disability of the feet and toenails to these examining physicians. It appears that he first reported an in-service history of fungal nails when he first was seen by Dr. Bembo in August 2007, although he had been receiving regular outpatient treatment for onychomycosis from other private physicians since at least 2003. He also reported to Dr. Bembo - for the first time - in August 2007 that he had been prescribed medication to treat his fungal nails during active service. The Board observes that there is no support whatsoever for the Veteran's report of an in-service prescription for treatment of fungal nails at any time during his nearly 21 years of active service. The Board also observes that, although the Veteran was seen by Dr. Bembo repeatedly between August 2007 and 2010, he did not report any relevant in-service medical history to Dr. Bembo after their initial outpatient treatment visit. More importantly, despite treating the Veteran regularly as an outpatient for several years, Dr. Bembo did not relate the Veteran's current chronic skin disability of the toenails and feet to active service. She only stated in her March 2010 letter that the Veteran had been under treatment for onychomycosis and xerosis and on topical medication for his fungal medication since 2007. The VA examiner concluded in September 2010 that he could not provide a medical opinion relating the Veteran's current skin disability of the feet and toenails (which he diagnosed as bilateral toenail fungal infections) to active service without resorting to mere speculation. His rationale was that, although the available service treatment records referred to left ankle dermatitis repeatedly, and although the Veteran insisted that the toenail fungal infection started in service and was treated in service with an oral medication, there appeared to be no reference to any toenail fungal infection in his service treatment records. The VA examiner concluded that the available evidence was insufficient to render a medically-based opinion in this case with any reasonable degree of confidence. There is no competent contrary opinion of record. The Veteran also has not identified or submitted any competent evidence, to include a medical nexus, relating his current skin disability of the feet and toenails to active service. As noted elsewhere, although the Veteran is competent to state what happened to him in service, because he is not reporting a medical diagnosis contemporaneous to service, his lay evidence alone is insufficient to establish a diagnosis or etiology for purposes of awarding service connection. See Davidson, 581 F.3d at 1313. In summary, the Board finds that service connection for a skin disability of the feet and toenails(characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis) is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. at 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements and sworn testimony, the Veteran has asserted that his symptoms of a skin disability of the feet and toenails have been continuous since service. He asserts that he continued to experience symptoms relating to the feet and toenails (dry skin and thickened, brittle, and discolored toenails) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a skin disability of the feet and toenails after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of a skin disability of the feet and toenails since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorder began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any history or complaints of symptoms of a skin disability of the feet and toenails. Specifically, the service separation examination report reflects that the Veteran was examined and clinical evaluation only showed pigmentation on the outer aspect of the left ankle which the in-service examiner attributed to stasis dermatitis. This examiner also stated that the Veteran's stasis dermatitis had been treated. The Veteran's in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to a skin disability of the feet and toenails for several decades following active service. The Board emphasizes the multi-year gap between discharge from active service (1969) and initial reported symptoms related to a skin disability of the feet and toenails in approximately 2003 (a 34-year gap). See Maxson, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board notes that the Veteran sought treatment for a myriad of medical complaints since discharge from service, including bilateral hearing loss, tinnitus, and stasis dermatitis of the left ankle. Significantly, during that treatment, when he specifically complained of other problems, he never reported complaints related to a skin disability of the feet and toenails. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). When the Veteran sought to establish medical care with VA after service in March 2008, he did not report the onset of symptomatology attributable to a skin disability of the feet and toenails during or soon after service or even indicate that the symptoms were of longstanding duration. He also did not report any relevant in-service history to his private treating physicians between February 2003, when he first complained of a skin disability of the feet and toenails, and August 2007, when he first reported experiencing fungal nails during active service. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Id. The Veteran also did not claim that symptoms of his disorder began in (or soon after) service until he filed his current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, his previous statements made for treatment purposes, and his own previous histories of onset of symptoms given after service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for a skin disability of the feet and toenails (characterized as a chronic fungal disorder of the feet and toenails, to include onychomycosis) is denied. ____________________________________________ MICHAEL A. PAPPAS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs