Citation Nr: 1124985 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 08-37 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to an initial compensable rating for prurigo nodularis. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD C. dR. Dale INTRODUCTION The Veteran served on active duty from November 1964 to November 1967 and from January 1969 to September 1984. He is the recipient of the Combat Infantry Badge. This matter comes before the Board of Veterans' Appeals (Board) from a July 2007 rating decision of a Decision Review Officer (DRO) at the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which granted the Veteran's claim of entitlement to service connection for prurigo nodularis and assigned an initial noncompensable evaluation, effective October 5, 2006. This case was previously before the Board in September 2008 and was remanded in order to provide the Veteran with a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). After the Veteran perfected his appeal, the case was remanded for evidentiary development in June 2010. As will be discussed further herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the previous remand orders and that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In December 2009, the Veteran and his spouse testified before the undersigned Acting Veterans Law Judge sitting at the RO in North Little Rock, Arkansas. A transcript of the hearing has been associated with the claims file. FINDINGS OF FACT 1. Prior to June 24, 2010, the Veteran's prurigo nodularis does not more nearly approximate deep acne affecting less than 40 percent of the face and neck or deep acne other than on the face and neck; scars that exceed an area of 6 square inches, or are deep, unstable, or painful on examination; visible or palpable tissue loss, gross distortion of asymmetry of one feature or paired set of features, or one characteristic of disfigurement; or limits the function of the affected part. 2. As of June 24, 2010, the Veteran's prurigo nodularis is manifested by an area of approximately 4 x 5 centimeters (cm.) that is raised with some hypertrophic areas consistent with scarring on the posterior neck, without evidence of that such symptomatology more nearly approximates deep acne affecting less than 40 percent of the face and neck or deep acne other than on the face and neck; scars that exceed an area of 6 square inches, or are deep, unstable, or painful on examination; demonstrate visible or palpable tissue loss, gross distortion of asymmetry of one feature or paired set of features, or additional characteristics of disfigurement; or limits the function of the affected part. CONCLUSIONS OF LAW 1. Prior to June 24, 2010, the criteria for an initial compensable rating for prurigo nodularis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7828 (2008). 2. As of June 24, 2010, the criteria for an initial 10 percent rating, but no higher, for prurigo nodularis have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Codes 7800, 7828 (2008). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Proper VCAA notice 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the appellant's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the 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 (AOJ) decision on the claim for VA benefits. The Board observes that the Veteran has appealed with respect to the propriety of the initially assigned rating for his prurigo nodularis from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for prurigo nodularis was granted and an initial rating was assigned in the July 2007 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records, VA treatment records, and private medical records have been obtained and considered. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. In this regard, the Board observes that the Veteran indicated during his December 2009 Board hearing that he would be attempting to see a physician to restart his prescription medication for his skin. However, the Veteran has not submitted evidence of further treatment nor has he identified any outstanding treatment records necessary to decide his pending appeal. Additionally, the Veteran has been afforded VA skin examinations in June 2007 and June 2010; the reports of which are of record. The Board finds that the examination reports are adequate as they were based on a review of the record, a physical examination, and the Veteran's reported history and symptomatology. Moreover, as the disabilities were described in sufficient detail, the Board finds that such adequately address the rating criteria necessary to evaluate the Veteran's prurigo nodularis. Therefore, further examination is not necessary. The Board observes that this case was remanded in September 2008 in order to provide the Veteran with a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999), which was accomplished in October 2008. The case was again remanded in June 2010 in order to obtain VA treatment records, and afford the Veteran a VA examination. As discussed in the preceding paragraphs, all requested development has been completed. Therefore, the Board finds that the AOJ has substantially complied with the September 2008 and June 2010 remand directives such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merit of his claim. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Fenderson v. West, 12 Vet. App. 119 (1999). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective in October 2008. However, the amendments are only applicable to cases where the claim was received on or after October 23, 2008, or if the Veteran requests review under the new regulations. See 73 Fed. Reg. 54708 (Sept. 23, 2008). Neither situation is applicable in this case. The Veteran's prurigo nodularis is rated under Diagnostic Code 7828, which provides that a noncompensable disability rating is assigned for superficial acne (comedones, papules, pustules, superficial cysts) of any extent; a 10 percent disability 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 disability rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. 38 C.F.R. § 4.118, Diagnostic Code 7828. Service treatment records (STRs) show that the Veteran had a small pimple on his neck in March 1976. In August 1979, he was diagnosed with an infected sebaceous cyst. In October 1979, the Veteran complained of a boil located on the left side of his neck. He reported that it had drained a little and stated that he was using moist heat. The diagnosis was folliculitis. The Veteran complained of a cyst on the back of his neck and was again diagnosed with chronic folliculitis in November 1979. Examination revealed carbuncles down the left side of the neck. In June 1982, the Veteran was seen for a follow up to his folliculitis. Physical examination revealed a 1 centimeter non-tender lesion with no drainage. The physician diagnosed the Veteran with resolving folliculitis. In October 1982, the Veteran complained of a cyst on his lower back. Physical examination revealed a 1.5 centimeter lesion with an open central core with no drainage noted. The diagnosis was furuncle (boil). Private medical records include a November 1986 report of a boil on the back of the Veteran's ear. In August 1990, he reported skin boils. In June 1992, the Veteran complained of a boil on his chest. In March 1994, he was diagnosed with cold-induced urticaria on the calves and forearms, dermatitis on the left upper facial area, and present intermittent boils since 1990. In December 2006, the Veteran was diagnosed with boils, generalized since 1990. The physician later noted that the Veteran had intermittent boils since 1990. A June 2007 letter from the Veteran's sister reported that the Veteran returned from Vietnam with a rash on his face, back of his hands, and arms. He also had several large boils on his back and neck. In June 2007, the Veteran was accorded a compensation and pension (C&P) skin diseases examination. During the examination, the Veteran reported that he has not seen a physician since the 1980's and that his sister, a nurse, took care of him at home. He also reported that his wife drains the lesions with a pin. He further reported that he used hot, soapy water and stated that his last occurrence was one month ago. Physical examination revealed a 1 x 0.2 cm. linear, white, flat scar with no keloid formation or ulceration on the occipital scalp. There were two excoriated pink nodules consistent with prurigo nodules on the upper back. The physician found probable furunculosis in the 1970's and 1980's now with prurigo nodularis of the upper back. The course has been chronic. Over the last 12 months the Veteran has treated his skin only topically at home with hot soapy water and occasional drainage by his wife. The total body surface area affected was one percent and exposed body surface area affected was one percent. There was no acne or chloroacne. VA medical records include an August 2008 dermatology consultation during which the Veteran was evaluated for a lesion underneath his chin, which he was concerned was skin cancer. Physical examination revealed numerous papules with central umbilication and some telagiectasias that are slightly yellowish, consistent with sebaceous hyperplasia over his upper back, shoulders, and neck. He also had numerous scarring and several hyperpigmented verrucous stuck-on papules consistent with seborrheic keratosis on his back. In the submental region he had a fleshy papule with some irritation and erythema consistent with an irritated seborrheic keratosis versus a prurigo nodule. The assessments were irritated seborrheic keratosis very prurigo nodule that was destroyed with cryotherapy; and sebaceous hyperplasia, seborrheic keratosis. During his December 2009 Board hearing, the Veteran and his spouse testified that he had a boil breakout every six weeks and that he treated them by using hydrocortisone and peroxide. He also testified that he had bleeding outbreaks every 12 weeks. He testified that his outbreaks occurred more on his neck and back than on his face. The Veteran stated that when he broke out on his face that it occurred in the cheek area and lower neck. He further testified that, when his boils broke, they hurt and were tender, but he denied tender and painful scarring. The Veteran's spouse testified that the Veteran's boils left scars all over the body part that had an outbreak. VA medical records include a May 2010 complaint of a rash predominantly on the back, shoulders, and upper chest that was extremely pruritic forming with itchy boils that took approximately six weeks to heal. He reported that he picked at the lesions. He also indicated that he was given keoconazole shampoo by his primary care physician which did not seem to help. An examination of the skin revealed hypopigmented circular and irregularly shaped scars on his upper back, shoulders, and upper chest consistent with scarring from prior dermatitis. He also had a couple of scattered folliculocentric erythematous, crusted papules consistent with folliculitis on his back. Overall, he had no active rash at the time of the examination. The diagnoses were suspected irritant contact dermatitis per his history and folliculitis with possible furunculosis per his history. In June 2010, the Veteran was accorded another C&P skin examination. During the examination, he reported that he used chlorhexidine body rinse twice daily, topical steroid cream twice daily, and lotion one to two days per week in the shower as an alternative. He denied use of any oral immunosuppressive drugs. He also denied use of intensive light therapy, UVB, PUT, or electron beam therapy. He reported that he had break outs of raised red lesions on his face, neck, or upper back that itched. The Veteran stated that the lesions would eventually fill with fluid and rupture and resolve in four to five days. He denied use of antibiotics and surgical procedures, such as irritations and debridement in over a year. He had not been totally incapacitated in the past 12 months and his lesions are not debilitating, ulcerating, or exfoliating. There was some exudate and the lesions itched. They were not grossly disfiguring. The Veteran's disease was intermittent, not progressive, and the frequency was monthly. There was no fever, weight loss, or systemic or nervous manifestation. There were no malignant or benign neoplasms, urticaria, primary cutaneous vasculitis, or erythema multiformes. The Veteran also reported no acne or chloroacne and he denied scarring. Physical examination revealed he had a lesion on the right posterior cervical triangle area just distal to the earlobe of the right ear. The lesion was annular, red, raised, and pruritic, but there was no exudate. It was slightly tender to touch and its dimensions were 0.5 x 0.5 cm. There was no evidence of scarring. He also had a 1 x 1 cm. annular scar in the mid cervical region of the upper neck that was hyperpigmented. It was superficial and linear and did not adhere to underlying tissue or effect joint function. The scar was not painful, tender, hyposensitive, or hypersensitive. There was no discharge or cellulites. On the posterior neck, there was an area of approximately 4 x 5 cm. that was raised with some hypertrophic areas consistent with scarring. The Veteran reported that these were areas where he had lesions in the past. There was no evidence of crusting, ulceration, exfoliation, exudation, or pruritic areas in the area at this time. It was not grossly disfiguring. The Veteran's face, ears, and neck were free of lesions. The chest, back, abdomen, buttocks, and upper and lower extremities showed no evidence of prurigo nodularis. There was also no acne or chloroacne. The examiner determined that the Veteran's acute lesion areas covered less than one percent of the body as a whole and less than one percent of total exposed area. He also determined that the scarring on the upper neck area covered less than one percent of the body as a whole and one percent of the exposed area. The Board finds that the evidence does not support the assignment of an initial compensable evaluation under Diagnostic Code 7828. In this regard, a 10 percent disability rating is warranted 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. At the June 2007 VA examination revealed a 1 x 0.2 cm. linear, white, flat scar with no keloid formation or ulceration on the occipital scalp and there were two excoriated pink nodules consistent with prurigo nodules on the upper back; however, the total body surface area affected was one percent and exposed body surface area affected was one percent. Moreover, the June 2010 VA examination revealed a 0.5 x 0.5 cm. lesion on the right posterior cervical triangle area just distal to the earlobe of the right ear, a 1 x 1 cm. annular scar in the mid cervical region of the upper neck that was hyperpigmented, and an area of approximately 4 x 5 cm. that was raised with some hypertrophic areas consistent with scarring on the posterior neck. The VA examiner determined that the Veteran's acute lesion areas covered less than one percent of the body as a whole and less than one percent of total exposed area. He also determined that the scarring on the upper neck area covered less than one percent of the body as a whole and one percent of the exposed area. Moreover, the VA treatment records and lay testimony of record fails to demonstrate that the Veteran's prurigo nodularis is consistent with deep acne. Therefore, as the evidence fails to demonstrate that the Veteran's prurigo nodularis more nearly approximates 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, the Veteran is not entitled to an initial compensable rating under Diagnostic Code 7828. In accordance with the Note following Diagnostic Code 7828, the Board has considered whether the Veteran's prurigo nodularis warrants an initial compensable rating under Diagnostic Codes 7800, 7801, 7802, 7803, 7804, or 7805. In this regard, the Board initially finds that, as the Veteran's prurigo nodularis, other than on his head, face, or neck, does not more nearly approximate scars that exceed an area of 6 square inches, or are deep, unstable, or painful on examination. In fact, while the Veteran has been treated over the years for a variety of skin disorders on his back, the June 2010 VA examination revealed that the chest, back, abdomen, buttocks, and upper and lower extremities showed no evidence of prurigo nodularis. Moreover, while the Veteran has indicated that his boils were tender and hurt when they broke and the June 2010 VA examiner observed that a lesion distal to the earlobe of the right ear was slightly tender to touch, there is no evidence, to include the Veteran's own statements at his Board hearing as well as the objective findings at the VA examinations and in treatment records, that his prurigo nodularis results in symptomatic scarring. Therefore, an initial compensable evaluation under Diagnostic Codes 7801, 7802, 7803, or 7804 (2008) is not warranted. Likewise, as there is no evidence that the Veteran's prurigo nodularis results in limitation of function of the affected parts, the criteria under Diagnostic Code 7805 is inapplicable. Under Diagnostic Code 7800, a 10 percent evaluation is assigned for one characteristic of disfigurement. A 30 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion of asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with four or five characteristics of disfigurement. An 80 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with six or more characteristics of disfigurement. See 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The 8 characteristics of disfigurement, for purposes of evaluation under § 4.118, are: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.);and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). See 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1) (2008). For the period prior to June 24, 2010, the Board finds that the Veteran is not entitled to an initial compensable rating under Diagnostic Code 7800 as the evidence fails to demonstrate visible or palpable tissue loss, gross distortion of asymmetry of one feature or paired set of features, or one characteristic of disfigurement. In this regard, the June 2007 VA examination, VA treatment records, and the lay testimony of record fail to show scars of the head, face, or neck that are 5 or more inches (13 or more cm.) in length, at least one-quarter inch (0.6 cm.) wide at widest part, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.), skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.), underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.), or skin indurated and inflexible in an area exceeding six square inches (39 sq. cm). Therefore, an initial compensable rating under Diagnostic Code 7800 prior to June 24, 2010, is not warranted. However, the Board finds that the Veteran is entitled to an initial 10 percent disability rating under Diagnostic Code 7800 as of June 24, 2010, the date of the VA examination demonstrating an increase in his skin disability. In this regard, the June 2010 VA examination revealed an area of approximately 4 x 5 cm. that was raised with some hypertrophic areas consistent with scarring on the posterior neck. The Board will give the Veteran the benefit of the doubt, and find that, as such area is hypertrophic and raised, it approximates a single characteristic of disfigurement, i.e., the surface contour of scar elevated or depressed on palpation. Therefore, an initial 10 percent rating under Diagnostic Code 7800 is warranted, effective from the date of the VA examination which noted such findings on June 24, 2010. However, as the evidence fails to demonstrate visible or palpable tissue loss, gross distortion of asymmetry of one feature or paired set of features, or additional characteristics of disfigurement, the Board finds that the Veteran is not entitled to an initial rating in excess of 10 percent under Diagnostic Code 7800 for the period beginning June 24, 2010. The Board has further considered whether the Veteran's prurigo nodularis is more appropriately rated under any other Diagnostic Code; however, upon a review of his symptomatology, the Board finds that there are no other Diagnostic Codes that adequately address the Veteran's service-connected skin disability. See Butts v. Brown, 5 Vet. App. 532, 539 (1993); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board is also cognizant that the Veteran has been diagnosed with dermatitis, sebaceous hyperplasia, seborrheic keratosis, and folliculitis; however, there is no evidence that such are related to or caused by his service-connected prurigo nodularis. Other Considerations The Board has considered whether staged ratings beyond those already assigned under Fenderson, supra, are appropriate for the Veteran's service-connected prurigo nodularis; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning additional staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant'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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected prurigo nodularis with the established criteria found in the rating schedule. The Board finds that the Veteran's prurigo nodularis symptomatology is fully addressed by the rating criteria under which such disabilities are rated. There are no additional symptoms of his prurigo nodularis that are not addressed by the rating schedule. Moreover, to the extent that the Veteran's prurigo nodularis may interfere with his employability, such interference is addressed by the schedular rating criteria. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Furthermore, there is no evidence of marked interference with employment or frequent periods of hospitalization. Therefore, the Board finds that the rating criteria reasonably describes the Veteran's disability level and symptomatology for his service-connected disabilities. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Veteran is employed and has not alleged that he was unemployable during the course of the appeal due to his prurigo nodularis. Therefore, as there is no evidence of unemployability, a TDIU is not raised by the record. In sum, an initial compensable rating for the Veteran's prurigo nodularis prior to June 24, 2010, or an initial rating in excess of 10 percent thereafter, is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Any reasonable doubt with regard to the severity of the Veteran's symptomatology has been resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, as the preponderance of the evidence is against the Veteran's claim for higher initial ratings than those presently established, the benefit of the doubt provision does not apply and the claim must be denied. ORDER Prior to June 24, 2010, an initial compensable rating for prurigo nodularis is denied. As of June 24, 2010, an initial 10 percent rating, but no higher, for prurigo nodularis is granted, subject to the legal criteria governing the payment of monetary benefits. ____________________________________________ A. JAEGER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs