Citation Nr: 1134591 Decision Date: 09/15/11 Archive Date: 09/23/11 DOCKET NO. 07-16 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a variously diagnosed skin disability, to include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas, claimed as secondary to sun and herbicide exposure in service. REPRESENTATION Appellant represented by: AMVETS WITNESSES AT HEARING ON APPEAL Appellant & Spouse ATTORNEY FOR THE BOARD A. Ishizawar, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1967 to July 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). In July 2009, a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. In September 2009, the case was remanded for additional development. In January 2011, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). The Board notes additionally that the Veteran submitted additional evidence and argument in January 2011 and in May 2011. The May 2011 argument was submitted with a waiver of initial agency of original jurisdiction (AOJ) consideration; however, the January 2011 was not. On review of the January 2011 submission, which consists of the Veteran's written statement, a statement from his treatment-provider, and a picture of his truck, the Board finds that it either represents argument (not evidence) or is cumulative of evidence/information previously submitted and considered by the AOJ. Therefore, it does not require return to the AOJ for initial review. See 38 C.F.R. § 20.1304(c). FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era. 2. The Veteran's various skin disability diagnoses, to include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas, are not listed diseases associated with exposure to certain herbicide agents in Vietnam; were not manifested during his active service or within one year thereafter; and are not shown to be related to his service, including as due to herbicide and/or sun exposure therein. CONCLUSION OF LAW Service connection for a variously diagnosed skin disability, to include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas, claimed as secondary to sun and herbicide exposure, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of his claim prior to its initial adjudication. July 2006, April 2008, and May 2008 letters explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed him of disability rating and effective date criteria. The Veteran has had ample opportunity to respond/supplement the record and he has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) are associated with his claims file, and pertinent postservice treatment records have been secured. The RO also attempted to secure records from the Social Security Administration (SSA), as there were indications in the record that he might be receiving SSA disability benefits. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (VA has a duty to assist the Veteran in obtaining records from other federal government agencies where it has "actual notice" that these records exist). In January 2008, SSA responded that after exhaustive and comprehensive searches, they were unable to locate any medical records for the Veteran. The Veteran subsequently clarified that he was receiving SSA retirement (and not disability) benefits; therefore, SSA does not have any medical records on file for him. The RO arranged for a VA examination in January 2010 with an addendum opinion in March 2010. For reasons discussed below, the Board found the examination and the examiner's addendum opinion inadequate and obtained a medical advisory opinion from the VHA. The Board notes that the VHA advisory opinion was ultimately provided by the same physician who conducted the January 2010 VA examination; there is nothing in the regulations that prohibits this. See 38 C.F.R. § 20.901(a). In a May 2011 statement, the Veteran argued that the VHA medical advisory opinion is inadequate because it states that he served in Vietnam from November 1967 to February 1968 when he actually served from November 1967 to September 1968 (for a period of 9 months). He stated that this oversight rendered the "research data inaccurate," as the "time frame more than doubles the time frame that data was made and the opinion based upon." The Board notes, however, that despite the VHA consulting physician's misstatement (presumably based upon an August 2006 statement by the Veteran wherein he indicated that he had served in Vietnam from November 1967 to February 1968), his opinion was based on research/calculations for a 9-(and not 3) month period. See March 2011 VHA medical advisory opinion ("I utilized nine months for my calculation . . . This was the longest estimate of the appellant's time in country found in the record, with the Veteran himself estimating his sun exposure at four months.") Accordingly, the Board finds the March 2011 VHA medical advisory opinion was premised on the correct period of Vietnam service, and is adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The Board also finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. B. Factual Background The Veteran's service personnel records reflect that he served in the Republic of Vietnam for 9 months and 20 days (from December 1967 to September 1968). His STRs show that from August 1968 to February 1969, he was treated for blisters, rashes, pustules, and lesions on the right hand. In August 1968, resolving pyoderma was diagnosed. In November 1968, it was noted that he had "just returned from Vietnam." In February 1969, he complained of a "rash which was received in Vietnam"; eczema was diagnosed. On June 1969 service separation physical examination, his skin and lymphatics were normal on clinical evaluation. The report is silent for any complaints, findings, treatment, or diagnoses relating to a skin disability. In an associated report of medical history, the Veteran denied having or having ever had any skin diseases. VA treatment records from January 1996 to October 1996 are silent for any complaints, findings, treatment, or diagnoses relating to a skin disability. On October 1996 VA general medical examination (conducted in association with the Veteran's then pending claim for an increased rating for his service-connected sebaceous cyst on the right, lower lip and for nonservice-connected pension benefits), no skin disability was observed. The Veteran's lymphatic and hemic systems were noted to be normal. Private treatment records from Dr. W.M.S. and New River Dermatology show that from October 1999 to June 2008, the Veteran received periodic and regular treatment for the following skin disabilities: basal cell carcinoma, actinic keratosis, multiple skin lesions, seborrheic keratosis, and squamous cell carcinoma. March 2006 to July 2006 private treatment records from Dr. O.W.R. are silent for any complaints, findings, treatment, or diagnosis relating to a skin disability. In an August 2006 statement, the Veteran related that while he was serving in Vietnam from November 1967 to February 1968, he was over-exposed to the sun, suffered from sunburns, and was treated for blisters. Noting that his postservice occupations did not involve sun exposure, he alleged that his current skin disability could be related to sun exposure in service. In subsequent statements, he also alleged that his skin disability might be related to herbicide exposure in Vietnam. In support of his claims, the Veteran submitted several letters from his private healthcare providers, D.S.H., D.O. (dated in February 2007) and B.M., FNP (dated in June 2008, April 2009, and in January 2011). Both providers stated that since the Veteran's establishment of dermatologic care with their office in August 2005, numerous precancerous actinic keratoses and squamous cell carcinomas have been removed from his face, neck, trunk, and upper extremities. They opined, in essence, that these conditions are primarily due to long-term, chronic, ultraviolet sun exposure, and also note that such lesions could form at an accelerated rate due to the Veteran's past history of exposure to multiple different various chemical carcinogens. In her January 2011 letter, B.M., FNP, also states that the Veteran's skin conditions were "caused by excessive exposure to [ultraviolet] rays from the sun," and that it was "more than likely that his time spent in the sun while in Vietnam contributed to this condition, if not entirely caused this condition." On January 2010 VA examination, the Veteran reported having a couple of severe sunburns while stationed in Vietnam for two years. He stated he did not wear shirts while he was there and had some blistering on his hands. He worked as a truck driver after he returned from Vietnam, from 1969 to 1995, and then in a factory from 1995 to 2007. He was first given a diagnosis of skin cancer (by a private dermatologist) in 2001, and then started taking precautionary measures like sunscreen and wearing hats. After a physical examination, actinic keratosis and possible nonmelanocytic skin cancers on sun-exposed areas were diagnosed. The examiner opined: Nonmelanocytic skin cancers including squamous cell carcinomas and basal cell carcinomas are well known to be associated with a constant sunexposure and damages from the UV light. Given the history of [the Veteran] staying in Vietnam for 2 years and working as a truck driver (that is known to be a significant sunexposing job) for 26 years, his sunexposure for the whole time would be a cause of his current skin problems. If the proportion of the cause for his skin problems because of his Vietnam sunexposure for 2 years out of 28 years overall exposure needs to be figured, less than 25% at the most would be appropriate concerning the intensity of UV light in Vietnam. In a March 2010 addendum opinion, the VA examiner diagnosed actinic keratosis on the Veteran's face, chest, back, and arms, and stated that by history the Veteran had diagnoses of basal cell carcinoma on the back and squamous cell carcinoma on the arms. He then noted that these disabilities are associated with consistent exposure to UV light, and opined, "Given the history of [the Veteran] staying in Vietnam for 2 years and working as a truck driver (that is known to be a significant sun-exposing job) for 26 years, his sunexposure for both times should be causes for his [skin disabilities]. Probably, his working as a truck driver for 26 years could be considered [a] more significant cause of his current [skin disabilities]. So his staying in Vietnam for 2 years during the service is related much less than 50% of his [skin disabilities]." In January 2011, the Board found the January 2010 VA examiner's opinions inadequate because they were based, in part, on an incorrect factual basis (the Veteran did not serve in Vietnam for two years, only nine months) and because the examiner did not (as was requested) opine as to whether the Veteran's current skin disabilities were related to the treatment he received in service for a skin condition. The Board also noted that the examiner's opinions required clarification because rather than offering opinion regarding the degree of probability that the Veteran's current skin disabilities were related to his service, he instead ascribed percentages of the Veteran's skin disability that might be attributable to his service (without adequate explanation of the bases for the estimates). Accordingly, a medical advisory opinion from the VHA was sought. In response to the Board's request for a VHA advisory opinion in this matter, the same dermatologist who provided the January 2010 and March 2010 medical opinions opined in March 2011 that there was a "less than 50 percent" probability that the Veteran's actinic keratosis, basal cell carcinoma, and squamous cell carcinoma were, at least in part, caused by his exposure to sunlight in service or related to the skin problems for which he received treatment in service. In reaching this conclusion, the VA examiner/VHA consulting expert researched the weather and sun conditions in Vietnam as compared to the Veteran's local area. Estimating the intensity of the ultraviolet (UV) light to be double in Vietnam to that in Southern Virginia (where the Veteran has resided since his separation from service), he concluded that less than 2.8% of the Veteran's life had been spent exposed to sun in Vietnam. The expert also noted that the Veteran had been treated for blisters, rashes, pustules on the right hand and for eczema in service, and stated they were "not likely" related to his service. He explained that blisters from sunburns occur less than a week after exposure, and opined that they were "more related" to the Veteran's lifestyles and environment. He noted that eczema was a preventable and treatable condition and further noted that blisters, rashes, pustules, and eczema had not been present when the Veteran underwent a fully body physical examination in January 2010. The consulting expert stated that he did not consider the picture of the truck provided by the Veteran, "as the angle of sunlight changes throughout the day," and because "it is not feasible to take into consideration every vehicle [he] has driven for the past 26 years." He suggested that an expert in physics be contacted if that "level of micro-calculation" was required. In a statement received in May 2011, the Veteran stated that his sunburn blisters had occurred within one to two days after his sunburns, and noted that he had been treated for blisters, rashes, pustules and eczema in Vietnam. Therefore, he argues that if they existed and were treated while he was in Vietnam, then the conditions had to have come from Vietnam. C. Legal Criteria and Analysis Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection also may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Hickson v. West, 12 Vet. App. 247 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The evidence shows that the Veteran has a variously diagnosed skin disability, to include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. His STRs show he was treated for pyoderma and eczema in service; he was not treated for melanoma, actinic keratoses, squamous cell carcinomas, or basal cell carcinomas. On June 1969 service separation examination, a clinical evaluation of his skin and lymphatics was normal. In an associated report of medical history, he denied having or having ever had any skin diseases. Consequently, service connection for a variously diagnosed skin disability on the basis that such became manifest in service and persisted is not warranted. Notably, after the Veteran's separation from service in July 1969, he did not seek treatment for any skin-related symptoms until October 1999. 38 C.F.R. § 3.303(b); see also Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). The Veteran presents alternate theories of entitlement for the benefit sought. First, he claims his variously diagnosed skin disability is causally related to his over-exposure to the sun in Vietnam. The Veteran's service personnel records show that he served in Vietnam for 9 months and 2 days (from December 1967 to September 1968); therefore, it is not in dispute that he was exposed to the sun during such period of time. The record includes both medical evidence that tends to support the Veteran's claim that his variously diagnosed skin disability is related to his sun exposure in service, and medical evidence that is against the claim. When evaluating this evidence, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The evidence that tends to support the Veteran's claim consist of the February 2007, June 2008, April 2009, and January 2011 letters from his private healthcare providers, D.S.H., D.O. and B.M., FNP. They opine essentially that the Veteran's variously diagnosed skin disability is the result of long-term, chronic, ultraviolet sun exposure. In January 2011, B.M., FNP, further clarified that it was her opinion that the Veteran's skin disabilities were caused by his "excessive exposure" to ultraviolet rays from the sun, and that his time in Vietnam contributed to his conditions, if not entirely caused them. The Board notes that neither D.S.H., D.O. nor B.M., FNP, provided explanations for the rationale of their opinions. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) ("A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"); see also Miller v. West, 11 Vet. App. 345, 348 (1998). Furthermore, apart from B.M., FNP's January 2011 opinion, the earlier opinions only note that the Veteran's skin disabilities are the result of long-term, chronic, ultraviolet sun exposure without specifically attributing them to his sun exposure in Vietnam/service. As for the B.M., FNP's January 2011 opinion, she does not explain how 9-months of sun exposure in Vietnam constitutes "excessive" sun exposure in light of the amount of sun exposure he has likely incurred since his separation from service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (the guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion). Other items of evidence potentially favorable to the Veteran are the opinions provided by the January 2010 VA examiner in January 2010 and in March 2010. However, as was explained in the Factual Background, these opinion were based, in part, on an incorrect factual basis and did not address all the questions that had been posed by the Board in its September 2009 remand. The examiner's opinions also required clarification because rather than offering opinion regarding the degree of probability that the Veteran's current skin disabilities were related to his service, he instead ascribed percentages of the Veteran's skin disability that might be attributable to his service (without adequate explanation of the basis for setting such percentages). Accordingly, the January 2010 VA examiner's January 2010 and March 2010 medical opinions are inadequate to properly address the matter of whether the Veteran's variously diagnosed skin disability is related to his sun exposure service. In response to a request for a VHA advisory opinion, the January 2010 VA examiner reviewed the claims file anew, and in March 2011 opined that there was a "less than 50 percent" probability that the Veteran's variously diagnosed skin disability was, at least in part, caused by his exposure to sunlight in service or were related to the skin problems for which he received treatment in service. In reaching this conclusion, the VA examiner/VHA consultant researched the weather and sun conditions in Vietnam and that of the Veteran's local area, and estimated that the intensity of the UV light in Vietnam to be double of that in Southern Virginia. He then calculated that even with the exposure to double-intensity UV rays in Vietnam, less than 2.8% of the Veteran's life had been spent exposed to sun in Vietnam. Given this duration of sun exposure in Vietnam, it was less than 50 percent likely that his variously diagnosed skin disability was caused by his time in Vietnam during service. The Board notes that the March 2011 VHA advisory opinion also suggested that a review of the Veteran's claims file by an expert in physics might be necessary to complement its opinion, but finds that such an evaluation is not necessary. In particular, it is not clear how such an evaluation would aid in the consideration of the Veteran's claim. Although the Veteran disputes that he was exposed to UV rays while driving a truck for 26 years, and has provided a picture of the truck to show that its design protected him from UV rays, the more significant question in this matter is whether the Veteran's exposure to UV rays in Vietnam was sufficient to either cause or aggravate his variously diagnosed skin disability. Here, the VA examiner/VHA consultant has opined that even assuming that the intensity of the UV rays in Vietnam were twice as strong as what the Veteran would experience outside of service, given that he served for only 9 months in Vietnam, such sun exposure would still only constitute less than 2.8% of his overall sun exposure. In essence, it is the VA examiner/VHA consultant's opinion that the amount of sun to which the Veteran was exposed in Vietnam does not constitute "long-term, chronic" exposure; therefore, his variously diagnosed skin disability must be attributable to other forms of sun exposure. In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Here, the Board places greater weight on the March 2011 VHA advisory opinion because it was provided by a dermatologist (who by virtue of specialized training and experience is eminently qualified to offer an opinion in this matter), and also because his opinion was based on a complete knowledge of the Veteran's medical history (which includes consideration/discussion of his postservice sun exposure), included rationale, considered possible alternative risk factors for the Veteran's variously diagnosed skin disability, and cited to clinical and scientific data that supported the conclusions reached. The Veteran has also alleged that his variously diagnosed skin disability is causally related to his exposure to Agent Orange in service. The law provides that, if a veteran was exposed to an herbicide agent during service, the following diseases shall be service connected if the requirements of 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes mellitus, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Effective August 31, 2010, VA amended its adjudication regulations governing service connection for diseases associated with exposure to certain herbicide agents by expanding the class of diseases that may be presumptively service-connected if present in a veteran who was exposed to Agent Orange in service. Specifically, the final rule amends 38 C.F.R. § 3.309(e) by removing "chronic lymphatic leukemia" and adding, in its place, "All chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia)"; by adding "Parkinson's disease"; and by adding "Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina)". See 75 Fed. Reg. 53202, 53216 (Aug. 31, 2010). Although there is evidence that the Veteran served in Vietnam and thus is presumed to have been exposed to herbicides, none of his variously diagnosed skin disabilities, which include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas, is listed among the diseases enumerated under 38 C.F.R. § 3.309(e), to include the newly included diseases effective August 31, 2010. Consequently, the presumptive provisions of 38 U.S.C.A. § 1116 do not apply. The United States Court of Appeals for the Federal Circuit has determined that a claimant who suffers from a disability that is not listed among those for which presumptive service is afforded based on exposure to Agent Orange is not precluded from establishing service connection for such disability as due to Agent Orange exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this regard, the Veteran submitted February 2007, June 2008, and April 2009 letters from his private healthcare providers, D.S.H., D.O. and B.M., FNP, which state, essentially, that his current skin disabilities "could also [have] form[ed] in an accelerated rate due to past history of exposure to multiple different various chemical carcinogens." The Board notes, however, that not only did his healthcare providers not provide an explanation for these opinion (see Stefl, 21 Vet. App. at 123), they are also stated in speculative terms. In Obert v. Brown, 5 Vet. App. 30 (1993), the United States Court of Appeals for Veterans Claims (Court) held that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim. Furthermore, it is significant to note that in May 2008, the Secretary of VA made a specific determination that melanoma and non-melanoma skin cancers (basal cell and squamous cell) did not warrant a presumption of service connection based on exposure to herbicides in the Republic of Vietnam. This determination was based on all available evidence in a 2006 report of the National Academy of Sciences (NAS) and prior NAS reports, which found that although recent studies provided some evidence of an association between melanoma and herbicides, "the evidence overall continues to weigh against an association," and that there continues to be "inadequate or insufficient evidence to determine whether there is an association between herbicide exposure and basal cell or squamous cell cancer." See 75 Fed. Reg. 32540, 32544(June 8, 2010). Finally, the Veteran also asserts that his variously diagnosed skin disability is related to the skin conditions for which he received treatment in service. The only opinion that addresses this question is the March 2011 VHA medical advisory opinion wherein the consulting expert opined that the Veteran's variously diagnosed skin disability is not related to the blisters, rashes, pustules, and eczema for which he received treatment in service. He explained that these conditions are typically the result of lifestyle habits and the environment in which one resides, and further noted that at the time of the Veteran's January 2010 VA examination, no blisters, rashes, pustules, or eczema were noted. Such evidence tends to suggest that the skin conditions for which the Veteran received treatment in service resolved in service without any residual disability. Significantly, none of the Veteran's postservice treatment records show that he has complained of, or been treated for, blisters, rashes, pustules, or eczema. In summary, the competent evidence of record does not show that the Veteran's variously diagnosed skin disability is related to his exposure to sun or herbicides in service, or to the skin conditions for which he received treatment in service. To the extent that he asserts his variously diagnosed skin disability is related to the environmental hazards he encountered in service and/or to the skin conditions for which he received treatment in service, the Board notes that he is a layperson and lacks the training to opine regarding medical causation; whether a disease is related to sun exposure, herbicide exposure, and/or distant and remote treatment of a differently-diagnosed skin condition in service, is a complex medical question requiring medical expertise, and incapable of resolution by lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Court). In light of the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's variously diagnosed skin disability is related to his service, and that the claim of service connection for such disability must be denied. ORDER Service connection for a variously diagnosed skin disability, to include melanoma, actinic keratoses, squamous cell carcinomas, and basal cell carcinomas, claimed as secondary to sun and herbicide exposure in service, is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs