Citation Nr: 1144720 Decision Date: 12/07/11 Archive Date: 12/14/11 DOCKET NO. 93-06 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an effective date earlier than January 23, 1991, for the grant of service connection for residuals of leech bites. 2. Entitlement to an initial disability rating greater than 30 percent prior to April 8, 1997 for residuals of leech bites. 3. Entitlement to a disability rating greater than 10 percent from April 8, 1997 to August 29, 2002 for residuals of leech bites. 4. Entitlement to a disability rating greater than 30 percent beginning August 30, 2002, for residuals of leech bites. WITNESSES AT HEARING ON APPEAL Appellant and his spouse. ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to January 1968, including service during the Vietnam Era. These matters come before the Board of Veterans' Appeals (Board) on appeal of a December 1999 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In that rating decision, the RO granted service connection for residuals of leech bites and assigned a 30 percent evaluation effective January 23, 1991, and a 10 percent evaluation effective April 8, 1997. The Veteran appealed for an earlier effective date for the grant of service connection and for higher evaluations. The RO assigned the effective date based on a VA hospital report dated January 23, 1991. In a January 2000 rating decision, the RO determined that the assignment of that date was clearly and unmistakably erroneous, and assigned an effective date of January 31, 1991, the date of receipt of the Veteran's claim to reopen. In September 2001, the Board remanded the appeal for further development. In that remand, the Board characterized the effective date issue as that of entitlement to an effective date earlier than January 23, 1991, for the grant of service connection for residuals of leech bites. Thus, the issue will remain as listed on the title page. In an October 2004 rating decision, the RO granted a 30 percent evaluation effective August 30, 2002. The Veteran has not indicated that he is satisfied with this rating. Thus, the claim is still before the Board. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Furthermore, the issues are as listed on the title page. The Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in June 2006. A transcript of this proceeding has been associated with the claims file. The above issues were previously before the Board in September 2006 at which time they were remanded for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). In a January 2006 Board remand the Board referred the issues of entitlement to service connection for central neuropathy and peripheral neuropathy, to include as due to exposure to herbicides, to the RO for appropriate action. Subsequently, in a September 2006 Board remand the Board referred the issue of entitlement to service connection for body tremors, to include as due to exposure to herbicides, to the RO for appropriate action. By rating decision dated in March 2011 the RO denied service connection for Parkinson's disease, to include as due to exposure to herbicides. In this March 2011 rating decision the RO noted that while the Veteran is presumed to have been exposed to herbicides and that Parkinson's disease is a presumptive disorder for those veterans exposed to herbicides during Vietnam service, the Veteran did not have a diagnosis of Parkinson's disease. The Board notes that while central neuropathy, peripheral neuropathy, and body tremors are often associated with Parkinson's disease, these disorders are not the same as Parkinson's disease, as such these issues have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The Board notes that there are two other issues in appellate status, claims of entitlement to service connection for a disability manifested by paralysis of the neck/shoulders, as a residual of Agent Orange exposure, which are not listed on the title page. These issues were remanded by the Board in January 2006 for additional development which has not yet been completed. The Board has administratively notified the Appeals Management Center of their need to process the January 2006 Board remand request. Notably, the undersigned Veterans Law Judge did not take testimony on these issues. FINDINGS OF FACT 1. It is not factually ascertainable from the evidence of record that the Veteran was entitled to service connection for residuals of leech bites prior to January 31, 1991. 2. Prior to April 8, 1997, the Veteran's residuals of leech bites was manifested primarily by hyperpigmented lichenified plaques of his neck, elbows, legs, and some groin with mild hyperpigmentation and some scaling. On the anterior chest there were some erythematous papules. There was no evidence of eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. Symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck are not found; nor is exfoliation, exudation or constant itching of an exposed or extensive area found. The skin manifestations involve between 3 to 20 percent of total body surface area and the condition does not require treatment with intermittent systemic therapy. 3. From April 8, 1997 to August 29, 2009, the Veteran's residuals of leech bites was manifested primarily by lichen simplex chronica of the scrotum and some pruritus, not well controlled as well as hyperpigmentation and evidence of previous lesions on his arms, back, chest, neck, and thighs. There was no evidence of eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. Symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck are not found; nor is exfoliation, exudation or constant itching of an exposed or extensive area found, and less than 5 percent of the entire body is affected and the condition does not require treatment with intermittent systemic therapy. 4. Beginning August 30, 2002 the Veteran's residuals of leech bites has been manifested primarily by eczematous dermatitis with erythema and lichenification overlapped affecting approximately 37 percent of the total body surface area. There is no evidence of eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. Symptoms that produce marked disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or of a paired set of features of the nose, chin, forehead, eyes, ears, cheeks, lips or 2 or 3 characteristics of disfigurement of the face, head or neck are not found; nor is exfoliation, exudation or constant itching of an exposed or extensive area found, and less than 5 percent of the entire body is affected and the condition does not require treatment with intermittent systemic therapy. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to January 31, 1991, for the award of service connection for residuals of leech bites are not met. 38 U.S.C.A. §§ 5110, 5111 (West 2002); 38 C.F.R. §§ 3.31, 3.400, 3.401 (2011). 2. Prior to April 8, 1997 the criteria for an initial disability rating greater than 30 percent for residuals of leech bites were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.7, 4.118, Diagnostic Code (DC) 7899-7806, effective prior to and as of August 30, 2002. 3. From April 8, 1997 to August 30, 2002 the criteria for a disability rating of 30 percent, and no greater, for residuals of leech bites were met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.7, 4.118, DC 7899-7806, effective prior to and as of August 30, 2002. 4. Beginning August 30, 2002 the criteria for a disability rating greater than 30 percent for residuals of leech bites were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.7, 4.118, Diagnostic Code (DC) 7899-7806, effective prior to and as of August 30, 2002. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is seeking entitlement to an effective date earlier than January 23, 1991 for the award of service connection for residuals of leech bites. He also contends that his service-connected residuals of leech bites are more disabling than evaluated prior to April 8, 1997, from April 8, 1997 to August 29, 2002, and beginning August 30, 2002. Factual Background A review of the record shows that the Veteran was treated for multiple granulomatous lesions on his legs as a result of leech bites during his Vietnam service in December 1967. The Veteran submitted an initial claim for service connection for rashes and sores from leech bites in Vietnam in June 1983. At that time the Veteran also submitted VA treatment records dated from January 1980 to May 1983 showing treatment for a fungal type rash, off and on, for the past twelve years in January 1980 and a diagnosis of chronic dermatitis in July 1981. He was afforded a VA examination in January 1984 that showed post-inflammation pigmentation (leech bites history). By rating decision dated in May 1984, the RO denied service connection for a history of leech bites, finding that there was no link between the Veteran's in-service leech bites and his current chronic dermatitis. The Veteran perfected an appeal of the May 1984 rating decision and by decision dated in March 1987 the RO also denied service connection for a skin disorder, claimed as residuals of leech bites, again finding that there was no link between the Veteran's current chronic dermatitis and his in-service leech bites. The Board's March 1987 decision is final. 38 U.S.C.A. § 7104(b). Subsequently, in January 1991 the Veteran filed a new clam for service connection for residuals of leech bites. While the RO initially denied this claim the Veteran again appealed the claim to the Board and, by rating decision dated in December 1999 the RO granted service connection for residuals of leech bites and assigned a 30 percent disability rating effective January 23, 1991, the date of a VA hospital report regarding the Veteran's skin disorder, and assigned a 10 percent disability rating effective April 8, 1997, the date of a VA examination report. As above, in a January 2000 rating decision, the RO determined that the assignment of that date was clearly and unmistakably erroneous, and assigned an effective date of January 31, 1991, the date of receipt of the Veteran's claim to reopen. In an October 2004 rating decision, the RO granted a 30 percent evaluation effective August 30, 2002. Earlier Effective Date Issue The effective date of an award based on a claim for increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C.A. § 5110(a). VA regulations provide that the effective date for increases shall be the "date of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(o)(1). Under this rule, an effective date for an increased rating may be assigned later than the date of receipt of the claim -- if the evidence shows that the increase in disability actually occurred after the claim was filed -- but never earlier than the date of receipt of the claim. The law provides an exception to this general rule: The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2). The regulations provide that the effective date shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if claim is received within one year from such date otherwise, date of receipt of claim. 38 C.F.R. § 3.400(o)(2). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). A claim is "a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit." 38 C.F.R. § 3.1(p). A report of examination or hospitalization which meets certain requirements will be accepted as an informal claim for benefits if the report relates to a disability which may establish entitlement. 38 C.F.R. § 3.157(a). Once a formal claim for compensation has been allowed, receipt of a report of examination or hospitalization by uniformed services will be accepted as an informal claim for increased benefits. 38 C.F.R. § 3.157(a), (b). When the following reports relate to examination or treatment of a disability for which service connection has previously been established, the date of outpatient or hospital examination or the date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of claim and the date of a uniformed service examination which is the basis for granting severance pay to a former member of the Armed Forces on the temporary disability retired list will be accepted as the date of receipt of claim. 38 C.F.R. § 3.157(b)(1). As noted above, a December 1999 rating decision granted service connection for residuals of leech bites and assigned a 30 percent disability rating effective January 23, 1991, the date of a VA hospital report regarding the Veteran's skin disorder, and a 10 percent disability rating effective April 8, 1997, the date of a VA examination report. A subsequent January 2000 rating action amended the effective date of the grant of service connection for residuals of leech bites to January 31, 1991. The Veteran contends that he is entitled to an earlier effective date for the award of service connection. Thus, the question for consideration is whether an award prior to this date is possible. In the present case, the Veteran separated from active service in January 1968. It is not in dispute that he failed to submit a claim of entitlement to service connection for residuals of leech bites within one year from his discharge. Therefore, assignment of an effective date back to the day following discharge is not possible. It is again noted that in a rating decision dated in May 1984, the RO denied service connection for a history of leech bites, finding that there was no link between the Veteran's in-service leech bites and his current skin disorder. The Veteran perfected an appeal of the May 1984 rating decision and by decision dated in March 1987 the RO also denied service connection for a skin disorder, claimed as residuals of leech bites, again finding that there was no link between the Veteran's current skin disorder and his in-service leech bites. The Board's March 1987 decision is final. See 38 U.S.C.A. § 7104(b). The effect of that finality is to preclude an award of an effective date prior that denial. Moreover, the Veteran has not raised a claim of clear and unmistakable error (CUE) such as to challenge the finality of that determination. Based on the foregoing, any effective date awarded in the present case must follow March 1987. Moreover, as previously noted, the appropriate effective date is the date of receipt of claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2). Here, the RO received the Veteran's application for compensation for residuals of a leech bites on January 31, 1991. Thus, that date serves as the date of claim. Although the evidence of record does not reveal an exact date upon which the entitlement arose, the Board notes that such information is not required in order to conclude that the January 31, 1991, date selected by the RO is the earliest possible effective date. The reason for this is that, if the entitlement arose prior to January 31, 1991, then the date of claim would be the later of the two, and hence the correct effective date as provided by 38 C.F.R. § 3.400(b)(2). Any evidence showing that the entitlement occurred after January 31, 1991, would not entitle the Veteran to an earlier effective date. The Board has also considered whether any evidence of record after the last final rating decision in March 1987, but prior to January 31, 1991, could serve as an informal claim in order to entitle the veteran to an earlier effective date. In this regard, any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155. After reviewing the record, the Board concludes that there are no such testimonial documents submitted between March 1987, and January 31, 1991, indicating an intent to reopen a claim of entitlement to service connection for residuals of leech bites. It is further noted that, under 38 C.F.R. § 3.157, a report of examination or hospitalization will be accepted as an informal claim for benefits. However, the provisions of 38 C.F.R. § 3.157 only apply once a formal claim for compensation or pension has been allowed or compensation disallowed because the disability is not compensable. Here, the Veteran's January 1991 claim was not pre-dated by an adjudication of the type cited in 38 C.F.R. § 3.157(b), and, as such, that regulation does not afford a basis for finding that his claim, be it formal or informal, of entitlement to service connection for residuals of leech bites was filed earlier than January 31, 1991. 38 C.F.R. § 3.157; Crawford v. Brown, 5 Vet. App. 33 (1993). In sum, the presently assigned effective date of January 31, 1991, is appropriate and there is no basis for an award of service connection for residuals of leech bites prior to that date. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating Issues Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. A request for an increased rating is to be reviewed in light of the entire relevant medical history. See generally 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The regulations for the evaluation of disabilities of the skin were amended twice during the course of this appeal, first effective August 30, 2002 (67 Fed. Reg. 49590 -49599 (July 31, 2002) and 67 Fed. Reg. 58448 -58449 (Sept. 16, 2002)) and again on September 23, 2008, when VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. The most recent amendments are only effective for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran has not requested such consideration. Accordingly, in this case the Board is required to review both the pre- and post-August 30, 2002, rating criteria to determine the proper evaluation for the Veteran's skin disorder. If it is determined that the new criteria is more favorable, the new criteria may not be applied for the period prior to the revision. See VAOPGCPREC 3-2000 (April 10, 2000). As limited by 38 U.S.C.A. § 5110(g) (West 2002), the effective date of any increase assigned under the amended version of the rating schedule can be no earlier than the effective date of the regulation. Prior to August 30, 2002, skin disorders were rated under 38 C.F.R. § 4.118, Diagnostic Codes (DCs) 7800-7806. Under DC 7806, a 10 percent rating was warranted for eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent rating was provided for eczema with exudation or itching constant, extensive lesions, or marked disfigurement. Eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant warranted a 50 percent rating. 38 C.F.R. § 4.118, DC 7806 (effective prior to August 30, 2002). Scars, other than of the head, face, or neck and which were not the result of burns, were to be rated under DCs 7803 to 7805. Under DC 7803, a 10 percent evaluation was assignable for scars, superficial, poorly nourished, with repeated ulceration. 38 C.F.R. § 4.118, DC 7803 (prior to August 30, 2002). Beginning August 30, 2002, disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of 3 or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 6 or more characteristics of disfigurement will be rated 80 percent. Such disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 4 or 5 characteristics of disfigurement will be rated 50 percent. Such disfigurement with visible or palpable tissue loss and either gross distortion or 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 will be rated 30 percent. Such disfigurement with one characteristic of disfigurement a 10 percent rating will be assigned. Note (1):The 8 characteristics of disfigurement, for purposes of evaluation under 38 C.F.R. § 4.118, are: Scar 5 or more inches (13 or more cm.) in length. Scar 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.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2): Rate tissue loss of the auricle under DC 6207 (loss of auricle) and anatomical loss of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate. Note (3): Take into consideration unretouched color photographs when evaluating under these criteria. 38 C.F.R. § 4.118, DC 7800, effective as of August 30, 2002. Beginning August 30, 2002, dermatitis or eczema with more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period warrants a 60 percent rating. With 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period a 30 percent evaluation will be assigned. With at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period a 10 percent rating will be assigned. With less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period a zero percent rating will be assigned. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, Code 7806, effective as of August 30, 2002. There are three periods of time at issue here: prior to April 8, 1997, when the Veteran's residuals of leech bites was evaluated as 30 percent disabling; from April 8, 1997 to August 30, 2002 when the Veteran's residuals of leech bites was evaluated as 10 percent disabling; and from August 30, 2002 to the present, while the Veteran's residuals of leech bites was evaluated as 30 percent disabling. The Board will consider the proper evaluation to be assigned for all three time periods. See Hart, 21 Vet. App. at 505. 1. Prior to April 8, 1997 Evidence relevant to the severity of the Veteran's residuals of leech bites prior to April 8, 1997 includes a January 1984 VA examination report and VA and private treatment records dated from approximately February 1968 through March 1997. During the January 1984 VA skin examination the Veteran complained of the periodic appearance of a reddish rash and boils around the lower part of the back of his head and neck which caused severe headaches and the loss of head hair in the back; around his fingers which impaired his writing ability; around his hands and elbows which caused slight paralysis in these areas; around his knees, waist, testicles, and pubis area which caused the loss of pubis hair; and around his legs and ankles. On physical examination the examiner noted several coin-sized areas on his right leg that were darker than normal skin. There was also mild darkening at his left hip. The examiner indicated that there was no evidence of a rash on other parts of the Veteran's body as noted in his history. The impression was post-inflammation pigmentation (leech bites history). A February 1968 examination report from Ford Motor Company notes an indication of "skin rash." A January 1980 VA treatment record shows complaints of a fungal type rash, off and on, for the past twelve years. An August 1980 VA treatment record shows an impression of lichenified pruritus of the scrotum, hips, elbows, and lateral lower legs. A September 1980 private treatment record shows an impression of eczema on the flanks, knees, elbow, and ankles. A July 1981 VA treatment record shows an impression of chronic dermatitis and indicates that a biopsy was done. A May 1983 VA treatment record also shows an impression of chronic dermatitis. In January/February 1991 the Veteran was hospitalized twice for skin complaints, first for a period of 9 days and then for a period of 4 days. During the first hospitalization he complained of severe itching, on and off, mostly around the neck, groin, anus, elbows, and hands over the past couple of months and occasionally over the past couple of years. He had not been using any recent medications. He also complained of some area of hair breakage in the area where he scratched. Physical examination showed positive hyperpigmentation with mild erythema and lichenification around the neck and elbows. The groin showed some mild erythema, fine scale, left greater than the right with some positive lichenification of the scrotum. HEENT (head, eye, ear, nose throat) examination was essentially unremarkable. On his scalp there was a small area on the left occipital area with some mild hair breakage, but perfectly normal follicles. He was treated with various medications and discharged with a diagnosis of atopic dermatitis. During the second hospitalization he was readmitted for completion of a tomato and high acid test of his atopic dermatitis. The Veteran complained of some chronic itching of the total body, specifically the legs, neck, arms, and groin over the past approximately 20 years. Skin examination showed hyperpigmented lichenified plaques of his neck, elbows, legs, and some groin with mild hyperpigmentation and some scaling. On the anterior chest there were some erythematous papules. The assessment was atopic dermatitis and mild folliculitis of the chest. After a review of all the evidence with emphasis on the January/February 1991 VA hospitalization reports, the Board finds that, prior to April 8, 1997, the Veteran's skin disorder was manifested primarily by hyperpigmented lichenified plaques of his neck, elbows, legs, and some groin with mild hyperpigmentation and some scaling. On the anterior chest there were some erythematous papules. These symptoms support the assignment of a 30 percent rating for the skin disorder under DC 7806, effective prior to or as of August 30, 2002. As above, to warrant a higher rating under the pre-August 30, 2002 rating criteria for eczema there must be eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. To warrant a higher rating under the post-August 30, 2002 rating criteria for dermatitis or eczema there must be more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. To warrant a higher rating under the post-August 30, 2002 rating criteria for scars there must be disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 4 or 5 characteristics of disfigurement. With regard to the pre-August 30, 2002 rating criteria, there is no evidence of ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. With regard to the post-August 30, 2002 rating criteria, while none of the medical evidence prior to April 8, 1997 indicates the percentage of the body affected the records do not show that the Veteran's skin disorder is productive of sporadic outbursts which are not controlled by constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs. There is also no evidence of characteristics of disfigurement. As such, a disability rating greater than 30 percent for the period prior to April 8, 1997 is not warranted. 2. From April 8, 1997 to August 29, 2002 Evidence relevant to the severity of the Veteran's residuals of leech bites from April 8, 1997 to August 29, 2002 includes an April 1997 VA examination report and VA and private treatment records dated from approximately April 1997 through August 2002. During the April 1997 VA examination the Veteran reported a history of rashes and itching that develops into sores on his neck, hands, groin, eyes, and other areas of his body. Objectively, he had lichen simplex chronica of the scrotum and secondary hyperpigmentation and headed excoriation marks. On history, wool made him itch a little more. His eyes frequently itched. He had no known medical nor did he admit any known food sensitivities. However, his record indicated that he was sensitive to tomatoes and perhaps other foods. He had a diagnosis of atopic dermatitis. He was hospitalized in 1991 at the VA hospital. Subsequent to this time, he was getting treatment for his skin disorder privately. He had one recent visit at a VA facility in 1994 but all other care was reportedly at a private facility. The examiner noted that, upon examination, the Veteran had lichen simplex chronica of the scrotum and some pruritus. Basically, his condition was fairly well controlled on the current medications. He offered an unusual situation in that he indicated that his usual medications did not control his itching, and she he used Lysol spray on his skin which burned but did stop the itching. Thus, the examiner surmised that the Veteran's condition was not well controlled at all. According to the examiner, the Veteran's itching must have been very, very, very severe for him to substitute Lysol for a therapeutic ointment. The examiner noted that the Veteran had some mental deficiencies and depression which probably contributed to inadequate judgment and perhaps not taking the best care of himself. The diagnosis was atopic dermatitis, active. The examiner indicated that the skin disorder was mild at the time of the examination as compared to previous visits to the facility. There was hyperpigmentation and evidence of previous lesions on his arms, back, chest, neck, and thighs. In a May 1998 addendum to the April 1997 VA examination report the examiner noted that the Veteran had a diagnosis of atopic dermatitis, chronic and extensive with post inflammatory hyperpigmentation. Historically, the onset of this disorder was during the Veteran's military service. The specific "trigger" for activation of this disorder was seldom known with certainty. However, according to the examiner if the Veteran related an onset of a skin problems to his leech bites during service, "we must take his word on it." According to the examiner, it certainly could have been this as well as food, detergents, soaps, and other exposures and stress that he encountered during his tour of duty. A March 2000 VA treatment record shows complaints of a rash on both legs, elbow, and left groin along with a 30 year history of sporadic outbursts, more pronounced the past week. Physical examination revealed erythematous plaques in the internal spaces of the right toes as well as well as diffuse xerosis. There were a few deep seated vesicles on the palms. A June 2000 VA treatment record shows a follow-up for pruritus and rash on the groin. Physical examination revealed lichenified plaque and scrotum scalp with erythema. There were no scales or dry skin. After a review of all the evidence with emphasis on the report of the Veteran's April 1997 VA skin examination, the Board finds that, from April 8, 1997 to August 29, 2002, the Veteran's skin disorder was manifested primarily by lichen simplex chronica of the scrotum and some pruritus, not well controlled as well as hyperpigmentation and evidence of previous lesions on his arms, back, chest, neck, and thighs. While the April 1997 VA examination characterized the disorder as "mild" the Board notes that the examiner also alluded to the fact that the Veteran was seen on several occasions for more severe symptomatology. Therefore, giving the Veteran the benefit of the doubt the Board finds that the Veteran's residuals of leech bites continued to meet the requirements for a 30 percent disability rating beginning April 8, 1997. With regard to the possibility of an even higher rating for the Veteran's skin disorder, there is no evidence of ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. Also, while none of medical evidence from April 8, 1997 to August 29, 2002 indicates the percentage of the body affected the records do show that the Veteran's skin disorder is productive of sporadic outbursts which are not controlled by constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs. There is also no evidence of characteristics of disfigurement. As such, a disability rating greater than 30 percent for the period from April 8, 1997 to August 29, 2002 is also not warranted. 3. Beginning August 30, 2002 Evidence relevant to the severity of the Veteran's residuals of leech bites beginning August 30, 2002 includes a July 2003 VA examination report and VA and private treatment records dated from approximately September 2002 to the present. During the July 2003 VA examination the Veteran complained of extreme itching in the groin to the point where he had to stop his history and vigorously scratch his scrotum during the examination. He also had pimples that frequently appeared. The itching interfered with sleep almost every night. He denied photosensitivity. He did complain of occasional pus bumps, and abscessed, but indicated that this was not currently a problem. Physical examination revealed the Veteran's back to be dyschromic with slight lichenification covering approximately eight percent total body surface area, and also three percent covered with lichenification of the inner thighs and the scrotum. The scrotum was quite lichenified. The gluteal cleft was discolored and lichenified and this covered another two percent total body surface area and erythema on the left abdomen, back, and chest with minimal rubbing of the skin, quite prominent erythema was noted. There was no frank urticaria noted. There were two little plaques one and 0.5 centimeters on the left dorsal hand, slightly scaly. There was one pustule on the back on the left shoulder . The base was clear. There was no scarring in this area. The diagnosis was eczematous dermatitis, more prominent on the back. The groin and scrotum showed erythema, easily elicited over the entire trunk area with no frank urtication or rash necessarily associated with this area, though the areas of erythema induced by rubbing and the areas of lichenification overlapped. Total body surface area affected by the rash if the erythema included basically the entire trunk and groin, which was approximately 37 percent of the total body surface area. If just lichenified areas were admitted to as rash the percentage was approximately 13 to 14 percent of the total body surface area, though exposed skin that was affected was quite trivial if the two plaques on the hands were the only manifestation of the rash except for some xerosis on the dorsal hand, which was manifested by palpation, but not visually apparent. The diagnosis was eczematous dermatitis, differential included contact dermatitis, asteatotic dermatitis. The Veteran also had easily elicited erythema from rubbing suggestive of atopic eczema as diagnosed in the early 1990s, but also a possibility of contact urticaria and/or factitial urticaria and plus or minus contact dermatitis were equally possible thereof approximately five one centimeter oval dyschromic, difficult to see scars on the leg and no protuberance, the only abnormality was the hyperpigmentation of the areas that were markedly disfiguring. A May 2004 statement from Dr. C.N.B. relates the Veteran's current skin disorder to his military service and reiterates diagnoses of atopic dermatitis and eczema. A March 2007 VA treatment note indicates that the Veteran was seen for a new rash/cyst. Examination of the low back revealed erythematous plaques with linear excoriations. The impression was xerosis of the arms and legs. He complained of a rash again monthly from November 2009 to February 2010. In December 2009 and January 2010 there were many hyperpigmented macules and papules on the lower extremities, buttocks, waistline, and few hyperpigmented, excoriated nodules. The impression was dermatosis. In February 2010 it was noted that the Veteran was started on Doxycycline, Benzoyl Peroxide, and Pramasone. A diagnosis of folliculitis was given and it was indicated that this affected the Veteran's lower extremities, buttocks, and abdomen. It was noted that the Veteran was to continue on Doxycycline for another 10 weeks, for a total treatment course of 12 weeks. After a review of all the evidence with emphasis on the July 2003 VA examination report, the Board finds that, beginning August 30, 2002, the Veteran's skin disorder was manifested primarily by eczematous dermatitis with erythema and lichenification overlapped affecting approximately 37 percent of the total body surface area. These symptoms support the assignment of a 30 percent rating for the skin disorder under DC 7806, effective prior to or as of August 30, 2002. As above, to warrant a higher rating under the post-August 30, 2002 rating criteria for dermatitis or eczema there must be more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. To warrant a higher rating under the post-August 30, 2002 rating criteria for scars there must be disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 4 or 5 characteristics of disfigurement. With regard to the pre-August 30, 2002 rating criteria, there is no evidence of ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. With regard to the post-August 30, 2002 rating criteria, while the July 2003 VA examination report shows that the Veteran's skin disorder affects 37 percent of his total body surface area, this is less than the 40 percent required for a higher rating. Also, the records do not show that the Veteran's skin disorder is productive of sporadic outbursts which are not controlled by constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs. While the Veteran was notably using Doxycycline for a period of 12 weeks in early 2010, there is no indication of "near-constant" use of this medication or systemic therapy such as corticosteroids or other immunosuppressive drugs. There is also no evidence of characteristics of disfigurement. As such, a disability rating greater than 30 percent for the period beginning August 30, 2002 is not warranted. Statements and testimony from the Veteran are to the effect that he has diffuse skin problems and scarring that warrants the assignment of higher evaluations for his skin disorder for the entire period on appeal. While the objective medical evidence corroborates his statements to the extent that he has diffuse skin problems with scarring, it does not corroborate his assertion that those manifestations support the assignment of a higher rating or the assignment of another separate compensable evaluation for the skin disorder. Extraschedular Consideration As to whether the record raises the matter of referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1), the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology. It appears that the Veteran previously worked as a police officer and retired in 1989, primarily due psychiatric problems. The competent medical evidence of record shows that his skin disorder is primarily manifested by intermittent itching. The applicable diagnostic codes used to rate the Veteran's disability provide for ratings based on such complaints. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Thun v. Peake, 22 Vet. App. 111 (2008). Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Substantially compliant notice was sent in August 2004, July 2005, March 2006, May 2006, October 2006, August 2007, May 2008, February 2009, and September 2009 letters and the claim was readjudicated in a November 2010 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant adequate physical examinations, obtained medical opinions as to the severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. With regard to any outstanding VA treatment records dated prior to 1980 the Board notes that the RO has made several attempts to obtain these alleged treatment records as noted in a September 2009 memorandum. Thus, further attempts to obtain these alleged records would be futile. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. ORDER The claim for assignment of an effective date earlier than January 31, 1991, for the award of service connection for residuals of leech bites is denied. An initial disability rating greater than 30 percent prior to April 8, 1997 for residuals of leech bites is denied. A disability rating of 30 percent, and no greater, from the period between April 8, 1997 to August 29, 2002 for residuals of leech bites is granted. A disability rating greater than 30 percent beginning August 30, 2002 for residuals of leech bites is denied. ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs