Citation Nr: 1237151 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 10-22 600 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a skin disorder. ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran (Appellant or Claimant) served on active duty from June 2000 to October 2000, and from February 2003 to April 2004, with a verified period of Army Reserves Active Duty for Training (ACDUTRA) from February 21, 2006 to March 12, 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran requested a Board hearing to be held via videoconferencing, but subsequently withdrew this request. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. REMAND The Board finds that additional development is required regarding the issue of service connection for a skin disorder prior to Board adjudication. 38 C.F.R. § 19.9 (2011). The Veteran essentially contends that he developed a skin disorder, specifically eczema of the hands, during a confirmed three-week period of ACDUTRA in El Salvador lasting from February 21, 2006 to March 12, 2006. In a May 2010 statement, the Veteran wrote that he experienced itchy red spots on his body during this period of ACDUTRA, but did not seek immediate medical treatment for the disorder because the only medical services available were emergency services. The Veteran stated that since his return from ACDUTRA he has experienced skin disorder symptomatology manifested by cracking and bleeding hands. A March 2002 private treatment record reflects a diagnosis of pityriasis rosea, reported as a rash on the abdomen, back, and armpits. A December 2005 private treatment record reflects complaints of dry rough patches on the cheeks of 3 weeks' duration that was worse in the cold, windy weather, and a diagnosis of eczema. The Veteran served a three-week period of ACDUTRA in El Salvador from February 21, 2006 to March 12, 2006, during which there were no reported complaints or treatment for a skin disorder during this period of service, although the Veteran later reports that he had red spots on his body during this time. A March 20, 2006 post-service private treatment record reflects a diagnosis of eczema, for which the Veteran was using a cream to treat. Post-service VA treatment entry in May 2006 reflects the Veteran's complaint of rash (hives) on the left index finger of a two month duration that is dry and occasionally itches, assessed as tinea corporis. An October 2006 private treatment entry reflects a history of treatment at VA several months ago with prescription of Ketoconazole, with no improvement, and diagnosis of dyshidrotic eczema over the left second digit. Subsequent private treatment entries include a diagnosis of eczema in August 2007 with a history that a dermatitis began following a mission trip to El Salvador, with a five month history of scaling on the left index finger, and a similar dermatitis on the right thumb two months prior; findings of a fine, red, scaling dermatitis of the palmar right thumb and the palmar left index finger; and diagnosis of hand eczema. In July 2008, the RO provided the Veteran with a VA medical examination to assist in determining the nature and etiology of the claimed skin disorder. In the July 2008 VA medical examination report, the Veteran stated that he developed eczema during ACDUTRA in El Salvador. Upon examination, the VA examiner diagnosed eczema of the hands. Having interviewed the Veteran and provided an examination, the VA examiner opined that it was less likely than not that the Veteran's eczema was related to the medication used by the Veteran to treat his service-connected hypertension. In support of this opinion, the VA examiner wrote that hypertension medications did not cause either fungal infections or eczema of the hands. Over the pendency of this appeal, the Veteran has contended that he developed a skin disorder in El Salvador while serving a three-week period of ACDUTRA in 2006. While the July 2008 VA medical examiner rendered an opinion on the question of whether a skin disorder was related to the service-connected hypertension, there is no opinion that addresses the question of whether the eczema diagnosed in March 2006 after ACDUTRA service is related to the three-week ACDUTRA period in El Salvador from February 21, 2006 to March 12, 2006. As part of this remand, the AMC/RO should provide a VA medical (skin disorders) examination with medical opinion request to assist in determining the nature and etiology of the Veteran's skin disorder. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should contact the Veteran and request that he identify specific names, addresses, and approximate dates of treatment for all health care providers who provided treatment for the claimed skin disorder. At a minimum, the AMC/RO should procure any VA treatment records dated after September 21, 2009, the date of the last VA treatment record included in the claims file. 2. After the completion of the above, the AMC/RO should schedule the Veteran for a VA medical (skin disorders) examination to assist in ascertaining the nature and etiology of the skin disorder. The relevant evidence from the claims folder should be provided to the VA examiner and should be reviewed by the VA examiner in connection with the examination. In reviewing the claims file, the VA examiner should note any treatment records indicating treatment for a skin disorder. Specifically, the VA examiner should note the December 2005 private treatment record diagnosis of eczema prior to the period of ACDUTRA, the March 20, 2006 private treatment record diagnosis of eczema after the Veteran's period of ACDUTRA, and all subsequent treatment records indicating treatment for a skin disorder. After an interview of the Veteran, a physical examination, and all tests and studies required, the VA examiner should list all skin disorder diagnoses and offer the following opinions: a. Is it at least as likely as not (50 percent or greater probability) that the Veteran's current skin disorder is related to the Veteran's service is caused by ACDUTRA service from February 21, 2006 to March 12, 2006? In rendering this opinion, please note and discuss the pre-service December 2005 diagnosis of eczema, the Veteran's report of red spots on the body during ACDUTRA service with treatment during service, and post-service diagnoses of eczema on the hands. b. Did the Veteran's current skin disorder preexist the period of ACDUTRA service from February 21, 2006 to March 12, 2006? In rendering this opinion, please note and discuss the pre-service December 2005 diagnosis of eczema. c. If it is your opinion that the skin disorder preexisted service, is it at least as likely as not (50 percent or greater probability) that the preexisting skin disorder was permanently worsened during the period of ACDUTRA from February 21, 2006 to March 12, 2006? If it is your opinion that there was permanent worsening, please indicate the baseline manifestations of a skin disease prior to the period of ACDUTRA service, and state what evidence or findings in the record reflects worsening in severity during ACDUTRA service? d. If it is your opinion that a preexisting skin disorder permanently worsened in severity during service ACDUTRA service (from February 21, 2006 to March 12, 2006), was any worsening beyond a normal progression of the disease during this period? In rendering this opinion, state what the normal progression is likely to be, and indicate what manifestations of skin disorder after service that are beyond the normal progression. The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as it is to find against causation. If the VA examiner finds that the Veteran had a pre-existing skin disorder prior to ACDUTRA, the VA examiner should discuss whether the Veteran's current skin disorder is a continuing manifestation of the same disorder, a new manifestation of a pre-existing skin disorder, or an entirely new skin disorder. A rationale should be provided for any opinion or conclusion expressed. If the VA examiner is unable to provide the requested opinions with what is considered to be a generally accepted degree of medical certainty, i.e., without resorting to speculation, the reasons should be so stated. The VA examiner should in such case explain why it would be speculative to respond. 3. After completion of the foregoing and all other necessary development, the AMC/RO should re-adjudicate the issue of service connection for a skin disorder. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2011). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2011).