Citation Nr: 1300916 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 06-16 907 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a chronic skin disorder, variously diagnosed. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from February 1983 to September 1992. This case originally came before the Board of Veterans' Appeals (Board) on appeal of a December 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, as well as a December 2004 rating decision by the VA RO in New Orleans, Louisiana. The jurisdiction of the file is most recently with the RO in St. Louis, Missouri. In a decision of June 2010, the Board denied entitlement to service connection for a chronic skin disorder, finding that new and material evidence had not been submitted sufficient to reopen the Veteran's previously-denied claims. However, in a September 2011 Order, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's June 2010 decision, and, in so doing, remanded the Veteran's case to the Board for action consistent with an August/September 2011 Joint Motion for Partial Remand. In a subsequent decision of March 2012, the Board found that new and material evidence had, in fact, been submitted sufficient to reopen the Veteran's previously denied claims for service connection for a chronic skin disorder. At that same time, the Board remanded for additional development the issue of entitlement to service connection for a chronic skin disorder on a de novo basis. The case is now, once more, before the Board for appellate review. FINDINGS OF FACT 1. The Veteran's skin disorder, variously diagnosed as keloids, pseudofolliculitis barbae, and acne, clearly and unmistakably preexisted his period of active military service. 2. The Veteran's skin disorder, variously diagnosed as keloids, pseudofolliculitis barbae, and acne, clearly and unmistakably underwent no clinically identifiable permanent increase in severity, including beyond natural progress, during his period of active military service. 3. The Veteran's skin disorder, dermatosis papulosa nigra, is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's period of active military service. CONCLUSIONS OF LAW 1. The Veteran's preexisting skin disorder, variously diagnosed as keloids, pseudofolliculitis barbae, and acne, was not aggravated by active military service. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2011). 2. The Veteran's skin disorder, dermatosis papulosa nigra, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. § 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in June 2003, October 2004, and March 2006 of the information and evidence needed to substantiate and complete his claim, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no pertinent and available evidence suggesting that additional records have yet to be secured, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, which includes his multiple contentions, as well as service treatment records, and both VA (including Virtual VA) treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000), and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection The Veteran in this case seeks service connection for a chronic skin disorder. In pertinent part, it is contended that the Veteran's skin disorder, which admittedly preexisted his period of active military service, underwent an increase in severity during that period of active military service. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may also be granted for any disease initially diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (2011). In order to establish service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). Alternatively, service connection may be awarded for a "chronic" condition when: (1) a chronic disease or disability manifests itself and is identified as such in service (or within the presumptive period under 38 C.F.R. § 3.307) and the Veteran currently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period) but is not identified until later, there is a showing of continuity of symptomatology after discharge, and the medical evidence relates that symptomatology to the Veteran's present condition. See Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2011). Pursuant to applicable law and regulation, every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). Only such conditions as are recorded in examination reports are considered as "noted." 38 C.F.R. § 3.304(b) (2011). A preexisting injury or disease will be considered to have been aggravated during active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable (obvious or manifest) evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all of the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2011). A review of the Veteran's service treatment records discloses that, at his service entrance examination in November 1982, the Veteran denied any problems with skin diseases. A physical examination conducted at that time was negative for the presence of any skin disorder, and no pertinent diagnosis was noted. Service treatment records, it is acknowledged, show rather extensive treatment for various skin disorders, including keloids, acne, and pseudofolliculitis barbae. However, during the course of outpatient treatment in March 1983, shortly following the Veteran's entry upon active service, it was noted that the Veteran had been experiencing skin problems for approximately one year, placing the origin of such problems at a point in time prior to the Veteran's entry upon active service. Significantly, while at the time of a subsequent VA dermatologic examination in September 1993, there was noted the presence of cystic acne on the Veteran's trunk and face, as well as a number of keloid formations in certain areas, no opinion was offered as to the relationship, if any, between those problems and the Veteran's period of active military service. VA outpatient records dated subsequent to that time, while showing ongoing treatment for acne and keloids, once again failed to demonstrate any relationship between such problems and the Veteran's active military service. The Board observes that, at the time of a more recent VA dermatologic examination in March 2012, which examination, it should be noted, involved a full review of the Veteran's claims folder, there was noted a history of acne and pseudofolliculitis barbae, both diagnosed in 1982, as well as dermatosis papulosa nigra, diagnosed in 2011. When questioned, the Veteran indicated that his acne and pseudofolliculitis barbae had begun while on active military service, at which time he was reportedly placed on a permanent shaving profile. According to the Veteran, despite these measures, shaving, wearing nuclear/biological/chemical warfare gear, and a gas mask and camouflage make-up during training worsened his acne and pseudofolliculitis barbae by causing him to sweat and itch. In the opinion of the Veteran, this "sweating and itching" led to scratching and subsequent keloid formation. On physical examination, there were noted two to three small macular lesions, with no cysts or pustules, no cellulitis, and no evidence of active cystic acne. The Veteran's pseudofolliculitis barbae was described as inactive, with no evidence of any ingrown hairs. Further examination revealed three to four small acne scars on the Veteran's nose and cheeks, all of which were less than 0.5 centimeters in diameter. Further examination revealed keloid scars on the anterior chest and back, as well as dermatosis papulosa nigra characterized by multiple small, hyperpigmented, flat and slightly raised lesions across the Veteran's upper back and face. Significantly, at the time of examination, there was no evidence of any associated inflammation or cellulitis. In the opinion of the examiner, the Veteran's acne and pseudofolliculitis barbae were preexisting conditions, which had been controlled with medication, and which were neither incurred in nor worsened beyond natural progression by military service. The Veteran's dermatosis papulosa nigra was less likely than not incurred in or caused by any claimed inservice injury, event, or illness. This was particularly the case given that the Veteran had developed dermatosis papulosa nigra involving his face and upper back following his discharge from military service. According to the examiner, papulosa nigra was a formal medical term for a benign skin condition which was not caused by or related to acne, pseudofolliculitis barbae, or keloid scars. Rather, it was a common condition which occurred in individuals who did not have acne, pseudofolliculitis barbae, or keloid scars, and was benign, requiring no treatment. The examiner further indicated that the Veteran's acne, pseudofolliculitis barbae, and keloid scars clearly and unmistakably existed prior to his entry upon active military service, and were clearly and unmistakably not aggravated beyond their natural progression by any inservice injury, event, or illness. Additionally noted was an ingrown hair on the Veteran's face. According to the examiner, the Veteran's skin condition had existed prior to his enlistment in February 1983. Significantly, when seen in the dermatology clinic in April 1983, pseudofolliculitis barbae with keloid scars was in evidence. The Veteran was subsequently placed on a shaving profile, which was described as permanent. Moreover, throughout his military career, the Veteran was not required to shave. Rather, he only trimmed his facial hair with scissors. Following review of the Veteran's claims folder, there was no documentation that military activities had exacerbated the Veteran's condition, which was considered congenital, and not incurred in or worsened beyond natural progress during military service. According to the examiner, the Veteran's acne, pseudofolliculitis barbae, and keloid scars were stable and unchanged, without objective findings of exacerbation or aggravation beyond natural progress. On subsequent scar examination, it was noted that the Veteran's keloid scars and acne had been diagnosed in 1982 (prior to his entry upon active military service). Further noted was that, according to the Veteran, his keloid scars had developed while on active military service. According to the Veteran, he had undergone no surgical procedures for removal of his keloids. However, he had received Kenalog injections for his keloid scars in the past. Following examination, it was the opinion of the examiner that the Veteran's keloid scars represented a preexisting condition which was controlled with medication, and neither incurred in nor worsened beyond natural progress by military service. The examiner additionally indicated that the Veteran's superficial scars as a result of acne represented a preexisting condition, which was likewise neither incurred in nor worsened beyond natural progression by military service. As noted above, a Veteran is to be taken as in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by such service. See 38 U.S.C.A. § 1111 (West 2002). Given the Veteran's normal service entrance examination, the "presumption of soundness" at service entrance clearly attaches. However, subsequent pertinent evidence of record is to the effect that, with the exception of the Veteran's dermatosis papulosa nigra, his skin disorders clearly and unmistakably preexisted his entry upon active military service. Moreover, there is no persuasive evidence that the Veteran's preexisting acne, pseudofolliculitis barbae, or keloids underwent a clinically-identifiable permanent increase in severity beyond natural progress during his period of active military service. Nor is there persuasive evidence that the Veteran's dermatosis papulosa nigra, first persuasively documented many years following service discharge, had its origin during, or is in any way the result of, an incident or incidents of that same period of active service. In fact, the Board finds the aforementioned opinion of a VA dermatologist highly probative, because that opinion was based upon a review of the Veteran's entire claims folder, as well as other pertinent medical records, and a full examination, including both history and clinical findings. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file, and the thoroughness and detail of the opinion). The VA dermatologist reviewed the Veteran's claims folder, discussed the Veteran's medical history, provided well-reasoned medical opinions, and alluded to the evidence which supported those opinions. See Hernandez-Toyens v. West, supra. Under the circumstances, the Board is of the opinion that the probative medical evidence of record fails to establish that the Veteran suffers from a chronic skin disorder related to his period of active military service. In evaluating the Veteran's claim, the Board has a duty to assess the credibility and weight to be given to the evidence of record. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). In that regard, the Veteran has attributed his current skin problems to his period of active military service. However, and as noted above, there is no persuasive evidence that the Veteran's keloids, pseudofolliculitis barbae, or acne underwent a permanent increase in severity beyond natural progress during his period of active military service. Nor is there evidence that the Veteran's dermatosis papulosa nigra, first shown many years following service discharge, is in any way the result of an incident or incidents of his active military service. Significantly, the passage of many years between discharge from service and medical documentation of a claimed disability is a factor which tends to weigh against a claim for service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). More importantly, in the case of dermatosis papulosa nigra, for service connection to be established by continuity of symptomatology, there must be medical evidence which relates the current condition to that symptomatology. See Savage, supra. In this case, there is no medical evidence suggesting a link between the Veteran's dermatosis papulosa nigra and his period of active military service. The Veteran argues that his dermatosis papulosa nigra had its origin during his period of active military service, and that his keloids, pseudofolliculitis barbae, and acne, while preexisting service, underwent aggravation during his period of active military service. However, the Board rejects those assertions to the extent that the Veteran seeks to establish such inservice incurrence or aggravation. The Veteran's statements and history, it should be noted, when weighed against the other objective evidence of record, are neither credible nor of particular probative value. Moreover, the aforementioned unrefuted medical opinions clearly indicate that the Veteran's preexisting keloids, pseudofolliculitis barbae, and acne did not, in fact, undergo aggravation during active service, and that his dermatosis papulosa nigra has no relationship to that service. Significantly, the Veteran, as a layperson, is not competent to provide medical evidence sufficient to establish the presence of inservice incurrence or aggravation. Rather, evidence which requires medical knowledge must be provided by someone qualified as an expert by knowledge, skill, experience, training, or education, none of which the Veteran possesses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the aforementioned, the Board is unable to reasonably associate the Veteran's dermatosis papulosa nigra, first persuasively documented many years following service discharge, with any incident or incidents of his period of active military service. Moreover, the evidence clearly and unmistakably shows that the Veteran's preexisting keloids, pseudofolliculitis barbae, and acne did not undergo a clinically identifiable permanent increase in severity beyond natural progress during his period of active military service. Accordingly, the preponderance of the evidence is against the Veteran's claim, and service connection for a chronic skin disorder must be denied. ORDER Entitlement to service connection for a chronic skin disorder, variously diagnosed, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs