Citation Nr: 1302583 Decision Date: 01/23/13 Archive Date: 01/31/13 DOCKET NO. 08-27 304 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a skin disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran had active service from June 1957 to January 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified during a hearing before a Decision Review Officer (DRO) at the RO in May 2008 and before the undersigned Veterans Law Judge during a February 2010 Travel Board hearing. Copies of the transcripts have been associated with the claims file. The Board subsequently remanded this matter for further development in December 2010 and September 2012. That development was completed, and the case was returned to the Board for appellate review. The issue of entitlement to a disability rating in excess of 10 percent for the service-connected anxiety disorder has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder ." Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT A current skin disorder did not have its onset during active service or become manifest within the first post-service year, and the Veteran's current skin disorder is not the result of an event, injury, or disease incurred in active service, to include in-service sun and/or herbicide exposure. CONCLUSION OF LAW A skin disorder was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the 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 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by a letter sent to the Veteran in June 2006 with regard to the claim of entitlement to service connection for a skin disorder. The letter addressed all of the notice elements and was sent prior to the initial unfavorable decision by the RO in September 2006. The duty to assist was also met in this case. All available service treatment records and private treatment records have been obtained and associated with the file. As an initial matter, the Board is cognizant that a full copy of the Veteran's service treatment records from his period of active duty has not been associated with the claims file. VA is required to obtain relevant records held by any Federal department or agency that the claimant adequately identifies and authorizes the Secretary to obtain. 38 U.S.C.A § 5103A(c)(3); 38 C.F.R. § 3.159(e) (2012). In an August 2006 VA Memorandum, the RO detailed its attempts to obtain the service treatment records, concluding that the Veteran's service treatment records were unavailable for review. In making a formal finding regarding the unavailability of these records, the RO noted that all efforts to obtain the information had been exhausted and that any further efforts to obtain the information would be futile. The RO advised the claimant of the unavailability of his service treatment records a July 2006 letter of record. The Board acknowledges that VA has a heightened duty to assist the Veteran in developing his claim since the records may have been lost. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The case law does not, however, lower the legal standard for proving a claim for service connection but, rather, increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. Russo v. Brown, 9 Vet. App. 46, 51 (1996). VA examinations with respect to the issue on appeal were obtained in July 2008 and February 2011. A VA medical opinion was obtained in October 2012. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the October 2012 VA medical opinion obtained in this case is adequate, as it is predicated on a full reading of the Veteran's claims file. It considers all of the pertinent evidence of record and the statements of the Veteran, and the examiner provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). In addition, the Board finds that the October 2012 VA medical opinion substantially complies with the September 2012 remand directive, as the October 2012 VA examiner provided a medical opinion that addressed each of the Board's requested instructions. Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (although under Stegall VA is required to comply with remand orders, substantial compliance, not absolute compliance, is required). For these reasons, the Board finds that VA has fulfilled the duty to assist the Veteran in this case. The available records and medical evidence have been obtained in order to make adequate determinations as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease 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). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Lay evidence can also be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Service connection for certain diseases, such as malignant tumors, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). Section 3.307(d)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(d)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II diabetes or adult-onset diabetes), 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). For purposes of this section, the term "acute and subacute peripheral neuropathy" means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 38 C.F.R. § 3.309(e), Note 2. On August 31, 2010, VA published a final rule amending 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease to the list of diseases associated with exposure to certain herbicide agents. 75 Fed. Reg. 53202. For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42600-42608 (2002). Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Factual Background and Analysis The Veteran asserts he has a current skin disorder that is casually related to in-service sun and/or herbicide exposure. The sole available service treatment record detailed that the Veteran indicated there was no change in his medical condition since his last separation examination. It was noted that no separation physical was taken in January 1979. The Board again observes that despite attempts to locate them, the Veteran's service treatment records have not been obtained. Service personnel records detailed that the Veteran was stationed in the Republic of Vietnam during active service from May 1965 to June 1966 and from June 1970 to June 1971. Post-service private treatment records dated from 2003 to 2008 showed numerous skin findings, to include multiple actinic keratoses and extensive sun damage; lentigos, seborrheic keratoses, and epidermal cyst; inflamed macular seborrheic keratosis with lichenoid reaction; superficial dermal fibrosis consistent with cicatrix of the mid anterior hairline; squamous cell carcinoma in situ arising within an actinic keratosis of the left posterior shoulder and right cheek; squamous cell carcinoma in situ of the left dorsal wrist; pagetoid squamous cell carcinoma in situ of the mid chest; porokeratosis of the left forearm and upper back; and chronic perifolliculitis, solar elastosis, and telangiectasia of the right forehead. Based on the foregoing, the Veteran is presumed to have been exposed to herbicide agents (Agent Orange). However, his current skin disorders are not among the list of diseases enumerated under 38 C.F.R. § 3.309(e). The presumption of service connection for actinic keratoses, squamous cell carcinoma, or any other diagnosed skin disorder due to herbicide is not warranted. Such is by the direction of the Secretary. The Board lacks the power and capacity to find the contrary. However, as noted above, the regulations governing presumptive service connection for Agent Orange do not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (1994). Accordingly, the Board will proceed to evaluate the Veteran's claim under the provisions governing direct service connection, 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303. As the Veteran currently has a skin disorder as noted in the post-service medical evidence of record. Concerning in-service injury, as the Veteran served in Vietnam, his exposure to Agent Orange is presumed. In addition, the Veteran is competent to assert that he was exposed to intense sun while stationed for two tours in Vietnam and at Fort Polk in Louisiana. However, a finding of a nexus or casual relationship between the Veteran's current skin disorders and in-service events is not shown. In this case, findings of any skin disorder were first shown many years after separation from active service and cannot be presumed to have been incurred during service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). In addition, the record contains divergent medical opinions discussing the etiology of the Veteran's current skin disorder. In a May 2008 statement, the Veteran's private physician, S.M.K., M. D., indicated that he recalled treating the Veteran for right foot fracture and hepatitis B as his primary physician during service at MacDill Air Force Base from 1974 to 1976. The physician further noted that since that time, he has treated the Veteran in private practice for rheumatoid arthritis, systemic hypertension, and obstructive sleep apnea. He also opined that the Veteran's pre-cancerous skin lesions which have required continual removal were probably related to his defoliant exposure in Vietnam. The Board acknowledges this favorable medical opinion with respect to the etiology of the Veteran's skin disorder. However, it finds that this private medical opinion is speculative. The use of equivocal language makes a statement by an examiner speculative in nature. The term "probably" could equally be seen to state "probably not." See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Furthermore, the private physician did not provide any rationale for his expressed medical opinion. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). The Veteran was afforded a VA examination in July 2008. The Veteran reported that he had numerous actinic keratoses on sun-exposed areas for years and had cancerous lesions removed in 2008. On physical examination, the examiner described the Veteran as a fair skinned individual with a few scattered actinic keratoses as well as evidence of previously treated actinic keratoses sites and a healing area over the upper sternal region consistent with recent excisional history of a skin lesion. The examiner reviewed the claims file and explained that he could not resolve the issue of the etiology of the Veteran's skin cancer without resort to mere speculation. The examiner noted that the claims file had no documentation of skin cancer. Without some type of report on the lesion, he indicated that any comment about a specific diagnosis or relationship to active duty service would be speculation. Parenthetically, the Board notes that following the July 2008 examination, the Veteran submitted additional medical records which revealed that the Veteran has been consistently treated for recurrent skin lesions, to include squamous carcinoma in the chest and in the left shoulder. However, as the VA examiner did not address the etiology of the skin disorder and the examination was shown to be of limited scope, the Board finds that the July 2008 VA examiner's opinion is void of probative value. In December 2010, the Board remanded this matter for a VA examination with nexus opinion. In pertinent part, the examiner was requested to provide an opinion as to whether any skin disorder is causally or etiologically related to his service in Vietnam or presumed exposure to Agent Orange. In a February 2011 VA skin diseases examination report, the Veteran reported that he had numerous actinic keratoses on sun-exposed areas for years and had lesions and malignant neoplasms removed from multiple areas by excision with good results. He indicated that he was exposed to the sun in two tours in Vietnam and "bathed in a lot of sun for a kid with Swedish heritage". On physical examination, the examiner noted that the Veteran did not have any upper extremity identifiable skin lesions at the current time but observed evidence of previously treated actinic keratosis sites on sun exposed areas. The examiner diagnosed squamous cell carcinoma (SCC) of the right chest wall, left wrist, left posterior shoulder, and right cheek status post excision as well as recurrent actinic keratosis status post liquid nitrogen (LN) treatment. After reviewing the claims file and examining the Veteran, the examiner opined that the Veteran's skin disorder was less likely than not caused by or a result of service. The examiner noted that frequent or intense exposure to ultraviolet (UV) rays, typically from the sun, caused actinic keratosis. It was further noted that actinic keratoses were directly related to cumulative sun exposure and that over 50 percent of fair-skinned people living in sunny climates develop those lesions. He also opined that the Veteran's squamous cell carcinoma was less likely than not caused by or a result of service. It was noted that the Veteran had multiple risk factors for development of squamous cell carcinoma. Risks factors for squamous cell carcinoma were listed as chronic sun exposure, fair skin, older adults, male sex, and positive smoking history. He indicated that the Veteran's sun exposure during his time in service would only be a small portion of time with relation to any sun exposure post service. He commented that the Veteran had lived in Tampa area since 1974, evidence of chronic sun exposure over many years post service. It was further noted that cumulative sun exposure caused mainly squamous cell carcinoma. When discussing a possible etiological relationship to exposure to Agent Orange, the examiner simply stated that the Veteran's diagnosed skin disorders, actinic keratoses and squamous cell carcinoma, were not presumptive conditions related to Agent Orange. The Board finds that the examiner's opinion is inadequate with respect to the question involving a relationship between the Veteran's skin disorders and his exposure to Agent Orange in Vietnam. As noted above, the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The examiner's bare conclusion that the Veteran's skin disorders were not related to Agent Orange exposure as they are not recognized as presumptive conditions under VA regulations greatly reduces the probative value of his medical opinion as to the question involving a relationship between the Veteran's skin disorders and his in-service herbicide exposure in Vietnam. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). In September 2012, the Board again remanded this claim to obtain a clarifying medical opinion. In an October 2012 VA medical opinion, the examiner, a VA physician, noted his review of the claims file. He opined that it was less than 50 percent likely that the Veteran's diagnosed skin conditions had their onset in active service. He highlighted that the Veteran was first diagnosed with squamous cell carcinoma many years after service. He further noted that squamous cell carcinomas often develop from actinic keratoses but that there was no documentation that of actinic keratoses on/near military discharge. The examiner acknowledged that the Veteran did have risk for actinic keratoses and squamous cell carcinoma (fair skin/sun exposure) but that he also had those same risk factors, in addition to older age, when living in the Tampa area for 26 years prior to squamous cell carcinoma. The VA examiner then acknowledged that Veteran's hearing testimony in February 2010 when he asserted that he began to get skin outbreaks during service a couple of years after herbicide exposure in Vietnam. He highlighted that the Veteran's first actinic keratoses and squamous cell carcinoma lesions were found and removed around 2004-2005 about 26 years after service. He then determined that if the lesions referenced by the Veteran in his February 2010 testimony that onset a couple of years after herbicide exposure had been actinic keratoses and squamous cell carcinoma, progression over the ensuing 26 years would have shown more marked progression other than the early squamous cell carcinoma in situ without local spread found around 2004. The VA examiner then opined that it was less than 50 percent likely that the Veteran's skin lesion of squamous cell carcinoma was related to Agent Orange exposure. He cited to medical literature research from the Institute of Medicine that clearly did not associate Agent Orange with basal cell carcinoma, squamous cell carcinoma, or malignant melanoma. Based on the foregoing, the Board concludes that the October 2012 VA physician's findings constitute the most probative (persuasive) evidence on the question of whether the Veteran's present skin disorder onset in and/or was incurred due to events during active service. The VA physician based his opinions on his review of the Veteran's entire claims file, discussed the medical evidence of record as well as the lay assertions of the Veteran, cited to medical literature research, and provided a detailed rationale for his conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board is cognizant that when requested to provide an opinion as to whether any diagnosed skin disorder was related to Agent Orange exposure, the VA examiner opined that it was less than 50 percent likely that the Veteran's skin lesion of squamous cell carcinoma was related to Agent Orange exposure. While it appeared that he focused only on one of the Veteran's diagnosed skin disorders, the Board notes that the examiner specifically indicated that in an earlier section of his opinion that squamous cell carcinomas often develop from actinic keratoses, highlighted that there was no documentation that of actinic keratoses on/near military discharge, and emphasized that the Veteran's first actinic keratoses and squamous cell carcinoma lesions were removed around 2004-2005 about 26 years after service. The Board may appropriately favor the opinion of one competent medical authority over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). In this case, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's present skin disorder was incurred due to events during active service weighs against the claim. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In lay statements of record as well as during his May 2008 and February 2010 hearings, the Veteran has asserted that he contracted skin cancer of the upper truck areas due to his in-service sun and/or herbicide exposure in Vietnam. He reported that his fair skin burned many times during his tours in Vietnam as well as when he was stationed in Louisiana and caused his skin cancer. The Veteran indicated that he started getting skin outbreaks on his hands and arms a couple of years after his exposure to herbicides. The Board acknowledges the Veteran's contentions that his current skin disorder is related to his presumed in-service herbicide and/or sun exposure. Although the Veteran might sincerely believe that his current skin disorder is related to events during service, as a layperson, his statements are not competent evidence of a medical opinion regarding the etiology of his skin disorder. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). The Board also recognizes that service connection may be granted on the basis of continuity of symptomatology. 38 C.F.R. § 3.303(b). Section 3.303(b) provides two alternative methods of establishing service connection: chronicity and continuity of symptomatology. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of postservice continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997); 38 C.F.R. § 3.303(b) (2010). As for the first requirement, notation of a condition during service "need not be reflected in any written document." Savage, 10 Vet. App. at 496-97; 38 C.F.R. § 3.303(b). With regard to the second requirement, lay testimony may be competent to show post service continuity of symptomatology. See Buchanan v. Nicholson, 451 F.3d 1331, 1335-36 (Fed.Cir.2006); see also Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). In this case, the Veteran has stated that he started getting skin outbreaks on his hands and arms during service a couple of years after his exposure to herbicides in Vietnam. The Board recognizes that the Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Furthermore, he can attest to lay-observable symptoms. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, in this case, the Board finds that the Veteran's statements are not credible with respect to the onset of his reported symptoms. Indiana Metal Prods. v. NLRB, 442 F.2d 46, 51-52 (7th Cir. 1971) (citations omitted). In this case, the VA examiner's October 2012 opinion that the Veteran's current skin disorders are not related to those conditions that the Veteran testified to experiencing during active duty "hangs together" in a consistent manner with the other evidence of record and renders it more believable and convincing. Although the Veteran can attest to having skin problems since service, he is not competent to state that these symptoms are his currently diagnosed skin disorder. Indeed, there is no documentary evidence to show that the Veteran received treatment for any disorder until 2003 at the earliest, many after his separation from active duty in 1979. Although he appears to be sincere in his belief as to service connection, in light of these factors, the Veteran's current statements to the effect that he has experienced continuous symptomatology since active service are not deemed to be credible. The absence of documented complaints or treatment for many years following his military discharge is more probative than his current recollection as to symptoms experienced in the distant past. See Curry v. Brown, 7 Vet. App. 59 (1994). Thus, the Board finds that service connection based on continuity of symptomatology is also not warranted. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(b). In light of the cumulative record discussed above, the criteria to establish entitlement to service connection for a skin disorder has not been established, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a skin disorder is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs