Citation Nr: 1307128 Decision Date: 03/01/13 Archive Date: 03/11/13 DOCKET NO. 10-44 175A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to a disability evaluation in excess of 10 percent for tinea barbae (infection of the skin in the facial area). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, his spouse and his daughter ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active service from July 1943 to December 1945. The Veteran was awarded the Purple Heart for his service in World War II. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which in part denied the claim currently on appeal. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in July 2012. A written transcript of this hearing has been prepared and incorporated into the evidence of record. In August 2012 the Board disposed of additional issues previously before it, and remanded the skin disorder claim to the RO for further development. Such has been completed and this matter is returned to the Board for further consideration. In January 2013, additional evidence was submitted by the RO in the form of photographs taken for the VA examination of December 2012. Based on the cumulative nature of each of this additionally submitted piece of evidence, there is no prejudice to the Veteran for the Board to proceed with decisions on the merits of the Veteran's claim without initial AOJ consideration, or without obtaining a waiver of this consideration. 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). FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran's service connected tinea barbae is not shown to be currently active; with currently diagnosed skin disorders affecting the face, head, back, trunk and upper extremities to include, past history of skin cancers, actinic keratosis, seborrehic dermatitis and seborrheic keratosis shown to not be a current manifestation of the tinea barbae. 2. The Veteran's service connected tinea barbae is not shown to result in disfigurement of the head and neck with visible or palpable tissue loss; nor does it result in 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, as set forth above; nor are 20 to 40 percent of either the entire body or exposed areas are affected; nor have systemic therapy such as corticosteroids or other immunosuppressive drugs been required for a total duration of six weeks or more during a 12-month period. CONCLUSION OF LAW The criteria for an evaluation in excess of 10 percent for tinea barbae have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2002); 38 C.F.R. §§ 4.1 , 4.3, 4.7, 4.85, Diagnostic Codes 7800, 7806, 7813, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). For an increased disability rating claim, VA is required to provide the Veteran with generic notice-that is, the type of evidence needed to substantiate the claim. This includes evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In the present case, all necessary notice was provided to the Veteran prior to the initial adjudication of his claim in letters dated December 2008 and January 2009. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) . Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, private treatment records, and VA examination reports. The electronic folder has also been reviewed. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. Also, the Veteran received multiple VA medical examinations in this case, with his most recent examinations taking place in December 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent features of the Veteran's skin disorder. The reports, prepared by a competent medical expert and informed by direct inspection and interview of the Veteran, provide probative medical evidence concerning the features of disability applicable to the rating criteria in this case. The examination reports obtained contains sufficient information to decide the issue on appeal. See Massey v. Brown, 7 Vet.App. 204 (1994). Thus, the Board finds that a further examination is not necessary. For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issue on appeal decided at this time. Analysis-Increased Rating The issue on appeal involves the Veteran's contention that a higher disability rating is warranted for his service-connected skin disorder. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2008); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and 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). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected skin condition of the face (diagnosed as tinea barbae) (also previously diagnosed as impetigo contagiosa chin) is presently rated under Diagnostic Code 7813 for dermatophytosis. This Diagnostic Code provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area (tinea cruris). This Diagnostic Code provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813 (2012). Pertinent to the service connected tinea barbae, this code instructs the rater to rate this condition as disfigurement of the head, face or neck under Diagnostic Code 7800. The Board notes that on September 23, 2008, VA amended certain criteria for evaluating the skin. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). These amendments are only effective for claims filed on or after October 23, 2008, or in cases where the Veteran has requested review under the "new" rating criteria. In the present case, the Veteran's claim was received in November 2008. Thus, the revised rating criteria in effect as of October 23, 2008, are applicable. Under Diagnostic Code 7800 (disfigurement of the head, face or neck) a 10 percent evaluation is warranted for one characteristic of disfigurement. A 30 percent evaluation is warranted for 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. A 50 percent evaluation is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. A 80 percent evaluation is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Note (1) of this section lists the 8 characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118. These are: (1) A scar of 5 or more inches (13 or more centimeters (cm)) in length; (2) A scar of at least one-quarter inch (0.6 cm) wide at widest part; (3) Surface contour of a scar is elevated or depressed on palpation; (4) A scar is adherent to the underlying tissue; (5) The skin is hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm); (6) The skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm); (7) The underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm); (8) The skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm). 38 C.F.R. § 4.118 (2012). Diagnostic Code 7806 provides ratings for dermatitis or eczema. Dermatitis or eczema is to be rated under either the criteria under Diagnostic Code 7806 or to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). Diagnostic Code 7806 provides that dermatitis or eczema that involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period, is rated 0 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). Dermatitis or eczema that involves 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, is rated 10 percent disabling. Id. Dermatitis or eczema that involves 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, is rated 30 percent disabling. Id. Dermatitis or eczema that involves 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, is rated 60 percent disabling. Id. By way of history, service treatment records revealed that the Veteran was treated for a sore (lesion) of the chin including in June 1945, with diagnosis made of impetigo contagiosa in August 1945. No other skin disorder affecting any area other than the chin region was shown in the service treatment records. In a July 1948 rating, service connection for impetigo, contagiosa, chin was granted for outpatient treatment purposes only. In September 1948, service connection was granted for the skin disorder of the face, now classified as tinea barbae, with an initial 10 percent rating assigned. The Veteran filed a claim for increase in November 2008. In December 2008 a report of contact reflects the Veteran as describing he had a skin disorder affecting his scalp, bilateral arms, face, head and neck. The evidence pertinent to this claim includes private treatment records showing treatment for squamous carcinomas of the right lower anterior thigh, right lateral mid hand and right lateral lower back, and basal cell carcinoma of the upper mid back diagnosed and treated in August and September 2008. There are also earlier records from 2001, showing private treatment for skin disorders including multiple actinic keratosis lesions (AK's) of both upper extremities, sebaceous cyst of the chest and skin cancer diagnosed as squamous cell carcinoma of the right mid forearm. An April 2009 letter from the Veteran's private dermatologist stated that he has treated the Veteran for several years. He noted that since World War II, the Veteran has been diagnosed as a fungus type condition of the skin. However this diagnosis was not accurate. It has been proven by biopsy that this condition on exposed areas is actually pre-cancers, skin cancers and severe sun damage. The doctor stated that this condition occurs because of excessive sun damage and taking years to present itself. The report of an April 2009 VA examination revealed the Veteran to report getting a rash on his chin every 1 to 2 years during the summer, treated with different medications prescribed by various dermatologists. He was unsure what the latest treatment was for it. He indicated that his most recent dermatologist biopsied several lesions that were not from the face. The examiner's review of the claims file indicated that lesions of various areas were biopsied and diagnosed as squamous cell carcinoma in various areas of the back and right hand. Nodular basal cell carcinoma was also noted to have been diagnosed in the left center back. Regarding the lesions of his chin he reported they were papular lesions and he was unsure of the treatment medication. He denied using systemic medications to treat them. He was unable to answer whether the cause was bacterial or fungal. He was unable to provide a duration of treatment. However the examiner was informed that he treated it the duration of the summer with an unknown cream within the past 12 months. He also stated that he had a rash on his forearms, head and legs. His wife initially stated he had a rash on his legs but examination revealed no rash on his legs. The examiner noted that the VA examinations of 1948 and 1953 only showed rash involving the face and neckline. The examiner also noted the lack of skin rash on separation examination in 1945 although the Veteran and his wife insisted he had abnormality at that time. Physical examination was negative for rash on the neck, chin or cheek. A few papular lesions were noted on his scalp, with a few scales, and some without. He had multiple papular lesions of irregular size on his trunk that were raised and scaly, and varied in size from 1 to 2 centimeters. He had numerous lentiginous liver spots on his posterior trunk and several follicular eruptions on his posterior trunk, all occupying less than 5 percent of total boy surface and 0 percent of exposed body surface. The lesions of his head occupied less than 1 percent of the exposed and total body surface. He also had bilateral forearm and hand lesions consistent with sun exposure. This was a macular thinning rash with confluent patches on both forearms and a few actinic keratotic lesions on his forearms that were papular in nature, raised with some scales. His AK lesions occupied less than 1 percent of the exposed and total body surface. He had solar elastosis of the forearms and dorsal hands occupying less than 5 percent of the exposed body surface and less than 10 percent of the total body surface. The examiner also noted a big toe fungus with the right toe that would occupy less than 0 percent of the exposed body surface and less than 1 percent of the exposed body surface. The pathology findings of the biopsy done in August 2008 diagnosing the squamous carcinomas of the right thigh, mid hand and right lower back and diagnosing nodular basal cell carcinoma of the mid back were noted in the diagnostic test section. The diagnosis was of no evidence of tinea barbae or impetigos lesion of the face or folliculitis of the face at this time. Also diagnosed was a coincidental finding of AK lesions and solar elastosis occupying less than 5 percent of the exposed body surface and less than 10 percent of the total body surface, consistent with the process of aging and sun exposure. An August 2009 VA primary care record revealed complaints of a "global rash" affecting his head, face, body, and extremities of 60 years duration, which was thought to be fungal but never responded to antifungal treatment. Examination revealed global excoriated skin lesions, with a diagnosis of global rash. He was recommended to see dermatology. VA treatment records from October 2009 include a dermatology consult with a history given of "corporeal rash" since 1943 thought to be fungal and worsened with anxiety. This was said to be of 60 plus years duration, with location on the arms, chest, and face. The dermatology record itself from October 2009 revealed complaints of a suspicious lesion of the right elbow, and history of recurrent fungal infections of the arms. Examination was significant for scaly erythematous papules on the scalp, neck, face, chest, back and arms consistent with AK. The assessment was neoplasm of uncertain behavior of the right elbow and AK. The right elbow lesion was biopsied and diagnosed as keratoacanthoma in October 2009. The report of an April 2010 VA examination for tinea barbae revealed the Veteran to contend that his skin condition worsened and progressed to other areas of his body. He stated that the condition did not affect his arms and chest. Since his last examination of April 2009, the Veteran stated he has not had any treatment of his facial rash, but reported spreading of the rash to other parts of his body. He reported he saw dermatology in October 2009 for a rapid growing lesion on his right elbow diagnosed by biopsy as keratoacantoma. During that visit, the dermatologist also noted scaly lesions consistent with AK on his nose, left ear, scalp, right hand and left arm. He also had scaly plaque on his forearms bilaterally. The examiner noted that the right elbow lesion diagnosed as keratocoacantoma was a benign sun exposure lesion that normally happens in fair skinned elderly people, but it can change into a squamous cell. The Veteran denied having any treatment for tinea or cellulitic lesion on his face at all since the last examination. He has used topical Efudex for 2 weeks of the last year. He had no oral treatment. He used Desonide cream on his forearm twice a week for the past 6 months, totaling 12 treatments a year. This did not affect his activities of daily living or occupational activities. The examiner reviewed the claims file and noted the Veteran had normal skin on separation in December 1945 but has claimed he had the same rash on his forearm since 1945. His August 1948 VA examination was noted to be significant for small reddish papule on his chin area and lip that was somewhat excoriated with no other skin rash abnormality. Examination revealed no rash consistent with tinea on his neck, chin, lip or cheek. His physical examination was essentially unchanged from that done by the same examiner in April 2009 when he was still noted to have a few papular lesions on the face. There were multiple lesions of irregular size on his trunk that were scaly and varied from 1 to 1.5 centimeters. These were raised, dark brown in color and greasy scaly. He had numerous Lentigo liver spots on the posterior trunk and several follicular eruptions on the anterior posterior trunk, all occupying less than 5 percent of total body surface and 0 percent of exposed body surface. He had bilateral forearm and hand rash that was solar elastosis consistent with sun exposure. This was a macular thickening rash with confluent patches on both forearms and dorsal hands. He had a few isolated macular papules on the volar forearm and a few actinic lesions on his forearm that were papular in nature and raised with some scales. His AK lesions occupied less than 1 percent of his exposed body surface and when considering the hands and head, less than 1 percent of the total body surface. The solar elastosis of the forearms and dorsal hands occupied less than 5 percent of the exposed surface and less than 10 percent of the total body surface. He had no lesions or rash on his legs. The diagnoses included no evidence of tinea barbae or impetigo of the face. This affected 0 percent of the body surface, both total and exposed. AK lesions and solar elastosis occupied less than 5 percent of the exposed body surface and less than 10 percent of the total body surface, consistent with the process of aging and sun exposure. The examiner referred to photos taken. The examiner opined that it was less likely than not that the solar elastosis and AK lesions are directly and proximate caused by his service. It is more reflective of the process of aging in a fair skinned person who had a sunburn in early childhood. The examiner opined that the Veteran's service has not caused nor aggravated his solar elastosis and AK of his skin beyond its natural progression. A VA dermatology consult dated in July 2010 revealed a history of lesions of both arms said to be 46 plus years in duration. Examination revealed lesions on the forehead, both temples, and left ear. His chest, neck and back had hyperpigmented macules. Both arms and hands had also had lesions. The assessment was multiple AK's on the arms, face, scalp and chest and seborrheic keratosis of the back. An October 2010 dermatology record gave a history of numerous AK's with significant actinic damage, here for a skin check, with examination showing diffuse actinic damage, especially some hyperkotic lesions on bilaterally dorsal forearms, hands and upper arms. There was also erythema and scaling on the scalp and posterior ear. Numerous brown verrucouse papules were also on the back. The assessment was AK, seborrehic dermatitis and seborrheic keratosis. In February 2011 the dermatology consult continued to reveal AK's that were present in multiple areas, including the scalp, ears, and left and right arms. In addition to the AK's he also had sun damaged skin to the left and right arms. The Veteran was seen for dermatology treatment multiple times in 2012. In March and April 2012 he was seen for essentially the same findings and complaints of a history of keratoacanthoma of the right elbow, and AK's, with examination showing mild erythematoma on the scalp, erythematous scaly papules on both upper extremities, and brown verrucous papules on the back. There was no evidence of recurrence of keratocanthoma of the right elbow. He was assessed with history of keratocanthoma, with no recurrence, severe xerosis, seborrheic dermatitis, seborrheic keratosis, and AK's. He was advised to use sunscreen and wear protective clothing. The March 2012 record included a notation that the Veteran's wife insisted that his actinic damage was caused by a fungus that had been present since he was stationed in the South Pacific many years ago. The dermatologist discussed at length the nature of the Veteran's skin condition as a sun induced pre cancerous condition. In a May 2012 dermatology skin check, he was diagnosed with a neoplasm of uncertain behavior of the left shoulder, in addition to AK's, with scaly erythematous papules shown on the bilateral forearms and left forehead. Biopsy of the left shoulder lesion diagnosed an infundibular keratinous cyst and solar elastosis with no evidence of malignancy. On dermatology skin check in June 2012, he was noted to continue to have many scaling lesions on the arms and head, diagnosed as AK's with planned treatment scheduled for November. He was also noted to have a well healing scar of the left shoulder without signs of recurrence or infection. The VA and private records throughout the pendency of this appeal do not indicate that the Veteran's skin disorder was an active tinea barbae condition. The records do reflect that his treatment included topical treatments such as prescribed ammonium lactate for dry skin and ketoconazole 2% shampoo. The records also reflect that he had multiple treatments for the AK's using cryodestruction to lesions, and surgical removal of the skin cancers diagnosed. The records do not reflect that he received any steroidal medications or active antifungals for the tinea barbae condition, which is not shown to be active. The Veteran's July 2012 hearing testimony alleged that his service connected skin disorder had spread to other parts of his body besides his face, to include both hands. His wife testified that he was prescribed a cream medication to use regularly. The report of a September 2012 VA examination's disability benefits questionnaire (DBQ), revealed the following diagnosed skin conditions. For nonservice connected conditions, the diagnoses included dermatitis or eczema diagnosed as seborrheic dermatitis and keratinazation skin disorder diagnosed as actinic keratosis (AK). The service connected infectious skin condition was noted to be tinea barbae. None of the diagnosed skin conditions were said to cause scarring or disfigurement of the head, face or neck. There were no benign or malignant skin neoplasms. He had no systemic manifestations due to any skin disease. He had treatment with oral or topical medications for the past 12 months for any skin condition, none of which were shown to be corticosteroids, immunosuppressive retinoids, sympathomimetics, or antihistamines. The medications were topical moisturizers only, for seborrhea and AK. No treatment for the tinea barbae was noted as it has been resolved for many years. No other treatments other than the topical medications were noted. No debilitating or non debilitating episodes from any of the following symptoms such as urticaria, primary cutaneous vasculitis, erythema multiforme or toxic epidermal necrolysis was reported within the past 12 months. Physical examination revealed dermatitis affected between 5 and 20 percent of the total body area, but less than 5 percent of the exposed area. Regarding the skin condition affecting these areas, AK and seborrheic dermatitis, hyperpigmented with scabbing were most severe on the dorsum of the hands and forearms, back and sides of the neck. Scattered AK's on the face and scalp were noted. None of these findings were from tinea barbae, nor were they related to tinea barbae. Other pertinent skin findings were noted to be due to age, thinning skin and aspirin therapy. These were multiple eccymotic areas on the forearms with multiple areas of scabbing which add to the unappealing appearance. None the Veteran's skin conditions affected his ability to work. The examiner remarked again that the service connected tinea barbae has likely resolved for several decades. Current skin conditions are unrelated to the service connected skin condition. In December 2012 another VA examination for the skin was conducted with review of the claims file confirmed. He was noted to be retired; with the history obtained from reviewing other examinations indicated he had worked in the automotive and real estate fields. He currently had no complaints and was not sure of the reason for this examination. When told of the purpose of the examination, he began talking about the treatment he was receiving for the skin condition of his arms (blue light treatment) and said he used long sleeves due to embarrassment about how his arms look. When asked about whether he used cream or any other medication for his face, he denied it. Discussion with the Veteran's wife revealed that she was unhappy with the results of the most recent examination because it was mentioned that she had never seen his facial rash, which she said was not accurate. His wife was convinced his arm and forearm issues were an extension of the fungal infection, or as a consequence of sun exposure from those 2 years he spent in active duty. She claimed she spent over a million dollars in skin treatment that she felt the VA should have paid for. Review of the electronic records were noted to reveal a diagnosis of AK made in August 2009 for findings of epidermal atrophy with scarring and erythematous scaly plaques over most of the forearms bilaterally. The 2010 VA examination for tinea barbae infection of the skin in the facial area was noted to have contained the Veteran's contentions that his skin condition had worsened and progressed to other areas of his body. Physical examination revealed no rash noted on the neck and face. Pictures were taken and submitted with the report. There was no diagnosis to support the claim of tinea barbae on the face or neck. His actinic keratosis on his upper arms were not caused by or related to his service connected tinea barbae. This was 2 different entities with 2 different etiologies. AK was not caused by or related to military service; this condition was most likely due to age, genetic makeup (fair skin) and lifelong sun exposure as supported by medical literature. The examiner further discussed that tinea barbae (affecting the beard) primarily affects men who work with animals, and with antifungal treatments the prognosis was excellent. Cosmetic changes may develop if the infection was not treated immediately but many of these were temporary. AK's were noted to be very common, affecting half the global population but was often seen most in fair skinned individuals. Prevalence may vary with geographical location and age. The DBQ accompanying the December 2012 VA examination again noted the diagnosis of tinea barbae diagnosed in 1945 and AK diagnosed in 2008. The history of his complaints and treatment regarding his arms as detailed above was repeated. The rest of the DBQ was generally the same as that reported in September 2012, with the exception that the topical moisturizers used for treatment was said to only be for AK, with no mention made of the seborrhea. The physical examination findings were again recited, with no other pertinent physical findings of skin conditions reported from the DBQ. The examiner did not mark off any percentage of total body or exposed areas of skin affected by any type of skin disorder, but stated that the Veteran did not have any of the listed skin conditions. The examiner commented that there was no diagnosis to support a claim of tinea barbae at this time, citing the findings from the physical examination as a basis for this conclusion. The Veteran's ability to work was said to not be affected by any skin condition. Photographs obtained pursuant to this December 2012 examination were associated with the claims file, but did not show any significant findings that deviated from the conclusions made by the VA examiner in December 2012. The Veteran is currently in receipt of a 10 percent evaluation under Diagnostic Code 7813. Under the provisions of this Diagnostic Code pertinent to this matter, the next highest evaluation, 30 percent, based on scarring/disfigurement of the head and neck would require 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, as set forth above. In this matter, the Board finds that such disfigurement is not shown based on the service connected tinea barbae, as the preponderance of the evidence reflects that this skin disorder has not been active during the pendency of this appeal. This was established not only by the findings and opinions from the September 2012 December 2012 VA examinations, but also by the earlier VA examinations of April 2009 and April 2010, which all found no evidence of an active tinea barbae condition. Where a medical expert has fairly considered all the evidence, his or her opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App.488, 493 (1995). The private dermatologist's letter of April 2009 also indicates that the Veteran's condition is not a tinea barbae condition, but rather is a condition due to sun damage. This statement is supported by the opinion from the VA examiner in September 2012 finding that the diagnosed skin disorders are not related to service, as well as the opinions from the VA examinations in April 2009, April 2010, and December 2012 finding that the AK lesions and solar elastosis diagnosed in the records and examinations are consistent with the process of aging and sun exposure. Likewise the private and VA records showing treatment for skin lesions and rashes are not shown to disclose a diagnosed tinea barbae, but rather other skin conditions. While the Board notes that there are records suggesting the Veteran's current skin condition had been present dating back some 60 years, the Board finds that the opinions stating that the current skin disorders are not related to the service connected tinea barbae to be more probative, based on the rationale provided as well as the evidence which tends to support such conclusions. A bare transcription of lay history is not transformed into medical evidence simply because it was transcribed by a medical professional. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). To the extent that any potentially disfiguring lesions are manifested on the head and neck, they are not shown by the competent medical evidence to be due to a service connected tinea barbae. Moreover, the VA examination reports do not reflect even the non service related skin conditions affecting the face and neck to more closely resemble 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), nor are two or three characteristics of disfigurement shown. Alternately, the Board notes that the potentially applicable criteria Diagnostic Code 7806 (dermatitis or eczema) assigns a higher 30 percent rating if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected or systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during a 12-month period. There is no evidence showing that systemic therapy such as corticosteroids or other immunosuppressive drugs were required for treatment. To the contrary, the evidence reflects that no treatment for the service connected tinea barbae itself was presently used, and the treatments for the other diagnosed skin disorders were not shown to involve systemic therapies. Further, while the Veteran and his wife have provided lay contentions stating that his service connected tinea barbae has spread to involve other areas of the body, including the arms, hands, chest and back, the preponderance of the competent medical evidence establishes that the skin involvements expanding to the arms, hands, chest and back are not related to the service connected tinea barbae, but rather are nonservice connected disorders, with etiologies shown to include sun exposure and age, as discussed above. Under certain circumstances, a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). Competency is a question of fact, which is to be addressed by the Board. Jandreau at 1377. In this case, the specific diagnosed skin condition cannot be determined by the Veteran as a lay person based on an inference, which is based personal observation without having specialized education, training, or experience. See, e.g., Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 Fed. Cir. 1998), cert. denied 119 S. Ct. 404 (1998). Thus while there is involvement of between 5 and 20 percent of the total body area by a dermatitis, as reported in the September 2012 VA examination, the Board finds that such condition is not shown to be related to service, nor an extension of the apparently dormant service connected tinea barbae. Therefore, that a higher evaluation is not warranted on any basis under Diagnostic Code 7806. In light of the above, the Board finds that a preponderance of the evidence is against the claim of entitlement to an increased disability rating for tinea barbae in this case. 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). The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is not inadequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected disabilities but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's skin disorder. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. ORDER Entitlement to a disability evaluation in excess of 10 percent for tinea barbae is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs