Citation Nr: 1310036 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 07-18 707 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for hypertensive vascular disease, to include as secondary to service-connected disabilities. 2. Entitlement to an increased rating for chronic cystic acne vulgaris of the face, chest and back, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from August 1979 to November 1981. These matters come before the Board of Veterans' Appeals (Board) from an August 2005 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Waco, Texas. The Board notes that the Board previously found that the matters came before the Board from a May 2006 rating decision; however, upon further review of the claims file, the Board finds that February 2006 correspondence from the Veteran can be reasonably construed as a notice of disagreement to the August 2005 RO rating decision. In addition, new records were submitted within one year of the August 2005 rating decision. These matters were previously before the Board in October 2010 and April 2012, and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that the RO substantially complied with the mandates of the remands and will proceed to adjudicate the appeal. FINDINGS OF FACT 1. The Veteran is service connected for status post left orchiectomy due to torsion, erectile dysfunction, dysthymic disorder/depression (claimed as depression and anxiety), and chronic cystic acne vulgaris of the face, chest, and back. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has hypertensive vascular disease (hypertension) causally related to, or aggravated by, active service or a service-connected disability. 3. The clinical evidence of record is against a finding that the Veteran has hypertensive vascular disease causally related to, or aggravated by, a service-connected disability. 4. The earliest clinical evidence of hypertension is in 2002, more than twenty years after separation from service. 5. During the rating period on appeal, the Veteran's service-connected chronic cystic acne vulgaris of the face, chest and back, has been manifested by deep acne, with superficial (non deep) scars which are not painful or unstable, and which are without visible or palpable tissue loss, without gross distortion, without asymmetry of facial features, and without limitation of function. CONCLUSIONS OF LAW 1. Hypertensive vascular disease (hypertension) was not incurred in, or aggravated by, active service, nor may it be presumed to have been so incurred or aggravated, nor is it caused by, or aggravated by a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a disability rating in excess of 30 percent for chronic cystic acne vulgaris of the face, chest and back are not met. 38 U.S.C.A. §§1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.350, 4.118, Diagnostic Codes 7800-7805 (prior to October 23, 2008 and from October 23, 2008), and 7828. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in March 2005 and March 2006. The claims were subsequently readjudicated, most recently in a November 2012 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA also has a duty to assist the Veteran in the development of the claims. The claims file contains VA and private medical records, photographs, written articles, and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. The claims file includes a statement from the office of Dr. R.S. that it does not have any records for the Veteran. The Veteran was afforded VA examinations in November 2012. 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 examinations and opinions obtained in this case are adequate, as they are predicated on a review of the Veteran's claims file and clinical examinations. They consider the pertinent evidence of record and provide rationale for the opinions proffered. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the post service symptoms. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013)(the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a)). Hypertension is included in 38 C.F.R. § 3.309(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Rating Disabilities - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, an appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. Rating Acne The Veteran filed a claim for increased rating in February 2005. Under Diagnostic Code (DC) 7828, a noncompensable or zero percent rating is for application for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent evaluation is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. A 30 percent evaluation is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. There is no available schedular evaluation for acne greater than 30 percent. 38 C.F.R. § 4.118, DC 7828. DC 7828 instructs that acne may be rated under alternate codes for disfigurement of the head, face, or neck (DC 7800), or scars (DCs 7801, 7802, 7803, 7804, 7805), depending upon the predominant disability. Rating Scars While the Veteran's claim was pending, new rating criteria for evaluating skin disabilities became effective on October 23, 2008; however, these regulations apply only to claims filed on or after October 23, 2008, or when requested by the Veteran. Although the Veteran did not specifically request review under the revised criteria, he did request a review of his 30 percent disability rating when he appealed the denial of an increased rating. The Board has an obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes his benefits. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008). The revised diagnostic criteria are potentially applicable for purposes of establishing an appropriate rating from October 23, 2008, onward. See Fenderson v. West, 12 Vet. App. 119 (1999). The below diagnostic criteria were in effect prior to October 23, 2008. DC 7800 provides for ratings for scars of the head, face, and neck, or other disfigurement of the head, face, or neck which have characteristics of disfigurement, or visible or palpable tissue loss and either gross distortion or asymmetry of feature(s). The ratings range from 10 percent to 80 percent depending on the number of characteristics of disfigurement or the number of features affected. DC 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that because limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7803 provides a 10 percent rating for superficial unstable scars. Note (1) to DC 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7804 provides a 10 percent rating for superficial scars that are painful on examination. Note (1) to DC 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. DC 7805 provides that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. The following rating criteria are effective October 23, 2008. Under Diagnostic Code 7800 for burn scars or other disfigurement of the head, face, or neck, a 10 percent rating is warranted for one characteristic of disfigurement. A 30 percent rating is warranted for a skin condition with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for a skin condition 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. An 80 percent rating is warranted for a skin condition 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. 38 C.F.R. § 4.118 , Diagnostic Code 7800 (2012). The Diagnostic Code also provides the following notes: Note (2): Tissue loss of the auricle under Diagnostic Code 6207 (loss of auricle) and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), are rated as appropriate. Id. Note (3): When evaluating under these criteria, unretouched color photographs are taken into consideration. Id. Note (4): Separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code. Id. Note (5): The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. Diagnostic Code 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear. Where there is evidence of such a scar area or areas exceeding 6 square inches (39 sq. cm.), a 10 percent evaluation will be assigned. A 20 percent evaluation is warranted where there is evidence of a scar area or areas exceeding 12 square inches (77 sq. cm.). A 30 percent evaluation is warranted where there is evidence of a scar area or areas exceeding 72 square inches (465 sq. cm.). A 40 percent evaluation for area or areas exceeding 144 square inches (929 sq. cm.) is assignable. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2012). Note (1) to Diagnostic Code 7801 defines a deep scar which is one associated with underlying soft tissue damage. Id. Note (2) to Diagnostic Code 7801 provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under 38 C.F.R. § 4.25. Qualifying scars are scars that are nonlinear, deep, and not located on the face, head or neck. Id. Under Diagnostic Code 7802, burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear, and that involve an area of 144 square inches (929 sq. cm.) or greater, warrant a 10 percent rating. Under Note (1) to Diagnostic Code 7802, a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2012). Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an additional evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118 (2012). Under Diagnostic Code 7805, any disabling effects of other scars (including linear scars), and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 not considered in a rating provided under Diagnostic Codes 7800-7804 are to be evaluated under an appropriate Diagnostic Code. 38 C.F.R. § 4.118 (2012). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claim on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Hypertensive vascular disease In a statement dated in February 2005, the Veteran stated that he has high blood pressure and that when he gets anxiety attacks, it feels as if his heart is "going to explode." As noted above, the Veteran separated from active service in November 1981. The Veteran's STRs are negative for any finding of hypertension in service. A review of the evidence of record reflects that the Veteran was not diagnosed with hypertension until more than 20 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). A December 31, 1995 record, 14 years after separation from service, reflects that the Veteran "denies a history of hypertension. He says he can watch his blood pressure at Eckerd's without difficulty. He will call us if it is consistently high." His blood pressure at the time examination was 126/95. There are numerous clinical records in the next five years, which reflect the Veteran's blood pressure readings, but they are negative for a finding of hypertension. A March 2002 private record notes "hypertensive." It was also noted that he had increased cholesterol (dyslipidemia). A September 2004 private record from Dr. S.W. reflects a diagnosis of hypertension, and notes that the Veteran was seen for a follow-up of hypertension. It reflects that the Veteran reported that he had not been taking his medication as he has started working out and wanted to try to not take it. The examiner noted that he discussed with the Veteran the importance of taking his medication on a regular basis. A June 2005 VA examination report reflects that the Veteran reported that he has had "an elevated blood pressure for two years. This is controlled on Fosinopril. He also has had a suspicion of heart disease because of the anxiety attacks, but he has had EKG's and stress tests, which were negative." The impression was "hypertensive vascular disease with marginal control." In a statement dated in February 2006, the Veteran stated that he thought that hypertension is a form of anxiety; therefore, he believes he is entitled to service connection for hypertension. In a statement dated in May 2007, he stated that his loss of a testicle, which is service-connected, caused or directly contributed to his hypertension. The Veteran is service-connected for status post left orchiectomy due to torsion, erectile dysfunction, dysthymic disorder/depression (claimed as depression and anxiety), and chronic cystic acne vulgaris of the face, chest, and back. The Veteran was diagnosed with depression in approximately April 1995. (An October 1995 private record reflects that the Veteran needed a refill on his Zoloft and had been on it for "about six months.") Thus, the record reflects that the Veteran was not diagnosed with hypertension until seven, or more, years after his diagnosis of depression. The record reflects that the Veteran reported that he started having elevated blood pressure while having anxiety/depression. The Board notes that the Veteran has been treated for depression and/or anxiety since approximately April 1995. Thus, his lay contention that he started having elevated blood pressure while having anxiety/depression is of little probative value as to etiology. The diagnosis of depression and the diagnosis of hypertension are seven years apart. There is no clinical evidence of record that merely because the Veteran was diagnosed with a disease, such as hypertension, while having a longstanding diagnosis of a mental disability, that there is an automatic correlation between the two. Initially, the Board finds that the Veteran did not have hypertension in service, or within one year of service. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has hypertension due to active service, or aggravated by active service. In addition, there has been no demonstration by competent medical, nor competent and credible lay, evidence of record that the Veteran has hypertension due to a service-connected disability, or aggravated by a service-connected disability. The claims file includes a May 2012 VA examination report which reflects an extensive opinion and rationale. The examiner opined that it is unlikely that the Veteran's service-connected disabilities have caused or aggravated his hypertension. The examiner noted that according to some medical literature, psychosocial factors have been associated with the occurrence or recurrence of cardiovascular disease (CVD); however the literature did not state that depression had an association with hypertension. He further stated that CVD and hypertension are not the same condition nor are they interchangeable. In addition, the term "association" does not indicate there is a causal relationship. The examiner cited additional literature which stated that the a relationship between hypertension and major depression cannot be ascertained. He noted that the bulk of studies have investigated the possibility of chronic disease causing or increasing the risk of depression. Fewer studies have tried to link depression/anxiety to causing chronic diseases such as hypertension. Therefore, the bulk of medical literature does not provide conclusive evidence that depression/anxiety causes hypertension. The examiner also noted that the Veteran has a 20 pack years smoking history and concurrent hyperlipidemia, and a family history of heart disease (his father has had two myocardial infarctions). (The evidence reflects that the Veteran reported that his father had his first myocardial infarction at age 34, and that the Veteran's brother has hypertension.) (See 1988 VA medical certificate record) The evidence also reflects that the Veteran was smoking as recently as 1998.) The examiner opined that the Veteran's hypertension is consistent with essential hypertension and not as likely as not related to service connected disabilities. The Veteran has not been shown to have the experience, training, or education necessary to render a clinical opinion as to hypertensive vascular disease. The Board finds that the relationship between hypertensive vascular disease and other disabilities, and the etiology of hypertensive vascular disease, is not something which a lay person is compete to provide a probative opinion. Jandreau, 492 F.3d at 1372. Thus, the Veteran's opinion is not probative. In addition, the opinion of the clinician, who has training, experience, and education, is more probative than a lay opinion. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Acne The Veteran is service connected for chronic cystic acne vulgaris of the face, chest and back, with an assigned disability evaluation of 30 percent from April 2003. In a statement dated in February 2005, the Veteran requested an increased rating. As noted above, the maximum scheduler evaluation for acne under DC 7828 is 30 percent, the Veteran's current evaluation. The Board will next consider whether the Veteran is entitled to an evaluation in excess of 30 percent under DCs 7800-7805. An October 2007 VA examination report reflects that the Veteran had acne vulgaris involving the face, neck, ears, the anterior and posterior chest, and the inguinal region with 6 percent involvement of the exposed area, and 10 percent involvement of unexposed areas, with a total of 16 percent of the total body area involved. An April 2011 VA examination report reflects that the Veteran's face had no pustules at present. He had mild scarring on his cheek, which the examiner was unable to measure because the scarring was "spotty scar measuring about a few millimeters in diameter about five to six of them are seen. The total body surface area involved in the face is less than 2 percent. The posterior and anterior chest wall. There are pustules and various stations of development with pitting seen and also shows open and closed comedones. No inflammatory inflammation around it. Areas of depigimentation are seen from prior involvement. Percentage of total body surface area involved in the [chest] and back is about 10 percent. Percentage of exposed body surface area involved is 0 percent." The impression was "acne vulgaris of the face, face and back presently his face lesions have improved after he started treating it with chemical peels and microdermabrasion but his chest and back lesions are still persistent and present." A May 2012 VA examination report reflects that the Veteran uses topical medication (benzoil peroxide) for his acne on a constant/near-constant basis. He was noted to have deep acne. None of the scars of the trunk or extremities were painful or unstable. The scars on the trunk were noted to be superficial non linear. There were 5 scars; 4 of which were each .3 x .3 cm in size, 1 was .5 x .5 cm. The examiner noted too many scars to count on the upper back in an area 20 x 20 cm and lower back area of 20 x 30 cm. The anterior trunk area had approximately 15 cm2 of superficial scars, and the posterior trunk had approximately 45 cm2 of superficial scars. With regard to the face, the record reflects a scar, not disfigurement, on the right cheek to midline jaw area with greater than ten 3-5 mm diameter. It was an indented scar which was 9 x 5 cm at its widest part. He also had a scar, not disfigurement, on the left cheek to midline jaw area with greater than ten 3-5 mm diameter. It was an indented scar which was 9 x 5 cm at its widest part. It was noted that the scars on the face had indentation like pox marks. There was no abnormal pigmentation or texture of the head, face, or neck. There was no gross distortion or asymmetry of the facial features or visible or palpable tissue loss. There was no limitation of function due to the scars. It was noted that the Veteran had some painful cystic acne under some of the scars. The scars did not affect the Veteran's ability to work. The Board finds that a rating in excess of 30 percent is not warranted for any period on appeal under either the prior or revised criteria. DC 7800 does not provide a higher evaluation as the Veteran does not have visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired set of features, or four or five characteristics of disfigurement. DC 7801 does not provide a higher evaluation as it requires that the scars be deep and nonlinear or that cause limited motion. A deep scar is one associated with underlying soft tissue damage, which the Veteran does not have. DC 7802 does not provide a higher evaluation as the maximum evaluation is 10 percent. DC 7803 is applicable for unstable scars, which the Veteran does not have. DC 7804 is applicable for painful scars, which the Veteran does not have. DC 7805 does not provide a higher evaluation as the Veteran's scars do not cause any other disabling effects. In sum, the evidence of record is against a finding that the Veteran is entitled to a rating in excess of 30 percent for any period on appeal. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extra schedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) . The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disability. The Veteran's acne is manifested in pustules, scarring, and a change in pigmentation. The rating criteria consider numerous aspects of acne and scarring, to include pain, stability, size, depth, limitation of motion, and adherence to underlying tissue. Hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to service connection for hypertensive vascular disease, to include as secondary to service-connected disabilities, is denied. Entitlement to an increased rating for chronic cystic acne vulgaris of the face, chest and back, currently evaluated as 30 percent disabling, is denied. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs