Citation Nr: 1313894 Decision Date: 04/25/13 Archive Date: 05/03/13 DOCKET NO. 11-25 867 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging. 2. Entitlement to service connection for anemia. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from January 1942 to December 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied, in pertinent part, the Veteran's claims of service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging (which was characterized as burn to both arms, scars) and for anemia. Having reviewed the evidence of record concerning the Veteran's service connection claim for a skin disorder of both arms, the Board finds that this issue is characterized more appropriately as stated on the title page of this decision. In January 2013, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the RO/AMC obtain updated treatment records for the Veteran and schedule him for examinations to determine the nature and etiology of his claimed disabilities. Additional treatment records have been associated with the claims file. The requested examinations were held in February 2013. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to service connection for a gastrointestinal disability (previously claimed as a spastic stomach) has been raised by the record but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran filed this claim in statements on his September 2011 substantive appeal (VA Form 9). This claim previously was referred to the RO in the Board's January 2013 remand. To date, however, the RO has not taken any action on this claim. Therefore, the Board does not have jurisdiction over this claim and it is referred again to the AOJ for appropriate action. 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 record evidence shows that the Veteran's residuals of a skin disorder of both arms are not related to active service or any incident of service. 2. The record evidence shows that the Veteran's anemia is not related to active service or any incident of service. CONCLUSIONS OF LAW 1. A skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Anemia was not incurred in or aggravated by active service nor may primary anemia be presumed to have been incurred during service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in July and November 2010, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claims. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As will be explained below in greater detail, the evidence does not support granting service connection for residuals of a skin disorder of both arms or for anemia. Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the July and November 2010 VCAA notice letters were issued prior to the currently appealed rating decision issued in May 2011; thus, this notice was timely. Because the Veteran's claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. Information obtained from SSA via SHARE in February and March 2012 shows that the Veteran is not receiving SSA disability benefits. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the Veteran shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the Veteran has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the Veteran's active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran also has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service. Id. Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims The Veteran contends that he incurred a skin disorder on both arms during active service and experienced continuous disability due to residuals of a skin disorder on both arms since service. He specifically contends that in-service blisters on both arms led to his current residuals of a skin disorder (diagnosed as purpura of aging following VA examination in February 2013). He also contends that he incurred anemia during active service. He specifically contends that a low red blood cell count and hemoglobin level recorded during active service demonstrated the presence of anemia which he experienced continuously since his service separation. Law and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including primary anemia, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claim in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). Because a skin disorder of both arms is not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to this claim. By contrast, because primary anemia is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's service connection claim for anemia. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background The Veteran's service treatment records show that, on enlistment physical examination in January 1942, clinical evaluation of his skin was normal. On outpatient treatment on January 14, 1943, the Veteran reported experiencing an "[e]ruption on right foot of two weeks duration. This was followed by a spread to hands and arms then to left foot. No itching." Physical examination showed a temperature of 98.4 degrees and a vesicle-pustular eruption of a weeping nature of both feet, and vesicular-papular lesions on both hands and arms which had spread and become very noticeable "in [the] past two days." The impression was fungus infection of the skin (arms and feet). The Veteran was transferred to a U.S. Navy hospital for further treatment. The Veteran was hospitalized at a U.S. Navy hospital from January 14, 1943, to February 19, 1943, for complaints of rash and itching of the feet and arms. On admission, he reported that this rash "started about one month ago on the top of the right foot as small pustules that broke and spread. Later it appeared on the left foot. About 2 weeks ago [he] developed a red raised [rash] on the back of the right hand that spread to the left hand and up the arms. Lesions do not itch much. No previous attacks." Physical examination showed a normal temperature, "a red raised rash with small blisters on both hands and forearms to the elbows. On the dorsal surface of both feet and between the toes are numerous pustules and an [inflamed] area where the pustules have ruptured." Laboratory results showed a red blood count of 4.3 million and a hemoglobin of 12 grams. The impression was fungus infection of skin (feet and arms). On January 18, 1943, the Veteran's lesions were improving. On January 23, 1943, the Veteran's lesions of the feet were "very much improved" and his hand was "improving slowly." On January 28, 1943, the Veteran's feet were "almost well. Hands very much improved." On February 18, 1943, the Veteran's lesions were "all healed. He is clinically well." The Veteran was discharged to duty on February 19, 1943. On outpatient treatment aboard a U.S. Navy ship on November 17, 1944, the Veteran complained of itching and swelling of his hands. The Veteran's prior hospitalization in January 1943 was noted. It also was noted that he had "[r]eported aboard ship for duty yesterday with infection already well spread over entire surface of right hand. Gave history of 4 days duration; treated aboard U.S.S. ANTEAUS" with Merthiolate. Physical examination showed a swollen right hand "with many weeping vesicules," a left hand that was "not swollen, but inflamed and covered with small blisters," a normal temperature, and no secondary infection. The diagnosis was a fungus infection of the skin of the right and left hands. This condition was "[m]uch worse" on November 13, 1944. Although it was "slightly improved, but [Veteran] is not responding well to treatment" on November 19, 1944. The Veteran was transferred to a U.S. Navy hospital for further treatment. The Veteran was hospitalized at a U.S. Navy hospital from November 19, 1944, to January 3, 1945 for complaints of swollen and itching hands. He reported "swelling of hands accompanied by scaling weeping lesions for [the] past six days. Also had lesions on his feet. The areas on the hand have spread up the arms and become locally worse under treatment." The Veteran's prior hospitalization in January 1943 was noted. Physical examination on admission on November 19, 1944, showed dirty skin, eczematoid lesions on the hands, arms, and feet, a few "small, scaling lesions" on the feet and ankles, "greatly swollen" hands with "excoriated, red, weeping areas varying in size," and discrete "papular eruptions...scattered over the arms as high as the axilla." Laboratory reports showed a red blood count of 5.0 and hemoglobin was 13 grams. The impression was a fungus infection of the skin with intradermal reaction. On November 22, 1944, the diagnosis was changed to fungus infection of the skin, hands, and feet. This diagnosis did not exist prior to service. On November 29, 1944, the Veteran's lesions were responding to treatment "except for one small area on right hand which continues to weep." On December 6, 1944, the Veteran's "[r]ight hand [was] still refractory to treatment." On December 20, 1944, the Veteran's "[r]ight hand [was] responding to applications of Barbasol." The Veteran was transferred to a different hospital ward on December 22, 1944, in satisfactory condition. He was found fit for duty and discharged to duty on January 3, 1945. On separation physical examination in December 1945, clinical evaluation of the Veteran's skin was normal. No relevant defects were noted. The post-service evidence shows that, on private outpatient treatment in September 1996, the Veteran's complaints included "feeling real tired." The impressions included anemia, probably iron deficient. Private laboratory results dated between 2004 and 2005 repeatedly show low hemoglobin level and low red blood cell counts. On January 3, 2005, the Veteran complained that "he is feeling kind of weak and played out and tired." It was noted that the Veteran's ferritin (or iron) level was "staying slightly lower at 24." The impressions included iron deficiency anemia. The Veteran was admitted to a private hospital via the emergency room on January 11, 2005, for complaints of abdominal pain. It was noted that the Veteran's abdominal pain had begun when "he was noted to be anemic" and started taking iron supplements. "He seemed to do well with this initially until it started irritating his stomach, therefore he had to stop." Physical examination showed a temperature of 96.8 degrees, "skin is hot to touch," and warm and dry extremities. Laboratory results showed hemoglobin of 11.6. The impressions included a history of anemia. On private gastroenterology consult while hospitalized on January 12, 2005, the Veteran's complaints included "feeling weak [but] he was otherwise doing well." A history of anemia was noted. Physical examination showed an afebrile temperature and no obvious skin rashes. The impressions included anemia. On private outpatient treatment on January 17, 2005, the Veteran's complaints included anemia. Physical examination was unremarkable. The impressions included anemia with a question of whether it was "secondary to hemorrhagic gastritis/colonic" arteriovenous malformations (AVMs) and rule-out small bowel AVMs. Private laboratory results dated on July 6, 2009, showed red blood cell count of 3.9 which was low and hemoglobin level of 10.1 which also was low. The Veteran was hospitalized at a private facility from July 20-22, 2009, for elective lumbar spine surgery. A review of the "Discharge Summary" for this hospitalization indicated that the Veteran "did require blood transfusion perioperatively as he has a baseline anemia and then on top of it the postsurgical anemia. His hemoglobin at discharge is baseline." The diagnoses included acute blood loss anemia and chronic baseline anemia. On private gastrointestinal consult in October 2009, the Veteran complained of fatigue and weakness. It was noted that the Veteran's hemoglobin level had dropped from 11.0 the day before the consult to 9.2. A history of iron deficiency anemia was noted. Physical examination showed a temperature of 98.5 degrees and warm and dry skin. Laboratory results showed hemoglobin of 9.2 The impressions included anemia. On private outpatient treatment in November 2009, no relevant complaints were noted. The Veteran was taking iron pills twice daily. Laboratory results showed hemoglobin level of 11.1 and his ferritin (or iron) level of 62. The assessment included anemia. Private laboratory results dated in 2009 and 2010 and between 2010 and 2013 repeatedly show low hemoglobin level, low red blood cell counts, and low iron level. On VA outpatient treatment in June 2010, a longstanding history of anemia "which is due to poor absorption of iron" was noted. It also was noted that the Veteran "continues to be on iron replacement." Laboratory results showed a red blood cell count of 3.32, which was low, and a hemoglobin level of 30.4, which also was low. Physical examination showed his skin was within normal limits. The assessment included normocytic anemia secondary to iron deficiency. In a November 2010 statement, the Veteran's daughter contended that her father experienced daily anemia and constipation or diarrhea due to taking iron supplements for his anemia. On VA skin diseases Disability Benefits Questionnaire (DBQ) in February 2013, the Veteran's complaints included "very thin" skin on his arms which bruised easily. The Veteran's daughter, who accompanied him to the examination, stated that his arms had been this way "for years." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported that he first experienced a skin disability during active service when "my skin got contaminated...little blisters swelling." He also reported that his skin healed with in-service treatment although "his skin was sensitive after the events in service." The Veteran did not experience "any recurrence of the blistering or the sloughing that had occurred in service. He denies any medical treatments for his skin after service." Physical examination showed no benign or malignant skin neoplasms, no scarring or disfigurement of the head, face, or neck, no debilitating episodes of or treatment for any skin problems in the previous 12 months, no visible skin conditions, the skin over the dorsal forearms bilaterally "is thin and smooth with loss of elasticity," some hyperpigmentation consistent with hemosiderin deposition "from prior bruising/purpura," the skin "appears thin like paper, but is currently intact," and this thin skin covered less than 5 percent of the total skin and less than 5 percent of the exposed skin. The VA examiner opined that the Veteran's purpura of aging was less likely than not causally or etiologically related to the Veteran's in-service skin disability. The rationale for this opinion was medical literature review, medical record review, and clinical experience. The VA examiner stated that he had considered Dalton v. Nicholson, 21 Vet. App. 23 (2007) "in arriving at this opinion." This examiner noted that the Veteran's skin had been normal at his separation physical examination and when seen by VA beginning in 2010. He also noted that the Veteran's current skin examination "shows findings commonly found in the elderly. These findings are generally considered 'NORMAL' for a gentleman this age." He noted further that "skin changes that lead to purpura of aging generally begin after age forty-twenty years after service for this Veteran." The diagnoses were acute dermatitis with infection in 1943 which was resolved with no residuals and purpura of aging which had lasted for years "per Veteran." On VA neurologic and lymphatic conditions, including leukemia, DBQ in February 2013, the Veteran's complaints included fatigue due to anemia. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's daughter reported that he had experienced anemia for approximately 15-20 years. The Veteran "does not recall having a diagnosis OR symptoms of anemia in service" although he had been told of a borderline/slightly low hemoglobin value "after his service records were reviewed several years ago." He also stated, "I had plenty of energy up until I was 70 years old." A history of 2 blood transfusions and a hemoglobin level which fluctuated between 9-11 in recent years was noted along with a reaction to iron infusion in the past. Continuous iron therapy was required for control of the Veteran's anemia which was active but was not caused by treatment for another hematologic or lymphatic condition. The Veteran's easy fatigability was multi-factorial and began at approximately age 70. Laboratory results taken in May 2012 showed a low red blood cell count and low hemoglobin level. The VA examiner opined that the Veteran's anemia was not causally or etiologically related to active service or any incident of service, to include the in-service low red blood cell count and hemoglobin level. The rationale was medical literature review, medical record review, and clinical experience. This examiner stated that he had considered Dalton v. Nicholson, 21 Vet. App. 23 (2007) "in arriving at this opinion." He noted that the Veteran's complete blood count "during service was drawn during an acute illness. The borderline to slightly low [red blood cell count] and [hemoglobin] values at that time most likely reflected the presence of that acute NON-HEMATOLOGIC illness, and were NOT an indication of a hematological disorder or onset of a chronic anemia condition." This examiner also noted that the Veteran denied any post-service symptoms or diagnosis of anemia. He noted further that the Veteran's current anemia onset had been within the previous 20 years and was due to iron deficiency and chronic renal insufficiency, both of which occurred more than 40 years after service separation and were not related to service, to include the in-service low red blood cell count and hemoglobin levels. The diagnosis was anemia. Analysis The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging. The Veteran contends that he incurred a skin disorder during active service (which he characterized as burn scars or blisters of the arms) which caused or contributed to his current residuals of a skin disorder. The Board acknowledges initially that the Veteran's available service treatment records support his assertions regarding in-service incurrence of a skin disorder of both arms as he received in-patient and outpatient treatment for a variety of skin problems on both arms during service. The competent evidence does not support the Veteran's assertions regarding an etiological link between his current residuals of a skin disorder of both arms and active service, however. As the VA examiner essentially determined in February 2013, the Veteran's in-service skin problems were acute, transitory, and resolved with treatment. The post-service evidence also does not support granting service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging. The Veteran has contended in lay statements submitted to VA that he experienced residuals of a skin disorder of both arms continuously since his service separation. As noted above, because a skin disorder of both arms is not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to this claim. See Walker, 708 F.3d at 1331; see also 38 C.F.R. § 3.309(a). The post-service evidence shows instead that the Veteran's current residuals of a skin disorder of both arms (which was diagnosed as purpura of aging) are not related to active service or any incident of service, to include as due to his in-service skin problems. The Board finds it significant that, when examined by VA in February 2013, the Veteran specifically denied receiving any post-service treatment for skin problems following resolution of his in-service skin infection during service. The February 2013 VA examiner concluded that the Veteran's in-service skin problems (which he diagnosed as acute dermatitis with infection) had resolved and were not manifested by any current residuals. This examiner also concluded that the Veteran's current residuals of a skin disorder of both arms (which he diagnosed as purpura of aging) were not related to active service or any incident of service, to include the acute dermatitis with infection which had resolved during active service, and were found commonly among the elderly and were considered normal for someone of the Veteran's age. There is no competent contrary opinion of record. The Veteran also has not identified or submitted any competent evidence, to include a medical nexus, supporting a link between his residuals of a skin disorder of both arms and active service or any incident of service. In summary, the Board finds that service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging, is not warranted. The Board also finds that the preponderance of the evidence is against the Veteran's claim of service connection for anemia. The Veteran has contended that he incurred anemia during active service. The competent evidence does not support his assertions concerning in-service incurrence or continuity of symptomatology since service for anemia, however. The Board acknowledges that the record evidence (in this case, the Veteran's available service treatment records) shows a low red blood cell count and hemoglobin level during active service; however, no diagnosis of anemia was rendered during the Veteran's active service. There also are no complaints of or treatment for anemia in the Veteran's available service treatment records, although the Board recognizes that the absence of contemporaneous service treatment records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). Critically, the VA examiner concluded in February 2013 that the Veteran's in-service low red blood cell count and hemoglobin level were taken during an acute illness and did not reflect the presence of anemia at that time. There further is no indication that the Veteran complained of or was diagnosed as having primary anemia during service or within the first post-service year (i.e., by December 1946) such that service connection for primary anemia is warranted on a presumptive basis as a chronic disease. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). The post-service evidence also does not support granting service connection for anemia. The Veteran has asserted that he has experienced continuous disability due to anemia since his service separation in December 1945. The record evidence does not support this assertion concerning continuity of symptomatology, however. It appears instead that, following his service separation in December 1945, the Veteran first was diagnosed as having anemia in September 1996, or nearly 51 years later. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran himself reported at his most recent VA examination in February 2013 that he only had experienced disability due to anemia in the previous 20 years or since approximately 1993. The Veteran's reported history of anemia going back only 20 years also was confirmed by what his daughter reported to the VA examiner at the February 2013 VA examination. These statements further are in accord with the record evidence which does not show the presence of anemia until approximately the mid-1990's, many decades after the Veteran's service separation. The February 2013 VA examiner opined that the Veteran's current anemia was due to iron deficiency and chronic renal insufficiency, both of which occurred more than 40 years after service separation and were not related to active service or any incident of service, to include the in-service low red blood cell count and hemoglobin level. There is no competent contrary opinion of record. The Veteran also has not identified or submitted any competent evidence, to include a medical nexus, supporting a link between anemia and active service or any incident of service. In summary, the Board finds that service connection for anemia also is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. See 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which 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. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, residuals of a skin disorder of both arms and anemia fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claims, in recent statements, the Veteran has asserted that his residuals of a skin disorder of both arms and anemia have been continuous since service. He asserts that he continued to experience symptoms relating to residuals of a skin disorder of both arms (itching and swelling of the arms) and anemia (fatigue and weakness, a low red blood cell count, and a low hemoglobin level) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of either of these disabilities after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of residuals of a skin disorder of both arms and anemia since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that these disorders began in service, the service separation examination report reflects that the Veteran was examined and his skin was found to be normal clinically. There also were no relevant laboratory results noted at that examination to indicate the presence of anemia at separation. The Veteran's separation physical examination is contemporaneous to service so it is of more probative value than his more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to either of these disabilities for several decades following active service. The Board emphasizes the multi-year gap between discharge from active service (1945) and initial reported symptoms related to a skin disorder of both arms when he was examined for VA purposes in 2013 (a 68-year gap). The Board also emphasizes the multi-year gap between service discharge in 1945 and initial reported symptoms related to anemia in 1996 (a 51-year gap). See Maxson, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board notes that, although the Veteran sought treatment for anemia beginning in September 1996, he never reported complaints related to residuals of a skin disorder of both arms during such treatment. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board finds it significant that, on VA hematologic and lymphatic conditions DBQ in February 2013, several decades after his service separation, the Veteran did not report the onset of anemia symptoms during or soon after service. Instead, as noted above, both the Veteran and his daughter reported at that examination that his anemia had begun approximately 20 years earlier in the mid-1990's or more than 4 decades after his service separation. As also noted above, on VA skin diseases DBQ in February 2013, the Veteran reported that, following resolution of his in-service skin problems with treatment during active service, he had not sought treatment for any skin problems since service. Id. He did not claim that symptoms of his disorders began in (or soon after) service until he filed his current VA disability compensation claims. Such statements made for VA disability compensation purposes are of lesser probative value than his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service for anemia. As noted elsewhere, continuity of symptomatology is no longer a valid theory for establishing service connection for non-chronic diseases like residuals of a skin disorder of both arms. See Walker, 708 F.3d at 1331; see also Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous findings at service separation, the absence of complaints or treatment for years after service, his previous statements made for treatment purposes, and his own previous histories of onset of symptoms given after service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for residuals of a skin disorder of both arms, to include burn scars, dermatitis, and purpura of aging (claimed as burn scars), is denied. Entitlement to service connection for anemia is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs