Citation Nr: 1315970 Decision Date: 05/15/13 Archive Date: 05/15/13 DOCKET NO. 10-22 600 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a skin disorder. ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from June 2000 to October 2000, and from February 2003 to April 2004, with a verified period of Army Reserves Active Duty for Training (ACDUTRA) from February 21, 2006 to March 12, 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. On his June 2010 substantive appeal, the Veteran indicated that he wanted a video hearing before the Board. In a June 2011 written statement, the Veteran withdrew his request for a hearing; therefore, the request for a hearing has been withdrawn. 38 C.F.R. § 20.704(e) (2012). The Board subsequently remanded the case in October 2012 for further development, to include a VA skin examination. This was accomplished, and the claim was readjudicated in a February 2013 supplemental statement of the case . Subsequent to the issuance of the February 2013 statement of the case, the Veteran submitted additional evidence and argument in March 2013. No waiver of consideration by the Agency of Original Jurisdiction (AOJ) was included with this evidence. While some of this evidence is duplicative of evidence previously considered by the AOJ, other evidence received has not been reviewed in regard to the skin disorder; therefore, this evidence is referred to the RO for consideration in the first instance. See 38 C.F.R. § 20.1304(c) (2012). The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claim for service connection for a skin disorder so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c)(4), (d) (2012). As noted above, the Veteran submitted evidence and argument in March 2013 without waiver of AOJ consideration subsequent to the issuance of the February 2013 statement of the case. The evidence submitted included an August 2007 letter from Dr. J.B., which the Board finds is already of record, and therefore, duplicative. In addition, the Veteran and his wife submitted argument in support of the Veteran's claim for service connection that was not previously submitted or considered by the AOJ. The wife's statement, in particular, discusses her first-hand knowledge of the Veteran's skin condition upon return from his ACDUTRA service in El Salvador in March 2006. Essentially, the Veteran's wife contends that the Veteran's skin condition was significantly worse after his tour in El Salvador. The wife stated that prior to leaving for El Salvador, the Veteran's hands were smooth and healthy; however, when the Veteran returned, he had a scaly and bleeding patch of skin on his left index finger. Moreover, the Veteran's wife stated that even when the Veteran experienced severe dry skin or eczema in the past (i.e. prior to the tour in El Salvador), it was easily treated with lotion. After his tour in El Salvador, the Veteran's wife claims that his skin condition is worsened and treatment has not provided relief. The Veteran's March 2013 statement, some of which is duplicative of his September 2009 and May 2010 statements already of record, contends that his skin condition worsened as a result of the tropical heat in El Salvador. As previously stated by the Veteran, he did not receive treatment during active duty service due to the fact that there were only emergency medical services available while in El Salvador, and a dermatologist was not available. Further, the Veteran asserted that he was treated by VA doctors and a private specialist upon return from El Salvador as the condition worsened. See May 2006 VA treatment note and August 2007 correspondence from Dr. J.B. The Veteran also stated that although he complained of eczema symptoms prior to his tour in El Salvador, he had never experienced eczema on his hands prior to that time. See December 2005 treatment note from Dr. H.K. (reveals complaints of dry rough patches on his face). The Board observes that the Veteran was provided with a VA skin examination in November 2012. The VA examiner stated that he reviewed the claims file and diagnosed the Veteran with eczema of the hands. The VA examiner opined that it was less likely than not that the Veteran's current skin disorder related to his ACDUTRA service in El Salvador from February 2006 to March 2006. In support of this opinion, the VA examiner stated that pre-service treatment records dated December 2005 diagnosed the Veteran with pre-existing eczema prior to his tour in El Salvador. The VA examiner further reasoned that the Veteran's report of red spots on his body during ACDUTRA service were per his oral history and there was no documentation in service treatment records of this rash. Therefore, the VA examiner opined that the Veteran's pot-service diagnosis of eczema on his hands was a continuation of a pre-existing eczematous condition. Finally, the VA examiner opined that it was less likely than not that the pre-existing skin disorder was permanently worsened during the ACDUTRA period as there was no documentation for this condition in the Veteran's service treatment records. The March 2013 lay statements from the Veteran and his wife have not been considered by the VA examiner as they were submitted after the November 2012 VA examination. Further, although the VA examiner opined that the Veteran's current condition was a continuation of a pre-existing eczematous condition, the VA examiner did not discuss the effects, if any, of a hot, tropical climate on the Veteran's pre-existing eczema. Further, the VA examiner did not discuss the discrepancy in the location of the eczema (i.e., in December 2005 it was on the Veteran's face, in May 2006 it was on his hand). Accordingly, the case is remanded in order to provide the VA examiner an opportunity to review and comment on these additional facts. Therefore, an addendum opinion is necessary in order to render a fully informed decision. In rendering such opinion, the examiner should specifically consider the March 2013 statements from the Veteran and his wife regarding the nature and severity of the skin disorder during ACDUTRA and after. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request an addendum opinion from the VA examiner who examined the Veteran in November 2012. The relevant documents in the claims folder should be made available to the VA examiner for review. Based upon a review of all the record, specifically including the pre-ACDUTRA service treatment records dated December 2005 from Dr. H.K, the post-service private treatment note from Dr. H.K dated March 2006, the VA treatment record dated May 2006, and the history of the Veteran, including the March 2013 statements from the Veteran and his wife, the VA examiner should provide an opinion to the following: Is it at least as likely as not (50 percent or greater degree of probability) that the currently diagnosed eczema was aggravated (permanently worsened in severity) by the Veteran's ACDUTRA service in El Salvador (from February to March 2006)? In reaching this opinion, the VA examiner should specifically address: (a) The discrepancies between the Veteran's pre-ACDUTRA service eczema (on his face) and his post-ACDUTRA service eczema (on his left hand). See December 2005 treatment note from Dr. H.K. (reveals complaints of dry rough patches on his face), and May 2006 VA treatment note (reveals dry, crusty, itching, raised rash on interior left pointer finger for two months). (b) The effects, if any, of a three week tour in a hot, tropical climate (El Salvador) on the Veteran's pre-existing eczema condition. See Veteran's March 2013 statement. (c) The Veteran and his wife's March 2013 contentions that the Veteran's eczema worsened after his tour in El Salvador and that treatment of post-ACDUTRA eczema has been unsuccessful. See March 2013 statements from Veteran and his wife. (Note: November 2012 VA examination report previously concluded that the Veteran's eczema pre-existed ACDUTRA service from February 21, 2006 to March 12, 2006). The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. "Aggravation" for legal purposes is defined as a worsening of the underlying disability beyond its natural progression versus a temporary flare-up of symptoms. The VA examiner is requested to provide a rationale for any opinion provided. If the VA examiner is unable to answer any question presented without resort to speculation, the VA examiner should so indicate the reason why the question could not be answered. 2. After completing the requested actions, and any additional notification and/or development deemed warranted, the issue of service connection for a skin disorder should be readjudicated in light of all the evidence of record. If any benefit sought on appeal remains denied, the RO should furnish to the Veteran an appropriate supplemental statement of the case, and should afford the Veteran the appropriate time period for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).