Citation Nr: 1316202 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 09-15 082 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to a higher initial rating for service-connected tinea dermatitis of the feet and hands, rated as noncompensable prior to November 26, 2012, and as 10 percent disabling from that date. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to July 1971. This matter is before the Board of Veterans' Appeals (Board) of the Department of Veterans Affairs (VA) on appeal from a June 2008 rating determination by the above Regional Office (RO) that granted service connection and a noncompensable rating for tinea dermatitis of the feet and hands, effective December 21, 2007. In response, the Veteran appealed for a higher initial rating for this disability. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (indicating in this circumstance VA adjudicators must consider whether to "stage" the rating, meaning to assign different ratings at different times since the effective date of the award to compensate the Veteran for occasions when the disability may have been more severe than at others). The Veteran testified at a videoconference hearing held at the Montgomery RO in July 2012, before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing is of record. In September 2012, the Board remanded this case to the RO via the Appeals Management Center (AMC) for additional development, and the case was subsequently returned to the Board. While this case was on remand, in a February 2013 rating decision, the AMC granted a higher 10 percent rating for the service-connected skin disorder, effective November 26, 2012. In response, the Veteran filed a notice of disagreement as to the effective date of the 10 percent rating, asserting that the 10 percent rating should have been in effect throughout the rating period on appeal, and also contended that an even higher rating should be assigned. The Board notes that the Veteran has already perfected an appeal as to the issue of entitlement to a higher rating throughout the entire rating period on appeal, i.e., since December 21, 2007. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (a Veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). In other words, the issue of entitlement to a higher (compensable) rating for the skin disorder prior to (and after) November 26, 2012 is already in appellate status, and will be addressed by the Board in this decision. In this case, recent VA medical records were added to the Veteran's electronic Virtual VA folder, which were considered by the RO and the AMC in supplemental statements of the case. Because the current appeal includes records that are located only in the Virtual VA system, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. Additional written argument was received from the Veteran in March and April 2013. As the Veteran has waived initial RO review of this evidence, the Board will consider it. 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. During the period prior to July 29, 2008, the Veteran's skin disorder was not shown to cover 5 percent of exposed areas or of the entire body; and was not shown to require systemic therapy or immunosuppressive drugs. 2. Resolving reasonable doubt in his favor, during the period from July 29, 2008, the Veteran's skin disorder has been manifested by constant or near-constant systemic therapy with oral medication. CONCLUSIONS OF LAW 1. During the rating period prior to July 29, 2008, the criteria for an evaluation in excess of 0 percent for the service-connected skin disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7806, 7813 (2008). 2. Resolving reasonable doubt in his favor, during the rating period from July 29, 2008, the criteria are met for a higher 60 percent rating for the service-connected skin disorder. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7806, 7813 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; 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). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, a January 2008 letter was sent to the Veteran regarding his initial service connection claim, prior to the June 2008 rating decision on appeal. In cases such as this, where service connection has been granted and an initial disability rating and effective date has been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). Neither the appellant nor his representative has advanced any such arguments. The provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved. This has been done; the Veteran has received both an SOC and supplemental statements of the case, most recently in February 2013, discussing the downstream disability rating element of his claim, citing the applicable statutes and regulations, and discussing the reasons and bases for assigning the initial 0 percent rating versus a higher rating. Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his claim, and as such, that he had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, the appellant's private and VA medical treatment records and private medical records have been associated with the claims file. The appellant was afforded VA medical examinations in May 2008, October 2011, and November 2012. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). These examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history. The examinations included a report of the symptoms for the skin disorder and demonstrated objective evaluations. The examiners were able to assess and record the clinical status of the appellant's skin disorder. Physical examination was accomplished. The Board finds that the examination reports were sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that the examinations were in any way incorrectly conducted or that the VA examiner failed to address the clinical significance of the appellant's symptoms. Further, the VA examination reports addressed the applicable rating criteria. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). Therefore, the Board concludes that the appellant was afforded adequate examinations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A United States Court of Appeals for Veterans Claims (Court) or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, VA and private treatment records were obtained and reviewed on remand. The RO also arranged for a medical examination as directed by the September 2012 Board remand. Therefore, substantial compliance has been achieved. All relevant facts with respect to the higher rating claim addressed in the decision below have been properly developed. Under the circumstances of this case, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). VA has complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. However, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the 2012 Board hearing. Analysis The Veteran contends that his service-connected skin disorder (tinea dermatitis of the feet and hands) is more disabling than currently evaluated. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). If there is a question as to which of two evaluations is to be assigned, 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. All reasonable doubt is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The RO and AMC have rated the service-connected tinea dermatitis of the feet and hands under Diagnostic Code 7806 as noncompensable prior to November 26, 2012, and as 10 percent disabling from that date. See 38 C.F.R. § 4.118. Since the Veteran's appeal for a higher rating arises from his disagreement with the initial rating assigned following the granting of service connection for this skin disorder, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "staged" ratings. See Fenderson, supra. On remand, the AMC has already assigned a staged rating for the Veteran's skin disorder. During the pendency of the appeal, the criteria for evaluating skin conditions under 38 C.F.R. § 4.118 were revised, effective October 23, 2008. However, these additional revisions only apply to the criteria for rating scars, and concern Diagnostic Codes 7800-7805. These revisions are applicable only to claims filed on or after that date or where the Veteran expressly requests review under such criteria. 73 Fed. Reg. 54708 (Sep. 23, 2008); see also 77 Fed. Reg. 2909-10 (Jan. 20, 2012) (correcting the applicability-date language for the revised rating criteria for scars). The Veteran's claim was filed in July 2007, and no such request for review was made. Accordingly, the revised schedular rating criteria are not applicable in this case and those in effect prior to October 23, 2008, must be applied. Under Diagnostic Code 7806, dermatitis or eczema can be rated as disfigurement of the head, face, or neck (Code 7800), scars (Codes 7801-7805); or dermatitis/eczema (7806); dependent on the dominant disability. Under Diagnostic Code 7813, dermatophytosis (including tinea corporis, tinea capitis, tinea pedis, etc.) is rated as disfigurement of the head, face, or neck, or as scars, or as dermatitis (Diagnostic Code 7806), depending on the predominant disability. In the instant case, as the primary disability appears to be skin symptomatology, the service-connected tinea dermatitis of the feet and hands is appropriately rated as dermatitis/eczema. 38 C.F.R. § 4.118, Diagnostic Code 7806. Diagnostic Code 7806 provides a noncompensable evaluation for dermatitis or eczema involving less than 5 percent of the entire body, or less than 5 percent of exposed areas affected, and no more than topical therapy was required during the prior 12-month period. A 10 percent rating is warranted for dermatitis or eczema with 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 if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks during the last 12-month period. A 30 percent rating is assigned for dermatitis or eczema with 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted with more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008). Private and VA post-service outpatient treatment records dated since 2007 reflect ongoing treatment for tinea dermatitis of the feet and hands. Private medical records from a private podiatrist, D.V.R., DPM, dated from June to July 2007 reflect treatment for complaints of a rash/athlete's foot, with blisters on the ankles and feet. The Veteran said the condition was intermittent and chronic and affected the plantar and dorsal surfaces of both feet. He stated that his symptoms were worse with enclosed shoes and heat. He described the intensity as moderate. He complained of burning, cracking skin, dry skin, itching, and peeling skin. On examination, there were skin lesions at the medial arch of the right foot, the lesions were pink and clear, elevated, and had well-demarcated margins. There was serous fluid, scaling, crusting, and drainage. There was bilateral interdigital athlete's foot at the 4th innerspace; the clinical description was macerated, peeling, scaling, cracking, and fissures. The diagnostic assessment was atopic eczema and tinea pedis. A skin biopsy was taken. Similar findings were noted in July 2007, and tinea pedis was diagnosed. Dr. R. prescribed Loprox gel for topical application. On VA examination in May 2008, the Veteran complained of "blisters" on his feet which he had constantly, and which he punctured with a pin. He said the blisters caused pain to his feet and between his toes, they did not limit activity. He said he constantly experienced a rough hyperpigmented rash to the hands, accompanied by itching, which he treated with a cream. He reported that he used Loprox gel, which the examiner indicated was not a corticosteroid or immunosuppressive medication. The examiner stated that the percentage of exposed areas affected was less than 5 percent, and the percent of total body area affected was less than 5 percent. On examination, there were small fluid-filled blisters to the medial aspect of both feet, also multiple scattered, faint hyperpigmented spots on the entire surface of both feet, which the Veteran said were residuals of previous blisters. There were faint hyperpigmented rough spots on the back of both hands and fingers. There was no evidence of scarring or disfigurement of exposed areas, and acne/chloracne were not at issue. The examiner indicated that a June 2007 skin biopsy performed by a private podiatrist, Dr. R., showed a tinea infection. The diagnoses were tinea dermatitis of the feet, and dermatitis of the hands. A December 2009 VA outpatient treatment record reflects that the Veteran presented with a skin rash on his feet. The pertinent diagnostic assessment was skin rash. The Veteran was referred for a dermatology assessment. There are no subsequent VA outpatient treatment records, and a January 2012 entry reflects that the Veteran had not been seen in the primary care clinic in over one year. On VA examination in October 2011, the examiner stated that the skin condition did not cause scarring or disfigurement the head, face or neck. He did not have any benign or malignant skin neoplasms, and did not have any systemic manifestations due to any skin diseases. He had been treated with a topical medication in the past 12 months for a skin condition, specifically Loprox gel, used constantly or near constantly. He was not using any oral medications, systemic corticosteroids or other immunosuppressive medication, and was not using topical corticosteroids. He had no treatments or procedures other than topical medication in the past 12 months for the skin disorder. He had no debilitating episodes in the past 12 months due to the skin disorder. On examination, dermatitis affected less than 5 percent of the total body area, and less than 5 percent of the exposed area. Skin infections affected less than 5 percent of the total body area, and less than 5 percent of the exposed area. The examiner indicated that the skin disorder impacted the Veteran's ability to work, in that he had to wear comfortable shoes to avoid blisters on his feet. He sometimes had to wear sandals to avoid irritating the blisters. The examiner diagnosed dermatitis and dermatophytosis. At his July 2012 hearing, the Veteran testified his skin rash had spread from his feet up his legs and into the thigh area. He also reported that the skin disorder affected his hands. He testified that in addition to the topical cream, his private treating physician had prescribed the pill griseofulvin to help control the burning and itching. He testified that he had been on this medication since about 2007. He denied skin infections, and said his skin disorder did not limit his activities. He said he had not seen Dr. R. since April 2009, but he could still call him for a prescription. He said he was not receiving VA treatment yet. In October 2012, the Veteran submitted copies of private medical records from Dr. R. dated from 2008 to 2009 reflecting treatment for dermatophytosis. A July 29, 2008 treatment note reflects that the Veteran had interdigital athlete's foot in the 4th innerspace bilaterally. The skin was macerated, peeling, scaling, cracking, and fissures. In the plantar arch, there was xerosis, peeling, scaling, crusting, and vesicular lesions. The diagnostic assessment was tinea pedis. Dr. R. started the Veteran on a daily oral medication, GRIS-PEG (griseofulvin). In an April 2009 statement, he noted that the Veteran complained of chronic peeling, itching, burning and cracking skin of both feet for 40 years. There was scaling, peeling, xerosis, maceration, fissures, and vesicular lesions of the interdigit skin and plantar skin. A skin biopsy showed dermatophytosis, and the diagnosis was dermatophytosis. The prognosis was poor, since this was a chronic recurring condition that had 50 percent involvement of the entire plantar surfaces of both feet. An April 2009 treatment note reflects that the Veteran was currently taking GRIS-PEG daily. Dr. R. stated that the Veteran was compliant with prescribed Gris Peg, and his condition seemed to be improving. On examination, there was athlete's foot of the plantar skin, located on the arch on the right. The clinical description was xerosis, peeling, scaling, crusty and vesicular lesion(s). He advised the Veteran to let his toes and feet "air", and to dry well between his toes. Associated symptoms included cracking skin. The diagnostic assessment was tinea pedis. He again prescribed Loprox gel. On VA examination in November 2012, the examiner stated that the Veteran was treated for mycotic eczema during military service, and continued to have problems with persistent small tender and pruritic blisters of the lateral dorsum of the hands as well as the circumference and the bottom of both feet. His symptoms were persistent during military service and had continued through the years. Therapy helped somewhat but did not resolve his chronic skin condition. The skin condition had features which overlapped eczema and tinea and thus the actual diagnosis had varied somewhat over the years, but the skin condition itself had not varied and represented one disorder. The examiner stated that the skin condition did not cause scarring or disfigurement of the head, face or neck. He did not have any benign or malignant skin neoplasms, and did not have any systemic manifestations due to any skin diseases. He had been treated with oral or topical medication in the past 12 months for a skin condition, specifically an oral medication: GRIS-PEG 250, for tinea dermatitis, with reported constant/near-constant use. He also used Loprox gel in the past year, with constant/near-constant use. He was not using any systemic corticosteroids or other immunosuppressive medication, and was not using topical corticosteroids. He had no treatments or procedures other than medication in the past 12 months for the skin disorder. He had no debilitating episodes in the past 12 months due to the skin disorder. He had no non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months. On examination, dermatitis affected 5 percent to less than 20 percent of the total body area, and 5 percent to less than 20 of the exposed area. The examiner diagnosed tinea dermatitis on the lateral aspect of the dorsal surface of the right and left hand, and the bottom of both feet, as well as the adjacent vertical 3 centimeters of the circumference of both feet. He did not have any benign or malignant skin neoplasms. The examiner stated that the Veteran's skin condition did not impact his ability to work. He had pruritis and patchy hyperpigmentation of the involved area with scattered small blisters. The constant itching was a very annoying and aggravating problem for the Veteran, and there was also mild discomfort from the scattered blisters. There was no ulceration or exfoliation. The examiner stated that the claims file was reviewed, and opined that the Veteran's skin disorder caused nearly constant itching of the involved areas but did not cause marked interference with employment. He had not been hospitalized due to this skin disorder. Outpatient clinical records show that the Veteran's skin condition has been treated with topical Loprox gel throughout the rating period on appeal. And on July 29, 2008, he was prescribed an oral anti-fungal medication, GRIS-PEG, to treat his service-connected skin disorder. He has not been prescribed any corticosteroids, immunosuppressive drugs, or light therapy. The Board notes that the last treatment record from Dr. R. is dated in April 2009, and that the Veteran testified in July 2012 that he had not seen Dr. R. since April 2009, but he could still call him for a prescription. Significantly, he did not state that he had called him for a prescription, although he did testify that he had been taking this oral medication since about 2007. However, as noted, the private medical records show that this medication was first prescribed in July 2008. The Veteran also testified he was not receiving VA treatment. The Board finds that it is unclear whether or not the Veteran is still taking this oral medication, since he is not shown to have received outpatient treatment from Dr. R. since April 2009, or from VA since December 2009, and the only prescription for this medication is dated in April 2009. Subsequent VA medical records do not list this as one of his current medications. There is no evidence, other than the Veteran's testimony, that a private or VA doctor has prescribed any oral medication for the service-connected tinea dermatitis of the feet and hands since April 2009. During the rating period prior to July 29, 2008, the Board finds that a higher compensable rating is not warranted for the service-connected tinea dermatitis of the feet and hands, as the weight of the evidence does not show that the skin condition affected 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 that intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks during the last 12-month period. The evidence of record during this period shows that the condition affected only portions of the feet and hands, and only topical (not systemic) medication was prescribed. Resolving reasonable doubt in the Veteran's favor, and considering all of the evidence of record, the Board finds that the medical and other evidence supports increasing the rating for service-connected tinea dermatitis of the feet and hands effective from July 29, 2008, the date he was first prescribed daily systemic oral anti-fungal medication to treat his service-connected skin disorder. See 38 C.F.R. § 4.118, Diagnostic Code 7806. The evidence in support of the claim includes the Veteran's sworn testimony, the medical evidence that systemic daily medication (griseofulvin) was prescribed for the Veteran's service-connected skin disorder in July 2008 by Dr. R., and the findings by the November 2012 VA examiner that he required constant or near-constant systemic therapy with this medication during the past 12-month period. The Board finds that an increased 60 percent rating, but no higher, is warranted from July 29, 2008, as the weight of the evidence shows that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the period since July 29, 2008 and during the past 12-month period. Id. The Board notes that the Veteran's statement that he has been taking GRIS-PEG since 2007 is contradicted by the medical evidence, which demonstrates that this medication was first prescribed in July 2008. The Board finds that his statement that he began taking this medication in about 2007 is not credible. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The Board has considered whether an even higher rating may be assigned under any applicable rating criteria, but finds that the medical evidence does not show systemic manifestations such as to warrant a higher rating under Diagnostic Code 7817, pertaining to exfoliative dermatitis. 38 C.F.R. § 4.118, Diagnostic Code 7817. There are no other relevant Diagnostic Codes for application. In sum, the Board finds that a rating higher than 0 percent is not warranted prior to July 29, 2008, and a higher 60 percent rating is warranted from that date. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Consideration also has been given to whether the schedular evaluation is inadequate, thus requiring referral of this claim to the Under Secretary for Benefits or to the Director of Compensation and Pension Service for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to this service-connected disability. 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the claim must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. The Veteran is now in receipt of the maximum rating available under Diagnostic Code 7806. An evaluation in excess of 60 percent is provided for certain manifestations of exfoliative dermatitis under Diagnostic Code 7817, but the evidence reflects that those manifestations are not present in this case. The Veteran's symptoms of tinea dermatitis of the feet and hands as demonstrated in the medical evidence are contemplated in the rating criteria. The blisters, crusting, itching, and surface area affected, etc., are all relevant considerations contemplated by the schedular rating criteria. Hence, the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See, too, Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). Also, all of the evaluation and treatment the Veteran has received for his tinea dermatitis of the feet and hands has been on an outpatient basis, not as an inpatient, much less frequent inpatient. So extra-schedular referral is not warranted in this instance. Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER During the period prior to July 29, 2008, a higher (compensable) rating for service-connected tinea dermatitis of the feet and hands is denied. During the period from July 29, 2008, a higher 60 percent rating for service-connected tinea dermatitis of the feet and hands is granted, subject to the regulations governing monetary benefits. ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs