Citation Nr: 1316450 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 99-13 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a rating higher than 30 percent for lichen simplex, from August 30, 2002 to the present. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Biswajit Chatterjee, Counsel INTRODUCTION The Veteran served on active duty from September 1955 to November 1957. This appeal to the Board of Veterans' Appeals (Board) is from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The RO's March 1999 granted the Veteran's claim for service connection for lichen simplex and assigned an initial 10 percent rating from September 1992 and assigned an initial 10 percent rating, retroactively effective from September 24, 1992, the date of receipt of the original claim for service connection. The Veteran appealed for a higher initial rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether he is entitled to a "staged" rating to compensate him for times since the effective date of his award when his disability may have been more severe than at others). In September 2001, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge at the RO. By decision of January 2002, the Board remanded this case to the RO for further development of the evidence and for due process development. By rating action of August 2003, the RO denied a higher initial rating beyond 10 percent for lichen simplex, from September 24, 1992 through August 29, 2002. However, the RO also partially granted a staged, increased rating by assigning a higher 30 percent rating for lichen simplex, retroactively effective from August 30, 2002, the date that the rating criteria for skin disabilities became effective. By decision of February 2004, the Board again remanded this case to the RO for further development of the evidence and for due process development. By decision of July 2007, the Board denied an initial rating in excess of 10 percent for lichen simplex, prior to August 30, 2002, and a rating in excess of 30 percent, on and after August 30, 2002. The Veteran appealed the denials to the U.S. Court of Appeals for Veterans Claims (CAVC). The CAVC issued an August 2010 Memorandum Decision that affirmed that portion of the Board's July 2007 decision that denied an initial rating in excess of 10 percent for lichen simplex prior to August 30, 2002. Notably, the CAVC also vacated that portion of the Board's decision that denied a rating in excess of 30 percent on and after August 30, 2002, and remanded this matter to the Board for further proceedings consistent with the Memorandum Decision. In May 2011, the Board remanded the claim for an increased rating beyond 30 percent for lichen simplex to the RO, via the Appeals Management Center (AMC), for additional development and consideration. This development was accomplished. In February 2012, the AMC issued a supplemental statement of the case (SSOC) continuing to deny the claim and returned the file to the Board for further appellate review. Most recently, in October 2012, the Board requested a specialist medical opinion from the Veterans Health Administration (VHA). 38 C.F.R. § 20.901(a) (2012). The requested opinion has been provided and associated with the Veteran's VA claims folder. The VHA opinion has also been provided to the Veteran and his representative, and he was afforded notice in early February 2013 that he had 60 days to provide additional argument or evidence. Because the Veteran's representative waived RO review soon after that 60-day period ended, as per an April 2013 Informal Hearing Presentation, the Board assumes that he has no further evidence or argument to submit. The appeal is now ready for disposition. 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 Veteran's lichen simplex is not productive of ulceration or extensive exfoliation or crusting, and systemic nervous manifestations, or exceptional repugnance. 2. The Veteran's lichen simplex has affected no more than 40 percent of his entire body or exposed areas, and has not required constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during any past 12-month period. CONCLUSION OF LAW The criteria are not met for a rating higher than 30 percent for lichen simplex, from August 30, 2002 to the present. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10 (2012); 38 C.F.R. § 4.118, Diagnostic Code (DC) 7806 (2002); 38 C.F.R. § 4.118, DC 7806 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VCAA Before addressing the merits of the issue decided below, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. VA's duty to notify under 38 C.F.R. § 3.159(b)(1) has been met by letters from the RO issued in February 2002 and April 2004 of the criteria for establishing direct service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. The more recent March 2006 letter also complied with Dingess. Since providing these notices, the AOJ has readjudicated the claim in the February 2012 SSOC, including considering the additional evidence received in response to this additional notice. So the timing defect in the provision of this additional notice, since it did not precede the initial adjudication of the claim, has been rectified ("cured"). See again Mayfield IV and Prickett, supra. The Veteran has not made any pleading or allegation of insufficient VCAA notice or shown that any such error is unduly prejudicial, meaning outcome determinative of his claim. The Veteran has this burden of proof as the pleading party, not VA. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claims, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). A review of the claims file shows that VA has conducted reasonable efforts to assist him in obtaining the evidence necessary to substantiate his claims during the course of this appeal. The RO has obtained post-service VA and identified private treatment records. He was afforded VA examinations to assess the severity of his service-connected lichen simplex in February 2001, February 2003, June 2003, August 2005, January 2007 and June 2011. The Veteran also submitted additional records and written statements in support of his claims. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. The Veteran was provided an opportunity to set forth his contentions during the hearing before a Travel Board hearing in September 2001 before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the Board hearing, the undersigned identified the issue on appeal as for a disability evaluation in excess of 10 percent for chronic lichen simplex, because that was the disability evaluation assigned at that time. The VLJ solicited the Veteran to testify on the nature, frequency and severity of his service-connected lichen simplex disability. Hearing Transcript (T.) at 23-30. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Further, a specific VA medical examination was obtained in June 2011 to assess the severity of his lichens simplex chronicus. The Veteran was also afforded a VHA medical expert opinion in October 2012, from a VHA dermatologist, to address important findings necessary to resolve his increased rating claim. To that end, 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 June 2011 VA examination is adequate to decide the issue, as it is predicated on an interview with the Veteran during the examination; a thorough review of the record, and physical examination with diagnostic testing. The findings and conclusions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. The October 2012 VHA opinion is also adequate, since based upon thorough review of the record, medical literature, and provided a complete rationale, relying on and citing to the records reviewed. See 38 C.F.R. § 3.327(a) (2011); Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to this issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). In light of the August 2010 CAVC Decision Memorandum, which vacated the Board's denial of an increased rating beyond 30 percent because of inadequate reasons and bases, there was reason for the Board to request the AMC to develop additional medical evidence. Accordingly, the Board remanded the claim in May 2011 for the AMC to arrange a comprehensive VA examination to address the severity of the Veteran's service-connected skin disability. Moreover, in order to ensure all remaining aspects of the increased rating claim were addressed, the Board also requested VHA to obtain an opinion from a medical expert. Such examination and medical opinion was then arranged by the AMC in June 2011, along with an October 2012 addendum opinion. The Board is therefore satisfied there was substantial compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) and Dyment v. West, 13 Vet. App. 141, 146- 47 (1999). The Board concludes that all the available records and medical evidence has been obtained in order to make an adequate determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, the Board finds that VA has complied with the duty-to-assist requirements. 38 U.S.C.A. § 5103A. II. Analysis The Veteran contends that his lichen simplex is more disabling than currently evaluated. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran's favor. 38 C.F.R. § 4.3. With respect to the claim for his lichen simplex disability, he is not appealing his initial rating assigned in a previous rating decision, so the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, that said, the Court recently held that in determining the "present level" of a disability for any increased-evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The relevant temporal focus for adjudicating the level of disability of an increased rating claim is from September 1991, the time period one year before the claim was filed in September 1992, until VA makes a final decision on the claim. See Hart, supra. See also 38 U.S.C.A. § 5110(b)(2) (West 2002); 38 C.F.R. § 3.400(o)(2) (2012). The Veteran's current rating assignment of 30 percent for the service-connected lichen simplex has been assigned under DC 7806, effective from August 30, 2002. Because the Veteran's original claim for benefits extends back to September 1992, the Board must consider the regulatory changes to rating skin disabilities in August 2002. Generally, where the rating criteria are amended during the course of the appeal for an increased rating, both the former and the current schedular criteria are considered. Should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991), to the extent it held that, where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version more favorable to appellant should apply); VAOPGCPREC 7-2003; 69 Fed. Reg. 25,179 (2004). During the course of this appeal, VA revised the criteria for evaluation of skin disabilities, effective on August 30, 2002. 67 Fed. Reg. 49590 (July 31, 2002) (codified at 38 C.F.R. § 4.118 (2008)). Under 38 C.F.R. § 4.118, for eczema, under 38 C.F.R. § 4.118, DC 7806 (2002): A 30 percent rating is available for eczema with exudation or itching constant, extensive lesions, or marked disfigurement. A 50 percent evaluation required ulceration or extensive exfoliation or crusting, and systemic nervous manifestations, or exceptional repugnance. 38 C.F.R. § 4.118, DC 7806 (2002) Under 38 C.F.R. § 4.118, DC 7806 (2008), the rating criteria for dermatitis or eczema, provide that: A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs be required for a total duration of six weeks or more, but not constantly, during the past 12- month period. A 60 percent rating requires more than 40 percent of the entire body, or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Alternatively, dermatitis or eczema is to be rated under either the criteria under Diagnostic Code 7806 or to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7806 (2008). The Board notes that the regulations for skin disorders under 38 C.F.R. § 4.118 were recently further revised, effective from October 23, 2008, so that it more clearly reflects VA policies concerning the evaluation of scars. 73 Fed. Reg. 54,708 -54,712 (September 23, 2008). Because these modifications were expressly made applicable only to claims filed on or after the effective date, they do not appear pertinent to the pending claim, which was received by VA in 1992, many years prior to the regulatory changes. In this case, the Veteran has not requested for his skin disability claim to be considered under the most recent amended regulations nor did the RO apply the October 2008 amended criteria. Thus, only the pre-October 2008 versions of the schedular criteria are applicable. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence does not support an evaluation beyond his current 30 percent assignment for lichens simplex, whether considering the former criteria (pre-August 2002 amendments) or the amended criteria (post-August 2002 amendments). As background, the Board summarizes the medical evidence of record that is pertinent to this claim. At the February 2003 VA dermatologic examination, the Veteran complained of itchy, sore skin that was occasionally dry and occasionally moist. The examination showed that the skin disease affected exposed areas as follows: approximately an overall total of 20 percent of the entire body (2 percent of the arms, 60 percent of the feet, 50 percent of the buttocks, 40 percent of the back, and 10 percent of the lower legs). Notably, the Veteran reported taking Nizoral cream and hydrocortisone 0.1% steroid cream every day for the past 12 months. At a June 2003 VA dermatologic examination, the Veteran gave a 40-year history of intermittent skin rashes that waxed and waned and was pruritic and occasionally sore. The examination showed only hyperpigmented patches from former lesions on the back, forearms, groin, buttocks, lower legs, and feet, with no new lesions. The assessments were probable groin intertrigo, and xerosis versus lichen simplex chronicus versus atopic dermatitis, all of which were currently resolved. The examiner commented that the Veteran probably had a chronic skin condition such as atopic dermatitis, which tended to have intermittent flares, contributing to xerosis (dry skin), frequent yeast or bacterial intertrigo (groin area), and itchy papules and plaques when it flared, which could lead to lichen simplex chronicus if not properly treated. It was noted that there was no cure for such a condition, and thus he would need intermittent treatment when it flared, depending on the severity of the flare. An August 2005 VA examination showed dry skin throughout, and a clear scalp. The examiner diagnosed chronic, moderately controlled atopic dermatitis; severe xerosis; and intertrigo with no evidence of infection. The examiner further stated that he had areas on the trunk and extremities that were consistent with constant pruritis, but there was no evidence of constant exudation or systemic symptoms, urticaria, vasculitis, erythema multiforme, scarring, disfigurement, acne, scarring alopecia, alopecia areata, or hyperhidrosis. The examiner stated that the Veteran had been treated with multiple topical steroids and moisturizers on and off, having been given topical steroids on 2 occasions in the past year, with no known side-effects of treatment, but had never had any light therapy or immunosuppressants, and had not used oral agents for treatment of the skin disease other than antibiotics for any superinfection. Moreover, the examiner opined that topical therapy with steroids and moisturizers should control the Veteran's disease, and that there was no need for systemic treatment or immunosuppressants. The examiner found that the skin disease affected 40 percent of the Veteran's body surface area. Of record are unretouched color photographs of the Veteran's face, back, chest, groin, and lower legs taken at a VA medical facility for treatment purposes in early March 2006. Late March VA outpatient dermatologic examination showed diffuse xerosis and hyperpigmented, scaling papules and plaques involving the antecubital fossa and back. There were hyperpigmented, lichenified plaques involving the dorsal feet. There was an erythematous, approximately 6 mm. erosion on the left scrotum. The assessments were atopic dermatitis, xerosis, left scrotal ulcer, and well-controlled intertrigo. On subsequent evaluation a few days later, the Veteran stated that the ulcer was resolving after treatment with medication. On January 2007 VA dermatologic examination, the Veteran complained of chronic generalized itching, mainly of the skin of the extremities. The examiner noted no systemic/nervous/constitutional symptoms with this condition specifically, and no scars. There was diffuse scarring of the face, neck, and chest likely from acne vulgaris, and not atopic dermatitis, and there were no exudates. On review of his prescribed medications, the examiner found he was not using systemic medication on a daily basis, and the physician stated that the Veteran had not required near-constant systemic daily medication during the past year or chemotherapy, radiation or light therapy, immunosuppressants, or steroid injections. His treatment over the past 12 months had consisted only of topical agents (steroids and moisturizing agents) in addition to oral antihistamines as needed for itching, and he had seen a VA dermatologist 5 times in the past year. The January 2007 examination showed diffuse scaling of both forearms and both lower extremities. The face, neck, head, hands, chest, abdomen, and back were clear, and there were no signs of infection, exudation, itching-scratching abrasions, extensive lesions, marked disfigurement, ulcers, or crusting. No underlying soft tissue was missing. The skin texture was scaly, but the skin was not indurated or inflexible. The skin of the distal third of the legs was thickened, but otherwise there was no thickened skin. There was an area of hyperpigmentation of the right calf, which was likely secondary to peripheral vascular disease due to cigarette smoking. There was diffuse skin xerosis and scattered comedomes of the back. The examiner found that the skin disease affected 0 percent of the Veteran's exposed areas (head, face, neck, and hands) and 20 percent of his entire body. The diagnosis was chronic, symptomatic atopic dermatitis, with more than topical therapy not indicated. An April 2009 letter from Dr. W.S.G., M.D., a private treating physician, noted that while in the service and persisting to the present, the Veteran had patches of intensely itching skin that responds to scratching and rubbing by thickening and darkening. This is known as lichenified plaques or lichen simplex chronicus, and is aggravated by stress, nervous tension and fatigue. It may have been aggravated by his service related experiences. This private treating physician also noted other dermatologic problems of PFB and hidroadenitis that were attributed to an inherited genetic tendency, but there was no indication these were secondarily related to his service-connected lichen simplex chronicus. Similarly, he had a non-service-related condition of asteatosis, which was noted to not be service-related, and there was no indication it was secondarily related to his service-connected lichen simplex chronicus. As mentioned, following the August 2010 CAVC Decision Memorandum, which vacated and remanded the Board's denial of an increased rating beyond 30 percent because of inadequate reasons and bases, the Board found it necessary to request the AMC to develop additional medical evidence to resolve the claim. Accordingly, on remand, the AMC obtained a specific VA medical examination in June 2011 to assess the severity of his lichens simplex chronicus. The Board also requested VHA to obtain a medical expert opinion from a dermatologist in October 2012, to address important findings necessary to resolve his increased rating claim. Subsequent to the January 2007 examination, VA outpatient treatment records showed ongoing evaluation and treatment for his diagnosed skin disability of lichen simplex chronicus. In a decision issued in August 2010, the Court of Appeals for Veterans Claims directed VA to discuss whether the medications used to treat the Veteran's skin disability, Nizoral and hydrocortisone, constituted systemic or immunosuppressive therapy. On remand from the Board, the AMC arranged for another VA compensation examination in June 2011. On review of his medical history, the Veteran complained that the course of his skin condition is constant, but worse during the summer months with excessive sweating. He complained of excessive itching and burning. Physical examination of the upper extremities, arms, chest and the back showed some scaly skin present, but no signs of lichenification were present; no signs of infection or erythema ( redness). Examination of the groin area revealed thick lichenification, some scaliness and whitish discoloration present in the groin and scrotal area. Also, the skin of the distal one third of the legs posterior aspects had some thickening of the skin with some scaliness present; no induration of the skin or inflexibility; and the skin was hyperpigmented throughout. The examiner noted treatment consists of Absorbase skin moisturizer, applied once a day. The Veteran also treats his skin disease with Hytone ointment steroid cream, applied every other day and as needed and is strictly for itching. The Veteran reported the medications are both applied topically, and work well with no side effects. The examiner found the skin disease affects 0 percent of the exposed area of the head, face, neck and hands; and the skin disease affects 30 percent of the entire body. The VA examiner who conducted June 2011 examination listed the medications in use in June 2011 to treat the Veteran's skin disorder. However, numerous medications have been used to treat the Veteran's skin disability since August 2002. Medications prescribed by VA for treatment of the skin since August 30, 2002, have included, but are not limited to, Absorbase, Lidex, hydrocortisone 0.1 percent ointment, ketoconazole 2 percent cream, Cordran (flurandrenolide) tape, ammonium lactate, 12 percent lotion, clotrimazole 1 percent, topical, tacrolimus 0.1 percent ointment, terbinafine 1 percent cream, urea 20 percent cream, triamcinolone, hytone ointment, and hydrocortisone ointment, among other medications. The Board then requested an expert medical opinion to help resolve questions raised the CAVC's August 2010 Memorandum Decision. Accordingly, the AMC arranged for a VHA opinion from a dermatologist in October 2012. In this regard, the examiner who conducted June 2011 VA examination stated that the Veteran was last seen for treatment of a skin disability in March 2010. However, the clinical records reflect that the Veteran sought treatment for an infected skin lesion on July 1, 2010. Surgical excision under general anesthesia of an infected sebaceous cyst of the left chest was performed in July 2010. Surgical treatment of a "baseball-size" abscess on the right shoulder was required in August 2010. The June 2011 VA examiner did not provide an opinion that these lesions were separate from the Veteran's service-connected disability, and offered no discussion as to whether the evidence regarding these lesions was relevant to the severity of the service-connected disability. The Board also notes that excision of a lesion at the jaw line was noted in December 2009. Medical discussion of the evidence about these lesions is required before the Board may determine the severity of the Veteran's service-connected skin disability. Importantly, in this regard, the October 2012 Veterans Health Administration (VHA) dermatologist's opinion report opined that it is not likely (1% or less) that the lesions of the left chest noted in January to July 2010 and chest lesion surgically treated in July 2010 were attributable to the service-connected disability of lichen simplex. Similarly, the VHA physician opined that it was not likely (1% or less) that the abscess of the right shoulder surgically treated in August 2010 was attributable to the lichen simplex. On review of his VA and private treatment records, VA examination reports and October 2012 VHA dermatologist's opinion report, there is no indication that he meets the criteria for a higher 50 percent rating under the pre-August 2002 regulations. Again, a 50 percent evaluation required ulceration or extensive exfoliation or crusting, and systemic nervous manifestations, or exceptional repugnance. 38 C.F.R. § 4.118, DC 7806 (2002). On review, the Board notes that the June 2011 VA examiner diagnosed the Veteran with lichen simplex chronicus, to account for his complaints of a rash of the legs, groin and buttocks area with extreme itching. The June 2011 examiner found that his service-connected skin disability affected 0 percent of his exposed area of his head, face, neck and hands. Although the Board acknowledges that the Veteran has also been diagnosed with pseudofolliculitis barbae (PFB), nonetheless, private physician Dr. W.S.G.'s April 2009 letter opined that PFB was instead an inherited genetic tendency. Similarly, the October 2012 VHA opinion stated that is not likely (1percent or less) that PFB was a manifestation of, related to, caused by, secondary to, or aggravated by the service-connected disability. The VHA opinion also found that the record revealed only one instance of a small scrotal ulcer, but no associated lichens simplex was noted and the area healed quickly with a topical antibiotic, and there were no systematic manifestations of the disability. Indeed, the examiner specifically opined that the Veteran "did not have "ulceration" due to service-connected skin disability during the period from August 30, 2002 to the present." Thus, the Board concludes that there are no medical findings that indicate his lichens simplex disability indicates ulceration or extensive exfoliation or crusting, and systemic nervous manifestations, or exceptional repugnance. 38 C.F.R. § 4.118, DC 7806 (2002). There is no basis for an even higher 50 initial rating for his skin disability under the pre-August 2002 version of DC 7806. Id. Turning to consideration of the regulations amended in August 2002, the Board has reviewed the Veteran's VA and private treatment records, VA examination reports and October 2012 VHA opinion report. Again, a 60 percent rating requires more than 40 percent of the entire body, or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. However, the Board finds there is also no indication that he meets the criteria for a higher 60 percent rating under the August 2002 amended regulations. At the outset, overall, the examiners did not find that his lichen simplex manifests as affecting more than 40 percent of the entire body or that more than 40 percent of the entire body. For instance, the February 2003 examiner found 20 percent of the body's surface area (BSA) affected, the August 2005 examiner found 40 percent of BSA affected, the January 2007 examiner found 20 percent of BSA affected, and the June 2011 examiner found 30 percent of the body affected. Similarly, the VHA dermatologist opined in October 2012 that "there was no time since August 2002 when the BSA of the Veteran's service-connected disability was more than 40 percent." In this regard, the VHA physician reasoned that the extent of the BSA affected varies in the record, but was usually given 20 percent, only was it stated to be 40 percent, and no documentation of a BSA over 40 percent was found in the records. The VHA physician added that on review of the Veteran's photographs, it appears that the BSA that is attributable to the service-connected lichen simplex chronicus, in particular, is no more than 1 or 2 percent and confined to the right lateral leg. Moreover, there is simply no competent evidence that establishes that the Veteran had constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period, such as would warrant a higher 60 percent rating under the 2002 amendments. In this regard, the October 2012 VHA physician thoroughly reviewed the medical record and considered the Veteran's . Ultimately, the VHA physician opined that "No topically-administered therapy was a systemic corticosteroid, systemic immunosuppressive, or systemic antibiotic therapy that was prescribed for the Veteran's LSC [(lichen simplex chronic)]. No oral steroids or immunosuppressive medications were prescribed either." The VHA physician reasoned that many topical medications were used to treat the Veteran's skin since August 2002 to the present, but that Triamcinocline cream 0.1% was the most commonly prescribed medication (or another topical steroid) for the lichen simplex. The VHA physician added in this regard that "This is the standard of care, and if used correctly over a long period of time, can reverse the itch-scratch-itch cycle. The records do not show that systemic corticosteroids or immunosuppressives were ever prescribed. Oral antibiotics were used when other skin problems, particularly atopic dermatitis, were thought to be infected. In addition to the medical evidence, the Board has considered the Veteran's personal assertions in support of his claim. He is competent, as a layman, to report on that as to which he has personal knowledge, such as the existence of skin symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). As a layman, without the appropriate medical training and expertise, he is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his service-connected skin disorder. Specifically, he cannot comment on whether his medications were topical or systemic corticosteroids, because such a question requires medical expertise. Indeed, the Board needed to request comment on many issues with his claim from a VHA medical expert in dermatology. The VHA dermatologist in October 2012 actually opined against accepting the Veteran's statements in support of his claim as inconsistent with the medical evidence, current dermatologic thought, and clinical practice. The VHA physician reasoned in this regard, "the Veteran's lay statements and testimony tend to include every skin problem he has ever been diagnosed with under the umbrella of his lichens simplex chronicus, which would be expected if he believed that they were all manifestations of his LSC." There is no basis to further "stage" his rating under Hart because his skin disability has never been more than 30 percent disabling at any time since August 30, 2003. And since, for these reasons and bases discussed, the preponderance of the evidence is against his claim, the benefit-of-the-doubt doctrine is inapplicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Extra-Schedular Consideration Next, the Board will consider whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. 38 C.F.R. § 3.321(b)(1); see Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. The Veteran's lichen simplex was applied to the applicable rating criteria, which specifically contemplate a sizeable area of the body affected by a skin disability and of the types of medications (topical ointments) used by the Veteran, as in the current case. Although the diagnostic codes in this case allow for higher ratings, the Board fully explained why the higher ratings were not warranted. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER The claim for a rating higher than 30 percent for lichen simplex is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs