Citation Nr: 1318985 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 92-23 982 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a skin disorder, to include as secondary to in-service herbicide exposure. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the benefit sought on appeal. The Veteran appealed that decision to the Board, and the case was referred to the Board for appellate review. Due the complex procedural history of the Veteran's skin disorder claim, the Board will provide a brief recitation of pertinent facts in order to clarify of the issue on appeal. In a January 1995 statement, the Veteran originally filed a claim for entitlement to service connection for a skin disorder, asserting that he received treatment for a skin disorder due to Agent Orange exposure. In a February 1996 rating decision, the RO found the claim for entitlement to service connection for a skin disorder was not well grounded. In a June 1997 rating decision, the RO denied entitlement to service connection for a skin condition. In August 1998 and December 1999, the Veteran filed claims for service connection for a skin disorder as well as sores on his head and face, due to exposure to Agent Orange. He stated that he had a rash on his face, head, arm, back, and hands. In a February 2000 rating decision, the RO denied service connection for a rash on the back, on the basis that there was no evidence of a current disability. The Veteran disagreed with that decision, and initiated this appeal. In an April 2001 Board remand, the Board mistakenly indicated that it did not have jurisdiction of this matter, incorrectly finding that the Veteran had not appealed the issue. In March 2003, the Veteran filed a claim for "exposure to Agent Orange and the residuals flowing therefrom." In May 2003, the Veteran stated that his claim for Agent Orange includes sores on his face and back, a rash on his back, and chloracne. Thereafter, in an August 2003 rating decision, the RO denied service connection for chloracne, claimed as sores of the face and back, on the basis that there was no evidence of the claimed skin condition in the Veteran's service medical records, and there was no evidence that he developed chloracne within one year of his last exposure to herbicides. The Veteran also disagreed with that decision, and the issue was perfected for appellate review. Although the RO developed two separate claims for skin disorders, the Board has previously merged these claims into one issue listed on the title page above, as the Veteran's contentions appear to encompass the same matter. The Board subsequently remanded this matter for further development in August 2005, May 2012, and October 2012. The Board's prior Remand instructions and the subsequent actions from the RO and VA Appeals Management Center (AMC) will be further discussed below. The Veteran's claim has now been returned to the Board for further appellate proceedings. In addition, the Veteran first presented testimony regarding his alleged skin disorder in a hearing held by a Veterans Law Judge (VLJ) in May 2000 at the RO. Thereafter, a Travel Board hearing was held in June 2003 before Kathleen K. Gallagher, a VLJ who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c) (West 2002) and who is rendering the determination in this case. Generally, VLJ's who conduct hearings must participate in making the final determination of the claim involved. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. By law, appeals can be assigned only to an individual VLJ or to a panel of not less than three VLJ's. See 38 U.S.C.A. § 7102(a). Thus, when a veteran has had a personal hearing before two separate VLJ's during the appeal, and these hearings covered one or more common issues, a third VLJ is assigned to the panel after the second Board hearing has been held, and the appeal is then ready for appellate review. The Board notes that Board's August 2005 and May 2012 Remands were signed by such a panel of VLJ's. The Court has interpreted 38 C.F.R. § 20.707 as requiring that a Veteran must be provided the opportunity for a hearing before all three VLJ's involved in a panel decision. Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). Pursuant to the Court's holding in Arneson, a letter was sent to the Veteran in October 2011 notifying him that he had the option of having a third hearing with a VLJ who would be assigned to the panel to decide his appeal. The Veteran did not respond to the letter. Therefore, the Board finds that there is no hearing request pending at this time, and the Board has complied with the requirements set forth in Arneson. 38 C.F.R. § 20.700(a) (2012). Further, the VLJ who conducted the May 2000 hearing and signed the prior Board Remands is no longer employed at the Board. Generally, when a VLJ who has conducted a hearing concerning an issue currently on appeal retires, the Veteran is afforded the opportunity to participate in another hearing. See 38 U.S.C.A. § 7102 (West 2002); 38 C.F.R. § 20.707 (2012). While the Board acknowledges the provisions of 38 U.S.C.A. § 7102 and 38 C.F.R. § 20.707, the unique facts of this case present a situation in which affording the Veteran the opportunity to participate in another hearing would be inappropriate. Specifically, due to the fact that the VLJ who conducted the May 2000 hearing is no longer employed at the Board, there remains only one VLJ (the undersigned) who has taken testimony concerning the Veteran's alleged skin disorder claim that is available to sign the current decision. Therefore, the Board may proceed without prejudice to the Veteran. Godfrey v. Brown, 7 Vet. App. 398 (1995); Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board makes a determination, it must consider whether the Veteran has been prejudiced thereby). This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT A current skin disorder did not have its onset during active service or become manifest within the first post-service year, and the Veteran's current skin disorder is not the result of an event, injury, or disease incurred in active service, to include in-service herbicide exposure. CONCLUSION OF LAW A skin disorder was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by a letters sent to the Veteran in March 2003, April 2003, May 2003, March 2006, January 2009, and February 2009 with regard to the claim of entitlement to service connection for a skin disorder. The letters addressed all of the notice elements but were sent after to the initial unfavorable decision by the RO in February 2000. However, the Veteran's claim was then readjudicated by the AMC in the February 2013 supplemental statement of the case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). The duty to assist was also met in this case. All service treatment records and service personnel records as well as VA and private treatment records have been obtained and associated with the file. VA examinations with respect to the issue on appeal were obtained in July 2008 and June 2012. An addendum VA medical opinion was obtained in October 2012. The Board also obtained three VHA medical opinions in 2011. 38 C.F.R. § 3.159(c)(4). 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 May 2011 VHA medical opinion and October 2012 VA medical opinion obtained in this case are adequate, as they were predicated on a full reading of the Veteran's claims file. Each considers all of the pertinent evidence of record and the statements of the Veteran, and the examiners provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). In addition, the Board finds that the October 2012 VA medical opinion substantially complies with the October 2012 remand directive, as the October 2012 VA examiner provided a medical opinion that addressed the Board's requested instructions. Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (although under Stegall VA is required to comply with remand orders, substantial compliance, not absolute compliance, is required). The Board is cognizant that the October 2012 VA examiner did not specifically mark that she had reviewed the Veteran's Virtual VA file as requested in the October 2012 remand directive and instead simply checked that she had reviewed the claims file in the June 2012 VA examination report and subsequent October 2012 addendum opinion. However, the Board has extensively reviewed the evidence in the form of VA treatment notes dated from 2008 to 2012 uploaded to Virtual VA but finds that the records consist of evidence that is essentially duplicative of evidence already located in the claims folder. Records simply showed additional treatment for previously diagnosed skin disorders. As noted above, the October 2012 VA examiner provided a medical opinion that addressed the Board's requested instructions based on her review of the claims file. In addition, there is no indication in the record that the examiner did not review the Virtual VA record. To send this matter back to the VA examiner for exact confirmation that she reviewed essentially duplicative evidence contained in the Virtual VA file would only result in unnecessary delay to a Veteran who has already waited many years for resolution of his appeal. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). For these reasons, the Board finds that VA has fulfilled the duty to assist the Veteran in this case. The available records and medical evidence have been obtained in order to make adequate determinations 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). Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain diseases, such as malignant tumors, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). Section 3.307(d)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(d)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; and atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42600-42608 (2002). Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Factual Background and Analysis The Veteran has asserted that he incurred a skin disorder due to exposure to Agent Orange while serving in the Republic of Vietnam. Service treatment records reflected complaints of and treatment for impetigo as well as unidentified rashes on his legs and groin area in January 1967 and May 1968, respectively. The Veteran's August 1968 separation examination report showed his skin was marked as normal on clinical evaluation. Service personnel records detailed that the Veteran was stationed in the Republic of Vietnam during his period of active service from February 1968 to October 1968. A December 1968 post-service VA examination report and a November 1993 VA emergency room nursing assessment revealed normal skin findings. VA dermatology notes dated in October and December 1993 showed complaints of a history of skin trouble with previous prescription for topical acne medications. On physical examination, there was a small, tender pustule on scalp and multiple telangiectasias on face. The October 1993 examiner listed an impression of rosacea. An April 1995 VA treatment note showed findings of folliculitis, seborrheic keratoses (SK), and actinic keratoses (AK). At that time, the Veteran underwent freezing of pre-cancerous skin areas. Additional VA treatment records dated in 1996 and 1997 showed complaints of lesions on skin and history of skin cancer with lesion behind ear frozen off as well as numerous skin findings, including cellulitis of right knee, nevi, nexus, blackhead, folliculitis, extracted trichilemmal cyst, SK, and AK. A June 1997 treatment record showed notations of skin lesions of the scalp and hands. A provisional diagnosis of skin lesions was listed with a notation questioning whether the lesions could be porphyria cutanea tarda. However, a December 1997 treatment note included reassurances that the lesions were SKs. In an undated VA treatment record, it was indicated that the Veteran had suffered a groin rash during service that resolved with treatment. In June 1998, the Veteran complained of lesions on the back of his head and back. The examiner listed an assessment of symptomatic epidermal cyst. The Veteran underwent excision of the posterior neck cyst in July 1998. In April 1996, October 1996, and August 1998 statements, the Veteran and his former attorney again asserted that he suffered from a skin disorder due to in-service Agent Orange exposure, had knots and bumps on his head, face, and back that drained and bled, received medications for skin treatment from VA, and had numerous cancerous growths on his neck, neck, hands, eyes, and stomach that were removed or burned off. In December 1999, the Veteran submitted copies of photographs purported to capture his claimed skin disorder. VA treatment records dated in November 2002 showed assessments of solar keratosis and actinic keratosis of the right forehead as well as acne rosacea of the nose. The examiner administered liquid nitrogen for destruction and anti-acne preparations for treatment. In March 2004, the Veteran was treated for basal cell carcinoma (BCC) with shave biopsy and AK. A VA treatment provider listed findings of BCC, AK, and SK lesions with freezing in April 2005. Treatment notes dated in September and October 2005 revealed assessments of SK with irritation, acne rosacea, and a few scattered AK across the forehead and anterior scalp that received cryodestruction. In August 2005, the Board remanded this matter to obtain additional VA treatment records. A November 2005 VA general medical examination report showed complaints of acne and cystic-like lesions that had been recurrent. The examiner specifically indicated that there were no scars, skin lesions, or pruritis on examination. Additional VA treatment records dated in October 2006 showed assessments of benign cysts, folliculitis, and scalp folliculitis. Physical examination findings were noted as several round papules and nodules with central pore, scattered erythematous pus-filled papules on upper back, scalp with erythema, and no skin lesions suspicious for skin cancers. A November 2007 treatment note listed assessments of xerosis, folliculitis, and AKs. Physical examination findings were noted as diffuse/dry/flaky skin of bilateral forearms and back, several erythematous papules on occipital scalp, and several erythematous, scaly papules on face, ears, and forearms. In a July 2008 VA general medical examination report, the Veteran complained of a rash on back/chloracne/skin condition that onset in 1968. He reported being sprayed with Agent Orange while in Vietnam and suffering an intermittent rash on skin since that time. Current symptoms were listed as intermittent pustules on back, face, neck, chest, and scalp with prescribed topical treatment. Skin examination findings were noted as solitary pustule on posterior occipital scalp with no bleeding or induration. The examiner listed a diagnosis of mild chloracne, noting that the disease or injury was incurred in service. In April 2010, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). The Board sought further VHA medical opinions in connection with the present claim in August 2010, December 2010, and April 2011. In an undated initial VHA opinion as well as March and May 2011 clarification opinions, a VA physician listed as a Chief in Dermatology, discussed his extensive and repeated reviews of the claims file. He first acknowledged the Veteran's service in Vietnam from February 1968 to October 1968. He then discussed in-service findings of impetigo of the lower leg that was successfully treated with topical antibiotic ointment. The physician indicated that impetigo is caused by a skin bacterial infection, is an acute process, and can be treated easily with systemic antibiotics. He opined that impetigo is not in any way related to Agent Orange. The physician then discussed the Veteran's successful in-service treatment for groin rashes for four days in May 1968. It was noted that intertrigo was a common skin condition affecting predominantly the groin area associated with high humidity, personal habit, and extreme environmental condition combining with work situation. He reported that it was a transient process, easily treated without sequel, and specifically highlighted that the Veteran did not currently suffer from intertrigo. The physician acknowledged the Veteran's normal service separation skin evaluation and then discussed his post-service skin treatments from 1993 to the present. It was noted that he did not understand how the Veteran received a diagnosis of chloracne with a normal skin evaluation, as a normal skin evaluation would exclude a diagnosis of chloracne. He further indicated that no documents of record were noted to substantiate any history of skin cancer. The physician noted that seborrheic keratosis was a benign process related to family history, genetic background, and age. He opined that the Veteran's diagnosed seborrheic keratosis was not related to service but to getting older and maturation. He also opined folliculitis was related to bacterial infection, occurred more frequently during hot and humid environment, that every human could contract it, and that it was not related to the Veteran's service experience. It was noted that the Veteran's folliculitis diagnosed post-service was related to hot and humid environment as well as the Veteran's working condition at that time. The physician further indicated that actinic keratosis was a very common skin disorder affecting predominantly Caucasians and was known to be related to excessive sun exposure and age. He opined that the Veteran's actinic keratosis was most related predominantly to his ethnic background, long time exposure to solar radiation from teenage to middle age, and was less likely related to service. In fact, he indicated that the Veteran's service might contribute to less than 10 percent of his actinic keratosis condition. The physician acknowledged post-service treatment in 2002 for acne rosacea, tinea versicolor, seborrheic keratosis, folliculitis, and actinic keratosis. He highlighted that the Veteran did not suffer from those conditions during service and that there were no published documents suggesting the relationship between Agent Orange exposure and those skin conditions. The physician again noted that there was no medical record suggesting that the Veteran had clinical signs of chloracne. Additional medical treatise searches were noted not to support the relationship between military service and development of seborrheic keratosis, rosacea, and folliculitis. The physician concluded that the Veteran's condition was not related to his military service. In May 2012, the Board remanded this matter to obtain updated VA treatment records as well as a VA examination with nexus opinion. In pertinent part, the examiner was requested to review the claims file and provide a diagnosis/diagnoses with respect to any skin disorder that might be present. The examiner was then requested to comment as to whether it was at least as likely as not (50 percent likelihood or greater) that any current skin disorder, to include chloracne as well as the skin disorders noted in the May 2011 opinion, was causally or etiologically related to his active service to include exposure to herbicides. In a June 2012 VA Skin Diseases Disability Benefits Questionnaire (DBQ) examination report, the examiner noted findings of actinic keratoses on sun exposed areas with no noted suspicious lesions. The examiner noted a history of basal cell carcinoma at the left forehead in 2005 and at the right lateral eye in 2004 as well as a history of seborrheic keratosis and actinic keratosis. She marked that the Veteran did not suffer from chloracne or other related disorders. It was further indicated that the Veteran had benign neoplasms that had been treated and were currently in watchful waiting status. After examining the Veteran and reviewing the claims file, the examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In her cited rationale, the examiner highlighted that basal cell carcinoma and actinic keratosis are more common in light skinned Caucasians similar to the Veteran. It was further noted that the Veteran also lived in the South, receiving increased sun exposure. The examiner clearly indicated that the conditions found above were not presumptive disorders for Agent Orange. She further commented that there was no indication that exposure to Agent Orange or combat duty in Vietnam would make the Veteran more subject to skin exposed lesions than a comparable person living in the South at his age, noting that approximately three in ten Caucasians develop basal cell carcinoma in their lifetimes. Computer printouts dated in May and June 2012 from the AMC showed that VA treatment records dated from June 2008 to June 2012 were associated with Virtual VA. A July 2008 dermatology clinic note revealed an assessment of seborrheic keratosis, resolved folliculitis, and resolved eczematous dermatitis. A February 2009 treatment note showed findings of several scaly, brown papules on face, arms, and chest and listed a diagnosis of seborrheic keratosis. Medication lists during this time period continued to show prescribed topical medications for treatment of folliculitis and rosacea. A November 2010 primary care note detailed that the Veteran reported sores on his arms had improved. A December 2010 dermatology consult showed complaints of rash over right temple with right eye pain and listed findings of xerosis and herpes ophthalmicus. An April 2012 treatment note showed a diagnosis of folliculitis. A May 2012 VA Teledermatology Imaging report showed findings of AK. In October 2012, the Board remanded this matter to obtain an additional medical opinion to ensure compliance with the prior May 2012 Board Remand. The Board sought an opinion as to whether the VA examiner's diagnosis of chloracne in the July 2008 VA examination report was at least as likely as not the result of in-service herbicide exposure. In an October 2012 VA Skin Diseases DBQ report, the June 2012 VA examiner again marked that she had reviewed the claims file. She acknowledged that she had been requested to provide an additional opinion as to whether the July 2008 diagnosis of chloracne was at least as likely as not the result of in-service herbicide exposure. The examiner again opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In her cited rationale, she clearly acknowledged the July 2008 VA examiner's findings of chloracne that was related to service. However, the examiner specifically indicated that the Veteran had not been diagnosed with chloracne by the VA dermatology clinic, a place where he had been receiving ongoing treatment for multiple skin disorders. She further highlighted that chloracne, by definition, occurred several days to several weeks after contact and that there were no complaints of a skin condition in the Veteran's service separation physical and that he had not been diagnosed with a skin condition during any of the benefit examinations performed after separation. In lay statements of record as well as during his May 2000 and June 2003 Board hearings, the Veteran has asserted that he suffers from a skin disorder due to his in-service herbicide exposure in Vietnam. During his May 2000 hearing, the Veteran reported that he suffered from sores on his head, face, back, and arms during service within days of being exposed to Agent Orange. He indicated that his unit suffered from the "103rd rash", named after his battalion. He further stated that he now suffers from a rash on his back and scalp. During his June 2003 hearing, the Veteran described his in-service exposure to Agent Orange and reported that he was told by a VA dermatologist that his growths were caused by Agent Orange. It was also asserted that the Veteran suffered from chloracne and porphyria cutanea tarda. In multiple lay statements, the Veteran's daughter asserted that her father suffered from sores on his back, neck, face, and head, including blackheads and pus filled sores or knots. She also indicated that she witnessed sores and rashes on the back of the Veteran's neck. Based on the foregoing, the Veteran is presumed to have been exposed to herbicide agents (Agent Orange). However, the probative medical evidence of record does not show his currently diagnosed skin disorders are not among the list of diseases enumerated under 38 C.F.R. § 3.309(e). The May 2011 VHA examiner and October 2012 VA examiner each specifically determined in reports of record that the Veteran's contention that he had chloracne was not substantiated clinically, citing a thorough rationale based on detailed review of the record and outside medical sources. The Board further acknowledges that the June 1997 VA treatment record a notation questioning whether the lesions could be porphyria cutanea tarda. However, the Board must highlight that this notation is highly speculative. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). In addition, evidence of record showed that the lesions were later found on biopsy in 1997 to be identified as seborrheic keratoses. The Board further acknowledges the sole favorable medical opinion of record provided by the July 2008 VA examiner with respect to the nature and etiology of the Veteran's skin disorder. Here, the July 2008 VA examiner did not provide any rationale for the expressed diagnosis of mild chloracne and opinion that it was incurred in service. The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). However, as noted above, the regulations governing presumptive service connection for Agent Orange do not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (1994). Accordingly, the Board will proceed to evaluate the Veteran's claim under the provisions governing direct service connection, 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303. As the Veteran currently has multiple skin disorders as noted in the post-service medical evidence of record. Evidence of record reflects that the Veteran has been diagnosed with several skin disorders during the pendency of his claim, to include tinea versicolor, xerosis, dermatitis, basal cell carcinoma, actinic keratoses, solar keratoses, acne rosacea, folliculitis, mild chloracne, and seborrheic keratoses. Concerning in-service injury, as the Veteran served in Vietnam, his exposure to Agent Orange is presumed. In addition, the Veteran's service treatment records reflected complaints of and treatment for impetigo as well as unidentified rashes on his legs and groin area in January 1967 and May 1968, respectively. However, a finding of a nexus or casual relationship between the Veteran's currently diagnosed skin disorders and in-service events is not shown. In this case, findings of any skin disorder were first shown many years after separation from active service and cannot be presumed to have been incurred during service. The Board also notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record also includes no probative medical opinion establishing a causal relationship between the post-service treatment for multiple skin disorders to any established event in service, including presumed in-service herbicide exposure. In fact, numerous VA examiners have specifically opined that the Veteran's current skin disorders are not casually related to events during his military service. In particular, the May 2011 VHA examiner and June/October 2012 VA examiner each based their opinions on review of the Veteran's entire claims file, extensively discussed the medical evidence of record as well as the lay assertions of the Veteran, cited to medical literature research, and provided a detailed rationale for their conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board again notes that the July 2008 VA examiner's conclusory opinion that the Veteran suffered from mild chloracne that was incurred in service is of little probative value, as it contained no stated rationale. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). The Board is also cognizant that the Veteran has asserted that a VA dermatologist had verbally told him that his claimed skin disorder was caused by his in-service herbicide exposure. However, a layman's account of what a doctor purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to hold any probative value. See generally Robinette v. Brown, 8 Vet. App. 69 (1995). The Board may appropriately favor the opinion of one competent medical authority over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). In this case, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the Veteran's present skin disorder was incurred due to events during active service weighs against the claim. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). The Board acknowledges the Veteran's contentions that his current skin disorder is related to his presumed in-service herbicide exposure. Although the Veteran might sincerely believe that his current skin disorder is related to events during service, as a layperson, his statements are not competent evidence of a medical opinion regarding the etiology of his skin disorder. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). In light of the cumulative record discussed above, the criteria to establish entitlement to service connection for a skin disorder has not been established, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a skin disorder, to include as secondary to herbicide exposure, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs