Citation Nr: 1319677 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-46 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to an increased rating for a skin disability, diagnosed as dermatographism, currently rated as noncompensably (0 percent) disabling. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from December 1963 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, in which the RO continued a 0 percent rating for dermatographism. In June 2011 and September 2012, the Board remanded the claim to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing the additional development, the AMC continued to deny the claim (as reflected in a February 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board. The Veteran's Virtual VA e-folder contains additional medical evidence that has been considered by the RO in the most recent SSOC. Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. The e-folder also includes more recent VA treatment records, dated from October 2012 to May 2013, which were not of record and considered at the time of the most recent SSOC. However, these records do not include treatment for the service-connected skin disability. Thus, while the Veteran has not waived RO consideration of the additional evidence dated since February 2012, a remand for such consideration is unnecessary. See 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. The Veteran's service-connected dermatographia has been manifested by recurrent episodes occurring four or more times a year and has responded to treatment with antihistamines; there is no evidence of recurrent debilitating episodes occurring at least four times a year, nor has this condition been shown to affect 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected or require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of at least six weeks during a 12-month period. CONCLUSION OF LAW The criteria for an increased rating of 10 percent, but no greater, for the service-connected skin disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.118, Diagnostic Codes 7806, 7825 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (Court) have been fulfilled. The Veteran's claim for an increased rating for his service-connected skin disability was received in October 2008. The Veteran was provided notice of what evidence was required to substantiate his claim for an increased rating, and of his and VA's respective duties for obtaining evidence in correspondence dated in November 2008. The claim was reviewed and the January 2009 rating decision was issued. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in the November 2008 letter. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records and VA and private treatment records have been obtained and associated with his claims file and Virtual VA e-folder. The Veteran was also provided with VA examinations to evaluate his service-connected skin disability in December 2008, August 2011, and October 2012. During the August 2011 VA examination, the Veteran asked for the examination to be rescheduled and it was ended. That examination was not completed and a physical examination was not conducted at that time. Nevertheless, the Veteran's service-connected skin disability was subsequently evaluated during VA examination in October 2012. The claim was remanded in September 2012 to comply with the June 2011 remand directives by affording the Veteran a VA examination to evaluate the service-connected skin disability. The Board also instructed that the Veteran's VA treatment records dated since March 2012 were to be obtained. The AMC was also to contact the Veteran and ask that he provide sufficient information and, if necessary authorization, to enable VA to obtain any non-VA treatment records pertinent to his service-connected skin disability. The Veteran's VA treatment records dated since March 2012 have been added to his Virtual VA e-folder. The AMC sent the Veteran a letter in October 2012 in which it asked the Veteran to provide the names, addresses, and dates of VA and non-VA healthcare providers who had evaluated or treated him for his skin disability. The Veteran was instructed to complete and return an enclosed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each healthcare provider so that his treatment information could be obtained. The Veteran was also informed that he could obtain and send the information himself. The Veteran did not subsequently provide a release to allow VA to obtain any private treatment records. The claims file reflects that the Veteran has received private treatment. A May 2010 VA treatment record indicates that the Veteran saw a private dermatologist, Dr. L.E. May and June 2011 records indicate that the Veteran was co-managed through his private primary care physician, Dr. J., and the VA Waterbury clinic. A March 2012 VA treatment record reflects that the Veteran saw his private allergist, Dr. D.H.D., earlier that week. While records from Dr. D.H.D., dated in May and June 2011, have been associated with the claims file, no more recent treatment records from this physician, or any records from Dr. L.E. or Dr. J., have been obtained. However, VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As the Veteran has not provided a release form to enable VA to obtain additional private treatment records, despite being specifically asked to provide a release for non-VA treatment in the October 2012 letter; it is not possible for VA to obtain them. No further action in this regard is warranted. A claimant has the responsibility to present and support a claim for benefits under laws administered by VA. 38 U.S.C.A. § 5107(a). While VA has a duty to assist the veteran in substantiating his claim, that duty is not a one-way street. Woods v. Gober, 14 Vet.App. 214, 224 (2000); see also Hurd v. West, 13 Vet.App. 449, 452 (2000) (the Veteran cannot passively wait for help from VA). The October 2012 VA examination report is responsive to the Board remand directives and includes findings necessary to evaluate the service-connected disability. Thus, this examination report is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). In the September 2012 remand, the Board had asked the examiner to indicate the frequency with which the Veteran required prescribed oral hydroxyzine pamoate, and whether hydroxyzine pamoate is a "systemic therapy such as corticosteroids or other immunosuppressive drug." The October 2012 VA examiner did not indicate whether or not hydroxyzine pamoate is a systemic therapy such as corticosteroids or other immunosuppressive drug; however, she found that the Veteran had not been treated with oral medications for his skin condition in the past 12 months. As will be discussed below, the record reflects that this medication is an antihistamine, as opposed to an immunosuppressive drug. Given the Board's present granting of the claim, the medical evidence currently available for the Board's review, including the most recent VA examination report, describes the severity of the Veteran's service-connected dermatographia, and includes findings responsive to the pertinent rating criteria. The evidence of record is adequate to evaluate the service-connected skin disability. Thus, there was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In his June 2009 notice of disagreement (NOD), the Veteran asserted that his skin condition was worse in the summer and, therefore, should be examined in the summer. In Ardison v. Brown, 6 Vet. App. 405, 408 (1994), a case that concerned the evaluation of a service-connected disorder that fluctuated in its degree of disability, that is, a skin disorder that had "active and inactive stages" or was subject to remission and recurrence, the Court remanded the case for VA to schedule the appellant - veteran for an examination during an "active" stage or during an outbreak of the skin disorder. Ardison, 6 Vet. App. at 408; see also Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) (frequency and duration of outbreaks and their appearance and virulence during outbreaks must be addressed). Thus, the frequency, duration, and severity of skin disease exacerbations must be addressed, and a skin disorder should be considered, whenever possible, at a time when it is most disabling. In this case, the Board has before it all available evidence for multi-year period on appeal, including VA dermatology treatment records from various times of year and VA skin examinations also conducted at different times. The evidence of record is therefore adequate to properly evaluate the service-connected dermatographia pursuant to the applicable rating criteria. The Veteran's service-connected skin disability has been evaluated pursuant to Diagnostic Code 7806. The regulations evaluating skin disabilities were revised effective August 30, 2002. See 67 Fed. Reg. 49,596 (July 31, 2002). As the current claim for an increased rating was filed in October 2008, the rating criteria, as revised effective August 30, 2002 are for consideration. The November 2009 statement of the case (SOC) included the version of Diagnostic Code 7806, as in effect prior to the August 30, 2002 revision, in the section titled "Pertinent Laws; Regulations; Rating Schedule Provisions." However, the RO discussed the correct rating criteria, as in effect since the August 30, 2002 revision, in discussing the reasons and bases for its decision. The inclusion of the prior version of the regulation in the November 2009 SOC, in this case, is harmless error. 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 claimant); 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 claimant are to be avoided). Notably, the Veteran has been represented by an accredited representative during his appeal and has clearly had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board is granting an increased, 10 percent rating for the service connected skin disability for the entire period pertinent to the current claim for an increased rating. There is no reasonable possibility that further assistance will aid in establishing an even higher rating. The Merits of the Claim Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In a September 2005 rating decision, the RO granted service connection and assigned an initial noncompensable (0 percent) rating for dermatographism, pursuant to Diagnostic Code 7899-7806, effective January 10, 2005. On October 8, 2008, the Veteran filed his current claim for an increased rating. In the January 2009 rating decision, the RO continued the noncompensable rating for dermatographism, pursuant to Diagnostic Code 7899-7806. The rating criteria for evaluating skin disabilities were amended during the course of this appeal, effective October 23, 2008. See 73 Fed. Reg. 54,708 (September 23, 2008) (presently codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7833 (2012)). Nevertheless, the revised criteria only apply to claims filed on or after October 23, 2008, and to those claims where a request for consideration of the new criteria has been received. See 73 Fed. Reg. 54,708. The Veteran's claim was filed on October 8, 2008, prior to the effective date of the revised criteria, and he has not requested consideration of his claim under the revised criteria. Therefore, those revised criteria are not for application. In any event, the pertinent diagnostic codes for consideration in this case, Diagnostic Codes 7806 and 7825, were unchanged by the October 2008 revisions. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. When an unlisted disease is encountered, rating by analogy is permitted pursuant to 38 C.F.R. § 4.20. The Veteran's disorder is rated under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. Id. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: The first 2 digits will be selected from that part of the schedule most closely identifying the part or system of the body involved; the last 2 digits will be "99" for all unlisted conditions. 38 C.F.R. § 4.27. Diagnostic Code 7806 rates dermatitis or eczema. A noncompensable rating is warranted if less than 5 percent of the entire body or less than 5 percent of the exposed areas are affected; and, no more than topical therapy is required during the past 12- month period. A 10 percent rating is warranted for dermatitis or eczema that affects 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, or; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema that affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. If more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period a 60 percent rating is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7806. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board is granting an increased, 10 percent rating for the service-connected dermatographia pursuant to Diagnostic Code 7825, evaluating urticaria. A 10 percent rating is warranted where there are recurrent episodes of urticaria occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics. A 30 percent rating is warranted where there are recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. A maximum 60 percent evaluation is warranted where there are recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 38 C.F.R. § 4.118, Diagnostic Code 7825. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of the inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran submitted his claim for an increased rating in October 2008. "The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Service treatment records reflect treatment for dermatographia, with welts forming on scratching the skin or carrying a pack. VA treatment records reflect that the Veteran was seen in the dermatology clinic in October 2007. He gave a history of extremely pruritic skin, and reported having few symptoms indoors, but exacerbation of symptoms when outdoors. He also reported having seasonal allergies and dermatographism, with symptoms present since his service in Vietnam. Examination revealed no active lesions, but there was noticeable dermatographism on the Veteran's arms and back. The assessment was atopic dermatitis and the Veteran was prescribed atarax (hydroxyzine) for flares and before doing yard work, as well as triamcinolone cream. A June 2008 treatment record lists hydroxyzine pamoate among the Veteran's active medications, with instructions to take one capsule by mouth as directed before working outside, up to four pills a day. The Veteran presented for reevaluation of his skin problem in August 2008. He reported that, since returning from Vietnam, he developed welts that hurt and itch with firm pressure (even a fold in the bed sheets) or rubbing. He stated that nothing helped except triamcinolone cream, adding that he did not like antihistamines as they interfered with his breathing. He stated that he had tolerated hydroxyzine, but had discontinued this medication because of pain in his shoulders, although this pain was not necessarily associated with the medication. Examination revealed no skin changes other than xerosis. There was no dermatographism, instead, the Veteran's skin was just a little pink, although he stated that the dermatologist did not rub deep enough The assessment was possible pressure urticaria versus subtle dermatographism. It was recommended that the Veteran take cetirizine daily and use triamcinolone ointment twice daily. In his October 2008 claim for an increased rating, the Veteran reported that he had been receiving treatment for his skin condition, but still broke out. He stated that he had had to keep his spouse, children, and grandchildren at arm's length for forty years because he broke out when touched. The Veteran was afforded a VA skin examination in December 2008. The examiner reviewed a prior, September 2005 VA examination report, as well as the dermatology treatment record from August 2008. The examiner reported that the Veteran was not treated with an immunosuppressive drug, intensive light therapy, UVB, PUVA, or electron beam therapy. His symptoms were described as pruritus during acute insult. Examination revealed 0 percent of the exposed body area and total body area to be affected. There was no urticarial lesion and the examiner did a scratch test on the forearm with pink changes but no wheal after several minutes. The impression was pressure urticaria with dermatographism controlled with almost daily use of topical steroids. In his June 2009 NOD, the Veteran, through his representative, asserted that he was being prescribed internal steroids (specifically, hydroxyzine pamoate) for his skin condition. A November 2009 VA medication list classifies both cetirizine and hydroxyzine pamoate as antihistamines. In April 2010, the Veteran presented to the Florida Center for Allergy and Asthma Care where he was diagnosed with dermatographism and rule out mushroom allergy/lip angioedema. The Veteran underwent allergy testing, and tested positive for several food products. A May 2010 VA treatment record reflects that the Veteran was seen in the VA dermatology clinic for the first time since August 2008. He reported that he had been seen by a private dermatologist since that time. The VA dermatologist reviewed the records from this private physician which indicated a diagnosis of dermographism, for which the Veteran had been prescribed hydroxyzine. The Veteran stated that, as long as he took this medication four times daily, his skin was "fine." The VA dermatologist further noted that the Veteran had been in Florida in early April and experienced an episode of lip swelling for which he went to a private healthcare provider and was diagnosed with angioedema of the lips and dermatographism, for which he was given Benadryl and Xyzal with good effect. The VA dermatologist commented that the April 2010 private allergy test results were not helpful because the Veteran continued to eat the items for which he had tested positive with no effect. There was no dermographism on examination; however, the VA dermatologist noted that the Veteran was taking hydroxyzine. The assessment was dermographism, and the Veteran was instructed to continue taking hydroxyzine. In August 2010, the Veteran reported to his VA dermatologist that his urticaria had been getting worse. He stated that his condition was somewhat controlled with hydroxyzine, but he did not like to take this medication and wanted to try to find the cause of his condition. He denied systemic symptoms such as joint pain, morning stiffness, myalgias, or fevers. Examination of the back revealed mild dermatographism. The assessment was chronic urticaria. Possible etiologies were discussed and the Veteran was referred to an allergist. The Veteran was evaluated by a private allergist in May 2011. The physician, Dr. D.H.D., stated that the Veteran was seen for allergy testing for hives and skin rashes and also had asthma. Because his asthma worsened with some antihistamines, he avoided taking these medications. He commented that the Veteran had recently had a severe allergic reaction after food including shellfish in Florida, but continued to consume shellfish. The assessment was allergic rhinitis, severe persistent asthma, extrinsic asthma, urticaria, allergic urticaria, angioedema, and anaphylaxis due to adverse food reaction. The Veteran was prescribed several medications, including prednisone, for which he was prescribed a tapering dose for seven days and then instructed to use for asthma/allergy exacerbations. The Veteran returned for follow-up the following month, at which time he stated that his nasal congestion, skin itching, and cough had all improved and he was off medication. The assessment was allergic rhinitis, moderate persistent asthma, extrinsic asthma, atopic eczematous dermatitis, and allergic urticaria. The Veteran was instructed to use skin moisturizer in addition to antihistamines, topical corticosteroids, and asthma therapy. He was told to call and start oral corticosteroids if asthma, eczema, or an allergy became worse prior to follow-up. During VA dermatology treatment in May 2011, the Veteran had no present skin complaints. March and June 2011 VA treatment records note that the Veteran had a prior medical history of chronic urticaria which was stable with triamcinolone and, occasionally, hydroxyzine. Examination of the skin revealed no current lesions or rashes. The Veteran presented for a VA skin examination in August 2011, at which time he reported that a wrinkle on his sheet even caused a skin reaction, to include itching. He stated that pressure of any sort bothered him a lot, though he had learned to deal with it. The examiner stated that the Veteran was a very unreliable historian and described a confrontation when he reported that he was taking hydroxyzine four times a day. The VA examiner noted that this medication had not been prescribed this way, but was prescribed to take as needed when working outside. The Veteran, in response, reported that he went outside everyday and considered that "working" but also stated that he no longer took the medication because it caused arrhythmias. The examiner further reported that she had applied linear pressure to the volar forearm and there was no wheal or urticaria after five to seven minutes, despite the Veteran insisting that there was. She added that the Veteran stated that the folds in his jeans when he crossed his legs would cause his skin reaction, but when she asked him to leave his legs crossed so she could see the induced lesions, the Veteran responded that he wanted to reschedule the appointment. No physical examination was conducted. The examiner did diagnose dermatographism and listed the Veteran's medications, including ventolin HFA, acyclovir, simvastatin, hydrochlorothiazide, triamcinolone actinide, hydroxyzine pamoate, advair, an epi pen, prednisone, flonase nasal spray, and allegra. The examiner commented that the Veteran had been diagnosed with asthma, allergy symptoms, and dermatographism/urticaria. He usually used topical medications for skin eruptions, but used oral hydroxyzine when working outdoors on an as needed basis. She added that the Veteran's allergic issues and asthma were treated with the other listed medications, including oral prednisone to be taken as needed. She stated that systemic medications were taken daily for allergies and asthma, and emphasized that oral medications were not taken daily for the service-connected skin disability. A January 2012 VA treatment record indicates that the Veteran had been prescribed fexofenadine to try for his dermatographism by Dr. D.H.D.; however, it was agreed with the Veteran's private allergist, that he would be given Zyrtec instead, with the first dose to be given in Dr. D.H.D.'s office because there was a question of an allergy to antihistamines. The Veteran presented to the VA Waterbury clinic in March 2012 reporting that he had eaten a chili dog six days earlier, after which he developed swelling of his lip and hives. The assessment was mild urticaria; however, because he was symptomatic, the Veteran was started on a prednisone taper. Dermatographism was also noted. In follow-up later that week, the Veteran reported that he had finished his course of prednisone but was itching all over with red skin. He declined continuing prednisone as recommended by his allergist. Examination revealed 2 small urticarial appearing lesions on arms with minimal erythema and slight elevation. The assessment was chronic urticaria. In October 2012, the Veteran told his VA primary care physician that he could cope with his skin condition and the treatment. He added that antihistamines and steroids made things worse. The assessment was chronic urticaria and the Veteran declined to take the antihistamine which had been prescribed by Dr. D.H.D. (loratidine) as he had previously had issues of his heart racing with antihistamines and did not tolerate prednisone. In an April 2012 statement, the Veteran expressed disagreement with the August 2011 VA examiner's description of his examination. He stated that his skin condition occurred any place and any time when pressure was applied to his skin, adding that this condition was worse in hot weather and was not as bad in the winter. He added that he could not take hydroxyzine pamoate because he was on disability for arrhythmias and this medication caused his heart to accelerate. He also stated that, on his way home following the examination, welts did appear on his left arm where the examiner had scraped him with an instrument. The Veteran was most recently afforded a VA skin examination in October 2012. The examiner noted that the Veteran had dermatographism/urticaria. He described skin symptoms when any pressure was applied, such as by being grabbed, when scratched while working outdoors, and sometimes even when there was a wrinkle in his sheets. He reported that he mostly had problems during the hot summer weather, with fewer incidents in the winter; although any pressure could still cause itchiness followed by hives and welts. The examiner applied strokes to the Veteran's forearm. He started itching in five minutes and welts developed about 15 minutes later. The Veteran stated that he was not able to take antihistamines because of breathing issues and was not able to take steroids because of heart palpitations. He added that his skin condition affected him mentally because of reduced physical activity with his family. Regarding medication, the Veteran reported that he was only presently using triamcinolone ointment twice daily when he had these episodes. The examiner commented that the Veteran had been using this topical treatment for six weeks or more, but not constantly, in the past 12 months. She added that the Veteran had not had any debilitating episodes in the past year due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. However, she reported that the Veteran had had non-debilitating episodes of urticaria occurring four or more times in the past 12 months, describing the development of itching and welts on the forearm after being stroked. She commented that the non-debilitating episodes of urticaria responded to topical triamcinolone ointment. Examination revealed dermatitis affecting none of the exposed or total body area. The examiner commented that the Veteran's dermatographism effected his ability to work in that he had to be very careful what he did because any pressure would cause welts accompanied by a lot of itchiness and discomfort. She later added that even the slightest stroke would cause itchiness and discomfort. She stated that the Veteran experienced mild functional impairment as a result of his dermatographism and observed that, when the Veteran left the room after 45 minutes, the welt/urticaria which she had induced was still there. The examiner further noted that the Veteran was unable to take oral prednisone due to tachycardia and unable to take antihistamines because of breathing issues. Considering the pertinent evidence of record in light of the law, and resolving all reasonable doubt in favor of the Veteran, the Board finds that an increased, 10 percent rating is warranted. The most recent VA examination report reflects that the Veteran has experienced non-debilitating episodes of urticaria occurring four or more times in the past 12 months, consistent with a 10 percent rating pursuant to Diagnostic Code 7825. The evidence reflects that the Veteran has taken antihistamines to control his dermatographia at various times since filing his current claim for an increased rating, though not continuously. He reported to the August 2008 VA examiner that he had stopped taking hydroxyzine because of pain in his shoulders. While he reported to his VA dermatologist in May 2010 that as long as he took hydroxyzine four times daily, his skin was fine, he reported to the August 2011 VA examiner that he had stopped taking this medication. He indicated during the October 2012 VA examination that he was not taking antihistamines or steroids, and was only using triamcinolone ointment twice daily when he had episodes of dermatographia. A VA treatment record from the same month reflects that the Veteran declined to take a different antihistamine prescribed by Dr. D.H.D. In any event, the Veteran's May 2010 report that his skin was fine as long as he took hydroxyzine four times a day, his August 2010 statement that his condition was somewhat controlled with hydroxyzine, and the March and June 2011 treatment records noting that the Veteran had a prior medical history of chronic urticaria which was stable with triamcinolone and occasional hydroxyzine indicate that the service-connected skin disability has, at least at times, responded to treatment with antihistamines, consistent with the requirements for a 10 percent rating pursuant to Diagnostic Code 7825. The Veteran reported to his VA physician in October 2012 that "antihistamines and steroids make things worse." However, it is not clear that this statement was in reference to making the service-connected skin disability worse (such that it would not be determined to be responsive to antihistamines). Rather, when read in the context of the October 2012 VA examination report, which indicates that the Veteran was unable to take oral prednisone due to tachycardia and unable to take antihistamines because of breathing issues it is more likely that his statement was intended to convey that the use of these medications had undesirable effects unrelated to the service-connected skin disability. The Board has considered that the dermatologist who evaluated the Veteran in August 2008 found no dermatographism on examination; however, the Veteran stated that the dermatologist did not rub deep enough. Earlier examination at the dermatology clinic in October 2007 did reveal noticeable dermatographism on the Veteran's arms and back. While the scratch test performed by the December 2008 VA examiner revealed pink changes but no wheal after several minutes, this examiner also, nevertheless, diagnosed pressure urticaria with dermatographism. There was, again, no dermographism on examination during VA treatment in May 2010; however, the VA dermatologist noted that the Veteran was taking hydroxyzine at that time. Examination of the back during VA treatment in August 2010 revealed mild dermatographism and the October 2012 VA examiner's application of strokes to the forearm resulted in itchiness and welts. Moreover, the Veteran has repeatedly described skin reactions, including itching, hives, and welts, when pressure is applied to the skin. He is competent to report such symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board has considered the opinion of the August 2011 VA examiner, that the Veteran is a very unreliable historian, but finds no reason to doubt the Veteran's credibility. Indeed, the Veteran's reports of symptoms of dermatographism are supported by findings of several other medical professionals as documented in the pertinent medical evidence dated since the current claim for an increased rating. While the August 2011 VA examiner commented that there was no wheal or urticaria five to seven minutes after applying linear pressure to the volar forearm, the Veteran subsequently reported that welts did appear after leaving the examination. His report is consistent with the findings from the most recent VA examination, that welts developed 15 minutes after the examiner applied strokes to his skin and these welts persisted for at least 45 minutes. Resolving any doubt in the Veteran's favor, and considering his consistent reports of skin symptoms, including itching, hives, and welts when pressure is applied to the skin, the Board finds that his service-connected dermatographism has been manifested by recurrent episodes of urticaria occurring at least four times during a 12-month period and responding to antihistamines. Thus, a 10 percent rating is warranted. As there is no evidence of an increase in disability within the one year period prior to the Veteran's October 8, 2008 claim for an increased rating, the proper effective date for the increased rating is October 8, 2008. See 38 C.F.R. § 3.400(o)(2). However, a rating in excess of 10 percent is not warranted. A higher rating pursuant to Diagnostic Code 7825 requires recurrent debilitating episodes occurring at least four times during the past 12-month period. There is no indication of any debilitating episodes of urticaria or dermatographia at any time since the Veteran filed his October 2008 claim for an increased rating. Rather, during the August 2011 VA examination, the Veteran reported that pressure of any sort bothered him a lot, but he had learned to deal with his skin condition. He told his VA primary care physician in October 2012 that he could cope with his skin condition and the October 2012 VA examiner commented that the Veteran experienced only mild functional impairment as a result of his dermatographism. The record also reflects that the Veteran has remained employed part-time. The Veteran has been prescribed various medications for his service-connected dermatographia, including, as discussed above, hydroxyzine. While the Veteran's representative asserted in the June 2009 NOD that the hydroxyzine pamoate was an internal steroid, he provided no basis for this classification. Significantly, the November 2009 VA medication list classifies both cetirizine and hydroxyzine pamoate as antihistamines. Diagnostic Code 7825 itself differentiates between antihistamines and systemic immunosuppressive therapy, as the former is listed in the criteria for a 10 percent rating and the latter is referenced in the criteria for higher ratings. The Board, therefore, finds that the antihistamines which the Veteran has taken to treat his service-connected skin disability at various times do not qualify as immunosuppressive drugs. The conclusion that hydroxyzine pamoate is not an immunosuppressive drug is further supported by the fact that the December 2008 VA examiner reviewed the VA records, including the August 2008 dermatology note indicating that the Veteran had tolerated hydroxyzine, but nevertheless found that no immunosuppressive drug was used to treat the service-connected skin disability. Additionally, Dr. D.H.D.'s May 2011 treatment record makes a distinction between antihistamines and oral corticosteroids (which are immunosuppressive drugs) in that the Veteran was instructed to use antihistamines but was to call and start oral corticosteroids if asthma, eczema, or an allergy became worse prior to follow-up treatment. The Veteran has been prescribed other oral medications to treat his service-connected skin disability, including Benadryl, Xyzal, fexofenadine, Zyrtec, and loratidine. However, like hydroxyzine and cetirizine, these medications are also antihistamines and, therefore, do not qualify as systemic immunosuppressive therapy as contemplated in the rating schedule. The Veteran was prescribed prednisone twice since filing his current claim for an increased rating, by Dr. D.H.D. in May 2011 and by his VA physician in March 2012. It is not clear that prednisone, which is a corticosteroid, was prescribed to treat the service-connected skin disability. Dr. D.H.D. prescribed a tapering dose for seven days and then instructed the Veteran to use this medication for asthma/allergy exacerbations. The August 2011 VA examiner commented that oral prednisone had been prescribed to take as needed for allergic issues and asthma. The VA physician prescribed prednisone after the Veteran experienced swelling of his lips and hives after eating a chili dog. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Even assuming that the Veteran was prescribed prednisone to treat his service-connected skin disability, the criteria for a 30 percent rating pursuant to Diagnostic Code 7825 are conjunctive, not disjunctive; thus all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Therefore, in the absence of four or more debilitating episodes of dermatographia a year, a higher rating pursuant to Diagnostic Code 7825 is not warranted. A rating in excess of 10 percent is also not warranted pursuant to Diagnostic Code 7806, as there is no showing that the service-connected skin disability has affected 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas. Rather, the December 2008 VA examiner found that the Veteran's service-connected skin disability affected 0 percent of his exposed body area and total body area. The most recent VA examination revealed only dermatitis which, percentage-wise, affected none of the exposed or total body area. The Veteran has also not required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more during a 12-month period. Even assuming that the prednisone which has been prescribed to the Veteran was intended to treat the service-connected skin disability, the record reflects that he has only been prescribed this medication twice since filing his claim for an increased rating, each time for a tapering dose, and the most recent VA examination report notes that he was unable to take oral prednisone due to tachycardia. Accordingly, a higher rating pursuant to Diagnostic Code 7806 is not warranted. The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. The Board has considered entitlement to an extra-schedular rating for the service-connected skin disability. However, the Veteran's skin disability does not markedly interfere with his ability to work, meaning above and beyond that contemplated by schedular rating. While the October 2012 VA examiner opined that this disability impacted the Veteran's ability to work in that he had to be very careful what he did because any pressure would cause welts accompanied by a lot of itchiness and discomfort, she also characterized the functional impairment experienced by the Veteran as mild. Further, some interference with employment is already contemplated by the disability rating that is assigned. The record reflects that he has maintained his part-time employment as a driver during the pendency of this appeal. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). 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. 38 C.F.R. § 4.1; VAOPGCPREC 6-96. See also, Bagwell v. Brown, 9 Vet. App. 337, 338 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). There is no medical evidence or lay assertion of "marked interference with employment" due to the service-connected disability to render impractical the application of the regular rating standards. See 38 C.F.R. § 3.321(b)(1). Finally, there is no evidence of any other exceptional or unusual circumstances, such as frequent hospitalizations due to his service-connected skin disability, to suggest he is not adequately compensated by the regular Rating Schedule. See 38 C.F.R. § 3.321(b)(1); VAOPGCPREC 6-96. The Board has considered the Veteran's reports of lessened physical activity with his family, but finds that the symptoms produced by his service-connected skin disability are part of the non-debilitating recurrent episodes he experiences, and for which an increased 10 percent rating is being assigned. The Board has resolved reasonable doubt the Veteran's favor in determining that a 10 percent rating is warranted for the service-connected skin disability, effective October 8, 2008, but finds that the preponderance of the evidence is against assignment of a rating greater than 10 percent. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 10 percent rating for the service-connected skin disability, diagnosed as dermatographism, is granted, effective October 8, 2008, subject to the legal authority governing the payment of VA compensation. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs