Citation Nr: 1323913 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 07-21 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for skin disability, including as secondary to herbicides. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active military duty from June 1969 to December 1970. His service included Vietnam service. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating action of the Department of Veterans Affairs Regional Office (RO) in Providence, Rhode Island. In that decision, the RO in part denied claims for service connection for a skin disability, and a bilateral knee disability. In a December 2010 decision, the Board, adjudicated several issues and remanded the service connection claims for skin and bilateral knee disability to the RO for further development. While the matters were pending on appeal, the RO granted service connection for a right knee disability in a June 2012 decision thereby removing this matter from appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Thereafter, the Board in a February 2013 decision adjudicated he left knee claim and remanded the skin disorder claim a second time for additional development. The remaining appellate issue of entitlement to service connection for a skin disability is returned to the Board for further consideration. FINDING OF FACT Chronic skin disability did not have its clinical onset in service and is not otherwise related to active duty, including presumed exposure to herbicides. CONCLUSION OF LAW Chronic skin disability was not incurred in or aggravated by service, including Agent Orange exposure therein. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a January 2006 letter, sent prior to the initial April 2006 rating decision, advised the Veteran of the evidence and information necessary to substantiate his service connection claim for a left knee disability, as well as his and VA's respective responsibilities in obtaining such evidence and information. In October 2009, the Veteran was informed of the process by which initial disability ratings and effective dates are established, as required by Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim was readjudicated by a SSOC in April 2013. The Board finds that the duty to notify has been met. Further, VCAA notice error is not presumed to be prejudicial. See Shinseki v. Sanders, 556 U.S. 396, 129 S. Ct. 1696, 173 L.Ed.2d 532 (2009). Neither the Veteran nor his representative has asserted any specific prejudice in any of the VCAA notice given. The rating decision and the statement of the case (SOC) set forth detailed reasons and bases as to why the Veteran's claims was denied as well as the evidence that is needed to prove the claims. Thus any error in the VCAA notice is shown to be harmless. Relevant to the duty to assist, the Veteran's service treatment and personnel records, VA treatment records, and private treatment records have been obtained and considered. The Board has reviewed the Veteran's Virtual VA claims file. Additionally, the Veteran was afforded a VA examination in March 2013. The proffered opinion regarding the etiology of the claimed skin disabilities was based on an interview with the Veteran, a review of the record, and a full examination. As such, the Board finds that the opinions proffered by the VA examiner is sufficient to decide the claim. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the appellant in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of 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). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the appellant will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis The Board has reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Also, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Generally, 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 pre-existing injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b) (2012). Service connection may 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) (2012). In addition to law and regulations regarding service connection, the Board notes that a disease associated with exposure to certain herbicide agents listed in 38 C.F.R. § 3.309(e) will be considered to have been incurred in service under the circumstances outlined in that section, even though there is no evidence of such disease during such period of service. 38 C.F.R. § 3.307(a) . 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, and has a disease listed in 38 C.F.R. § 3.309(e) 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. 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 § 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 § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; type II diabetes; Chronic lymphocytic leukemia; Hodgkin's disease; Multiple myeloma; Non-Hodgkin's lymphoma; Acute and subacute peripheral neuropathy; Porphyria cutanea tarda; Prostate cancer; Respiratory cancers (cancer of the lung, bronchus, larynx or trachea); Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The term "soft-tissue sarcoma" includes the following: Adult fibrosarcoma; Dermatofibrosarcoma protuberans; Malignant fibrous histiocytoma; Liposarcoma; Leiomyosarcoma; Epithelioid leiomyosarcoma (malignant leiomyoblastoma); Rhabdomyosarcoma; Ectomesenchymoma; Angiosarcoma (hemangiosarcoma and lymphangiosarcoma); Proliferating (systemic) angioendotheliomatosis; Malignant glomus tumor; Malignant hemangiopericytoma; Synovial sarcoma (malignant synovioma); Malignant giant cell tumor of tendon sheath; Malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; Malignant mesenchymoma; Malignant granular cell tumor; Alveolar soft part sarcoma; Epithelioid sarcoma; Clear cell sarcoma of tendons and aponeuroses; Extraskeletal Ewing's sarcoma; Congenital and infantile fibrosarcoma; Malignant ganglioneuroma. For purposes of this section, the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall be service connected if they manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, shall have become manifest to a degree of 10 percent or more within one year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. A presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. Diseases Not Associated With Exposure to Certain Herbicide Agents, 68 Fed. Reg. 27,630 (May 20, 2003); see also Health Outcomes Not Associated With Exposure to Certain Herbicide Agents, 72 FR 32395-01 (June 12, 2007). The United States Court of Appeals for the Federal Circuit has held, however, that a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status will not always constitute competent medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 . The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076 ; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303 -04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service treatment records do not reflect any evidence of skin problems noted or treated in service. His June 1969 preinduction and the December 1970 separation examination revealed normal skin and the accompanying reports of medical history were negative for any history of skin diseases. Private treatment records reflect that the Veteran had mole removed from the right hand in June 1997, and in July 1997 he had recheck of a right forearm and back lesion. In April 1999 he had removal of a mole from the left eye area. In August 2002 while treated for bladder cancer, it was noted that there was question of a rash after angiogram. In April 2004 he had an eyelid mass of 2 years duration removed and biopsied. Results of the biopsy in May 2004 were consistent with squamous papilloma with no evidence of dysplasia or malignancy. VA treatment records reveal that in October 2006 the Veteran was followed by primary care for a skin infection of the right groin with an erythematous area with mild tenderness to palpation. It was also reported that there was a past medical history of dry skin both legs with blistering in the sunlight. This past medical history was again repeated in VA records from 2007. In April 2007 he was noted to have abrasions of the back and both hands. In June 2007 telephone request, he wanted a dermatology consult for long standing problems in both legs, of white spots from the calf down into his feet, which he indicated he was told was dry skin by his primary care doctor. Primary care records from June 2007 gave a history of skin rash of the lower legs with extension to the right thigh said to have been present since Vietnam. On physical examination his skin was unremarkable. He was assessed with rash of the lower legs with extension to the right thigh to be referred to VA dermatology. In August 2007 the Veteran was seen by dermatology clinic for the complaints of white spots on his bilateral lower extremities of several years duration. He also complained of raised lesion of the right lateral ankles. Physical examination revealed him to be very tanned. On his upper back was a 4 millimeter brown hyperkeratotic papule. Located on the left dorsal hand were 2 lesions approximately 6 millimeters that were scaly skin colored plaques with excoriations. Distributed on the lower extremities were multiple 2-3 millimeter white to skin colored papules. On the right lateral ankle was a 3 millimeter hyperkeratotic light brown papule. The diagnosis was stucco keratosis of the lower extremities which the Veteran was advised were benign. Also diagnosed was seborrheic keratosis (SK) of the right lateral ankle treated with liquid nitrogen times 2. He was also diagnosed with likely irritated SK's versus actinic keratosis (AK's) of the left dorsal hand also treated with liquid nitrogen. He was also diagnosed with likely SK versus basal cell carcinoma (BCC) of the left upper back, biopsied. A June 2008 VA examination for post traumatic stress disorder (PTSD) noted active medical problems including skin cancer. He reported having had same day surgery at a private hospital to remove cancerous lesions along his upper lip area, with this area noted to still be swollen. Skin cancer was included in the Axis III diagnosis. The Veteran was followed up by the VA dermatology clinic in August 2008 for squamous cell carcinoma (SCC) of the left upper cutaneous lip, status post Moh's in May 2008, stucco keratosis of the lower legs benign, with no treatment required. He was tan, with risks of tanning discussed as associated with skin cancer. On examination, his skin was very tanned in the photo distributed areas, he had diffuse xerosis, and his right scalp had a 5 millimeter pink, pearly papule. Located on his left upper lip was a 2 millimeter verucca vulgaris (VV) papule with crust. On his right hand was a thin 4 millimeter papule. He was assessed with rule out BCC right scalp and a biopsy was taken. The VV of the left upper lip and the AK were treated with cryotherapy. His xerosis was prescribed treatment with various moisturizers. Regarding the skin cancer, he was educated on sun protection and to monitor a suspicious lesion. On follow-up in September 2008 he was seen for suture removal and biopsy results. The surgical pathology results included intradermal nevus. He was also assessed with inflammatory papule right posterior scalp to be treated with medication for 2 weeks, and if not resolved in 2 weeks to be reevaluated. In October 2009 he was seen for shave biopsy of skin lesions, with the biopsy results consistent with AK's. In January 2011 the Veteran underwent a VA examination. The claims file was reviewed with an examination for malignant neoplasm and benign neoplasms. His history included being in Vietnam. Since 2000 he had various lesions removed from his face, chest and arms. His only skin cancers were on the left glabella and left hand. Most of the lesions were benign AK's. Since 2005 while in the VA system, he had more lesions biopsied and removed, the last in October 2009. He also reported bilateral lower leg skin roughness from the bootline down since leaving the service. He had no changes over the years. Service treatment records were noted to show no evidence of skin disease. The claims file confirmed multiple treatments as well as a history of skin cancer on the face, treated with Moh's. The VA file showed multiple evaluations and treatments for AK's. He was also diagnosed with stucco keratosis of the legs that was benign and untreated. His condition was intermittent for skin lesions and stable for leg dermatosis. His skin individual lesions were without symptoms. Examination revealed evidence of multiple previous superficial skin cancer removals from his arms, torso (front and back), and face. All were well healed. Also there was stucco keratosis of both lower legs below the sockline without inflammation or excoriations. The last biopsy of October 2009 for a right lower leg lesion was noted to be consistent with AK. The diagnosis was history of multiple benign and malignant skin lesions with no lesions at this time, and chronic stucco keratosis of the legs. The medical opinion was that it was as likely as not that the skin disabilities are related to active duty. The rationale was that medical literature supports that chronic chemical irritant exposures that the Veteran claims may be a precursor to later skin lesions. Records from late 2011 to early 2012 reflect ongoing treatment for skin issues. In November 2011 the Veteran underwent a shave biopsy of a lesion on his left hand. Another November 2011 addressing back complaints revealed findings on physical examination of SK's on his chest and back and eczema lesions on his hand, with a left hand scab. Another dermatology record from November 2011 provided a diagnosis of skin lesions on the left upper extremity as eczema with scab from picking at it. Also assessed as keratosis and actinic damage. In a December 2011 family medicine note he had lesion of the back with history of skin cancer, with examination showing a dark area on the right side of his back, extensive SK's, and AK's of the legs, arms and face. He was assessed with nevus, rule out melanoma, SK's and AK's. A January 2012 note revealed on dermatology consult he was to be evaluated for lesion of the right back, of unknown duration and history of BCC. The provisional diagnosis was nevus, rule out melanoma. A June 2012 addendum to the January 2011 VA examination provided another medical opinion regarding the skin lesions history and the chronic stucco (seborrheic) dermatitis of the lower legs as related to active duty service. The Mayo Clinic was noted to state that "the exact cause of SK's are not known, they are very common and generally increase in number with age. They tend to run in some families so inheritance may play a role." There was no evidence that Vietnam services causes skin disease according to the VA guidelines of 2012 as reviewed by this examiner today. All of the Veteran's lesions are related to a natural progression. Hence his skin conditions are not related to service. The examiner reviewed his exam of January 2011 and the claims file was returned. There were no lesions at that time only well healed ancient sites. In March 2013 the Veteran underwent a VA dermatology examination. The multiple diagnoses included history of SCC left hand, status post excision with no recurrence and no current objective evidence, SK diagnosed August 2007 and stucco keratosis of the legs and feet diagnosed in June 2007. Other additional diagnoses included solar lentigo of the arms and faced diagnosed in March 2013, history of lichen simplex chronicus/prurigo nodularis of the hands diagnosed in November 2011 with no recurrent and no objective evidence. He was also diagnosed with history of AK's as follows, in the chest diagnosed in 2010, right lower leg diagnosed in 2009, left hand diagnosed in August 2007 and left forearm diagnosed in 2009. No residuals, no recurrence and no objective evidence of any of these AKs were present. Additional diagnoses included history of intradermal nevus scalp status post excision, diagnosed from November 2005 to September 2008, history of inflammatory papule status post intradermal nexus excision diagnosed September 2008, history of well differentiated SCC left cutaneous upper lip status post Moh's procedure diagnosed April 2008, history of xerosis diagnosed November 2005, September 2008 and January 2012 and history of skin infection, left groin diagnosed October 2006. For these diagnosed conditions, no residuals, no recurrence and no objective evidence were present. Finally he was diagnosed with Verucca Vulgaris (VV) of the left upper lip, diagnosed in September 2008 and history of mole diagnosed in 1997. Regarding his current problems, these included AK's SKs, SCC and eczema. His history included a skin disorder going down his bilateral lower extremities, that was not too bad now but it could be felt. It extended from the bootline down to the foot and was bumpy. He reported he complained about this about 7-8 years ago but reported he had it "forever." It worsened on its own, and he had no specific treatment. His skin cancer spot was removed from the left spot above his upper lip with biopsy. His AK lesion was removed from the le. He also reported "frozen" stuff at different times including on his back and hands. He currently reported having a lesion on his chest and another below his belt. He reported he saw dermatology last year in January and was prescribed creams which he hasn't used. He denied any other treatment with medication in the past year. On physical examination there was no evidence of acne or chloracne. He had a malignant tumor and neoplasm that had a Moh's procedure, with no further treatment or residuals. Examination of the upper body, face, scalp, ears, neck, chest, abdomen, back and upper extremities revealed no evidence of suspicious lesions. Solar lentigo was present on his face. On his trunk, chest and right groin, excoriated scaly brown or tan verrucous stuck on papules without suspicious features were presented. His skin was tanned on sun exposed parts. The examiner reviewed the claims file. Findings of no skin disorder or history therein in the service treatment records, including entrance and separation examinations were noted. The post service medical history of treatment for various skin disorders were reviewed and recited in detail, as were the prior examinations and their conflicting opinions. The examiner found that the Veteran's medical record revealed history of multiple skin conditions, 14 total diagnosed as noted above, although the diagnoses also included a keratacanthomatous SCC of the left hand diagnosed in June 2009 and a solar lentigo diagnosed in March 2013 in addition to the above diagnosed disorders. The examiner gave an opinion that any and all claimed disability diagnosed was less likely than not related to, caused by or aggravated by exposure to Agent Orange on a direct basis. The rationale was that presumptive Agent Orange conditions were chloracne and porphyria cutanea tarda. The Veteran did not have any of these presumptive skin conditions from review of service treatment records, VA, and private medical records. The examiner further stated that none of the diagnosed conditions are presumptive conditions due to Agent Orange exposure, nor were they aggravated by such exposure. Further medical literature supported that prolonged skin exposure (to the sun) causes SCC, AK and solar lentigo. Medical literature also supported that the cause of SK is unknown but is common and more so in older adults. This also tended to run in families. Regarding stucco keratosis, medical literature supported that this is commonly seen in the legs and feet of older males and is a benign condition of unknown cause. Regarding the lichen simplex chronicus-prurigo nodularis, such condition was caused by repeated scratching or rubbing which ultimately causes the skin to thicken. The medical literature supported that moles and intradermal nevus are genetically determined and sun exposure can weaken this condition. In addition, the Veteran gave a history of boating, fishing and not using sunscreen, despite being prescribed it. He was noted to have tanned skin not only on this examination, but also previously noted on dermatology examination in 2008. Thus chronic skin disability, variously characterized, is less likely related to service, including presumed herbicide exposure therein. The VA examiner pointed to the fact that there was no evidence of any skin disability in the service treatment records including entrance and separation examinations. Regarding the conflicting opinions regarding the etiology of the skin disorder in the November 2011 VA examination and June 2012 addendum, the examiner noted that the lesion described alternately in November 2011 as eczema and as AK, was actually formally diagnosed by biopsy as lichen simplex complex chronicus/prurigo nodularis. This pathological diagnosis was deemed more accurate than the differing impressions. Regarding the June 2012 addendum noting the history of multiple lesions at different times, none of these conditions were related to or caused by Agent Orange. Further the conflicting evidence regarding the other diagnosed disorders, the examiner stated that medical literature does not support that AK causes or aggravates stucco keratosis as these 2 conditions are separate conditions with different etiologies. Medical literature supported that stucco keratosis is of unknown origin and is benign. Medical literature also supports that AK is caused by sun damage by UV rays and can predispose to SCC. Medical literature also supports that lichen simplex chronicus/prurigo nodularis is caused by repeated scratching or rubbing of the skin which ultimately causes the skin to thicken. The medical literature does not support that lichen simplex chronicus/ prurigo nodularis can cause AK. Having reviewed the evidence, the Board lends the greatest weight to the findings and conclusions of the March 2013 VA examination which determined that none of the diagnosed skin disorders are related to service, to include due to exposure to Agent Orange. The examiner included a comprehensive review of the records and examination of the Veteran and provided solid rationale for the opinions rendered regarding causation. The examiner delved deep into the history of the various skin disorders, and addressed the findings from the conflicting evidence. Regarding the conflicting opinions from the examiner in the January 2011 VA examination and the June 2012 addendum, the Board lends little weight to the opinion from January 2011 which stated that it was as likely as not that the skin disabilities are related to active duty. The rationale was that medical literature supports that chronic chemical irritant exposures that the Veteran claims may be a precursor to later skin lesions. This opinion is equivocal at best, and the rationale merely suggests the possibility of chemical exposure as a precursor to lesions, without further explaining why. This opinion is further undermined by the unfavorable opinion given by the same examiner in the June 2012 addendum. The Board finds both opinions are of lesser weight than the findings and opinions from the VA examiner in the March 2013 VA examination. The Board notes that there is no additional evidence of record that directly contradicts the findings and conclusions made by the examiner in the March 2013 VA examination. The Board does note that the treatment records for skin disorders including the VA examination reports give a long standing history for the skin disorder of the lower extremities diagnosed as stucco keratosis, as being of long duration. It is the only skin disability consistently reported as having existed since leaving the service (see Veteran's reported history during the VA examination of January 2011, and of it existing "forever" in the March 2013 VA examination). However, between service and 1997 there is no evidence of any treatment for skin problems, a period of more than 25 years. There was no mention of long standing skin problems when the Veteran first received treatment for skin problems and the initial history recorded dating it back to service was after the Veteran filed his claim for compensation. The Board does not find it likely that skin problems were present since service but went untreated for more than 25 years and that history referring it back to service would not be reported until after he filed his claim for compensation several years later. Treatment in June1997 was limited to removal of a right hand lesion, and in July 1997 for recheck of a right forearm and back lesion, during which examination for skin issues was accomplished, a lower leg rash or other skin disability was not mentioned. Problems with a skin condition of the legs is not shown until 2006 when it was described as "dry skin." The Board finds no credible lay evidence of continuity of skin symptoms since active duty. The evidence does not support a finding that stucco keratosis of the lower extremities, which has been found by competent medical evidence to likely to be due to excessive rubbing or scratching, dates back to service. None of the other claimed conditions are shown to date back to service or be otherwise related to service. In regards to whether service connection for a skin disorder as a result of exposure to Agent Orange is warranted, the Veteran is not shown to have any of the enumerated diseases under 38 C.F.R. § 3.309(e) (including chloracne) resulting in any disability of the skin for which presumptive service connection is warranted. Likewise service connection is not warranted based on such exposure on a direct basis. As discussed above, the preponderance of the medical evidence indicates that there is no link between Agent Orange exposure and any such claimed disability; service connection for any skin disorder due to Agent Orange exposure is not warranted. The Board has weighed the evidence and found that it is not in equipoise; the reasonable doubt rule is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Based on all of the evidence, the claim is denied. ORDER Service connection for a skin disability is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs