Citation Nr: 1324859 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 09-30 281 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for skin disorder at the posterior region of the neck, to include a keloid scar. ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran served on active duty from May 2001 to December 2007. This matter initially came before the Board of Veterans Appeals (BVA or Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board remanded the claim in March 2012. The claims file has been lost and the record available for review is a rebuilt file. It appears from the rebuilt file that the Veteran seeks service connection for a skin disorder at the posterior region of the neck, to include a keloid scar. In his August 2009 substantive appeal, the Veteran requested a videoconference hearing before the Board. He was initially scheduled for a hearing in May 2011, but on the date of his hearing, he contacted the RO and asked that it be rescheduled for a later date due to the fact that he was feeling ill and would be unable to travel to the RO. In August 2011, the Veteran was notified of a date for a rescheduled videoconference hearing. He failed to report. As such, his hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (which stipulates that, if an appellant fails to appear for a scheduled hearing, the case will be processed as though the request for a hearing had been withdrawn). FINDINGS OF FACT 1. The Veteran reported acne when he entered active service, and a diagnosis of acne of the chest and back was noted on the report of the Veteran's medical entrance examination; the only noted scar was on the Veteran's left elbow. 2. During the Veteran's service, the Veteran's acne on his neck became symptomatic, required treatment, and a keloid scar formed and became symptomatic. CONCLUSION OF LAW The criteria for service connection for a skin disorder of the nape (back) of the neck, to include a keloid scar, nape of neck, have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION As best the Board can determine from the rebuilt record, the Veteran contends that he is entitled to service connection for a skin disorder on the back of his neck, to include a keloid scar due to that disorder. As noted above, the Veteran's original claims file cannot be located, so the Veteran's specific allegations from his claim, notice of disagreement, and substantive appeal are not known. Since the decision below is wholly favorable to the Veteran, it is not necessary to further discuss whether VA has met its duties to assist and notify the Veteran regarding the elements required to substantiate the claim. The Veteran asserts that his acne of the neck was aggravated in service and he now has a scar. The Veteran reported acne when he entered active service, and this disorder was noted on the medical report of entrance examination. No scar, other than on the left elbow, was noted. During service, the Veteran initially sought treatment in November 2001, about 5 months after his service induction, for complaints that he had a rash on his neck. At that time, diffuse acne, with papules on the back, shoulders, and chest, and a keloid scar on the neck, was noted. A diagnosis of acne keloidalis nucha (AKN) was assigned. For purposes of information, the Board notes that a keloid is defined as an irregular hyperplastic scar tissue mass. Acne keloidalis is a chronic eruption of fibrous papules that develop at the site of deep folliculitis. Stedman's Medical Dictionary 943 (27th ed. 2000). The term "nucha" refers to the back of the neck, also called the nape. Stedman's Medical Dictionary 1231 (27th ed. 2000). Thus, acne kelodalis nucha refers to eruptions of fibrous papules on the back of the neck. In November 2001, the provider prescribed antibiotics and use of a specific soap. In July 2002, the Veteran reported that he had been experiencing the problem for a year, and had been seen and treated. He reported that treatment helped, but the problem did not go away. In July 2004, the Veteran again sought treatment. He had one "large" scar on the back of the neck and several small affected areas. Over the next few months, the Veteran was seen multiple times. He was placed on a permanent profile limiting cutting of the hair at the back of the neck, and was treated with steroids and other medications and laser therapy. The affected area was described in January 2005 as "dramatically less symptomatic." On VA examination in April 2008, the Veteran reported itching, crusting, shedding, and pain in the affected area. The examiner noted that there was a lesion on the back of the neck that caused pain on extension. Pathology examination disclosed a keloid scar secondary to folliculitis. The examiner who conducted an April 2012 examination concluded that AKN clearly and unmistakably existed prior to the Veteran's service and was not aggravated beyond its natural progression. The examiner stated that the clear and unmistakable evidence that the disease preexisted the Veteran's service was the diagnosis of acne at entry. The examiner stated that the basis for the opinion that the disease was not aggravated beyond the expected normal progression was the treatment note in service which stated that the laser treatment had improved the skin condition. April 2012 VA examination at page 16. A photograph of the nape of the Veteran's neck is of record. The Board observes that the Veteran appears to have visible "spots" or areas of abnormal skin on his neck. Generally, in order to establish direct service connection, three elements must be established. There must be medical evidence of a current disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2012); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). "[E]very Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment ... ." 38 U.S.C.A. § 1111; see also 38 C.F.R. § 3.304(b) (implementing regulation for section 1111); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). Therefore, when no preexisting medical condition is noted upon entry into service, a Veteran is presumed to have been sound in every respect. Horn, 25 Vet. App. at 235, citing Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In this case, the evidence clearly and unmistakably shows that the Veteran had acne when he entered service. If a pre-existing disability is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disability, but the Veteran may bring a claim for service-connected aggravation of that disability. The Veteran may establish service connection if there was an increase in disability during service. 38 U.S.C.A. § 1153; see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). The statutory provisions setting forth the criteria for service connection based on aggravation establish a presumption that aggravation has been incurred in service if there is an increase in disability during service. The statutory provisions setting forth the criteria for service connection based on aggravation establish a presumption that aggravation has been incurred in service if there is an increase in disability during service. The provision has been interpreted as requiring clear and unmistakable evidence to rebut the presumption. In this case, the service treatment records establish that the Veteran's acne on his neck was not symptomatic when he entered service. He developed increased symptoms and he complained of pain at a location which was found to be a keloid scar. The examiner who conducted the 2012 VA examination concluded that the Veteran's AKN did not progress beyond the expected natural progression in service because the condition improved in service after treatment. However, the condition had not been symptomatic or required treatment prior to the Veteran's service. The provided concluded that it was less than likely that AKN was aggravated beyond the natural progression of the disorder. The provider did not address whether there was clear and unmistakable evidence to rebut the presumption of aggravation. Thus, the opinion does not rebut the presumption of aggravation. In particular, the examiner did not address the fact that the Veteran did not have a scar on the neck that was noted at entry into service. The scar is a permanent aggravation of AKN the skin disorder. Service connection for the skin disorder and the scar resulting from the skin disorder is therefore warranted. ORDER Service connection for acne keloidalis nucha, to include a keloid scar, nape of neck, is granted. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs