Citation Nr: 1324995 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 06-07 389 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased rating in excess of 30 percent for lichen simplex chronicus and moniliasis. REPRESENTATION The Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to November 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In January 2009 the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in Waco, Texas. A transcript of the hearing is in the claims file. In June 2010, October 2011, and October 2012, the Board remanded the claim for an increased rating for a skin disability. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT The competent medical evidence shows that the Veteran's current skin disability, lichen simplex chronicus and moniliasis, is manifested by itching and lesions, but did not require the use of systemic corticosteroids or immunosuppressive drugs, nor was the skin disability shown to affect more 40 percent of the entire body or more 40 percent of exposed areas and compensable scarring or disfigurement is absent. CONCLUSION OF LAW The criteria for a disability rating greater than 30 percent for a skin disability, lichen simplex chronicus and moniliasis, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code (DC) 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- and post- adjudication VCAA notice by letter, dated in October 2004, and March 2006. The notice included the type of evidence needed to substantiate the claims for increase, namely, evidence that the symptoms had increased. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim); and of Vazquez-Flores v. Peake, 580 F.3d 1270 (Fed. Cir. 2009) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment). Further VCAA notice is not required. To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing error was cured by content-complying VCAA notice after which the claims were readjudicated as evidenced by the supplemental statements of the case, dated in June 2007, November 2007, June 2008, June 2011, July 2012, and June 2013. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, records from private medical caregivers, and afforded the Veteran a VA examination in January2005, May 2007, July 2010, and June 2013, and a hearing before the undersigned in January 2009. The Board notes that in the October 2012 remand, the Board requested the VA examination include color photographs. The examination report from the January 2013 VA examination included black and white photographs. The Veteran was given a full VA examination regarding his skin disability. The photographs display the lesions found on the examination. Further, the VA examination report gives detailed descriptions of the lesions such as their dimensions. The report itself gives findings and other information that allows the Board to rate the disability even if the photographs were absent. For the foregoing reasons, the Board concludes that having the photographs in color, as opposed to black and white, would not add anything that would aid the Board in its decision. The Board also directed in the October 2012 remand that the VA examination occur when the Veteran is having a flare-up of his skin disability. In Ardison v. Brown, 6 Vet. App. 405, 407 (1994), the United States Court of Appeals for Veterans Claims (Court) held that the duty to assist requires that, when a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA must provide a medical examination during the period of recurrence in order to provide a proper disability rating. Subsequently, in Voerth v. West, 13 Vet. App 117 (1999), that an examination is not necessary during the active phase of a disease that did not interfere with employment and where the short duration of the active phase made arranging for an examination infeasible. As discussed below, the veteran's disability has active phases of short duration. He has tried to see his medical providers during active phases but by the time he is able to make an appointment and seek treatment, the condition has receded. There also is no evidence that his skin disability has affected employment. As there is no evidence of an effect on employment nor is there evidence of prolonged periods of flare-ups during the appellate period, the Board finds that because of the inconsistency with which the Veteran's skin flares arise, it may not be feasible to schedule the examination during a period of flare-up. Accordingly, the Board finds that the RO substantially complied with the directive for a VA examination with the examination that occurred in January 2013. In sum, for all of the foregoing reasons, the Board finds that the examination in January 2013 substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The reports of all VA examinations included a review of the Veteran's medical history, an interview and an examination of the Veteran, as well as sufficient findings to rate disability. Therefore, the Board concludes that the VA examination is adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to the Board hearing in January 2009, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c) (2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Board hearing in January 2009, the Veteran was assisted at the hearing by an accredited representative from Texas Veterans Commission. The representative asked questions to ascertain the etiology and symptoms of the skin disability, including the representative arguing that medication used by the Veteran met the criteria for a higher rating. There was no pertinent evidence identified by the Veteran or his representative that might have been overlooked and that might substantiate the claim. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for an increased rating for his skin disability. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c) (2). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Principles The Veteran's disability, lichen simplex chronicus and moniliasis, has been rated at 30 percent since 1972. The Veteran, however, asserts that since he filed his current claim for an increased rating, his symptoms have warranted a rating higher than 30 percent. A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). The Veteran's service-connected skin disability, lichen simplex chronicus and moniliasis, currently is evaluated as 30 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7806 (dermatitis or eczema). Lichen simplex chronicus is an eczema caused by repeated itching and rubbing or scratching of the skin. Dorland's Illustrated Medical Dictionary 1048 (31st ed. 2007). A 30 percent rating is assigned for dermatitis or eczema affecting between 20 and 40 percent of the entire body or exposed areas of the body or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent rating is assigned under Diagnostic Code 7806 for dermatitis or eczema affecting more than 40 percent of the entire body or the exposed areas of the body or requiring constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806. Diagnostic Code 7806 also provides for alternate rating on the basis of disfigurement of the head, face, or neck under Diagnostic Code 7800, or scars under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805, depending on the predominant disability. Stated another way, the Veteran's skin disability may be rated under Diagnostic Codes 7800-7805 if the rating criteria under those codes warrant a higher rating than a rating using the schedular criteria of Diagnostic Code 7806. The Board notes these Diagnostic Codes were amended effective October 23, 2008, Diagnostic Code 7800, in effect prior to October 23, 2008, provided ratings for disfigurement of the head, face, or neck. Under Note (1), the 8 characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118, Diagnostic Code 7800 are as follows: a scar 5 or more inches (13 or more cm.) in length; a scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Id. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. Id. Under Diagnostic Code 7801, in effect prior to October 23, 2008, scars, other than on the head, face, or neck, that are deep or that cause limited motion are assigned a 40 percent evaluation for an area or areas exceeding 144 square inches and a 30 percent evaluation for an area or areas exceeding 72 square inches. Note (1) provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, are separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. A deep scar is one associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7802, in effect prior to October 23, 2008, scars, other than on the head, face, or neck, that are superficial and that do not cause limited motion are assigned a 10 percent evaluation for an area or areas of 144 square inches or greater. A ten percent rating is the highest rating available under Diagnostic Code 7802. Scars that are in widely separated areas are separately rated and combined in accordance with § 4.25. Note (1). A superficial scar is one not associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7803, in effect prior to October 23, 2008, superficial and unstable scars are assigned a 10 percent evaluation. A ten percent rating is the highest rating available under Diagnostic Code 7893. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (1). A superficial scar is one not associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7804, in effect prior to October 23, 2008, scars that are superficial and painful on examination are assigned 10 percent evaluation. A ten percent rating is the highest rating available under Diagnostic Code 7804. A superficial scar as one not associated with underlying soft tissue damage. Note (1). Other scars are rated on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). After October 23, 2008, under Diagnostic Code 7800, a 30 percent rating is provided for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent evaluation for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The Board notes that the characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, remained unchanged by the amendments of October 2008. Diagnostic Code 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear. A 30 percent evaluation is warranted where there is evidence of a scar area or areas exceeding 72 square inches (465 sq. cm.), but less than 144 square inches (929 sq. cm.). A 40 percent evaluation for area or areas exceeding 144 square inches (929 sq. cm.) is assignable. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2012). Note (1) to Diagnostic Code 7801 defines a deep scar as one associated with underlying soft tissue damage. Id. Under Diagnostic Code 7802, burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear, and that involve an area of 144 square inches (929 sq. cm.) or greater, warrant a 10 percent rating. Under Note (1) to Diagnostic Code 7802, a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Three or four scars that are unstable or painful warrant a 20 percent rating and five or more such scars warrant a 30 percent rating, 38 C.F.R. § 4.118, Diagnostic Code 7804. Under Diagnostic Code 7805, any disabling effects of other scars (including linear scars), and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 not considered in a rating provided under Diagnostic Codes 7800-7804 are to be evaluated under an appropriate Diagnostic Code. 38 C.F.R. § 4.118 (2012). The Veteran was provided a VA examination in January 2005. The Veteran reported a severe itch in the groin and darkening of skin in the area between the thighs and the scrotum. The Veteran also believe the rash spread to his calves, although the Board notes this is the only time he has made this assertion and no other medical evidence suggests an ongoing rash in the calves. The Veteran uses miconazde cream which helps the itch but does not completely alleviate the symptom. He also uses baby powder. Nevertheless, he develops pruritus so intense, he needs to scratch until the skin is peeled off and raw. This happens two to three times a year. He is then treated with additional antibiotic medication and the condition improves. Upon examination, the Veteran had a 5 by 5 inch hyperpigmented area in the medial aspect of the thighs and papules on the scrotum with hyperpigmented areas. The hyperpigmented area spread to the perineal region. The examiner did not find any peeling of the skin or lichenified area currently suggesting a fungal infection. The only other significant finding was a dry, healing pustule on the scalp. There were no other scaling areas. The examiner stated the disability covered 0 percent of the exposed area and 10 percent of the total body area. There was no scarring or disfigurement. VA treatment records at this time indicate the Veteran was prescribed hydrocortisone cream to be applied twice a day for itchiness and inflammation. In January 2006, the Veteran requested a dermatology consult for a dermatophytosis condition of the skin and scalp which the Veteran stated comes and goes. In July 2006, the Veteran had 3 lesions on top of his head which the Veteran reported had been present for weeks. There was a 5mm pustule lesion over the vertex of the head plus 2 mm and 1 mm papules on the surface of the head. All lesions were non-erythematous and were not draining. In October 2006, it was noted that the Veteran complained of sores on the top of his head. He had treated the areas with peroxide and alcohol but there were still some patchy areas all over. The Veteran described pain, 5/10, at the sites of the sores and pruritis. In the past, similar lesions had bled with yellow pus coming out of it. A prescription shampoo, chlorhexadine, did not provide relief although an antibiotic provided some relief. The diagnosis was questionable folliculitis versus tinea versicolor. Selenium shampoo was prescribed. In December 2006, the Veteran complained of pus bumps in his groin and bumps in his scalp. Various creams helped. The problem comes and goes and the Veteran at that time did not have any lesions. The scalp had areas of hair loss and a few follicular papules secondary to excoriation with short broken off hairs. There were no pustules in the groin. The diagnosis was hidradentis suppurativa, which was not currently in active. In April 2007, the Veteran reported he had been given pills and had no flare-ups since taking the pills. He complained of an irritated spot on the right neck and a scaly itchy spot on the right elbow. The scalp was clear and there were no pustules in the axilla or groin. The neck lesion was consistent with seborrheic keratosis on an erythematous base. The right elbow lesion was a hyperpigmented, scaly plaque. Later that month, the Veteran complained of a pruritic rash to the groin that stayed moist. The medication was not helping. Examination revealed erythema to the groin area bilaterally. No pustules or drainage was noted and the rash had a fungal appearance. Hydrocortisone and Terbenafine creams were prescribed. In a VA examination in May 2007, the Veteran reported pus bumps break out in both groin areas 2 times a week. He has pus bumps on his head 3 times a month. He used an antibiotic which helps the bumps on the head, but not the groin. The Veteran used Lamisil and hydrocortisone creams and Hibiclens daily to wash his skin. He was also receiving treatment for the right elbow lesions. The lesions itch and drained milky pus but not every day. Upon examination, the Veteran had bilateral exophthalmus and arcus senilis. The scalp was completely clear. There was no evidence of skin rashes, pus bumps, scarring or disfigurement. He did have hair loss in the pubic area. The diagnosis was hidradentis suppurativa. There was no visible rash in the pubic area or the groin and no skin lesions in the inguinal or rectal areas. During episodes of a flare-up, the examiner concluded that 1 percent of the total body area and zero percent of exposed areas were involved. As noted there were no scars or areas of disfigurement. The examiner also diagnosed xerosis which he stated was not present at the examination but also covered zero percent of the exposed or total body areas. In June 2007, it was noted the Veteran had one erosion in the left parietal scalp and one flesh colored pedunculated papule in each axillia. There were no pustules or nodules in the groin area. There was hyperpigmentation and lichenification of the scrotum. There was no scaling, pustules, or nodules. In July 2007 the Veteran complained of worsening symptoms in the inguinal and scrotum skin with pruritis for several days. It was noted he was being followed by a dermatologist for hidradentis suppurativa, currently inactive folliculitis, and scrotal lichen simplex chronicus. The Veteran asserted the hydrocortisone cream helped for 1 hour and then the pruritis returned. There was no skin breaks or rashes. The examination revealed mild to moderate erythema without induration or tenderness to palpitation over the left inguinal area or left upper thighs and left scrotal skin. No lesions, lichenification, or scaling was noted. The diagnosis was scrotal skin pruritis NOS. The Veteran had a daily medication which provided some improvement. He was to continue his topical medications. In August 2007, the folliculitis in the scalp was also noted and that the condition occurred every now and then. An antibiotic worked. He also uses a sulfur based shampoo. He also had a bump on the left neck that in the past had been treated cryogenically without resolution. On examination, it was noted the Veteran had a flesh colored papule in the left neck with pseudofolliculitis barbae and lichenification of the scrotum and perianal region. The Veteran submitted a statement in October 2007 that his lichen simplex chronicus had spread to his head with sores and bumps and submitted an online article originating from the Mayo Clinic that stated it is a stubborn condition that is characterized by itching and scratching. He has no social life and the condition has affected his marriage because he does not want to go out in public and be seen scratching his groin area. He also testified he has tried to show up at VAMC while the lesions are active but by the time he gets an appointment, the bumps have disappeared. He also testified that the lesions had spread from his groin to his legs. The condition sometimes makes it difficult to walk. The condition has spread to his neck, head, elbows, and knees. He uses hydrocortisone cream twice a day. In January 2008, the hidradentis suppurativa was stable and the Veteran was satisfied with current treatment. In November 2008 VA dermatology evaluation, the past medical history was scalp folliculitis, prurigo, and pseudofolliculitis barbae. The Veteran ran out of the medication and had a flare-up, but it resolved by the time he was seen by VA dermatology. It was noted he had significant pruritis but it was well controlled on hydrocortisone and Ataraz. The Veteran stated he gets recurrent pus bumps with scars but he has learned to live with it. The examination revealed hyperpigmented macules and focal non-scarring alopecia centered around the folic units without prominent scaling. There were no pustules or erythemia or evidence of tinea. The diagnosis was the forehead had exophthalmos versus familial variant. The Veteran declined an examination of the groin. In March 2009, the hidradentis suppurativa was stable and the Veteran was satisfied with current treatment. In April 2009, the Veteran had one small hyperpigmented lichenified plaque on the scrotum. The penis and thighs were currently without evidence of lichen simplex chronicus. The Veteran had minimal pseudofolliculitis barbae as he kept a beard. In March 2010, the Veteran had an itchy spot on his scalp that was treated with an antibiotic ointment. The scalp had a 1 cm lichenified patch with broken off hairs. There also was an itchy tender bump at the base of the penis which heals and recurs approximately 3 times a year. At this time, the lesion, a 4 mm pink papule with a center ulcer, was clearing. A biopsy of the lesion did not determine the etiology of the lesion because the biopsy was superficial. In July 2010, the Veteran was diagnosed with eczema, lichen simplex chronicus, folliculitis in the scalp and beard, and hidradentis suppurativa in the groin. Scalp bumps improved with treatment. The Veteran stated the scrotum lesions had cleared and had not recurred. The Veteran was provided a VA examination in July 2010. The Veteran stated his disability was primarily in the groin and perirectal area, but it had now migrated to his scalp. The disability caused intermittent bumps but there was constant itching. The Veteran used hydrocortisone cream, Nystatin powder, Flucinode, Selenium shampoo, Hydroxyzine, Chlorhexidine, and ammonia lactate. Due to the itching in the groin area, the Veteran stated it interfered with his social life and his sex life. On examination, the Veteran had intertriginous dermatitis in the groin area with hyperpigmentation in the folds of the upper thigh and around the scrotum. The examiner did not find any lichenfied areas, bullae vesicles, ulcerations, cellulitis, or papules. Zero percent of the exposed and 1 percent of the total body areas were involved. In December 2010, the Veteran complained of itchy bumps in his scalp and beard. He used selsun shampoo and synalar soln to the scalp. He also had a chronic itchy groin rash which was worse during the summer. If the area was raw, he used baby powder although it was currently clear. The occipital scalp had a 1 cm patch with short, broken off hairs. There was no scaling, erythemia, pustoles, scarring, or other skin changes. "PIH" was noted in the groin. A medical note indicated the medications identified in the July 2010 VA examination were topical. In a May 2011 dermatology follow-up, the scalp was clear but there were a few hyperpigmented follicular papules in the hair bearing areas of the face and neck. The panus and groin, inguinal folds were clear. The inner thighs had striae of loose skin. The lesions on the face were described as mild and the Veteran was told to keep his beard approximately 1/4 inch long. For the striae in the inner thighs, the Veteran was told to continue his topical steroids. In July 2011, the Veteran reported problems with papules in the beard area. The scalp had a 3 cm area hyperpigmented flat papule without discharge or inflammation on the face. There was a 3mm hyperpigmented papule on the left check. The panus and groin, inguinal folds were clear. The left cheek lesion was described as a likely prurigo nodule and the dermatologist stated the beard folliculitus was controlled. In January 2013, the Veteran was provided a VA examination. The diagnosis was hidradentis suppurativa, folliculitis in the face and beard, and pruritis. The Veteran reported a history of a rash to the face, scalp, and groin to a skin condition that started in service. The Veteran uses topical medication on a constant or near constant basis. He does not use systemic corticosteroids or other immunosuppressive medication. The Veteran does not take any mediation for exfoliative dermatitis. He has not had any debilitating or non-debilitating episodes due to urticaria, erythema multiforme, primary cutaneous vasculitis, or toxic epidermal necrolysis. Physical examination revealed a 3.0 cm by 5.0 cm lesion (total of 15 sq. cm) in the left groin area and a 3.5 by 5.2 lesion (total of 18.2 sq. cm.) in the right groin area. The lesions were superficial, stable, nonlinear, and nonpainful. There were no active lesions, only the hyperpigmented lesions. On the face and head, there was a .5 by .5 cm papular lesion at the base of the neck, and a 1 cm. papular lesion in the occipital area of the scalp. There also was a 5 cm by 2 cm area if alopecia in the occipital area of the scalp. Finally, there was a 4 cm by 2 cm hyperpigmented area on the left cheek. The lesions covered an approximate total of 8 sq. cm. None of these lesions were painful, unstable, or due to a burn. There was no sign of elevation, depression, adherence to the underlying tissue, or missing soft tissue. The lesions did not result in gross disturbance, asymmetry of the facial tissue, or palpable tissue loss. The examiner stated the lesions in total covered less than 5 percent of the exposed areas and less than 5 percent of the total body areas. The lesions as noted were considered by the examiner to be residuals of hidradentis suppurativa and pseudofolliculitis barbae. The lesions do not cause any limitation of function and had no impact at work. The Board finds that the preponderance of the evidence is against the Veteran's claim for a disability rating greater than 30 percent for the Veteran's skin disability characterized as lichen simplex chronicus and moniliasis. The Board observes that, to qualify for a higher disability rating under DC 7806, the service-connected skin disability must involve more than 40 percent of the entire body or exposed areas of the body, or the Veteran must be undergoing systemic therapy such as corticosteroids or immunosuppressive drugs. The competent medical evidence shows that, at worst, the Veteran's service-connected skin disability affects less than 40 percent of his entire body or exposed areas of the body. The Board notes that the objective medical evidence of records shows that the Veteran's service-connected skin disability has affected, at most, approximately 5 percent of the exposed areas of the body (as seen on VA examination in January 2013) and approximately 10 percent of the total body area (as seen on VA examination in January 2005). The Board acknowledges that at all relevant times, the Veteran has been prescribed and uses steroid creams such as a hydrocortisone cream. These creams, however, are not considered systemic therapy because "systemic" is defined as pertaining to or affecting the body as a whole. See Dorland's Illustrated Medical Dictionary 1888 (31st ed. 2007). As noted above, the topical steroid creams the Veteran uses only affect the area covered by the lesions that have developed in the groin area or any other affected area. All other medications or therapies, such as the shampoos or powders, also appear to be topical as the medical notes indicate they are applied to the affected areas. In sum, the Veteran does not meet the schedular criteria for the next higher rating of 60 percent for his skin disability As noted above, Diagnostic Code 7806 allows the lichen simplex chronicus and moniliasis disability to be rated under Diagnostic Codes 7800-7805 if the criteria for disfigurement and scars are the predominate disability. As to the lesions in the exposed areas of the Veteran's face and neck, none of the identified characteristics of disfigurement are present, which were unchanged by the October 2008 amendments. Therefore, the Veteran is not entitled to a higher rating under Diagnostic Code 7800. Diagnostic Code 7801 can provide a higher rating but only of the Veteran has scars that are deep, cause limited motion, (before October 2008) or (after (October 2008) nonlinear, which the Veteran does not have. Before October 2008, Diagnostic Codes 7802, 7803 and 7804 do not allow a higher rating for the Veteran's disability and in event, his lesions do not cover an area or areas of 144 square inches (929 sq. cm.) or greater. After October 2008, Diagnostic Code 7802 still does not allow a higher rating for the Veteran's disability and the Veteran also does not meet the schedular criteria for Diagnostic Code 7804 as the Veteran's lesions are not unstable or painful. The amendments in October 2008 eliminated Diagnostic Code 7803. There also is no evidence that the lesions are causing symptoms which would allow a rating under a Diagnostic Code other than the ones discussed, and therefore, Diagnostic Code 7805, either before or after October 2008, does not apply to the Veteran's claim. The Board has considered the Veteran's lay assertions. For instance, because of the constant scratching of his groin, he does not go out to restaurants and this has affected his social life and marriage. In evaluating a claim for an increased schedular disability rating, however, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). The Board is not free to ignore VA's duly promulgated regulations, which include the Rating Schedule. Franklin v. Brown, 5 Vet. App. 190, 193 (1993). The Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C.A. §§ 503, 7104; Harvey v. Brown, 6 Vet. App. 416, 425 (1994). Furthermore, in rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). In this case, the Veteran is competent to report symptoms, such as itching, because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes, nor is he competent to attribute any symptom or abnormality to his service-connected disability. That involves specialized knowledge or training in the management, identifying of diseases and complications related to skin diseases and injuries. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis. Such competent evidence concerning the nature and extent of the Veteran's lichen simplex chronicus and moniliasis disability have been provided by the medical personnel who have examined him during the current appeal period and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated, including whether any abnormality has resulted from the lichen simplex chronicus and moniliasis. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology or their relationship to his service-connected lichen simplex chronicus and moniliasis disability. Accordingly, for the reasons explained above, the preponderance of the evidence is against a rating higher than 30 percent for lichen simplex chronicus and moniliasis, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Evaluation Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe a disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service- connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). In this case there are no exceptional or unusual factors with regard to the Veteran's disability. In this regard, the Board notes that the Veteran has not had frequent periods of hospitalization nor has he reported marked interference with employment. The VA examiner in January 2013 specifically noted the skin disability had no effect on employment. The Veteran has described how the disability affects his social life and marriage, but has not said it has interfered with his employment. As seen in the analysis above, the Board has considered the Veteran's disability, and finds that the rating schedule (Diagnostic Code 7806) adequately provides for ratings based on his symptoms or impairments. The Veteran also does not offer any explanation or argument to explain how the assigned rating is inadequate to describe the lichen simplex chronicus and moniliasis symptoms and their effect. The evidence before the Board also does not establish any functional impairment that would not be covered or contemplated by the current rating or to refer the case for his lichen simplex chronicus and moniliasis for an extraschedular rating. In short, his disability picture is contemplated by the rating schedule under Diagnostic Code 7806 and the assigned schedular evaluation is, therefore, adequate. Consequently, referral to the Under Secretary for Benefits or the Director, Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. As the rating schedule is adequate to rate the Veteran's referral for extraschedular consideration is not warranted. Total Disability Rating for Compensation Based on Individual Unemployability The Veteran has not raised and the record does not reasonably raise the claim for a total disabled rating for compensation based on individual unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (in a claim for increase, where the Veteran expressly raises a claim for a total disability rating on the basis of individual unemployability or the claim is reasonably raised by the record, the claim is not a separate claim, but a part of a claim for increase). Here, the Veteran was employed as of July 2011 at a car rental agency. Therefore, in the circumstances of this case, the Board declines to take jurisdiction over a total disability rating claim. ORDER Entitlement to a rating higher than 30 percent for lichen simplex chronicus and moniliasis is denied. ____________________________________________ Robert C. Scharnberger. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs