Citation Nr: 1325751 Decision Date: 08/14/13 Archive Date: 08/16/13 DOCKET NO. 07-23 475 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a skin disorder of the right hand, to include as secondary to service-connected genital herpes. 2. Entitlement to an increased rating in excess of 10 percent for genital herpes. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran had active service from April 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction over this matter has been transferred to the Columbia, South Carolina, RO. The Veteran initially requested a hearing before the Board in his substantive appeal, but he effectively withdrew his request for a hearing in August 2008. See 38 C.F.R. § 20.704. In February 2011 the Board determined that based upon the Veteran's statements a claim for TDIU was part and parcel of the claims on appeal under Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) and remanded it for further development. The Board also remanded the issue of entitlement to service connection for a skin disorder and the issue for an increased rating for the service-connected genital herpes for further development. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records; however, these records were reviewed by the RO in the May 2012 Supplemental Statement of the Case (SSOC) and February 2013 SSOC and by the Board. The issue of entitlement to a TDIU rating is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran's skin disorder of the right hand is not related to his military service nor is it caused or aggravated by his service-connected genital herpes. 2. Throughout the entire appeal period, the Veteran's genital herpes are not manifested by a total of 20 to 40 percent of the total body or 20 to 40 percent of the total body of the exposed area; in addition, there has not been use of systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during a twelve-month period. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder of the right hand, to include as secondary to the service-connected genital herpes, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310(a) (2012). 2. The criteria for an increased rating in excess of 10 percent for the service-connected genital herpes have not been met. 38 U.S.C.A. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159. VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With regard to his claim for an increased rating and service connection, the Veteran was provided notice of the VCAA in February 2006 and May 2011. The VCAA letters indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The February 2006 letter also provided the Veteran with notice of how to substantiate a claim for service connection on a secondary basis. In addition, August 2006, June 2008, and May 2011 letters also informed the Veteran of the criteria of the applicable disability ratings and effective date elements of his claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case back to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also 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). All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records, private medical records, VA outpatient treatment reports, VA examinations, and statements from the Veteran and his representative. The Veteran was afforded VA examinations in June 2006, January 2012, and February 2012 to evaluate the nature and severity of his service-connected herpes and to assess the nature and etiology of his right hand skin disorder. With regard to the increased rating claim, the Board finds that these examinations are adequate for rating purposes because they conveyed pertinent medical findings stated in terms conforming to the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). With regard to the service connection claim, the examination and opinions are adequate to evaluate the etiology of his claimed right hand skin disorder. The Board notes that these examinations/opinions, in conjunction with the other evidence of record, contain sufficient competent information for the Board to evaluate whether service connection on a direct or secondary basis has been established and, therefore, a remand for an additional opinion is not necessary. In February 2011, the Board remanded the issues of entitlement to an increased rating for genital herpes and service connection for a right hand disorder for further development; specifically to afford the Veteran a VA examination and to obtain any outstanding treatment records. In the February 2011 remand, the Board sated that the RO should contact the Veteran to obtain authorization to obtain any outstanding medical records and listed both VA and private treatment facilities. The RO contacted the Veteran in May 2011, and, in June 2011, the Veteran submitted VA 21-4142 Authorization and Consent to Release Information to the Department of Veterans Affairs. However, no private physician, clinic, or hospital was listed by the Veteran. Duty to assist in the development and adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). If a veteran wishes help, he cannot passively wait for it in circumstances where he may or should have evidence that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193, reconsideration denied, 1 Vet. App. 406 (1991) (per curiam). Pursuant to the directives, the AMC obtained an opinion on direct service connection and evaluated the current level of severity of the Veteran's herpes. Thus, the Board finds that the requested development has been substantially completed and no further action to ensure compliance with the remand directive is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issue herein decided, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103. II. Analysis Service Connection for Skin Disorder of the Right Hand Service connection may be granted for disability resulting from disease or injury incurred or aggravated during a Veteran's active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). 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). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). When such chronic diseases are at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran asserts that his current diagnosis of a skin disorder of the right hand is either directly related to his military service or is secondary to his service-connected genital herpes. Initially, the Veteran claimed in February 2006 that his skin disorder of the right hand was secondary to his service-connected genital herpes. However, in a letter dated in December 2006, he asserted that he had blisters on his hand in service in 1968, which was misdiagnosed and associated with his genital herpes. In a letter dated in May 2007, the Veteran asserted that his psoriasis of the hand was manifested at least as early as 1974 and was caused by exposure to chemicals that he first came into contact with when he was trained as a dental technician in service. However, after a careful review of the Veteran's claims file, the Board finds that the preponderance of the evidence is against the Veteran's claim on both a direct-service-connection basis and a secondary-service-connection basis. The Veteran's service documents indicate that his military occupational specialty (MOS) was a dental laboratory technician. His service treatment records are silent for any complaints, treatment, abnormalities, or diagnosis of a skin disorder other than genital herpes. The Board notes that his representative argued in his January 2010 Informal Hearing Presentation that the Veteran's right hand "may have been mentioned" in a February 1970 service treatment record. However, the Board finds that the report does not show treatment for any skin problems of the Veteran's hands. Rather, the record shows treatment for the Veteran's genital herpes, and it was indicated that there was a slightly painful lesion on the left side of a "hard folate" on the penis. While the handwritten treatment note in question was somewhat illegible, when viewed in context of the entire report, it is evident that the examination was confined to the Veteran's genital area and that there was no reference to his hands or any other anatomical body part. Moreover, on his January 1970 Report of Medical History for Separation, the Veteran checked "yes" to skin diseases; however, there was no specific mention of a skin condition on either hand, and the January 1970 Report of Medical Examination for Separation listed the skin as normal, with no pertinent abnormalities noted on examination. The Veteran's post-service treatment records reflect that the first evidence of any complaints or treatment for a skin disorder of the Veteran's hands was on a private report dated in July 1998. The partially illegible handwritten note indicated that the Veteran had psoriasis on the palms of his hands and had tried over-the-counter medication. A treatment note from a private dermatologist, dated in March 1999, indicated that the Veteran had been treated for psoriasis of the hands with topical steroids and anthralin for seven months by another private doctor with little success. The impression was eczema. The Board also notes that a treatment report by the same private dermatologist, dated in February 2005, indicated that the Veteran had a history of eczematous dermatitis on his hands and feet, which occasionally looked like psoriasis. The physician indicated that the Veteran's eczematous dermatitis on the feet and hands cleared-up with Clobetasol and that he had been treated recently by VA for a red circular lesion with small papules on the dorsum of the right hand. The impression included granuloma annulare of the right hand and eczema, but it also indicated that psoriasis could not be ruled out. The report indicated that the Veteran was instructed continue to apply ointment to the rash on his hands and legs. In January 2006, the Veteran had a diagnosis of hand dermatitis and granuloma. In March 2006, it was noted that the Veteran had hand dermatitis for the past six years and that the most recent hand dermatitis occurred at the same time as his most recent herpes flare-up. In June 2006, the Veteran was diagnosed with chronic hand dermatitis, and it was stated that it was still possibly due to contact because it was localized on his right hand. The Veteran was afforded a VA examination in June 2006 and the Veteran stated that he had flare-ups of the hands when he had flare-ups of his genitals. However, he was diagnosed with psoriasiform dermatitis, and the VA examiner opined that the Veteran's current hand condition was not secondary to his genital herpes. In support of this opinion, it was explained that a pathology report was reviewed and there was no evidence of any fungus or evidence of herpes. In July 2006, it was noted that the Veteran's contact dermatitis began in 1997, which places the onset many years after service. Significantly, it was also noted that the Veteran's June 9, 2006 patch test was negative for fungi and there was no evidence of herpes, which is further evidence that suggests that the right hand disorder was not caused by or aggravated by his service-connected genital herpes. Moreover, in July 2006, the Veteran's treating VA physician stated that the Veteran was her patient since February 2003 and the Veteran was evaluated and treated for chronic hand dermatitis. It was noted that the Veteran was unable to perform his usual duties as a dental technician since he was unable to hold the instruments and do the actual manipulations which were required for his job. It was noted that the Veteran's form of dermatitis was chronic and he would always be subjected to possible exacerbations if exposed to certain triggers, which included the compounds that he worked with. A July 2006 VA treatment report also reflected an assessment of "[c]hronic irritant hand dermatitis: Patch test negative. And history very consistent w/ irritational cause." In a December 2006 statement, a different VA treating physician stated that the Veteran began his treatment at the VA Dermatology Clinic in 2004 for contact dermatitis of the hands. He stated that the Veteran's condition was quite life-altering since he worked in the dental industry for years and developed allergies to the chemicals in dental prostheses and other dental devices. The Veteran's job was impossible if he did not want to have contact dermatitis. In a May 2007 letter, a private dentist and business associate of the Veteran indicated that he started a ceramic (dental) lab in 1972, and that the Veteran worked for him in the lab until 1980, when he turned the business over to the Veteran, who then relocated to a larger facility but continued to do dental work for him. The dentist stated that he noticed that the Veteran had chronic skin problems on his fingers and hands for "all these years" and that it has grown from the finger tip involvement in 1970-1980. In a January 2008 VA Allergy and Immunology Consult note, the Veteran reported that he had symptoms of a skin condition since 1968 when he poured dental impressions and that he was told it was herpes because he had lesions on both his groin and hands. In May 2012, it was noted that the Veteran had granuloma annulare and that it may be in the groin. At the January 2012 VA examination, the Veteran was diagnosed with dermatitis and he was skin tested to be allergic to numerous chemicals. At a February 2012 VA examination, it was stated that the Veteran had a definite diagnoses of eczema and psoriatic eczema; the condition originally involved the hands but spread. It was noted that the diagnosis was made after military service and there was no evidence that he was evaluated for a skin rash in service. At another February 2012 VA examination it was opined that there was no evidence to indicate that his psoriasis was related to his military duties as a dental technician. Turning first to direct service connection, after a careful review of the Veteran's claims file, the Board finds that the preponderance of the evidence is against the Veteran's claim. The Board notes that the Veteran does have a current skin diagnosis of contact dermatitis. Although the Veteran checked "yes" to skin diseases on his January 1970 Report of Medical History for Separation there was no specific mention of a skin condition on either hand and on examination his skin was listed as normal and no pertinent abnormalities were noted. Moreover, the Veteran's service treatment records are silent for any complaints, treatment, abnormalities, or diagnosis of a skin disorder other than genital herpes. In regard to the Veteran's statements, as well as the statement provided by the private dentist, a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); (Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). To the extent that the lay evidence of record suggests hand problems starting in service, to include the Veteran's statements and the statement of the private dentist, however, the Board finds these assertions to be inconsistent with other evidence of record, including the July 2006 VA treatment record indicating a 1997 onset date for his right hand complaints. The treatment records were generated with a view towards ascertaining the appellant's then-state of physical fitness; they are akin to statements of diagnosis and treatment and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). In light of evidence as noted above, the Veteran's recent lay assertions that his skin condition of the right hand began in service lack credibility because they are contradicted by service treatment records and other statements he made indicating that his skin condition of the right hand began in 1974 and in 1997. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statement, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). Moreover, the Board finds that the private dentist is not competent to offer an opinion as to the etiology of the symptomatology that he saw just the finger tips or whether it is related to his current right hand disorder. The dentist is not competent to opine as to matters outside his scope of expertise, and there is no evidence that as a dentist he has the expertise of skin conditions. LeShore v. Brown, 8 Vet. App. 406 (1995) citing Layno v. Brown, 6 Vet. App. 465, 469 (1995). Thus, the Board finds that this is not probative evidence to establishing that the Veteran's current right hand disorder began during service or is related to service. Rather, the private dentist's statement is outweighed by the other competent medical evidence of record, suggesting an onset as early as 1997 for the right hand disorder. The Board also finds probative the VA medical opinions of record addressing the etiology of the Veteran's right hand disorder. As January 2012 and February 2012 VA examiners are qualified and took into account the pertinent history and facts, the medical opinions constitute competent medical evidence. Moreover, the examiners offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Consequently, the Board assigns great probative value to the VA examiners' opinions regarding direct service connection. The Board notes that the Veteran does have a current diagnosis of contact dermatitis of the right hand from working with the compounds and tools as a dental hygienist (July 2006 and December 2006 VA treating physician's statements) as a result of being allergic to numerous chemicals (January 2012 VA examination); however, there is no indication that he had this same allergy to the compounds and tools he used during his military service. Rather, the VA examiners' opinion found to the contrary. To the extent the Veteran stated at a January 2008 VA Allergy and Immunology Consult that his skin condition began in-service when he worked with dental compounds, as explained above, his lay statements are found to lack credibility; accordingly, the Board finds that this is not probative medical evidence but, rather, is merely a recitation of veteran's self-reported and unsubstantiated history. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999); Swann v. Brown, 5 Vet. App. 229 (1993). Because the weight of the evidence suggests a post-service and non-service related cause of the Veteran's current right hand disorder, the Board finds that his claim for service connection on a direct basis must be denied. With respect to secondary service connection, as stated above, the Board finds that the preponderance of the evidence relates the Veteran's current skin condition to his current occupation as a dental hygienist (see July 2006 and December 2006 VA records) as a result of an allergic reaction to numerous chemicals (January 2012 VA examination). The Board fully acknowledges that there was initially some question as to whether the Veteran's right hand symptoms were related to herpes (see, e.g., June 2006 VA treatment records noting "hand cellulitis ?herpetic"). However, subsequent testing was conducted, which was negative for herpes; instead, the testing showed an irritational cause. See July 2006 VA treatment report. The negative test results also formed the basis of the June 2006 examiner's opinion that the right hand disorder was not secondary to his genital herpes. The June 2006 VA examiner offered a clear conclusion with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). Consequently, the Board assigns great probative value to the VA examiner's opinion. Thus, the competent and probative evidence does not establish that herpes either caused or aggravated the right hand condition. To the extent that the Veteran has stated that his skin condition of the hands is secondary to his service-connected genital herpes, the Board finds that the question regarding the potential relationship between the Veteran's skin condition of the hands and his service-connected genital herpes, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is non-probative evidence. In this case, the weight of the evidence is against the Veteran's claim that his skin condition of the right hand is secondary to his service-connected genital herpes; as discussed above in greater detail, the evidence of record establishes that the Veteran's skin condition of the right hand is an allergic reaction to the compounds he currently uses as a dental technician. Thus, service connection must be denied on a secondary service connection basis, as well. Increased Rating for Genital Herpes Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2012). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The July 2006 rating decision continued the Veteran's 10 percent disability rating for his service-connected genital herpes. The Veteran was granted a 10 percent disability rating under 38 C.F.R. § 4.118, Diagnostic Code 7599-7820. The Board notes that prior to this appeal, the diagnostic criteria for evaluating skin disorders, including 38 C.F.R. § 4.118, Diagnostic Code 7806, were substantially revised. Since these revisions were effectuated as of August 30, 2002, and the Veteran's claim was filed in February 2006, the Board finds that only the new rating criteria is effective. See 67 Fed. Reg. 49,590 - 49,599 (2002). The Board also notes that the regulations pertaining to rating skin disabilities were revised once again, effective October 23, 2008. However, those revised provisions are applicable only to claims received on or after October 23, 2008. Because the current claim was received prior to that date, those revisions do not apply in this case. 73 Fed. Reg. 54708 (Sept. 23. 2008). The Board notes that Diagnostic Code 7599 represents an unlisted disability requiring rating by analogy to one of the disorders rated under 38 C.F.R. § 4.118. See 38 C.F.R. § 4.27. The Veteran's genital herpes is rated under Diagnostic Code 7820, which directs evaluations to be assigned under the rating schedule for the skin (7800-7806), depending on the predominant disability. See 38 C.F.R. § 4.118. Diagnostic Code 7806 provides for a noncompensable rating if less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12- month period. A 10 percent rating is warranted if the eczema or dermatitis results in at least 5 percent, but less than 20 percent, of the entire body being affected, or at least 5 percent, but less than 20 percent, of exposed areas being affected; or, if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent evaluation is assigned in cases where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted in cases of more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. After a careful review of the Veteran's claims file the Board finds that the service-connected genital herpes does not warrant an increased rating. In February 2003 it was noted that the Veteran had three episodes of genital herpes in the past year and in January 2006 it was noted he currently had an outbreak of genital herpes. At the Veteran's June 2006 VA examination, he was not examined for his service-connected genital herpes but discussed it on the phone with the VA examiner. He stated that he had 8 to 10 outbreaks in the past year; when he had an outbreak, there were red bumps and pimple like blisters. He was on the medication Acyclovir. The Veteran stated that a physical examination was not needed since an outbreak just resolved. In December 2007 and July 2008, it was noted that the Veteran was continuously on Acyclovir for his herpes. In a September 2008 list of the Veteran's medications, it was noted that the Veteran was Clobetasol ointment and Mupirocin Ointment for his skin conditions with no skin condition specified. An April 2009 VA treatment note stated that he has not had a genital herpes breakout in 30 years. At the February 2012 VA examination it was stated that the Veteran had no current symptoms, signs, residual scars, or treatment of genital herpes in the past 12 months. In November 2012 the Veteran's VA medication list stated that the Veteran was on Miconzalone nitrate. In order for the Veteran to warrant an increased rating, the Veteran's service-connected genital herpes must be manifested by 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. However, the Veteran's herpes has only been noted to be on his genitals and, at the February 2012 VA examination, it was stated that the Veteran had no symptoms, signs, residual scars, or treatment of genital herpes in the past 12 months. Additionally, the Veteran does not warrant a higher rating based on the use of systemic therapy such as corticosteroids or other immunosuppressive drugs. Although VA treatment records dated throughout the appeal period show that the Veteran's was given numerous prescriptions for his skin symptomatology, these medications are either topical and/or are not systemic in nature; the Board notes that any notations to the Veteran taking steroids, such as a January 2008 VA treatment note, were in relation to the Veteran's contact dermatitis of the hands. Thus, the Board finds that the Veteran's genital herpes is not manifested by systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during any 12-month period during the appeal. Accordingly, a higher rating of 30 percent is not more nearly approximated. The Board has also considered whether higher disability ratings are warranted under the alternative diagnostic codes enumerated in Diagnostic Code 7806, under Diagnostic Codes 7800 for disfigurement of the head face or neck or Diagnostic Codes 7801 to 7805 for scars. However, the there is no evidence of any scarring or disfigurement, underlying soft tissue damage, limited motion, instability, pain, or limitation of function that would afford the Veteran a rating higher than currently assigned, such diagnostic codes are not for application under the circumstances of this case. In reaching the above determination, the Board has considered the Veteran's statements as to the nature and severity of his skin disability. The Veteran is certainly competent to report that his symptoms that he experiences. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Board finds that, even considering his statements, the criteria for the next higher rating have not been more nearly approximated. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-scheduler rating: (1) the established scheduler criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-scheduler disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111(2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the Veteran's genital herpes is contemplated by the rating criteria. In January 2012, it was noted that the Veteran's genital herpes did not impact his ability to work and, at the February 2012 VA examination, it was noted that any work disabilities were not related to his service-connected herpes. Thus, the Board finds that there is no evidence that takes the Veteran's service-connected genital herpes out of the rating schedule; instead, the Board finds that any limitations are taken into account with the Veteran's 10 percent disability rating. Thus, the rating criteria are therefore adequate to evaluate the Veteran's disability, and referral for consideration of extraschedular rating is not warranted. Moreover, given the above evidence indicating that his genital herpes does not affect his occupational or daily activities, the Board finds that this issue is not inextricably intertwined with the development requested below for the TDIU claim. In sum, the Board finds that the Veteran's service-connected genital herpes is not manifested by 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during a 12-month period. Therefore, an increased rating higher than 10 percent is not warranted for any time during the appeal period. ORDER Service connection for a skin disorder of the right hand, to include as secondary to the service-connected genital herpes, is denied. An increased rating in excess of 10 percent for the service-connected genital herpes is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria provide for a total rating when there is a single disability or a combination of disabilities that result in a 100 percent scheduler evaluation. Subjective criteria provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. For the purposes of this analysis, the following will be considered a single disability: disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system such as the orthopedic system. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In this case, the Veteran is service-connected for genital herpes as 10 percent disabling and keratitis sicca due to pterygium, bilaterally, as 10 percent disabling. As such, the Veteran does not meet the minimum scheduler criteria for TDIU under 38 C.F.R. § 4.16(a). However, even when the percentage requirements are not met, entitlement to a total rating, on an extraschedular basis, may nonetheless be granted, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). In May 2012, it was noted that the Veteran was having trouble working because his eyes were interfering him with working with details. The Veteran was afforded a VA eye examination in June 2012. The VA examiner stated that the Veteran worked as dental technician which is a very demanding specialty and given the Veteran's very severe dry eye syndrome in both eyes with a tear breakup time of less than 1 second in each eye it would be quite difficult for him to complete an entire work day demanding strong visual concentration. The VA examiner opined that, due to this, he felt the Veteran would have trouble securing and following a substantially gainful occupation given his level of education and special training on a full time basis. He further stated that the Veteran might be able to work on a part-time basis where he would be able to work for a short amount of time prior to his eyes becoming more bothered by his dry eye syndrome. He further stated that it would be possible to try and rehabilitate his dry eye syndrome appropriately to see if he would be a candidate for full time work after that. However, based on the examination, it was his opinion that the Veteran would be not be able to secure substantially gainful employment in his field due to his severe dry eye syndrome. However, the Board notes that the Veteran's VA treatment records include a November 2012 treatment note that he went back to work. As discussed above, the Veteran's combined evaluation is 20 percent disabling since September 27, 2002; therefore, the Veteran does not meet the minimum scheduler criteria for TDIU under 38 C.F.R. § 4.16(a). However, even when the percentage requirements are not met, entitlement to a total rating, on an extraschedular basis, may nonetheless be granted, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). Given the June 2012 VA opinion indicating that the Veteran is unable to work due to his service-connected eye condition, yet the conflicting evidence that indicates that the Veteran returned to work, the Board finds that additional information is required. First, the Veteran should provide his employment history on a VA Form 21-8940, and then addendum opinion should be obtained to ascertain whether the Veteran's service-connected disabilities alone are so severe so as to prevent the Veteran from obtaining and maintaining substantially gainful employment. Finally, if the evidence indicates an affirmative answer to this inquiry, the Board finds that the Veteran's claims file should be sent to the Director of Compensation Service for review and to determine whether the Veteran is entitled to a TDIU evaluation on an extraschedular basis under 38 C.F.R. § 4.16(b). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be asked to provide his occupational history on an Application for Increased Compensation Based on Unemployability [VA Form 21-8940]. 2. After completing the development outlined in step (1), obtain an addendum opinion regarding the effect of the Veteran's service connected disabilities on his ability to obtain and maintain substantially gainfully employment. An examination of the Veteran is not required unless deemed necessary by the medical professional selected to offer the opinion. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner is directed to discuss the Veteran's occupational history. 3. If the evidence indicates that the Veteran's service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment, refer the Veteran's service-connected disabilities to the Director of Compensation and Pension Service pursuant to the provisions of 38 C.F.R. § 4.16(b) for consideration of whether an extraschedular rating on the basis of TDIU is warranted for the Veteran's service-connected for genital herpes and/or service-connected keratitis sicca due to pterygium. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim for TDIU should be readjudicated based on the entirety of the evidence, to include all evidence received since the issuance of the February 2013 SSOC. If any of the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ K. GIELOW Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs