Citation Nr: 1326015 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 04-20 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, other than posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 10 percent for service-connected blistering dermatitis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran had active service from June 1980 to December 1990. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. By that rating action, the RO, in part, continued a 10 percent disability rating assigned to the service-connected blistering dermatitis. The RO also denied service connection for depression. The Veteran appealed this rating action to the Board. In February 2010, the Veteran testified before the undersigned Acting Veterans Law Judge at the RO in Montgomery, Alabama. A copy of the hearing transcript has been associated with the record. The issues remaining on appeal were previously before the Board in August 2010 and December 2012 and were remanded for additional development. The issues have returned to the Board for appellate consideration. FINDINGS OF FACT 1. An acquired psychiatric disorder other than PTSD was not manifest during active service, a psychosis was not manifest within one year of discharge from active service, and an acquired psychiatric disorder other than PTSD is not shown to have developed as a result of a service-connected disability or an established event, injury, or disease during active service. 2. The Veteran's service-connected blistering dermatitis has been manifested by subjective complaints of flare-ups of itchy dry rashes on his extremities, but without objective evidence of any active lesions, blisters or ulcers. 3. There is no evidence of blistering dermatitis affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected that have required systemic immunosuppressive medications; and, no evidence of marked disfigurement, exceptional repugnant condition, ulceration, systemic or nervous manifestations, scarring, or limitation of function of any affected part. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder other than PTSD was not incurred in or aggravated by service nor as a result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a disability rating in excess of 10 percent for blistering dermatitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7806 (before and after October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Before addressing the merits of the increased rating issue on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. VA's duty to notify has been satisfied. The Veteran was notified via a December 2002 letter of the evidence that was necessary to substantiate his claims and his and VA's respective duties for obtaining evidence. This letter predated the initial adjudication in June 2003. Additional notice correspondence was issued in March 2003, February 2007, and September 2008. In a post-adjudication letter to the Veteran, issued in January 2013, addressed the notice elements of how VA determines disability ratings, to include the post-2002 schedular criteria for evaluating skin disabilities. The Board also notes that the duty to assist the Veteran in the development of his claims has been satisfied. The Veteran's relevant post-service VA and private treatment and examination reports have been associated with the physical claims files, as well as uploaded to his Virtual VA electronic claims file. The Veteran has actively participated in the processing of his increased evaluation claim, and the statements submitted in support of his claim have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). The Veteran was afforded VA examinations in connection with the claims, most recently in July 2011. Recently, pursuant to the Board's December 2012 remand directives, a VA examiner reviewed the claims files to provide an opinion as to the manifestations of the Veteran's service-connected blistering dermatitis during its active period. The requested opinion and addendum were provided in February and April 2013, respectively. Copies of the opinion and addendum have been associated with the Veteran's physical claims files. The service connection issue was addressed in a May 2013 examination report. The Board finds the provided opinions to have been thorough and adequate upon which to base decisions on these claims. The examiners reviewed the Veteran's entire claims files, to specifically include VA and private treatment and examination report. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. The Board finds that there has been substantial compliance with its December 2012 remand instructions. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board notes that the Veteran's increased rating claim has been evaluated under the applicable criteria for skin disabilities in effect from August 30, 2002. As will be explained in the analysis below, the medical evidence of record clearly shows that the Veteran has not had any active manifestations of his service-connected blistering dermatitis throughout the appeal period; thus, a higher rating under the criteria in effect either prior or subsequent to August 30, 2002 is not warranted. Thus, the Board finds that under these circumstances a remand for the sole purpose of informing the Veteran of the pre-August 2002 skin regulation criteria would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). Finally, in February 2010, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Acting Veterans Law Judge. 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 RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the above-cited hearing, information was solicited regarding the present claims and it was also discussed whether there were any outstanding medical records available. Therefore, not only was the above-cited issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issue material to substantiating the claim" were also fully explained. The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. VA's duties to notify and assist are met, and the Board will address the merits of the claims in the analysis set forth below. II. Service Connection Claim Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be established on a secondary basis for a disability which is proximately due to or aggravated by service-connected disease or injury. 38 C.F.R. § 3.310 (effective before and after October 10, 2006). When aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition a veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). Where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of the Veteran's service as shown by the veteran's service record, the official history of each organization in which the Veteran served, the Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Service connection can be granted for certain chronic diseases, including psychoses, if manifest to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact incurred during the service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Continuity of symptomatology applies to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Lay evidence presented by a Veteran concerning his continuity of symptoms after service may be considered credible, and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2012). Based upon the evidence of record, the Board finds that an acquired psychiatric disorder other than PTSD was not manifest during active service, that a psychosis was not manifest within one year of discharge from active service, and that an acquired psychiatric disorder other than PTSD is not shown to have developed as a result of a service-connected disability or an established event, injury, or disease during active service. The pertinent evidence of record shows that pursuant to the Board's December 2012 remand directives, a VA psychologist reviewed the claims file in May 2013 in order to provide an opinion as to the etiology of any manifest depression. The examiner noted that he, along with an April 2012 VA psychologist, had concluded that it was less likely than not (i.e., less than 50/50 percent probability) that the Veteran had a psychiatric disorder beyond PTSD that had been caused by or a result of military service. It was further stated that an additional diagnosis, such as depression, required the examinee in question to have depressive symptoms there were significantly more severe than might be found among most individuals diagnosed with PTSD. The Board notes that the April 2012 VA psychologist had provided diagnoses of depressive disorder in May, September and October 2011, which he had attributed to the Veteran's inability to work. In addition, treatment records dated in April and June 2012 uploaded to the Veteran's Virtual VA electronic claims file include diagnoses of a mood disorder and depression. The Board finds, however, that the May 2013 VA examiner's opinion as to the matter is persuasive and based upon adequate rationale. The opinion is shown to have been based upon a thorough examination, a thorough review of the evidence of record, and adequate consideration of the Veteran's statements. Although the record includes diagnoses of other acquired psychiatric disorders, those examiners from whom those diagnoses were provided did not address whether the diagnoses or any manifest additional disability were distinct from the symptoms attributable to the Veteran's service-connected PTSD. Overall, the May 2013 examiner's is found to more persuasive based upon a more comprehensive review of the record. The Board notes that care must be taken concerning the effect of any change in diagnoses. 38 C.F.R. § 4.13 (2012). While the Veteran is competent to provide evidence as to observations and some medical matters, his statements are, at most, conclusory assertions of a nexus between his post-service mental health problems and active service. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006). As questions of a diagnosis of an acquired psychiatric disorder other than PTSD and any relationship to service are complex etiological questions akin to the type of medical matters which courts have found laypersons are not competent to provide, his statements are insufficient to establish service connection. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether the claimed disability is a type of disability for which a lay person is competent to provide etiology or nexus evidence). The Veteran is not found to be competent to state that he has an additional an acquired psychiatric disorder other than PTSD as a result of active service. The Board finds the preponderance of the evidence is against the claim for entitlement to service connection. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Rating Claim Disability ratings are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In determining the level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. §§ 4.2, 4.41 (2012). An evaluation of the level of disability present also includes consideration of the functional impairment of the appellant's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). When the appeal arises from an initial rating consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also appropriate in increased-rating claims in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When, an already established service-connected disability, such as in this case, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). 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 required for that rating. 38 C.F.R. § 4.7 (2012). In this case, the Veteran seeks a disability rating in excess of 10 percent for his service-connected blistering dermatitis. In January 2002, the RO received the Veteran's claim for increased compensation for his service-connected blistering dermatitis. The RO assigned a 10 percent disability rating to the service-connected blistering dermatitis under 38 C.F.R. § 4.71a, Diagnostic Code 5299-7806. Hyphenated Diagnostic Codes are used when a rating for a particular disability under one Diagnostic Code is based upon rating under another Diagnostic Code. See 38 C.F.R. § 4.27. The four digits before the hyphen is the Diagnostic Code for the disability. Id. 99 indicates that the Veteran's disability is not listed in the Schedule for Rating Disabilities, while 78 indicates that it is related most closely to the listed skin disability. See 38 C.F.R. §§ 4.20, 4.27. The four digits after the hyphen is the Diagnostic Code for the disability specifically found to be most analogous. 38 C.F.R. § 4.27. In this case, Diagnostic Code 7806, the Diagnostic Code used to evaluate eczema, is most applicable based upon the available evidence. See 38 C.F.R. § 4.118, Diagnostic Code 7806; see also Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended in August 2002 (see 67 Fed. Reg. 49490 -99 (July 31, 2002)) and again in October 2008 (see 73 Fed. Reg. 54708 (September 23, 2008)). A subsequent final rule correction also provided that the revised criteria for scars were applicable to all claims received before October 23, 2008, and still pending in the appeals process. See 77 Fed. Reg. 2910 (January 20, 2012). Significantly, however, the October 2008 revisions nor January 2012 corrections did not revise the applicable criteria under Diagnostic Code 7806. Nonetheless, given the Veteran's January 2002 claim, VA may apply the pre-2002 rating criteria for the entire time the appeal has been pending and VA may only consider the pre-October 2008 since August 2002. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board will address each criteria separately in its analysis below. (i) Skin Criteria-Prior to August 30, 2002 Under Diagnostic Code 7806, prior to August 30, 2002, a 10 percent disability rating was assigned where there was evidence of exfoliation, exudation or itching, if it involved an exposed surface or extensive area. A 30 percent rating was assigned for eczema with exfoliation or itching constant, extensive lesions, or marked disfigurement. A 50 percent rating was assigned for eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or if it was exceptionally repugnant. 38 C.F.R. § 4.118, Diagnostic Code 7806 (effective before August 30, 2002). The Veteran maintains that he has flare-ups every six (6) months of a rash on his legs and arms with little patches of bumps that dry up and are treated with topical creams. (See January 2002 and July 2011 VA skin examination reports and January 2012 VA general medical examination report). With regard to evaluating the Veteran's claim under the criteria for eczema under Diagnostic Code 7806 prior to August 30, 2002, VA and private examination and treatment reports, dated from 2002 to 2013, reflect that the Veteran has subjectively complained of painful lesions on his back and legs that are filled with fluid and itch when intact. During the January 2012 VA examination, the examiner noted that the Veteran had dry skin over his arms, legs, abdomen, and feet but without any evidence of active vesicular lesions. There was no evidence of scarring in the trunk or extremities related to the service-connected blistering dermatitis. Although there was significant hypo pigmentation and moderate facial scarring, the January 2012 VA examiner attributed this to the service-connected pseudofolliculitis barbae, as opposed to the service-connected blistering dermatitis. Overall, and as noted by a VA examiner who had reviewed the Veteran's claims files in February and April 2013, the January 2002, July 2011, and January 2012 VA examination reports did not show that the Veteran had any active manifestations of his blistering dermatitis throughout the appeal period. In his April 2013 addendum, the examiner opined that if the Veteran's blistering dermatitis had been active, as he had alleged, there would have been evidence of blistering lesions with fluid filled vesicles, which was not shown on any of the above-cited VA examination reports, or private and VA treatment records. (See April 2013 VA opinion). Thus, in the absence of any active lesions related to his service-connected blistering dermatitis, a disability rating of 30 percent is not warranted under Diagnostic Code 7806. See 38 C.F.R. § 4.118 (effective before August 30, 2002). In addition, as there are no visible active lesions of the face, head or neck during the appeal period that are attributable to the service-connected blistering dermatitis, a higher rating is also not warranted under Diagnostic Code 7800, the Diagnostic Code used to evaluate disfiguring scars of the head, face or neck, prior to August 30, 2002. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2002). Similarly, there is no evidence of scarring such that an increased or separate rating under Diagnostic Codes 7801-7805, prior to August 30, 2002, is warranted. (ii) Criteria effective August 30, 2002 and after October 2008 Effective August 30, 2002, Diagnostic Code 7806, dermatitis or eczema will be assigned a 10 percent rating where at least 5 percent, but less than 20 percent, of the entire body or of exposed areas are affected, or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. Higher ratings are available where larger percentages of the entire body or exposed areas are affected, or longer periods of systemic therapy such as corticosteroids or other immunosuppressive drugs are required. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2008). In this case, and as noted above, there is no evidence of any active lesions as a result of the Veteran's service-connected blistering dermatitis during the appeal period. According to VA treatment reports, dated in June 2012 and uploaded to the Veteran's Virtual VA electronic claims file, he has been prescribed topical ointments for his skin, such as Urea cream and Vitamin A and D ointments. These are not oral drugs that are immunosuppressive in nature. In addition, there is no indication that they were prescribed for the Veteran's service-connected blistering dermatitis, especially since corresponding physical evaluations of the skin show that the Veteran's skin was without patches, ulcers or lesions. Accordingly, a rating in excess of 10 percent rating is not warranted under the revised Diagnostic Code 7806. In addition, as there are no visible active lesions of the face, head or neck during the appeal period that are attributable to the service-connected blistering dermatitis. Nor evidence of residual scarring from his service-connected blistering dermatitis that has resulted in impairment of function. For all the foregoing reasons, the Board finds that there is no basis for staged ratings for the service-connected blistering dermatitis. Rather, the above-cited symptomatology associated with the service-connected blistering dermatitis is essentially consistent throughout the appeal period and is fully contemplated by the assigned 10 percent disability rating. (iii) TDIU Consideration In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The RO awarded the Veteran a TDIU in a December 2012 rating action; thus, the issue is moot. (iv) Extraschedular Consideration In evaluating the Veteran's claim for a disability rating in excess of 10 percent for the service-connected blistering dermatitis, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected blistering dermatitis is inadequate. A comparison between the level of severity and symptomatology of this disability, with the established criteria found in the rating schedule, shows that the rating criteria reasonably describe this disability under both sets of rating criteria, as discussed in the preceding analysis. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that that the Veteran has required any hospitalization for his service-connected blistering dermatitis. There is no persuasive evidence in the record to indicate that this disability would cause any impairment with employment over and above that which is already contemplated in the assigned schedular rating. In this regard, and as noted by the Board in its December 2012 decision, a VA examiner found the Veteran to have been unable to secure or maintain any substantial gainful employment, both sedentary and physical, as a result of his service-connected low back disability, not his service-connected blistering dermatitis. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Further, 38 C.F.R. § 4.1 (2012) specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence does not demonstrate in this case is that the manifestations of the Veteran's service-connected blistering dermatitis has resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disabilities contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is denied. A disability rating in excess of 10 percent for service-connected blistering dermatitis is denied. ______________________________________________ T. L. DOUGLAS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs