Citation Nr: 1327444 Decision Date: 08/27/13 Archive Date: 09/24/13 DOCKET NO. 10-12 406 ) DATE AUG 27 2013 On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for psoriasis. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Zenzano, Associate Counsel INTRODUCTION The Veteran had active military service from February 1970 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Waco, Texas, which denied service connection for psoriasis of the hands and feet (also claimed as eczema of the hands and feet). This case was remanded by the Board in January 2013 and an expert opinion from the Veterans Health Administration (VHA) was obtained in August 2013. As noted in the January 2013 remand, the Board observes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009). In this regard, the Veteran initially characterized such claim as eczema, redness, peeling, and crackings of the hands and feet, and subsequently requested that such should be recharacterized as psoriasis. The record shows diagnoses of psoriasiform dermatitis on the hands and feet, contact dermatitis, tinea manus, scirrhuses, eczema, and psoriasis. However, the August 2013 VHA expert indicated that dermatitis and eczema are different names for the same condition and, although psoriasisform dermatitis was an initial working diagnosis, to was revised to psoriasis. He concluded that eczema and dermatitis are not part of the Veteran's current medical picture. Therefore, the Board has recharacterized the issue as shown on the first page of this decision. In November 2011, the Veteran and his spouse testified at a hearing before a Decision Review Officer at the RO. Additionally, in July 2012, the Veteran offered testimony at a personal hearing before the undersigned Veterans Law Judge sitting at the RO. The transcripts of both hearings are of record. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals additional VA treatment records dated through -2- May 2013 that were not considered by the agency of original jurisdiction (AOJ); however, as the Board is granting the Veteran's claim for service connection in full, there is no prejudice to him in the Board considering such records. FINDING OF FACT The Veteran's psoriasis is related to service. CONCLUSION OF LAW Service connection for psoriasis is warranted. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION As the Board's decision to grant service connection for psoriasis herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. The Veteran claims that his skin disorder was incurred during his military service, to include as a result of anti-malarial drugs taken while stationed in Vietnam. Therefore, he contends that service connection for his skin disorder, diagnosed as psoriasis, is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). -3- Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. 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). 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) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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). Service treatment records reflect that the Veteran was hospitalized for allergic dermatitis in February 1970 after his exposure to poison oak. He spent one night in the hospital. He received at least two treatments of Decadron (dexamethasone), an anti-inflammatory drug and corticosteroid. The remainder of his service treatment records, to include the October 1971 separation examination, are negative for skin complaints, treatment, or diagnoses. Of record are lay statements from the Veteran and his family members indicating that his skin disorder has existed since service. -4- In November 2008, the Veteran underwent a VA examination, at which time the examiner noted that the Veteran had no known treatment for a skin condition during active duty and had no symptoms for more than thirty years after his separation from military service. Consequently, he concluded that the condition was less likely than not the result of an anti-malarial drug that the Veteran took during service. He indicated that there was no known correlation between the anti-malarial drug and skin conditions such as psoriasis or eczema. Subsequently, the Veteran submitted medical treatise evidence suggesting a link between anti-malarial drugs and psoriasis; specifically, that the anti-malarial drug chloroquine can worsen or induce pre-existing latent psoriasis. The Veteran also submitted several pages of objective medical studies pertaining to skin conditions suffered by Vietnam Veterans related to heat and chemical exposures during service, including that the tropic environment of Southeast Asia may play a role in the development of skin conditions. In January 2012, the Veteran submitted a statement from his VA treating physician noting that the Veteran reported that his rash started while he was in Vietnam, and that it is typical for psoriasis to begin at that age. The physician opined that it was more likely than not that the Veteran's psoriasis began when he was in Vietnam. In January 2013, the Board remanded the Veteran's claim for further development. In particular, the Board found the November 2008 VA examination inadequate for adjudication purposes, as the opinion was rendered prior to the receipt of records showing the Veteran's in-service treatment for poison oak and the medical treatise suggesting probable causes between the Veteran's service and skin disorder. Furthermore, the November 2008 VA examiner did not address whether the Veteran's skin condition is related to his service in Vietnam and/or exposure to herbicides coincident with such service. Additionally, the January 2012 favorable opinion warranted consideration by an examiner. -5- Consequently, in February 2013, the Veteran underwent another VA examination. At such time, the examiner found that the Veteran's skin disorder was less likely than not related to service. His rationale stated, in pertinent part, that: ...There are no skin conditions listed on the Agent Orange presumptive list so the skin condition (as per criteria reviewed today) is not related to an environmental condition and/or herbicides. This examiner has previously opined that the skin condition is not related to anti-malarial drugs as there is no known correlation as per all reviewed resources... Thus, although the examiner stated he reviewed the medical treatise provided by the Veteran, described above, he did not reconcile those studies with his opinion. In light of the inadequate opinions of record, the Board obtained a VHA expert opinion in August 2013, in which a dermatologist found that the Veteran's skin disorder, which, as noted in the Introduction, he classified as psoriasis, was at least as likely as not related to service. In so finding, the examiner noted that, although the Veteran's discharge examination found no skin abnormality, psoriasis is a chronic condition in which exacerbations and remissions are common. He further explained that dermalogical literature establishes that chloroquine and other antimalarial drugs can exacerbate or precipitate psoriasis. The Board accords the August 2013 examiner's opinion significant probative value on the question of etiology, as it reflects an opinion based on a thorough review of the Veteran's medical records and provides a rationale which discusses the Veteran's assertions and pertinent medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Furthermore, the examiner offered clear conclusions with supporting data and reasoned medical explanations. Id., 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"). -6- Accordingly, as the most probative evidence of record relates the Veteran's psoriasis to service, the Board finds that service connection for such disorder is warranted. ORDER Service connection for psoriasis is granted. A. JAEGER Veterans Law Judge, Board of Veterans' Appeals -7-