Citation Nr: 1327571 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 07-11 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to a disability rating greater than 60 percent for a skin disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran had active service from October 1971 to December 1975 and from October 1979 to October 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In May 2010 and April 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The RO/AMC was directed to obtain the Veteran's up-to-date VA and private treatment records and these records subsequently were associated with the claims file. The RO/AMC also was directed to schedule the Veteran for updated VA examination and this examination occurred in June 2012. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The record evidence shows that the Veteran's service-connected skin disability does not result in distortion or asymmetry of more than two features or paired sets of features, five characteristics of disfigurement, unstable areas, limitation of function, or painful scarring of the head, face, or neck. 2. The record evidence shows that the Veteran's service-connected skin disability does not result in tissue loss, unstable areas, limitation of function, or painful scarring per se of the chest and back and the affected area is less than 144 square inches of the chest and less than 144 square inches of the back. 3. The record evidence shows that the Veteran's service-connected skin disability results in six inches of tissue loss at the groin, but no painful scarring per se, unstable areas, or limitation of function to approximate loss of use or penile deformity. CONCLUSION OF LAW The criteria for a disability rating greater than 60 percent for a skin disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes (DC's) 7800 to 7806, 7828, 7829 (effective before and after October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO provided the appellant pre-adjudication VCAA notice in this case in a June 2006 letter. The RO also provided the Veteran with notice of the "old" and "new" criteria pertaining to the skin in the March 2007 statement of the case and September 2012 supplemental statement of the case and considered entitlement to an increased rating under both sets of criteria. Although the claim was not readjudicated after the September 2012 supplemental statement of the case, the record indicates that the Veteran had actual knowledge of the new rating criteria for skin disabilities. He asked for his claim to be reviewed under the revised rating criteria and provided argument in favor of a higher rating under those criteria. Additionally, the Veteran was represented by a Veterans Service Organization throughout the pendency of this appeal. Overton v. Nicholson, 20 Vet. App. 427 (2006). Thus, the Board finds the Veteran had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected by VA error. VA also has obtained VA treatment records, assisted the Veteran in obtaining evidence, and afforded him the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file. The Veteran has not contended otherwise. VA examinations were obtained in July 2006, February 2007, May 2009, July 2010, and June 2012. 38 C.F.R. § 3.159(c)(4). With the exception of certain findings presented in the July 2010 examination record (as discussed in more detail below), the Board finds that the examination records and associated findings and opinions are adequate, as they are predicated on a full reading of the medical records in the Veteran's claims file and are consistent with the medical evidence of statements from the Veteran. The Veteran has not alleged an increase in manifestations of the disability since the June 2012 examination. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). In summary, VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Increased Rating The Veteran seeks a higher rating for his skin disability. He contends that a higher rating is warranted by rating his skin disability under separate diagnostic codes, notably those pertaining to disfigurement, rather than together by analogy to eczema. He has reported that the skin disability is constant, never healing fully, and causes him to miss work due to flare-ups. He also has reported numerous days of flare-ups involving the neck, back, anus, and scrotum. He has explained that the sores on the scrotum and anus are painful and prevent him from sitting at his desk and sometimes the sores break resulting in soiling of his clothes and requiring him to leave work to change clothes. Law and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 38 C.F.R. § 4.14. While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection 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. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. During the pendency of the appeal, VA amended certain criteria for evaluating the skin. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are effective only for claims filed on or after October 23, 2008, or in cases where the Veteran has requested review under the "new" rating criteria. The Veteran has requested review under the "new" rating criteria. As such, the Board will discuss the "old" and "new" rating criteria. The Board notes that the "new" rating criteria can be applied only as of the effective date, however. See VAOPGCPREC 3-2000. The skin disability is currently rated at 60 percent under Diagnostic Code (DC) 7806, which rates eczema. 60 percent is the maximum rating provided by the "old" or "new" DC 7806; thus, a higher rating is not available under that diagnostic code. DC 7806 indicates that the condition can be evaluated under disfigurement of the head, face, and neck or scars, depending upon the predominant disability. Disfigurement of the head, face, or neck is rated under DC 7800. DC 7800 provides a 10 percent rating for one characteristic of disfigurement; a 30 percent rating for disfigurement 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; a 50 percent rating for disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or with four or five characteristics of disfigurement; and an 80 percent rating for disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features or with six or more characteristics of disfigurement. The amendment added two relevant notes: Note (4) which instructs the rater to separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury and Note (5) which states that the characteristic(s) of disfigurement may be caused by one scar or by multiple scars. With respect to the affected areas other than the head, face, or neck, DC 7801 rates scars which are deep or limit motion under the "old" criteria or are deep and nonlinear under the "new" criteria. DC 7802 rates scars not of the head, face, or neck, that are superficial or limit motion under the "old" criteria or are superficial and nonlinear under the "new" criteria. The "old" and "new" rating criteria instruct that the scars of each extremity and posterior and anterior trunk should be separately rated based on total area and then combined under 38 C.F.R. § 4.25. The rating criteria also provide compensable ratings for scars which are unstable or painful. The "old" rating criteria provided 10 percent ratings for superficial scars that are unstable or that are "painful on exam." 38 C.F.R. § 4.118, DC 7803, 7804 (2008). The "new" rating criteria provide a 10 percent rating is provided for one or two scars that are unstable or painful, a 20 percent rating for three or four scars that are unstable or painful, and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804 (2012). The "old" and "new" rating criteria also indicate that any limitation of function should be rated under the applicable diagnostic code. The evidence contains no findings of unstable scars; rather, examiners have consistently found that that the scars are not unstable. Factual Background A June 2005 VA treatment record reflects the Veteran's history of boil on the posterior left upper leg and neck area. The record indicates that minimal drainage was noted to the neck area. The Veteran reported a different flare of a boil over the weekend as well as a recent boil under the chin. Examination revealed a draining boil on the neck and an induration of about ten centimeters on the left buttock which was very deep in the tissue and draining. The Veteran was prescribed antibiotics due to the depth of the induration and encouraged to take more vitamin C. A subsequent June 2005 VA treatment record reflects the Veteran's history that three days after being seen previously, he developed more boils. He explained that the one on his leg went away after using salve but the one around the anus was still draining. Examination revealed multiple healing "boils," which were "mostly sores with no underlying induration." The Veteran was encouraged to use antibacterial soap and a rag to scrub the skin and to take Vitamin C daily. A July 2005 VA treatment record reflects the Veteran's history of recurrent sores on the buttocks and neck. He denied itch, color change, or rash. A December 2005 VA treatment record reflects the Veteran's history that the boils had not flared as much recently. The Veteran was assessed with boils, "doing better" due to use of antibacterial soap and use of rag to scrub skin. A July 2006 VA examination record reflects the Veteran's history of exudation, itching, shedding, crusting, and slow-to-heal lesions. He reported use of topical medication and indicated that the associated functional impairment was an inability to sexually perform due to scrotal pain when the lesions are present. He also reported recurrent skin lesions on the face, neck, earlobes, groin, and scrotum which were associated with functional impairment due to pain when reaching overhead with extended arms. Examination revealed depressed scars at the face, neck, earlobes, groin, and scrotum and numerous pitted scars measuring 15 centimeter (cm) by 0.5 cm with tenderness, disfigurement, adherence, inflammation, tissue loss of less than six square inches, and abnormal texture of more than six square inches. There was no ulceration, instability, edema, keloid formation, hypopigmentation, or hyperpigmentation. The scars over the face caused distortion of pitted scars on both sides of the face and earlobes but did not cause asymmetry of the nose, chin, forehead, eyes, or lips. The face scars did cause asymmetry of the ears and cheeks. Examination also revealed deep chloracne of the anterior neck and scrotum, which had features of inflamed nodules. The examiner reported that the skin condition located on the face, neck, earlobes, groin, and scrotum had induration of less than six square inches and abnormal texture of more than six square inches. There was no ulceration, exfoliation, crusting, tissue loss, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. The skin lesion coverage was estimated at 60 percent of exposed areas and two percent of the whole body. The skin lesions were not associated with systemic disease and did not manifest in connection with a nervous condition. The examiner diagnosed chloracne with lesion, manifested by objectively visible active lesions and deep pitted scars, and disfiguring scars of the face, neck, and pubic area. A January 2007 VA treatment record reflects the Veteran's history of recurrent "boils" on the buttocks. The record notes that there were "no problems presently." The Veteran indicated that he "seem[ed] to have flare-ups" one to two times per year. A February 2007 VA examination record reflects the examiner's determination that the Veteran had severe cystic acne, for which he used topical medication. The Veteran reported that the condition affected his face, neck, back, and groin and that the condition became "particularly severe from time to time" in the perineal region. He explained that in the perineal region, "it suppurates, foul smelling exudates, and gets so painful he is sometimes unable to sit." He added that he gets periodic episodes of a painful cyst on his face and neck. There were no systemic symptoms. Examination revealed severe pitting scar on the face, "some" pitting scars on the hairline of the back of the neck and entire back, and cystic lesions on the anterior neck. There were numerous large comedones with black hyperpigmented areas where he had some previous lesions. The examiner diagnosed chloracne which affected 40 percent of the entire body surface: the face, one percent of the neck, 100 percent of the back and 100 percent of the perineal region. A January 2008 VA treatment record reflects the Veteran's history that his acne was "doing well with current topical treatment" and a January 2009 VA treatment record indicates that the treatment was "effective." A May 2009 VA examination record reflects the Veteran's history of disfiguring scars of the face which were associated with constant flare-ups, swelling, soreness, and sores filled with pus. The Veteran also reported disfiguring scars of the neck, which were tender, sore, and filled with pus, and disfiguring scars on the pubic areas, which were manifested by soreness, pus-filled areas, elevated scar, tenderness, and soreness. Finally, he reported acne with lesions which involved the face, neck, back, chest, pubic area, and groin area. He reported exudation on the face and groin, itching on the back, shedding on the face and back, and crusting on the back and chest. He indicated that he had these symptoms intermittently, as often as four times a year, with each occurrence lasting three days. He reported three attacks within the past year. He added that he had very limited activity during flare-ups. He indicated that he used topical cleanser and a systemic antibiotic. He explained that he had functional impairment due to decreased exposure to personnel and clients when the condition became acne and decreased activity. Examination revealed deep acne at the neck and face, which was associated with inflamed nodules and which covered 90 percent of the face and neck. There was also acne of the face and neck which was associated with induration and abnormal texture of more than six square inches but no ulceration, exfoliation, crusting, disfigurement, tissue loss, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. The condition affected 80 percent of exposed areas and five percent of the total body. The skin diseases were not associated with systemic disease and did not manifest in connection with a nervous condition. There was elevated scarring on the face, measuring about 23 cm by 10 cm. The scarring had disfigurement and abnormal texture of more than six square inches but no tenderness, ulceration, adherence, instability, inflammation, edema, keloid formation, hypopigmentation, hyperpigmentation, or limitation of motion. There was scarring of the anterior neck measuring 14 cm by 4.5 cm, scarring of the chest measuring 27 cm by 11 cm, and scarring of the back measuring 34 cm by 14 cm. Each area of scarring had disfigurement and abnormal texture of more than six square inches but no tenderness, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, inflammation, edema, or limitation of motion. The examiner indicated that the facial scarring did not cause distortion or asymmetry of the nose, chin, forehead, eyes, ears, cheeks, or lips. The examiner found the effect of the skin conditions on occupation and daily activity was mild. A May 2010 private treatment record from J.A.C., M.D., reflects the Veteran's history of increasing acne which the Veteran described as "severe" and which was described as affecting the "back (buttock line and pubic area), chest, and face." The record adds that the acne was characterized by painful pus-filled cysts, scarring, and inflamed papules, for which the Veteran used topical medication. Examination revealed inflamed papules with pain, scarring, pruritus but no dryness, itching, new lesion, multiple skin lesion, skin color change, or ulceration. The dermatologist reported that there were no visible lesions or palpable masses on the neck and that distribution and scalp and body hair was normal. There were multiple erythematous and irritated hair follicles on the face with hypertrophic, firm, raised, flesh-colored to pink to hyperpigmented scars extending beyond its base "(consistent with keloid scar)." There was a non-tender nodular mass without sign of infection to the buttocks, groin, and right and left axilla and an external hemorrhoid. The Veteran was assessed with hemorrhoid, other specified disease of hair and hair follicles, and keloid scar. A July 2010 VA examination record reveals findings of massive scarring of the entire face with disfigurement secondary to the opening of multiple cystic-type acne of the face. The Veteran reported one or two lesions a year that have to be opened and drained on his face or neck. He added that the last one to be opened on his left cheek was one month earlier. The Veteran reported that the acne involved the entire face, cheeks, nose, eyebrows, forehead, upper part of the anterior chest, and the back. The reported symptoms were pain and drainage of the lesions when the cystic acne lesions come to a head. The Veteran reported that the lesions "frequently" have to be lanced and drained, which caused pain, discomfort, and disfigurement and which required him to lose two to three days of work each year. The examiner also noted multiple small scars over the entire face and disfigurement that limited some of the Veteran's social life. The examiner noted tiny scars continuously located on the Veteran's cheeks involving 60 square inches in total (5x6 inches bilaterally), scars on the back involving 84 square inches (6 x 14 inches), scars on his chest involving 48 square inches (6 x 8 inches), and scars in the groin involving 6 square inches (1 x 6 inches). The scars were not painful on examination, though the examiner noted that the scars reportedly became painful when active and nearing the time to be lanced and drained. There were no painful lesions on examination. The examiner found the scars were depressed and adherent to the underlying tissue and involved 40% of the entire body and 38% of the exposed areas of the body. The examiner determined the entire area was irregular and abnormal in texture because of the multiple tiny scars adjacent to each other. There examiner found no skin breakdown or elevation. The examiner found the scars were deep and involved soft tissue in the entire measurement of the face and body provided above because "these are small tiny scars immediately adjacent to each other, which are the result of lancing cystic-type acne." There was no inflammation, edema, or keloid formation. The examiner reported that the areas of the skin that were hypo- or hyperpigmented were difficult to delineate and unable to be defined. The examiner determined the face was involved, involving the entire cheeks bilaterally, the nose bilaterally, the earlobes bilaterally, the eyebrows bilaterally, and the lower forehead bilaterally. This skin was indurated and inflexible over the entire area of measurements given above for the face and the body. There was no limitation of motion or function except when the cystic lesions came to a head and had to be drained; they became painful and it was difficult for him to appear in public and do his job. The examiner noted that the Veteran had been treated over the past year with a local, nonsystemic, treatment. The examiner added that the Veteran had not been treated with cortisone. The examiner diagnosed severe scarring of the entire face and a portion of the neck, the upper anterior chest, two-thirds of the back, and groin. The percentage of body involvement is 40% of the entire body and 38% of the exposed areas of the body due to this scarring from the lancing of the cystic acne. A March 2011 VA treatment record indicates that the Veteran had nodular acne on the face and was positive for scarring. The record adds that the Veteran requested Benzacline for his acne. A July 2011 private treatment record and medical statement reflect the Veteran's history of constant, severe symptoms. Examination was normal except for a finding of folliculitis of the face and back and severe acne-like scarring of the face, upper back, chest, and groin. The dermatologist noted that the Veteran reported episodes of hidradenitis-like lesions occasionally. The dermatologist believed the Veteran had follicular triad syndrome. The dermatologist explained that "this means [the Veteran] has features of severe inflammatory follicular disorders" which was associated with scarring acne, hidradenitis supurativea, and pilondial cysts. See M.F.N., M.D. records. A July 2012 VA treatment record indicates that the Veteran had pustular acne on the face and was positive for scarring. The record notes that the Veteran was instructed to continue use of benzoyl peroxide and clindamycin. The records indicate that clindamycin, which is an antibiotic, was prescribed in February 2012. A July 2012 VA "scars/disfigurement" examination reflects findings of scars on the trunk and head, face, and neck. There were no scars on the extremities. The scars of the trunk, which were too numerous to count, were not painful, deep, or unstable; the examiner determined they were superficial. The examiner estimated that the scars of the trunk affected 40 square centimeters of the anterior trunk and 40 square centimeters of the posterior trunk. The scars on the head, face, and neck, which were also too numerous to count, were not painful or unstable. There was no elevation, depression, adherence, abnormal pigmentation or texture, or missing underlying soft tissue. There was also no gross distortion or asymmetry of facial features or visible or palpable tissue loss, and the scars did not limit function or impair ability to work. A July 2012 VA "skin" examination reflects a notation of past diagnosis of eczema of the face and body. The examiner found no systemic manifestations and indicated that the Veteran had used topical medication for six weeks or more but not constantly or near-constantly for acne. The examiner determined that the skin condition did not impact the ability to work. The examiner found that there was no evidence of eczema at the time of examination. Instead, the examiner found extensive comedone acne of the face, neck, chest, and back which produced scarring in the form of pits and comedone cysts and lipomas. The examiner indicated that the lesions were producing the scars noted in the scar examination. The examiner explained that comedone acne is an inflammatory process produced by the presence of a comedone leading to cystic lesions. The examiner added that it is characterized by the formation of cysts and scarring as well as infection of cysts leading to boils. The examiner estimated that one percent of the face and neck, nine percent of the chest, and nine percent of the back was involved. There was no current genital or buttock involvement and no involvement of the extremities. There was a mixture of comedones and pitted scars affecting the chest, back, neck, and face. Analysis The Board finds that the preponderance of the evidence does not support assigning a disability rating greater than 60 percent for the Veteran's service-connected skin disability at any time during the pendency of this appeal. The record evidence supports, at best, a 50 percent rating as the highest rating available under DC 7800 for the Veteran's service-connected skin disability. The Board acknowledges that the record includes often conflicting findings as to whether there is tissue loss, adherence, distortion, and asymmetry. Giving the Veteran the benefit of the doubt, however, the Board finds the skin disability results in at least intermittent distortion or asymmetry of two features or paired set of features (the cheeks and ears), adherence to underlying skin, depressed surface contour, and abnormal texture in an area exceeding six square inches and that the scarring affects an area more than five inches long and one-quarter inch wide. A rating greater than 50 percent is not warranted under DC 7800 at any time during the appellate period. The record evidence indicates that the skin disability never results in gross distortion or asymmetry of three or more features or six or more characteristics of disfigurement. The medical records reveal no findings of asymmetry or distortion of features other than the cheeks and ears. Furthermore, the probative evidence does not indicate that there is ever an area of abnormal pigmentation exceeding six square inches, inflexibility exceeding six square inches, or missing soft tissue in an area exceeding six square inches. There are no findings of abnormal pigmentation affecting an area exceeding six square inches, and the record does not suggest such a finding. With the exception of the May 2010 private finding of some hyperpigmentation, the record documents findings of no abnormal pigmentation. The Board acknowledges that the record includes the 2010 VA examiner's finding of inflexibility and missing soft tissue throughout the face. The Board finds the 2010 VA examiner's findings are less probative than the otherwise consistent findings of no inflexibility and tissue loss of less than six inches, however. This is particularly so because the countervailing findings date before and after the 2010 examination record. This indicates that the 2010 VA examiner's findings are not due to a worsening of the condition. The 2010 VA examiner's findings further are not consistent with the photos of record and are not supported by an adequate rationale for the determination that there was tissue loss or inflexibility. It appears instead that these determinations were based solely on the existence of multiple scars and not any evidence of tissue loss or inflexibility per se. As such, the Board concludes that a 50 percent rating is the highest rating available under DC 7800 for the Veteran's service-connected skin disability. The Board also finds that the preponderance of the evidence indicates that the scarring of the back and chest is superficial and does not limit motion VA examiners have found consistently that the Veteran's scars do not limit his motion. The Board acknowledges that the 2010 VA examiner found the scars were deep, meaning they were associated with tissue loss. The Board again finds that the 2010 VA examination is less probative than the otherwise consistent findings, including those made during the 2012 examination, that the Veteran's scars are superficial and are not associated with tissue loss. This is particularly true because the 2010 VA examiner did not provide an adequate explanation for why the frequency and overlapping of the scars resulted in tissue loss. As such, the Board finds that the Veteran's scars must be rated under DC 7802. DC 7802 provides a 10 percent rating for superficial scars affecting an area of 144 square inches (929 sq. cm.) or greater. The medical records do not reveal any such findings. At best, the examiners who have seen the Veteran during the pendency of this appeal found 48 square inches affected on the chest and 84 square inches on the back. As such, the Board concludes that a compensable disability rating is not warranted for the scarring of the Veteran's chest or the scarring of the Veteran's back under DC 7802. The Board further finds that the evidence does suggest that the Veteran has deep scarring at the groin. The July 2006 VA examination record reflects a finding of deep scarring of the groin with tissue loss of less than six square inches and the July 2010 VA examination record reflects a finding of deep scarring of the groin affecting six square inches. The "old" DC 7801 provides a 10 percent rating for deep scars affecting an area or areas exceeding 6 square inches (39 sq. cm.). The "new" DC 7801 provides a 10 percent rating for deep scars affecting an area of at least six square inches. A compensable rating is not warranted under the "old" DC 7801 as the evidence does not reveal any probative findings of deep scar of the groin affecting more than six square inches. A 10 percent rating would be warranted under the "new" DC 7801 as of the July 2010 VA examination, however, based on the finding that the groin scars then affected six square inches. The Board also finds further that the evidence does not suggest that the Veteran's scars limit function of the chest or back. As noted above, medical examiners consistently found that the Veteran's scars did not limit motion. Although the Veteran has reported limitation of some activities, his reported limitation is not analogous to a compensable rating based on limitation of motion of the shoulder. See generally 38 C.F.R. § 4.71a, DC 5201. The Board also has considered whether a separate rating is warranted for limitation of function secondary to the Veteran's groin scars. The rating criteria only provide compensable ratings for loss of use of a creative organ or penile deformity, however, which has not been shown or alleged in this appeal. See generally 38 C.F.R. §§ 3.350(a)(1), 4.115b, DC 7522. Thus, even assuming for the sake of argument only that the Veteran's reported history of limitation of function is credible, the evidence does not suggest that a compensable rating is warranted for flare-ups of pain involving the scrotum. The Board finally finds that the record evidence does not indicate that the Veteran's scars are painful. Although the Veteran has reported pain, the record evidence indicates that this reported pain is not associated with the scarring per se but is associated instead with the Veteran's active sores. The Board finds the history of pain associated with active flare-ups is credible. A separate 10 percent rating for pain is warranted by analogy to the "old" DC 7804 based on the Veteran's credible reported history of pain with flare-ups. In summary, the Board finds that separately rating the Veteran's service-connected skin disability would result in a 50 percent rating under DC 7800, a 10 percent rating under the "old" DC 7804, and a 10 percent rating effective July 21, 2010, under the "new" DC 7801. These ratings combined would not exceed the currently assigned 60 percent rating. Rather, combining these separate ratings for the Veteran's service-connected skin disability would result in a 60 percent rating throughout the appellate period. See 38 C.F.R. § 4.25. The Board has considered whether a higher or separate schedular rating is warranted under a different diagnostic code pertaining to the skin but finds that none is applicable. The Board acknowledges that there are separate rating criteria for acne (DC 7828) and chloracne (DC 7829). The maximum rating available under either diagnostic code is 30 percent, however. The diagnostic codes specify that the condition can be rated as acne/chloracne, disfigurement, or scars, depending upon the predominant disability. This indicates that a condition may not be rated under the criteria for scars and disfigurement and acne. Thus, the Board finds that a higher rating is not available by rating the Veteran's service-connected skin disability under DC 7828 or 7829. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected skin disability. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). As noted elsewhere, the Veteran currently is in receipt of the maximum schedular 60 percent rating available for his service-connected skin disability under the "old" DC 7806. See 38 C.F.R. § 4.118, DC 7806 (effective prior to October 23, 2008). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluation assigned for the Veteran's service-connected skin disability is not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected skin disability. This is especially true because the 60 percent rating currently assigned for the Veteran's skin disability contemplates moderately severe impairment. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The evidence shows that the Veteran's service-connected skin disability has resulted in cystic acne, scarring, and mild occupational impairment, all of which is contemplated within the currently assigned 60 percent rating. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability rating greater than 60 percent for a skin disability is denied. ____________________________________________ MICHAEL T. OSBORNE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs