Citation Nr: 1327688 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 11-00 830 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to a rating higher than 30 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) prior to January 31, 2012 and 60 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION In February 2010, the Veteran raised the issue of entitlement to service connection for a head disorder, which has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from October 1951 to December 1951 and from April 1955 to April 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). A rating decision in July 2009 denied a rating higher than 30 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash). In July 2009, a statement was received from the Veteran whereby he indicated that he wanted a higher rating for his service-connected skin disability. The Board construes this statement as a timely Notice of Disagreement with the July 2009 rating decision. See 38 C.F.R. § 20.201 (Notice of Disagreement does not require special wording); Palmer v. Nicholson, 21 Vet. App. 434, 437 (2007) ("VA has always been, and will continue to be, liberal in determining what constitutes a Notice of Disagreement") (quoting 57 Fed. Reg. 4088, 4093 (Feb. 3, 1992)). While the RO has treated a rating decision in February 2010 as the decision on appeal, for the reasons explained above, the Board finds that the Veteran appealed the earlier July 2009 rating decision. The RO in a rating decision in April 2013 granted a rating of 60 percent for the Veteran's service-connected skin disability effective January 31, 2012. Thus the issue has been characterized as reflected on the title page. In October 2012 the Veteran, through his representative, withdrew his claim of service connection for rib cage pain, Parkinson's disease, appendicitis, depression, anxiety, low back disability, and cervical spine disability. He also withdrew his claim for a total disability rating based on individual unemployability (TDIU) and a claim to reopen service connection for hearing loss. Thus these claims are no longer in appellate status. Under certain circumstances, the claim for an increased rating for a service-connected disability includes a claim of entitlement to a total disability rating for individual unemployability (TDIU). Rice v. Shinseki, 22 Vet. App. 447 (2009). As indicated above, the Veteran withdrew his claim of entitlement to TDIU in October 2012 and this issue is not before the Board. In April 2013, the Veteran withdrew his request for a Board hearing. Records in the Virtual VA paperless claims processing system (Virtual VA) and the Veterans Benefits Management System (VBMS) have been reviewed and considered. The Board notes that Virtual VA includes VA treatment records from 2006 to 2012. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the period prior to January 31, 2012, the service-connected folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) has been manifested primarily by a rash, lesions, itchiness, and papules, affecting no more than 20 to 40 percent of the exposed areas; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were not required. 2. For the period from January 31, 2012, the service-connected folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) has been manifested primarily by a rash, itchiness, and lesions affecting no more than 20 to 40 percent of the exposed areas; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required. CONCLUSIONS OF LAW 1. Prior to January 31, 2012 the criteria for a rating higher than 30 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic 7806 (2012). 2. From January 31, 2012 the criteria for a rating higher than 60 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre-adjudication and post-adjudication VCAA notice by letter dated in June 2009 and in December 2009. The Veteran was notified of the evidence needed to substantiate the claim for an increased rating as well as what information and evidence must be submitted by the Veteran, what information and evidence would be obtained by VA, and the provisions for disability ratings and for the effective date of the claim. To the extent that the VCAA notice pertaining to degree of disability and effective date came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided substantial content-complying VCAA notice, the claim was readjudicated as evidenced by the Statement of the Case, dated in December 2010. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) Duty to Assist VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claim. Service treatment records, post-service treatment records, and lay statements have been associated with the record. Additionally, during the appeal period the Veteran was afforded VA examinations in June 2009, January 2010, May 2012, and in April 2013. The Board has carefully reviewed the VA examinations of record and finds that the examinations in conjunction with the other medical and lay evidence are adequate for rating purposes. Thus, with respect to the Veteran's claim, there is no additional evidence which needs to be obtained. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Rating Criteria A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings". Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, there was a significant change (medication) in the disability and a staged rating is warranted. The Veteran's service-connected folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) is rated under Diagnostic Codes 7899-7806. The use of Diagnostic Code 7899 indicates a rating by analogy. 38 C.F.R. § 4.20. Under Diagnostic Code 7806 for dermatitis or eczema, a 30 percent rating is warranted for a skin disorder that affects 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas, or that requires systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for a skin disorder that affects more than 40 percent of the entire body or more than 40 percent of the exposed areas, or that requires constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. This Code also provides that dermatitis or eczema is to be rated as dermatitis or eczema (Diagnostic Code 7806); as disfigurement of the head, face, or neck (Diagnostic Code 7800); or as scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. The criteria for rating scars under Diagnostic Codes 7800-7805 were amended effective October 23, 2008 and apply to all claims received by VA on or after October 23, 2008. In the instant case the Veteran's claim was received in June 2009 and the revised criteria are applicable. Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are the following: scar is 5 or more inches (13 or more cm.) in length; scar is at least one-quarter inch (0.6 cm.) wide at the widest part; surface contour of scar is elevated or depressed on palpation; scar is adherent to underlying tissue; skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); and skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7800 provides that a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7800. Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 pertains to unstable or painful scars. Five or more scars that are unstable or painful are 30 percent disabling. This is the highest rating available under this Diagnostic Code. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board notes that dermatophytosis is rated under Diagnostic Code 7813, which provides essentially the same criteria as Diagnostic Code 7806 and consideration of Diagnostic Code 7813 would be duplicative. Facts The Veteran contends that he has had an itchy rash that affecting most of his body. See. e.g. August 2011, September 2011 statement. In September 2010, his spouse stated that he had a bad skin rash. A private dermatopathology report in June 2009 based on three different specimen shows the Veteran had the following skin conditions on his back: focal acantholytic dyskeratosis, spongiotic follicular dermatitis, and papulosquamous dermatitis overlap. On VA examination in June 2009, the Veteran reported having intermittent outbreaks of skin infection, manifested by itchy pimples, on his neck, scalp, and on the back of his head. The examiner noted that the Veteran used a 1 percent topical cream constantly for the past 12 months. Physical examination shows that between 20 percent and 40 percent of exposed areas were affected and greater than 5 percent but less than 20 percent of the total body area was affected. The examiner noted that there were few pustular lesions on the posterior of the neck and occipital region of the scalp. He also noted that there was no evidence of a groin rash and there was no apparent residual scarring. The diagnosis was recurring folliculitis of the neck and posterior scalp and resolved tinea cruris. VA progress notes from 2009 to 2013 on multiple occasions show the Veteran had dermatitis. Private medical records show that on June 3, 2009 the Veteran was treated for inflammatory dermatitis and was prescribed Prednisone 20 mg once a day by his treating physician until his next visit. On June 17, 2009, he had keratotic red papules on his chest and back with inflammation, swelling, tenderness and excoriation. His doctor prescribed Vitamin A, antihistamines, and a topical cream. On VA examination in January 2010, the examiner noted that as for folliculitis, the Veteran reported having a rash that was red, itchy, with vesicle and pustule lesions. The Veteran reported that he was told his condition was "flake cancer". He said he had the rash intermittently from his head to feet, which was worse on his head, neck, and chest, but was well controlled with topical medication/shampoo on a regular basis twice per day. As for dermatophytosis cruris, the Veteran had a rash on a monthly basis in the groin and upper inner leg. It was manifested by a rash with erythema and edema and controlled with topical medication and shampoo. The examiner noted that in the past 12 months, the Veteran was treated for a rash on his forehead, neck, and left eyebrow. He occasionally had a groin rash that extended to his legs. During the past twelve months he was treated with a 1 percent prescription cream mixed with "cephell OTC". The examiner stated that the cream was neither a corticosteroid or an immunosuppressive and the type of medication was uncertain. The Veteran used a tar shampoo for head treatment. The examiner also noted that she was unsure of the name and type of medication that the Veteran used but indicated that the medication may be a steroid. Physical examination shows that less than 5 percent of the exposed areas and total body area were affected. There also were less than 10 scars ranging from less than 1-2 centimeters in each of the following locations: behind the ears, posterior neck, anterior neck, left neck, and left shoulder. There was a reddened flat rough patch beneath the lateral brow, and the top center of the head had patchy dry skin in two areas less than .5 centimeters. There was a reddened area at the base of the posterior neck. There examiner noted that there was no active folliculitis or active tinea cruris. There were no other abnormalities seen over the entire body. The diagnosis was recurring folliculitis and recurring tinea cruris. VA progress notes in June 2010 show that the Veteran was to apply .1 percent Cloderm cream to the skin daily. In May 2010, the records show that the Veteran was using Fluocinolone .01 percent oil and Clocortolone .1 percent cream from his private doctor. Private records in August 2010 show the Veteran was treated for an inflamed external ear canal secondary to seborrheic dermatitis and was prescribed antibiotics. He also was given Taclonex scalp solution. A private dermatopathology report in September 2011 based on two different specimen of the left side of the abdomen shows patchy superficial perivascular lymphohistiocytic inflammation and subacute spongiotic dermatitis. That same month the records show that the Veteran was treated for dermatitis of the abdomen, chest, and back and complained of itching and burning in his ears. He was given samples of Taclonex and prescribed TMC 1 percent cream and betamethasone and dipropionate cream to be used as required. Private medical records in January 2012 show the Veteran was prescribed Prednisone for his skin condition by his treating physician. On VA examination in May 2012, the examiner indicated that the Veteran has had the following skin conditions: dermatitis or eczema diagnosed as folliculitis of the neck and an infectious skin condition diagnosed as dermatophytosis of the crural region. The Veteran reported that he always had a rash present on his face, neck, upper chest, and upper back. At times the rash appeared on the rest of his body including his arms, legs, abdomen, and groin area. He complained that his skin was itchy and burned even when there was no visible rash. The examiner indicated that the Veteran did not any benign or malignant skin neoplasms and did not have any systemic manifestations due to any skin diseases. The examiner noted that in the past 12 months the Veteran was treated with the corticosteroid Prednisone for itching secondary to dermatitis but the treatment was for 6 weeks and was not constant. The examiner also indicated that the Veteran has not had any treatment in the past 12 months for exfoliative dermatitis or papulosquamous disorders and there were no debilitating and non-debilitating episodes in the last 12 months. Physical examination shows that dermatitis affected less than 5 percent of the total body area and 20 percent to 40 percent of the exposed area. The examination shows the Veteran had dermatitis-folliculitis manifested by a raised red rash of the face, anterior/posterior of the neck, upper chest and upper back. There also was raised red rash in the groin area. There were multiple hypopigmented small scars on the anterior/posterior of the neck, upper chest, and upper back. The Veteran reported that he was a retired factory worker and television repairman and that over the years he missed work due to medical appointments for his rash. The examiner found that the Veteran had scars that were secondary to folliculitis. As for scars on the trunk and extremities, the Veteran reported that the scars on his upper chest and upper back were the result of his rash as his rash was itchy and the scars were due to scratching. There were no scars that were painful, and/or unstable with frequent loss of covering of the skin over the scar. There were no scars due to burns. On the anterior trunk, there were multiple superficial irregularly shaped white scars on the upper chest ranging up to 2 centimeters in diameter. As for the posterior trunk there were multiple superficial irregularly shaped white scars on the Veteran's upper back ranging up to 2 centimeters in diameter. The approximate total area of the anterior trunk affected by the scars was 5 cm2. The total area of the posterior trunk was 10 cm2. The examiner indicated that there were no deep nonlinear scars. As for the scars on the head, face, or neck, the Veteran reported that they were the result of his rash as his rash was itchy and the scars were due to scratching. There were no scars that were painful, and/or unstable with frequent loss of covering of the skin over the scar. There were no scars due to burns. Physical examination shows that there were multiple superficial irregularly shaped white scars on the anterior and posterior neck ranging up to 2 centimeters in diameter. There was no elevation, depression, adherence to underlying tissue or missing underlying soft tissue. There was hypopigmentation. There was no gross distortion or asymmetry of facial features or visible palpable tissue loss. None of the scars resulted in limitation of function. There were no other physical findings, complications, conditions, signs and/or symptoms associated with any scar to include muscle or nerve damage. The examiner indicated that the scars did not impact the Veteran's ability to work. Private medical records from May 2012 to August 2012, show the Veteran was treated for a rash and diffuse xerotic changes of the skin. He continued being on Prednisone. Most of the findings on VA examination in April 2013 are cumulative of the ones presented on VA examination in May 2012. Additionally, the April 2013 VA examination shows that the Veteran reported having a rash from his head to feet that was red and itchy with vesicle and pustule like lesions. Like the May 2012 VA examiner, the April 2013 examiner indicated that the Veteran did not have any benign or malignant skin neoplasms nor any systemic manifestations due to skin diseases. The April 2013 VA examiner indicated that the Veteran had constant/near constant use of the corticosteroid Prednisone for itching secondary to dermatitis. The examiner also indicated that the Veteran has not had any treatment in the past 12 months for exfoliative dermatitis or papulosquamous disorders. As shown on the May 2012 VA examination, physical examination on the April 2013 VA examination shows that dermatitis affected less than 5 percent of the total body area and 20 percent to 40 percent of the exposed area. The April 2013 examination also shows that less than 5 percent of skin infections affected the total body area. The diagnoses for each skin condition are the following: folliculitis manifested by a few discrete pustular lesions in the lower chest region, dermatophytosis of the crural region with a red raised rash noted to the inner thighs and groin area, and dermatitis with a slightly raised red rash on the face, anterior/posterior neck, upper chest and upper back region. As for the scars, the April 2013 provided a diagnosis of scars secondary to folliculitis. The Veteran related his scars to itching. There were no scars of the trunk or extremities that were painful, and/or unstable, or due to burns. There were multiple superficial irregular shaped scars noted on the upper chest region. The approximate total area affected on the anterior trunk was 10 cm2. The approximate total area affected on the posterior trunk was 15 cm2. There were no deep linear scars in this area. On VA examination in April 2013, the Veteran also related scars on his face, head or neck to itching associated with his skin condition. Scars of the head, face, or neck were not painful, and/or unstable, or due to burns. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was hypopigmentation. The approximate total area of the head, face, and neck that was affected was 5 cm2. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The examiner indicated that none of the scars, regardless of location, caused limitation of function. Analysis The analyses focus on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. The pertinent evidence is addressed in detail below. The Board finds that the Veteran's skin condition does not more nearly approximate the criteria for the next higher rating of 60 percent under Diagnostic Code 7806 prior to January 31, 2012. The evidence shows that no more than 40 percent of the entire body or no more than 40 percent of the exposed areas were affected. On VA examination in June 2009, between 20 percent and 40 percent of exposed areas were affected and greater than 5 percent but less than 20 percent of the total body area was affected. On VA examination in January 2010 less than 5 percent of the exposed areas and total body area were affected. Findings from the VA examinations are consistent with VA and private treatment records from 2009 to 2011, which show that the Veteran's rash variously affected different parts of his body to include his back, abdomen, chest, and ears. As for the Veteran's therapy prior to January 31, 2012 the evidence shows that except for a brief period in June 2009 when was prescribed Prednisone, his skin condition was intermittently treated with Vitamin A, antihistamines, medicated shampoos, and topical creams. See VA and private treatment records 2009 to 2011. While on VA examination in June 2009 the examiner noted that the Veteran used a 1 percent topical cream constantly for the past 12 months, there was no indication that this medication was a corticosteroid or another type of immunosuppressive drug. Furthermore 6 months later, on VA examination in January 2010 a different examiner clarified that the topical cream that the Veteran used for the past 12 months was neither a corticosteroid nor an immunosuppressive type of medication. Thus the Board finds that prior to January 31, 2012 while the Veteran had some steroid therapy he did not require constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during a 12 month period. As discussed above, the RO in the April 2013 rating decision granted a 60 percent rating effective January 31, 2012 under Diagnostic Code 7806. The RO based its determination on the following: a private medical record dated on January 31, 2012 that showed the Veteran's treating physician prescribed Prednisone to control his skin condition and the April 2013 VA examination whereby the examiner indicated that constant or near-constant systemic corticosteroid therapy was required to control the Veteran's skin condition. The record also established that Prednisone was to be tried. This evidence establishes that prior to January 2012, the use of such medication had not been continuous or nearly continuous. The highest rating available under Diagnostic Code 7806 is 60 percent. However, Diagnostic Code 7806 provides that depending on the predominant disability, the skin condition may be rated under Code 7806 or Codes 7800 to 7805. In the instant case, while the Veteran has scarring his service-connected skin disability has been manifested primarily by a rash, lesions, itchiness, and papules. On VA examination in May 2012 and in April 2013 each examiner determined that the Veteran's scars were secondary to folliculitis and during the examinations the Veteran himself indicated that these scars were the result of his scratches due to itching. Thus the Veteran's residual scarring is not his predominant disability and his skin condition is appropriately rated under Diagnostic Code 7806. The Board notes that even if the scarring was the predominant disability, the Veteran would not be assigned a rating higher than 30 percent prior to January 31, 2012 and 60 percent thereafter under Diagnostic Code 7800 as he does not have visible or palpable tissue loss or gross distortion or asymmetry of any features of the face or head, nor does he have four or more characteristics of disfigurement. Diagnostic Codes 7801, 7802, 7804, and 7805 would not be applicable as the Veteran's scars are not deep, do not cover an area or areas of 144 square inches or greater, are not unstable or painful, and do not cause disabling effects. See VA examination May 2012, April 2013. The Veteran on VA examination in January 2010 reported that he was told that he has "flake cancer". Under certain circumstances, a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However the Veteran's statement is outweighed by the VA examinations, VA treatment records, and private treatment records during the appeal period which show that he does not have skin cancer. Thus Diagnostic Codes 7818 and 7819 pertaining to skin neoplasms are not applicable. The Veteran has reported that his skin condition is manifested by itchiness and a rash that spreads throughout most of his body. His wife reported that his rash was severe. The Veteran and his spouse are competent to report such symptoms and the Board finds their reports of symptomatology to be credible. In this case, however, the Board finds the objective medical findings by skilled professionals are more persuasive which, as discussed above do not support higher ratings. In essence, the lay evidence, while accepted as credible, does not provide a basis for higher evaluations. The Veteran is in receipt of a 60 percent rating under Diagnostic Code 7806 from January 31, 2012, which as noted above is the highest rating available under that Code. The Board has considered whether the Veteran may be entitled to higher rating under other applicable Diagnostic Codes. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case" and involves consideration of such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Butts v. Brown, 5 Vet. App. 532, 538 (1993). In light of the evidence of record discussed above, the Board finds that RO has appropriately rated the Veteran's skin disability during under Diagnostic Code 7806 for dermatitis or eczema as his symptoms are manifested by a rash, lesions, itchiness, and papules requiring systemic therapy. Thus there are no other applicable codes to consider in the instant case that would afford him higher ratings. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence does not support a rating higher than 30 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) prior to January 31, 2012 and 60 percent thereafter, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Extraschedular Consideration While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology pertaining to his service-connected folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash). His skin disability is manifested by a rash, lesions, itchiness, and papules, covering various parts of his body. The rating criteria contemplate these symptoms. The Veteran has not described any exceptional or unusual features or symptoms of the disability. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER For the period prior to January 31, 2012 a rating higher than 30 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) is denied. For the period from January 31, 2012 a rating higher than 60 percent for folliculitis of the neck and dermatophytosis of the crural region (claimed as skin rash of the face and neck with residual scars from the rash) is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs