Citation Nr: 1330003 Decision Date: 09/19/13 Archive Date: 09/25/13 DOCKET NO. 10-16 234 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for pseudofolliculitis barbae (PFB). 2. Entitlement to an initial compensable disability rating for hyperhidrosis. 3. Entitlement to an initial compensable disability rating for herpes simplex I infection. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from January 2005 to October 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which, in relevant part, denied the Veteran's claim of service connection for PFB, and granted service connection for hyperhidrosis and herpes simplex I, assigning these disabilities a noncompensable disability rating, effective October 28, 2008. The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2013. A transcript of that hearing is of record. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to an initial compensable disability rating for herpes simplex I is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran's current PFB was at least as likely as not incurred during his active service. 2. The symptoms associated with the Veteran's hyperhidrosis have included severe sweating of the feet, hands, axilla, and groin. Such symptoms have been only minimally responsive to therapy and have resulted in a diminished ability to handle paper and tools. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for PFB have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 2. The criteria for a 30 percent rating for service-connected hyperhidrosis have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.6, 4.10, 4.119, Diagnostic Code (DC) 7832 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran's claim of entitlement to a compensable disability rating for his service-connected hyperhidrosis arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted, the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of a claim. This duty includes assisting him in the procurement of service treatment records and pertinent private treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). With respect to the Veteran's increased rating claim for PFB, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains, in relevant part, the Veteran's private treatment records and multiple fee basis examination reports. Additionally, his statements in support of his claim are of record. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is further available outstanding evidence that would substantiate this increased rating claim. Additionally, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeal for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that VA employees have two duties in conducting hearings. These duties consist of (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 Veteran's March 2013 Board hearing, the issues were adequately identified, and the VLJ and the Veteran's representatives at that time asked specific questions directed at identifying the severity of the Veteran's service-connected hyperhidrosis and identifying additional evidence that could substantiate his claim. As such, the Bryant duties were met. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of his increased rating claim for hyperhidrosis. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). With respect to the Veteran's service connection claim, the Board, herein, grants entitlement to service connection for PFB. As this represents a complete grant of the benefit sought on appeal with respect to this claim, a specific discussion with respect to VA's duty to notify and assist pursuant to the VCAA is not necessary. II. Service Connection The Veteran seeks entitlement to service connection for PFB. He contends that this disability first became manifest during his service and that he has continually suffered PFB symptoms since his separation from service. A. Governing Law and Regulations Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson, 2 Vet. App. at 618. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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."). 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. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Analysis Turning then to the evidence of record, a review of the Veteran's post-service treatment records shows that he has been receiving current treatment for PFB. A February 2010 treatment note from Reston Dermatology and Cosmetic Center showed that the Veteran suffered from PFB of his neck. A February 2013 letter from the Veteran's treating dermatologist, Syed Amiry, D.O., noted that he had been treating the Veteran for PFB since January 2010. Based on this evidence, the first required element for service connection for PFB has clearly been met. See Walker, supra. With respect to evidence of an in-service incurrence of PFB, a review of the service treatment records (STRs) reveals that he was treated multiple times for PFB during the time period of his active service. The first evidence of record of treatment for PFB is found in records associated with a course of laser treatment the Veteran received for PFB on his jaw line and neck beginning in September 2005. This course of laser hair removal treatment appears to have extended through January 2006. Later, in February 2008, the Veteran again sought medical treatment for PFB. He complained of having a history of PFB for several years. He reported having tried multiple forms of treatment, including laser hair removal, electric razor, and topical and oral medications. Later STRs dated through July 2008 show ongoing complaints associated with PFB. Based on these multiple in-service instances of treatment for PFB, the second required element for service connection has also been met. See Walker, supra. Accordingly, the Board is only left to consider whether there is a nexus between the Veteran's currently diagnosed PFB and his noted in-service incidents of PFB. Here, the record reveals some inconsistency in the Veteran's post-service history for PFB. In this regard, the Veteran was afforded a VA fee basis examination for multiple service connection claims in September 2008. During that examination, the examiner noted the Veteran's history of a diagnosis of PFB in 2005, during service. The examiner then indicated that after separation, he was no longer required to shave closely on a daily basis, and thus, that the condition had resolved. Consequently, the examiner did not make a PFB diagnosis at that time. Regardless of the examiner's findings, in his February 2013 letter, the Veteran's current treating dermatologist, Dr. A., noted that he had been treating the Veteran's PFB since January 2010. The Veteran reported during a February 2010 consultation, that he first developed PFB during service, and that at that time he had laser hair removal performed and applied over the counter topical ointments. Dr. A. indicated that he advised the Veteran to continue with laser hair removal treatment and that he had provided additional techniques for shaving. Courses of laser hair removal treatment, however, have shown only minor improvement in the Veteran's PFB. Dr. A. further noted that he reviewed the Veteran's STRs with respect to his PFB treatment, and noted periods of treatment in February 2008, and July 2008. He noted that it was his opinion that the Veteran's PFB symptoms during service were consistent with his current medical evaluation and treatment. He further noted that the Veteran continued to experience inflamed papules and pustules of the neck and under the chin due to PFB. During his March 2013 Board hearing, the Veteran was noted to have current pustules and papules of the neck which were reportedly due to his PFB. Notably, the physical claims file also contains photographs of multiple pustules and papules of the neck and under the chin area. The Veteran credibly testified during his hearing that the PFB began during his active service, and that he has chronically suffered from PFB since that time. He testified that current treatments have had minimal impact on his PFB. Based on the foregoing, the Board concludes that the record contains sufficient evidence of a nexus between the Veteran's current PFB and his service. His STRs clearly show an onset of PFB during service, and he has credibly testified that he has continued to suffer from PFB since that time. Moreover, the letter from Dr. A. concludes that the Veteran's current treatment and diagnosis of PFB was consistent with the symptoms noted in his service records. Dr. A. was clearly familiar with the Veteran's treatment history and provided an adequate assessment regarding the relationship between his current PFB and his service based on current findings and the evidence in his service records. See Nieves-Rodriguez, 22 Vet. App. at 304. Accordingly, the final required element for service connection has been met. See Walker, supra. Thus, the Board finds that all required elements to establish service connection for PFB have been met. The Veteran has a current PFB diagnosis, he clearly suffered from PFB during service, and his testimony and the medical evidence provided by Dr. Amiry have adequately established a nexus between his current PFB and his first incurrence of PFB during service. See 38 C.F.R. § 3.303 (2013). Accordingly, all doubt with respect to this claim is resolved in favor of the Veteran and his claim for service connection for PFB is granted. 38 U.S.C.A. § 5107(b) (West 2002). III. Increased Disability Rating The Veteran seeks a compensable disability rating for his service-connected hyperhidrosis. He contends that his hyperhidrosis is more severe than currently rated. A. Governing Law and Regulations Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2013). Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2013). Otherwise, the lower rating will be assigned. Id. In Fenderson v. West, 12 Vet. App 119 (1999), the United States Court of Appeals for Veterans Claims (Court) emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case, such as this one, where a veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. In these cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." See also Hart v. Mansfield, 21 Vet. App 505 (2007). The Veteran bears the burden of presenting and supporting his claims for benefits. 38 U.S.C.A. § 5107(a) (West 2002). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b) (West 2002). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board affords the benefit of the doubt to the claimant. Id. B. Analysis The symptoms associated with hyperhidrosis are rated under 38 C.F.R. § 4119, Diagnostic Code 7832. Under Diagnostic Code 7832, ratings of zero and 30 percent are authorized. A noncompensable rating is warranted where, after therapy, the Veteran is able to handle paper and tools, while a 30 percent rating is warranted where the Veteran is unable to handle paper or tools because of moisture, and the disability is unresponsive to therapy. In the instant case, during the Veteran's October 2008 VA contract examination, he was noted to have hyperhidrosis that affected his axillary areas, hands and feet, bilaterally. He was noted to be currently taking Drysol. The examiner noted that there was no functional impairment. A review of post-service treatment records reveals that the Veteran has received multiple forms of treatment for his hyperhidrosis, including repeated Botox injections and multiple forms of oral and topical medication. Botox injections appear to have been performed in June and July 2009. Ongoing private treatment records show that the he has been receiving continual treatment for his hyperhidrosis. In an undated letter, Dr. A. noted that the Veteran had been using antiperspirants, such as Drysol and Glycopyrrolate, since 2008 and that they had done little to prevent his hyperhidrosis. Botox treatment was recommended. A February 2013 statement from an N. G., who indicated that she lived with the Veteran, noted that she was a witness to the severity of his hyperhidrosis. She noted in her statement that the Veteran had severe sweating of his hands, feet, armpits, and groin area. She noted that his wet hands caused many difficulties, including with driving, writing letters, exercising, and handling tools. She reported that she had witnessed objects slip out of his hands, causing damage to the house. She also noted that he frequently had to change his clothes and that he took six pills every day to reduce his sweating. She further noted that his sweating caused an emotional strain on his personal and professional life. At his March 2013 hearing, the Veteran testified that he could no longer receive Botox injections in his hands, because they would become paralyzed for long periods of time. He required gloves for driving due to the excessive sweat. He noted that the Botox injections worked well for his armpits. He also noted that he took Robinul, which infrequently controlled the sweating in his groin area. He reported that he needed to change clothes frequently, and that he frequently used multiple pairs of underwear. He testified that his hyperhidrosis affected nearly 40 percent of his body, even with treatment, and the areas affected included more than just his hands. He reported that he was currently taking six pills of his prescribed medication per day. He noted that he has had to gradually increase his dose from two to six pills per day over the years, but that his physician was hesitant about increasing the dosage any more. The Veteran further reported that though he remained employed and at the same salary level, he has had to change his job responsibilities due to his hyperhidrosis and that his ability to be promoted was diminished. In his February 2013 letter, Dr. A. noted that he initially evaluated the Veteran's severe hyperhidrosis of the hands, feet and axilla in January 2010. He noted that the treatment the Veteran received during service, Drysol, had been ineffective in controlling his excessive sweating. The Veteran had significant social and workplace issues as a result of his condition and the hyperhidrosis caused occupational difficulties, such as with handling documents, typing, and giving presentations. Daily activities such as driving, exercising, and performing home improvements were dangerous and posed a risk of personal injury. Dr. A. further noted that he prescribed Botox injections for the Veteran's axilla and Robinul to help control the excessive sweating. He indicated that the Botox injections resulted in significant improvement in the axilla region. Dr. A. further administered Botox in the Veteran's hands on two occasions, which he indicated was only done for patients with severe cases of hyperhidrosis. He noted, however, that the results were mixed and the pain and loss of functionality did not justify further injections in the hands. Dr. A. further remarked that the Robinul had minimal and inconsistent results at controlling the Veteran's excessive sweating of the hands, feet, and groin. Based on the foregoing evidence, the Board finds that the symptoms associated with the Veteran's service-connected hyperhidrosis most closely approximate the criteria for a 30 percent disability rating, the highest schedular disability rating available for hyperhidrosis. Notably, his hyperhidrosis has largely been unresponsive to therapy, and, per medical and lay evidence, has resulted in a significantly diminished ability to handle paper and tools because of the excessive moisture. Thus, overall, the Board finds that throughout the entire appellate period, the disability picture associated with the Veteran's service-connected hyperhidrosis most nearly approximates the criteria for a 30 percent disability rating under Diagnostic Code 7832. C. Extraschedular Consideration and TDIU The rating schedule represents as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. See 38 C.F.R. § 3.321(a), (b) (2013). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The symptoms associated with the Veteran's service-connected hyperhidrosis (i.e., extreme sweating of the feet, hands, axilla and groin; only minimally responsive to therapy, and resulting in a diminished ability to handle paper and tools) are largely contemplated by the rating criteria set forth above, and reasonably describe the Veteran's service-connected disability. The rating criteria are, therefore, adequate to evaluate the Veteran's service-connected hyperhidrosis and referral for consideration of an extraschedular rating is not warranted in this case. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) due to service-connected disability is part of an initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In the instant case, the Veteran testified during his March 2013 hearing that he remained employed and that, although he had experienced a change in position, he had not experienced a reduction in hours or salary. Thus, consideration of a TDIU is not warranted at this time. ORDER Entitlement to service connection for pseudofolliculitis barbae is granted Entitlement to an initial 30 percent disability rating for hyperhidrosis is granted. REMAND The Veteran's remaining claim on appeal is that of entitlement to an initial compensable disability rating for service-connected herpes simplex I infection. Unfortunately, a remand is required with respect to this issue. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide this claim so that the Veteran is afforded every possible consideration. The severity of the Veteran's herpes condition was last evaluated during the September 2008 VA fee basis examination. The outbreak was noted to be limited to the Veteran's lips. He had been using Valtrex to control outbreaks, taking two tablets per day for five days. No pathology was noted during the examination. The frequency of the outbreaks, and the required duration for the use of his medication, was not noted in the examination report. In her February 2013 statement, N. G., indicated that the Veteran experienced a herpes outbreak on his lips about every three months, and that he would get many large and small blisters. She reported that the outbreaks lasted up to two weeks at a time. She further noted that he used Valtrex, Abreva, and Campho Phenique to help reduce the appearance and length of time of each outbreak. During his March 2013 hearing, the Veteran also contended that he experienced herpes outbreaks about three months. He also reported using Valtrex, which he believed reduced the recovery time. He reported that his outbreaks were seemingly worse during the summertime. An essential component of the rating criteria that has been used to evaluate the Veteran's service-connected herpes condition is determining whether he has required the use of systemic therapy, such as corticosteroids or other immunosuppressive drugs; and if so, the total duration of time that such use was required over preceding 12-month intervals. This information is not readily provided in the existing evidence of record, including in the prior examination report. See 38 C.F.R. § 4.2 (2013) (stating that if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). As such, this claim must be remanded in order to afford the Veteran a contemporaneous VA examination based on all evidence of record. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA dermatological examination to assess the current severity of his service-connected herpes simplex I infection. The claims file and a complete copy of this remand must be made available to and reviewed by the examiner in association with the examination. The examination report should indicate that this has been accomplished. All necessary studies and tests should be conducted. The examiner should describe the severity and all manifestations associated with the Veteran's herpes outbreaks. The examiner should specifically determine the percentage of body area affected, and the percentage of exposed areas affected during outbreaks. The examiner should describe any systemic therapies, to include corticosteroids or other immunosuppressive drugs, used to treat the Veteran's herpes outbreaks and the approximate total duration of any such therapies over 12-month intervals since October 2007. The examiner should also describe any residuals scars associated with the Veteran's herpes outbreaks. The examiner should note whether any scars present are deep, superficial, unstable, or painful on objective demonstration. (A deep scar is one associated with underlying soft tissue damage; a superficial scar is one not associated with underlying soft tissue damage, and an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar). The size (width and length) of the scars should be measured. With respect to herpes associated scars of the head, face, or neck, the examiner should also specifically note the extent of any palpable tissue loss, whether there is gross distortion or asymmetry of any paired sets of facial features, and whether any of the 8 characteristics of disfigurement are present in the face, head or neck. The features of disfigurement are: (1) scar five or more inches (13 or more centimeters) in length; (2) scar at least one-quarter inch (0.6 centimeters) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 square centimeters); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); (7) underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and (8) skin indurate and inflexible in an area exceeding six square inches (39 square centimeters). The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 2. Thereafter, review the claims file to ensure that the foregoing requested development has been completed. In particular, thoroughly review the VA examination report to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 3. Finally, readjudicate the Veteran's increased rating claim on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, provide him and his representative with a supplemental statement of the case, and after they have had an adequate opportunity to respond, return this appeal to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs