Citation Nr: 1333483 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-15 690 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to an increased rating (or evaluation) in excess of 10 percent for furunculosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. J. Dempsey, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, which denied an increased disability rating in excess of 10 percent for service-connected furunculosis. The Board has reviewed the Veteran's physical claims files, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. FINDING OF FACT For the entire increased rating period, the Veteran's furunculosis has affected 20 to 40 percent of the Veteran's entire body. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an increased rating of 30 percent disabling, but not greater, for furunculosis have been met for the entire increased rating period. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.118, Diagnostic Code 7806 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims 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, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, 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, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claim prior to initial adjudication. An August 2009 letter explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. With regard to the duty to assist, the Veteran's service treatment records and pertinent post-service treatment records, including VA treatment reports, have been secured. The RO arranged for a VA skin examination in August 2009, which the Board finds adequate to rate the skin disorder. The Veteran has asserted that the VA examination is inadequate to evaluate the current state of the service-connected furunculosis. See September 2013 Appellant's Brief. Specifically, the Veteran contends that a remand for a new examination is necessary because the August 2009 VA examination took place during an inactive stage of furunculosis. See id (citing Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994) (finding an examination inadequate when administered during the inactive stages of the claimant's condition)). However, the Board may rely on an examination administered when the claimant's condition is not inflamed if there has been no allegation that the condition affects earning capacity and when the active stage lasts only a few days, rather than weeks or months. See Voerth v. West, 13 Vet. App. 117, 122-23 (1999). Here, the VA examiner clearly noted the "intermittent" nature of the Veteran's furunculosis and, considering such, specifically stated that there were "no effects on occupation or [activities of daily life]." There is no indication that these facts were overlooked when the examiner presented the examination findings. See Rizzo v. Shinseki, 580 F.3d 1288, 1291 (Fed.Cir.2009) (holding that a VA medical professional is presumed competent to discharge her official duties in the absence of clear evidence to the contrary). The 2009 VA examiner reviewed the Veteran's claim file, made clinical observations, and reported findings pertinent to the rating criteria for skin conditions. Thus, the Board finds that the August 2009 VA skin examination report is adequate to rate the Veteran's service-connected furunculosis. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran stated that furunculosis affects his daily activities during flare-ups (see February 2010 Notice of Disagreement). The Board has considered these statements, included them when evaluating the furunculosis' severity, and acknowledged the practical aspects of scheduling a medical examination within the short term flare-up period described by the Veteran. See Voerth, 13 Vet. App. at 122-23 (explaining how the temporal nature of a cyclical condition may be a factor in determining the adequacy of a VA examination). As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. See Mayfield, 444 F.3d at 1328. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the claim. Disability Rating Criteria and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable 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). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. at 303. The Board has reviewed all of the evidence in the Veteran's claims file, to include VA treatment reports in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the appeal for an increased disability rating for furunculosis. Service connection for furunculosis was granted in a September 1969 rating decision that assigned a 10 percent disability evaluation, effective May 18, 1969. The Veteran submitted a claim for an increased rating in June 2009, stating that the furunculosis condition had become worse. The Veteran's furunculosis is evaluated at 10 percent disabling under Diagnostic Code (DC) 7899-7806. 38 C.F.R. §§ 4.118, 4.27 (2013) (when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition). Under DC 7806, the rating code for dermatitis and eczema, a 10 percent rating is assigned when at least 5 percent, but less than 20 percent of the entire body is covered; or at least 5 percent, but less than 20 percent of exposed areas are affected; or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118. The provisions of DC 7806 indicate that the skin disability may be rated as disfigurement of the head, face, or neck under DC 7800 or as scars under DCs 7801 to 7805, depending on the predominant disability. 38 C.F.R. § 4.118. For disfigurement of the head, face, or neck under DC 7800, a 10 percent rating is warranted when a veteran experiences one characteristic of disfigurement. A 30 percent rating is warranted 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; two or three characteristics of disfigurement. A 50 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features or paired sets of features, or; with six or more characteristics of disfigurement. Note (1) indicates that the 8 characteristics of disfigurement for the purposes of evaluation under § 4.118 are: scar of 5 in. or more (13 or more cm.) in length; scar at least 1/4 in. (0.6 cm.) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). Note (5) indicates that the characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118. Under DC 7801, a burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10 percent rating. A scar in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm) warrants a 20 percent evaluation. A scar in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm) warrants a 30 percent evaluation. A scar in an area or areas of at least 144 square inches (929 sq. cm.) or greater warrants a 40 percent evaluation. 38 C.F.R. § 4.118. Under DC 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (1) indicates that a superficial scar is one not associated with underlying soft tissue damage. Note (2) indicates that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. 38 C.F.R. § 4.118. Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent evaluation. Five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118. Under DC 7805, any disabling effects of other scars (including linear scars), and other effects of scars rated under DCs 7800, 7801, 7802, and 7804 not considered in a rating provided under DCs 7800-7804 are to be rated under an appropriate diagnostic code. 38 C.F.R. § 4.118. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, the evidence is at least in equipoise as to whether the furunculosis has affected more than 20 percent, but not greater than 40 percent, of the entire body, as required for a higher, 30 percent rating under DC 7806. 38 C.F.R. § 4.118. In August 2009, the Veteran underwent a VA skin examination. The VA examiner reported that the furunculosis manifested as sebaceous cysts on the groin, back, and buttocks. The VA examiner noted in the report that the cysts occasionally drain and make the Veteran's clothes bloody. The examiner indicated that the furunculosis affected greater than 5 but less than 20 percent of the Veteran's total body, and 0 percent of exposed areas. Significantly, the examiner also noted that the course of the furunculosis was "intermittent," indicating it was cyclical in nature. The VA examiner explained that minocycline - a systemic form of therapy - was used for a period of 30 days between June and July 2009 before side effects caused the Veteran to discontinue usage. Clindagel, a topical treatment, was in current use. Additionally, the VA examiner reported that the furunculosis had no effects on the Veteran's occupation or activities of daily life. In the February 2010 Notice of Disagreement, the Veteran asserted several contentions to suggest that his furunculosis symptoms were not accurately captured in the 2009 VA examination report. First, the Veteran stated that residual scarring from the furunculosis affected exposed areas, specifically his neck and cheeks. Second, the Veteran estimated that the furunculosis affected 40 percent of his entire body. Third, he explained that furunculosis flare-ups affect his daily life activities. Specifically, he reported that flare-ups in the groin area prevent him from wearing pants or underwear; flare-ups on the legs and buttocks prevent him from sitting for any length of time; and flare-ups on the back, chest, or neck present problems with wearing shirts. Fourth, the Veteran stated that he would not be appropriate for corticosteroids or other immunosuppressive therapy, and that he failed systemic therapy with minocycline. For each subject above, the Veteran is competent to testify. Regarding the existence of scars and boils/furuncles, the Veteran is competent to observe their presence on his neck and cheeks. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a veteran is competent observe skin conditions such as boils, blotches, and rashes). With respect to how flare-ups impact daily activities, the Veteran is competent to report how furunculosis and its symptoms have affected him. See Layno, 6 Vet. App. at 169-70 (lay evidence is competent to establish features or symptoms of injury or illness). Finally, the Veteran is competent to report a contemporaneous medical diagnosis, including drug prescriptions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Additionally, the Board finds the Veteran credible in each point made above. First, photographs of the Veteran's neck and cheeks from the August 2009 VA examination report confirm, and are consistent with, the Veteran's statements regarding the presence of scars in these areas. Second, VA medical center (VAMC) treatment records show that the furunculosis has affected a considerable amount of the Veteran's total body for the entire rating period, as indicated by the body areas shown to be affected. See e.g., VAMC entries from May 9, 2008 (scalp, neck, chest, legs); August 19, 2009 (back); February 4, 2010 (face). Third, VA medical records also show that the Veteran faces limitations on his treatment options. See February 4, 2010 VAMC entry (Veteran "would not be a candidate for immunosuppressive therapy as he has a diagnosis of 'gamma globulin' deficiency"); August 2009 VA examination (confirming side effects of minocycline/systemic therapy). In light of this consistency of statements, which are also consistent with other evidence of record, the Board finds that the Veteran is credible when reporting how furunculosis has affected daily activities. Based on a careful review of the evidence, the Board finds that the percentage of the Veteran's entire body area affected by service-connected furunculosis more nearly approximates 20 to 40 percent. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, 4.3, 4.7, 4.118, DC 7806. In consideration of the intermittent nature of the furunculosis and the Veteran's credible account of the disability's manifestations during flare-ups, the Board attributes equally probative value to the Veteran's testimony and the August 2009 VA examination report on the question of body area covered. By expressing a range of 5 to 20 percent instead of a specific percentage of total body area covered, the VA examiner provided evidence that the Veteran's condition may have been as much as 20 percent during an inactive stage. Although he did not clearly identify whether he was speaking about the effect of flare-ups or normal conditions in the February 2010 Notice of Disagreement, the Veteran estimated that 40 percent of his entire body was affected by the furunculosis. Here, the Board is also guided by the notes of a VAMC clinician who differentiated between the scarring and the active furunculosis: "[A]lthough one could argue that his face has scarring from follicular disease and this is an exposed area and that a large [body surface area] is affected although the actual area of disease is small because of the nature of the discrete follicular involvement." See February 2, 2010 VAMC entry. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's furunculosis affects an area between 20 and 40 of the entire body and, therefore, more closely approximates the criteria for a 30 percent disability rating. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, 4.3, 4.7, 4.118, DC 7806. The Board also finds that a rating in excess of 30 percent is not warranted for any period as the weight of the lay and medical evidence demonstrates, at most, that 40 percent of the Veteran's entire body is affected by the furunculosis. To merit the next higher rating of 60 percent, furunculosis must be shown to affect more than 40 percent of the entire body or exposed areas. It has not been shown or alleged that furunculosis has at any time during the increased rating period affected an area that was greater than 40 percent of the Veteran's entire body or exposed areas. Moreover, the previous 20 percent threshold (required for a 30 percent disability rating) was only surpassed after considering the lay evidence of the body area affected by furunculosis during flare-ups - the most active stage of the condition and most favorable to the Veteran for rating purposes - and resolving reasonable doubt in the Veteran's favor on the question of what body percentage is affected. As such, as the evidence only more nearly approximates the criteria even for a 30 percent rating, an increased rating in excess of 30 percent based on these criteria is not warranted for any period. Further, the Board has determined that the weight of the evidence is against a higher rating than 30 percent under DC 7806 based on constant or near-constant required use of systemic therapy such as corticosteroids or other immunosuppressive drugs during any 12-month period. From June to July 2009, the Veteran used minocycline - a systemic treatment - before discontinuing use on account of side effects. See August 2009 VA examination report. However, the Veteran has used clindagel - a topical treatment that is not a corticosteroid or an immunosuppressive drug - to treat the furunculosis since June 2009. See June 3, 2009 VAMC entry. During a follow-up visit with the prescribing VAMC physician in August 2009, the physician recorded that the Veteran "has occasional flares when hot/humid but overall doing better." See August 19, 2009 VAMC entry. Over time, clindagel has not prevented the furunculosis from being worse in the summer. See February 2, 2010 VAMC entry. However, while the Board is sympathetic to the fact that the Veteran used one form of systemic therapy unsuccessfully in 2009, the preponderance of the evidence assembled in the weeks and months that followed does not support a finding of constant or near-constant required use of systemic therapy during the past 12-month period. The level of impairment in the Veteran's service-connected furunculosis has been relatively stable throughout the rating period, and has never been worse than what is warranted for a 30 percent evaluation; therefore, the application of staged ratings is inapplicable. See Hart. The Board has also considered whether alternative evaluation under DCs 7801-7805 would result in a more favorable outcome for the Veteran. 38 C.F.R. § 4.118, DC 7806 ("Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability"). The evidence does not show the presence of any scars that are unstable, painful, or disabling; therefore DCs 7804 and 7805 are not applicable. 38 C.F.R. § 4.118. Additionally, DC 7802 provides for a single 10 percent disability rating and therefore evaluation under this DC would not be more favorable for the Veteran. However, the scars described in this case may be rated alternatively under DCs 7800 or 7801. Id. The evidence does not show that the Veteran has four of five characteristics of disfigurement or other symptoms required for a disability rating in excess of 30 percent under DC 7800. While the August 2009 VA examination photographs show that disfigurement may be found with hypopigmentation in an area exceeding six square inches and/or a scar at least one-quarter inch wide at its widest part, the evidence does not show that two additional characteristics of disfigurement are present. Specifically, the evidence does not show a scar five or more inches in length; surface contour of scar elevated or depressed on palpation; skin adherent to underlying tissue; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; or skin indurated and inflexible in an area exceeding six square inches. Further, the evidence does not show visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or paired sets of features. Thus, the criteria for a 50 percent rating have not been met. Id. Additionally, the evidence does not show that the Veteran meets the criteria for a rating in excess of 30 percent under DC 7801. A VA clinician has described "multiple scars throughout scalp, neck, chest, legs [consistent with] previous cysts." See May 9, 2008 VAMC entry. However, the evidence does not show that these scars cover an area or areas of 144 square inches or greater, as required for a 50 percent rating. 38 C.F.R. § 4.118. Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. The Board finds that the symptomatology and impairment caused by the Veteran's furunculosis is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. In this case, considering the lay and medical evidence, the furunculosis has been manifested by sebaceous cysts on the groin, back, and buttocks, and by residual scarring throughout the scalp, neck, chest, and legs. The schedular rating criteria, including DC 7806 and the alternative evaluations under DCs 7801 and 7802 specifically provide for disability ratings based on skin conditions and residual scarring affecting the head, face, neck, and all other parts of the body. In sum, these ratings consider disfigurement, scars, types of treatment, longevity of treatment, and the percentages of the entire body and exposed areas affected by a particular skin disorder. For these reasons, the Board finds that the schedular rating criteria for skin conditions are adequate to rate the Veteran's furunculosis, and referral for consideration of an extra-schedular evaluation is not warranted. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 115. Lastly, an inferred claim for a total disability rating based on individual unemployability (TDIU) has not been raised by the Veteran or the evidence of record. While the Veteran has complained that furunculosis flare-ups make it difficult to wear pants or underwear, and to sit for any period of time, he has not alleged that he has been unable to secure or follow substantially gainful employment due to this disability; therefore, the Board finds that the issue of entitlement to a TDIU has not been reasonably raised by the record or by the Veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER An increased rating to 30 percent disabling, but no higher, for furunculosis is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs