Citation Nr: 1334656 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 09 35-115 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for a skin disorder, to include tinea cruris, to include as secondary to diabetes mellitus type II. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from January 1964 to January 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied service connection for a skin disorder. The Veteran appealed the denial of service connection in this decision, and perfected an appeal to the Board. In September 2010 and March 2012 the Board remanded this matter for additional development including obtaining unassociated treatment records and providing the Veteran with a VA examination. Based on a review of the claims file, the Board finds that the RO substantially complied with the remand directives. See Stegall v. West, 11Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). The Veteran testified before the undersigned Acting Veterans Law Judge at a hearing held in Detroit, Michigan on April 1, 2010. A transcript of that hearing has been associated with the claims file. Consideration of the Veteran's appeal has included review of all documents within the Virtual VA paperless claims processing system. The documents within the system do not include any non-duplicative materials pertinent to the present appeal. FINDINGS OF FACT Affording the Veteran the benefit of the doubt, tinea cruris is secondary to diabetes mellitus type II. CONCLUSION OF LAW The criteria for service connection for tinea cruris have been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). The Board is granting, in full, the benefit sought on appeal and VA has no further duty to notify or assist. Service Connection for a Skin Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2013). This includes any increase in disability (aggravation) that is proximately due to or the result of a service connected disease or injury. See 38 C.F.R. § 3.310(b) (2013). Establishing service connection on a secondary basis requires (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). Thus, in this case, in order to warrant service connection for on a secondary basis, the evidence must show that the claimed disorder was caused or aggravated by a service-connected disease or injury. The Board notes that the Veteran is currently service-connected for prostatitis, diabetes mellitus type II, and erectile dysfunction associated with diabetes mellitus type II. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran's contentions are twofold. First, he contends that a currently diagnosed skin disorder of the groin area are related to, or aggravated by, service-connected diabetes mellitus. The Veteran has separately contended that the current skin disorder was incurred in service and is related to service in tropical regions. However, at his April 2010 hearing before the undersigned he specifically denied that the disorder was related to service directly. While the claim has been adjudicated broadly as entitlement to service connection for a skin disorder, the Veteran's oral and written statements indicate that his claim is specifically related to a skin condition of the groin. First, the Board finds that while the Veteran was treated for a skin disorder to the pubic region during service; the disorder resolved prior to separation. Service treatment records show that in September 1964 the Veteran complained of irritation and itching around the glands of the foreskin. The assessment was prostatitis. The remainder of the Veteran's service treatment records show no complaints or treatment referable to the skin. In a report of medical history at separation in January 1966, the Veteran affirmatively denied any current or past skin diseases and on separation examination in January 1966, the Veteran skin was normal. In April 1993, the Veteran testified before a hearing officer at the Detroit RO that he wore a diaper at all times due to urinary incontinence which he described as "leakage." As a result, the Veteran's groin area was chronically wet. A "computerized problem list" from a VA medical record generated in May 2007 indicated a history of contact dermatitis and other eczema from February 2004. On VA diabetes examination in April 2008, the Veteran reported a chronic rash in the groin area that had been ongoing for the prior two to three years. The area of the rash was itchy and he had been using Clotrimazole for treatment during the prior year. The course of the condition was chronic and intermittent. On physical examination the Veteran's skin was normal and there was no rash in the groin area, nor was scaling or intertrigo present. The assessment included tinea cruris of the groin bilaterally, which was described as not caused or aggravated by diabetes mellitus, nor present on examination. On VA dermatology consultation in November 2009, the Veteran endorsed a long-standing history of pruritus in the groin area; particularly in the right inguinal fold. Previous fungal cultures were reportedly negative, and the Veteran had been using Pramasone lotion and nystatin powder for treatment. These treatments controlled the itch, but relief lasted only a few hours. Physical examination revealed hyperpigmentation, without erythema, scaliness or maceration in the right inguinal fold. The left inguinal fold had mild hyperpigmentation. During his April 2010 hearing before the undersigned, the Veteran stated that he had seen a dermatologist who did a "scope test" and culture test to determine the nature of the Veteran's rash. With regard to the culture, the test was apparently negative for any "living organism" which may have been causing the symptomatology. The Veteran stated that he treated the rash with topical applications twice a day of a lotion - hydrocortisone - and a powder which he could not recall the name of. A March 2010 list of the Veteran's prescribed medications accompanying VA records confirms the Veteran's prescription for hydrocortisone. On VA examination in October 2010, the examiner reported that the Veteran was seen at a VA Medical Center in 2007 and 2008 and that he was diagnosed with right groin intertrigo and/or lichen simplex chronicus. The Board has reviewed the record and cannot locate dermatological treatment from 2007 or 2008. Nonetheless, for the reasons indicated below, this deficiency of development is nondetrimental to the Veteran's claim. Physical examination of the groin area revealed "no findings whatsoever on the right side," and "occasional flaking changing deep in the groin" on the left. Scrapings to identify fungus were taken and one area showed a "possible hyphal form," but this was determined not to be tinea cruris. The VA examiner stated that there was a single instance in reported medical literature of chronic prostatitis resulting in dermatitis. Following consideration and discussion of urinalysis generally, the examiner concluded that the Veteran's itch symptom was due to one of three causes: tinea, urethritis, or neuropathy. The examiner reported diagnostic testing results, and based on such results concluded that urethritis was not the cause of the Veteran's itching symptoms, and therefore the cause was more likely neuropathy, diabetes, or tinea cruris. In May 2011 the Veteran submitted an article entitled "Jock Itch (Tinea Cruris)" which indicated that diabetic patients often complain of tinea cruris. Because such treatise evidence, standing alone, discusses only generic causalities and relationships without applying the specific facts of the Veteran's case, the Board remanded this matter for an addendum VA examination opinion in March 2012. See Wallin v. West, 11 Vet. App. 509 (1998). In an April 2012 addendum opinion to his prior opinion, the VA examiner reviewed the Veteran's claims file, including his service treatment records. The examiner noted that the Veteran's history of treatment and symptomatology was highly suggestive of tinea; both tinea pedis and tinea cruris. The examiner reviewed several articles and noted that one identified moisture buildup in tight clothing as one factor in the development of tinea cruris. Other factors included obesity and the use of corticosteroids - the examiner then incorrectly stated that there was no evidence of corticosteroids use in spite of the Veteran's documented use of hydrocortisone. Nonetheless, the examiner went on to state that several medical articles, note a high incidence of tinea in patients with diabetes. One such article from the Journal of the American Podiatric Medical Association recorded that the prevalence of tinea pedis in individuals with diabetes was 42.5 percent, while it was just 37.5 percent in those without. Research suggested that diabetes may make individuals more susceptible to fungal infections, and the articled noted that tinea cruris was a common side effect of tinea pedis. The examiner went on to cite from another article which notes that diabetes impairs the integrity of the skin, allowing for bacterial and fungal infections and accounting for the higher rates of tinea seen in diabetic patients. The examiner then opined that diabetes could predispose someone to tinea, but that the evidence linking the two in this case was not clear. The examiner's subsequent discussion of the difference between "service-connected," "secondary," and "aggravated" standards for VA benefits purposes reveals some confusion on the part of the examiner. However, after indicating that diabetes causes sweating abnormalities - which may increase the prevalence of moisture in the groin area - the examiner opined that such increased moisture makes it likely that tinea was "aggravated by or secondary in some ways to, at least as far as severity, the diabetes mellitus." The examiner went on to state that the initial cause of moisture during service was likely the Veteran's in-service balanitis, but that ongoing moisture was due to diabetes mellitus, stating that "the scientific/clinical evidence that there was moisture resulting from service and continuing to the exam is there, be it possibly due to two completely separate diseases." The opinion of the VA examiner is, as the Veteran's representative noted in an August 2013 statement on the Veteran's behalf, "not the height of clarity." However, the Board finds the opinion of the examiner to be highly probative and the examiner's description of the evidence of record clearly indicates that the entire claims file was carefully reviewed in great detail. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (upholding Board determination that VA examination reports were more probative because they were more thorough and detailed, they discussed the conflicting opinions, and examiners had access to the claims file). Furthermore, the examiner supported all opinions with analysis of the Veteran's specific facts, in combination with discussion of general medical principals and application of medical treatises. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Based on the foregoing, and resolving doubt in the Veteran's favor, the Board concludes service-connection for the Veteran's skin condition of the groin, tinea cruris, is granted on a secondary basis. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for tinea cruris is granted. ____________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs