Citation Nr: 1334658 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-12 626 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a right foot disability, to include plantar fasciitis and pes planus. 2. Entitlement to service connection for a left foot disability, to include plantar fasciitis and pes planus. 3. Entitlement to service connection for a skin disability, to include dermatosis. 4. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from June 1979 to October 1979 and from February 2003 to April 2004. The Veteran also has various periods of active duty for training and/or inactive duty training with the Army National Guard. These matters come before the Board of Veterans' Appeals (Board) from an October 2008 rating decision (feet) and an August 2009 rating decision (skin and hypertension) of the Department of Veterans Affairs (VA), Regional Office (RO) in Columbia, South Carolina. In September 2011, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were previously before the Board in December 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. During the pendency of the Veteran's appeal, the Appeals Management Center (AMC) granted service connection for bilateral elbow and bilateral knee disabilities; thus, the issue of entitlement to service connection for painful joints of the elbows and knees is no longer for appellate consideration. The issue of entitlement to service connection for a skin disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The earliest clinical evidence of the current right foot disability is in January 2008, more than three years after separation from the Veteran's final period of active service. 2. The earliest clinical evidence of the current left foot disability is in January 2008, more than three years after separation from the Veteran's final period of active service. 3. The Veteran's testimony with regard to the onset of his current bilateral foot disability is outweighed by other more objective evidence. 4. The competent credible evidence of record is against a finding that the Veteran has a current bilateral foot disability causally related to active service. 5. The Veteran was diagnosed with hypertension more than seven years after his first period of active service and several years prior to his second period of active service. 6. The competent credible evidence of record is against a finding that the Veteran's hypertension is causally related to, or was aggravated by, active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right foot disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for a left foot disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in July 2008 and June 2009. VA also has a duty to assist the Veteran in the development of the claims. The claims file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. In its December 2011 remand, the Board directed that VA attempt to obtain records from Dr. G. Counts. In December 2011 correspondence to the Veteran, the AMC requested that the Veteran provide treatment records, or authorization for it to obtain records, from Dr. G. Counts. The Veteran did not comply with this request; thus, VA does not have a further duty to assist the Veteran in obtaining any such treatment records. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate VA examinations/opinions are of record for the issues decided herein; they are predicated on consideration of the Veteran's disabilities, his symptoms, and his medical history. Adequate rationale was provided for the opinions offered. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Analysis The Board has reviewed all of the evidence in the Veteran's claim file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, 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 claims. Right and Left Foot Disability The Veteran avers that he has a bilateral foot disability due to active service, to include wearing boots for extensive periods of time while in Iraq and/or Kuwait. The Board finds, based on the evidence discussed below, that service connection for a right and/or left foot disability is not warranted. An essential element of a claim for service connection is evidence of a current disability. VA clinical records reflect that the Veteran has bilateral plantar fasciitis and pes planus. Thus, this element has been met. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran testified that he had to went through several pairs of boots while deployed and that at times he would wear a pair of boots for 24 hours at a time. (See Board hearing transcript page 17-19.) The Veteran's STRs are negative for any complaints of, or treatment for, the feet related to wearing boots or prolonged standing or walking. The only service records with regard to a foot complaint involve a left foot contusion. A July 2003 DA Form 2173 (Statement of Medical Examination and Duty Status) reflects that the Veteran reported that he injured his left foot while in Iraq on July 29, 2003. The record reflects that the Veteran was standing on a runway beside a tractor when the operator of the tractor dropped the front scoop bucket on the Veteran's left foot. The STR reflects that the Veteran reported throbbing pain. The foot was painful on palpation and had edema and swelling. It was negative for a fracture. The assessment was "contusion'. The Veteran was given a profile of no running or jumping for five days, and prescribed Motrin and rest. A March 2004 report of medical assessment also reflects that the Veteran reported that he had injured his left foot in July 2003 when a bucket was lowered and smashed his left foot. It was noted that an x-ray revealed that there was no facture. The residual was noted to be pain with no swelling. As noted above, the Veteran's second period of active service ended in April 2004. The Veteran completed a post-deployment health assessment form in February 2004. He noted that his health "stayed about the same or got better" during his deployment. He also reported only one medical problem which developed during deployment and that was a left foot injury. A post active service August 2004 report of medical history for retention purposes reflects that the Veteran reported that he had no foot trouble. Notably he noted sinusitis, recurrent back pain, numbness and tingling, and frequent indigestion. The Board finds that if the Veteran had foot trouble it would have been reasonable for him to have noted it when he noted his other four complaints. An August 2004 report of medical examination for retention purposes reflects that the Veteran had a normal arch of feet, and normal feet. He had a physical profile of "1" for the lower extremities. A "1" reflects that the Veteran had a high level of medical fitness (e.g. he did not have any limitations). See AR 40-501. Thus, more than three months after separation from his second period of service, the Veteran still had normal arches, and normal feet with no foot complaints. A March 2005 "initial medical review- annual medical certificate" reflects that the Veteran denied any current medical condition other than blood pressure, reflux, and insomnia. Again, the Board finds that if the Veteran had chronic foot complaints, it would have been reasonable for him to have noted it when he noted his other conditions. The earliest post service complaint of the bilateral feet is in January 2008, more than three years after separation from active service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible; however, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) In the present case, not only is there a lack of clinical records, but the Veteran specifically denied foot trouble in August 2004 and subsequently has reported the onset of his current foot problems as being in 2007, as noted below. A January 2008 VA clinical record reflects that the Veteran reported bilateral heel pain. An April 11, 2008 VA clinical record reflects that the Veteran reported painful bottom of feet for approximately 6 to 8 months getting worse. This timeframe corresponds to when the Veteran began working for a road crew. (An August 2007 VA examination for PTSD reflects that the Veteran recently started working as a supervisor for a road crew for a state government.) An April 14, 2008 VA clinical record reflects that the Veteran reported bilateral foot pain mainly in the heels which was one year in duration. Again, this would have been several years after separation from active service. A May 2008 VA record reflects heel pain planar, one year duration of increasing pain and tenderness on bottom of both heels. Any statement by the Veteran that he has had bilateral foot pain since service is less than credible when considered with the record as a whole, to include the February 2004, August 2004, March 2005 STRs, and the VA clinical records noted above. The Board finds that the Veteran's statements made in 2004, 2005, and 2008 contemporaneous to service and treatment, are more credible than those made later for compensation purposes. See Cartright v. Derwinski, 2 Vet. App.24, 25 (1991) (finding that, while the Board may not ignore a Veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits, personal interest may affect the credibility of the evidence); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). The claim file includes a January 2012 VA examination report. It reflects that the Veteran reported that he started having more foot problems when he came back from Iraq. The examiner opined that "it is less likely as not that the Veteran's bilateral foot disability is related to the veteran's military service. The veteran was shown to have had an injury to his right [sic] foot when a heavy object was dropped on it in 2003. There is no indication of chronic disability as a result of this injury. The Veteran's current complaints are not related to an injury and STR's do not indicate an onset of his problem during active service." The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g. bilateral foot pain). See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, he has not been shown to have the education, training, and experience necessary to provide a competent opinion as to etiology of his foot disabilities and whether they are related to wearing boots several years prior to the onset of the pain. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, plantar fasciitis and pes planus with onset after service and after working post service as a supervisor for a road crew, an erosion control inspector, and in a job which required "of a lot of standing and walking, you know for long periods of time." (See Board hearing transcript page 16.) The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In sum, the Veteran had normal arches and no reported heel pain while in service, and the clinical evidence is against a finding that his current disabilities are causally related to, or aggravated by, active service, to include a foot injury in 2003. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Hypertension The Veteran contends that service connection is warranted for hypertension because his hypertension was aggravated by his active service in Iraq and/or Kuwait, particularly because he alleges that his hypertension requires more medication to control since his return from Iraq. Initially, the Board finds that the Veteran's hypertension was not caused by a period of active service. The Veteran's initial period of active service was from June 1979 to October 1979. The Veteran's September 1979 report of medical examination for separation (REFRAD (release from active duty)) purposes reflects that his blood pressure was 100/70. Records reflect that the Veteran was diagnosed with hypertension in the mid 1990s, more than 15 years after conclusion of his first period of active service. His earliest report of high or low blood pressure is in 1987, more than seven years after conclusion of his first period of active service. The clinical evidence of record does not reflect, and the Veteran does not contend, that his hypertension is causally related to his first period of active service. As noted above, subsequent to his 1979 active service, the Veteran served in the National Guard. A February 1987 report of medical history for periodic examination purposes reflects that the Veteran reported that he was not taking medication but that he had high or low blood pressure. His examination report was 140/80. The Veteran was not on active duty at this time. Records in February 1987 and November 1995 note that the Veteran was not taking any medication. A September 1996 report of medical examination and a November 1996 Annual Medical Certificate reflect that Veteran was taking the medication, Univasc, for hypertension. An October 1997 handwritten note on a prescription form from Dr. G. Counts reflects that "[the Veteran] has been placed on Univasc 7.5 for BP on 8/4/97." An October 1998 Annual Medical Certificate also reflects that the Veteran was taking 7.5 mg of Univasc. A January 2000 Annual Medical Certificate reflects that the Veteran was taking 15 mg. of Univasc for high blood pressure. Thus, more than three years prior to his second period of active service, the Veteran's hypertension medication had been increased from 7.5 mg. to 15 mg. A January 2003 individual medical history record, one month prior to the Veteran's second period of active service, again reflects that the Veteran was taking blood pressure medication. The Veteran entered his second period of active service in February 2003. A July 12, 2003 record reflects that the Veteran's blood pressure was "minimally elevated" but that no treatment would be initiated at that time. His blood pressure readings over a four day period were 136/88, 136/96, 142/90, 142/88, 136/90, 116/96, 142/84, and 133/79. A subsequent July 2003 STR reflects that the Veteran's blood pressure as 120/77. The Veteran completed a post-deployment health assessment form in February 2004. He noted that his health "stayed about the same or got better" during his deployment. He also reported only one medical problem that developed during deployment and that was a left foot injury. The Veteran's second period of active service ended in April 2004. The Veteran's August 2004 report of medical history for retention purposes does not reflect that he had an increase in medication for hypertension. A March 2005 "Initial Medical review- Annual Medical Certificate" reflects that the Veteran reported that he was taking Univasc and that his blood pressure was controlled. VA clinical records reflect that in February 2006, the Veteran was started on Losartan, and that he was on Felodipine from February 2006 to February 2008. A January 2008 VA clinical record reflects that the Veteran reported that his blood pressure was better at home. The Board notes that Univasc is a hypertension medication known as an ACE inhibitor. Losartan is a hypertension medication known as an ARB. Plendil (felodipine) is a calcium channel blocker used to treat hypertension. In correspondence dated in September 2011, Dr. G. Counts stated, in pertinent part, as follows: [The Veteran] was on blood pressure medicine when he was sent to active duty in Iraq. He has been seen by the VA since he has returned. He has had other medications since then. The probative value of medical opinions is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The Board finds that the opinion by Dr. G. Counts has little, if any probative value. Dr. Counts stated that medication has been added since the Veteran returned from Iraq but he does not discuss the medications, and importantly does not note that, even though some were added, his Univasc was discontinued. In addition, he fails to provide an adequate opinion as to why the medications were changed. He does not mention if the change in medication was due to adverse side effects with one medication, an increase in severity of the disease, or an interaction between one medication and another medication. Dr. Counts also fails to state whether there was a chronic increase in hypertension severity, and if so, whether it was due to the natural progression of the disease, the Veteran's service, age, or another factor. In addition, while Dr. Counts noted that he believed that the Veteran was suffering from stress from his service in Iraq, he did not equate this with a chronic increase in hypertension severity. The claim file includes a January 2012 VA examination report which reflects that it "is less likely as not that the Veteran's hypertension was permanently aggravated by military service. Veteran was not treated for hypertension during active service and he had only transient elevations of his blood pressure. He claims that stress is causing permanent aggravation of his hypertension. It is true that stress has an effect on blood pressure, but this is a transient, not permanent effect. There is no evidence that stress causes progression of the disease of hypertension beyond its natural course." A Veteran is competent to attest to factual matters of which he has first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran has not been shown to have the education, training, and experience necessary to provide a competent opinion as to the etiology of any chronic increased severity of hypertension, or if there is any such increase. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, hypertension and the natural progression of it and medication effectiveness and types of medication. The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In sum, the onset of the Veteran's hypertension was not within one year of active service, and the Veteran's hypertension was not aggravated by active service. The change in medication has not been shown by competent evidence to have been due to a chronic increase in severity of hypertension due to service. Moreover, the change in medication occurred more than a year after separation from the Veteran's second period of active service. The most probative evidence of record does not reflect that the Veteran's hypertension is caused by, or aggravated by service or a service-connected disability. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for a right foot disability, to include plantar fasciitis and pes planus, is denied. Entitlement to service connection for a left foot disability, to include plantar fasciitis and pes planus, is denied. Entitlement to service connection for hypertension is denied. REMAND The Board finds that a supplemental opinion is warranted on the issue of entitlement to service connection for a skin disability. The Veteran's STRs do not reflect complaints of, or treatment for, a skin disability during a period of active service, or within one year of active service. The Veteran contends that his skin disabilities are due to exposure to heat, sun and/or burn pit smoke/fumes in Iraq and/or Kuwait. The Veteran's February 2004 post deployment health assessment reflects that he denied skin diseases or rashes. A March 2004 report of medical assessment reflects that the Veteran reported a left foot injury, an injury to the back, and sinus problems. He did not report any skin abnormality. An August 2004 report of medical history reflects that the Veteran denied having had a skin disease. The Veteran's August 2004 report of medical examination reflects that his skin was normal with the exception of a scar on the left lower quadrant of the abdomen. A March 2005 Initial Medical Review- Annual Medical Certificate reflects that the Veteran reported reflux, hypertension, and insomnia since his return from deployment in March 2004. He did not report any skin abnormality. The earliest clinical evidence of record of a skin complaint is in April 2009, five years after separation from the Veteran's second period of active service. The Veteran reported a red rash and brown spots on his legs. A May 2009 record reflects diagnoses of actinic keratosis, mild papulopustular rosacea, and pigmented purpuris dermatoses (Schamberg disease). The Veteran underwent a VA examination in January 2012. The examiner expressed an opinion with regard to the actinic keratosis and carbuncle, but failed to provide an adequate rationale as to the rosacea and Schamberg disease. Thus, a supplemental opinion is warranted. Any opinion should include an adequate rationale and discuss whether it is as likely as not that these skin disabilities are causally related to active service. In addition, a March 2002 clinical record, approximately year prior to the Veteran's active service, reflects that the Veteran had had a mole removed one year earlier. The removal of a mole indicates that the Veteran may have seen a dermatologist in 2001 or 2002. VA should attempt to obtain records from such examination and/or treatment. In December 2011 correspondence to the Veteran, the AMC requested that the Veteran provide treatment records or authorization for it to obtain records from Dr. G. Counts. The Veteran did not comply with this request; thus, VA does not have a further duty to assist the Veteran in obtaining any such treatment records. However, as the claim is being remanded, the Board finds that the Veteran should be given one more opportunity to provide VA with the records or with authorization for it to obtain them. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to identify all providers (VA and private) from whom he has received treatment for his skin, and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for each provider identified, to include the removal of a mole in 2001 or 2002 and records from Dr. G. Counts. 2. Thereafter, make arrangements with a dermatologist, or appropriate clinician, to provide a supplemental medical opinion in this case. The clinician should provide an opinion as to whether it is at least as likely as not (whether there is a 50 percent or greater probability) that the Veteran has a skin disability of a.) mild papulopustular rosacea and/or b.) pigmented purpuris dermatoses (Schamberg disease) which is causally related to, or aggravated by, active service. The clinician should consider the entire claims file to include a.) the Veteran's contention that his skin disabilities are due to exposure to heat, sun and/or burn pit smoke/fumes in Iraq and/or Kuwait, b.) the February 2004 post deployment health assessment which reflects that the Veteran denied skin diseases or rashes, c.) the March 2004 report of medical assessment which reflects that the Veteran did not report a skin abnormality, d.) the post active service August 2004 report of medical history which reflects that the Veteran denied having had a skin disability, e.) the post active service August 2004 report of medical examination which reflects that his skin was normal with the exception of a scar on the left lower quadrant of the abdomen, f.) the March 2005 Initial Medical Review- Annual Medical Certificate which reflects that the Veteran did not report any skin abnormality, and g.) the April and May 2009 VA clinical records. The clinician is requested to provide a complete rationale for his or her opinion, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. If pertinent, any rationale should discuss the relevance, if any, of the length of time between the Veteran's active service and diagnosis of a skin disability. 3. Thereafter, readjudicate the issue on appeal of entitlement to service connection for a skin disability. If the benefit sought is not granted, issue a Supplemental Statement of the Case and afford the appellant and his representative an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter 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. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs