Citation Nr: 1335571 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 10-03 448 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 10 percent for a skin disability. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Becker, Counsel INTRODUCTION The Veteran served on active duty from July 1992 to December 1999 and from October 2001 to March 2002. This matter comes before the Board of Veterans' Appeals (Board) from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that granted service connection and assigned an initial 0 percent rating effective March 1, 2007, for a skin disability characterized as chronic staph infection of the scalp, arms, and thighs (methicillin-resistant Staphylococcus aureus (MRSA)) with post inflammatory hyperpigmentation of the right arm and no active infection. In appealing this rating, the Veteran requested a hearing. He withdrew his request before one was scheduled, however. The Board remanded this matter for additional development in August 2012. Following completion of this development, the Appeals Management Center issued a rating decision in January 2013. It increased the assigned rating for the Veteran's skin disability, recharacterized as follicular dermatitis secondary to MRSA, to 10 percent effective March 1, 2007. The benefit sought partially was granted, in other words. Whether a rating even higher than 10 percent is warranted remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The following determination is based on review of the paper claims file and Virtual VA electronic claims file. FINDING OF FACT The Veteran's skin disability does not affect between 20 and 40 percent of his entire body or of his exposed areas, does not require constant or near-constant systemic therapy, has not resulted in any disfigurement of the head, face, or neck, and does not include scars that are deep, cause limited motion, or otherwise limit function. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for a skin disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.27, 4.118, Diagnostic Codes 7806, 7820 (2013); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2008). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has a duty of notification regarding a claim for VA benefits. 38 U.S.C.A. § 5103 (West 2002); 38 C.F.R. § 3.159 (2013). VA must notify the claimant and his representative prior to initial adjudication of any information and evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification of how a rating and an effective date are to be assigned for a service-connected disability also must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged any prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found. A May 2007 letter informed the Veteran and his representative of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. It also informed them of how a rating and effective date would be assigned if service connection was granted. The letter therefore was complete. Further, the letter was sent on time prior to the initial adjudication by the RO in the January 2008 rating decision. The purpose of notice finally was fulfilled since the benefit sought, which initially was service connection, was granted therein. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In addition to the duty to notify, VA has a duty to assist with obtaining evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2013). That includes a requirement to aid the claimant in the procurement of relevant Federal and non-Federal records. 38 U.S.C.A. § 5103A(b-c) (West 2002); 38 C.F.R. § 3.159(c)(1-3) (2013). VA also must provide a medical examination or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013). Neither the Veteran nor his representative has identified any outstanding evidence. The record also does not indicate any. The Veteran's VA treatment records have been obtained by VA. Indeed, the most recent were obtained in compliance with the Board's remand. No private treatment records regarding the Veteran have been obtained by VA since there is no indication whatsoever that any exist. Three VA medical examinations have been conducted, the last in compliance with the Board's remand. It was to be conducted during the active stage of the Veteran's skin disability. Substantial as opposed to strict compliance with remand instructions is required. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). The Veteran's skin disability was symptomatic, and thus at least somewhat active, during the last examination. The first two were noted to include review of the paper claims file, and it is clear that the last also included such review even though this was not noted as directed in the remand. In any event, lack of review of the paper claims file or of the electronic claims file is of no consequence because the Veteran accurately reported his medical history at each examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). He also was interviewed and physically assessed at each. Those actions provide sufficient detail so that this determination is fully informed. Therefore, the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Given the above, the Board finds that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Adjudication thus may proceed. Bernard v. Brown, 4 Vet. App. 384 (1993). Doing so is fair to the Veteran since VA has notified him regarding this matter and has assisted in obtaining evidence with respect to it, in other words. It also is fair because he was afforded, but ultimately declined, the opportunity to participate meaningfully in the processing of this matter via a hearing. Increased Rating Disability ratings represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). A rating is assigned under the Rating Schedule by comparing the extent to which a claimant's disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by his symptoms, with the rating criteria for the disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.10 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Examinations must be interpreted, and if necessary reconciled, into a consistent picture so that the rating is accurate. 38 C.F.R. § 4.2 (2013). If two ratings are potentially applicable, the higher is assigned if the disability more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). The claimant thus prevails if the evidence supports an increased rating or is in relative equipoise, but does not prevail when the preponderance of the evidence is against an increased rating. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The assignment of a staged rating, where two or more ratings are assigned for different portions of the period on appeal, must be considered. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's skin disability is rated as 10 percent disabling under Diagnostic Code 7806-7820. 38 C.F.R. § 4.118 (2013). Hyphenated Diagnostic Codes are used when the rating for a disability under one Diagnostic Code is based upon the rating under another Diagnostic Code. 38 C.F.R. § 4.27 (2013). The first Diagnostic Code is for the disability. 38 C.F.R. § 4.27 (2013). The second Diagnostic Code is for the disability found to be most analogous. 38 C.F.R. § 4.27 (2013). Diagnostic Code 7806 concerns dermatitis or eczema. It provides for a noncompensable rating if less than five percent of the entire body is affected, less than five percent of exposed areas are affected, or no more than topical therapy is required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). A 10 percent rating requires at least five percent but less than 20 percent of the entire body being affected, at least five percent but less than 20 percent of exposed areas being affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs being required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). A 30 percent rating is warranted if 20 to 40 percent of the entire body is affected, 20 to 40 percent of exposed areas are affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). The maximum rating of 60 percent is reserved for when more than 40 percent of the entire body or more is affected, 40 percent or more of exposed areas are affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). In the alternative to the above, Diagnostic Code 7806 also provides for a rating based on disfigurement of the head, face, or neck under Diagnostic Code 7800 or on scars under Diagnostic Code 7801, 7802, 7803, 7804, or 7805 depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). Diagnostic Code 7820 concerns infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic diseases). It similarly calls for a rating based on dermatitis under Diagnostic Code 7806, disfigurement of the head, face, or neck under Diagnostic Code 7800, or scar under Diagnostic Code 7801, 7802, 7803, 7804, or 7805 depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7820 (2013). The Board notes that the criteria for evaluating skin disabilities under 38 C.F.R. § 4.118 , Diagnostic Codes 7800 through Diagnostic Code 7805, were revised effective October 23, 2008. They were specifically limited to claims filed on or after October 23, 2008, or if the Veteran requests review pursuant to the revisions. Here, the Veteran's initial claim (from which the initial rating action stems) for service connection was received in 2007 and he has not requested review pursuant to the revised scar Diagnostic Codes. Additionally, neither he nor his representative has argued for use of any Diagnostic Code(s) other than 7806 or 7820 with consequential use of Diagnostic Codes 7800-7805. The record further does not indicate that any other Diagnostic Code(s) should be used. Indeed, the Veteran's medical history, diagnoses, and current symptomatology are most appropriately addressed by the aforementioned assigned Diagnostic Codes. Butts v. Brown, 5 Vet. App. 532 (1993). Under the criteria in effect prior to October 23, 2008, a 10 percent rating was merited under Diagnostic Code 7800 when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). A 30 percent rating required 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. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). A 50 percent rating was warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features or four or five characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The maximum evaluation of 80 percent was reserved for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features or six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). There were eight characteristics of disfigurement: scar five or more inches (13 or more centimeters) in length, scar at least one-quarter inch (0.6 centimeters) wide at the 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 six square inches (39 square centimeters), skin texture abnormal (irregular, strophic, shiny, scaly, etc.) in an area exceeding six square inches, underlying soft tissue missing in an area exceeding six square inches, and skin indurated and inflexible in an area exceeding six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1) (2008). Diagnostic Codes 7801 addressed scars other than head, face, or neck that are deep or that cause limited motion. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). A 10 percent rating required that the area or areas exceed six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). A 20 percent rating was warranted when the area or areas exceeded 12 square inches (77 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). When the area or areas exceeded 72 square inches (465 square centimeters), a 30 percent rating was assigned. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). The maximum rating of 40 percent was reserved for when the area or areas exceeded 144 square inches (929 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). With respect to scars other than on the head, face, or neck that are superficial and that do not cause limited motion, Diagnostic Code 7802 established a maximum 10 percent rating if the area or areas was 144 square inches or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). Diagnostic Code 7803 provided for a maximum 10 percent rating for superficial scars that are unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). Diagnostic Code 7804 set forth a maximum 10 percent rating for superficial scars that are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Finally, Diagnostic Code 7805 pertained to other scars. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). It provided for a rating based on limitation of function. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2) (2008). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Codes 7802 and 7803, Note (2) and Diagnostic Code 7804, Note (1) (2008). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (1) (2008). An assessment of the probative value of the evidence must be undertaken. 38 C.F.R. § 4.6 (2013). The Board must account for evidence it finds to be persuasive or unpersuasive and provide reasons for rejecting any evidence favorable to the Veteran. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). That includes any lay evidence in addition to the medical evidence. Only the most relevant evidence need be discussed, even though all the evidence has been reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Upon VA medical examination in November 2007, the Veteran complained of a breakout or infection on his scalp and the back of his neck lasting one week one to two times per year. It was noted that the Veteran treated the skin on his scalp, arms, and legs topically with tea tree oil and erythromycin, which was neither a corticosteroid nor an immunosuppressant, as well as with oral ingestion of antibiotics as needed. Assessment revealed nothing on his scalp or arms other than three hyperpigmented macules on his right forearm. Only one percent of his entire body was affected, and zero percent of his exposed areas were affected. There was no disfigurement to include scars or impairment of function. The Veteran's continued use of topical erythromycin is reflected in a June 2008 VA treatment record. A November 2008 VA treatment record documents his report of multiple scattered scalp lesions for the previous week. Multiple scattered two to three millimeter pustules on his scalp were noted. They were described as painful and with surrounding erythema. Bactrim was prescribed. In a December 2008 VA treatment record, it was noted that the lesions never went away but rather had started to grow and get painful again. There were three or four scalp pustules with surrounding redness, induration, and tenderness. Linezolid and Motrin were prescribed. May 2009 VA treatment records show that the Veteran complained of painful sores with pus on his scalp for the past three days. One complaint with respect to his groin also was made. Three small erythematous papules with tiny pustules were found on the back of his scalp. Later, the Veteran complained of skin eruptions approximately every three months. He indicated treating them with tea tree oil, Vancomycin, Keflex, Cipro, and Augmentin. With respect to Accutane, he reported discontinuing use after only two days due to fear of side effects. A one centimeter dermal nodule was found on the right occipital scalp. June 2009 VA treatment records show that it was excised, but that others had appeared to include one on the left retroauricular scalp. It was described as a five millimeter erythematous tender papule. Clindamycin or Clindamycin Phosphate gel and Doxycycline or Doxycycline Hyclate were prescribed. In his January 2010 substantive appeal, the Veteran detailed constant itching, lesions, and scarring on his scalp, arms, and legs which require continued use of oral antibiotics. A September 2010 VA medical examination reflects that the Veteran complained of recurrent episodes of infected blisters on the back of the neck, scalp, groin, and axillary areas that were intermittent and caused pain and itching.. His noted treatment regimen included Doxycyclin taken twice daily nine times in the past year, which was characterized as near constant, as well as Clindamycin cream. Neither was noted to be a corticosteroid or an immunosuppressive. Assessment revealed multiple three to five millimeter papules on the scalp on the back of the Veteran's head as well as several diffuse areas of hyperpigmentation varying in size and shape on his right upper arm. Less than five percent of his entire body was affected. The same was true for his exposed areas. April 2011 VA treatment records show that the Veteran reported a scalp rash. Areas of excoriation there were noted. He later reported intermittent red dots that become pussy and are painful on his scalp. There were a few erythematous papules there. Cephalexin to be taken orally was prescribed. A May 2011 VA treatment records reflects that this medication worked. The top and sides of the Veteran's scalp were clear. No papules were found on his posterior scalp, though there were a few small erythematous macules. He was directed to continue Cephalexin. The Veteran's complaint of a skin infection along his hairline and back is contained in a February 2012 VA treatment record. Multiple infected follicles were found along his hairline. Multiple papular/pustular lesions with erythema were found on his back. Hibiclens, Septra, and Mupirocin were prescribed. The Veteran additionally was directed to continue using antibacterial soap. Improvement was noted in a March 2012 VA treatment record. Only mild residuals remained on the Veteran's upper back. He was prescribed Doxycycline and directed to continue Hibiclens and Lactobacilus. No skin abnormalities were noted in a June 2012 VA treatment record. Later that month, the Veteran reported painful tiny papules on his chest and upper back for the previous two to three weeks. Chlorhexidine Gluconate to be applied topically was listed among his medications. Oral Sulfamethoxazole further was listed. Painful tiny papules were found at the base of the Veteran's hair follicles on his anterior chest, upper back, and neck. Bactrim was prescribed. A July 2012 VA treatment record mentions pustular lesions on his trunk, back, and scalp. Cipro or Ciprofloxacin was prescribed along with Ketoconazole cream and shampoo. August 2012 VA treatment records show that the Veteran had no improvement. There still were painful sores on his scalp and back. He was directed to discontinue Cipro and take Doxycycline instead. Scalp lesions were complained of by the Veteran in a September 2012 VA treatment record. There were multiple follicular lesions/comedomes on his scalp, torso, and upper extremities. Tetracycline and Metronidazole cream was prescribed. In an October 2012 VA treatment record, six months of Accutane was mentioned. The Vancomycin was noted to be intravenous. Follicular papules surmounted with pustules were detected on the Veteran's anterior chest and posterior scalp. Some punctate, erythematous papules additionally were detected around his nose. Basis or Neutrogena soap and Phisohex soap were recommended. Upon VA medical examination in January 2013, the Veteran complained that his skin problems were more painful and more widespread than they were at the time of his previous examination. He noted using Tetracycline, Phisohex, Chlorhexidine, Flagyl cream, Ketoconazole Cream, and Mupirocin to treat these problems. There were not characterized as systemic corticosteroids or immunosuppressives, but the Ketoconazole was characterized as a topical corticosteroid. Its use was characterized as constant or near-constant. Assessment showed that the Veteran did not have any scarring or disfigurement of the head, face, or neck. There were follicular papules over his chest and posterior scalp, a few pustules on the anterior chest, two to three sites of faint hyperpigmentation in the right armpit, and a few superficial hyperpigmented scars with a maximum size of three millimeters under the armpits. It was noted that there was exfoliation involving an extensive area but generally no exudation. Between five and 20 percent of the Veteran's total body was affected, but less than five percent of his exposed areas were affected. There was no functional impairment. The Board finds, based on the aforementioned, that an initial rating in excess of 10 percent for the Veteran's service-connected skin disability is not warranted under Diagnostic Code 7806. In this regard, there is no indication that at least 20 percent but less than 40 percent of the Veteran's total body or of his exposed areas ever has been affected, the criteria needed for the next higher disability rating. Each VA medical examination found these percentages to be far smaller. Measurements were not otherwise taken. Since the Veteran has received continuous skin care, however, it is expected that there would be at least some suggestion in his VA treatment records if such an extensive amount of his entire body was or exposed areas were affected. Buczynski v. Shinseki, 24 Vet. App. 221 (2011). No such suggestion has been made. There similarly is no indication that the Veteran has required intermittent systemic therapy for more than six weeks but not constantly during any 12-month period. None of the medications he has taken is an immunosuppressive. Only one, Ketoconazole, has been labeled as a corticosteroid. Where this label came from is unclear since Ketoconazole otherwise is known as an antifungal agent. Dorland's Illustrated Medical Dictionary 997 (31st ed. 2007). In any event, it does not qualify as systemic therapy. The Veteran indeed applies it topically to his skin rather than ingests it or engaging in some other mechanism of delivery impacting his entire body to include his skin. This determination renders it unnecessary to discuss how often he uses it. In addition, an initial rating in excess of 10 percent for a skin disability is not warranted under Diagnostic Codes 7800-7805. Diagnostic Code 7800 is not applicable because no disfigurement to include scarring of the Veteran's head, face, or neck has been found. Even if his recurrent scalp and face lesions there did somehow constitute disfigurement, which typically is permanent instead of episodic, the criteria for even the next highest rating of 30 percent are not met. There is no indication, whether from him, his representative, or the record, of any visible or palpable tissue loss or of gross distortion or asymmetry of a feature or paired set of features. There also is no indication of any characteristic of disfigurement, let alone two or three. The Veteran does not have any scars on his head, face, or neck, much less any approaching five or more inches in length or at least one-quarter inch wide at the widest part. No suggestion of abnormal surface contour, abnormal texture to include hardening or inflexibility, adherence to underlying tissue or soft tissue loss, or color changes exists. Diagnostic Code 7801 is not applicable because no deep scars or scars causing limited motion have been found on the Veteran's body other than his head, face, or neck. The only scars detected, which were near his armpits as opposed to on his legs as the Veteran competently but not credibly indicated in his substantive appeal, indeed were superficial. The area or areas affected equal(s) less than 12 square inches given that the maximum scar size was only three millimeters. It follows that the criteria for the next highest rating of 20 percent are not met even assuming the presence of scars that are deep or cause limited motion. The Veteran's currently assigned 10 percent rating is the maximum rating allowable under Diagnostic Codes 7802, 7803, and 7804. Diagnostic Code 7805 finally is not for application because there is no indication, whether from him, his representative, or the record, of any limitation of function due to scarring. This includes on motion and otherwise. Indeed, no functional deficit from any skin problem was found since the Veteran filed his claim. Nothing suggests any change in this regard during the interim years. Thus, considering the pertinent evidence in light of the above, the Board finds that an initial rating in excess of 10 percent for the Veteran's service-connected scar disability is not warranted at any time since the March 1, 2007 effective date of the grant of service connection. The Board further concludes that the medical findings on examination, to include the most recent when his disability was symptomatic, are of greater probative value than the Veteran's allegations regarding the severity of his skin disability. In reaching this determination, the Board remains sympathetic to the Veteran's assertions and does not question the sincerity of his belief that his symptoms warrant a higher rating. Moreover, the Board recognizes that the Veteran is competent to report symptoms, such as pain and itching, which are capable of lay observation. Layno v. Brown, 6 Vet. App. 465 (1994). Nevertheless, the Board observes that, as a lay person without the appropriate medical expertise, the Veteran is competent to provide a probative opinion on a medical matter, such as the severity of a current disability within the context of the applicable rating criteria. Bostain v. West, 11 Vet. App. 124 (1998); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Therefore, the Veteran's, standing alone, are insufficient to refute the probative assessments of the VA examiners and treating providers, which the Board has used to determine the most appropriate rating for the Veteran's disability. The above disability determination is based on application of pertinent provisions of VA's rating schedule. The Board finds that at no point since the effective date of the grants of service connection has the Veteran's service-connected skin disability on appeal been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2013). In this regard, there is no evidence of an exceptional or unusual disability picture with related factors, such as marked interference with employment or frequent periods of hospitalization, so as to warrant referral of the case to appropriate VA officials for consideration of an extra schedular rating for these issues. See Shipwash v. Brown, 8 Vet. App. 218 (1995). Here, the record does not reflect that the Veteran was hospitalized for his service-connected disability considered herein. There is no objective evidence revealing that his service-connected disability caused marked interference with employment, e.g., employers' statements or sick leave records, beyond that already contemplated by the schedular rating criteria. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2013). In this case, the Board finds that schedular criteria are adequate to rate the Veteran's service-connected disability under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Thun v. Peake, 22 Vet. App. 111 (2008). Lastly, the Board notes that a total disability rating based on individual unemployability (TDIU), because it involves an attempt to obtain an appropriate rating for a disability, finally is part of an increased rating claim if entitlement to such is raised by the Veteran or the record. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case, the Veteran has not contended that his service-connected skin disability is so severe that it has rendered him unable to work. The evidence further does not indicate this to be the case. It is reiterated that he has been working notwithstanding his disability. Consideration of a TDIU as a component of this matter therefore is not warranted. In sum, the weight of the competent and credible evidence shows that the Veteran's service-connected skin disability does not qualify for a rating in excess of 10 percent under the pertinent diagnostic criteria. Moreover, while consideration has been given to staged ratings, the evidence of record does not establish that a higher rating has been warranted at any point since the effective date of the grant of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). As the preponderance of the evidence is therefore against the Veteran's claim for an initial higher rating for a skin disability, that claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating in excess of 10 percent for a skin disability is denied. ____________________________________________ LESLEY A. REIN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs