Citation Nr: 1336191 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 10-28 501 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a skin disorder other than radiation induced dermatitis and shingles. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from April 1943 to December 1945. This case is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The appeal was remanded in May 2011 to fulfill the Veteran's request to appear for a personal hearing at the RO in St. Petersburg, Florida before a traveling Veterans Law Judge; however, the Veteran subsequently withdrew his request for the hearing and the matter was returned to the Board. In March 2012 and August 2012 the appeal was remanded again for additional development of the record. The Veteran had filed for a radiation-induced skin disability, claimed as lichen planus. Before the appeal was returned to the Board, the RO issued a rating decision in December 2012. In that decision, the RO granted service connection for radiation induced dermatitis as well as hyperpigmentation changes in the groin area; and assigned a noncompensable disability rating for both disabilities, effective from January 26, 2009. The RO issued a Supplemental Statement of the Case (SSOC) in December 2012. The SSOC addressed the issue of entitlement to service connection for locking of joint/multiple joint conditions to include bilateral conditions of the hands. The December 2012 SSOC did not address the issue of entitlement to service connection for a skin disorder other than radiation induced dermatitis and shingles because it considered the Veteran's "skin" condition as granted in full by way of the December 2012 rating decision which granted service connected for radiation induced dermatitis and hyperpigmentation changes in the groin area. However, the Veteran had always maintained that he had a rash affecting areas other than the groin area, and, various medical professionals have diagnosed various skin conditions affecting parts of the Veteran's body other than the groin area. As such, the claim of service connection for a skin disorder other than radiation induced dermatitis and shingles remains in appellate status and before the Board at this time. In an April 2013 decision, the Board denied entitlement to service connection for locking of joint/multiple joint conditions to include bilateral conditions of the hands. The Board also remanded the remaining issue on appeal of entitlement to service connection for a skin disorder other than radiation induced dermatitis for the issuance of a supplemental statement of the case. In October 2012, the Veteran submitted a statement from his private cardiologist who confirmed that the Veteran was under his care as a cardiac patient. According to the cardiologist, the Veteran's first "PCI" under his care was dated February 4, 1999; and, the second PCI was dated April 20, 2007. The Veteran's Cover Letter submitted with that doctor's statement indicated that the statement was submitted in support of his ongoing claim; and, that the stress from the length of time that it was taking for a decision on his [pending] claim had caused diabetes and high blood pressure. As the Board does not currently have jurisdiction to address these issues, the issues of entitlement to service-connection for diabetes and high blood pressure are referred to the RO for appropriate action. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's presently diagnosed skin conditions, or those diagnosed during the period covered by this appeal, other than the radiation-induced dermatitis and shingles, are unrelated to any disease, injury or event in service. CONCLUSION OF LAW A skin condition, other than radiation-induced dermatitis and shingles, was not incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letter dated April 2009. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a service connection claim, and the relative duties of VA and the claimant to obtain evidence. The letter also notified the Veteran regarding how initial disability ratings and effective dates are assigned for all grants of service connection, pursuant to the holding in Dingess. In the Veteran's response, which was received at the RO in May 2009 he indicated that he has no additional evidence to submit regarding his claim. Regarding the duty to assist, the RO attempted to obtain records from the Social Security Administration (SSA) but the agency responded that the medical records had been destroyed and further efforts to obtain them would be futile. The RO made a formal finding in this regard in November 2009. The Veteran was informed by way of a November 2009 letter, in accordance with 38 C.F.R. § 3.159(e), that the SSA records could not be obtained, the efforts that were made to obtain the records, and that the Veteran should submit the records if he had a copy in his possession or that a decision would be made within 10 days based on the evidence of record. The matter was remanded to afford the Veteran a hearing before a Veterans Law Judge at the RO, but the Veteran subsequently withdrew his request for a hearing and the case was sent back to the Board. The Board, however, determined that additional development was necessary and remanded the case in March 2012. On remand, the RO sent another letter to the Veteran notifying him that some of his service treatment records had been destroyed during the NPRC fire in 1973 and were therefore not available for review. The Veteran was notified by way of an April 2012 letter, in accordance with 38 C.F.R. § 3.159(e), that the RO attempted to obtain missing service treatment records in particular those pertaining to radiation therapy, that the National Personnel Records Center informed that records were damaged due to a fire, and if he had the records or knew the location thereof, he should submit the records or report the location thereof. He was informed to submit the additional evidence or information within 10 days otherwise a decision might be made after 10 days. He was also informed of alternate sources of evidence that could substitute for missing service treatment records, including statements from military medical personnel, buddy statements, state or local accident and police reports, employment physical examinations, other medical evidence where treatment was sought after separation, letters written during service, pharmacy prescription records and insurance examinations. The Veteran submitted a copy of a private treatment record from April 2012 and he informed the RO that he had been treated at the Tampa VA Medical Center and the Port Richey VA Clinic. The RO subsequently attached these records to the Veteran's virtual VA folder which has been reviewed by the Board. The Veteran's case was re-adjudicated and he was issued a supplemental statement of the case in May 2012, which included consideration of VA medical records uploaded to Virtual VA. In August 2012, the Board denied service connection for shingles, and remanded the other issues on appeal because at that point, there remained some unanswered medical questions leaving the record inadequate to render an informed decision as to these issues. On remand, the Veteran was afforded a comprehensive VA examination that adequately addressed the remaining unanswered medical questions. The examination is adequate as the examiner reviewed the claims file, and extensively reviewed all of the medical evidence of record. The examiner's opinions are highly probative because they are based on sound medical principles, in conjunction with an examination of the Veteran and a review of the record. The agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Moreover, in light of the notice sent to the appellant, as discussed above, the duty to notify has been met. As noted above, VA has obtained service treatment records, to the extent that they are available, and not destroyed by fire. VA has assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the likely etiology of all skin conditions, and whether the Veteran has any residuals of any in-service skin disorder, and if there is any relationship between any current skin and/or joint disorder and service. The Veteran was afforded an opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Service Connection The Veteran seeks service connection for a skin disability other than radiation-induced dermatitis, for which service-connection has already been established. Moreover, as the Board previously denied service connection for shingles, that matter is not before the Board at this time. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed .Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed.Cir.2004); 38 C.F.R. § 3.303 (2013). Insofar as the appellant presents an argument of continuity of symptomatology, the U.S. Court of Appeals for the Federal Circuit has held that service connection can be based on continuity of symptomatology only with respect to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir. 2013). 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). The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competent and credible lay evidence may establish the presence of observable symptomatology and, in certain circumstances, may provide a basis for establishing entitlement to service connection. When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh the lay testimony and make a credibility determination as to whether it supports service connection. See, e.g., Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is therefore not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Nonetheless, although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, separated shoulder, pes planus (flat feet), tinnitus (ringing in the ears), varicose veins, etc., they are not competent to provide evidence on more complex medical questions beyond simple observations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (indicating lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Id at 1337. See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. The Veteran seeks service connection for a disability manifested by a skin disorder with accompanying pain in the areas where the skin eruption exists, or existed at one time. The STRs show that the Veteran was treated for some type of dermatological outbreak in service in 1943. Although the Veteran's discharge examination report is negative for any type of skin condition, the Veteran maintains that he developed a skin condition in service that has continued to the present day, which is manifested by flare ups from time to time. VA records from 1962 show that the Veteran was treated for skin lesions on his fingers and right leg, which he claimed had been ongoing since 1944 with severe itch. The Veteran reported that the disorder was called lichen planus in service. On examination in November 1962, it was noted that the Veteran had eruptions on his right leg, hands and wrists for years. Although difficult to read the handwriting, it appears that the diagnosis was lichen planus and variation of erythema multiforme. In a December 1962 letter to the Veteran, the RO noted that the Veteran's STRs revealed treatment for a skin condition during service; however, the letter also indicates that according to service department records, the condition responded to treatment leaving no apparent residual disability. The Veteran was asked to submit additional evidence in support of the claim, however, he did not respond. At a VA examination in June 2009, the Veteran reported that he experienced penile lesions, and itching, and was seen for this by providers in service. The Veteran also noted that he was treated in service and diagnosed with lichen planus. The Veteran also reported that he was treated with radiation therapy and that the symptoms resolved. Additionally, the Veteran reported that during service he also developed lesions on fingers and legs; and, that throughout the years the skin on his hands has flared with itchy redness on his fingers. He also reported itchiness to "BUE", knees, and rib areas through the years. The June 2009 examiner noted slight redness to all fingers on the dorsum aspect at the PIPs and MTP joint areas bilaterally. The areas were non-raised, and there were no white or lace looking lesions that were typical of lichen planus. The Veteran was not in an active flare. The examiner's diagnosis was atypical dermatitis. He noted that lichen planus was not confirmed. The examiner also opined that the Veteran's dermatitis was not caused by or a result of the same condition in service. The examiner further noted that the Veteran had minimal symptoms on examination that day, and his description of his flares was not consistent with lichen planus. Further, the examiner noted that the Veteran's STRs did not confirm his stated history that the lesions started on his penis and that he was treated with radiation therapy. The examiner noted that the STRs show that the Veteran was treated in 1943 for dermatophytosis or athlete's foot. The examiner also noted that the post-service records from 1962 supported treatment for lichen planus vs. erythema multiforme lesions, but neither were confirmed. The examiner also noted that a review of the Veteran's VA records did not support diagnosis for or treatment of either skin condition. Further, the examiner noted that the Veteran had not been treated for a 10-year period, per the Veteran's own report, and that this decades-long gap in time without any documentation between when he was in service and the current time provides no support for his claim. In essence, the examiner concluded that the available evidence did not support a diagnosis of lichen planus and did not support any current skin condition as having its origin in service. At a VA examination in May 2010, the Veteran reiterated that he developed a rash in service that has continued to the present day. The examiner noted that, per a claims folder review, the Veteran had a history of a skin condition in the service. He was seen in the service with a penile lesion and diagnosed with lichen planus. He underwent XRT (radiation therapy) for these lesions. Discharge examination was negative for any skin condition. Significantly, the examiner also noted that there had been no skin biopsy performed and no dermatology consult. However, she did note that a primary care clinic note from May 2010 (also located in the Veteran's Virtual VA Folder) indicated that the Veteran continued to complain of diffuse itching on various areas of the body, which he claims began during service. The Veteran reported itching but no rash was identified, although there was some slight thickening of the skin with mild erythema on several fingers that also itched. This outpatient treatment note also indicates that the genitalia revealed 2 pink macular patches measuring 3-4 x 2-3 mm on the Veteran's penis, likely scarring from the previous radiation therapy to the penis for the presumed lichen planus that the Veteran was previously diagnosed with. As for the pruritis, the Veteran was not getting much benefit from the prescribed sarna lotion, so a skin scraping was taken from the penile lesion site and sent for analysis to assess a possible alternate etiology. The VA examiner in May 2010 opined that the Veteran had a diagnosis of xerosis, or dry skin, and that this was in no way related to any skin disorder in service, or to the Veteran's current joint pain. The examiner noted that the Veteran was seen and treated, per the claims file, in service for lichen planus; however, he had no rash on examination and no evidence of current lichen planus. The examiner further opined that the Veteran's xerosis was age-related and was the cause of his pruritis and that it had no relationship to his skin condition in service. The May 2010 examiner referred to a VA outpatient treatment record from that same month that indicated a skin scraping was taken and sent to pathology to determine whether there was some other etiology to account for the Veteran's itching that has been ongoing since service. A review of the Veteran's VA outpatient treatment records located in his Virtual VA folder indicate that the results from the May 2010 skin scraping revealed staph. The examiner, however, did not believe that staph was causing the Veteran's problems because a certain amount of staph on the skin was normal. The examiner indicated that it would take another few weeks to get the results of a fungal study, and any positive findings would thereafter be reported. The remainder of the VA records show no positive fungal findings. At the March 2012 VA examination, the examiner noted a thorough review of the Veteran's claims file, documenting all prior VA examinations, as well as the history reported by the Veteran. With regard to current skin conditions, the examiner noted diagnoses of dermatitis of the hands, ankles and left knee manifested by erythematous dry skin and slight hyperkeratosis. There was no rash noted. In addition, tinea involving the bilateral big toe nails with mild thickening and yellowish discoloration was noted, with slightly erythematous, dry flaking skin on the sides of the feet without any open wounds. There was no rash currently noted in the groin, however, slight hyperpigmentation changes were noted in the groin area. The examiner also noted that there were no characteristic lichen planus lesions with violaceous lesions with reticular surface, and there was no scarring consistent with healed lichen planus lesions. In addition, the examiner observed slight hyperkeratosis on the head of the Veteran's penis in the area where the Veteran states he had radiation therapy in service. The examiner opined that the Veteran's current skin condition was less likely as not caused by or a result of claimed lichen planus that occurred during service. The examiner indicated that lichen planus typically affected the skin, nails, mucous membranes (especially oral mucosa) and the vulva and penis. On the skin, it was most commonly expressed as an eruption of shiny flat, poly gonal violaceous papules. The examiner further explained that Wickham's striae are characteristic white, lacelike patterns on the surface of the papules and plaques; and, the flexor surfaces of the extremities, particularly the wrists, are common sites of the skin involvement. Lesions were rarely asymptomatic. Most patients experienced pruritis, which could be severe. The examiner further explained that the lesions could become intensely painful if they ulcerated or eroded. In addition, Lichen planus patients could exhibit the Koebner reaction, which the examiner explained was the development of skin lesions in areas of trauma, most often in areas of scratching. The examiner noted that the disease usually healed with significant post inflammatory hyperpigmentation; and, when nails were involved, the disease spectrum varied from minor dystrophy to total nail loss. The natural history of most cases of lichen planus was to remit within one to two years, with the exception of oral lichen planus, which was often chronic. On examination of the Veteran, there was no sign of oral lesions or evidence in the record noting complaints of recurrent oral lesions; thus, the examiner concluded that the Veteran did not currently have the oral variant of lichen planus. The examiner reiterated that lichen planus resolves within 2 years in an overwhelming majority of cases and does not recur, so it was very unlikely based on the medical literature and examination of the Veteran, that his current condition was a continuation of the lichen planus in service, assuming that the Veteran, in fact did have that disease in service. The examiner noted that the Veteran was documented to have had shingles in October 2000, with typical symptoms of right-sided truncal area. Based on the Veteran's reported symptoms of joint pain, rash of the extremities, the examiner opined that the Veteran's current complaints are unrelated to any skin disorder in service or to the shingles documented in October 2000. Finally, the examiner noted that the Veteran was diagnosed by his primary care provider with dermatitis in 2001 and tinea unguim and that neither of these disorders were related to or caused by lichen planus. Tinea pedis was diagnosed at the current examination, but again, the examiner found no relationship between it and lichen planus. The Veteran submitted a private medical examination report from April 2012. In the report, the examiner indicates that the Veteran presented with a chief complaint of generalized body rash. He complained of a rash over his genital area, including the perineum and knuckles bilaterally. The examiner noted a history of lichen planus over his penis and groin which was treated via radiation therapy in Guam in 1945. Since that time, the Veteran reports recurrent lesions in the above mentioned areas. On examination, the examiner noted mild erythema over the metacarpal phalangeal joints bilaterally and radiation induced dermatitis over the intertrigal areas of the buttocks. The impression was, in part, history of lichen planus. The clinician noted that the Veteran was treated for this disease in the 1940s which affected his penis at that time, via radiation therapy. Since then, he stated that he had issues with recurring lesions; however, they were not mucocutaneouos as would be expected. Dermatitis, radiation induced, over the perineum was also diagnosed. At a VA examination in September 2012, the examiner noted a diagnosis of eczema in 2011, tinea unguium in 2001, tinea pedis in 2012; and, xerosis in 2010. The Veteran reported his prior medical history to the examiner with regard to skin disorders during service, and after service. The Veteran indicated he had an itchy, swollen, red rash with welts on his penis, knuckles, and gluteal creases which he was told was lichen planus. The examiner summarized the Veteran's STRs and the Veteran's post-service medical evidence of record, including the findings at the previous VA examinations, all of which is summarized above. The examiner made the following findings on examination: (1) minor thickening/discoloration of the outer edge of the right great toenail; fingernail of the right ring finger also had chronic changes of the fungal infection; (2) minor flaking and fissuring toes of both feet; (3) subtle erythema and slight thickening of skin over the "MCPs and PIPs" of both hands; (4) very dry skin noted over both distal lower extremities; (5) no evidence of active lichen planus. With regard to all skin disorders, the examiner opined that the claimed conditions were less likely than not incurred in or caused by the claimed in-service skin condition. The examiner noted that the objective evidence failed to demonstrate that the Veteran had a current skin disorder caused by, a result of, and/or incurred during, his active duty service. With regard to dermatophytosis/tinea pedis and tinea unguium, the examiner pointed out that the Veteran's available STRs only had one brief mention of dermatophytosis, apparently of one or both feet; this was in the 1940s. Although the Veteran's STRs may be incomplete, it appeared to the examiner that the dermatophytosis condition resolved while the Veteran was still on active duty, as he had a separation examination in December 1945 which reported a normal skin examination. In addition, the examiner noted that the Veteran did not claim any skin conditions (except for appendectomy scar) in his initial VA disability claim in 1946. Also, the dermatophytosis/tinea conditions had been noted on various exams done recently, but there was no documented evidence of chronicity of dermatophytosis/tinea conditions in the multi-decade interval between 1943 and recent examinations. The examiner further reasoned that there was no objective evidence confirming that the Veteran's dermatophytosis was caused by, or incurred during, his active duty or was a result of any other disease/condition/event incurred during or a result of his active duty. Regarding the lichen planus, the examiner found no documentation of lichen planus or treatment thereof in the available STRs. The examiner opined that if the Veteran did have lichen planus during service, it would appear that any such lichen planus was acute and transitory given that the separation examination from December 1945 reported a normal skin examination. Furthermore, the Veteran did not claim lichen planus or other chronic dermatitis in his initial VA disability claim made circa 1946, and the first documented claim of a chronic dermatitis/skin condition found in the claims folder was in 1962, many years after service. Although poorly legible medical reports from 1962 document some kind of dermatitis, the information in the 1962 note is not sufficient to confirm or disprove the presence of lichen planus at that time. Also, according to the most up-to-date literature, lichen planus typically resolved in a year or two. Thus, the examiner reasoned that even if the Veteran did have lichen planus during active service, or in 1962, it would be very unusual for lichen planus to persist over a 50-70 year period (1942-1962-2012). The examiner also mentioned that the Veteran had been examined by numerous clinicians over the prior 10 to 12 year period, both in the context of prior compensation and pension examinations and in the course of his regular medical treatment; and the examiner indicated that he spent several hours reviewing dozens of the Veteran's medical evaluations/prior C& P examinations, but was unable to find any record where a trained medical clinician had actually seen and documented an active dermatitis consistent with lichen planus within the prior 10 year period. Further, the examiner noted that there was no biopsy in the record to confirm a diagnosis of lichen planus, and no evidence of active lichen planus on current examination. Finally, the examiner also opined that the Veteran's current skin disabilities were separate and disorders unrelated to lichen planus. Regarding the current diagnosis of xerosis, the examiner opined that xerosis was most likely associated with the aging process; and, up-to-date medical literature supports this finding because it explains that the dermis and epidermis cause reduction of normal skin "moisturizers" (sweat and sebum) in aging skin. Moreover, there is no objective evidence to connect the xerosis to his active service or to any other condition caused by his active service. Regarding the diagnosis of eczema, the up-to-date literature reports that the cause of eczema is thought to be due to abnormalities of the permeability of the epidermal skin layer, with loss of normal epidermal hydration. Genetic factors are also suspected. The examiner indicated that there was no evidence of record demonstrating that the Veteran's eczema was due to or a result of his active duty and/or any disease/conditions associated with his active duty. An April 2012 private treatment record indicates that the Veteran has radiation-induced dermatitis. Although the most recent VA examiner of September 2012 explained that the Veteran's in-service skin disorder remains unknown, the totality of the evidence reveals that the Veteran had some skin disability in service in the groin area that was treated with a type of therapy that left residual scarring. The private examiner in April 2012 opined that the scarring was radiation-induced, and the Veteran's current symptoms in the area of the scarring were consistent with a radiation-induced dermatitis. In light of the foregoing, the RO issued a December 2012 rating decision granting service connection for radiation-induced dermatitis and hyperpigmentation changes in the groin area. The Veteran's skin condition(s) were reevaluated at a June 2013 VA examination. According to the report, the examiner reviewed the Veteran's claims file, as well as relevant VA medical records/VBMS. The examiner noted that the Veteran had been diagnosed as having tinea unguim (date of diagnosis unknown) and xerosis (diagnosed in 2010). The Veteran also reported that he had xerosis with itchy skin on both calves, back, lateral chest (ribs) for years and bilateral tinea pedis that been present "forever" with symptoms of itching/cracking/irritation, mostly in between toes, where it cracks and becomes sore. The Veteran also indicated that he had tinea unguim which had been present for a long time and involved the toenails of both feet as well as dermatitis of upper extremities which occurred over the PIP joints of both hands. The Veteran indicated that he had not seen a dermatologist recently, and there had been no biopsies of these areas to allow confident identification of this condition. The examiner reported that numerous prior exams had shown the same findings as that day, namely a very subtle erythema over the PIP joints of fingers of both hands without a discrete eruption or rash. The Veteran also reported that there was "eczema" of various upper and lower/extremities-/chest/ribs/etc, which was the same as the xerosis condition noted earlier. Xerosis is typically more severe in the lower calves, and the veteran had signs of it on examination, but it was also noted to commonly affect the flanks (ribs)/back area; the dry skin causes itching and an eczematous reaction can form after persistent itching/scratching. Physical examination of the Veteran's skin revealed that there was obvious dry skin (xerosis) affecting the lower anterololateral calves, lateral chest wall and ribs; some of these areas showed evidence of excoriation (scratching) but no discrete "rash" or "dermatitis" was noted in these areas. The examiner found that xerosis (dry skin) was responsible for most of his active symptoms. The outer edges of several toenails of both feet had modest thickening/discoloration, consistent with tinea unguim. Both feet were inspected for tinea pedis, but the condition was not found on concurrent exam; the condition appeared to be inactive currently, as no significant flaking/scaling/cracking/etc was noted on either foot. Very mild erythema was noted over the dorsum of the PIP joints of fingers both hands. No discrete skin lesions such as vesicles/papules/ulcerations etc were noted here. The clinical appearance was so mild and non-specific that it did not allow for a definite diagnosis to be made, and normal aging was not excluded from the differential diagnosis. As has been true on prior VA examinations, no objective evidence of lichen planus was identified. The examiner opined that the skin disorders were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the objective evidence linking any of these current skin conditions to his active duty service fails to meet the 50% probability threshold. The examiner reasoning was the "same as those which have been exhaustively detailed in the multiple prior C&P skin exams..." They included the lack of records documenting the skin condition occurred during service, lack of documentation showing the conditions have been persistent since his active duty service, and that the Veteran's primary skin disorder at this time was xerosis (dry skin). The examiner explained that abundant evidence in the medical literature explains that xerosis (dry skin) is part of the aging process and is in fact the most common cause of itchy skin in the absence of an obvious rash. The examiner referred to the prior VA opinions of 9/10/12 and 5/25/10, with literature references cited therein. The examiner did not opine further regarding lichen planus, as multiple exams have shown this condition is not present. Notwithstanding the establishment of service connection for residual disability in the groin area, the Veteran continues to maintain that he has additional skin disability in other areas of his body that is related to the in-service skin disability. While the Veteran is competent to report his symptoms, he is not competent as a lay person to diagnose the type of skin disorder he has or to provide an etiological opinion therefore as this is beyond the capability of a lay person to observe. The evidence does not show that the Veteran had a chronic skin disorder, including xerosis, eczema, dermatitis, or tinea unguium in service as the separation examination did not note evidence of such and any lichen planus that may have existed during service has not existed at any time during the period covered by this claim. Service connection has been established for radiation-induced dermatitis based on the totality of the medical evidence and the Veteran's credible statements regarding his in-service treatment for a skin disorder. In other words, the Veteran is found credible for the purposes of (1) establishing his current symptoms, (2) reporting what type of symptoms he had during service; and, (3) what treatment he received for his in-service skin symptoms. The issue here is not whether the Veteran had lichen planus during service; but rather, whether the Veteran has a current diagnosis of a skin condition (including but not limited to lichen planus), that had its onset during service or it otherwise related thereto. In this case, the medical evidence of record shows that while the Veteran may have had lichen planus during service, he does not have any signs of the disease currently. Moreover, VA has already recognized that the Veteran had a skin condition during service in his groin area and has established service connection for such. The record indicates that the Veteran did not have any other skin conditions during service that he currently manifests. The Veteran's current skin conditions are acknowledged, but the preponderance of the evidence is against the claim because the record lacks objective findings of current lichen planus and VA examiners have opined that current disabilities are not related to service and provided rationales for their conclusions. Insofar as the Veteran reports continuity of symptoms since service, none of the current skin conditions are listed in 38 C.F.R. § 3.309 as being a chronic disability for which service connection is presumed. See Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir. 2013). Although the Veteran is credible as to what he experienced in service and what symptoms he currently experiences, he is not competent to provide a medical nexus opinion in this case because such an opinion in this case requires medical expertise in order to identify the current conditions and to opine as to any nexus between the current skin condition(s) and any disease, injury or other event during service (other than radiation-induced dermatitis of the groin area with hyperpigmentation changes). There is no doubt that the Veteran suffers from various skin conditions, such as xerosis, tinea unguium and tinea pedis. However, the medical evidence in this case outweighs the Veteran's credible reports. These examiners have reviewed the medical history and have provided detailed opinions with complete rationales as to why the Veteran's current skin conditions are unrelated to service. Hence, the preponderance of the evidence is against the claims of service connection for a skin disorder other than radiation induced dermatitis and shingles; there is no doubt to be resolved; and, service connection is not warranted. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 4.3. ORDER The claim of service connection for a skin disorder other than radiation induced dermatitis and shingles is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs