Citation Nr: 1337390 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 08-33 125 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for atopic dermatitis, eczematoid type, prior to March 12, 2009. 2. Entitlement to an evaluation in excess of 80 percent for atopic dermatitis, eczematoid type, since March 12, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from December 1970 to September 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, in which the RO granted an increased, 30 percent rating for atopic dermatitis, eczematoid type, effective February 21, 2008, the date of the Veteran's claim for an increased rating. In October 2010 the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO; a transcript of the hearing is of record. In May 2011, the Board granted a 60 percent rating for the service-connected atopic dermatitis, effective March 12, 2009. The matters of entitlement to a rating in excess of 30 percent prior to March 12, 2009, a rating in excess of 60 percent since March 12, 2009 on an extra-schedular basis, and entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) were remanded for additional development. The Veteran appealed the Board's May 2011 decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2011 Order, the Court granted a Joint Motion by the parties to vacate and remand the May 2011 decision to the extent that it denied a schedular rating in excess of 60 percent for the period beginning on March 12, 2009. In March 2012, the Board granted an 80 percent schedular rating for atopic dermatitis, effective March 12, 2009. In February 2013, the Board remanded the claims listed on the title page for further development. The case has now been returned to the Board. As pointed out in February 2013, in a December 2012 rating decision, the RO granted a TDIU, effective March 12, 2009. The Veteran has asserted that he is unemployable as a result of his service-connected skin disability during the pendency of the appeal. Accordingly, the TDIU claim is part and parcel of the claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, entitlement to TDIU must be considered back to the date of the claim for an increased rating, in this case, February 21, 2008. However, the Board is granting a 100 percent rating for the service-connected skin disability, on an extraschedular basis, effective from the date of the claim for an increased rating. This grant of a 100 percent rating renders any pending claim for a TDIU prior to March 12, 2009 moot. The Board is cognizant that VA's General Counsel's opinion 6-99, which held that "[a] claim for [TDIU] for a particular service-connected disability may not be considered when a schedular 100-percent rating is already in effect for another service-connected disability," has been withdrawn in light of the holding in Bradley v. Peake, wherein the Court determined that a separate TDIU rating predicated on one disability when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). In Bradley, the Veteran had been in receipt of TDIU until the time at which he was awarded a 100 percent combined schedular rating. Bradley, 22 Vet. App. at 293. The Court determined, however, that "the Secretary should have assessed whether [the Veteran's] TDIU rating was warranted based on his [posttraumatic stress disorder (PTSD)] alone before substituting a combined total rating for his TDIU rating." Id. at 294. The Court reasoned that "a TDIU rating for PTSD alone would entitle [the Veteran] to SMC benefits as an additional benefit not otherwise provided to persons with a 100 [percent] combined rating." Id. Accordingly, under Bradley, VA should potentially consider whether TDIU is warranted for a particular service-connected disability even when a schedular 100-percent rating is already in effect for other service-connected disabilities in order to determine the veteran's eligibility for SMC under section 1114(s). Id. The instant case, however, is distinguishable from Bradley in that here, the Veteran's only service-connected disabilities are his atopic dermatitis (for which a 100 percent rating, effective February 21, 2008, is being granted in this decision) and asthma (evaluated as 30 percent disabling, effective February 21, 2008). The Veteran has asserted that he is unemployable due to his service-connected skin disability. Thus, this is not a case in which there are multiple disabilities that, when combined, resulted in the Veteran's 100 percent disability evaluation, and the case is therefore not controlled by Bradley, supra, but rather by Herlehy v. Principi, 15 Vet. App. 33 (2001). In Herlehy, the Court held that the grant of a schedular 100 percent disability evaluation moots the issue of any entitlement to TDIU after the effective date of that rating. Id. at 35 (finding request for TDIU post-July 1989 moot where 100 percent schedular rating was awarded in July 1989); see Locklear v. Shinseki, 24 Vet. App. 311, 314 fn 2 (2011) (noting that because the Veteran was awarded a 100 percent schedular disability rating effective from May 20, 1990, entitlement to TDIU since that date effectively was mooted). The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that was considered in the most recent supplemental statement of the case (SSOC). Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. Resolving any reasonable doubt in his favor, prior to March 12, 2009, during flare-ups, the Veteran's service-connected atopic dermatitis, eczematoid type, has approximated disfigurement of the face with gross distortion of three or more features or paired sets of features. 3. Resolving any reasonable doubt in his favor, throughout the pendency of the claim for an increased rating, the Veteran's service-connected atopic dermatitis, eczematoid type, has presented such an exceptional disability picture with such related factors as marked interference with employment, as to render impractical the application of the regular schedular standards; this disability has resulted in total occupational impairment. CONCLUSIONS OF LAW 1. The schedular criteria for a disability rating of 80 percent for atopic dermatitis, eczematoid type, from February 21, 2008, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.118, Diagnostic Code 7800 (2013). 2. The criteria for an extraschedular 100 percent rating for atopic dermatitis, eczematoid type, have been met from February 21, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 3.321 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Court, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), has held that the VCAA notice requirements apply to all elements of a claim. Given the favorable disposition of the claims on appeal, the Board finds that all notification and development actions needed to fairly adjudicate these claims have been accomplished. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). On February 21, 2008, the Veteran filed a claim for an increased rating for his service-connected atopic dermatitis. As discussed in the introduction, he was granted a 30 percent rating, effective from the date of his claim, and was subsequently awarded an 80 percent rating effective March 12, 2009. The Veteran's atopic dermatitis is evaluated pursuant to Diagnostic Code 7806-7800. The rating criteria for evaluating skin disabilities were amended during the course of this appeal, effective October 23, 2008. See 73 Fed. Reg. 54,708 (September 23, 2008) (presently codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7833 (2013)). Nevertheless, the revised criteria only apply to claims filed on or after October 23, 2008, and to those claims where a request for consideration of the new criteria has been received. See 73 Fed. Reg. 54,708. The Veteran's claim was filed in February 2008, prior to the effective date of the revised criteria, and he has not requested consideration under the revised criteria. Therefore, those revised criteria are not for application. In any event, Diagnostic Code 7806 was unchanged by the October 2008 revisions. Diagnostic Code 7800 was revised only insofar as, prior to October 23, 2008, it was used to evaluate disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). Since the October 23, 2008 revision, this Diagnostic Code is used for rating burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2013). The only other change to the diagnostic code in October 2008 was to add two notes. The first note indicates that disabling effects other than disfigurement associated with individual scars should be evaluated separately and combined, as should residuals of associated muscle or nerve injury. The second note indicates that the characteristics of disfigurement may be caused by one scar or by multiple scars. Diagnostic Code 7806 rates dermatitis or eczema. A 30 percent rating is warranted for dermatitis or eczema that affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; when 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. If more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period a 60 percent rating is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7806. Diagnostic Code 7800 provides ratings based on distortion or asymmetry of paired sets of features or based on characteristics of disfigurement. A 50 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. An 80 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. According to Note (1) of this diagnostic code, the eight characteristics of disfigurement are: (1) Scar 5 or more inches (13 or more cm.) in length; (2) Scar at least one-quarter inch (0.6 cm.) wide at its widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo or hyperpigmented in an area exceeding six square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Id. In the March 2012 decision, the Board granted an 80 percent rating for the Veteran's service-connected skin disability, effective March 12, 2009, based on a finding that the condition resulted in gross distortion of three features or paired sets of features. The Board cited an April 2009 letter from a private physician, Dr. D.L., who reported examining the Veteran on March 12, 2009. Dr. D.L. described active lesions of atopic dermatitis around both eyes, both cheeks, and in the area of the Veteran's sideburns. He reported that about 70 percent of the facial area was affected. The evidence of record, however, reflects that the Veteran's atopic dermatitis affected his face prior to March 12, 2009. In August 2013, the Veteran noted that he had been making complaints regarding his atopic dermatitis during the year prior to March 12, 2009 and asserted that it was illogical to assume that the extent of his condition manifested on the date of his examination by Dr. D.L. Supporting his claim for an increased rating prior to March 12, 2009, on VA examination in April 2008, the Veteran reported that his skin disease had existed since 1971 and involved areas exposed to the sun, including the face and neck; although it did not include his hands. He reported exudation, itching, and crusting, but denied ulcer formation and shedding. He stated that his symptoms occurred intermittently, as often as three times a year, with each occurrence lasting one month. Over the past year, he had experienced two attacks. He reported using topical medication only over the past 12 months, and denied side effects from treatment. On examination, there were no signs of skin disease. The diagnosis was atopic dermatitis, eczematoid type, in remission. In an October 2008 letter, the Veteran reported that he had made many adjustments to his lifestyle to avoid flare-ups of his skin condition, and reported that a VA physician in Portland had told him to stop using cortisone cream around his eyes because of thinning skin and the development of dark circles. He reported applying creams to his eyelids and eye sockets twice a day to prevent cracking. He nevertheless indicated that he sometimes experienced flare-ups resulting in cracks in the creases on his eyelids. He added that, when he had a flare-up on his face, usually around the lower part of his ear, he could not shave. He stated that his flare-ups were uncomfortable, adding that "bad flare-ups can result in skin infections, the resulting lesions that sometimes ooze with a clear liquid look hideous." The Veteran reported that bad flare-ups usually occurred two to three times a year and less severe flare-ups averaged two to three times a month. In October 2008, the Veteran presented to his VA physician with a complaint of a flare-up of a rash on his face and feet. He reported using topical steroid creams, which usually helped. Examination revealed multiple pruritic erythematous papules in the periorbital areas, bilateral and left temporal/mandibular areas. There were also pruritic erythematous papules on the soles and dry yellowish keratinous papules. The Veteran was seen in the VA dermatology clinic the following month. He complained of chronic erythematous, pruritic papules in the soles, face, and inguinal areas. The Veteran stated that his symptoms were intermittent and worse in the winter months. He described marked itching with perspiration as well as eyelid dermatitis, for which he reported using hydrocortisone cream "for years." The Veteran reported tiny vesicular lesions along the fingers and lateral aspects of the palms and soles which would pop or desquamate and peel. He stated that he sometimes got painful fissures. He also reported inflamed follicles in the sideburn areas. He brought in photographs to demonstrate this reported "eczema flare." On examination, there was no facial rash, although there were faint pink papules on the preauricular cheeks, without active inflammation. There was no erythema of the eyelids, but the upper lids were roughened and the lower lids were somewhat darkened (noted to be possible allergic shiners). The Veteran also pointed out faint pink areas on his lower extremities where eczema lesions had previously been. The dermatologist's assessment was history and symptoms of atopic dermatitis, though no obvious findings on examination except somewhat darker skin on the lower eyelids; eyelid dermatitis, probable eyelid eczema; dyshidrotic eczema; and history of folliculitis on preauricular cheeks, questionable etiology. The Veteran was prescribed Hydroxyzine as well as several topical medications. In November 2008, the Veteran submitted photographs of facial skin lesions near his ears. He stated that these lesions had been treated with topical medication for three days and had already subsided by 40 percent. He reported that the lesions on his face tended to gather along his sideburns and run down the side of his face and under his jaw line, but never past the center of his cheeks. He added that the lesions occasionally extended to behind his lower ears, but the outbreaks never came across the front of his face. He reported that his eyelids itched and cracked during outbreaks. The above evidence indicates that, prior to March 12, 2009, the Veteran's service-connected skin condition, during flare-ups, affected his face, including his eyelids, cheeks, left temporal/mandibular area, and sideburn areas. While the condition was described as in remission by the April 2008 VA examiner and the dermatologist who evaluated the Veteran in November 2008 reported no obvious findings on examination except somewhat darker skin on the lower eyelids, the October 2008 treatment record documents multiple pruritic erythematous papules in the periorbtial areas, bilateral and left temporal/mandibular areas, consistent with the Veteran's reports. Importantly, the Veteran is competent to report flare-ups of his skin condition affecting his face, as this is the type of condition capable of lay observation. See Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009). The Board has considered that, in June 2008, the Veteran reported to a VA pharmacist that his skin condition was limited to the extremity area, specifically the elbows and knuckles. However, this statement is interpreted as indicating that, at the time he made that statement, the skin condition was limited to the elbows and knuckles, and does not mean that the condition did not, at other times, affect his face. In light of his reports of exudation, itching, and crusting (as made during the April 2008 VA examination), cracked skin and occasional oozing lesions (as reported in October 2008), and chronic erythematous, pruritic papules in various areas, including the face (as reported in November 2008) the Board finds that, during flare-ups, the Veteran's service-connected skin disability results in gross distortion in the reported areas of the face. Thus, during the period prior to March 12, 2009, the service-connected atopic dermatitis more nearly approximates gross distortion of three sets of features or paired sets of features (the area around the eyes, the cheeks, and the sideburns). Accordingly, an 80 percent schedular rating, pursuant to Diagnostic Code 7800, is warranted from February 21, 2008, the date of the current claim for an increased rating. The 80 percent rating, now assigned effective February 21, 2008, is the maximum schedular rating available pursuant to Diagnostic Code 7800. In exceptional cases where schedular ratings are found to be inadequate, extraschedular rating is for consideration. 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111 (2008); VAOGCPREC 6-96 (Aug. 16, 1996). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. The Board cannot assign an extraschedular rating in the first instance, but the Board has jurisdiction to review the denial of an extraschedular rating on appeal when the RO has previously referred an increased rating claim to the Director of Compensation and Pension, and the Director finds that an extraschedular rating is not warranted. Anderson v. Shinseki, 23 Vet. App. 423, 428-429 (2009); Barringer v. Peake, 22 Vet. App. 242 (2008). In compliance with the Board's February 2013 remand, the matter of entitlement to an extraschedular rating was referred to the Director, Compensation and Pension Service. In July 2013, the Chief of the Compensation Service denied an extraschedular evaluation for atopic dermatitis, evaluated as 80 percent disabling from March 12, 2009. Although the July 2013 decision suggests that the Compensation and Pension Service was considering entitlement to extraschedular rating only as of March 12, 2009, this is most likely simply due to the fact that this is the manner in which the issue was phrased in the Board's prior remand. Importantly, the evidence cited in the July 2013 decision includes Social Security Administration (SSA) records, which discuss the severity of the Veteran's condition both prior to and since March12, 2009. Because the July 2013 decision determined that "the totality of the evidence did not support the contention that the Veteran's service connected atopic dermatitis is so exceptional or unusual as to render the use of the regular rating schedule standards impractical" the Board finds that the decision effectively considered entitlement to extraschedular rating during the pendency of the appeal. Accordingly, and in light of the above determination that the schedular criteria for an 80 percent rating prior to March 12, 2009 have been met, the Board will address entitlement to an extraschedular rating throughout the pendency of the claim. The Veteran has asserted that he is unemployable as a result of his service-connected atopic dermatitis. He has also reported using numerous medications to treat this disability, resulting in negative side effects, in particular, drowsiness. During VA treatment in January 2008 the Veteran reported that had lost his last several jobs due to frequent sick leave. In his June 2008 notice of disagreement (NOD), the Veteran asserted that his sleep patterns and work performance were affected by his atopic dermatitis. In an October 2008 letter, the Veteran reported that he had made many adjustments to his lifestyle to avoid flare-ups of his skin condition. He stated that, in 2007, he began suffering from increased frequency of asthma and outbreaks of atopic dermatitis. He reported that it was too hot to wear long-sleeved shirts to hide his skin outbreaks, but he was too embarrassed to let customers see the scaly and sometimes scabby patches on his arm. In November 2008, the Veteran was prescribed Hydroxyzine as well as several topical medications to treat his skin condition. The following month he reported that he was experiencing side effects from Hydroxyzine, including drowsiness, blurred vision, headaches, and dry mouth. In another December 2008 letter, he asserted that he was unable to obtain gainful employment as a result of side effects, including drowsiness and dizziness, from Hydroxyzine. In his April 2009 letter, Dr. D.L. noted that Hydroxyzine restricted the Veteran's daily activities due to sedating properties. In May 2009, the Veteran's wife wrote that, because of Hydroxyzine, the Veteran fell asleep during the day if he was not actively involved in something. On VA examination in June 2010, the Veteran reported that his skin symptoms occurred intermittently, as often as eight times per month, lasting five days at a time. He reported 96 attacks during the past year and stated that, during a flare-up, the desire to scratch became unbearable and he scratched to the point of bleeding. He commented that this behavior was very awkward/embarrassing in work or social situations. The Veteran reported using Lidocaine every two hours, with side effects including dizziness and drowsiness. He also reported using Hydroxyzine four times a day, with side effects including dizziness, blurred vision, loss of balance, drowsiness, and loss of mental clarity. The Veteran stated that a regular regimen of Hydroxyzine maintained a fairly "flare free" environment, with flare-ups occurring once or twice a month with topical creams resolving his condition very quickly. He added that the frequency of topical cream application required numerous daytime breaks, which was difficult in a work setting. The Veteran also reported side effects of dizziness from two medications he took to treat asthma. The examiner remarked that the Veteran was unemployed, but his daily activity was limited due to his asthma. During his October 2010 hearing, the Veteran stated that he last worked in December 2007 and reported that it had become difficult to work due to his skin condition and asthma. He reported that he was unable to work due to drowsiness from Hydroxyzine. He added that his skin treatment regimen was "morning, noon and night" which had affected his lifestyle because he could not take a break. On VA examination in July 2011, the Veteran reported that, with a regimen which included three topical creams and Hydroxyzine, wrapping his feet in Saran wrap for 30 minutes twice a day, wearing gloves for 30 minutes twice a day, and showering and applying Vaseline all over his body before bed, he was able to control his atopic dermatitis quite well. However, a major issue he had was sedation from the Hydroxyzine. He stated that, after being laid off in December 2007, he built furniture on his own, but did not feel comfortable using a table saw on Hydroxyzine and stopped working because of the sedation. The impression was severe atopic dermatitis requiring multiple medications and oral Hydroxyzine. The examiner opined that the Veteran was unemployable due to the side effects of Hydroxyzine. The examiner added that, although he had very few lesions on examination, it did not mean that the Veteran did not have severe atopic dermatitis; rather, it was being controlled with numerous medications and extensive lifestyle changes. In regard to his asthma, the Veteran reported that this condition did not affect his ability to work. The examiner opined that the Veteran's employability was not significantly impacted by his asthma. SSA records reflect that the Veteran reported flares of atopic dermatitis in 2006 which required him to start wearing long sleeved shirts to work. He reported that his employer reduced his hours and he went to a different job in 2007 which had more flexible hours. The Veteran testified that this job ended because he was reluctant to commit to a full-time schedule. He described his dermatitis as being out of control when he subsequently attempted to work as a furniture builder. SSA records further document that the Veteran reported that, prior to starting Hydroxyzine, the flare-ups of atopic dermatitis prevented him from working. A July 2011 statement included in the SSA records reflects that the Veteran reported worsening atopic dermatitis in 2007 which caused him to stop working. The above evidence, in particular the July 2011 VA examiner's opinion that the Veteran was unemployable due to the side effects of Hydroxyzine, reflects that the service-connected skin disability is totally disabling. This is not contemplated in the schedular rating criteria. The Board has considered that the June 2010 VA examiner opined the Veteran's daily activity was limited due to his asthma; however, the Veteran clarified during the October 2010 hearing that he was unable to work due to drowsiness from Hydroxyzine and the July 2011 VA examiner opined that the Veteran's employability was not significantly impacted by his asthma. In addition to rendering him unemployable, the side effects of medications prescribed to treat the service-connected skin disability have impacted the Veteran's daily life outside of employment. For example, in an August 2013 statement, the Veteran again reiterated the side effects of Hydroxyzine, in particular, drowsiness and stated that he was prone to involuntary scratching during sleep, so he took a higher dose of medication at bedtime to put him into a deep sleep and prevent scratching. However, as a result he did not awaken to normal stimuli and experienced nighttime incontinence. He added that he could not be left alone in the house while sleeping for fear that he would not awaken in case of emergency. The medical evidence of record documents the sedating effects of Hydroxyzine. Additionally, the extensive treatment regimen, which was described by the July 2011 VA examiner as requiring extensive lifestyle changes, is also not contemplated in the schedular rating criteria. While the Veteran was prescribed Hydroxyzine in November 2008, the pertinent evidence prior to this time also reflects that the service-connected atopic dermatitis resulted in marked interference with employment. As stated above, the Veteran reported in January 2008 that he had lost his last several jobs due to frequent use of sick leave. In a September 2009 VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, the Veteran's former employer indicated that he stopped working in December 2007 due to health and ongoing medical problems, concerns/issues. A second VA Form 21-4192, dated in October 2009, reports that the Veteran was not working because he did not meet job standards. These responses from the Veteran's former employer corroborate his report of marked interference with employment resulting from the service-connected skin disability. SSA records also include the Veteran's report of an inability to work due to flares of this service-connected disability prior to the initiation of treatment with Hydroxyzine. Accordingly, resolving any doubt in favor of the Veteran, the Board finds that the service-connected atopic dermatitis has been totally disabling since the date of the Veteran's claim, February 21, 2008. Therefore, a 100 percent rating is warranted on an extraschedular basis. 38 C.F.R. § 3.321(b). The Board recognizes that the decision above concluded that the schedular criteria for an 80 percent rating for atopic dermatitis, eczematoid type, were met for the period prior to March 12, 2009. However, the Board has determined that the rating criteria are inadequate to evaluate the Veteran's service-connected skin disability and has awarded a 100 percent extraschedular evaluation for the entire period since the February 21, 2008 claim. Such an award clearly represents the greater benefit to the Veteran and the lesser award is encompassed therein. ORDER A 100 percent extraschedular rating for atopic dermatitis, eczematoid type, is granted, effective February 21, 2008, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs