Citation Nr: 1338339 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 07-00 382 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE 1. Entitlement to a rating in excess of 60 percent for chloracne. 2. Entitlement to an initial increased rating for acne scar, nose, disfiguring, rated as 10 percent disabling as of August 29, 2013. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from September 1969 to June 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which granted an increased rating of 60 percent for the Veteran's service-connected chloracne, effective January 13, 2006. The Veteran testified at a personal hearing before the undersigned Veterans Law Judge in March 2011. A transcript is of record. The Board remanded the claim in June 2011 and July 2013 for additional development. It has been returned for appellate review. The Board also remanded claims for service connection for a skin disorder of the feet and entitlement to a total disability rating for compensation based upon individual unemployability (TDIU). Those claims were granted in a September 2013 rating decision and are no longer before the Board. The Board notes that the September 2013 rating decision also granted a separate 10 percent rating for acne scar, nose, disfiguring, effective August 29, 2013. Since the assignment of that separate rating stems from the already-service-connected chloracne, it is part and parcel of the issue remaining before the Board, and the Board will consider both whether the Veteran is entitled to the separate rating prior to the August 29, 2013, effective date as well as whether he is entitled to a rating in excess of 10 percent. That issue has been included on the title page. The record before the Board consists of paper claims files and an electronic file known as Virtual VA. FINDINGS OF FACT 1. The currently assigned 60 percent rating for chloracne is more than and equal to the maximum ratings allowed under diagnostic codes 7829 and 7806, respectively, and there is no evidence of disfigurement of the head, face or neck with 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. 2. There is no evidence prior to August 29, 2013, that the Veteran had painful scarring on his nose. 3. There is no evidence as of August 29, 2013, that the Veteran has manifested three or four unstable or painful scars on his nose. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 60 percent for chloracne have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7806, 7817, 7829 (2007). 2. The criteria for an initial rating for acne scar, nose, disfiguring, is denied prior to August 29, 2013. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). 3. The criteria for an initial rating in excess of 10 percent for acne scar, nose, disfiguring, is denied as of August 29, 2013. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100%" based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO provided the appellant pre-adjudication notice regarding the claim for an increased rating for chloracne by a letter dated in March 2006. Additional notice was sent by a letter dated October 2006 and the November 2006 statement of the case. The claim was readjudicated in supplemental statements of the case dated August 2009, January 2011, December 2012, January 2013 and September 2013. Mayfield, 444 F.3d at 1333. In regards to the initial rating for acne scar, nose, disfiguring, which, in this case, is a downstream element of the claim for an increased rating for chloracne, the service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has obtained service treatment records; assisted the appellant in obtaining evidence, to include records from the Social Security Administration (SSA); afforded the appellant physical examinations; obtained medical opinions as to the severity of his disability; and afforded the appellant the opportunity to give testimony. There was also substantial compliance with the Board's June 2011 and July 2013 remands as additional VA treatment records were obtained, as were the Veteran's records from the SSA, and additional examinations were scheduled. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization throughout the adjudication of the claim. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claims at this time. Increased Rating Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When service connection has been in effect for many years, the primary concern for the Board is the current level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Yet, the relevant temporal focus for adjudicating an increased rating claim is on the evidence establishing the state of the disability from the time period one year before the claim was filed until a final decision is issued. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, staged ratings may be assigned if the severity of the disability changes during the relevant rating period. Service connection was originally granted for chloracne in a June 1997 rating decision, which assigned a 10 percent evaluation effective October 17, 1996, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board notes that the RO did not delineate what areas of the Veteran's body the chloracne affected. In an April 2004 rating decision, the rating was increased to 30 percent, effective September 24, 2002, pursuant to Diagnostic Code 7806 in conjunction with Diagnostic Code 7829. The Board notes that in the April 2004 rating decision, the RO indicated that the chloracne affected the Veteran's face, neck, arms, chest, legs, thighs, shoulders and lower abdomen. In the May 2006 rating decision that is the subject of the current appeal, the rating for chloracne was increased to 60 percent effective January 13, 2006. The RO utilized the same diagnostic codes assigned in the April 2004 rating decision. The Veteran contends that he is entitled to a rating in excess of 60 percent because his condition has worsened, no treatment seems to help, he has trouble sleeping at night, and the itching is intense. See VA Form 21-4138 received January 13, 2006. He reports that the chloracne is all over his face, back, arms, neck and legs. See September 2006 statement in support of claim. The Veteran also described a big knot on his left shoulder filled with pus in his December 2006 VA Form 9 and in a February 2011 VA Form 9, he reported that his face and arms were breaking out worse. See also January 2013 statement in support of claim. The Veteran testified in March 2011 that he became afraid when the chloracne began affecting his face and that the condition had gotten worse in the three months prior. He asserted that if the chloracne is affecting approximately 80 percent of his body, he should be entitled to an 80 percent disability rating. In terms of treating his condition, the Veteran testified that he just bears it as the medication he had been prescribed made him break out such that he had to stop taking it. The Veteran also showed a large red nodule on his left shoulder and testified that the condition was all over his back and was painful. The rating criteria used to evaluate the skin, namely 38 C.F.R. § 4.118, Diagnostic Codes 7800 through 7833, were amended during the pendency of the Veteran's claim, effective October 23, 2008. The October 2008 revisions are applicable only to claims filed on or after October 23, 2008. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). However, a Veteran rated under the previous criteria may request review under the revised criteria. In this case, the Veteran submitted his claim prior to 2008 and has not requested such consideration. As such, only the criteria in effect prior to October 23, 2008, will be considered. Diagnostic Code 7829 provides the rating criteria for chloracne. Prior to October 23, 2008, a noncompensable rating was assigned for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent rating was assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. A 30 percent rating was assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. A 30 percent evaluation was the maximum allowed under this diagnostic code. Prior to October 23, 2008, Diagnostic Code 7806 provided a maximum rating of 60 percent for dermatitis or eczema if more than 40 percent of the entire body or more than 40 percent of exposed areas were affected, or; if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. The currently assigned 60 percent rating is more than and equal to the maximum ratings allowed under diagnostic codes 7829 and 7806, respectively. Therefore, the assignment of a rating in excess of 60 percent is impossible under these diagnostic criteria. A note associated with both Diagnostic Code 7806 and Diagnostic Code 7829, prior to October 23, 2008, however, indicates that the service-connected disability should be rated as chloracne (Diagnostic Code 7829) or dermatitis or eczema (Diagnostic Code 7806), respectively, or disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. The only rating in excess of 60 percent provided prior to October 23, 2008, was under Diagnostic Code 7800, which provided a maximum 80 percent rating for disfigurement of the head, face or neck with 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. The eight characteristics of disfigurement, for purposes of evaluation under 38 C.F.R. § 4.118, are: (1) A scar five or more inches (13 or more centimeters (cm.)) in length; (2) A scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) The surface contour of the scar is elevated or depressed on palpation; (4) The scar is adherent to underlying tissue; (5) The skin is hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) The skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) There is underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); (8) The skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1) (prior to October 23, 2008). Since the note associated with both Diagnostic Code 7806 and Diagnostic Code 7829, prior to October 23, 2008, indicates that the rating should be based on the predominant disability, to include disfigurement of the head, face, or neck under Diagnostic Code 7800 or scars under diagnostic codes 7801, 7802, 7803, 7804, or 7805, the Board will also provide the rating criteria for diagnostic codes 7801 through 7805 prior to October 23, 2008. Prior to October 23, 2008, Diagnostic Code 7801 provided the rating criteria for scars other than head, face, or neck, that were deep, or that caused limited motion, based on the area of the scars. The minimum compensable rating of 10 percent required an area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent rating contemplated an area or areas exceeding 12 square inches (77 sq. cm.). A 30 percent rating contemplated an area or areas exceeding 72 square inches (465 sq. cm.). A 40 percent rating contemplated an area or areas exceeding 144 square inches (929 sq. cm.). Prior to October 23, 2008, Diagnostic Code 7802 provided a sole compensable rating of 10 percent for scars other than head, face, or neck, that were superficial and that did not cause limited motion in an area of 144 square inches (929 sq. cm.) or greater. Diagnostic Code 7803 provided a sole compensable rating of 10 percent for superficial, unstable scar. Diagnostic Code 7804 provided a sole compensable rating of 10 percent for a superficial scar that was painful on examination. Diagnostic Code 7805 indicated that other scars should be rated on limitation of function of the affected part. As noted in the Introduction, a separate 10 percent rating was assigned for acne scar, nose, disfiguring, in a September 2013 rating decision. It appears that this grant was made pursuant to the Board's notation in its July 2013 remand that because the Veteran's chloracne involves his head, face, and neck, a separate disability rating may be warranted under Diagnostic Code 7800. The Board notes, however, that the 10 percent rating assigned for acne scar, nose, disfiguring, was made pursuant to the current version of 38 C.F.R. § 4.118, Diagnostic Code 7804, effective August 29, 2013. Since the assignment of that separate rating stems from the already-service-connected chloracne, it is part and parcel of the issue remaining before the Board, and the Board will consider both whether the Veteran is entitled to the separate rating prior to the August 29, 2013, effective date as well as whether he is entitled to a rating in excess of 10 percent. Since the Appeals Management Center (AMC) has used the current rating criteria to evaluate that scar, the Board will consider both the criteria in effect prior to October 23, 2008, as well as the criteria currently in effect and utilized by the AMC. Under the current version of Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful; a 20 percent rating is assigned for three or four scars that are unstable or painful; and a 30 percent rating is assigned for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. The Board will now proceed with adjudicating the claims before it. It notes that the medical evidence in this case consists entirely of VA treatment records and several VA examination reports. The Board has reviewed the evidence in its entirety, but will only be discussing that evidence which is relevant to the Veteran's skin in relationship to areas other than his feet. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (the Board is presumed to have considered all evidence presented in the record; it is not required to specifically discuss every piece of evidence). This is so because the Veteran is now separately service-connected for a skin disorder of the feet. See September 2013 rating decision. A November 2005 dermatology clinic note reveals that the Veteran presented for follow up on chloracne. He reported a new "bump" on his lower back and was noted to be tolerating the treatment regimen of Doxycycline and Benzac wash without problem. Examination revealed follicular red papules on his back and one pustule with erythematous rim on the central lower back. There was also cystic scarring on the face, particularly the malar crescent. The assessment was chloracne. The Veteran underwent a VA skin diseases examination in March 2006. He reported recurrent and persistent inflammatory skin lesions for at least seven years. The lesions were sometimes so painful that he had difficulty sleeping and also could not perform in the workplace. Current treatment consisted of topical and systemic antibiotics as well as antihistamines for itching. Symptoms reported were painful, pruritic skin lesions. Physical examination revealed that the extent of the disease affected the face, trunk and extremities. The neck and hands were free of lesions. The examiner noted comedones of the face as well as inflammatory papules of the face, trunk and extremities. There were also numerous areas of post-inflammatory hyperpigmentation. At least 80 percent of the covered areas and 75 percent of exposed areas were involved. There were no associated systemic manifestations. The diagnosis was chloracne and the examiner noted that it appeared to be a very disabling condition. A May 2009 dermatology consult noted that the Veteran had greenish, exudative, eroded areas in the webspaces of his hands, with some follicular papules on the dorsal hands as well. The results of a culture were noted to be 2+ pseudomonas aeruginosa, not chloracne, and the assessment was pseudomonal skin infection of the hands. This condition also affected the Veteran's feet. Another VA skin diseases examination was conducted in August 2009. The Veteran reported that the course of his disease was progressive and constant. The Veteran was not currently using any treatment and there was no recent use of antibiotics. The Veteran reported that local lesions were pruritic and of burning sensation, and that his sleep was disturbed as a result. There were no constitutional symptoms. Physical examination revealed several healed and active lesions distributed throughout the body except face and upper extremities from forearm below and neck. There were otherwise healed lesions on the back, anterior chest wall and on the lower extremities. These areas were described as hyperpigmented and as large as a dime in size. There were some papular and slightly pustular areas but no evidence of active inflammation. 80 percent of unexposed areas and 75 percent of exposed areas were affected. No scarring or disfigurement was noted. The diagnosis was chronic acne. A September 2009 dermatology clinic note reveals that the Veteran reported a tender lesion on his right chest, which had been present for few weeks. He denied fever. Physical examination revealed a two centimeter fluctuant nodule on the right lateral chest and a four millimeter non fluctuant papule on the right forearm. The assessment was furuncle, right chest wall and arm. It was noted that the arm seemed to be improving but that the chest wall lesion was fluctuant. There was no surrounding cellulitis and the Veteran underwent an incision and debridement under local anesthesia to remove the two centimeter purulence. During a May 2010 VA general medical examination, the Veteran reported that he continued to have numerous scars on his face and papules on the body. The bacterial infection of pseudomonas involving the bilateral feet was noted. Physical examination, in pertinent part, revealed scars all over the face with pitting and closed papules on the bilateral upper extremities. The examiner noted that the scars and pot marks on the face were numerous and that there were several papules closed on the upper extremities and trunk. At least 80 percent of covered areas and 75 percent of exposed areas were involved. The diagnosis was chloracne and the examiner noted that the Veteran could function in an occupational environment. A July 2010 emergency department note reveals that the Veteran was seen with complaint of pruritic rash on his right buttock and thigh for about three days. He reported some burning sensation but denied new food, new medication, using new products, shortness of breath, chest pain, fever, and/or chills. Physical examination was positive for erythematous base vesicles on the right buttock/thigh area. The clinical impression was herpes zoster, not chloracne. An August 2012 primary care physician note contains an impression of acne, diffuse on face. There were no complaints noted by the Veteran nor physical examination of his skin. A September 2012 dermatology consult note reveals that the Veteran was seen with complaint of worsening comedones on his face. He had tried several topical agents in the past without efficacy. He also complained of an abscess on the left upper thigh. The Veteran denied fever/chills, malaise and weight loss. Physical examination revealed multiple comedones on the nose, superior malar cheeks, and posterior ears; multiple hyperpigmented scars on the trunk; and a two centimeter nodule with central pustule on the left upper thigh. The assessment included chloracne and furuncle. The Veteran underwent a VA skin diseases Disability Benefits Questionnaire (DBQ) in November 2012. In pertinent part, a diagnosis of chloracne was provided. The Veteran reported that he got lesions on his face, back, anterior trunk (primarily the chest), and upper and lower extremities. He indicated using medication daily for the condition but still had lesions present from time to time. The examiner noted that chloracne affected the Veteran's face, extremities and trunk with multiple small, discolored lesions. No tissue loss was noted. There were no systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma). The examiner noted that the Veteran had been treated with oral or topical medications in the past 12 months, specifically Cipro, an oral medication, for the condition affecting his feet. Topical medication for chloracne was also noted as being constant/near-constant. There had been no treatment or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. Physical examination revealed that chloracne affected 40 percent or more of the face and neck and affected body areas other than the face and neck. The examiner noted discolored (hyperpigmented) lesions on the back, anterior trunk and upper and lower extremities. No tissue loss was noted. Approximately 75 percent of uncovered skin and 60 percent of covered area was affected. The Veteran had small comedones noted to the face with no pustules or papules on any body surface. The skin condition did not impact his ability to work. A December 2012 dermatology clinic note reveals that the Veteran was seen for follow up for chloracne. Physical examination revealed multiple comedones on the malar cheeks, chin, and posterior ears; and rhinophymatous change on the nose. The assessment was chloracne. Pursuant to the Board's July 2013 remand, the Veteran underwent VA skin diseases and scars/disfigurement DBQs in August 2013. During the former, the Veteran was noted to now have or have had the following skin conditions: eczema; tinea; chloracne and rhinophyma. In pertinent part, the Veteran described skin lesions of the face, neck, trunk, left axilla and, occasionally, the anterior surface of the thighs. The examiner noted that tinea barbae, rhinophyma and chloracne caused scarring or disfigurement of the head, face or neck. The Veteran did not have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma). He had been treated with oral or topical medications in the past 12 months for chloracne. The Veteran had used Tretinoin, an immunosuppressive retinoid, for 6 weeks or more, but not constantly. Doxycycline, an oral medication, and several topical medications were also noted. Of the four reported, all but one had been used for more than 6 weeks but not constantly. The Veteran had not had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. Physical examination revealed that chloracne affected the face and abdomen; that tinea affected the face, feet, and likely posterior trunk; and that rhinophyma affected the nose. Eczema was noted to affect five to less than 20 percent of the Veteran's total body area and none of his exposed area. Infections of the skin were noted to affect five to less than 20 percent of the Veteran's total body and exposed areas. The examiner reported that the Veteran had a reticular pattern of hyperpigmentation of his back with scattered follicular lesions, likely related to prior tinea versicolor and, perhaps, acne. He also had a subcutaneous nodule in the left axilla consistent with a non-acute blockage of a sweat gland. None of the Veteran's skin conditions impacted his ability to work. During the scars/disfigurement DBQ, the Veteran was noted to have one or more scars anywhere on the body, or disfigurement of the head, face, or neck, but no scars on the trunk or extremities (regions other than the head, face or neck). The examiner indicated that the Veteran had acne scarring of the nose, cheeks and perioral areas. None were painful or unstable, with frequent loss of covering of skin over the scar. They were too numerous to count. The surface contour was elevated on palpation, but there was no depression, adherence to underlying tissue, or missing underlying soft tissue. There was also no abnormal pigmentation or texture of the head, face, or neck. The examiner noted that there was there gross distortion or asymmetry of facial features or visible or palpable tissue loss located only on the nose. More specifically, there was rhinophyma and scarring of the nose progressive over the past 10 years when compared with ID pictures the Veteran had with him that day. The scars did not impact his ability to work. The preponderance of the evidence does not support assigning a disability rating greater than 60 percent for the Veteran's service-connected chloracne at any time during the pendency of this appeal. The Board acknowledges that the August 2013 VA skin diseases examiner noted several skin disorders in addition to chloracne affecting the Veteran, to include eczema, tinea, and rhinophyma. The examiner also indicated, however, that tinea barbae and facial acne were noted in the Veteran's service treatment records and that the post-discharge skin conditions, to include the tinea-related problems, are related to the acne, bacterial, and tinea conditions noted in service. Given that these conditions have been linked to service, the original grant of service connection for chloracne did not delineate what areas of the Veteran's body the chloracne affected, and a subsequent (April 2004) rating decision indicated that the chloracne affected the Veteran's face, neck, arms, chest, legs, thighs, shoulders and lower abdomen, the Board will assume that the eczema, tinea, and rhinophyma noted by the August 2013 VA examiner are part of the service-connected chloracne condition. The Board also acknowledges the Veteran's assertions regarding the various locations on his body that are affected by his skin disability, as well as its reported effects, and finds that his assertions are both competent and credible. As noted above, the assignment of a rating in excess of 60 percent is impossible under diagnostic codes 7806 and 7829 prior to October 23, 2008, and the only rating in excess of 60 percent provided prior to October 23, 2008, was under Diagnostic Code 7800. There is no evidence at any time during the appellate period, however, that the Veteran's service-connected chloracne results in disfigurement of the head, face or neck with visible or palpable tissue loss. Rather, the August 2009 and August 2013 VA examiners specifically noted the absence of disfigurement and the November 2012 VA examiner specifically noted the absence of tissue loss. There is also no evidence at any time during the appellate period of gross distortion or asymmetry of three or more features or paired sets of features. Rather, the August 2013 VA scars/disfigurement VA examiner specifically noted that only one facial feature, namely the nose, was affected by gross distortion or asymmetry. Lastly, there is only evidence of one characteristic of disfigurement, namely acne-related scarring with elevated surface contour on palpation, noted at the time of the August 2013 VA scars/disfigurement examination. Other than this, there is no evidence from the VA treatment records or VA examination reports that the Veteran manifested a scar on his face five or more inches in length and/or at least one-quarter inch wide at its widest part. Nor is there any evidence of a facial scar with depressed surface contour on palpation and/or adherence to underlying tissue; abnormal skin texture in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and/or indurated and inflexible skin in an area exceeding six square inches. Lastly, although post-inflammatory hyperpigmentation was noted at the time of the March 2006 VA examination, the examiner did not comment as to where this was manifested. Even assuming it was located on the Veteran's head, face or neck, there is no indication it was located in an area exceeding six square inches (39 sq. cm.). The Board notes at this juncture that scarring on various parts of the Veteran's body has been variably reported throughout the appellate period. See November 2005 dermatology clinic note (cystic scarring on the face, particularly the malar crescent); May 2010 VA general medical examination report (scars all over the face with pitting; numerous scars and pot marks on face); September 2012 dermatology consult note (multiple hyperpigmented scars on the trunk); August 2013 scars/disfigurement Disability Benefits Questionnaire (DBQ) (acne scarring of the nose, cheeks and perioral areas; too numerous to count; none painful or unstable with frequent loss of covering of skin over scar). It appears from the medical evidence that the active and healed lesions, nodules, papules, pustules, comedones and hyperpigmentation associated with the service-connected chloracne, not the scars, make up the Veteran's predominant disability. The Board must consider, however, whether separate ratings for the scarring noted on the Veteran's face and trunk would result in a combined rating in excess of 60 percent under Diagnostic Codes 7800 through 7805 (prior to October 23, 2008). As none of the scars were noted to affect function, the Board finds that Diagnostic Code 7805 is not for application. The Board acknowledges that the medical evidence related to the noted scars is not very detailed. Of the scarring noted, only the September 2012 dermatology consult note noted scarring in an area other than the face. Even assuming that the multiple hyperpigmented scars on the trunk noted in September 2012 comprised an area exceeding 144 square inches, which would support the assignment of the highest (40 percent) rating under Diagnostic Code 7801 prior to October 23, 2008, the Veteran would have to have ten compensable scars on his face in order to meet the criteria under 38 C.F.R. § 4.25 for a combined rating in excess of 60 percent. There is no indication, however, that other than the now service-connected disfiguring acne scar located on the Veteran's nose, any of the other scars located on the Veteran's face would merit the assignment of a compensable rating under the remaining applicable rating codes (7800, 7803, or 7804). This is so because none of the facial scars noted in November 2005 or May 2010 were noted to be disfiguring, superficial, unstable, or painful on examination and the August 2013 VA examiner specifically noted that the scarring on the Veteran's nose, cheeks and perioral areas was not painful or unstable. The Board has considered whether the Veteran is entitled to a higher rating for chloracne under Diagnostic Code 7817, which provides the criteria for exfoliative dermatitis (erythroderma) and was the only other diagnostic code prior to October 23, 2008, that provided a rating in excess of 60 percent. More specifically, a 100 percent disability rating was warranted when there is generalized involvement of the skin, plus systemic manifestations (such as fever, weight loss, and hypoproteinemia), and; constant or near-constant systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments, or electron beam therapy required during the past 12 month period. 38 C.F.R. § 4.118, Diagnostic Code 7817 (prior to October 23, 2008). The evidence of record shows that the Veteran's service-connected skin disability does not involve exfoliative dermatitis. Furthermore, there is no evidence that the service-connected skin disability results in systemic manifestations such as fever, weight loss or hypoproteinemia. In fact, the Veteran has consistently denied fever and weight loss. See September 2009 dermatology clinic note; July 2010 emergency department note; September 2012 dermatology consult note. Moreover, the examiners who conducted the November 2012 and August 2013 VA examinations specifically noted that there were no systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma). Based on the foregoing, a rating in excess of 60 percent pursuant to Diagnostic Code 7817 is not warranted for the service-connected chloracne. In regards to the now service-connected acne scar, nose, disfiguring, the Board notes that although scarring on the Veteran's face was noted on several occasions during the course of the appeal, see November 2005 dermatology clinic note (cystic scarring on the face, particularly the malar crescent) and May 2010 VA general medical examination report (scars all over the face with pitting; numerous scars and pot marks on face), it was not until a December 2012 dermatology clinic note that the Veteran's nose was specifically mentioned (rhinophymatous change on the nose). The August 2013 scars/disfigurement Disability Benefits Questionnaire (DBQ) expounded on this finding by noting rhinophyma and scarring of the nose progressive over the past 10 years when compared with ID pictures the Veteran had with him that day. It is important to note that the August 2013 VA examiner specifically noted that none of the scars on the Veteran's head, face or neck, to include the scarring on his nose, were painful or unstable. The preponderance of the evidence of record does not support the assignment of a 10 percent rating under Diagnostic Code 7804 prior to August 29, 2013. This is so because in the 10 years prior to this date, there was no indication from the VA treatment records or VA examination reports that the Veteran had painful scarring on his nose. Therefore, the Veteran did not meet the criteria for a 10 percent rating under Diagnostic Code 7804 in effect prior to October 23, 2008. The preponderance of the evidence of record also does not support the assignment of a rating in excess of 10 percent as of August 29, 2013. This is so because there is no evidence of three or four scars that are unstable or painful so as to meet the criteria for the next highest rating (20 percent) under the current version of Diagnostic Code 7804. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that neither the Veteran's service-connected chloracne nor his disfiguring acne scar on the nose, are so unusual or exceptional in nature as to render the respective 60 and 10 percent ratings inadequate at any time during the period on appeal. Both disabilities are evaluated under the Rating Schedule for the skin, the criteria of which is found by the Board to specifically contemplate the level of disability and symptomatology for both. 38 C.F.R. § 4.118. The Veteran's chloracne disability is manifested by subjective and objective evidence of pain and objective evidence of occasionally active lesions and scarring. The disfiguring acne scar on the nose is manifested by objective evidence of an elevated surface contour on palpation and progressive scarring. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the 60 and 10 percent disability ratings assigned. Ratings in excess of 60 and 10 percent are provided for certain manifestations of a skin disability, but the medical evidence of record did not demonstrate that such manifestations were present in this case. The criteria for the 60 and 10 percent disability ratings more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. ORDER A rating in excess of 60 percent for chloracne is denied. An initial rating for acne scar, nose, disfiguring, is denied prior to August 29, 2013. An initial rating in excess of 10 percent for acne scar, nose, disfiguring, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs