Citation Nr: 1340877 Decision Date: 12/11/13 Archive Date: 12/20/13 DOCKET NO. 10-35 472 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to an increased rating in excess of 10 percent for a skin disorder. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from September 1971 to November 1986. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. The Veteran testified at December 2011 Board Travel Board hearing. The hearing transcript has been associated with the claims file. The Board remanded the case in January 2013 for additional development that included a request to obtain updated VA treatment records and for a VA examination to address the increased rating claim. This was accomplished, and the Board finds that it may proceed with a decision at this time. See 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 (Fed. Cir. 2002). FINDING OF FACT For the entire rating period, a service-connected skin disorder has been manifested by dermatitis with itching and burning of the skin and areas of hypopigmentation affecting less than 20 percent of the entire body, and less than 5 percent of exposed areas with no more than topical therapy required for treatment. (CONTINUED ON NEXT PAGE) CONCLUSION OF LAW For the entire rating period, the criteria for an increased disability rating in excess of 10 percent for a skin disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7806 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO issued a June 2010 preadjudicatory notice letter to the Veteran which met the VCAA notice requirements. The Veteran was afforded VA examinations in June 2010 and March 2013 to address his service-connected skin condition. 38 C.F.R. § 3.159(c)(4) (2013). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations of record are adequate for rating purposes, because they were performed by a medical professional, were based on a thorough examination of the Veteran, and reported findings pertinent to the rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that VA must provide an examination that is adequate for rating purposes). The Veteran has been afforded two separate examinations, and the Board finds that the more recent March 2013 examination adequately addressed symptoms related to the Veteran's skin disorder during an active phase, as well as treatment required during the course of the rating period. See Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994); Voerth v. West, 13 Vet. App. 117, 122-23 (1999). The Veteran's skin disorder is not shown to have affected his occupational functioning during flare-ups. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes VA treatment records, to include updated VA dermatology reports, VA examinations, and the Veteran's statements and testimony. Moreover, the Board finds that the RO substantially complied with the January 2013 Board remand directives in obtaining the March 2013 VA examination and updated VA dermatology reports. See Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. As the Board will discuss in more detail below, the Board finds that symptoms related to the Veteran's skin disorder have not changed in severity over the course of the appeal to warrant a staged rating. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Veteran is in receipt of a 10 percent rating for a service-connected skin disorder under Diagnostic Code 7899-7806. The Veteran has a current diagnosis of dermatitis, with a noted history of mycosis fungoides. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1208 (30th ed. 2003)(defining mycosis fungoides as a chronic or rapidly progressive form of cutaneous T-cell lymphoma.) A specific diagnostic code does not exist which sets forth criteria addressing mycosis fungoides. When an unlisted condition is encountered, it is permissible to rate that condition under a closely related disability as to which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. See 38 C.F.R. § 4.20 (2013). Accordingly, the Board has also considered whether an alternate rating under Diagnostic Code 7819 (benign skin neoplasms) is warranted. Under Diagnostic Code 7806 (dermatitis or eczema), a 10 percent evaluation is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation requires involvement of 20 to 40 percent of the entire body or of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum evaluation of 60 percent requires involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. A disability under Diagnostic Code 7806 may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Codes 7801 - 7805) depending on the predominant disability. 38 C.F.R. § 4.118. Diagnostic Code 7819 (benign skin neoplasms) provide that such disability is to be rated as a disfigurement of the head, face, or neck, (Diagnostic Code 7800), scars (Diagnostic Codes 7801- 7805), or based on impairment of function. 38 C.F.R. § 4.118. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2013). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Increased Rating Analysis After a review of all the evidence, lay and medical, the Board finds that, for the entire appeal period, the Veteran's skin disorder has been manifested by dermatitis with itching and burning of the skin, and areas of hypopigmentation affecting at least 5 percent, but less than 20 percent of the entire body, and less than 5 percent of exposed areas with no more than topical therapy required for treatment, consistent with a 10 percent rating under Diagnostic Code 7806. The Board finds that the evidence of record does not reflect a change in the severity of a skin disorder over the course of the rating period on appeal. The Veteran contends, during a December 2011 Board hearing, that he was diagnosed with mycosis fungoides in service, characterized by yellow spots on the body, requiring extensive treatment. The Veteran testified that his skin condition has "cleared up" since service, but indicated that his current skin condition is related to the past diagnosis of mycosis fungoides with nitrogen treatment. Service connection for a skin disorder has been in effect since November 1986, and the present April 2010 claim is for an increased rating for the service-connected skin disorder. Service treatment records show that the Veteran had a skin biopsy in August 1986 which revealed diagnoses of mycosis fungoides and chronic dermatitis in service. March 1987 post-service skin biopsies revealed mild dermatitis with no evidence of mycosis fungoides. While the Board finds that the Veteran is credible describing a history of mycosis fungoides with extensive treatment in service, where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board has, however, considered the past diagnosis of mycosis fungoides as well as current residuals of mycosis fungoides in evaluating the Veteran's current skin disorder. During a June 2010 VA examination, the Veteran reported a history of skin discoloration in service that had resolved. The VA examiner stated that the Veteran now had normal skin color, but he reported a burning sensation all over the body, including in the feet. There was no rash present on examination, and the Veteran denied fever, chills, weight loss, or skin cancer. Over the last 12 month period the Veteran had not used any medication on his skin. There was no pain or itching, and there was no restriction of activities and no restriction of employment due to any skin condition. A physical examination showed multiple seborhic keratoses on the upper back, but the remainder of the skin was clear. The VA examiner stated that there was no skin disorder identified on examination, and therefore, no percentage as to the affected area could be given. The VA examiner stated that the Veteran had no functional impairment due to any skin condition. A VA dermatology treatment report dated in October 2010 reflects a history of skin rash 23 years prior, but the Veteran stated that those skin lesions had resolved on their own. The Veteran identified "light spots" on the buttock from the prior skin lesions. A physical examination revealed scattered brown papule on the medial cheeks and forehead, the midline of the back, slightly erythamatous papules on the upper extremities bilaterally, and xerosis on the lower extremities bilaterally. The Veteran also had two or three hypopigmented patches on the left superior buttock. He was diagnosed with possible atopic dermatitis versus contact dermatitis of the arms with generalized pruritus as well as post-inflammatory hypopigmentation on the buttock. He was prescribed topical medications, to include triamcinolone cream, desonide, and lidex. He was seen for follow-up treatment in December 2010. The Veteran reported itching over his arms and legs but reported overall improvement with use of triamcinolone cream. A physical examination revealed scattered brown papule on the medial cheeks and forehead, the midline of the back, and xerosis and patches of dry skin on the upper and lower extremities bilaterally. He was assessed with xerosis of the arms and legs with general pruritus. A June 2011 VA dermatology treatment note shows that the Veteran reported a history of mycosis fungoides treated with nitrogen in 1986 which had resolved. The examiner stated that the only residual was some discoloration over the buttocks. The Veteran also had some discoloration present on the arch of the foot. A physical examination shows that the Veteran had several pigmented papules on the chest and back, but the skin was stated to be within normal limits. The skin on the upper extremities was within normal limits. The Veteran had mottled hyperpigmented macules on the soles of the feet and hypopigmented patches on the buttocks. The Veteran was assessed with a history of mycosis fungoides that had resolved, and the hypopigmented patches on the buttocks consistent with that diagnosis. The Veteran also had a possible history of dyshidrosis on the feet with pigmented macules. During a December 2011 Board hearing, the Veteran testified that he still had problems with itching and sometimes burning of the skin, and reported that he had been treated at VA dermatology twice. A March 2013 VA examination included a review of claims file and an interview of the Veteran. The Veteran was noted to have mycosis fungoides in service, diagnosed via biopsy, which was stated to have improved. The Veteran reported that a few years prior, the itching and burning sensation in the skin returned. At the time of examination, he was using a skin cream daily with some benefit. The Veteran also had hypopigmented patches present on the thighs, buttocks, and feet. A physical examination shows that the Veteran's skin condition did not cause scaring or disfigurement of the head, face, or neck. The Veteran was treated with an over-the-counter skin moisturizer. Treatment with corticosteroids or immunosuppressive drugs was not indicated. The VA examiner stated that visible skin conditions affected at least 5 percent but less than 20 percent of the entire body, and less than 5 percent of exposed body area. He did not have benign or malignant neoplasms present on the skin. Hypopigmented patches were present in the upper thighs, buttocks, and feet with no papules/pustules, or scratch marks. The Veteran reported subjective symptoms of itching and burning all over, but mostly present in the upper thighs and buttocks where he previously had lesions. The Veteran was diagnosed with residuals of chronic dermatitis related to the above findings. For the entire initial rating period, the Board finds that an evaluation in excess of 10 percent is not warranted for a skin disorder under Diagnostic Code 7806. 38 C.F.R. § 4.118. The evidence of record, both lay and medical, shows that the Veteran had a history of mycosis fungoides which resolved, and that present residuals include hypopigmented areas present on the upper thighs and buttocks as well as chronic dermatitis with symptoms of itching and burning. The Veteran's skin disorder is shown to affect at least 5 percent, but less than 20 percent of the entire body, and less than 5 percent of exposed areas with no more than topical therapy required for treatment, and the Board finds that this is consistent with a 10 percent rating under Diagnostic Code 7806. A higher 30 percent rating requires involvement of 20 to 40 percent of the entire body or of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more during the past 12-month period. 38 C.F.R. § 4.118 The June 2010 VA examiner indicated that the Veteran had no skin disorder present at the time of examination and, accordingly, did not identify the percent of total body affected by the service-connected skin disorder. The Board, accordingly, finds that a March 2013 VA examination provides more probative evidence with regard to the severity of the Veteran's skin disorder during an active phase. The March 2013 VA examination evaluated current residuals of mycosis fungoides, to include areas of hypopigmentation on the skin, as well as current symptoms related to chronic dermatitis, to include areas affected by itching and burning of the skin. See Ardison, 6 Vet. App. at 407-08 (holding that an examination during remission phase did not accurately reflect elements of disability that caused veteran to miss three to four months of work at a time). The Board finds that an additional examination is not necessary to evaluate variations in severity of the Veteran's skin disorder where his skin disorder is not shown to result in any functional limitations and does not affect occupational functioning. See Voerth v. West, 13 Vet. App. 117, 122-23 (1999) (holding that condition that became inflamed approximately twice a year for a few days did not require examination during flare-up). A March 2013 VA examiner stated that the Veteran's skin disorder did not affect his ability to work and, evidence of record indicates only minor variations in the extent of the Veteran's rash during an active phase over the course of the appeals period. The Veteran was shown to be asymptomatic at the time of a June 2010 VA examination. He was treated for dermatitis affecting the arms and legs, with hypopigmentation on the buttocks in October 2010 and December 2010. In June 2011 skin symptoms were present only on the soles of the feet and buttocks. While the Veteran has testified to a history of mycosis fungoides in service and has reported the same during VA examinations and dermatology treatment, both lay and medical evidence of record shows that mycosis fungoides has resolved. Hypopigmented patches on the skin, with itching and burning in areas of hypopigmentation were noted during the March 2013 VA examination and were considered by the VA examiner in evaluating the percent of body area affected by the Veteran's skin disorder. The Board finds, accordingly, that the March 2013 VA examiner's findings sufficiently address the current extent of the Veteran's skin disorder. While the Veteran reported generalized symptoms of itching and burning over the skin during VA examinations, he clarified during the March 2013 examination that symptoms were predominantly present in the upper thighs, buttocks, and feet where hypopigmentation was present and he only identified itching over areas affected by his rash during VA dermatology treatment. The Veteran has not been treated with systemic therapy any time during the rating period. Instead, VA treatment records and VA examinations reflect treatment with no more than moisturizers and topical corticosteroids. While topical triamcinolone cream and desonide prescribed by VA dermatology are corticosteroids, the Board finds that use of a topical corticosteroid does not approximate a rating based on "systemic therapy" under Diagnostic Code 7806. In that regard, topical treatments are not characterized as "systemic," as they do not reach cells through the bloodstream, and Diagnostic Code 7806 specifically provides for a 0 percent, noncompensable evaluation, based on treatment with "no more than topical therapy" required. Because the Veteran's skin disorder is not shown to involve 20 percent or more of the entire body or of exposed areas affected, and systemic therapy was not required for treatment at any time during the rating period, the Board finds that a higher 30 percent rating is not warranted under Diagnostic Code 7806. See 38 C.F.R. § 4.118. A disability under Diagnostic Code 7806 or 7819, may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Codes 7801 - 7805), or based on impairment of function. See 38 C.F.R. § 4.118. The Board finds that the Veteran's predominant disability most closely approximates a rating based on dermatitis and eczema under Diagnostic Code 7806, and is appropriately rated based on total body are affected. Because disabilities under Diagnostic Code 7806 are to be rated either as dermatitis "or" based on as a disfigurement of the head, face, or neck, "or" scars "depending on the predominant disability," the Board finds that the Veteran may not receive separate ratings in addition to currently assigned 10 percent rating under Diagnostic Code 7806 for the same disability. See 38 C.F.R. § 4.118. Additionally, despite the past diagnosis of mycosis fungoides, the Veteran is not shown to have benign neoplasms on the skin, or impairment of function due to his skin disorder. While residuals of mycosis fungoides or dermatitis are shown to result in areas of hypopigmentation of the skin, the Board finds that a higher evaluation would not be warranted under Diagnostic Codes 7800, where hypopigmentation is not shown to affect the head, face, or neck. See 38 C.F.R. § 4.118. Hypopigmentation was not identified on the head, face, or neck at any time, and the March 2013 VA examiner indicated that the Veteran's skin disorder did not cause scarring or disfigurement of the head, face, or neck. The Veteran's skin disability is not shown to approximate a rating based on the presence of scars that are deep; scars covering an 144 square inches or greater; scars that are unstable or painful; and his skin disorder is not shown to be otherwise disabling to warrant consideration under Diagnostic Codes 7801-7805. See 38 C.F.R. § 4.118. Both June 2010 and March 2013 VA examinations show that the Veteran's skin disability did not result in any functional impairment. For these reasons, the Board finds that a higher evaluation is not warranted under Diagnostic Codes 7800-7805 at any time during the initial rating period. For the reasons discussed above, the Board finds that an increased evaluation in excess of 10 percent for a skin disorder is not warranted. Because the preponderance of the evidence is against the claim for service connection for a bilateral shoulder disability, the claim must be denied, and the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation 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." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, 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 extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by a skin disorder, diagnosed as dermatitis with a past history of mycosis fungoides, is contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Code 7806 specifically provide for disability ratings based dermatitis, and the Board has considered whether alternate ratings are warranted based on benign skin neoplasms, disfigurement, scars, or limitation of function. In this case, considering the lay and medical evidence, the Veteran's skin disorder is manifested by hypopigmentation, itching, and burning affecting less than 20 percent of total body area with only topical treatment. Such symptoms and impairment are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). For these reasons, the Board finds that the schedular rating criteria is adequate to rate the service-connected skin disorder, and referral for consideration of an extraschedular evaluation is not warranted. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran, such as symptoms of itching and burning, are specifically contemplated by the criteria discussed above. His present skin disorder is not shown to result in any functional limitations or limitations on his occupation and daily life, and the Board finds that the assigned 10 percent evaluation addressing his overall impairment adequately addresses his current disability picture. In the absence of exceptional factors associated with the Veteran's disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER An increased disability rating, in excess of 10 percent, for a skin disorder is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs