Citation Nr: 1415835 Decision Date: 04/09/14 Archive Date: 04/15/14 DOCKET NO. 09-01 065 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to special monthly compensation (SMC ) on account of the loss of use of both hands due to service-connected atopic dermatitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty as a commissioned officer in the United States Army from December 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2008 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, denied SMC for loss of use of both hands due to service-connected atopic dermatitis. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Here, the Veteran has not raised, nor does the record show, a claim for TDIU. He reports full-time employment. Therefore, the issue is not before the Board at this time. In October 2010, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record and associated with the claims folder. The Board remanded the instant claim in December 2010 for further evidentiary development. Previously, in May 2012, the Board issued a decision that denied the appealed claim for SMC on account of the loss of use of both hands due to service-connected atopic dermatitis. Pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F. 3d 1312 (Fed. Cir. 2013), the May 2012 Board decision was identified as having been potentially affected by an invalidated rule relating to the duties of the VLJ that conducted the October 2010 Travel Board hearing. In order to remedy any such potential error, the Board sent the Veteran a letter notifying him of an opportunity to receive a new hearing and/or a new decision from the Board. Subsequently, in correspondence dated September 2013, the Veteran requested only to have the prior May 2012 decision vacated and a new one issued in its place. No additional hearing was requested. In a March 2014 decision, the Board vacated its earlier May 2012 decision in compliance with the Veteran's request. The decision below satisfies his request for a new decision. FINDINGS OF FACT The Veteran does not have loss of use of either hand as a result of service-connected atopic dermatitis which would be equally well served by an amputation stump at a site of election below the elbow with use of a suitable prosthetic appliance. CONCLUSION OF LAW The criteria for entitlement to special monthly compensation on account of loss of use of one or both hands have not been met. 38 U.S.C.A. §§ 1114 , 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102 , 3.159, 3.350, 4.63 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duty to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. As for the claim for SMC on account of the loss of use of both hands due to service-connected atopic dermatitis, the VCAA duty to notify was satisfied by a letter dated in June 2007. He was advised as to what was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. In a July 2007 letter, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With these letters, the RO effectively satisfied the notice requirements with respect to the issue on appeal, which was subsequently adjudicated in a September 2008 statement of the case, and readjudicated in a March 2009 and a June 2011 supplemental statement of the case. Under these circumstances, the Board finds that adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). VA also has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The RO associated the Veteran's service treatment and VA treatment records with the claims file. The Board remanded the claim for further development, which included additional VA outpatient treatment records not previously associated with the claims folder. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The Veteran was afforded two November 2007 VA examinations for the purpose of determining the nature and severity of his atopic dermatitis and whether he had loss of use of the hands as a result. In February 2009, a VA examiner provided an opinion to determine whether the Veteran had loss of motion of his fingers as a result of his service-connected atopic dermatitis or as a result of degenerative arthritis not related to his skin disorder. Significantly, after the Board's December 2010 remand of the claim for further development, the Veteran underwent additional VA examination of his hands in January 2011 to expressly address the loss of use question. 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 the above VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The November 2007 VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria. The VA February 2009 opinion thoroughly reviewed the evidence of record and provide an opinion based on the entirety of the medical evidence. The January 2011 examination was performed; and, after consideration of the physical findings, the Veteran's medical history, and his complaints and lay history, an opinion was provided on the loss of use question. A rationale was accompanied with the opinion. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Additionally, in October 2010, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned VLJ. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the October 2010 hearing, the undersigned VLJ related the issue on appeal. See Hearing Transcript (T.) at p. 2. Information was solicited regarding flare-ups of dermatitis affecting the use of one or both of his hands (see T. at p.3), pain, motor skills, and ability to use his hands (see T. at p. 6-9), effects on basic activities of daily living (T. at 10), and association with arthritis of the hands (T. at 12-14). Therefore, not only was the issue "explained in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence (other than his statement that he was going for follow-up treatment on his hands which had already shown improvement) that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's SMC claim. As such, the Board finds that, consistent with Bryant, the undersigned VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and the Board may now proceed to adjudicate the claim based on the current record. In view of the foregoing, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Special Monthly Compensation The Veteran is service connected for atopic dermatitis, evaluated as 60 percent disabling and major depressive disorder evaluated as 70 percent disabling. The Veteran is seeking special monthly compensation (SMC) for loss of use of both hands. SMC is payable in addition to the basic rate of compensation otherwise payable on the basis of degree of disability. See 38 U.S.C.A. § 1114 (West 2002 & West Supp. 2013); 38 C.F.R. § 3.350 (2013). SMC is payable at the (m) rate for, among other things, anatomical loss or loss of use of both hands as the result of service-connected disability. 38 U.S.C.A. § 1114(m); 38 C.F.R. § 3.350(c)(1)(i). Loss of use of a hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. §§ 3.350(a)(2); 4.63 (2013). The Veteran asserts that he has loss of use of both hands as a result of his service-connected atopic dermatitis. The Veteran's hands are not amputated. He states that the slightest movement of his hands causes them to crack and bleed and this requires him to wear gloves so that he does not bleed on individuals he comes in contact with or documents that he handles. He complains of pain in his hands, loss of sensation in his fingertips, and difficulty with daily activities which require manipulation with his hands. He testified at his October 2010 Travel Board hearing that he was unable to grab, grasp, or carry things without his hands cracking and bleeding. VA outpatient treatment records from August 2006 to February 2007 were obtained and reviewed. In August 2006, a physical examination showed generalized xerosis and scaly lichenified plaques. There was also mild keratoderma of the palms. He was also given Lubriderm as an emollient. In September 2006, the Veteran was seen for a follow-up of his atopic anemia and he complained of headaches and nausea on Cyclosporin. He reported improvement of the fissures of the hands but reported burning with Lachydrate. Physical examination showed marked generalized xerosis and white scaly lichenified plaques involving the majority of his body with mild ectropion and mild to moderate keratoderma of the palms. The assessment was atopic dermatitis. The Veteran was asked to decrease his usage of Cyclosporin by half. He related that he had been taking that amount because of medication shortage and he did not want to lower the dosage any further. In November 2006, it was noted the Veteran had fine scaly pink plaques, left hand worse than his right hand. He also had dystrophic thickened finger nails with keratoderma and fissures. In January 2007, his moderate to severe atopic dermatitis with hand dermatitis was considered stable. He related to the examiner that he was unsure as to what medications and how much he was presently taking. The Veteran underwent a VA dermatology examination in April 2007. He complained of peeling and itching, especially at night, causing loss of sleep, loss of use of hands functionally due to bleeding, cracking of hands, flaking, loss of fingernails and toenails, and he related that any pressure to the hands caused bleeding. He related no systemic symptoms. He used Aquaphor ointment, Protopic ointment, and Clobetasol cream. He used these topical medications with some relief. He was previously on Cyclosporin which caused some adverse reaction with stomach upset and headaches. It had since been discontinued. He also used Acitretin which caused headaches and had since been discontinued. Atopic dermatitis was shown on lower and upper extremities, face, and palms. The dermatitis was also on the torso and he had nail dystrophy. Scaly poor circumscribed lesions with accentuation of skin markings were shown. Marked severe dryness and peeling to areas of bilateral extremities, upper and lower including bilateral hand and nail beds were noted. Laboratory findings showed subacute spongiotic dermatitis. There was no evidence of psoriasis. Atopic dermatitis was to be clinically excluded. The pertinent diagnoses were atopic dermatitis and pruritis secondary to atopic dermatitis. The examiner indicated that the Veteran related that he wore rubber gloves to bed at night to prevent scratching. He had to constantly change his bed linens due to blood. His wife had to button his shirt. He was unable to apply any pressure to fingers/hands. He must have his wife cut his steak and open containers. Due to these limitations, he had difficulty using his hands. It was also noted that the Veteran worked as a registered investment advisor and had lost over 90 percent of his income due to inability to interact with clients in person due to the bleeding and severity of itching and loss of use of hands preventing shaking hands, personal contact with clients, and inability to apply pressure to fingers and hands. Writing was also noted to cause bleeding. VA outpatient treatment records from May 2007 to July 2007 were associated with the records and reviewed. In May 2007, the Veteran was seen in the VA dermatology clinic for follow-up atopic dermatitis. He was noted to be minimally better since his last visit, but still complained of pruritis which caused bleeding from scratching too much. He was trying to get as much sunlight as possible, as this helped relieve his pruritis. He was offered light therapy in Miami, but he was unable to go to Miami so frequently. He had a skin history of severe atopic dermatitis. The pain assessment was negative. Physical examination showed eczematous patches, more pronounced on the extremities and sparingly on the face. Both hands had severe xerosis and fissures of the fingertips. He had nail dystrophy with slight atrophy of the fingertips. The assessment was severe atopic dermatitis. He was instructed to continue his current regimen as he was seen to slightly improve. He was also instructed to get sunlight three times a week. The examiner stated that he was trying to hold off from starting systemic medicines at this point in his treatment. In July 2007, the Veteran was seen with longstanding atopic dermatitis, especially worse on both hands. He was complaining of cracking hands and bleeding. At the time of the examination, he was on topical steroids and Protopic. A limited skin examination revealed generalized erythema with overlying fine scale of the trunk and extremities. There were fissures on the dorsal aspects of the hands. The assessment was severe atopic dermatitis. Ultraviolet light A therapy was recommended. The Veteran underwent a VA examination in November 2007. He had been suffering with eczema for several years. He related that it was affecting his hands, particularly the fingertips and the palms of his hands. Whenever he tried to grip or apply any pressure to the fingertips or the palm of his hands, they began to bleed. He stated that he was unable to open bottles or cans. He had difficulty buttoning his shirts. He could not use kitchen utensils such as knives to cut meat and vegetables because the pressure made his hands bleed. He had no hospitalization or surgery of his hands. There was no history of any trauma. He had been taking multiple medications for this condition, none of which worked. He was also applying hand lotions to maintain softness and for prevention of the skin bleeds. He was noted to be right hand dominant. He related that his inability to grip anything with the hands was confining to his work. He worked as a financial advisor, 40 hours per week, using mainly computers and phones. He claimed to have lost no time from work in the last 12 months. The condition was not painful and there were no flare-ups of the condition. He used rubber-type gloves at night to sleep and applied lotion at night prior to applying the gloves to prevent the hands from bleeding. Physical examination showed generalized eczematous skin lesions all over his body. He had atrophic nails except for the right third, fourth, and fifth fingernails, which were in healthy condition. He had bloody scabs over the left thumb, middle finger, and the base of the right thumb. He had slight flexion contracture of the proximal interphalangeal joint and distal interphalangeal joint of all of the digits except the left thumb. He had full opposition of the thumb to all of the digits of both hands. Range of motion of the metacarpophalangeals was 0 degrees to 80/90 degrees. Proximal interphalangeal joint was from -10 degrees to 80/100 degrees. Distal interphalangeal joint was from -10 degrees to 60/80degrees. He had good sensation to very light pinprick. He was quite apprehensive about this because he thought his fingers were going to bleed. There was no bleeding. He had the ability to make a closed fist to the palm of the hand with the fingertips approximately 1 cm proximal to the transverse crease of the palm of the hand. He was able to write his name and open the round doorknob. He refused to unbutton his shirt as he believed his hands would bleed. His grip was weak, also because of apprehension. He had good pulling and twisting, which was also very light because of fear of bleeding. He had good dexterity. The flexion deformity of the digits did not interfere with the function of any of the digits. Repetitive motions of the digits had no effect on the Veteran's pain, fatigue, weakness, coordination, or lack of endurance. X-ray examination of the hands showed evidence of a flexion deformity of distal interphalangeal joints in the digits. There were also degenerative changes of the joints as well as the first metacarpophalangeal joint on the first, bilaterally. The diagnoses were degenerative arthritis of both hands, flexion contracture of the digits as described, and eczematous conditions of the skin of both hands. Opinions of whether there would be any further decrease of the range of motion during flare-ups could not be given because the Veteran had no flare-ups. Another VA examination performed that month showed the Veteran stated he was unable to use his hands to perform activities because the slightest pressure caused cracking of the skin and bleeding. He complained of constant itching and flaking of the entire body, especially the hands which bled with the slightest pressure. The skin biopsy showed subacute spongiotic dermatitis, no evidence of psoriasis, and atopic dermatitis should be excluded. The examiner stated occupational limitations were severe secondary to inability to write and use pens secondary to bleeding. VA outpatient treatment records from December 2007 to January 2008 were associated with the claims folder. In December 2007, the Veteran was seen with mild improvement compared to his last visit, and complained of generalized itching. In January 2008, he related a flare-up which was controlled by Protopic under plastic gloves. The assessment was atopic dermatitis, poorly controlled. He also was seen in the mental health clinic in January 2008. He was upset about his skin condition and was not able to care for his business because of his anxiety and depression related thereto. In February 2009, a medical opinion was solicited in connection with the Veteran's skin condition. A review of the Veteran's claims file was made and the examiner stated that it was his opinion that loss of motion of the Veteran's fingers (hand condition) was secondary to his degenerative arthritis of both hands. It was the examiner's opinion that the degenerative arthritis of the hands was not related to the Veteran's dermatitis or skin condition. Therefore, it was less likely as not that the degenerative arthritis of the hands was the result of the Veteran's skin condition. VA outpatient treatment records from February 2009 to October 2010 were obtained and associated with the claim folder. In February 20009, the Veteran was seen with severe atopic dermatitis, mainly on his hands. He tried Acitretin for two weeks which was stopped after side effects (dryness). He presented with some fissuring of the hands and requested refills of some medications. Physical examination revealed few scattered areas of fissuring and hyperkeratosis. He had generalized xerosis. He was provided refills for his medication, and told that the examiners may consider methotrexate in the future. In September 2009, the Veteran was seen with a history of severe atopic dermatitis and intractable pruritis. At the time of the examination, he was using moisturizers and had tried phototherapy for at least two months without any benefit. He presented for examination with regular xerosis and pruritis, but not worse than in the past. He was hesitant to try any systemic therapies. Physical examination revealed severe generalized xerosis and widespread eczema with occasional fissuring on hands and fingers. A trial of Pramosone was recommended. The Veteran was seen in November 2009 with complaints of chronic skin pain with continuous itching and bleeding. He was continued on his current therapies. In August 2010, he was seen with a history of severe atopic dermatitis and intractable pruritis. He had fissures on the dorsum of the fingers. He was continued on his current regimen. In October 2010, there was reported improvement in his skin condition with the initiation of Prednisone and more potent topicals. His worst areas remained his hands, feet, and lower legs. The itching was much improved. The assessment was severe atopic dermatitis. The plan was to continue Prednisone on a tapered dosage, continue the use of his topicals, to include Crisco shortening on the most severe areas, use of cyanoacrylic adhesive liquid bandages to fissures as needed, and after discussion of systemic antibiotics for possible subclinical infection, the Veteran declined this treatment. In October 2010, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. He testified that his hands, at the time of the hearing, were in better than normal shape. He stated that he went to VA on an emergency basis at the beginning of the month and was given steroids for the entire month of October. He stated that he was also provided steroid creams that he had been using on a regular basis. He related that his hands were very infrequently in good shape. While on heavy doses of steroids, he described his hands as both having significant lesions, open sores, discoloration, scabby, discolored nails, with an incredible amount of swelling. He related that he was barely able to extend his fingers, and if he did, blood would shoot out from his hands. He related that he was able to grab, grasp, and carry things, but his hands would bleed as a result. He also testified that if he attempted to turn a door knob or opened a container, he would experience pain and bleeding. He related that he had feeling in his fingers, but he was unable to button a shirt (limited fine motor skills). He also testified that he had a stock brokerage firm which barely made money because of his inability to interact with people because of the conditions of his hands. He stated that his wife assisted him in buttoning clothing, he wore slip on shoes or clothing with Velcro. However, he testified that he was able to attend to activities of daily living and able to attend to his wants of nature without assistance. VA outpatient treatment records show that the Veteran was seen in November 2010 following a two week course of Prednisone. The itching was well controlled but his hands continued to be a significant problem. Examination revealed less erythema and scaling of the lower extremities. There was diffuse scaling and some fissuring of the dorsal surface of the hands. In December 2010, the Veteran indicated that the itching had decreased somewhat with the use of topicals. His hands were the more affected area and he needed a refill of his medication. There was also improvement in the pruritis. In February 2011, he reported that there was some improvement in his hands. Pursuant to the Board's remand, the Veteran underwent a VA examination in January 2011. He complained of decreased use of his hands due to cracking and bleeding of the skin. He wore gloves daily to keep lubrication in and to minimize the cracking and bleeding. He related that sometimes he had to use his wrists and forearms to pick things up due to the painful cracking and bleeding of his hands. He was treated with topical and oral medication, to include corticosteroids. Physical examination revealed that the Veteran had diffuse scaling, erythema, scabs and fissuring over 40 percent of his body. His hands had severe, deep fissuring. He had a full range of motion and effective function in terms of grasping and manipulation. There was no evidence of psoriasis. The diagnosis was atopic dermatitis. The examiner stated that the Veteran would not benefit from amputation stump at the election site below the elbow with the use of a suitable prosthetic appliance. She observed that the Veteran indicated that his work as a registered investment advisor did not require the use of his hands. His usual activities of daily living were severely affected as he required constant lubrication to his skin which limited his movement and had him using gloves to be able to use his hands. With such in mind, the examiner felt that an amputation would present the Veteran with a disability far greater than his current functional impairments. Color photographs of the Veteran's hands were submitted, which visibly demonstrate that the state of the Veteran's skin and fingernails on both hands are consistent with their clinical descriptions as presented in the examination and treatment reports discussed above. In consideration of the evidence of record, the Board finds that the Veteran does not have loss of use of either hand as a result of service-connected disability. The evidence shows that the Veteran's atopic dermatitis impairs function of his hands as to fine motor skills such as buttoning a shirt. He also has bleeding when attempting to perform some activities such as gripping, grasping, and carrying things. This is also apparent given the schedular ratings that have been assigned for his service-connected skin disability. As a result of the December 2010 remand and additional January 2011 VA examination, service connection was granted for flexion contractures of both hands and awarded a 20 percent rating for each hand. VA examination reports, VA treatment records, and lay statements from the Veteran reflect that the skin disability causes bleeding, and on occasion, complaints of pain were made. The Veteran's skin disability also affects his ability to manipulate his hands and fingers when undertaking tasks. Nevertheless, the evidence does not show that the Veteran's service-connected disabilities result in loss of use of either hand for VA purposes. He is able to perform many tasks and uses gloves in order to prevent any bleeding to get on documents he may handle. He stated that he was unable to use a pen or pencil, and according to one VA examiner, this made his occupational limitations severe. However, during another VA examination, he was able to use a pen to sign his name and it was noted that he mostly used phones and computers in connection with his work. During his November 2007 VA examination, he was noted to have good dexterity, good pulling and twisting techniques, and although his grip was weak, the examiner stated that this was caused by his apprehension. During his most recent January 2011 VA examination, he informed the examiner that he did not require the use of his hands to perform his occupation. He had full range of motion of his hands and effective function in terms of grasping and manipulation. Although he has reported that there were some problems with fine motor use and his wife had to help him button shirts and cut his meat, his hands did not affect his activities of daily living and he was able to attend to the wants of nature independently. As noted previously, the regulations provide that loss of use of a hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow with use of a suitable prosthetic appliance. The VA treatment records and November 2007 VA examination reports and February 2009 VA opinion addressed the impairment caused by the Veteran's service-connected skin disability. More importantly, the January 2011 VA opinion squarely indicated that the Veteran would not benefit from an amputation stump at the site of election below the elbow with use of a suitable prosthetic appliance. The examiner specifically stated that this would present the Veteran with a disability far greater than his current functional impairment. The record still shows the ability to grasp, manipulate, and grab with his hands. Thus, the evidence shows that the Veteran retains some function in the hands, even if some of the function is limited. It is important to note that the Veteran testified that he had been seen by VA on an emergency basis the month of the hearing in October 2010. He related that his hands had shown improvement and that he was scheduled to be seen by VA the day after the hearing for a follow-up. The Board remanded the matter to obtain any additional VA treatment records. As noted above, the follow-up VA treatment records of November 2010 and thereafter were obtained and showed an improvement in the Veteran's atopic dermatitis. Crucially, none of the medical evidence obtained during the course of this appeal has shown that he has loss of use of the hands based on the evidence of record. Indeed, by his own admission, the Veteran testified at his hearing that he had experienced an improvement in his overall condition. Without sufficient evidence showing that the Veteran's service- connected skin disability causes such functional loss that he would be equally well served by amputation and the use of a prosthetic appliance, SMC on account of the loss of use of both hands (or one hand) is not warranted. See 38 U.S.C.A. § 1114; 38 C.F.R. § 3.350 . The Board has considered the Veteran's statements that he has loss of use of both hands due to his service-connected skin disability. In rendering a decision on appeal, the Board must 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. See 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. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter 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"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, he is not competent to identify a specific level of disability of his level of use of his hands due to his service-connected atopic dermatitis, according to the appropriate rating criteria. Such competent evidence concerning the nature and extent of the Veteran's level of use of his hands due to his service-connected atopic dermatitis has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings address the criteria under which SMC is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable and the appeal is denied. ORDER SMC on account of the loss of use of both hands due to service-connected atopic dermatitis, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs