Citation Nr: 1416845 Decision Date: 04/15/14 Archive Date: 04/24/14 DOCKET NO. 06-38 489 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a skin condition of the bilateral feet, to include neurogenic dermatitis, diabetic microangiopathic disease, and neuropathic ulcers; and to include as secondary to the service-connected diabetes mellitus and posttraumatic stress disorder (PTSD), and to include as due to herbicide exposure. 2. Entitlement to service connection for a skin condition of the bilateral hands, to include neurogenic dermatitis and diabetic microangiopathic disease, and to include as due to herbicide exposure. WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J. J. Tang, Associate Counsel INTRODUCTION This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The Veteran served on active duty from August 1966 to August 1968. This case is before the Board of Veterans' Appeals (Board) on appeal of a February 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) in Huntington, West Virginia which denied the claims sought on appeal. The RO has denied service connection for neurogenic dermatitis of the bilateral feet and hands; however, the Board has broadened the claims under Clemons v. Shinseki, 23 Vet. App. 1 (2009), based on the medical evidence of record. In a May 2011 Board decision, the Board remanded the issues to provide the opportunity to present testimony at a hearing and to allow initial review of the newly submitted evidence by the agency of original jurisdiction (AOJ). In an August 2013 Board decision, the Board remanded the issues for further development and VA examination. In a January 2014 supplemental statement of the case, the RO continued the previous denials of the issues on appeal. The Veteran's VA claims folder has been returned to the Board for further appellate proceedings. In October 2009, the Veteran withdrew his Power of Attorney appointing private counsel to represent him. The Veteran testified before a Decision Review Officer (DRO) in September 2003 and before the undersigned Acting Veterans Law Judge in November 2010. These hearing transcripts have been associated with the claims file. All documents on the Virtual VA paperless claims processing system and the Veterans Benefits Management System have been reviewed and considered. FINDINGS OF FACT 1. The Veteran has neuropathic ulcers of the bilateral feet that are proximately due to and the result of the service-connected diabetes mellitus. 2. The Veteran's neurogenic dermatitis of the bilateral hands and feet is not related to service and is not proximately due to or the result of the service-connected diabetes mellitus and PTSD; and, the Veteran does not currently have diabetic microangiopathic disease of the bilateral hands and feet. CONCLUSIONS OF LAW 1. Entitlement to service connection for neuropathic ulcers of the bilateral feet, secondary to the service-connected diabetes mellitus, is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2013); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). 2. Entitlement to service connection for a skin condition of the bilateral hands and feet other than neuropathic ulcers, to include neurogenic dermatitis and diabetic microangiopathic disease, is not warranted, and service connection may not be presumed. 38 U.S.C.A. §§ 1110, 5107 (West 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Compliance with Board Remand In August 2013, the Board remanded the claim and directed the AOJ to afford the Veteran with a VA medical examination to determine whether the Veteran's neurogenic dermatitis was likely caused or aggravated herbicide exposure and/or by the service-connected diabetes mellitus. The Veteran was afforded a VA examination in October 2013, and a November 2013 addendum opinion was submitted thereafter. The VA examiner examined the Veteran, provided the requested opinions as to etiology, and provided complete rationale for all opinions expressed. The Veteran's claim was readjudicated in the January 2014 supplemental statement of the case. Therefore, the Board's prior remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist VA has met all the duty to notify and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2013); 38 C.F.R. §§ 3.159, 3.326 (2013). Duty to Notify When VA receives a complete or substantially complete application for benefits, it will notify the Veteran of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must also provide the Veteran with information regarding how VA determines effective dates and disability ratings. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre-adjudication VCAA notice by letter in September 2007, in which the Veteran was notified of how to substantiate his claim, information regarding the allocation of responsibility between the Veteran and VA, and information on how VA determines effective dates and disability ratings. The Board finds that VA has fulfilled its duty to notify. Duty to Assist VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claim. Service treatment records, relevant post-service treatment records, Social Security Administration records, and lay statements have been associated with the record. Further, during the appeal period the Veteran was afforded VA medical examinations in December 2007 and October 2013, and VA medical opinion were provided in May 2009 and November 2013. The examiners conducted thorough examinations and provided sufficient information to allow the Board to make an informed decision as to each claim. The Board finds that the examinations in conjunction with the opinions and other lay and medical evidence of record are adequate for purposes of determining entitlement to service connection. Because there is no indication in the record that any additional evidence pertinent to the claims is available and unassociated with the file, the Board concludes VA has satisfied its duty to assist. Service Connection A veteran is entitled to VA disability compensation for service connection if the facts establish that a disability resulted from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. When a veteran seeks service connection for a disability, due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A § 1154. Generally, to establish a right to compensation for a present disability, a veteran must show (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). To be considered for service connection, a claimant must first have a disability. Congress specifically limited entitlement for service-connected disease or injury to cases where the disease or injury has resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). So long as the Veteran had a diagnosed disability during the pendency of the claim, the service connection criteria requiring a present disability are satisfied. McClain v. Nicholson, 21 Vet. App. 319 (2007). A disability that is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). Analysis The Veteran contends that he has a skin condition of the bilateral feet and hands and sores on his feet due to military service. See April 2007 claim. In September 2009, the Veteran reported bleeding of the fingers and toes and that it had been present since service. The Veteran also submitted pictures of the lesions of the hands and feet in September 2009. In the July 2008 notice of disagreement, the Veteran states that his bilateral neurogenic dermatitis condition is not self-inflicted. The Veteran also contends that the dermatitis is a result of poor circulation [from diabetes mellitus]. On private examination in April 1984, the skin of the feet was completely clear, and a 3cm triangulate hyperkeratotic scaling lesion on the right palm was noted. Private treatment records from Dr. M. show a history of psoriasis of the hands. See e.g., October 1991 records. A private dermatology treatment note from Dr. B. in March 1996 shows that the Veteran complained of erythema, scaling and fissuring of the bilateral index fingers in October or November 1995. The Veteran was diagnosed with eczema. The Board notes that the Veteran has not been diagnosed with psoriasis or eczema during the appeal period. VA treatment records show that the Veteran has received ongoing treatment for skin conditions of the bilateral hands and feet. In June 2003, no deformity of the toenails was noted. In August 2003, the Veteran's nails were not mycotic but the left hallux nail tibial side was ingrown without infection. In April 2004, it is noted that the Veteran had erythematous toes with small nails with no discharge or infection. In an July 2004 VA podiatry note, the Veteran's nails were not mycotic. In April 2005, the Veteran was assessed with mycotic nails secondary to candida [fungal infection]. In October 2006, examination of the foot by the staff physician showed toes with no nails with wet looking erythematous nail beds with serious discharge consistent with microangiopathic disease of the toes. The Veteran was assessed with toe nail infection and diabetic microangiopathic disease. On several occasions from an April 2007 VA treatment record, the Veteran was assessed with diabetic microangiopathic disease resulting in finger and toe nail deformities. See e.g., April 2008, April 2009, January 2010 and December 2011 VA treatment records. In a December 2007 VA dermatology clinic note, the Veteran denied trauma to his fingernails and toenails. On examination, all toenails and fingernails were dystrophic with new nail seen at the bases. Blood and eschar were present. On the left foot second toe, confluent indurated plaque, violaceous with warmth was noted. The Veteran was assessed with neurogenic dermatitis (factitial disorder). The dermatologist stated that based on the "new" nail growing in and signs of trauma (blood), he believes the Veteran is inflicting this damage to his nails. VA treatment records show that the Veteran has also been treated for chronic non-healing diabetic ulceration of the left foot. See e.g., October 2008, December 2010, and October 2012 VA treatment records. Also, the records occasionally show diagnosis of ulcers on both feet. See e.g., October 2010 VA treatment records. The Veteran was hospitalized in December 2010, and his diagnosis on discharge included chronic non-healing ulcer. See December 2010 VA treatment record. In a September 2010 VA treatment note, a wound care nurse reported that the Veteran had a history of diabetic microangiopathic disease that affected both his toe nails and finger nails. The nurse instructed the Veteran not to pick at ulcers. It is noted that he has a strong history of sitting and picking at his finger and toe nails constantly. On VA examination in December 2007, the Veteran states he lost nails one at a time about ten years ago [1997]. He stated that since that time they try to grow back occasionally then begin to catch on pockets, etc. and the Veteran trims them back. He stated that he has symptoms of occasional open lesions to the feet and ankles. It is noted that the Veteran has been evaluated in podiatry and treated for diabetic ulcers. The examiner noted that during the interview, the Veteran stated, "If this claim goes through, they are going to owe me $600,000 - $700,000, so they aren't going to go down easy." On examination examiner noted avulsion of fingernails to the majority of fingers and toes. Nails were partially present on certain fingers and the toes. Regarding the nail beds, the examiner noted "eschar and dried blood at base - indicating likely trauma." A single open ulcerated lesion to the right medial malleolus and left second toe was also noted. The Veteran was diagnosed with traumatic avulsion of the nails - neurogenic dermatitis (factitial disorder). The Veteran was also evaluated by Dr. D. A., a VA dermatologist. Dr. D. A. stated that the Veteran's condition may have begun as a fungal infection, but the Veteran continues to pick at new growth and will not allow new growth to occur. On VA examination in October 2008 for diabetes mellitus, it is noted that during the course of the interview, the Veteran was almost constantly picking at his nails and the skin on his arms during the time he was in the examination room. In May 2009, a VA psychologist reviewed the claims file and submitted the opinion that it is less likely as not that the Veteran's traumatic avulsion of the nails-neurogenic dermatitis (factitial disorder) is caused by or related to his service-connected PTSD. The psychologist explained that there is no research to support the contention that PTSD can cause traumatic avulsion of the nails-neurogenic dermatitis, and VA progress notes raise the suspicion that the Veteran's avulsion of the nails is self-inflicted or related to diabetes or fungal infection. The psychologist stated that clinic exam, clinical observation, and review of the medical research do not support the Veteran's contention that PTSD is causing the loss of fingernails and toenails. On VA examination in September 2010 for diabetes mellitus, the skin examination showed plaque-like lesions over the tibia and an ulcer to the dorsum proximal to the fifth left toe. On examination of the left lower extremity, dystrophic nails and deep ulcer(s) were noted. On examination of the right lower extremity, dystrophic nails, thin skin, and superficial ulcerations were noted. Dystrophic nails and thin skin of the bilateral upper extremities were also noted. The examiner diagnosed the Veteran with skin ulceration, stated that it is a complication of diabetes, and reasoned that the Veteran's diabetes has been poorly controlled for the duration of the disease. On VA examination in October 2013, the examiner, a VA dermatologist, diagnosed the Veteran with neuropathic wounds with slowed healing secondary to diabetes mellitus. The Veteran was also diagnosed with traumatic avulsion of nails - neurogenic dermatitis (factitial disorder). The Veteran reported that he has loss of fingernails and toenails which will not grow back. The Veteran also reported sores of the bilateral feet. The Veteran stated that he developed sores around 2008 and ended up with osteomyelitis (for which he is service-connected). The examiner noted that the Veteran is routinely treated at the VA wound clinic for management of chronic neuropathic wounds. The examiner provided objective findings, including the absence of toe and finger nails, the presence of small open wounds on the bilateral feet, and the presence of eschar and dried blood at base of fingernail beds "indicating likely trauma." Regarding the Veteran's diagnosis of neuropathic wounds with slowed healing secondary to diabetes mellitus, the examiner opined that the condition is at least as likely as not proximately due to or the result of the Veteran's service-connected diabetes mellitus. The Veteran developed these lesions about five years ago. One of these lesions evolved into osteomyelitis [of the left foot]. The examiner explained that the Veteran has had recurrent ulceration and wounds of the feet which is a common secondary complication of diabetes. The examiner explained that diabetic wounds/ulcers also heal more slowly due to poor control of diabetes. Regarding a skin condition of the bilateral hands, the examiner referred to and reiterated the December 2007 VA opinion that diagnosed the Veteran was neurogenic dermatitis which is a factitious dermatitis/disorder, and stated that it is a self-inflicted skin condition often attributed to a psychological or interpersonal problem. In the November 2013 addendum opinion to the October 2013 VA examination, the examiner opined that the skin condition of the bilateral hands is less likely than not proximately due to or the result of the Veteran's service-connected diabetes mellitus or to herbicide exposure. The examiner reasoned that the Veteran's claimed fingernail condition (anonychia or loss of fingernails) is most likely secondary to neurogenic dermatitis which is a factitious dermatitis/disorder which is a self-inflicted skin condition. The examiner disagreed with the diagnosis given in the January 2010 and September 2010 wound clinic notes. The examiner stated that the diagnosis was given by a wound care nurse rather than a dermatology specialist. The examiner further stated that as noted in medical literature, diabetes is a cause of microangiopathy; however microangiopathy typically affects cerebral vessels, coronary vessels, retinal, renal, and nerve vascular (not typically that which supplies fingernails.) The examiner added that the examination of the Veteran is most consistent with trauma to the nail beds because there is evidence of new nail growth attempted but the presence of eschar and dried blood indicate trauma. The examiner added that anonychia (loss of nails) is a rare disorder, and diabetes is not a known cause thereof. The examiner cited medical literature in stating the possible causes of anonychia, which include self-inflicted trauma, but not diabetes mellitus. The examiner cited further medical literature to support her opinion. As a general matter, lay witnesses are competent to testify as to their observations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The Board has considered the Veteran's lay statements and acknowledges that the Veteran is competent to provide evidence regarding his loss of finger and toe nails. However, the determination regarding etiology of a disability is a medical matter beyond a layperson's comprehension. See Jandreau v. Nicholson, 492 F.3d 1372 (2007). Specifically, the determinations of whether the Veteran's skin condition of the bilateral hands and feet is etiologically related to exposure to herbicides in service, or is proximately due to or the result of diabetes mellitus and PTSD, require specialized medical training and is not susceptible of lay opinion. Because the record does not indicate that the Veteran has medical expertise, Board finds that the Veteran's contentions that his skin conditions of the bilateral hands and feet are related to his military service are of no probative value. Having considered the Veteran's statements as to his symptoms and observations, Board finds the objective medical results by the VA medical professionals are of significant probative value, as they performed medical examinations and based their opinions on the Veteran's medical history and lay statements. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (finding that the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Further, the medical opinions in the October 2013 and December 2007 VA examinations are of especially high probative value as they reflect the examiner's specialized knowledge, training, and experience regarding dermatology and the nature and etiology of the Veteran's skin conditions. Thus, the Veteran's lay opinions that his skin conditions of the bilateral hands and feet are related to his military service or to his diabetes mellitus and PTSD are outweighed by the medical findings. Neurogenic Dermatitis First, the Veteran has been diagnosed with neurogenic dermatitis of the bilateral hands and feet. Therefore, the first Shedden element, a present disability, is met. Second, the Veteran is presumed to have been exposed to an herbicide agent in service. Therefore, the second Shedden element, an in-service incurrence or aggravation of a disease or injury, is met. Third, the Board finds that the preponderance of the evidence shows that the Veteran's neurogenic dermatitis of the bilateral hands and feet is not related to service. The medical evidence shows that the Veteran is currently diagnosed with neurogenic dermatitis, which is a factitial disorder, and that the condition is self-inflicted. See e.g., December 2007 and October 2013 VA examinations. On the other hand, the Veteran argues that his neurogenic dermatitis is not self-inflicted. However, the medical findings show that the Veteran's neurogenic dermatitis is consistent with trauma. See e.g., December 2007 VA dermatology clinic note; October 2013 VA examination. Further, medical reports have noted objective observations and a history of the Veteran constantly picking at his fingernails and toenails. See e.g., October 2008 VA examination. The Board also notes that on VA examination in December 2008, the Veteran stated, "If this claim goes through, they are going to owe me $600,000 - $700,000, so they aren't going to go down easy." Evaluation of credibility may include factors such as monetary interest, bias, inconsistent statements, demeanor, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995). The Veteran clearly has a monetary interest in this claim. In light of the objective findings that the neurogenic dermatitis is self-inflicted, the Board finds that the Veteran's argument is not credible, and his contention is outweighed by the objective medical evidence showing that the condition is self-inflicted. The Board acknowledges that the Veteran has contended that the bleeding in his fingernails and toenails had been present since service. See September 2009 Vet statement. However, there is no medical evidence that indicates that the Veteran complained of or was treated for problems with his finger and toe nails until about 2003. Further, the Veteran has stated that his finger and toe nail condition did not begin until about 1997. See December 2007 VA examination. Because the Veteran's contention is inconsistent with the other evidence of record, the Board finds that the Veteran's contention that the finger and toe nail condition existed since service is not credible. Accordingly, the Board concludes that the condition did not begin until over two decades after discharge from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that it is proper to consider the Veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised). For these reasons, though the Veteran currently has neurogenic dermatitis and was exposed to herbicide agents in service, the Board finds that there is no relationship between the Veteran's current neurogenic dermatitis of the bilateral hands and feet and military service. Therefore, the third Shedden element, a causal relationship between the present disability and a disease or injury in service, is not met, and service connection for neurogenic dermatitis of the bilateral hands and feet is not warranted on a direct basis. 38 C.F.R. § 3.303. In addition, the Board finds that the preponderance of the evidence shows that the Veteran's neurogenic dermatitis of the bilateral hands and feet is not proximately due to or the result of the service-connected PTSD. The Board acknowledges that the October 2013 VA examiner stated that the neurogenic dermatitis is often attributed to a psychological or interpersonal problem. However, findings by a VA psychologist, who specifically took into account the Veteran's history, to include clinical observation, examination, and medical research, stated that the Veteran's neurogenic dermatitis is less likely than not caused by or related to PTSD. The Board finds this opinion to be of significant probative value as the psychologist based his opinion on the Veteran's medical history and has specialized expertise in psychology. In light of the May 2009 VA opinion, the Board finds that the preponderance of the evidence shows that the neurogenic dermatitis of the bilateral hands and feet is not proximately due to or the result of the service-connected PTSD. See 38 U.S.C.A. § 5107. Further, the Board finds that the preponderance of the evidence shows that the Veteran's neurogenic dermatitis of the bilateral hands and feet is not proximately due to or the result of the service-connected diabetes mellitus. The October 2010 VA examination and November 2013 VA opinion show that the skin condition of the bilateral hands is less likely than not proximately due to or the result of the Veteran's service-connected diabetes mellitus or to herbicide exposure. The Board finds these medical findings to be of significant probative value as the examiner examined the Veteran, based the opinion on the Veteran's medical history, and has specialized expertise in dermatology. In light of this opinion, the Board finds that preponderance of the evidence is against the finding that the Veteran's neurogenic dermatitis of the bilateral hands and feet is proximately due to or the result of the service-connected diabetes mellitus. See 38 U.S.C.A. § 5107. Because the preponderance of the evidence is against the finding that the Veteran's neurogenic dermatitis of the bilateral hands and feet is proximately due to or the result of the service-connected diabetes mellitus and the service-connected PTSD, service connection is not warranted on a secondary basis. 38 C.F.R. § 3.310. The Board notes that neurogenic dermatitis is not a disease listed under 38 U.S.C.A. § 1116(a)(2) or 38 C.F.R. § 3.309(e). Therefore, service connection for the Veteran's neurogenic dermatitis may not be presumed based on the Veteran's exposure to herbicides in service. 38 C.F.R. § 3.307(a). For the above reasons, and in light of the finding that the neurogenic dermatitis is self-inflicted, the Board finds that the preponderance of the evidence is against the claim for service connection for neurogenic dermatitis of the bilateral hands and feet. See 38 U.S.C.A. § 5107. Diabetic Microangiopathic Disease The Board acknowledges that the Veteran has been assessed with diabetic microangiopathic disease resulting in finger and toe nail deformities. See e.g., VA treatment records from October 2006 through December 2011. The Board notes that many of the assessments were copied and pasted from a April 2007 assessment. The Board also notes that none of the assessments were rendered by a dermatological expert. On the other hand, the Board finds that the November 2013 VA opinion is of significant probative value as the examiner performed an examination, based the opinion on the Veteran's history and lay statements, provided a thorough rationale to support the opinion, and has specialized expertise in dermatology. Further, the examiner provided specific reasons for why a diagnosis of diabetic microangiopathic disease is not warranted. For these reasons, the Board finds that the November 2013 opinion by the VA dermatology specialist to be of greater probative value than the VA treatment records that assessed diabetic microangiopathic disease. The November 2013 VA opinion does not support a finding that the Veteran has diabetic microangiopathic disease. Therefore, though VA concedes that the Veteran was exposed to herbicides in service, the first Shedden element, a present disability, is not met, and service connection for diabetic microangiopathic disease is not warranted. 38 C.F.R. § 3.303; see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Thus, the preponderance of the evidence is against the claim for service connection for diabetic microangiopathic disease of the bilateral hands and feet. See 38 U.S.C.A. § 5107. Ulcers of the Bilateral Feet The Veteran is diagnosed with chronic neuropathic ulcers of the bilateral feet. See e.g., September 2010 and October 2013 VA examinations. Further, the medical evidence shows that the Veteran's neuropathic ulcers are proximately due to or the result of the service-connected diabetes mellitus. For example, the September 2010 VA examiner opined that the Veteran's skin ulceration of the bilateral lower extremities is a complication of diabetes. Also, on VA examination in October 2013, the Veteran was specifically diagnosed with neuropathic wounds with slowed healing secondary to diabetes mellitus, and the examiner opined that the condition is at least as likely as not proximately due to or the result of the Veteran's service-connected diabetes mellitus. The Board notes that though chronic ulceration is found more often on the left foot, the medical findings reflect that ulcers have affected both feet during the appeal period. See e.g., December 2007 VA examination, October 2010 VA treatment records. For these reasons, the Board finds that the Veteran's neuropathic ulcers of the bilateral feet are proximately due to or a result of the Veteran's service-connected diabetes mellitus. Accordingly, service connection for neuropathic ulcers of the bilateral feet is warranted on a secondary basis. 38 C.F.R. § 3.310. ORDER Entitlement to service connection for neuropathic ulcers of the bilateral feet, secondary to the service-connected diabetes mellitus, is granted. Entitlement to service connection for a skin condition of the bilateral hands, to include neurogenic dermatitis and diabetic microangiopathic disease, and to include as due to herbicide exposure, is denied. ____________________________________________ NANCY RIPPEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs