Citation Nr: 1418131 Decision Date: 04/23/14 Archive Date: 05/02/14 DOCKET NO. 10-46 730 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to service connection for a skin disorder, other than epidermophytosis of the feet with recurrent tinea cruris, to include as due to herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from June 1967 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 decision by the RO which denied the benefits sought on appeal. In a Form 9 filing received in November 2010, the Veteran limited his appeal to the issue listed on the title page. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Although further delay is regrettable, the Board finds that the appeal must be remanded for a comprehensive dermatological examination to determine the nature and etiology of the Veteran's multiple skin disorders. The evidentiary record shows that the Veteran has been treated for various skin problems periodically since service and was examined by VA in August 2011, but this VA examination does not adequately address the nature and etiology of the Veteran's various skin problems. The Veteran contends that he was treated for chronic skin problems in service and has had recurring skin problems since his discharge from service. Historically, the service treatment records (STRs) show that the Veteran was treated for chronic cellulitis on his right forefinger and right ankle on several occasions over a four month period in 1969, had a cyst on his forehead drained in October 1969, and was seen for a chills, weakness and breaking out all over his body about a week prior to his discharge from service in March 1971. On the latter occasion, the Veteran had a fever and isolated pustule lesions on his face, truck and left lower extremity, and urethral discharge. The impression included pustule folliculitis. His symptoms were improved when seen the following day, though he still had some urethral discharge. By the fourth day, the rash was clearing and the urethral discharge was dissipating. On the seventh day, the facial and trunk lesions had improved, and the Veteran was removed from medical hold and discharged from service the following day. When examined by VA in June 1974, the Veteran reported a history of chronic skin problems on his feet since service and a rash on his groin for six months. The diagnoses included tinea pedis and tinea cruris. The Veteran made no mention of any other skin problems and no additional findings were noted. Similarly, VA outpatient records from 1979 to 1980 showed no complaints, treatment, abnormalities or diagnosis for any skin problems. The first evidence of a skin problem other than on his feet and groin, was on a VA outpatient note in June 2001. At that time, the Veteran reported a history of multiple lipomas since Vietnam, and said that he was service-connected for this. The report noted multiple, relatively small lipomas (2-3 cm) scattered over his legs, back and abdomen. When seen by VA in December 2001, the Veteran reported that he had one lipoma excised from his arm in 1997. A VA skin biopsy of the Veteran's chest in May 2002 revealed a basal cell carcinoma on the left chest area and a seborrheic keratosis on the right chest area. VA records showed numerous soft tissue masses palpable in the left upper back and left arm when seen in October 2008, and excision of a painful lipoma from his left chest area in January 2009. When seen by VA dermatology services in November 2009, the Veteran reported a two year history of pleuritic vesicles that developed in sun-exposed areas, involving his posterior neck, face and dorsum of the hands and arms. The assessment was possible porphyria cutanea tarda versus Grover's disease versus photosensitivity dermatitis form of lupus versus dermatitis herpetiforms. A punch biopsy of the sun-damaged areas in January 2010 revealed a hair follicle associated with suppurative and chronic inflammation and a perivascular and interstitial lymphohistiocytic infiltrate with neutrophils immediately adjacent to the hair follicle. The overlying epidermis showed mounds of parakeratosis that focally contain neutrophils. A GMS stained section was negative for fungal elements. A VA outpatient report, dated in December 2010, noted numerous excoriated lesions on the forearms, dorsum of both hands and on the posterior scalp area in various stages of healing. The assessment included impetigo. Although the Veteran was examined by VA in August 2011, to determine the nature and etiology of his skin problems, the Board finds that the examination does not adequately address all demonstrated skin disorders as to their nature and potential etiologies. In order to establish service connection, in general, there must be competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). While the Veteran is competent to testify to medical problems that are readily observable, such as chronic skin problems, he is not competent to the render a medical opinion as to the specific etiology of any current skin disorder. Here, the record shows that the Veteran has a current skin disorder, was treated for a skin disorder in service, and contends that he has had chronic recurring skin problems since service. However, given the multiple diagnosis for his various skin problems since service, the Board is unable to determine whether any of the diagnosed skin disorders was manifested in or is otherwise related to service. Where a medical examination does not contain sufficient detail to decide the claim on appeal, the Board must return the report as inadequate for evaluation purposes. Hayes v. Brown, 9 Vet. App. 67, 73 (1996); see also, Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (noting that once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Accordingly, the case is REMANDED for the following action: 1. The AMC should take appropriate steps to obtain any VA treatment records from January 2014 (most recent report of record) to the present, and any additional private treatment records since November 2010, and associate them with the claims file. All attempts to procure records should be documented in the file. If any records identified by the Veteran cannot be obtained, a notation to that effect should be inserted in the file. 2. The Veteran should be afforded a VA dermatological examination to determine the correct diagnosis and etiology of all chronic skin disorders. The claims folder and a copy of this remand must be made available to the examiner for review, and a notation to the effect that this record review took place should be included in the report. The examiner is requested to a) identify the diagnosis(es) of all chronic skin disorders and, for each diagnosed disorder, provide an opinion as to b) whether it is at least as likely as not that such identified skin disorder had its onset in, or is otherwise related to service, including the Veteran's presumed herbicide exposure in Vietnam, exposure to the sun in service and/or treatment for cellulitis, forehead cyst and postule folliculitis in service; c) whether it is at least as likely as not that such identified skin disorder has been caused by service-connected diabetes mellitus; OR d) whether it is at least as likely as not that such identified skin disorder has been aggravated by service-connected diabetes mellitus beyond the normal progress of the disorder. In providing these opinions, the examiner's attention is directed towards the following evidence: * the service treatment records reflecting treatment for chronic cellulitis of the right forefinger and right ankle on several occasions over a four month period in 1969, cyst drainage of the forehead in October 1969, and treatment in 1971 for fever and isolated pustule lesions on his face, truck and left lower extremity with urethral discharge assessed as pustule folliculitis; * the results from VA examination in June 1974; * a June 2001 VA clinic record reflecting the Veteran's report of a history of multiple lipomas since Vietnam with multiple, relatively small lipomas (2-3 cm) scattered over his legs, back and abdomen; * a May 2002 VA skin biopsy revealing basal cell carcinoma on the left chest area and seborrheic keratosis on the right chest area; * October 2008 VA treatment record reflecting excision of a painful lipoma from his left chest area; * a November 2009 VA dermatology consultation reflecting differential diagnoses of porphyria cutanea tarda versus Grover's disease versus photosensitivity dermatitis form of lupus versus dermatitis herpetiforms; * the results from a punch biopsy of sun-damaged areas in January 2010; and * a December 2010 VA clinic record reflecting an assessment of impetigo. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. A fully articulated medical rationale for any opinion expressed should be set forth in the examination report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If the examiner is unable to render an opinion because of a lack of specified evidence, the AMC should attempt to obtain that evidence and return the claims file to the examiner for completion of the opinion. 3. Following completion of the foregoing, the AMC should review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC should determine whether the examiner has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2013). 4. After the requested development has been completed, the AMC should readjudicate the claim. If the benefits sought on appeal remain denied the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).