Citation Nr: 1605983 Decision Date: 02/17/16 Archive Date: 03/01/16 DOCKET NO. 08-18 442 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to a rating in excess of 10 percent for pityriasis versicolor, posterior chest with exfoliation of the palms. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from February 1967 to February 1970, February to March 1991, and from September 2004 to October 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. This case was previously remanded by the Board in September 2010, February 2014 and March 2015. The Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge in February 2010. A transcript of this hearing has been associated with the record. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless, electronic claims processing systems. FINDING OF FACT For the entire period on appeal, the Veteran's pityriasis versicolor has affected less than 20 percent of his entire body and the exposed areas, and has not been treated with systemic therapy or intensive light therapy. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for pityriasis versicolor have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.27, 4.118, Diagnostic Code 7899-7822 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In a claim for increase, the VCAA requires only generic notice as to 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, 1277 (2009). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a letter dated January 2007, sent prior to the October 2007 rating decision, advised the Veteran of the evidence and information necessary to substantiate his increased rating claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. VA also has a duty to assist the claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other relevant records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In the instant case, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this regard, the Veteran's service treatment records as well as post-service VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded VA examinations in April 2007, November 2009, March 2011, May 2014 and August 2015 in conjunction with the claim on appeal. He has not alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected pityriasis versicolor as they include interviews with the Veteran, reviews of the record, and full examinations, addressing relevant rating criteria. The Board further notes that when there is a history of remission and recurrent of a condition, the duty to assist encompasses the obligation to evaluate a condition during an active, rather than inactive phase. See Ardison v. Brown, 6 Vet. App. 405 (1994) (concluding that examination during remission phase did not accurately reflect elements of disability that caused the Veteran to miss three to four months of work at a time). Subsequently, the Court found Ardison was inapplicable where the Veteran's disability, in its recurrent state, did not affect his earning capacity and the worsened condition did not last more than a few days. Voerth v. West, 13 Vet. App. 117 (1999) (holding that condition that became inflamed approximately twice a year for a few days did not require examination during flare-up). In the present case, the Veteran reports outbreaks of symptoms related to his pityriasis versicolor occur in the summer months. As a result, in its March 2015 remand, the Board instructed the AOJ to schedule an examination in the summer, when the likelihood of a breakout was highest. Subsequently, the Veteran underwent a VA examination in August 2015. Thus, VA has fulfilled its duty with respect to providing an examination and is not required to conduct a new examination in this regard. This is especially true in light of the fact that the Veteran has not alleged, nor has the evidence of record shown, that the Veteran's pityriasis versicolor affects his earning capacity in any way. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's claim and no further examination is necessary. The Veteran also offered testimony before the undersigned Acting Veterans Law Judge at a Board hearing in February 2010. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to 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. Here, during the February 2010 hearing, the undersigned Acting Veterans Law Judge noted the issues on appeal. Additionally, testimony regarding the nature and severity of the Veteran's service-connected pityriasis versicolor, posterior chest with exfoliation of the palms was solicited, to include the type and frequency of the symptoms he experiences as a result of the disability, as well as the impact it had on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. As the hearing discussion raised the possibility that there were outstanding treatment records available and that the Veteran's disability may have worsened in severity, the undersigned subsequently remanded these issues for further development, as discussed below. Therefore, under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. As noted in the Introduction, the Board previously remanded this claim in September 2010, February 2014 and March 2015. The Board finds that the AOJ substantially complied with the remand orders such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); 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 (2002)). In the September 2010 remand, the Board directed the AOJ to obtain any outstanding VA records and schedule the Veteran for a VA examination to determine the nature of his skin disorder. The AOJ was then to readjudicate the Veteran's claim in a supplemental statement of the case. VA records were associated with the claims file and, in March 2011, the Veteran underwent a VA examination. The claim was then readjudicated in a March 2012 supplemental statement of the case. In February 2014, the Board again remanded the claim to schedule the Veteran for a VA examination. In this regard, the Veteran's representative asserted that the Veteran's skin disorder had worsened since his last VA examination. The Board found that, therefore, a new exam was warranted. The AOJ was to schedule an exam and then readjudicate the claim in a supplemental statement of the case. As noted above, the Veteran underwent VA examination in May 2014. A supplemental statement of the case was issued in October 2014. Finally, in the Board's March 2015 remand, the AOJ was directed to obtain any outstanding VA records and schedule the Veteran for a VA examination to determine the nature of his skin disorder. The AOJ was instructed to coordinate with the Veteran and schedule the examination at a time when his skin condition was in an active stage. Once an examination was completed, the AOJ was directed to readjudicate the claim in a supplemental statement of the case. Additional records were associated with the claims file and, in August 2015, the Veteran underwent a VA examination during an active stage of his disorder. The claim was then readjudicated in a September 2015 supplemental statement of the case. Thus, the Board finds that the AOJ has substantially complied with the September 2010, February 2014 and March 2015 remand directives such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disorders is duplicative or overlapping with the symptomatology of the other disorder. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board may consider whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's service-connected pityriasis versicolor, posterior chest with exfoliation of the palms (hereinafter, "skin disorder") is rated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7899-7822. The Board notes that hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. When an unlisted disease, injury, or residual condition is encountered, required rating by analogy, the DC number will be "built-up" as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the skin, and the last two digits will be "99" for all unlisted conditions. Then, the disability is rated by analogy under a DC to a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27. Under Diagnostic Code 7822, a 10 percent evaluation is warranted in cases where 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 are affected, or; systemic therapy or intensive light therapy was required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is assigned in cases where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy or intensive light therapy was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is assigned in cases where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, and constant or near-constant systemic medications or intensive light therapy were required during the past 12- month period. According to Diagnostic Code 7822, the Veteran's service-connected skin disorder may also be evaluated as disfigurement of the head, face, or neck (under Diagnostic Code 7800) or scars (under Diagnostic Codes 7801-7805), depending upon the predominant disability. During the pendency of the appeal, the Board notes that effective October 23, 2008, VA amended criteria for rating the skin so that it more clearly reflects VA's policies concerning the evaluation of scars. Specifically, these amendments concern 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 and apply to all applications for benefits received by VA on or after October 23, 2008. See Notice, 73 Fed. Reg. 54,708 (September 23, 2008). A Veteran previously evaluated under the previous criteria may request review under the revised criteria. Id. In the instant case, the Board notes that none of the evidence of record indicates that the Veteran's skin disorder causes scarring or disfigurement of the head, face, or neck. As such, consideration of the rating criteria based on disfigurement of the head, face, or neck (Diagnostic Code 7800) under the old or new criteria is not warranted. Additionally, none of the medical evidence indicates that the Veteran has scars from his skin disorder. Therefore, consideration of diagnostic codes for scars (Diagnostic Codes 7801-7805) under the old or new criteria is also not warranted. As such, the Veteran's skin disorder is appropriately considered under the criteria of Diagnostic Code 7822 for papulosquamous disorders, which has remained unchanged. The Veteran's VA treatment records from 2006 show a topical cream was prescribed to treat his skin disorder. In April 2007, the Veteran underwent a VA skin examination. At that time, his service-connected pityriasis versicolor was found to be affecting only the palms of his hands, and not his back and neck. The VA examiner noted the Veteran's disorder was being treated with antifungal cream, applied twice a week. There were no side effects noted. On examination, the Veteran's skin disorder was found to affect less than 5 percent of his body. In October 2007, the Veteran underwent an evaluation concerning a possible traumatic brain injury. At that time, the Veteran reported experiencing a persistent or nodular skin rash on his hands. It was noted, however, that there was no rash visible. A March 2009 VA mental health treatment note indicated the Veteran's skin was normal, without patches, wounds or other skin problems. In June 2009, the Veteran was seen for a recurrent rash on his left forearm, which was asymptomatic. A cream was prescribed at that time. In September 2009, a VA treatment note showed the cream was still being prescribed. In November 2009, the Veteran underwent a VA skin diseases examination. At that time, the Veteran's skin disorder was treated with creams, applied twice a day, on a constant basis over the previous 12 months. No side effects were noted. At the time of the examination, no some lesions were noted on the Veteran's wrist and upper torso. His palms were free of lesions other than a 1millimeter (mm) pigmented area. In a January 2010 addendum to the examination, the examiner reported that the affected area was .001 percent of the Veteran's body. In December 2009, the Veteran was seen for a skin checkup. At that time, several lesions were noted on various parts of his body, to include above his right elbow. He indicated at that time that the lesions changed color, and were itchy. A February 2010 examination showed the presence of a papulosquamous disorder. Scars on the Veteran's forearms were noted, with some small patches of depigmentation. At that time, no other skin lesions were evident. In March 2011, the Veteran underwent a VA examination. At that time, it was noted that the Veteran applied a topical steroid cream twice daily for treatment of his skin disorder. No side effects of the treatment were noted. There were no symptoms, such as fever or weight loss, present that were due to the skin disorder. No neoplasms were noted. The Veteran indicated he experienced outbreaks approximately 2 to 3 times a month. While the examiner noted there were no skin lesions present at the time of the exam, he indicated that the total percentage of the Veteran's body affected during attacks was 30 percent. The face and neck were noted to be unaffected by the skin disorder. In May 2014, the Veteran underwent a VA skin diseases examination. At that time, the diagnosis of pityriasis versicolor was confirmed. The Veteran indicated that the condition usually flared up in the summer months. He reported using cream to treat the condition; his last use was a year prior. At the time of the examination, a mild rash of the bilateral hands was noted. The Veteran was otherwise asymptomatic. On examination, no scarring of the head, face or neck was noted. The Veteran did not have any benign or malignant skin neoplasms, nor any systemic manifestations (such as fever, weight loss or hypoproteinemia) associated with any skin conditions. In the prior 12 months, there had been no oral or topical medications used to treat any skin condition. The Veteran had no treatments or procedures other that systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. No debilitating episodes were noted. The examiner found that the Veteran's skin condition affected less than 5 percent of his total body area, and less than 5 percent of his exposed area. The Veteran was found to have some skin colored, scattered papules to the palms of his hands with no vesicles, pustules, fissures, excoriation or lichenification. There were no tumors or neoplasm found. The Veteran had no other pertinent physical findings, complications, conditions, signs or symptoms. The examiner found that the Veteran's skin condition did not impact his ability to work. In August 2015, in response to the Board's March 2015 remand, the Veteran again underwent a VA skin diseases examination. At that time, the Veteran described symptoms that usually occurred in July or August, consisting of small raised areas of peeling skin on the hands and neck. The Veteran reported that the creams and lotions prescribed in the past did not help the condition. On examination, no scarring or disfigurement of the head, face or neck was found. The Veteran did not have any benign or malignant skin neoplasm, nor any systemic manifestations associated with skin conditions. In the previous 12 months, there was no treatment using oral or topical medications, nor any treatments or procedures other than systemic or topical medications. The examiner noted the lack of both debilitating and non-debilitating episodes in the prior 12 months. The examiner found that the Veteran's skin condition affected less than 5 percent of his total body area, and less than 5 percent of his exposed area. The Veteran was found to have scattered papules on the palmar surface of both hands, which were approximately 3 mm in diameter and the same color as the surrounding skin. The examiner found 10 such lesions on the Veteran's left hand, to include one of a finger, and 3 on his right hand. The Veteran had no tumors or neoplasms. The examiner noted that there were no visible manifestations of a skin condition affecting the Veteran's neck, and that his skin condition did not impact his ability to work. The examiner then provided a detailed explanation of his findings. As concerned the percentage of the entire body affected by the skin disorder, the examiner noted that there were no manifestations of the disorder affecting the neck or posterior chest. The only observable, measureable areas of the disorder were found on the palms of the Veteran's hands, and the lateral aspect of one finger. The examiner described the process used to measure such areas, noting that the palm of a patient's hand is approximately .5 percent of the total body surface area and the entire palmar surface including the fingers is 1 percent. Therefore, the examiner indicated, the most generous estimate of the Veteran's skin disorder would be a finding that 10 percent of both palms would be affected. Since the total area of both palms was 1 percent of the body and if 10 percent of the area is involved, the total area affected by the Veteran's skin disorder was .1 percent. Conversely, the examiner continued, if he counted each of the Veteran's 13 lesions, which were an average of 3 mm each, the affected area would be 91.9 square millimeters. Since 2 square millimeters is equal to .01 square centimeters, the total body area affected would be .92 square centimeters. Using a body surface area calculator, the examiner found that the Veteran's body surface area-based on his reported height and weight-was 20,132 square centimeters. Therefore, the percentage of body area affected by the Veteran's skin disorder was .0046 percent. The examiner also noted the lack of systemic therapy for the Veteran's skin disorder. The Board concludes that the preponderance of the evidence shows that, at no time during the appeal period, did the Veteran's skin disorder affect over 20 percent of his total body or the exposed area, or require systemic therapy or intensive light therapy of any kind. Hence, the evidence indicates that a rating in excess of 10 percent is not warranted. Specifically, the Board finds that the evidence of record does not, at any time pertinent to the period on appeal, indicate that 5 percent or more of the Veteran's total body or the exposed area was affected by his skin disorder. In this regard, during the November 2009, May 2014 and August 2015 VA examinations, the physicians specifically determined that less than 5 percent of the Veteran's total body area and less than 5 percent of exposed area was affected. While the March 2011 examiner estimated that the Veteran's skin condition affected 30 percent of his body area during an outbreak, he provided no explanation or rationale for such a finding, especially in light of the fact that there was no outbreak present at the time of the examination. Therefore, such a finding is given no probative weight. See Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). In addition, there is no record of any kind of systemic therapy for the Veteran's skin disorder in the whole of his medical records. Thus, the Board finds that the preponderance of the evidence does not support a rating in excess of 10 percent for his skin disorder. In addition, the Board has considered whether the Veteran's skin disorder should instead be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805); however, as determined by the VA examiners and unrefuted by the Veteran, such disability does not result in disfigurement of the head, face, or neck, or scarring that is deep and nonlinear, at least 144 square inches, unstable or painful, or results in functional impairment. Therefore, such rating is inapplicable here. In reaching the foregoing determination, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected skin disorder and notes that his lay testimony is competent to describe certain symptoms associated therewith. When 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 his symptoms because this requires only personal knowledge as it comes to him through his senses. See Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability relating his skin disorder to the appropriate diagnostic code. Rather, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of such service-connected disability. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of the severity of the Veteran's symptoms, the extent to which it affects his body as a whole, and the details of the clinical features therefrom. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected skin disorder; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. The Board also notes the Veteran's contentions, raised at the February 2010 hearing and in a contemporaneous statement from the Veteran's representative, that the Veteran's multiple skin disorders are related to his service-connected skin disorder and, as such, should be considered part of the total percentage of the body affected by the condition. However, in January 2011, the Veteran was granted service connection for hyperkeratosis-type lesions and inflamed seborrheic keratosis of both upper extremities, effective October 31, 2006, and in March 2012 he was granted service connection for seborrhea dermatitis of the left lower extremity, also effective October 31, 2006. To award a higher evaluation based on these symptoms would be considered pyramiding. As noted above, pyramiding is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings 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, supra. In this case, the symptomatology of the various conditions would be duplicative. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the AOJ or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected skin disorder with the established criteria found in the rating schedule and finds that the Veteran's symptomatology is fully addressed by the rating criteria under which his disability is rated. Specifically, the rating criteria contemplates the type of symptoms the Veteran experiences as a result of his skin disorder and provides for higher disability ratings for more severe and extensive symptomatology. Therefore, the Veteran's symptoms and their resulting impairment are contemplated by the rating schedule, and there are no additional symptoms of his skin disorder that are not addressed by the rating schedule. Furthermore, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, as the decision does not involve evaluation of multiple service-connected disabilities, further discussion of Johnson is not necessary. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. The rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating due to individual unemployability (TDIU) is part of a rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, the record does not show either an express or implied TDIU claim in connection with the Veteran's service-connected skin disorder. Specifically, the Veteran has not contended, nor does the evidence of record reflect, that his skin disorder affects his employability. In this regard, the May 2014 and August 2015 VA examiners noted that the Veteran's disability did not impact his ability to work. There is no indication that the Veteran would be unable to maintain employment due to his disability. Therefore, the Board finds that the issue of entitlement to TDIU is not expressly raised by the Veteran or reasonably raised by the record, and, consequently, further consideration of such is not necessary. Based on the evidence of record, the Board finds no basis upon which to award a rating in excess of 10 percent for the Veteran's service-connected skin disorder. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, there is no reasonable doubt to be resolved with respect to this issue. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3; Gilbert, supra. ORDER Entitlement to a rating in excess of 10 percent for pityriasis versicolor, posterior chest with exfoliation of the palms, is denied. ____________________________________________ A. TURNIPSEED Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs