Citation Nr: 1623137 Decision Date: 06/09/16 Archive Date: 06/21/16 DOCKET NO. 10-32 575 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial compensable evaluation for eczema prior to April 23, 2010, and in excess of 10 percent thereafter. 2. Entitlement to an initial rating in excess of 10 percent for posttraumatic headaches. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served in the U.S. Air Force from July 1986 to July 2008. These matters come comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Jurisdiction currently resides at the RO in North Little Rock, Arkansas. The January 2009 rating decision addressed a number of claims, and included granting service connection for a second skin condition, seborrheic dermatitis of the scalp. The Veteran specifically substantively appealed increased ratings for eczema, headaches, and entitlement to service connection for sinusitis to the Board, and did not continue her appeal of additional claims. In a March 2014 decision, the Board denied entitlement to service connection for sinusitis, and remanded the increased ratings on appeal for additional development. As such, the claim for sinusitis is no longer on appeal. On her VA Form 9 dated August 2010, the Veteran requested a hearing before a Veterans Law Judge. She was thereafter scheduled for a videoconference hearing in August 2013. However, prior to the hearing, the Veteran cancelled her hearing request. Accordingly, her request for a hearing is considered to be withdrawn and her claims will be reviewed based on the evidence of record. See 38 C.F.R. § 20.704(d)(2015). In a June 2010 rating decision, the RO awarded the Veteran a 10 percent disability rating for her posttraumatic headaches effective August 1, 2008, as well as a 10 percent rating for her eczema from April 23, 2010. However, as the increased ratings did not constitute a full grant of the benefits sought for either claim, the Veteran's claims for higher evaluations remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims (Court) held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of a rating claim when unemployability is expressly raised by a veteran or reasonably raised by the record during the rating appeal. Here, treatment records indicate that the Veteran is employed full time. There are no statements from the Veteran or her representative that she has lost this employment, or that the employment should be considered marginal. As such, a claim for TDIU is not raised by the record. The issue(s) of entitlement to a rating in excess of 10 percent for eczema from April 23, 2010 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to April 23, 2010, resolving reasonable doubt in the Veteran's favor, her eczema covered at least five percent but less than 20 percent of her entire body, or at least five percent but less than 20 percent of her exposed areas, during flare-ups of symptoms. 2. During the entire period on appeal, the record does not show that the Veteran's posttraumatic headaches have resulted in headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. CONCLUSIONS OF LAW 1. Prior to April 23, 2010, the criteria for an initial 10 percent rating for eczema have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.118, Diagnostic Codes 7806 (2008). 2. The criteria for an initial rating in excess of 10 percent for posttraumatic headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 4.3, 4.10 4.124a, Diagnostic Codes 8100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A. Here, the Veteran was provided proper notice in April and August 2010 letters. With respect to the duty to assist, the Veteran's service treatment records, and post-service medical treatment records have been obtained. She was afforded VA examinations in 2008, 2010 and 2014. The examiners reviewed the Veteran's claim file, past medical history, recorded her current complaints, and conducted appropriate evaluation. Notably, the 2008 skin examination did not include information about regarding signs and symptoms of eczema. It is unclear if this was because she was not currently having a flare up of the skin disease. However, subsequent examinations noted the eczema. The Board, therefore, concludes that the examination report is adequate for the purpose of rendering decisions on the current appeals. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and her representative have not contended otherwise. The Veteran was provided with the opportunity to testify at a hearing, but she declined this opportunity. Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). Eczema During the appeal, the regulations pertaining to the evaluation of skin disabilities were amended. See 73 Fed. Reg. 54,708 (effective October 23, 2008). The amendments were specifically made effective only to applications received on or after October 23, 2008, although a claimant may request consideration under the amended criteria. See 73 Fed. Reg. 54,708. In this case, the Veteran's claim was received in July 208, and she has not requested consideration under the amended provisions. Therefore, the rating criteria in effect from October 23, 2008, forward are not for consideration. The Board notes that Diagnostic Code (DC) 7806 for eczema did not change with the amendments in 2008. Under the revised provisions of DC 7806, dermatitis or eczema will be assigned a 10 percent rating 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 where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. Higher ratings are available where larger percentages of the entire body or exposed areas are affected, or longer periods of systemic therapy such as corticosteroids or other immunosuppressive drugs are required. See 38 C.F.R. § 4.118, DC 7806. In this case, there is no evidence of scarring or impairment of function due to the Veteran's eczema. As such, a rating is not warranted under DCs 7801 through 7805. See 38 C.F.R. § 4.118 (2003). As there is a specific diagnostic code which addresses eczema, the Veteran's specific diagnosis, the Board will not consider analogous ratings. The Board notes that the Veteran is separately service connected for eczema and seborrheic dermatitis. The Veteran did not appeal the initial rating assigned for her seborrheic dermatitis, and it its rating is not currently on appeal. Service treatment records include an October 2003 complaint of a slightly pruritic rash on her arms for the past five days. She wondered if she came into contact with something "while working in the yard." She reported a history of intermittent eczema on her hands. She tried to treat the rash with triamcinolone, but it was not working. She was assessed with contact dermatitis and given a "trial of Lidex cream, 0.05 percent." IN January 2004, it was noted she was on "immunotherapy treatment" in the past due to her sinuses. On her January 2008 retirement examination she was diagnosed with dermatitis seborrhea involving the scalp. She was noted to have some "dermatitis" on her eyelids. In October 2008, the Veteran was afforded a general medical VA examination. She was noted to have eczema that started prior to service. She reported her eczema covered her hands, and that it was "under control" through the use of lotion. She also had seborrheic dermatitis of her scalp, with onset in 1992. Her skin examination included the measurements of several scars, and the notation of a "rash or other lesions" described as "scant papules on the left hand; has some scaly patch along the hair line in the back of the scalp." This was noted to measure 0.5 cm x 0.25 cm. The measurement is listed as associated with both the papules on her hand and the hair line scaly patch of skin. As such, it does not provide information solely about the eczema, and does not even specifically state that the scaly patch at the hairline is related to her seborrheic dermatitis vs. her eczema. At the time of the examination, she reported she was not employed. In November 2008, the Veteran was afforded a second VA examination. She was noted to have a diagnosis of seborrheic dermatitis. Her medications included moisturizing lotion applied to the affected area as needed, Selsun lotion used as a shampoo one weekly, and Head and Shoulders shampoo daily. She used the lotion at least daily and sometimes up to three times a day in the winter, on both hands. She reported intermittent itching as her skin symptom. She had a small area of erythematous spots on both hands and the right upper arm. This affected area was about one percent of exposed skin area and two percent of the total body surface was involved. She was noted to have mild seborrheic dermatitis. An addendum, after review of the record, noted she had the additional diagnosis of eczema. In April 2010, the Veteran was afforded a third VA examination. Her eczema was noted to have initially involved her hands, arms and fingers, but it had improved and now she only had a localized patch over the proximal mid-arms bilaterally. Flares were intermittent with the condition being stable. She had flare-ups every two weeks involving the proximal arms. She did not require treatment for the condition. She described a papular type rash involving the arms during a flare-up. Flare-ups would resolve over two days without treatment. There was no scarring from the condition, and no functional restriction. On physical examination, the Veteran had scattered flaking from seborrhea throughout her scalp, with a few superficial excoriations without scarring. She had a few scattered papules. The total body surface area of the rash was three percent, and mainly involved the scalp. It was zero percent of the exposed body surface area. In the mid-face there was evidence of faint erythema, which was diffuse. It was likely related to the seborrhea. There was no scaling. It involved approximately two percent of her total body surface and five percent of her exposed body surface area, and was mainly more of an erythema from the seborrhea. On her skin and arms she had small scattered papules in the mid proximal arm region, typical of mild eczema, with no other rash noted. There was no scarring for any of the skin conditions. The area involving the arms was two percent of her total body surface area and five percent of exposed body surface area for each arm. She was diagnosed with seborrheic dermatitis of the head and face and eczema of the arms. In July 2010, the Veteran complained of a rash on her legs, hand and neck for the last month. The rash was worsening and was not associated with increased itching. She was using topical Benadryl. The physician noted areas of redness and contact dermatitis on the neck, arms and right lower leg. She was told to avoid all jewelry containing nickel and was given a topical betamethasone ointment. By August 2010, the rash was better but she still had red spots over her body. She sought treatment again in November 2010, with a rash on her hands and legs for the last month. "She was seen in July with a similar recurrence of her eczema." She used topical steroids with moisturizers for three to four weeks. Her medications included betamethasone dip .05 percent, topical, "apply small amount to affected area every 12 hours as needed for rash." She complained of a persistent, itchy rash on her bilateral calves and hands. There were multiple red rashes that varied in size. A specific diagnosis was not listed. In April 2011, it was noted that she had a rash, "dermatitis," on her lower extremities. In June 2011, she was noted to have multiple pruritic, scaly, erythematous plaques on her legs. She was assessed with eczematous dermatitis, and she was given a renewal of her topical steroid cream for continued used during flare-ups. She used derma cera cream daily. A January 2014 VA treatment record noted the Veteran's dermatitis had resolved after the use of steroidal cream. Her prescriptions included Fluocinonide .05 percent, topical, "apply small amount to affected area as needed." In December 2013, the Veteran wrote to the VA that her skin condition had worsened since her 2010 VA examination. The Board remanded the claim for a new examination, which was provided in July 2014. The Veteran was noted to have had eczema on her hands since childhood, and seborrheic dermatitis since her teen years. The eczema was aggravated by her service and she was treated with a steroid cream. It was noted that at the time of the examination, she was treated for intermittent rash on her hands with fluocinonide (topical corticosteroid) with good response. Her skin condition did not cause scarring or disfigurement of her head, face or neck. She did not have malignant skin neoplasms or any systemic manifestations due to any skin diseases. She had been treated in the prior 12 months with six weeks or less of topical corticosteroid and six weeks or more of Selsun shampoo. It was noted that her eczema covered less than 5 percent of her total body area and less than 5 percent of her exposed areas. However, it was noted that there was no eczema present at the time of the examination. At the time of the examination she did not "have scaliness seen in her scalp or eczematoid lesions." There was "no impact on occupation," no scarring noted, no indication for photographs as no lesions consistent with eczema. It was also noted that "PRN treatment for eczema-not found in recent records of Little Rock VAMC." Here, the October 2008 VA examination did not provide information regarding the percentage of total body affected or exposed skin affected by the Veteran's eczema. The November 2008 examination noted her eczema covered one percent of her exposed skin and two percent of her total body. In April 2010, her eczema covered two percent of her total body surface area and "five present of her exposed body surface area for each arm." From at least 2010 to 2011 the Veteran had a flare-up of eczema which affected her arms, legs and neck. Unfortunately, VA treatment records from that time period do not indicate the percentage of her exposed skin or percentage of her total body that was involved. It was noted in January 2014 that her dermatitis had resolved after the use of topical steroid cream, and by the July 2014 examination, the Veteran did not have any eczema lesions for examination. The records indicate that the Veteran has flare-ups of her eczema. At one point she indicated she had flare-ups every two weeks. The record shows that she had one prolonged flare up in 2010-2011. The April 2010 examination revealed that her eczema covered five percent of her exposed body on her arms, "each." The Board finds that the 10 percent rating provided from April 23, 2010 due to the findings of the examination, should be applied for the entire period on appeal. If the April 2010 examination was provided during a flare-up, then the affected areas of skin in that examination are accurate to what her flare-ups were prior to 2010 even if the 2008 examinations occurred during calm periods of her eczema. There is no indication in the record that a rating in excess of 10 percent should be provided prior to April 23, 2010. Her flare-up of eczema, seen during the April 2010 examination, showed that five percent "each" of her exposed skin (arms) was impacted by her eczema. There is no indication in the record that 20 percent or greater of her exposed skin or 20 percent or greater of her entire body was affected by her eczema, to include during a flare-up. Additionally there is no evidence that the Veteran was prescribed systemic therapy for her eczema for a period of six weeks or greater prior to April 23, 2010. As such, the Board finds that a rating of 10 percent, but no higher, is warranted prior to April 23, 2010. The Board notes that the Veteran reported her 2013 that her eczema had worsened in severity since her 2010 examination. Treatment records from 2010 and 2011 indicate that she developed eczema on her legs and neck, where prior records had noted her eczema was limited to her hands and arms. The 2014 VA examination occurred after treatment with topical corticosteroid cream had resolved the eczema flare-up. As such, the record does not contain adequate information on the Veteran's symptoms during a flare-up of eczema symptoms since her increase in symptoms after 2010. The Board is therefore remanding the claim for a rating in excess of 10 percent from April 23, 2010. Headaches The Veteran's posttraumatic headaches were granted with an initial evaluation of 10 percent disabling, under Diagnostic Code 8100 for migraine headaches. Under Diagnostic Code 8100, a 10 percent evaluation is warranted for characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent evaluation is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. A 50 percent evaluation is the maximum available schedular evaluation for headaches. Neither the rating criteria nor the Court has defined the term "prostrating". According to Webster's New World Dictionary of American English, Third College Edition 1080 (1986), "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in Dorland's Illustrated Medical Dictionary 1367 (28th ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." "Inadaptability" is not defined in Diagnostic Code 8100, nor can a definition be found elsewhere in Title 38 of the Code of Federal Regulations. See Pierce v. Principi, 18 Vet. App. 440, 446 (2004). Further, it has been held that nothing in Diagnostic Code 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 446 (2004). Service treatment records include a note from December 2006 where the Veteran reported "bad headaches" for the past 8 days. She had an upper respiratory infection which resolved a week prior, and had constant frontal/facial pressure since then. She was assessed with sinusitis. In September 2007, she reported a cough, congestion, runny nose and headache. She reported her headaches were recurrent. The Veteran was afforded a VA examination in November 2008. She reported she hit her head in 1992 while in service and noted chronic headaches ever since. She described headaches "almost every day that can last all day." She can work through the headache but generally tries to take pain medication and lie down to alleviate them. She had nausea associated with some headaches, but had no vomiting. She did not have any photophobia or phonophobia with her headaches. She was assessed with mild posttraumatic headaches. An October 2009 VA treatment record included the Veteran's complaint of seven weeks of headaches. She reported waking up dizzy, but without vomiting. She reported she woke up with the headache. She had a normal CT and MRI. She recently started on steroid nasal spray, so she stopped using it. She reported she "turned her neck this [morning] and the [headache] restarted-also if she rubs the head it will start [headaches]-went back to her [regular] pillow due to back." Her headaches were "whole cranium" and she reported nausea with her headaches. She reported she was thought to have migraines at age 19, but the diagnosis was changed to tension headaches. Her headaches used to be in the sinus area, but now involved her whole head. She had minimal caffeine use, but the physician discussed decreasing her pain medication and her caffeine use due to her headaches. She was on Prometrium, which can cause headaches. She had paraspinous spasm in her cervical spine area. She was assessed with probable migraine headaches, with "recurrence due to some factor." A February 2010 record noted her headaches were "stable" and "seem most related to sinus congestion." In April 2010, the Veteran was afforded another VA examination. She reported her headaches started after she struck her head on a nearby post while firing an M-16 rifle. She reported headaches since that time but with improvement. She reported headaches twice weekly, described as throbbing and located frontal head radiating to the side of the head and into the neck. Her headaches were associated with nausea and photophobia. There was no vomiting, phonophobia, incapacitation, or prostration to the headaches. They would usually last a few hours and resolve with over the counter Tylenol and napping with ease over two hours. Triggers for the headaches were reported as poor sleep and diet. She did not require any maintenance medication for her headaches. She was diagnosed with posttraumatic headaches. In June 2010, the Veteran reported to treatment providers that she had headaches almost every day, and she was using Aleve, without much relief. . It was suggested that her headaches were a combination of tension headaches and seasonal allergies, and she was started on seasonal allergy medication. In another June 2010 record, she reported frequent headaches which started following her hysterectomy in January 2010. She reported having headaches related to her sinuses in the past, but that these headaches were different. It was suggested that she have her thyroid levels checked since she developed headaches and depression right after her hysterectomy. Service treatment records noted she was diagnosed with primary hypothyroidism in early 2008. A July 2008 MRI of the brain was unremarkable. In July 2010, the Veteran complained of migraine/tension-like headaches which had been occurring for several months. They began shortly after her hysterectomy in February and she began hormone replacement therapy. She had various other headaches (sinus and tension) throughout her life but the more recent headaches were different and more severe. She reported severe 10/10 pain, without aura. She was mildly photophobic during a headache. Her headaches begin in her neck and moved upward, and the pain was "vice-like." They occasionally throbbed with her heartbeat. She reported no symptoms specific to the headache period, which generally lasted all day. She reported dull tinnitus that started at the same time as the headaches. Her weekend headaches were less severe. Sleep did not relieve her headache symptoms, but temporarily reduced the headaches. She reported sleeping 8 hours at night, broken up into 2 to 3 hour increments. The neurologist noted that her pain was likely due to some occipital neuralgia and she was started on Nortriptyline, and felt a prior difficulty with the drug was due to not titrating up the medication. There was also concern for obstructive sleep apnea. In August 2010, the Veteran underwent an occipital nerve block for occipital neuralgia, chronic headache. She stated that two or three months prior she began to have headaches and hear constant ringing tinnitus. She said this started after taking a new medication, which she stopped taking after a few weeks of the headaches and ringing. She said the headaches and ringing continued even after quitting two of her medications. In October 2010, the Veteran complained of headaches and neck pain. The pain started in her neck and spread to her head. Her headaches usually started during the day and continued until night. In November 2010, she complained of a headache beginning April 2010 following hysterectomy. Headaches decreased with Nortriptyline and bilateral occipital nerve block in August 2010. She had no symptoms of numbness, tingling, upper extremity weakness. An MRI of her spine showed mild disc bulges at C3-4 and C4-5. She reported constant pain on her posterior cervical paraspinal and right upper trapezius. Her neck pain was greater than her headache pain. By November 2011, the Veteran reported her chondric pain and headaches were causing her difficulty in functioning in everyday life. It was noted that anhedonia, low mood, trouble staying asleep, tiredness, low self-esteem, difficulty concentrating, and slowed movements caused her problems in her personal and work life. She was retired from the Air Force, and working full time for the VA. In December 2013, the Veteran argued that her headaches had worsened since the 2010 VA examination. She argued her migraine headaches were very frequent, with characteristic prostrating attacks occurring on an average of two to three times per month. Based on her December 2013 statement, the Board remanded the Veteran's claim for an updated VA examination. In July 2014, the Veteran underwent a third VA examination. She was noted to have posttraumatic headaches, diagnosed in 1997. She treated her headaches with Ibuprofen. She described constant head pain that was bifrontal or all over. She had no non-headache symptoms associated with her headaches. Her headache pain typically lasted less than one day, on both sides of her head, and would occur once every two weeks. The examiner found that she did not have characteristic prostrating attacks of headache pain. Her "neurological exam is non focal;" did not show abnormality. Her headache condition was noted to not impact her ability to work. Her headaches were "relieved with neck exercises, relaxation, Ibuprofen." They were aggravated by bad posture, lack of sleep, and stress. Here, the Veteran is uniquely able to participate in the determination of the severity of her disability as headaches, and their severity, are lay observable. In fact, the VA examinations are generally interviews requesting a description of the severity and symptoms of the Veteran's headaches. Additionally, the Board feels that the Veteran has been credible in her description of having headaches, the causes or seeming triggers of those headaches, and the approaches she uses to alleviate her headache pain. Here, the examiners are using her responses to the onset and alleviation, as well as the symptoms associated with her headaches to determine if they are characteristically prostrating and from her statements, how frequently they occur. The record indicates that following her hysterectomy and subsequent hormone treatment, the Veteran began to experience headaches that were "different" and more severe than those she experienced in connection with allergies and sinus symptoms. She reported the increased headaches began in April 2010, subsequent to her VA examination, and that there was improvement in these headaches following an August 2010 occipital nerve block and the use of medication. During her 2008 examination, the Veteran reported daily headaches that lasted all day; however, she was able to work through these headaches, and they were alleviated with over-the-counter medication and rest. By her 2010 examination, she reported headaches twice weekly, associated with nausea and photophobia and they would resolve with over-the-counter medication and rest/sleep. In July 2010, her headaches were more severe, and she was mildly photophobic during one. She indicated they lasted all day, and also it appeared they occurred daily as she stated her weekend headaches were less severe. Following her occipital nerve block in August 2010, she indicated that her headaches began in her neck and that her neck pain was more severe than her headaches. By her 2014 examination, the Veteran's headaches lasted less than one day and would occur once every two weeks. Her headaches were relieved with neck exercises, relaxation and Ibuprofen. The 2010 and 2014 examiners noted that her headaches were not prostrating headaches. Despite her statement in 2013, which listed part of the criteria for a 50 percent rating, the Veteran did not describe headaches that resulted in "utter physical exhaustion or helplessness," or another similar description. Instead, her headaches, though painful, were described as things she could work through, or that were alleviated with over-the-counter medication, rest, or neck exercises. Based on the available evidence (the Veteran's statements regarding her headache symptoms, treatment and alleviation), the Board finds that a rating in excess of 10 percent for posttraumatic headaches is not warranted because the evidence does not show characteristic prostrating attacks of headaches. The 10 percent currently provided is based upon the frequency of her current headaches, despite the fact that they are not characteristically prostrating. However, she does not meet the criteria for an increased rating, and the evidence (based on her statements) does not show characteristic prostrating attacks occurring one a month over the last several months, or very frequent completely prostrating and prolonged attacks. As such entitlement to an increased rating for posttraumatic headaches is denied. Extraschedular consideration The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). The schedular ratings in this case are adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's disabilities, including taking into consideration pain, and symptoms during a flare-up. Id, at 115. When comparing the eczema and headache symptoms with the schedular criteria, the Board finds that her symptoms are congruent with the disability pictures represented assigned ratings. Accordingly, a comparison of the Veteran's symptoms and functional impairments with the pertinent schedular criteria does not show that her service-connected disabilities present "such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular ratings are adequate to rate the Veteran's disabilities. Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the veteran's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Finally, the Board notes that under Johnson v. McDonald, 762 F.3d. 1362 (2014), a Veteran may be awarded an extraschedular 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 service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Specifically, the Veteran is service-connected for numerous disabilities associated with the medical records listed above, including residuals of hysterectomy, degenerative disc disease of the cervical spine, hypothyroidism, allergic rhinitis and seborrheic dermatitis. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER Entitlement to an initial rating of 10 percent for eczema, for the period prior to April 23, 2010, is granted. Entitlement to an initial rating in excess of 10 percent for posttraumatic headaches is denied. REMAND As noted above, following the 2010 VA examination the Veteran had a flare-up of symptoms of her eczema, as shown in 2010 and 2011 treatment records. This included eczema on her legs and neck, where it had previously only been reported on her hands and arms. When she was afforded her examination for increased symptoms in 2014, her symptoms had cleared following the use of topical steroids. As such, the 2014 examination results to not show the severity of the Veteran's eczema. On remand, the Veteran should be scheduled for an additional skin examination during a flare-up of symptoms, if possible. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA skin examination to determine the current severity of her eczema. Work with the Veteran to schedule this examination during a flare-up of her eczema. 2. After completion of the above and any additional development deemed necessary, the issue on appeal must be reviewed with consideration of all applicable laws and regulations. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished an appropriate supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. 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 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs