Citation Nr: 1638828 Decision Date: 09/29/16 Archive Date: 10/13/16 DOCKET NO. 09-45 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE 1. Entitlement to service connection for lichen planus. 2. Entitlement to service connection for a skin disability, other than lichen planus. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from November 2000 to November 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In October 2010, the Veteran presented sworn testimony at a Board hearing before a Veterans Law Judge (VLJ). In a January 2016 letter, the Board informed the Veteran that the VLJ who conducted his hearing was no longer employed by the Board and offered the Veteran the opportunity to testify at another hearing. See 38 C.F.R. §20.717 (2015). The Veteran was also informed that he had 30 days to respond to this letter, and if he did not respond within 30 days, the Board would assume that he did not want another hearing and would proceed accordingly. The Board notes that the Veteran never responded to this letter. As such, the Board will proceed with adjudication of her claim. In June 2011, the Board determined that new and material evidence had not been submitted to reopen a previously denied claim of service connection for lichen planus. Thereafter, the Veteran filed an appeal to the United States Court of Appeals for Veterans Claims (Court). In an April 2013 Memorandum Decision, the Court reversed the Board's determination on the question of whether the claim should be reopened and remanded the matter for further proceedings. In December 2013, the Board reopened the previously denied claim of service connection for a skin disability in accordance with instructions from the Court. The Board remanded the underlying claim for additional development. The Board also remanded the issue of entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD). A May 2014 rating decision thereafter granted service connection for a mood disorder and assigned a 100 percent disability rating for this disability. There appears to be no further disagreement with respect to how this claim was handled. Grantham v. Brown, 113 F.3d 1156, 1158-59 (Fed. Cir. 1997). By way of the February 2015 decision, the Board adjudicated the Veteran's claim for a higher rating for GERD with repaired hiatal hernia, and remanded the claim seeking service connection for a skin disability once again for additional development. After the development had been conducted and the claim returned to the Board, in March 2016, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). 38 U.S.C.A. § 7109; 38 C.F.R. § 20.901(a)(2015). The opinion, received in May 2016, has since been associated with the Veteran's claims file and scanned into VBMS. Copies of the opinion were sent to the Veteran in June 2016. 38 C.F.R. § 20.903 (2015). No additional argument was submitted in response by the Veteran or his representative. In light of the medical evidence of record, and multiple diagnoses for disabilities associated with the Veteran's skin condition, and the differing opinions provided for these diagnoses, the Board finds it appropriate to bifurcate the Veteran's claim of service connection for a skin disability into two issues - one for entitlement to service connection for lichen planus, and one for entitlement to service connection for skin disability other than lichen planus. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, lichen planus had its onset during active service. 2. The competent and probative evidence of record does not relate the Veteran's current skin disorders (other than lichen planus) to his period of active service and weighs against a conclusion that the Veteran's current skin disorders other than lichen planus were causally or etiologically related to any disease, injury, or incident during his period of active service. CONCLUSIONS OF LAW 1. Lichen planus was incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). 2. A skin disability other than lichen planus was not incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See eg. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). In the instant case, VA provided adequate notice in a letter sent to the Veteran in August 2008. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As a prefatory matter, with regard to the Veteran's lichen planus claim, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. With regard to the claim seeking service connection for a skin disability other than lichen planus, 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). The Veteran's service, VA, and private medical records have been retrieved and associated with the claims file. Pursuant to the December 2013 Board remand, VA afforded the Veteran a relevant examination in March 2014, and pursuant to the July 2014 and February 2015 remands, additional addendum opinions were issued in August 2014 and September 2015. Also, in March 2016, a VHA medical expert opinion was obtained in May 2016, and the Veteran was given an opportunity to respond. The Board finds that collectively, the VA examination report, in conjunctions with the VA medical opinions, addendums, and VHA opinion are adequate for purposes of rendering a decision in the instant appeal. 38 C.F.R. §4.2 (2015); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). They reflect that the physicians reviewed the Veteran's past medical history, took into account the private medical opinions and medical treatise evidence and rendered appropriate opinions consistent with the remainder of the evidence of record. The VA physician and medical expert also provided complete rationales for the opinions stated, relying on the complete record, including the Veteran's reports, as well as medical literature and other medical opinions. When considered with the other evidence of record, there is adequate medical evidence of record to make a determination in this case. More importantly, together these medical opinions address the questions listed in the December 2013, July 2014 and February 2015 Board remand directives. Accordingly, the requirements of these remands were ultimately accomplished by way of these examination reports. See Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board finds that VA's duty to obtain a VA examination or opinion with respect to claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. II. Analysis A. Lichen Planus Then Veteran contends that his current skin disorder, diagnosed as lichen planus, had its onset in service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110 (West 2014); 38 C.F.R. § 3.303(a) (2015). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) 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"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154 (a); 38 C.F.R. § 3.303 (a). Review of the Veteran's service treatment records reflects that the clinical evaluation of the Veteran's skin was shown to be normal at his May 2000 enlistment examination. In addition, the Veteran denied a history of skin diseases in his medical history report. An undated treatment report reflects that the Veteran was seen at the military clinic with complaints of a rash on his face and genital area. He was initially assessed with having contact dermatitis, but this was subsequently crossed out, and the word "impetigo" was hand-written over it. Subsequent records reflect that the Veteran was seen at the military clinic in February 2001 with complaints of a rash on his face that was spreading to his genital area. He was diagnosed with having impetigo. Subsequent records show that he was treated in July 2001 for a lesion on his glans penis. According to the Veteran, he had been diagnosed with lichen planus prior to service, but the current lesion appeared different. The Veteran was assessed with lichen planus and syphilis was to be ruled out. He was thereafter treated with hydrocortisone. A follow-up note that same month included an assessment of "resolved lichen planus." At the August 2001 separation examination, the clinical evaluation of the Veteran's skin and lymphatic system was marked as abnormal, and in the adjoining notes section, the medical examiner noted that the Veteran had had lichen planus on his groin. The Veteran also reported a history of skin diseases in the medical history report, and in the explanation section, it was noted that the Veteran had had a diagnosis of lichen planus. During a December 2001 treatment visit with his private dermatologist after military service, the Veteran reported a recurring lesion on his penis that comes and goes. He stated that he was currently taking Valtrex and had also applied hydrocortisone to the affected area. According to the Veteran, he had recently visited a medical facility and was informed he had lichen planus. A January 2002 treatment report reflects that the Veteran presented for follow-up treatment for penile lesions that he had experienced for many years. It was noted that a sexually transmitted disease (STD) workup was unremarkable, and that the Veteran had stopped using the hydrocortisone cream for a period of time and was there for re-evaluation of his symptoms. Physical evaluation of the genital region revealed several erythematous scaling patches on the shaft of the penis and some on the head, but was negative for purplish papules or "Wickham's stria." The results of the evaluation were clinically consistent with "papulosquamous eruption, most likely psoriasis [given the Veteran's] family history." During an October 2003 treatment visit, the Veteran presented with a diagnosis of facial and buttock acne. Upon reviewing his clinical record, his physician noted that the Veteran was last seen in March 2003 for treatment of herpes simplex outbreak. He was thereafter assessed with having facial acne that had had cleared, and folliculitis on his buttocks. The Veteran was seen for treatment of herpes simplex virus in March 2004. The Veteran was afforded a VA dermatological examination in October 2009. During the examination, the Veteran reported that his skin condition, diagnosed as lichen planus, had its onset in service while he was stationed in Okinawa. According to the Veteran, this disorder recurs several times a year, is highly variable, comes and goes for variable lengths of time, and remits for variable lengths of time. The examiner observed no present signs of a rash, and it was noted that the Veteran's last outbreak was reportedly several weeks prior. Upon physical examination of the Veteran, the examiner observed no active lesions, but acknowledged the Veteran's reported history of recurrent intermittent lesions on his penis. He (the examiner) did note a small area of pigmentation that measured 0.4 x 0.8 centimeters (cm) on the left lateral shaft of the penis. Based on his discussion with, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having a history of lichen planus of penis that was now in remission, with residual minute discoloration. According to the examiner, the Veteran's lichen planus was neither caused, nor permanently aggravated, by his military service. In reaching this determination, the examiner explained that lichen planus was not a communicable or sexually transmitted disease, and the cause of lichen planus was not known but often was considered to be an autoimmune disorder. According to the examiner, the course of lichen planus is consistent with the Veteran's statement and while some cases of lichen planus may be associated with medications, to include nonsteroidal anti-inflammatory agents, the Veteran has not made this association. During his October 2010 hearing, the Veteran testified that he had been diagnosed with a possible STD such as lichen planus, immediately prior to service, and that there was a "real increase or aggravation" of his rash during his service. See Hearing Transcript, pp. 11-12. Private treatment records dated from 2011 to 2012 reflect that the Veteran had a past medical history of herpes simplex virus. During a March 2012 treatment visit, the objective medical findings were negative for evidence of any rashes, lesions or petechiae. Although a problem list which includes an annotation of a July 2012 treatment visit indicated that the Veteran had a rash, a narrative of the July 2012 treatment visit is absent any complaints of, or treatment for a rash. This same problem list included an annotation of treatment for chronic folliculitis from April 2011 to November 2011 that had resolved. The Veteran was afforded another VA dermatological examination in March 2014, during which time he provided his military and medical history, and stated that although he was unsure as to the onset of his skin condition, he recalled undergoing a single treatment for lesions on his penis, and received treatment with topical hydrocortisone for this disorder. With regard to his present condition, the Veteran reported experiencing lesions and water-filled blisters on the plantar aspect of his feet that spread to the ankles, which recurs an average of two to three times a year. The Veteran also described lesions that arise on his penis two to three times a year, that are typically specific to one area, and take an average of three to four weeks to resolve. In addition, the Veteran reported having acne since he was twelve or thirteen years of age that was controlled through topical and oral agents. He stated that he had undergone a biopsy of the acne on the back of his neck at a clinic, and the results of the biopsy showed folliculitis. Upon conducting a physical examination of the Veteran, the examiner observed evidence of dermatitis, facial acne and a rash on the right inguinal skin fold area. The examiner noted that the right inguinal skin fold had "a linear non-blancing erythematous lesion without induration but with excoriation in evidence." The examiner further noted that the lesion extended for 6 cm along the inguinal skin fold. Based on his review of the Veteran's claims file, as well as his evaluation of the Veteran, the VA examiner diagnosed the Veteran with having intermittent facial acne, intermittent folliculitis on the back and thighs, and a rash on the right inguinal groin. The examiner determined that the Veteran's acne as well as his lichen planus had their onset prior to his service. Based on his understanding of the Veteran's medical history, as well as his detailed review of the records, the examiner determined that the Veteran's lichen planus was not aggravated in service. The examiner further determined that based on the available records, the Veteran's statements, and the current examination findings, a skin condition that was caused, or permanently aggravated, by service was not currently traceable to the Veteran's period of military service. In reaching this determination, the examiner reviewed and recounted all the relevant clinical and treatment records pertinent to the issue on appeal, and noted that the Veteran sought treatment in August 2000 for a rash on his penis that occurred after sexual intercourse with his girlfriend. According to the examiner, the Veteran was diagnosed with having dermatitis of the penis and a culture for herpes infection was taken. The examiner also referenced a treatment report dated in September 2000 which reflected that the rash on the penis had not resolved. This treatment report reflected a diagnosis of lichen planus of the penis, and the lab results were negative for signs of the herpes virus. After reviewing these records, along with the service and post-service treatment records, the examiner acknowledged that while the Veteran's enlistment examination was negative for any complaints, history or findings of any skin condition, between the time of this examination and his service, the Veteran sought treatment for his skin problems and was diagnosed with having lichen planus. The examiner noted that the Veteran was assessed with having impetigo that was treated and resolved without chronicity, recurrence or sequela. The examiner also noted that the Veteran sought evaluation and treatment for possible STDs in July 2001, and reported to have had a prior diagnosis of lichen planus - a statement the medical examiner at the time accepted. The VA examiner found that this single treatment episode showed complete resolution on follow-up examination, and no further episodes of skin lesions were noted in the Veteran's service treatment records. According to the examiner, based on his review and understanding of the medical evidence "with the legal medical records felt to be considered irrefutable along with the veterans lay statements...[the] veteran is considered to have had a skin condition most noted as involvement of the penis at least by pre-service records as onset by at least August 2000 that shows no worsening or increased frequency of treatment while in service." The examiner further reasoned that "[a]fter service treatment for possible for acute STD and the long standing recurrent penis lesions that veteran at that time was stated by veteran as for years in duration." The examiner determined that a skin condition attributable to service or permanently aggravated by service is not established based upon all the evidence presented, to include the Veteran's lay statements at the time of the VA examination. In an August 2014 VA addendum opinion, the same VA physician who examined the Veteran in March 2014, determined that the Veteran's skin disorders clearly and unmistakably preexisted his entry into active duty in November 2000. In reaching this determination, the VA physician referenced the August 2000 and September 2000 treatment records which reflected diagnoses of dermatitis and lichen planus. The VA physician further determined that the private medical records clearly and unmistakably reflect that the Veteran's current skin disorders were neither related to nor permanently aggravated by his period of active service. In a subsequent addendum opinion, dated in September 2015, the same VA examiner again determined that the Veteran's lichen planus pre-existed his service. In reaching this assessment, the examiner relied again on the August and September 2000 treatment records, which reflected a diagnosis of lichen planus prior to the Veteran's entrance to active duty, as well as the service treatment records which reflected a diagnosis of lichen planus in service. The VA physician diagnosed the Veteran with having acne and chronic folliculitis. He (the VA examiner) appears to have relied on the Veteran's statements wherein he stated that he had acne during his teenage years, in determining that the Veteran's acne pre-existed his service. The VA physician also diagnosed the Veteran with chronic folliculitis, but noted that the post service treatment records reflected no treatment for this disorder, and thus this disorder had resolved. The VA physician further noted that the Veteran had been diagnosed with having a right inguinal rash at the March 2014 VA examination, and this rash was non-specific, and not related to his period of active service. According to the examiner, based on the available data, the Veteran's diagnosed skin disorders did not have their onset in service, and were not aggravated in service. In March 2016, the Board requested a VHA medical opinion by a VA dermatologist. In the letter requesting the opinion, the Board referenced the relevant medical evidence and noted that because the Veteran's skin was clinically normal at the time of his entry into service in 2000, VA regulations dictated that he was presumed to have no skin condition when he entered service. Thus, for purposes of the medical opinion required to adjudicate the Veteran's claim, the dermatologist was instructed to presume that the Veteran had no skin disability prior to service or at the time of entry into service. The dermatologist was asked to (1) identify all current skin disorders, to include lichen planus, acne, folliculitis, herpes simplex virus papulosquamous eruptions, psoriasis, and an inguinal rash; and (2) opine as to the likelihood that any currently diagnosed skin disorders were related to, and/or had their onset during the Veteran's service. The Board obtained a VHA medical opinion by a VA dermatologist dated in May 2016. In the opinion, the VA physician, J.G., M.D., reviewed the Veteran's medical records in full, and noted that the first notation of a skin problem in service was in February 2001, when the Veteran was diagnosed with having impetigo. After reviewing the remainder of the service treatment records, as well as the post-service treatment records and the March 2014 VA examination report, Dr. G. concluded that the Veteran's medical records reflected an episode of impetigo that was treated with an antibiotic, and the development of a rash on his penis, which was diagnosed as lichen planus, and resolved with the use of hydrocortisone cream. According to Dr. G., the March 2014 examination was negative for evidence of lichen planus. Based on his review of the claims file, as well as his understanding of the relevant medical principles as they stood, Dr. G. opined that the Veteran did not exhibit a current skin condition that had its onset in, or was related to the Veteran's period of military service. In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for lichen planus. As noted above, the October 2009 VA examiner determined that the Veteran had lichen planus that was in remission at the time of the examination. Thus, the Board finds that the element of a current disability is met as the Veteran had a diagnosis of lichen planus at some point during the course of the appeal. With respect to evidence of an in-service incurrence of a disease or injury, as discussed above, the clinical evaluation of the Veteran's skin condition was absent any signs, notations, complaints or diagnosis of a skin condition at his May 2000 enlistment examination, and he denied a history of any skin problems in his medical history report. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. See 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304(b) (2015). Although the March 2014 VA examiner referenced treatment records dated in August and September 2000 which reflected diagnoses of dermatitis and lichen planus, no such records are in the Veteran's claims file. Even assuming that such records existed and showed actual diagnoses of the conditions prior to the Veteran's entrance into service in November 2000, VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2002; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Thus, even if VA was able to show that the disability clearly and unmistakably preexisted service, VA would also have to show that the disability clearly and unmistakably was not aggravated during service in order to rebut the presumption of soundness. As noted, the Veteran's skin was normal at the time of the May 2000 entrance examination and July 2001 clinical records reflect that the Veteran was seen and treated for manifestations of his lichen planus. Thus, because the skin was clinically evaluated as normal upon entrance in May 2000 and there were manifestations of lichen planus in July 2001 during service, the Board finds that VA has not met the onerous burden of showing by clear and unmistakable evidence that the disability was not aggravated during service. "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence"). It is an "onerous" evidentiary standard, requiring that the pre-existence of a condition and the no-aggravation result be "undebatable." See Cotant v. West, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Accordingly, the Board finds that the presumption of soundness has not been rebutted. The Board finds that the Veteran is competent to report that he developed skin problems in service and has suffered continuing symptoms of a skin disorder since his period of service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay testimony is competent to determine the presence of observable symptomatology and "may provide sufficient support for a claim of service connection."). In addition, based on the evidence submitted and statements made in support of his claim, the Board finds the Veteran credible with respect to his assertions. In light of the Veteran's competent and credible assertions, and given the Veteran's current diagnosis of lichen planus, the service treatment records which demonstrate that this disease was first identified and diagnosed by a healthcare provider in service, the Board resolves reasonable doubt in favor of the Veteran and finds that service connection for lichen planus is warranted. Therefore, the Veteran's claim of entitlement to service connection for lichen planus is granted. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. B. Skin Disability other than Lichen Planus The Veteran contends that his current skin disabilities other than lichen planus, which have been diagnosed as folliculitis, facial acne, and the rash on his right inguinal groin, were also incurred in service. In considering all of the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a skin condition other than lichen planus. With regard to whether a skin disorder other than lichen planus had its onset in service, the Board acknowledges the service treatment records which reflected an assessment of impetigo in February 2001, as well as an assessment of lichen planus in July 2001. However, as noted by the 2014 VA examiner, the Veteran's impetigo resolved with treatment, and he did not experience any recurrent episodes or residuals of this condition in service. More importantly, there is no evidence of any impetigo subsequent to service, to include any evidence of a current disability of impetigo. The remainder of the Veteran's service treatment records is predominantly negative for any recurrent skin problems other than lichen planus. Additionally, the Board notes that the competent medical evidence of record does not relate the Veteran's diagnosed skin disorders to his period of service. In the relevant medical opinions provided, the VA examiners determined that the Veteran's diagnosed skin conditions were neither caused by, nor related to, his period of active service. As noted above, the March 2014 VA examiner opined that the Veteran's skin conditions were not related to his period of service, and reiterated this conclusion in the August 2014 and September 2015 opinions. In making this conclusion, the VA examiner explained (in the September 2015 medical opinion) that the service treatment records were negative for any findings of folliculitis, and any folliculitis diagnosed post-service, was diagnosed after service sometime between April and November 2011, and had since resolved. With regard to the right inguinal rash, the examiner determined that this condition had its onset in March 2014, and did not arise during the Veteran's period of active service. Dr. G. also acknowledged the March 2014 objective medical findings reflecting a diagnosis of a nonspecific rash in the right inguinal crease, and still determined that the Veteran's current skin condition was not related to his service. With regard to the Veteran's facial acne, the VA examiner found that this condition arose prior to service, but this is based solely on the Veteran's reported history. Importantly, there is no objective evidence of any acne noted in service or at the time of discharge from service. With regard to whether the Veteran's facial acne is directly related to his period of active service, although the VA examiner did not provide a specific opinion with regard to this particular condition, Dr. G. took note of the March 2014 VA examination report, which included a diagnosis of facial acne, and still found that the Veteran did not have a skin disorder that had its onset in, or was related to, the Veteran's period of service. Indeed, based on his review of the medical records, Dr. G. determined that the Veteran did not exhibit any current skin condition that had its onset in, or was related to the Veteran's period of military service. In reaching this determination, Dr. G. took into consideration the service treatment records as well as the relevant post-service treatment records. Thus, the Board finds that the VA examination report, medical opinions, and May 2016 VHA opinion are entitled to more probative weight than the Veteran's assertion that a skin disorder other than lichen planus was incurred in service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of the Veteran's skin disorders other than lichen planus falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of a skin condition, the etiology of a skin disorder can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Whether the symptoms the Veteran experienced in service or following service are in any way related to any current skin disorder (other than lichen planus) requires medical expertise to determine because it involves a complex medical matter. To the extent that the Veteran believes that his skin disorders are due to his period of service, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran's opinion as to the etiology of any current skin disorder is not persuasive probative evidence. Due to the complexity of the nexus question involved in this case, medical expertise is necessary to resolve the issue. Indeed, the medical opinion evidence shows that the Veteran's skin disorders other than lichen planus did not have their onset in service. For the reasons set forth above, the Board finds the VA medical opinions issued by the March 2014 VA examiner along with the May 2016 VHA opinion to be of far greater probative value than the Veteran's lay contentions regarding the etiology of his skin disorders other than lichen planus. In sum, the Board finds that the competent medical evidence has shown that the Veteran's current skin disorders other than lichen planus did not have their onset in service, and were not causally or etiologically related to his military service. Given the absence of any competent evidence linking any current skin disorder other than lichen planus to service, the preponderance of the evidence is against this claim. Accordingly, service connection for a skin disability other than lichen planus is not warranted on any basis. ORDER Service connection for lichen planus is granted. Service connection for a skin disability other than lichen planus is denied. ____________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs