Citation Nr: 1750107 Decision Date: 11/03/17 Archive Date: 11/13/17 DOCKET NO. 10-13 517 DATE THE ISSUE Entitlement to service connection for a skin disability, to include chloracne as due to herbicide agent exposure. (The issues of entitlement to service connection for a sinus disability and bilateral hearing loss are addressed in a separate decision of the Board.) ORDER Service connection for a skin disability, to include chloracne, is denied. FINDINGS OF FACT 1. The Veteran had service in Vietnam and exposure to herbicide agents is presumed. 2. The Veteran has not been diagnosed with chloracne. 3. The Veteran has diagnoses of lipoma, pigmented macules diagnosed as lentigo, eczema, dermatitis, cysts consistent with lipoma, and verruca vulgans, which did not manifest during service or to a compensable degree within a year thereafter, have not been continuous since service separation, and were not caused by any in-service event, including herbicide exposure. CONCLUSION OF LAW The criteria for service connection for a skin disability, to include chloracne, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.306, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from August 1968 to July 1971, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied service connection for a skin condition and for cysts on stomach. The Veteran testified in December 2008 at a Board hearing before Veterans Law Judge (VLJ) Bush, and the Board remanded the issue for additional development in July 2009. In March 2011, the Veteran testified at a Board hearing before VLJ Seesel. In July 2011, the Veteran was sent a letter notifying him that because he had two Board hearings before two different VLJs on the issue, his claim would have to be decided by a three-member panel of Veterans Law Judges. He was notified that he was entitled to present testimony on this issue before a third VLJ. See Arneson v. Shinseki, 24 Vet. App. 379 (2011) (holding that claimants are entitled to an opportunity for a hearing before every panel member who will ultimately adjudicate the appeal). The letter indicated that if a response was not received within 30 days, the Board would assume the Veteran did not want a third hearing. To date, no response to the letter has been received. In February 2012, the Board recharacterized the issue to entitlement to service connection for a skin disability, to include chloracne as due to herbicide agent exposure, and remanded the issue again for additional development. The remand instructions included making attempts to obtain relevant private treatment records and scheduling the Veteran for a VA dermatological examination to determine the nature and etiology of any diagnosed skin disability. The Veteran was subsequently sent a letter in June 2016 requesting that he submit the treatment records or sign an authorization form to allow VA to obtain the records, and he had a VA skin examination in September 2016. The Board is therefore satisfied that there has been substantial compliance with the remand's directives and will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). Service connection for a skin disability The Veteran contends that that he has various skin problems, including having 13 cysts removed, lumps all over his body, and possible chloracne, which are the result of his service, including exposure to Agent Orange in Vietnam. See the January 2005 statement, November 2005 DRO hearing transcript. He asserts that in Vietnam he began noticing boils or lesions on his legs, arms, neck, and chest, some of which were areas of skin that had been exposed to barbed wire. See the August 2010 DRO hearing transcript. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). If a Veteran was exposed to an "herbicide agent," such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases, including chloracne or other acneform disease consistent with chloracne, will be presumptively service connected even if there is no record of the disease in service. 38 U.S.C.A. §§ 1110, 1116, 1131; 38 C.F.R. §§ 3.307(a)(6), (d), 3.309(e). Here, it is well-established that the Veteran was assigned to an artillery unit in Vietnam during the applicable timeframe, as noted on his DD Form 214; as such, his exposure to herbicide agents such as Agent Orange is presumed. See 38 C.F.R. §§ 3.307(a)(6), 3.309(e). The question for the Board is whether any current skin diagnosis either began during active service, or is etiologically related to service. The Board finds that competent, credible, and probative evidence establishes that the Veteran's diagnoses of lipoma, pigmented macules diagnosed as lentigo, eczema, dermatitis, cysts consistent with lipoma, and verruca vulgans are not etiologically related to the Veteran's active service, to include as due to herbicide agent exposure. Service treatment records (STRs) indicate that in an August 1968 service enlistment examination, the Veteran's skin and lymphatics were found to be clinically normal and he denied having a history of any skin diseases. In February 1971, the Veteran was seen for unhealed sores on his legs, hands, and feet, which were thought to be caused by cuts and scratches from barb wire and boils. In a July 1971 separation examination, the Veteran's skin and lymphatics were again found to be clinically normal and the Veteran noted that "I am in good health." Post-service VA treatment records show that in a January 2004 appointment to establish care, the Veteran was noted to have "a few" lipomas on his arms and neck. The treating nurse practitioner explained to the Veteran that lipomas typically ran in families and were not usually treated unless they became bothersome. In a June 2005 annual physical examination, the Veteran reported having a scaly rash on his hands and lumps scattered on his arms, abdomen, and legs, which he had for more than seven years. He also reported easily bruising. He was noted to have tapioca-like deep-seated vesicles and scaling and fissures in the fingers of both hands, as well as multiple subcutaneous nodules on his back, arms, and abdomen. The doctor indicated that the Veteran had dyshidrotic eczematous dermatitis. He was prescribed antibiotic cream. During an August 2005 dermatology consultation the assessment was possible familial lipomatosis, which were benign, and verruca vulgaris on the left elbow, which was treated with liquid nitrogen. In a November 2005 hearing with a Decision Review Officer (DRO), the Veteran asserted that he first sought treatment for skin problems approximately two years ago, but that he first noticed skin problems during service in Vietnam. He stated that the symptoms started with itching, but had progressed since then. The Veteran was seen in an ER in January 2008 with complaints of a rash on his arms and abdomen for the last several weeks. He indicated he had a similar rash two years prior without a specific diagnosis. He had an erythematous, scaly rash with dry skin on his bilateral forearms and was given eczema triamcinolone ointment. In March 2008, the Veteran reported having a rash for 2-3 years and was found to have atopic dermatitis, which did not improve with triamcinolone cream. In July 2008, the Veteran was noted to have several epidermal inclusions cysts, a possible sty or basal cell carcinoma on his lower lashes, open comedones, benign nevus, benign lentigo, and benign lipomas. Another July 2008 treatment record noted diagnoses of atopic dermatitis and acne vulgaris. In a December 2008 Board hearing, the Veteran testified that he was exposed to herbicide agents in Vietnam and that his subsequent skin problems were given various diagnoses but were all related to sores that he had on the legs, hands, and feet from barb wire in Vietnam. The Veteran asserted that he has had nodules on his skin since then, and that he was told in his separation examination to use a salve. He indicated that his daughter had a similar skin condition. The Veteran testified in another DRO hearing in August 2010 that he developed a skin condition in service in Vietnam and has had the same condition since then. His representative indicated that chloracne is the acne-like eruption of blackheads, cysts, and pustules, particularly linked to toxic exposure to dioxins, which were byproducts of the manufacture of herbicide agents. He stated that although the Veteran had never been given a diagnosis of chloracne, his symptoms were consistent with such a diagnosis. The Veteran had a VA dermatology consultation in December 2010. He was assessed as having epidermal inclusions cysts on his neck and back (for which he declined surgery); numerous subcutaneous nodules on his face, trunk, and extremities, which raised the possibility of familial lipomatosis; open comedones; benign nevus; and benign abdominal lentigo. In October 2011, the Veteran had a skin lesion excision on his posterior neck; results of a biopsy of the lesion were consistent with a ruptured epidermal inclusion cyst. In a March 2011 Board hearing, the Veteran testified that he began getting boils on his skin during his tours in Vietnam, where he was exposed to Agent Orange, and he had continued to have skin problems since that time. He stated that he had boils on his neck, chest, back, and legs, which sometimes broke open and smelled terrible. He also had "fatty tissues" all over his body, which he was told were hereditary but no one in his family had. He stated that his two skin conditions were related, and that he did not receive any treatment after service because he thought the conditions would go away, but they got worse. In December 2014, the Veteran had another skin lesion excision on his right lower back. The Veteran had a VA skin examination in September 2016. He reported having "knots all through me" that occurred to both arms, legs, stomach, and back, with prior excisions from the left wrist, left forearm, and posterior neck. The examiner diagnosed atopic dermatitis, resolved without residuals; verruca vulgans of the left elbow, treated and resolved without residuals; acne vulgaris, treated and resolved; and multiple lipomas/subcutaneous nodules. After reviewing all provided records, the examiner opined that the Veteran's skin conditions, including lipoma, pigmented macules diagnosed as lentigo, eczema, dermatitis, cysts consistent with lipoma, and verruca vulgans, were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the in-service history of being treated for unhealed sores or boils on the Veteran's legs, hands, and feet, which were thought to be caused by cuts and scratches from barbed wire, was a separate and distinct medical condition that healed without residuals. The examiner indicated there was no medical, clinical, or significant research evidence to support the contention that the treatment for unhealed sores thought to be caused by cuts and scratches from barbed wire caused any chronic skin disability. In addition, there was no medical, clinical, or significant research to support the contention that the presumed exposure to herbicide agents during service caused any chronic skin disability. In sum, based on the above, the Board must conclude both that the Veteran does not have a diagnosis of chloracne, and that the skin diagnoses he does have did not have their onset during service and have not been continuous since that time. First, there is no medical evidence that the Veteran has, or has ever had, a diagnosis of chloracne. Rather, the only evidence of such a diagnosis is the Veteran and his former representative's assertions that the Veteran's symptoms are consistent with chloracne. Lay testimony on skin diagnoses and etiology is not competent in the present case because neither the Veteran nor his former representative have been shown to possess the knowledge of the complexities of dermatology, the various causes of skin disorders, and the results of exposure to various chemicals that is required to diagnose skin disorders, or to opine on their etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). The Veteran has also not alleged that he was told of such a nexus by a competent expert, and such assertions have not subsequently been verified by such an expert. As such, presumptive service connection is not for application as the Veteran has not been diagnosed with a skin condition listed in 38 C.F.R. § 3.309(e). The Board also finds that the weight of the competent and credible evidence establishes that the current skin diagnoses, including lipoma, pigmented macules diagnosed as lentigo, eczema, dermatitis, cysts consistent with lipoma, and verruca vulgans, are not medically related to active service. The September 2016 VA examiner opined that the Veteran's skin conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the in-service history of being treated for unhealed sores or boils on the Veteran's legs, hands, and feet, which were thought to be caused by cuts and scratches from barbed wire, was a separate and distinct medical condition that healed without residuals. The examiner indicated there was no medical, clinical, or significant research evidence to support the contentions that the in-service treatment for unhealed sores thought to be caused by cuts and scratches from barbed wire caused any chronic skin disability, or that the presumed exposure to herbicide agents during service caused any chronic skin disability. She also pointed to the references in VA treatment records that the Veteran's lipomas are familial or heredity in nature. The Board finds that the VA examiner's opinion is competent and credible, and as such, is entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The VA examiner's opinion was rendered after reviewing the Veteran's claims file, which included STRs; soliciting a medical history from the Veteran; and conducting a physical examination of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The VA examiner provided the facts and rationale on which she based her opinion. The probative value of the VA examiner's opinion is further bolstered by its consistency with the evidence in the claims file. The opinion is therefore probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has made a general assertion that his skin diagnoses are related to service. The Board, however, cannot rely on the Veteran's general assertions as to medical nexus to service because, as discussed above, although he is competent to report observable skin symptoms such as bumps and itching, he is not shown to possess the type of medical expertise that would be necessary to opine regarding the etiology of skin disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The question of causation in this case involves a complex medical issue, requiring knowledge of the types and presentation of skin disorders, and the Veteran has not been shown to have the medical expertise required to address such an issue. Moreover, there is no medical opinion to contradict the conclusions of the VA examiner. Thus, there is no competent evidence to establish a nexus between the current skin diagnoses and any documented event or incident of service. There can be no doubt that the Veteran rendered honorable and faithful service for which the Board is grateful, and he is sincere in his belief that his skin diagnoses are related to the in-service skin treatment on his legs, feet, and hands. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted for a skin disability. The Board has weighed the evidence of record, and finds that the preponderance of the evidence is against a finding that any of the skin diagnoses are related to service. As such, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). S. BUSH M. SORISIO Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals __________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD N. Nelson, Associate Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs