Citation Nr: 1759996 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 13-13 051 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD. 2. Entitlement to service connection for a skin disability, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1984 to January 1985, and from January 2002 to August 2002, with additional service in the Army Reserve until August 2014. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In July 2015, the Board remanded the Veteran's claims for further development. The Veteran was recently awarded service connection for posttraumatic stress disorder (PTSD). See Rating Decision, March 2015. In June 2017, the Board remanded the issues of entitlement to service connection for hypertension and for a skin condition for further development. The remand required the RO to take appropriate steps to obtain a VA medical opinion concerning both reported disabilities. In compliance with the remand directives, a new VA medical opinion was obtained. The directives having been substantially complied with concerning the issue of service connection for hypertension, and the matter is again before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of entitlement to service connection for a skin disability is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Hypertension was not manifest in service or within one year of separation. 2. Hypertension was not caused or aggravated by the Veteran's PTSD. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by service, and may not be presumed to have been incurred therein, and was and was not proximately due to, the result of, or aggravated by the Veteran's PTSD. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection To establish service connection a Veteran must generally 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be established for cardiovascular-renal disease, including hypertension, manifesting to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. 3.307, 3.309(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). For a Veteran who had active service in the Southwest Asia theater of operations during the Persian Gulf War (a Persian Gulf veteran), presumptive service connection may be established for a qualifying chronic disability, which specifically includes a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as fibromyalgia. See 38 U.S.C.A. §§ 1117, 1118 (2012); 38 C.F.R. § 3.317 (2017). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317 (b). As noted above, service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Here, the Veteran's DD-214 for his period of active service in Kuwait in the Southwest Asia Theater of Operations. 38 C.F.R. § 3.317 (e)(1). The Veteran underwent a Gulf War General Medical Examination most recently in May 2016. His chief complaints were a skin condition, sleeping difficulties, and a respiratory disorder. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). III. History The Veteran reports that during his first period of active duty from August 1984 to January 1985, and during his subsequent service, he was exposed to paints, cleaning solvents, fuels, oil, grease, and diesel exhaust. See medical records, received January 2016 at p. 7 of 8. In a November 1984 Health Questionnaire for Dental Treatment, the Veteran did not indicate high blood pressure, heart trouble/chest pain, or list hypertension. See STRs, received November 2015 at p.21 of 278. An April 1997 Reserve quadrennial examination, the examiner noted the Veteran's report of a history of hypertension, for which he took medication. However, the examiner noted no cardiovascular abnormalities and did not confirm a current diagnosis if hypertension. In the Veteran's August 2001 Report of Medical History, the Veteran denied pain or pressure in the chest, palpitation, pounding heart or abnormal heartbeat, heart trouble or murmur, and high or low blood pressure. His August 2001 Report of Medical Examination was clinically normal for the heart. Prior examinations were substantially the same. The Veteran reports that in Kuwait in 2002, he was exposed to smoke screens (fog oil), sand/dust, smoke from burning trash or feces, smoke from oil fires, solvents, vehicle or truck exhaust fumes, and industrial pollution. See, e.g., STR, January 2009 (received November 2015 at p. 57 of 278). He reported in an August 2002 post-deployment health assessment (Kuwait) that he was exposed to a "power plant [that] runs 24 hours with smoke coming out of stack" and to dust storms. See STRs, received November 2015 at p.43 of 278. In a March 2006 physical examination, the Veteran reported that he had high blood pressure in 2002. However, the examination report was silent for any cardiovascular abnormalities and blood pressure was measured as 122/70 mmHg. A January 2009 VA treatment record shows an impression of hypertension. A May 2009 VA examination report shows the examiner noted a history of hypertension since 2002, apparently by the Veteran's reported history; but no etiological opinion was provided. In an October 2009 Preventative Health Assessment, the Veteran endorsed taking medications for high blood pressure. See STRs, received November 2015 at p. 145 of 278. In an October 2009 Chronological Record of Medical Care, the Veteran had hyptertension which was currently being managed by the VA. He was on a single medication with good control. See STRs, received November 2015 at p. 189 of 278. In July 2015, the Board remanded the claim to obtain a VA medical opinion. Subsequently, a new October 2015 VA examination was performed. The VA examiner opined, in short, that it is less likely than not that the Veteran's hypertension is related to his active service, essentially noting there was no evidence in the service treatment records linking the Veteran's hypertension to service. A May 2016 VA medical opinion was obtained from a different VA examiner, who likewise opined that it is less likely than not that the Veteran's hypertension is related to service based on the lack of nexus evidence in the service treatment records. She explained that there was no documentation found for a diagnosis of active duty hypertension prior to a 2006 STR Dental Questionnaire which reported he was taking blood pressure pills. She noted that elevated blood pressure readings have been documented in VA records since the Veteran initiated VA care on January 31, 2009 (with a provider statement that there is history of hypertension not currently on medication). She pointed out that in service readings are scant. She noted that October 2009 are the earliest blood pressure readings that can be located in STRs. The physician stated that she was unable to locate the documentation of consistent active duty blood pressure elevations such that a nexus can be established between military service and the present condition. The Veteran was afforded a subsequent June 2017 VA medical opinion. The physician reviewed the claims file and opined that it is less likely than not that the Veteran's hypertension is related solely to stress from his period of active duty from August 1984 to January 1985, as well his any subsequent intermittent periods of active duty for training (ACDUTRA). She explained that there is inadequate objective evidence in the STR's of a diagnosed hypertensive condition from 1984 and beyond during periods of active duty service. She also opined that it is less likely than not that the Veteran's hypertension is solely caused by/secondary to or aggravated by his service connected PTSD. The physician opined that the etiology of the Veteran's hypertension is multifactorial. It may be partially associated with PTSD. However, she noted that the Veteran has other significant risk factors for hypertension including morbid obesity, alcohol abuse, OSA, hyperlipidemia, diabetes mellitus, and chronic pain. Ongoing VA treatment records are substantially the same. They show impressions of and treatment for diabetes mellitus, hypertension, and obesity. The Veteran submitted a lay statement with argument received in July 2017. He claims that his blood pressure was sky high during his deployment in Operation Enduring Freedom in 2002. Because of all the stress and pressure placed on him, the dangerous mission he was given, and not being able to sleep, he was not able to get any sleep and his heart rate was on fast forward at all times. He had to go to the clinic to get blood pressure pills to lower his blood pressure before he had a heart attack. He was told that he would be on this medicine for the rest of his life. IV. Analysis The Veteran alleges that his hypertension is due to exposure to toxic chemicals in service, due to stress from combat in Kuwait, and otherwise stress of serving 26 years in the Army Reserve. See Claim, March 2009 (toxins), October 2010 Notice of disagreement (stress). The Veteran is competent to report that he was exposed to burn pits, exhaust, fumes, and smoke. He is competent to report feeling an increased pulse. He is competent to report that he was told by his physician that he had high blood pressure and hypertension in 2002 which required medication. The Board finds these reports credible. Despite the lack of evidence of a nexus to a period of active service, the Board acknowledges that the Veteran has alleged that his hypertension was the result of "stress" over the course of his 26 years of service. The Veteran's STRs are clinically normal for hypertension and are not consistent with his reports. The Veteran served on active duty from August 1984 to January 1985, and from January 2002 to August 2002. In the Veteran's August 2001 Report of Medical History, the Veteran denied pain or pressure in the chest, palpitation, pounding heart or abnormal heartbeat, heart trouble or murmur, and high or low blood pressure. His August 2001 Report of Medical Examination was clinically normal for the heart. The Board finds this to be highly probative. It was not until January 2009 that a treatment record showed an impression of hypertension. This was many years removed from discharge. The VA examinations support this finding. While a May 2009 VA examination report shows a history of hypertension since 2002, apparently by the Veteran's reported history, no etiological opinion was provided. A subsequent May 2016 VA medical opinion was obtained from a different VA examiner, who opined that it is less likely than not that the Veteran's hypertension is related to service based on the lack of nexus evidence in the service treatment records. In the June 2017 VA medical opinion, the physician reviewed the claims file and opined that it is less likely than not that the Veteran's hypertension is related solely to stress from his period of active duty from August 1984 to January 1985, as well his any subsequent intermittent periods of active duty for training (ACDUTRA). She explained that there is inadequate objective evidence in the STR's of a diagnosed hypertensive condition from 1984 and beyond during periods of active duty service. The Board finds this to be highly probative. While years later he reported he was diagnosed with hypertension in 2002, there is no record of any such diagnosis during his second period of active duty from February 2002 to August 2002. No mention of hypertension is made on his August 2002 post-deployment assessment. In fact, hypertension was not conclusively and consistently identified until a January 31, 2009 VA treatment record. To the extent STRs show that the Veteran had hypertension in April 1997, and the Veteran reported an onset in 2002, such evidence is inconsistent with the weight of the contemporary medical evidence of record. This further diminishes its credibility. The Board acknowledges that the Veteran has alleged that his hypertension was caused by stress, pressure while deployed, and exposure to burn pits, dust storms, feces, and smoke stacks. Regardless, the Board finds that there is no medical evidence tending to indicate that the Veteran's chronic hypertension was caused by such exposure in service. Rather, as explained by the June 2017 VA examiner, the etiology of the Veteran's hypertension is multifactorial. The Veteran has other significant risk factors for hypertension including morbid obesity, alcohol abuse, OSA, hyperlipidemia, diabetes mellitus, and chronic pain. The Board finds this to be highly probative. Regarding direct service connection, the Board finds that the preponderance of the evidence is against finding that the Veteran's hypertension is related to service. The Board finds the opinions of the May 2016 and June 2017 VA medical opinions to be the most probative evidence regarding the etiology of the Veteran's hypertension. The most probative evidence suggests hypertension first manifest in January 2009, many years after discharge. Although the Veteran may have experienced episodes of elevated blood pressure including from the stress of deployed service, the Veteran did not have the characteristic manifestations in service necessary to identify a chronic disease entity. The Veteran also claims that he has hypertension that is related to his service connected PTSD. In addressing the Veteran's claim for secondary service connection, the June 2017 VA examiner opined that it is less likely than not that the Veteran's hypertension is solely caused by/secondary to or aggravated by his service connected PTSD. The Board finds this to be highly probative. To the extent that the Veteran attributes his hypertension to service and to his service-connected PTSD, the Board ultimately finds the medical opinion of the VA examiner to be by far more probative based on their medical education, training, and experience, and based on the detailed rationales provided for their conclusions. See 38 C.F.R. § 3.159(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The competent and probative evidence suggests that the Veteran's hypertension was not caused or aggravated by his PTSD. Consequently, the Veteran is also not entitled to service connection for a back disability on a secondary basis. 38 C.F.R. § 3.310. Although the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, there is no disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses manifesting with the same symptomatology as his currently identified hypertension. See 38 C.F.R. § 3.317. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypertension is denied. REMAND A remand is necessary for additional development concerning the Veteran's skin disability. The Veteran claims that he has a skin condition that is related to service, including as due to an undiagnosed illness or medically unexplained chronic multisymptom illness relating to his service in Kuwait. As explained above, the Board acknowledges that the Veteran has alleged various environmental exposures during his service in Kuwait, including but not limited to burning trash or feces, smoke stacks, dust storms, and exhaust; and that he alleges exposure during his first period of active service from August 1984 to January 1985, and during his subsequent service, to paint, cleaning solvents, fuels, oil, grease, and diesel exhaust. In a November 2013 buddy statement, E.M. reported that dust storms in Kuwait left burning rashes on the Veteran's skin, and that his face was dry and flaky. On his February 2009 claim, the Veteran reported he experienced "dry facial skin." A September 2012 VA examination report prepared by Dr. D.C. shows the Veteran reported a history of chronically dry, red, chapped areas of facial skin on either side of nose nasolabial folds and chin that looked like a rash when flared ever since he returned from the Persian Gulf. The physician diagnosed chronic dermatitis but opined in October 2012, however, that "the Veteran should be evaluated by preferably a VA Dermatologist to determine if his nonspecific chronic dermatitis condition is a single symptom illness associated with a hazardous Gulf War exposure." A January 2013 VA Gulf War medical examination report shows that the intended VA dermatology exam request was in fact returned to the same VA examiner as in September 2012, Dr. D.C. (not a dermatologist). The VA examiner noted that the Veteran presented demonstrating chronic constant nonspecific facial erythema with sandpapery texture and flaking/peeling, including on his nose, nasolabial folds, glabella and cheeks bilaterally. The VA examiner opined it was an "undiagnosed illness," but further opined that a medical opinion was not warranted. In July 2015, the Board remanded the claim for a new VA examination for clarification as to the nature and etiology of the claimed skin condition. An October 2015 VA examination report (skin diseases) by V.G., a nurse practitioner, shows the Veteran reported that he experiences a red rash at intervals behind the ears and under the chin, and that he used Vaseline and cocoa butter everyday on his "dry" skin. The examiner noted, however, that examination of the Veteran's skin was normal. In her separate October 2015 VA medical opinion (Gulf War), the examiner reiterated that the September 2012 VA examiner wrote that the Veteran should be evaluated by a VA dermatologist. In the other separate October 2015 VA medical opinion (non-Gulf War report); however, the VA examiner opined that the Veteran had symptomatology attributable to an unknown clinical diagnosis. A May 2016 VA examination report reflects the Veteran reported facial breakouts once per week. The VA examiner noted there was no visible skin condition on examination. In a separate VA medical opinion report, the VA examiner opined that there was no chronic skin condition diagnosed on examination or in the VA treatment records, and opined she could not provide an opinion without resorting to mere speculation. As shown above, the Board remanded this claim for a clarifying VA medical opinion. The Board noted in the July 2015 remand that the Veteran had in fact been diagnosed with chronic dermatitis, but there was no clear opinion regarding the etiology of the Veteran's diagnosed dermatitis in September 2012. Also, in light of the fact that the Veteran's skin condition was not active at the time of the last two VA examinations in October 2015 and May 2016 (despite his report of experiencing symptoms every week), the Board found that a new VA examination should be obtained. The Veteran was afforded a May 2016 Gulf War examination. There was no chronic skin condition identified. The Veteran's current medical records from VA primary care records revealed no skin condition upon examination or diagnosed condition per medical records. The Veteran's 2009 VA examination had documented chronic dermatitis; however, the last exams revealed no visible skin condition upon assessment. The Veteran complained of burning and itching to his facial area. The VA examiner indicated that an opinion could not be offered as to whether the Veteran's objective symptomatology is attributable to a diagnosis without resorting to mere speculation. The VA examiner concluded that there is no current diagnosis for the Veteran's skin condition. In July 2017 the Veteran submitted a lay statement indicating that he has caking dry skin on his face area and head dropping off and red rash scaly patches. He reported treatment by Dr. T. L. with topical steroids to relieve constant itching. Associated April 2017 private treatment records from Dr. T. L. show the Veteran has a hyperpigmental nummular scaly patch x 2 presternal. The Veteran reported that his skin condition began when he was deployed to Kuwait and Iraq. The dermatologist's clinical assessment was neoplasm of uncertain behavior of skin, flexural eczema, and seborrheic dermatitis of scalp with facial changes as well. In June 2017, the Board remanded the Veteran's claims for additional development. The Board remand required the AOJ to schedule the Veteran for a new VA examination to address the nature and etiology of his claimed skin condition, including his diagnosed dermatitis. A June 2017 VA medical opinion was subsequently obtained. The VA examiner wrote that, "The Veteran has no current active diagnosis of a skin disorder. An opinion cannot be provided." See June 2017 VA Examination p. 5. The June 2017 VA remand directives specifically requested a medical etiology opinion be provided, and also highlighted the evidence of record that the Veteran has at the very least lay evidence of dry skin, and chronic dermatitis identified in September 2012 VA examination by Dr. D. C. The June 2017 remand also explicitly required, "If no active skin condition is found, then the VA examiner should nevertheless address the etiology of the diagnosed dermatitis in September 2012, and address - with a thorough rationale - whether the Veteran otherwise has a skin condition that is due to an undiagnosed illness, a medically unexplained chronic multisymptom illness relating to his Kuwait service, or directly the result of the environmental exposures in Kuwait." The VA examiner also did not address whether the Veteran's skin complaints or manifestations are related to an "undiagnosed illness" or medically unexplained chronic multisymptom illness relating to his service in the Persian Gulf. Compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Consequently, a remand is necessary to obtain a VA examination that complies with the June 2017 remand directives. Accordingly, the case is REMANDED for the following actions: 1. Obtain a VA medical opinion from an appropriate examiner to address the nature and etiology of his claimed skin condition, including his diagnosed dermatitis. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner should opine as to whether it is "at least as likely as not" that the Veteran's diagnosed dermatitis is related to his active service, including both periods of active duty from August 1984 to January 1985, and from February 2002 to August 2002. Request that the VA examiner address the Veteran's contention that his skin condition was caused by his reported exposures during his first period of active service from August 1984 to January 1985 to paint, cleaning solvents, fuels, oil, grease, and diesel exhaust; and during his second period of active service from February 2002 to August 2002 in Kuwait to smoke screens (fog oil), sand/dust, smoke from burning trash or feces, smoke from oil fires, solvents, vehicle or truck exhaust fumes, and industrial pollution. See, e.g., STR, dated January 2009 (received November 2015 at pp. 57-60 of 278). The VA examiner is also asked to address whether the Veteran's skin complaints or manifestations are related to an "undiagnosed illness" or medically unexplained chronic multisymptom illness relating to his service in the Persian Gulf. Please include a rationale for any such conclusion. Any opinion must be accompanied by a complete rationale. If no active skin condition is found, then the VA examiner should nevertheless address the etiology of the diagnosed dermatitis in September 2012, and address - with a thorough rationale - whether the Veteran otherwise has a skin condition that is due to an undiagnosed illness, a medically unexplained chronic multisymptom illness relating to his Kuwait service, or directly the result of the environmental exposures in Kuwait. 2. After the development requested above has been completed to the extent possible, if a benefit remains denied, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and given the opportunity to respond thereto. The appellant 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. §§ 5109B, 7112 (2012). ______________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs