Citation Nr: 1800036	
Decision Date: 01/02/18    Archive Date: 01/19/18

DOCKET NO.  11-14 760	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, Ohio


THE ISSUE

Entitlement to service connection for a skin disability, including psoriasis and eczema.  


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

S. Hurley, Associate Counsel

INTRODUCTION

The Veteran had active military service from September 1977 to March 1978.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for psoriasis.  

The Veteran testified before the undersigned at a videoconference hearing in May 2016.  A transcript of the hearing has been reviewed and associated with the claims file.  

This matter was before the Board in August 2016, at which time it was remanded for further evidentiary development, including a VA examination to determine the etiology of any diagnosed skin disability.  Pursuant to the Board's remand instructions, a VA examination was performed in August 2016.  

In September 2017, the Board requested an advisory opinion from a Veterans Health Administration (VHA) medical expert with respect to the question of whether the Veteran's skin disability was related to his service.  The opinion was submitted in October 2017 and the Veteran and his representative were provided a copy of it.  The Veteran's representative submitted a response to the opinion in December 2017.  As such, the case is now ripe for adjudication.  


FINDING OF FACT

The weight of the evidence is against a finding that the Veteran's skin disability, including psoriasis and eczema, had its onset during military service or is otherwise related to such service.  



CONCLUSION OF LAW

The criteria for service connection for a skin disability, including psoriasis and eczema, have not been met.  38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.309 (2017).  


REASONS AND BASES FOR FINDING AND CONCLUSION

Duty to Notify and Assist

In this case, VA sent a notification letter in November 2009 to the Veteran.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Next, VA has a duty to assist the Veteran in the development of the claim.  This duty includes assisting him in the procurement of service treatment records and pertinent records, including treatment records, and providing an examination when necessary.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159.  Service treatment and personnel records are associated with the claims file.  Available post-service medical records have been obtained.  Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied.  The Veteran was provided VA examinations in March 2012, June 2013, December 2015, and August 2016.  The Board subsequently requested an expert medical opinion through VHA.  As such, the Board will proceed to the merits. 

Legal Criteria

Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active military service.  38 U.S.C.A. § 1131 (2012); 38 C.F.R. § 3.303(a).  

To establish service connection the evidence must show: (1) a present disability; 
(2) an 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).  

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant.  38 U.S.C.A. § 5107(b) (2012); 38 C.F.R. § 3.102 (2016); Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990).    

Factual Background and Analysis

The Veteran filed a claim for a skin disability, including psoriasis, in September 2009 and asserts it is related to his skin disability in service.  

Throughout the pertinent time period on appeal, the Veteran has been diagnosed with psoriasis and eczema.  See August 2016 VA examination report.  Thus, 
a present disability has been established by the evidence.  

The Veteran's service treatment records reveal that in September 1977, the Veteran complained of a rash on his neck and waist.  Physical examination revealed small red blisters on his neck, waist, and axilla.  He was assessed with a heat rash and given Desenex powder.  He returned in November 1977 with a papule type rash under both arms.  He was diagnosed with dermatitis and treated with hydrocortisone cream.  As such, an in-service incurrence has been shown.  

The remaining question for consideration is whether the Veteran's current psoriasis is related to the heat rash and dermatitis incurred in service.  

The Veteran's January 1978 separation examination revealed a normal clinical evaluation of his skin.  

From 2000 through 2008, the Veteran complained of recurrent rashes and lesions and was assessed with a medley of skin diseases, including folliculitis, atopic dermatitis, recurrent scabies, fungal dermatitis, hyperkeratosis, dermatophytosis, prugrio nodularis, and recurrent keratotic lesions.  See 07/11/2000, VBMS, Medical Treatment Record- Government Facility; 11/13/2000, VBMS, Medical Treatment Record- Government Facility; 02/05/2004, VBMS, Medical Treatment Record, pp. 51, 137-138; 02/05/2004, VBMS, Medical Treatment Record, pp. 20, 69-70; 05/01/2008, VBMS, Medical Treatment Record- Government Facility, pp. 3-4; 05/06/2011, VBMS, Medical Treatment Record-Government Facility, pp. 5, 7, 32.  

During the pertinent time period of this claim, he was assessed with eczematous dermatitis in February 2009 and psoriasis in August 2009.  See 06/05/2017, Legacy Content Manager Documents, CAPRI, p. 490; 05/06/2011, VBMS, Medical Treatment Record- Government Facility, p. 37; M21-1, Part IV, Subpart ii, 2.B.1.b (noting a near-contemporaneous diagnosis is a diagnosis that is dated approximately within one year prior to the date of the claim being submitted and is deemed a current disability for VA disability compensation purposes).  

In August 2009, the Veteran's treating provider indicated that he had eczematous dermatitis with clinical lesion morphology consistent with psoriasis.  See 06/05/2017, Legacy Content Manager Documents, CAPRI, pp. 493-494.  

The Veteran was afforded a VA examination by a resident in March 2010.  The resident assessed the Veteran with plague type psoriasis.  Based on the Veteran's statements that he was initially treated for eczema in 1977, which remained unimproved until being diagnosed with psoriasis in 2009, the resident concluded that it was likely that the Veteran's psoriasis began while he was in service.  After a review of the record, the Board finds that this opinion is inconsistent with the facts of the case given that the Veteran was diagnosed with a heat rash and dermatitis in service and not eczema.  As such, the weight of this opinion is diminished.

The Veteran was afforded a VA examination by a physician assistant (PA) in June 2013 and August 2016.  The PA concluded that there was no relationship with the Veteran's psoriasis, which is a chronic skin condition, and the heat rash and dermatitis diagnosed in service.  Given that there was no documentation of psoriasis in service and he was not diagnosed with psoriasis until 33 years later, it was less likely than not that his current skin conditions, including psoriasis, were related to the documented skin conditions in his service treatment records.  

A VA examination was performed by an internist in December 2015, who concurred with the June 2013 opinion.  

Given the complexity of the Veteran's skin disabilities, the Board requested an expert medical opinion through VHA.  J.G., PA-C, MS in the VA dermatology department, performed a review of the record in its entirety and issued an opinion in October 2017.  Based on his review of the record, J.G. assessed the Veteran with psoriasis and eczema since September 2008 and concluded that it was less likely than not that the Veteran's skin disorders of eczema or psoriasis had its onset during the Veteran's active duty service and/or is otherwise etiologically related to his service.  J.G. reasoned that a diagnosis of psoriasis or eczema does not appear as described in the service treatment records and the recommended treatment of Desenex and hydrocortisone cream in service would not work for psoriasis or eczema.  Furthermore, psoriasis is an immune system disorder and hydrocortisone cream would be ineffective and would not respond to Desenex powder which is an antifungal.  

After a review of the evidence, the Board finds that service connection for a skin disability, including psoriasis and eczema, is not warranted.  In this regard, the evidence of record does not show that the Veteran's psoriasis and/or eczema are related to his diagnosis of a heat rash and dermatitis in service.  The VHA expert in dermatology, J.G., concluded that the Veteran's current skin disabilities of psoriasis and eczema were not related to his in service diagnoses of heat rash and dermatitis given that psoriasis and/or eczema were not described in his service treatment records and the in service treatment of hydrocortisone cream and Desenex would not treat psoriasis and/or eczema.  The Board finds this opinion to be credible, competent medical evidence that weighs heavily against a nexus.  In this regard, the VHA expert had familiarity with the Veteran's pertinent medical history, to include his in-service treatment and provide a comprehensive rationale for the opinions provided that referenced medical literature as support.

The Board acknowledges the March 2010 VA opinion which indicated that it was likely that the Veteran's psoriasis began while he was in service.  However, this opinion was based on the Veteran's statement that he was initially treated for eczema in 1977 and not the actual review of the Veteran's service treatment records.  Furthermore, the Board has reviewed the Appellate Brief submitted in December 2017, which asserts that the Veteran has been living with the same skin disability since being treated in September 1977.  In this regard, the Board notes that the October 2017 expert opinion notes that in January 2000 the Veteran had scabies, which is a mite that burrows under the skin and causing itching.  Additionally, the 2017 VHA opinion notes that the Veteran was diagnosed with axillary and low back rash in 2003 and 2006 with very little or no evidence of rash and treated with antifungal creams.  The expert stated that such treatment would be inconsistent with a dermatitis that began 25 years earlier.  The Board finds that the contentions in the brief are addressed and outweighed by the competent medical evidence.  

Furthermore, the Board acknowledges the Veteran's statements that his skin disability was misdiagnosed in service and after service.  Although in some cases a layperson is competent to offer an opinion addressing the etiology of a disorder, the Board finds that, in this case, the determination of the origin of his current skin disability and correct diagnosis is a medical question not subject to lay expertise.  The Board finds that due to the number and complexity of skin disorder, a lay person is not competent to provide evidence of a diagnosis (or misdiagnosis) or etiology.  See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007).  
As such, the Board places no weight on the Veteran's statements to this effect.  The Board adds that the Veteran is competent to report his obseravation of his skin related symptoms such as itching and redness and these have been considered in adjudicating this appeal.  

In light of the foregoing, the Board finds that service connection is not warranted for the Veteran's skin disability, including psoriasis and eczema.  As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection for a skin disability must be denied.  See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53.


ORDER

Service connection for a skin disability, including psoriasis and eczema, is denied. 




____________________________________________
Paul Sorisio
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs