Citation Nr: 1802914 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 11-23 833A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an initial rating in excess of 30 percent prior to November 7, 2014 and in excess of 70 percent thereafter for anxiety disorder, not otherwise specified. 3. Entitlement to an initial rating in excess of 30 percent for pseudofolliculitis. 4. Entitlement to an initial compensable rating for allergic rhinitis, status post sinus surgery. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability prior to December 2, 2015. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Crawford, Associate Counsel INTRODUCTION The Veteran had active military service from October 1975 to November 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2010, June 2012, and September 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In the January 2010 rating decision, the RO granted service connection for anxiety disorder, and assigned a 10 percent rating, effective June 5, 2008. Thereafter, in the June 2012 rating decision, service connection was granted for pseudofolliculitis and a 30 percent rating was assigned, effective July 22, 2011. In the September 2013 rating decision, the RO denied service connection for hearing loss and granted service connection for allergic rhinitis, status post sinus surgery and assigned a noncompensable rating, effective October 26, 2012. Thereafter, in a February 2015 rating decision, the RO increased the rating for the Veteran's anxiety disorder to 30 percent, effective June 5, 2008, and to 70 percent, effective November 7, 2014. Since this was not a full grant of benefits, the Veteran's claim for an increased rating for anxiety disorder remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In January 2016, the Veteran submitted a VA Form 21-8490 Veterans Application for Increased Compensation Based on Unemployability, indicating he was unemployable due to his service-connected mental disorder. Although this application was adjudicated in a January 2017 rating decision, which granted entitlement to TDIU, effective December 2, 2015, the Board notes that the Veteran's claim for TDIU was raised in conjunction with his claim for an increased rating claim for his service-connected mental disorder, which remains on appeal. As entitlement to TDIU has not been awarded for the entire appeal period, his claim for TDIU prior to December 2, 2015, also remains on appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The issues of entitlement to initial increased ratings for an anxiety disorder and pseudofolliculitis were before the Board in August 2014, at which time they were remanded for additional evidentiary development. In February 2017, the Board remanded the claims for service connection for bilateral hearing loss, and initial increased ratings for anxiety disorder, pseudofolliculitis, and allergic rhinitis for further development. FINDINGS OF FACT 1. The Veteran does not have a current bilateral hearing disability loss for VA compensation purposes. 2. For the appeal period prior to November 7, 2014, the Veteran's anxiety disorder was manifested by symptoms no greater than occupational and social impairment with reduced reliability and productivity; symptoms productive of occupational and social impairment with deficiencies in most areas were not shown. 3. For the appeal period from November 7, 2014, the Veteran's anxiety disorder has been manifested by symptoms no greater than occupational and social impairment with deficiencies in most areas; total occupational and social impairment has not been shown. 4. The Veteran's pseudofolliculitis is manifested by dermatitis or eczema covering 20 to 40 percent of the entire body or 20 to 40 percent of exposed body areas affected; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period has not been shown. 5. The Veteran's allergic rhinitis has not been productive of polyps, an obstruction of the nasal passage greater than 50 percent on both sides, or a complete obstruction on one side. 6. The Veteran was employed full-time prior to December 2, 2015. CONCLUSIONS OF LAW 1. Service connection for bilateral hearing loss is not warranted. 38 U.S.C. §§ 1101, 1131, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 2. For the appeal period prior to November 7, 2014, the criteria for an initial rating of 50 percent, but no higher, for the Veteran's service-connected anxiety disorder, not otherwise specified, have been met. 38 U.S.C. §§ 1155, 5107(b), 5110 (2012); 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9413 (2017). 3. For the appeal period from November 7, 2014, the criteria for an initial rating in excess of 70 percent for the Veteran's service-connected anxiety disorder, not otherwise specified, have not been met. 38 U.S.C. §§ 1155, 5107(b), 5110 (2012); 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9413 (2017). 4. The criteria for an initial rating in excess of 30 percent for pseudofolliculitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.118, Diagnostic Codes 7899-7806 (2017). 5. The criteria for an initial compensable rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6522 (2017). 6. The criteria for entitlement to TDIU, prior to December 2, 2015, are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In this case, required notice was provided and neither the Veteran nor his representative has alleged or demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). Thus, VA's duty to notify has been satisfied. As to VA's duty to assist, 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). All pertinent records have been obtained, to the extent available. The Veteran was also afforded VA examinations for his claimed disabilities. In November 2017, the Veteran's representative argued that although the Veteran had been afforded a VA examination in April 2017, pursuant to the Board's February 2017 remand, it was inadequate because there was no indication in the examination report as to how the Veteran's hearing loss impaired his daily activities. The Veteran's representative observed that the Board's February 2017 remand had specifically instructed that during the VA examination, the examiner was to also note how the Veteran's hearing loss impacted him in his daily life. See November 2017 Appellate Brief. A review of the April 2017 VA examination report shows, however, that no impact of the Veteran's hearing loss was noted because it was concluded that the Veteran's hearing loss did not impact his ordinary conditions of daily life, including ability to work. Additionally, despite the Board's February 2017 remand instructions, it is noted that the impact of a Veteran's hearing loss disability on his daily life is not pertinent to a service connection claim (and instead is pertinent to the matter of the rating to be assigned for a service-connected disability). As the issue before the Board is one of service connection, any failure to elicit information regarding the impact of the Veteran's hearing loss disability on his daily life is not detrimental to the claim. Accordingly, the Board finds there has been substantial compliance with its February 2017 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand). Neither the Veteran nor his representative has raised any other issues with the duty to notify or 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 the duty to assist argument). For these reasons, the Board concludes that VA has fulfilled its duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. II. Legal Criteria, Factual Background, and Analysis As an initial matter, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the analysis will focus specifically on what the evidence shows, or fails to show, as to the issues on appeal. A. Service Connection for Bilateral Hearing Loss Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection may 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) (2017). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a), including organic diseases of the nervous system, to include sensorineural hearing loss, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. §§ 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). With chronic disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2017). 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. Id. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2017). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in 38 C.F.R. § 3.309(a)." Walker, 708 F.3d at 1337. Service connection may nonetheless be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1) (2017). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (2017). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Furthermore, it is the responsibility of the Board to assess the credibility and weight to be given to the evidence. Hayes v. Brown, 5 Vet. App. 60 (1993). The Veteran is seeking service connection for bilateral hearing loss. It is the Veteran's contention that while serving in the Marines, he was exposed to hazardous noise levels, such as weapon fires and explosives, and that this history of in-service noise exposure is the reason for his current bilateral hearing loss. . According to the Veteran's DD 214, his military occupational specialty was that of a bulk fuel man. He was also awarded a Rifle Marksmanship Badge. Such evidence suggests the Veteran was likely exposed to at least some form of noise trauma while in the Marines. Therefore, the Veteran's exposure to noise trauma in service is not in dispute. Instead, at issue in this case is whether the Veteran has a current bilateral hearing loss disability. A hearing loss disability is defined by regulation. For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). The only audiological evaluations of record are those conducted in October 2012 (private examination), January 2013 (VA audiology consultation), August 2013 (VA audiological examination), June 2015 (VA audiology consultation), and April 2017 (VA audiological examination). On October 2012 private audiological examination, the Veteran complained of ringing in his ears and hearing loss. Puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 40 50 50 50 LEFT 35 40 50 50 50 The Board notes that while the above audiological results were provided in graph format, VA is not precluded from interpreting the graph data from an audiology report that otherwise meets the requirements of an examination for hearing impairment for VA purposes and converting such information into numerical data. Kelly v. Brown, 7 Vet. App. 471 (1995). Speech audiometry revealed speech recognition ability of 100 percent in each ear. The scores were not shown to be from a Maryland CNC speech discrimination test; instead, the W-22 word list was used. The Veteran was diagnosed with mild to moderate bilateral sensorineural hearing loss. In January 2013, the Veteran had a VA audiology consultation. The Veteran complained of difficulty hearing "higher pitches" and others over the phone. It was reported that the Veteran's volunteered responses to puretone stimuli suggested essentially mild to moderate hearing loss bilaterally; however, the findings during the current audiometry testing were inconsistent and the Veteran had to be instructed multiple times. The Veteran's volunteered responses to puretones worsened after reinstruction. The Veteran's word recognition was excellent at 100 percent. The VA audiologist concluded that based on the objective findings, the Veteran had normal hearing sensitivity bilaterally and was not an ideal candidate for amplification at that time. In August 2013, the Veteran was afforded a VA audiological examination for his hearing. The Veteran reported that he had difficulty understanding conversation, especially in the presence of background noise. Puretone thresholds in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 60 70 75 75 85 LEFT 60 60 65 70 80 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. However, it was noted that the validity of the puretone results were not valid for rating purposes (not indicative) of organic hearing loss. The Veteran was reinstructed and retested; however, the examination was inconsistent and considered unreliable because the speech recognition test and pure tone averages were not consistent. The VA examiner stated that he could not provide a medical opinion regarding the etiology of the Veteran's hearing loss without resorting to speculation because the audiometric results were not valid for rating purposes due to inconsistencies stated previously; the examiner also could not determine if hearing loss existed prior to service due to lack of evidence. In June 2015, the Veteran had a VA audiology consultation. The Veteran's audiometric puretone testing results for his right and left ears were reported to be within normal limits. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 100 percent in the left ear. In April 2017, the Veteran was afforded a VA audiological examination for his hearing, which reflected the following puretone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 20 20 LEFT 25 25 25 20 25 Speech audiometry revealed speech recognition ability of 100 percent in each ear. The VA examiner reported that the Veteran's history of noise exposure included potentially hazardous levels of noise incidental to military occupational specialty of infantry: weapons fires and explosives. The VA examiner noted that the Veteran was right-handed, but did not wear hearing protection. The VA examiner diagnosed normal hearing in the left ear and sensorineural hearing loss in the frequency range of 6000 Hertz or higher frequencies in the right ear. The VA examiner then opined that the Veteran's hearing loss was not at least as likely as not caused by or a result of an event in military service. The VA examiner explained that the Veteran had normal hearing in both ears, with the exception of mild sensorineural hearing loss 6000 Hz to 8000 Hz at the right ear only. This loss was not likely related to military noise exposure. After reviewing the foregoing evidence, the Board cannot conclude that the Veteran has a hearing loss disability that meets the requirements of 38 C.F.R. § 3.385. Although the Veteran's October 2012 private audiological examination suggests that he has a current bilateral hearing loss disability, this examination report is an outlier compared to the remainder of evidence which shows that the Veteran does not have a hearing loss disability by VA standards. In particular, January 2013 and June 2015 VA audiology consultations show that the Veteran had normal hearing sensitivity bilaterally. The most recent April 2017 VA audiological evaluation also showed that the Veteran did not have a hearing loss disability by VA standards. See 38 C.F.R. § 3.385. The October 2012 private audiological examination is also not probative because it was not conducted in accordance with controlling regulations. Specifically, pursuant to 38 C.F.R. § 4.85(a), an examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. In the case of the October 2012 private audiological examination, the W-22 word list was used to conduct the speech discrimination test, and not the Maryland CNC. Therefore, it may not be used to establish whether the Veteran has a hearing loss disability for VA purposes. As to the findings in the August 2013 VA audiological examination, these results are not of probative value and are not assigned any weight because, as mentioned by the VA examiner, the results were inconsistent and considered unreliable. In conclusion, and in consideration of all aforementioned evidence, the Veteran does not have "hearing loss" for VA purposes. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability during the period of the appeal. See 38 U.S.C. § 1131 (2012). In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, in the absence of competent evidence showing a current diagnosis of bilateral hearing loss, it is unnecessary to address the remaining elements of the claim for service connection. See Brammer, 3 Vet. App. at 225. Accordingly, service connection for bilateral hearing loss must be denied. B. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C. § 1155 (2017); 38 C.F.R. §§ 3.321(a), 4.1 (2017). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2017). Otherwise, the lower rating will be assigned. Id. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where (as here) the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). i. Anxiety Disorder Currently, the Veteran's anxiety disorder, not otherwise specified, is assigned an evaluation of 30 percent prior to November 7, 2014, and an evaluation of 70 percent from that date under 38 C.F.R. § 4.130, Diagnostic Code 9413. Under these criteria, a 30 percent is warranted where the psychiatric condition produces occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130, Diagnostic Code 9413 (2017). A 50 percent rating is warranted where the psychiatric condition produces occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted where the psychiatric condition results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21 (2017); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Global Assessment Functioning (GAF) scores of 61-70 indicate some mild symptoms or some difficulty in social, occupational, or school functioning, with the ability to generally function pretty well and have some meaningful personal relationships. DSM-IV (1994). GAF scores of 51-60 indicate moderate symptoms, such as a flat affect, circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, as evidenced by having few friends and having conflicts with peers or co-workers. Id. GAF scores of 41-50 indicate serious symptoms, such as suicidal ideation, severe obsessional rituals, and frequent shoplifting, or serious impairment in social, occupational, or school functioning, as evidenced by having no friends and being unable to keep a job. Id. GAF scores of 31 to 40 reflect some impairment in reality testing or communications (e.g. speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g. depressed man avoids friends, neglect family, and is unable to work). Id. It is important to note that a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Secretary of VA recently amended the portion of the Schedule for Rating Disabilities dealing with psychiatric disorders and the associated adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). However, the amended provisions do not apply to claims that were pending before the Board (i.e., certified for appeal to the Board) on or before August 4, 2014, even if such claims are subsequently remanded to the Agency of Original Jurisdiction. The instant appeal was initially certified to the Board in February 2014. Therefore, the pre-August 2014 version of the Schedule for Rating Disabilities is for application in the instant appeal. The Veteran is currently seeking an initial rating in excess of 30 percent prior to November 7, 2014, and 70 percent thereafter for the service-connected anxiety disorder. After careful review of the evidence, the Board finds that a rating in excess of 30 percent prior to November 7, 2014 is warranted, and a rating in excess of 70 percent from November 7, 2014 is not warranted. In November 2007, the Veteran was seen by a private physician, Dr. E.W.H., for a psychiatric evaluation. The Veteran was diagnosed with chronic posttraumatic stress disorder (PTSD) and dysthymic disorder. The Veteran's in-service military stressors were that he was in a fight with another Marine and received lacerations over his eyes. He was on guard duty when he found another soldier who had committed suicide. The Veteran felt that training to kill others was very stressful. The private physician noted that the Veteran began having nightmares in 2005 and he currently had nightmares at least two to three times per week, waking in a panic and sweats lasting two to three minutes. The physician noted that the Veteran had intrusive thoughts; startled easily; was hypervigilant, and could not tolerate anyone behind him. The Veteran socialized occasionally, but only with family. Dr. E.W.H. reported that the Veteran's memory was severely impaired; so much so that the Veteran could not remember what he read and got lost while traveling. The physician further reported that the Veteran' working memory was 100 percent impaired. The physician concluded that the Veteran's prefrontal cortex was dysfunctional because the Veteran experienced anger, sadness, and fear without understanding the reason for those feelings. The Veteran felt depressed 50 percent of the time with no energy and little interest in things. The Veteran was suicidal at times and became angry and agitated easily. Dr. E.W.H. assigned the Veteran with a GAF score of 40. In October 2008, the Veteran was evaluated at a private psychiatric clinic. It was reported that his symptoms included anger, sadness, fear, feelings of helplessness and hopelessness, mood swings, and worry. It was noted that the Veteran had hallucinations. However, he denied being suicidal. The Veteran was prescribed medications to take, such as Trazadone and Wellbutrin. In a July 2009 VA treatment record, it was reported that the Veteran had poor concentration and endorsed some symptoms of depression; however, this did not interfere with his daily work. In December 2009, the Veteran was afforded a VA examination for PTSD. The Veteran was diagnosed with anxiety disorder, not otherwise specified, at Axis I. He was assigned with a GAF score of 65. The Veteran reported that he had a very difficult childhood; he was abused and rejected by his parents because he was born out of wedlock. He reported that he had been married four times. He had three adult children raised by their mothers, and one raised by a non-spousal liaison. He saw his adult children about once or twice a year. The Veteran did not have any real friends, but had some acquaintances. The Veteran also went to church. The Veteran did not report any history of suicide attempts. However, he did report a history of violence. Upon physical examination, the VA examiner noted that the Veteran appeared clean and casually dressed. The VA examiner reported that the Veteran's mood was dysphoric. The VA examiner noted that the Veteran had thoughts of hurting others in the way he was trained as a marine, but no intention or desire. The VA examiner noted that the Veteran did not have the ability to maintain minimum personal hygiene. The VA examiner further noted that the Veteran had recurrent and intrusive distressing recollections of the in-service event, including images, thoughts, or perceptions. The VA examiner noted that the Veteran had difficulty falling or staying asleep, difficulty concentrating, and exaggerated startle response. The Veteran denied hallucinations. The Veteran reported that he started to have nightmares about a year after a soldier's suicide. The VA examiner reported that the Veteran did not have PTSD, and that it appeared that the Veteran was willfully over reporting and distorting problems. The VA examiner concluded that the Veteran had transient or mild symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, such as when the Veteran had claustrophobia while using the elevator. In September 2010, the Veteran had a follow-up for his PTSD, depression, and health maintenance at a VA Medical Center (VAMC)s. His PTSD/depression was evaluated to be stable overall. In September 2011, the Veteran denied having acute mental health issues at that time. In February 2012, the Veteran was seen by a private physician, Dr. E.W.H, for a psychiatric evaluation. The Veteran was diagnosed with chronic PTSD and dysthymic disorder. The Veteran was assigned a GAF score of 40. Dr. E.W.H. reported that the Veteran began having nightmares in 2005. The Veteran currently had nightmares at least two to three times per week, and woke up in panic attacks three to five times per week. He averaged six hours of sleep per night. The private physician stated that the Veteran occasionally had intrusive thoughts, startled easily, and was sometimes hyper vigilant. The Veteran did not socialize at all. Dr. E.W.N noted that the Veteran's recent memory was severely impaired; therefore, he could not remember what he read, often misplaced things, forgot what he had been told, and occasionally got lost driving on trips. The Veteran's memory was 75 percent impaired. Anger, sadness, and fear came upon the Veteran 40 percent of the time, without his understanding why, which indicated that his prefrontal cortex was dysfunctional. The Veteran had difficulty concentrating, making decisions, learning new information, and processing emotions in context. Dr. E.W.H. noted that the Veteran had hallucinations and illusions. For example, the Veteran heard noises in his house and saw shadows moving out of the corners of his eyes. The Veteran felt depressed 50 percent of the time, with low energy and little interest in things. He became angry and agitated easily; he sometimes felt helpless. The private physician concluded that the Veteran was unable to sustain social relationships, and that he was moderately comprised in his ability to sustain work relationships. The Veteran was afforded another VA examination for his mental disorders in November 2014. He was diagnosed with unspecified anxiety disorder under DSM-5 criteria. It was noted that the Veteran did not have more than one mental disorder. The VA examiner reported that the Veteran complained of irritability and difficulty getting along with others. The Veteran stated that he felt nervous around others. However, the Veteran did not specifically relate his difficulties to anything that happened in the military. The VA examiner reported that the Veteran had moderate psychosocial maladjustment secondary to his anxiety. Also, the Veteran complained of memory problems, anxiety, depression, insomnia, mild irritability, panic attacks (about once per week), social anxiety, and self-isolation. However, the Veteran did not report any intrusive thoughts, such as flashbacks or nightmares regarding anything that had been in the military. The Veteran stated that his nightmares were "just about killing." The Veteran denied suicidal or homicidal ideation. The VA examiner noted that the Veteran did not have psychosis, but was vague and appeared to be confused at times and had difficulty with words. Further, the Veteran was still working full-time. The Veteran took off only half to one day per month if he felt excessively stressed or irritable; it had mainly to do with getting along with others at work, dealing with pressures at work, etc. The Veteran did not have major difficulties performing his duties. He had been an employee of the VA as a custodian for twelve years and his work experience was satisfactory. The VA examiner reported that the symptoms that applied to the Veteran's diagnosis included: depressed mood; anxiety; suspiciousness; panic attacks that occurred weekly or less often; mild memory loss; circumstantial, circumlocutory, or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; and disturbances of motivation and mood. The VA examiner observed that the Veteran was alert and cooperative; however, his affect was flat and the Veteran frequently became irrelevant, seeming to have difficulty with word finding. The VA examiner reported that the Veteran was "better and still did not appear to have PTSD." The VA examiner stated that the Veteran was service-connected for unspecified anxiety disorder, and that it appeared to be the most appropriate diagnosis. The VA examiner noted that the Veteran had some difficulty from time to time at work with his anxiety and depression, which caused him to miss about one day per month. The examiner concluded that this put the Veteran's impairment in the mildly to moderately impaired range, perhaps slightly more severe than at the time of the last evaluation, but certainly not incapacitating. The VA examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In December 2015, the Veteran was again examined by private physician, Dr. E.W.H., for his mental disorder. He was diagnosed with chronic PTSD and dysthymic disorder at Axis I. The Veteran was assigned a GAF score of 35. Dr. E.W.H. stated that he was putting the Veteran on permanent medical leave because of worsening symptoms of PTSD. The physician noted that the Veteran had nightmares at least seven to 10 times per week, waking in a panic and sweats lasting five to ten minutes. The Veteran had flashback one to two times per day. The Veteran had panic attacks two times per day lasting one to two minutes. He averaged four hours of sleep per night. The Veteran felt depressed all of the time with no energy and little interest in things. Also, he had frequent crying spells, and was easily agitated and angered. Dr. E.W.H. additionally reported that the Veteran had intrusive thoughts, startled easily, was hyper vigilant, and could not tolerate any behind him; the Veteran did not socialize. The Veteran's working memory was 90 percent impaired. The Veteran had feelings of anger, sadness, and fear that would come upon him without his understanding the reason for such feelings 80 percent of the time. The private physician concluded that this indicated that the Veteran's prefrontal cortex was dysfunctional. Dr. E.W.H. opined that the Veteran was unable to sustain social relationships, and was also unable to sustain work relationships. The private physician therefore considered the Veteran to be permanently and totally disabled and unemployable. Dr. E.W.H. increased the Veteran's medications and required the Veteran to be seen every 16 weeks for twenty minutes for medication monitoring and cognitive behavior psychotherapy. In October 2016, the Veteran was afforded a VA examination for mental disorders. He was diagnosed with unspecified anxiety disorder. The VA examiner noted that the Veteran reported that that he had a "bad" relationship with his wife, and that they did not sleep in the same room. The Veteran stated that he had been married and divorced three times; his marriages lasted a year, a couple years, and six months. The Veteran reported that was currently married and had been with his current wife for four to five years. He stated that he no longer worked due to mental problems. The Veteran described his current symptoms as being "stressed out all the time," having difficulty controlling anxiety and relaxing, feeling easily fatigued, and having difficulty focusing and remembering things. He also reported that he was sometimes angry and irritable, and had muscle tension, weekly panic attacks, and disturbed sleep. The Veteran reported that his anxiety made it difficult for him to do his job around people. He also reported other symptoms, such as having nightmares and unwanted memories of his military stressors, feeling like people were following him while driving, and feeling intense anger. The VA examiner noted that the symptoms that applied to the Veteran's diagnosis included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, impairment of short-and long-term memory, flattened affect, speech intermittently illogical, difficulty in understanding complex commands, impaired judgment and abstract thinking, disturbance of motivation and mood, suicidal ideation, neglect of personal appearance and hygiene, and spatial disorientation. The VA examiner also reported that the Veteran had difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a work like setting. The VA examiner concluded that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. During behavioral observations, the VA examiner noted that the Veteran appeared to be sleepy and wearing dirty clothes; however, the Veteran's hygiene was fair. The VA examiner reported that the Veteran was cooperative with the evaluation, but did not make eye contact and stared at the wall. Further, the examiner noted that the Veteran drove over to the examination, but arrived an hour late because he got lost. In November 2016, a VA addendum medical opinion was obtained regarding functional limitations and the impact on occupational and employment activities of the Veteran's mental disorder. The VA examiner opined that the Veteran's occupational limitations appeared to be primarily related to mental health symptoms, including anxiety, fatigue, difficulty focusing, irritability, anger, social withdrawal, and sleep problems; however, he did have gout and physical pain that interfered with his work. The VA examiner concluded that the Veteran did not appear to be physically limited, related to sedentary occupational tasks, but might have difficulty completing tasks that required the Veteran to be on his feet for extended periods of time. As was indicated earlier, the Veteran is currently assigned a 30 percent rating for his anxiety disorder prior to November 7, 2014, and a 70 percent rating from that date. After considering the evidence of record under the laws and regulations as set forth above, the Board finds that a 50 percent rating, but no higher, is warranted prior to November 7, 2014, and a rating in excess of 70 percent is not warranted thereafter for the Veteran's anxiety disorder. In particular, throughout the appeal period prior to November 7, 2014, the Veteran's service-connected anxiety disorder was manifested by occupational and social impairment with reduced reliability and productivity. The Veteran's symptoms included nightmares, insomnia, intrusive thoughts, impaired memory, and feelings of sadness, anger, and depression. The Veteran was also sometimes suicidal. In a July 2009 VA treatment record, it was reported that the Veteran had poor concentration and endorsed some symptoms of depression; however, this did not interfere with his daily work. The VA examiner in December 2009 reported that the Veteran did not have the ability to maintain personal hygiene, although the examiner noted that on the day of the examination, the Veteran appeared clean and casually dressed. The Veteran went to church; however, he only had acquaintances and no real friendships. Also, the VA examiner noted that it appeared the Veteran was willfully over reporting and distorting problems. The VA examiner concluded that the Veteran had transient or mild symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. Further, VA treatment records in September 2011 showed that the Veteran denied having acute mental health issues at that time. Additionally, in a February 2012 private psychiatric evaluation, the physician concluded that the Veteran was unable to sustain social relationships, and that the Veteran was moderately compromised in his ability to sustain work relationships. The Board has also examined the record to ascertain whether the Veteran's symptoms warrant a higher rating under 38 C.F.R. § 4.130, Diagnostic Code 9413, for the appeal period prior to November 7, 2014. Although the Veteran's symptoms included nightmares, intrusive thoughts, impaired memory, and feelings of sadness, anger, and depression, it did not cause occupational and social impairment with deficiencies in most areas. For example, the Veteran went to church and he did have a few acquaintances. A February 2010 VA treatment record revealed that the Veteran's mental condition was stable overall. Also, a September 2011 VA treatment record revealed that the Veteran denied having acute mental issues at that time. Finally, the Veteran's GAF scores for the appeal period prior to November 7, 2014 ranged from 40 to 65, which is a range from severe to mild symptoms. When considering all the symptoms of record, the Board finds that the Veteran's symptoms more closely approximate a 50 percent evaluation for the appeal period prior to November 7, 2014. See 38 C.F.R. § 4.130, Diagnostic Code 9413 (2017). For the appeal period from November 7, 2014, a rating higher than 70 percent for the Veteran's anxiety disorder, not otherwise specified, is not warranted. The evidence of record shows that the Veteran's disability picture more closely approximates occupation and social impairment with deficiencies in most areas. It has not been shown that the Veteran has total occupational and social impairment. The Veteran's symptoms included depression, anxiety, insomnia, intrusive thoughts, panic attacks, feelings of anger and sadness, suspiciousness, neglect of personal appearance and hygiene, and spatial disorientation. In a November 2014 VA examination, the VA examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The VA examiner also noted that the Veteran was working at that time, and that the Veteran did not have major difficulties performing his duties. In a December 2015 private psychiatric evaluation, the private physician concluded that the Veteran was unable to sustain social relationships, and was unable to sustain work relationships. The Veteran was assigned a GAF score of 35. In an October 2016 VA examination, the VA examiner noted that the Veteran drove over to the examination, but arrived an hour late because he got lost. The VA examiner concluded that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Also, although the Veteran had suicidal ideation, it had not been shown that the Veteran had intent to carry it out and was in danger of harming himself or others. It was not shown that the Veteran had persistent delusions or hallucinations, grossly inappropriate behavior, or gross impairment of thought processes. The Board has considered the Veteran's symptoms and the assignment of the GAF score of 35, and has concluded that the Veteran's disability picture, on average, more closely approximates a rating of 70 percent and no higher for the appeal period from November 7, 2014. ii. Pseudofolliculitis The Veteran's service-connected pseudofolliculitis is currently rated at 30 percent under Diagnostic Codes 7899-7806, 38 C.F.R. § 4.118 (2017). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2017). When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using "99" for the last 2 digits. Based on the evidence of record, a rating in excess of 30 percent is not warranted for the Veteran's service-connected pseudofolliculitis. While acknowledging the criteria pertaining to Diagnostic Codes, 7899-7805, the Board notes that the Veteran's service-connected pseudofolliculitis more closely approximates the ratings under the diagnostic code for dermatitis or eczema, Diagnostic Code 7806. The Veteran's skin disability has not been manifested by benign or malignant skin neoplasms, unstable or painful scars, or disfigurement. Although it was noted in the January 2012 VA examination that the Veteran only had one non-debilitating episode of uticaria within the past 12 months, this disability would be evaluated at most at 10 percent under Diagnostic Code 7825. See 38 C.F.R. § 4.118, Diagnostic Code 7825 (2017). Additionally, the Veteran's symptoms have mostly been characterized as dermatitis, acne rosacea, eczema, and pruritic keratosis. Therefore, Diagnostic Code 7806 is the most applicable code to rate the Veteran's service-connected pseudofolliculitis. Diagnostic Code 7806 addresses dermatitis or eczema. A 0 percent rating is assigned for dermatitis or eczema affecting less than 5 percent of the entire body or less than 5 percent of exposed areas, and when no more than topical therapy is required during a 12-month period. A 10 percent disability rating is assigned for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas, or; when intermittent systemic therapy (such as corticosteroids or other immunosuppressive drugs) are required for a total duration of less than six weeks during the past 12-month period. A 30 percent disability rating is assigned for dermatitis or eczema affecting at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; when systemic therapy is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent disability rating is assigned for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or; when constant or near-constant systemic therapy is required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The U.S. Court of Appeals for Veterans Claims held that topical use of corticosteroids constituted systemic therapy under this diagnostic code. Johnson v. McDonald, 27 Vet. App. 497 (2016). The Federal Circuit, however, reversed the decision by the U.S. Court of Appeals for Veterans Claims. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). In reversing, the Federal Circuit agreed with the Secretary that the U.S. Court of Appeals for Veterans Claims erred when it "read DC 7806 as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of 'systemic therapy.'" Id. The Federal Circuit noted that Diagnostic Code 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code." Id. The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical antiinfective applied to a certain area of the skin and affecting only the area to which it is applied.'" Id.; see also Dorland's Illustrated Medical Dictionary 1865 (32d ed. 2012). Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. In July 2011, the Veteran had a VA outpatient dermatology consultation for his skin. The attending physician, Dr. R, assessed the Veteran for seborrheic dermatitis, acne rosacea, and eczema. The Veteran reported that he went to an outside provider for pruritic keratosis pilaris, and received an injection which made the itching better, but keratosis pilaris remained. The Veteran was using medicated shampoo for his scalp, but he continued to get pruritic pustules on his scalp. Upon physical examination, Dr. R. noted that the Veteran scalp and forehead and scattered inflammatory pustules and his post arms were hyperpigmented with follicular papules. Dr. R. further noted that although the Veteran did not have evidence of seborrheic dermatitis, acne rosacea, or eczema at that time, he did have keratosis pilaris and scalp folliculitis. In January 2012, the Veteran was afforded a VA examination for his skin condition. He was diagnosed with pseudofolliculitis. The VA examiner noted that the Veteran did not have any scarring or disfigurement of the head, face, or neck. Also, the Veteran did not have any benign or malignant skin neoplasms (including malignant melanoma). The VA examiner noted that the Veteran used antihistamines, Cetirizine, for itching associated with rash. The Veteran also used other topical medications for his folliculitis. The Veteran did not have any debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. However, it was noted that the Veteran had one non-debilitating episode of urticaria within the past 12 months. The episode included recurrent itching and, at times, hive-like eruptions, which required the Veteran to take antihistamines. The VA examiner noted that the Veteran responded to treatment with antihistamines or sympathomimetics. Upon examination, the Veteran's eczema covered 20 to 40 percent of the Veteran's total body area and 5 percent to less than 20 percent of the Veteran's exposed body area. Further, the VA examiner reported that the Veteran's conditions were hyperkeratosis pilaris (on face, arms, and legs) and occasional hives; the Veteran responded well to the treatment of Cetirizine. The VA examiner reported that it impacted the Veteran's ability to work in a public environment because he was embarrassed of the rash on his face. In August 2012, the Veteran visited a VA dermatology clinic because he had a new rash on his arms and legs, which began about 1 week ago on the upper arms. The Veteran reported that his rash was very itchy and became worse at night. The attending physician noted that the Veteran had been using Hydrocortisone cream and Benadryl gel and taking Cetirizine occasionally for the itch. The physician reported that the Veteran had a flare of rash on his face and scalp with increased redness and flaking. In April 2012, the Veteran had a VA outpatient dermatology consultation for his skin with Dr. H. The physician noted that the Veteran had been previously treated for rosacea, seborrheic dermatitis, and eczema. The Veteran had mild erythema/hyperpigmentation on the scalp, ears, and chest with mild scaling, and follicular papules with hyperkeratosis on the arms. In November 2014, the Veteran was afforded a VA examination for his skin condition. The Veteran was diagnosed with eczema and keratosis pilaris. The VA examiner reported that the Veteran continued to complain of itchy areas on his face, scalp, chest, shoulders, and extremities. The Veteran stated that bumpy lesions on these areas were controlled by his medications. The VA examiner noted that the Veteran did not have any benign or malignant skin neoplasms (including malignant melanoma). The Veteran also did not have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma). The VA examiner reported that the Veteran used topical corticosteroids for his skin problems, such as Triamcinolone and Hydrocortisone cream, constantly or nearly constantly in the past 12 months. The Veteran did not have any episodes of uticaria, primary cutaneous vasculitis, erythema multiform, or toxic epidermal necrolysis. The VA examiner reported that the Veteran's dermatitis covered 5 to less than 20 percent of his total body area and 5 to less than 20 percent of his exposed area. The Veteran did not have obvious folliculitis of shoulders, scalp or extremities. The VA examiner noted that the Veteran's skin condition impacted his ability to work. The Veteran stated that he felt embarrassed by the lesions, which limited his interest in social activities. Additionally, the VA examiner opined that the Veteran's first diagnosis by a private dermatologist and VA dermatologist was keratosis pilaris, a condition inherited in autosomal dominant fashion. The VA examiner opined that while in the military and afterwards, it had been labeled as pseudofolliculitis barbae, eczema, acne rosacea, and most recently, keratosis pilaris by a private doctor as well as a doctor form the VA. After reviewing the evidence of record, the Board finds that a rating in excess of 30 percent for the Veteran's service-connect pseudofolliculitis is not warranted. In order to be rated at the next higher rating, 60 percent, he would have had to have dermatitis or eczema of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2016). It is clear that the Veteran's disability more closely approximates the 30 percent rating. In a July 2011 VA treatment record, the dermatologist noted that the Veteran's scalp and forehead had scattered inflammatory pustules, and his post arms were hyperpigmented with follicular papules. Although the Veteran used medicated shampoo for his scalp, he continued to get pruritic pustules on his scalp. In the January 2012 VA examination, the VA examiner reported that the Veteran's skin condition covered 20 to 40 percent of the Veteran's total body area and 5 to less than 20 percent of the Veteran's exposed body area. The VA examiner noted that the Veteran took antihistamines to help with the itching associated with the rash, and other topical medications for his folliculitis. In an April 2012 VA treatment record, it was reported that the Veteran had mild erythema/hyperpigmentation on his scalp, ears, and chest with mild scaling, and follicular papules with hyperkeratosis on his arms. In November 2014, the VA examiner reported that the Veteran's dermatitis covered 5 to less than 20 percent of the Veteran's total body area and 5 to less than 20 percent of his exposed body area. The VA examiner reported that the Veteran used topical corticosteroids for his skin problems constantly or nearly constant in the past 12 months. It should be noted that the Veteran's use of topical corticosteroids for his skin problems does not amount to the level of "systemic therapy" as defined by the Federal Circuit in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). It has not been shown that the Veteran's use of topical corticosteroids was of such a large scale use that it affected the body as a whole. Also, it was indicated on the Veteran's January 2012 VA examination that he used antihistamines for his rash and itching; however, it was not shown to be required to be used constantly or nearly constant within the past 12 months. In conclusion, the weight of the most probative evidence is against the claim of entitlement to an initial rating in excess of 30 percent for the Veteran's service-connected pseudofolliculitis. iii. Rhinitis The Veteran's service-connected allergic rhinitis, status post sinus surgery (claimed as sinus condition) is currently rated at 0 percent under 38 C.F.R. § 4.97, Diagnostic Code 6522. Under that diagnostic code, a 10 percent evaluation is assigned for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. Diagnostic Code 6522, 38 C.F.R. § 4.97 (2017). A 30 percent evaluation is warranted for allergic or vasomotor rhinitis with polyps. Id. Where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). The Veteran is seeking an initial compensable rating for his service-connected allergic rhinitis. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a compensable evaluation for his service-connected allergic rhinitis. In October 2012, the Veteran had a private ear, nose, and throat consultation. The Veteran complained of sinus drainage down his throat and sinus congestion and pain down in his lungs. The private physician noted that the Veteran had taken Tylenol for relief and had been treated with antibiotics with temporary relief. The Veteran used saline nasal spray and some type of prescription nasal spray, which helped temporarily. The Veteran sometimes woke up in the mornings with headaches. The private physician diagnosed the Veteran with chronic rhinitis. In August 2013, the Veteran was afforded a VA examination for his nose condition. The Veteran reported that he had a sinus infection requiring antibiotics, and that his condition began twelve years ago. He had a greenish drainage from the nose every morning. The VA examiner diagnosed with allergic rhinitis, status post endoscopic sinus surgery. The VA examiner determined that continuous medication was required to control the Veteran's condition. The VA examiner reported that the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. The Veteran did not have complete obstruction on one side due to rhinitis, nor did he have permanent hypertrophy of the nasal turbinates. He did not have nasal polyps or granulomatous conditions. Further, the Veteran did not have any larynx or pharynx conditions. No tumors or neoplasms were present, and the Veteran did not have a deviated nasal septum due to trauma. Although the Veteran was not diagnosed with chronic sinusitis, the VA examiner found that the Veteran had non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. Also, the examiner found that the Veteran had 1 incapacitating episode of sinusitis requiring prolonged (4 to 6 weeks) antibiotics treatment in the past 12 months. The VA examiner reported that the Veteran's condition did not impact his ability to work. After careful review of the evidence, the Board finds that the criteria for a compensable evaluation under Diagnostic Code 6522 have not been met. The Veteran's symptoms included sinus drainage down his throat and sinus congestion. According to the August 2013 VA examination, the Veteran did not have nasal passage obstruction greater than 50 percent on both sides, complete obstruction of either side, permanent hypertrophy, polyps, or granulomatous conditions. Also, the Veteran did not have any larynx or pharynx conditions. The Board notes that it has a duty to acknowledge and consider all diagnostic codes that are potentially applicable when evaluating the Veteran's allergic rhinitis. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). However, the Veteran has been diagnosed with, and is in receipt of service connection for, allergic rhinitis, a condition that is specifically listed in the Rating Schedule. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) ("[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy"). Although in the August 2013 VA examination, the VA examiner reported that the Veteran had one incapacitating episode of sinusitis requiring prolonged antibiotics treatment over the past 12 months, this has not been shown to be related to a diagnosis of rhinitis. In any event, there is no evidence or argument that a higher rating is warranted under any alternate diagnostic code. C. TDIU In order to establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 U.S.C. § 1155 (2012 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). In reaching such a determination, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2016); Van Hoose v. Brown, 4 Vet. App. 361 (1993). "Substantially gainful employment" is that employment "which is ordinarily followed by the non-disabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). As further provided by 38 C.F.R. § 4.16(a), "Marginal employment shall not be considered substantially gainful employment." The regulatory scheme allows for an award of a TDIU when, due to service-connected disabilities, a Veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. For the purposes of finding one 60 percent disability or one 40 percent disability in combination, disabilities resulting from a common etiology, affecting one or both lower extremities or affecting a single body system will be considered as one disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). It is also the policy of the VA, however, that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b) (2017). Where the veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), an extraschedular rating is for consideration where the veteran is unemployable due to service-connected disability. 38 C.F.R. § 4.16(b) (2017); see also Fanning v. Brown, 4 Vet. App. 225 (1993). In January 2016, the Veteran submitted a VA Form 21-8490 Veterans Application for Increased Compensation Based on Unemployability. The Veteran indicated that he was unemployable due to his service-connected mental disorder. In a January 2017 rating decision, the RO granted TDIU, effective December 2, 2015 (date most recent employer reported that the Veteran resigned from employment). Therefore, the period on appeal is prior to December 2, 2015. Prior to December 2, 2015, the Veteran was service-connected for an anxiety disorder, not otherwise specified, rated 30 percent from June 5, 2008, and 70 percent from November 7, 2014; pseudofolliculitis, rated 30 percent from July 22, 2011; tinnitus, rated 10 percent from October 26, 2012; bilateral chronic epididymitis with residual testicle pain, rated 0 percent from August 27, 2010; and allergic rhinitis, rated 0 percent from October 26, 2012. His combined disability ratings were 30 percent, effective June 5, 2008; 50 percent, effective July 22, 2011; 60 percent, effective October 26, 2012; and 80 percent, effective November 7, 2014. From November 7, 2014, to December 2, 2015, the Veteran met the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a). However, prior to November 7, 2014, the Veteran did not meet the schedular criteria for TDIU under 38 C.F.R. § 4.16(a). As such, in addition to determining whether the evidence demonstrates that the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service connected disabilities from November 7, 2014, to December 2, 2015, the Board will also consider whether referral for extraschedular consideration under 38 C.F.R. § 4.16(b) is warranted for the period prior to November 7, 2014. Following a review of the evidence of record, the Board finds that TDIU is not warranted for any period prior to December 2, 2015. As such, there is no need to refer the claim for extraschedular consideration under 38 C.F.R. § 4.16(b) specifically for the period prior to November 7, 2014. On the Veteran's January 2016 Application for Increased Compensation Based on Unemployability, the Veteran indicated that he was employed full-time as a house keeper from 2001 until April 15, 2016. In January 2016, the Veteran submitted a note from his private treating psychologist, Dr. E.W.H., dated December 2015, which stated that the Veteran needed to be on medical leave until April 15, 2016. In August 2016, the Veteran's former employer submitted information verifying that the Veteran worked as a full-time house keeper beginning on March 11, 2001, and ending on May 5, 2016. The date of the last time the Veteran worked was listed as December 1, 2015. Also, a November 2014 VA examination report revealed that the Veteran was still working full-time during that time. Based on the foregoing evidence, the claim for TDIU prior to December 2, 2015 is denied. The Veteran was gainfully employed during that stated period. ORDER Service connection for bilateral hearing loss is denied. An initial rating of 50 percent (but no higher) for anxiety disorder, not otherwise specified, prior to November 7, 2014, is granted, subject to controlling regulations applicable to the payment of monetary benefits. An initial rating in excess of 70 percent for anxiety disorder, not otherwise specified, from November 7, 2014, is denied. An initial rating in excess of 30 percent for pseudofolliculitis is denied. An initial compensable rating for allergic rhinitis, status post sinus surgery, is denied. Entitlement to a TDIU prior to December 2, 2015, is denied. ______________________________________________ A. ISHIZAWAR Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs