Citation Nr: 1803372 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 17-43 750 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington THE ISSUE Entitlement to a higher (compensable) initial disability rating for lichen simplex chronicus, in excess of 0 percent from October 21, 2008 to March 17, 2014, and in excess of 30 percent from March 17, 2014. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran (the Appellant), and the Veteran's spouse ATTORNEY FOR THE BOARD S. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1974 to March 1977. The instant matter is a Veterans Benefit Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to ensure a total review of the evidence. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision from the Appeals Management Center (AMC) that granted service connection for lichen simplex chronicus (skin disability) and assigned a 0 percent initial disability rating, effective October 21, 2008. Although a formal notice of disagreement (NOD) was received in November 2017, the Board finds that the correspondence received March 2014, requesting reconsideration of the 0 percent rating for the skin disability, can reasonably be construed as disagreement with the AMC's initial disability rating and, therefore, was an effective NOD sufficient to initiate an appeal as to the initial disability rating of the service connected skin disability. See Phillips v. Brown, 10 Vet. App. 25 (1997) (while NOD does not require special wording, it must be in terms which can reasonably be construed as disagreement with determination of RO and desire for appellate review); see also Holland v. Gober, 10 Vet. App. 433 (1997) (veteran's statements in correspondence to VA in which he expressed disagreement with decision of RO as to disability rating and effective date assigned to service-connected back disability claim constituted NOD sufficient to initiate appeal on those two issues, and to entitle veteran to statement of the case from RO regarding rating and effective date). The Veteran has appealed from the initial rating assigned for the service-connected skin disability. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans' Claims (Court) addressed a similar appeal and directed that such appeal of the initial rating assigned following a grant of service connection was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. By way of history, a May 2014 rating decision increased the initial disability rating for the service-connected skin disability to 30 percent effective March 17, 2014. Following a July 2014 request for reconsideration of the disability rating, the RO in Seattle, Washington assigned a 10 percent rating from September 1, 2015. See June 2015 rating decision. Thereafter, an August 2017 Decision Review Officer (DRO) decision assigned a 30 percent rating September 1, 2015. Because the Agency of Original Jurisdiction did not assign the maximum disability rating possible, the appeal for a higher disability rating for a skin disability remains before the Board. See A.B. v. Brown, 6 Vet. App. 35 (1993) (noting that where a claimant filed a notice of disagreement as to a RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefits does not abrogate the pending appeal). Since issuance of the August 2017 statement of the case, additional evidence has been received by the Board for which a waiver of initial RO consideration was provided in writing in November 2017. 38 U.S.C. § 7105(e) (2012); 38 C.F.R. § 20.1304 (2017). In November 2017, the Veteran testified at a video conference Board hearing in Seattle, Washington, before the undersigned Veterans Law Judge in Washington, DC. The hearing transcript has been associated with the record. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2012) and 38 C.F.R. § 20.900(c) (2017). FINDINGS OF FACT 1. For the initial rating period from October 21, 2008 to March 17, 2014, the service-connected lichen simplex chronicus has been manifested by a rash that affected at least 5 percent but less than 20 percent of the total body area, and required no more than topical therapy during any 12-month period. 2. For the initial rating period from March 17, 2014, the service-connected lichen simplex chronicus has been manifested by a rash requiring systemic therapy with corticosteroids for a total duration of six weeks or more, but not constantly, during any 12-month period. It did not manifest as a skin disorder affecting more than 40 percent of the entire body or more than 40 percent of exposed areas; or, constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during any 12-month period. CONCLUSIONS OF LAW 1. From October 21, 2008 to March 17, 2017, the criteria for an initial disability rating of 10 percent, but no higher, for lichen simplex chronicus have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7806 (2017). 2. From March 17, 2014, the criteria for an initial disability rating in excess of 30 percent for lichen simplex chronicus have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5126 (2012); 38 C.F.R. §§ 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). As the appeal for a higher initial rating for the service-connected skin disability arises from the Veteran's disagreement with the initial rating following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial ratings and effective dates). With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence with respect to rating the skin disability. Specifically, the information and evidence that has been associated with the claim file includes service treatment records, private treatment records, relevant VA examination reports, the November 2017 Board hearing transcript, and the Veteran's lay statements. The RO also searched for clinical records from VA Medical Centers, but no records where available, as the Veteran has received all treatment through private providers. See December 2016 DRO conference report; August 2017 Statement of the Case. VA provided skin examinations in July 2009, June 2012, April 2014, and March 2015. The VA examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). When considered together, the VA examination reports reflect that the VA examiners made clinical measures and observations regarding the severity of the disability at issue, interviewed the Veteran about past and present symptomatology and functional impairment of the skin disability, and reported on the relevant rating criteria. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the appeal. In view of the foregoing, the Board will proceed with appellate review. Disability Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155 (2012). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In an appeal for a higher initial rating after a grant of service connection, all evidence submitted in support of a veteran's claim is to be considered. In initial rating claims, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. 38 C.F.R. § 4.2; Fenderson, 12 Vet. App. at 125-26. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Higher Initial Rating for Lichen Simplex Chronicus from October 21, 2008 to March 17, 2014 For the initial rating period on appeal from October 21, 2008 to March 17, 2014, the Veteran is in receipt of a noncompensable (0 percent) rating for the service-connected skin disability under Diagnostic Code 7806. 38 C.F.R. § 4.118. Under Diagnostic Code 7806 (dermatitis or eczema), a 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires involvement of 20 to 40 percent of the entire body or of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum rating of 60 percent requires involvement 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. A disability under Diagnostic Code 7806 may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Code 7801-7805) depending on the predominant disability. 38 C.F.R. § 4.118. The Veteran contends that a higher (compensable) rating is warranted for the skin disability. Specifically, the Veteran contends that a 60 percent rating is warranted for the skin disability because of constant or near constant use of an oral Prednisone (corticosteroid) and Protopic (topical immunosuppressive drug), for treatment of the of the skin disability. Additionally, the Veteran contends that the skin disability has manifest as a rash that has affected the face, neck, chest, stomach, arms, hands, and legs at various times over the years, causing pain and itching. See August 2017 Correspondence and November 2017 Board hearing transcript. After review of all the lay and medical evidence of record, the Board finds that for the initial rating period from October 21, 2008 to March 17, 2014, the service-connected skin disability more nearly approximates the criteria for a 10 percent disability rating, and does not more nearly approximate the criteria for a higher (30 percent) rating under Diagnostic Code 7806. 38 C.F.R. § 4.118. For the initial rating period on appeal from October 21, 2008 to March 17, 2014, the service-connected skin disability manifested as a rash that affected at least 5 percent, but less than 20 percent, of total body area. The service-connected skin disability did not manifest as 20 to 40 percent of the entire body or of exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during any 12-month period during the appeal period. During the November 2017 Board hearing, the Veteran testified that the skin disability has affected the legs (below the knees), the stomach, the chest, the face, the top of the head, the arms, the posterior thighs (along the edge of the buttocks), and the groin area; however, the primary areas affected are the front of the body, from the knees below, the stomach, and the chest. November 2017 Board hearing transcript, at 13-15. The Veteran did not state that the skin disability caused widespread rashes in all of the above mentioned areas of the body at once. For example, the Veteran stated he had a rash on both of his legs during the hearing, but he stated that the rash on the legs will clear up and then move to other places on the body, ultimately moving to various locations on the body over time. The Veteran also testified that the rash is either on the chest, or the stomach, or the arms, the hands, the legs, or the groin region, further indicating that the skin disability generally is not present in all of the reported locations at once. November 2017 Board hearing transcript, at 12. Additionally, the Veteran and his wife testified that the skin disability has required chronic use of oral Prednisone since at least 2014 and he uses the topical immunosuppressive drug, Protopic (Tacrolimus) daily. The medications provide some relief, but do not completely resolve the skin rash. November 2017 Board hearing transcript, at 4-5. The Veteran's testimony that the rash affects various locations of the body over time, not all the reported locations at once, is similar to the disability picture reflected in private treatment records, photographs, and VA examination reports during the appeal period. For example, an October 2008 and July 2010 private treatment record reflects that the Veteran presented for treatment of a rash on the lower leg. During a July 2013 private examination, the Veteran exhibited a mildly erythematous and scaly rash that extended from the right wrist to the upper forearm. Although the Veteran presented the private physician with pictures of a rash on the face, the rash was not present on examination. The physician diagnosed dermatitis, which, at the time was being treated with topical corticosteroids (Halobetasol Propionate) for six weeks or less. The private physician assessed that skin disability affected less than five percent of total body area, and less than five percent of exposed area on examination. See July 2013 skin disability questionnaire. The Board has reviwed the photographs the Veteran submitted in November 2009 and September 2013, which are consistent with the Veteran's reports of the areas of the body on which the skin disability has been present. The photographs show small rashes located in various areas of the body, including the right upper quadrant of the stomach, the left chin, the neck, the right wrist, the forearms, the elbows, and the legs (below the knees); however, because the photographs are not date stamped, they provide little insight into percentage of total body area or exposed areas affected during a particular period of time. As noted above, the Veteran testified that the rash tends to move around the body over time, and he has presented pictures of a rash to a treating physician that were not present on examination. VA skin examinations were conducted in July 2009 and June 2012. During the July 2009 VA examination, the VA examiner assessed neurodermatitis (lichen simplex) located on the arms and legs, characterized by active exfoliation, ulceration, hyperpigmentation, and abnormal texture of the skin. At the time, the skin disability was treated with daily Ultravate (topical corticosteroid) during the past 12 months. The VA examiner assessed that the skin lesion covered 7 percent of the whole body and 0 percent of exposed area. During the June 2012 VA examination, the VA examiner assessed that the skin disability affected less than five percent of total body area and less than five percent of exposed area on examination. Additionally, the Veteran continued to treat the skin disability with Ultravate and nothing else. A July 2012 pulmonology treatment note reflects that the Veteran was prescribed a 15 day course of oral Prednisone; however, the record indicates that the Prednisone was prescribed for the nonservice-connected asthma. There were no reports of problems with a skin disorder and no new rashes or lesions noted during examination, as the Veteran was only treated and counseled regarding the non-service connected asthma, allergic rhinitis, and obesity. For the initial rating period from October 21, 2008 to March 17, 2014, the lay and medical evidence reveals that the skin disability manifested as a rash that affected various locations of the body over the years, but did not affect more than 7 percent of the total body area, at any given time, which is greater than 5 percent, but less than 20 percent under Diagnostic Code 7806. 38 C.F.R. § 4.118. Additionally, the service-connected skin disability did not require systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during any 12-month period, as required for a higher (30 percent) rating. In this case, the Veteran's use of topical corticosteroid treatment, such as skin creams (Ultravate), does not constitute "systemic therapy" under 38 C.F.R. § 4.118. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied). Moreover, the oral Prednisone noted above was prescribed for the non-service-connected respiratory disorders and, in any event, was only prescribed for a course of 15 days, which is consistent with intermittent systemic therapy for a total duration of six weeks or less (10 percent). Based on the foregoing, the Board finds that from October 21, 2008 to March 17, 2014, the service-connected skin disability total affected body area more nearly approximates 7 percent, which warrants the higher rating of 10 percent, but does not more nearly approximate total body area between 20 and 40 percent so as to warrant the higher (30 percent) rating under Diagnostic Code 7806. 38 C.F.R. § 4.118. The record also reflects that at no point during the appeal period did the service-connected skin disability require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during any 12-month period during the appeal as required for a higher (30 percent) rating. Higher Initial Rating for Lichen Simplex Chronicus from March 17, 2014 The Veteran is in receipt of a 30 percent rating from for the initial rating period from March 17, 2014. During the April 2014 and March 2015 VA examinations the Veteran stated that the skin disability had worsened over the years as the rash that had come and gone all over the body, varying from area to area, depending upon where it shows up. The Veteran and his wife stated that the rash has improved with the use of immunosuppressive and corticosteroid drugs; however, the Veteran still contended that the service-connected skin disability requires constant to near-constant treatment with oral Prednisone and Protopic ointment (Tacrolimus), so was requesting a 60 percent disability rating. See November 2017 Board hearing testimony. After a review of all the lay and medical evidence of record, the Board finds that, for the initial rating period from March 17, 2014, the weight of the evidence is against finding that the service-connected skin disability met or more nearly approximated more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or required constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs during any 12-month period. During a March 2014 pulmonary follow-up, Dr. Eagan noted that a rash had resolved since receiving oral Prednisone treatments for the nonservice-connected asthma, and no new rashes or lesions were present; therefore, the Veteran was referred to a dermatologist to consider starting chronic systemic treatment of the service-connected skin disability. A June 2014 dermatology treatment note reflects that the Veteran had a localized pruritic rash on the right arm, for which Halobetasol ointment (topical corticosteroid) was not effective. Although the Veteran inquired about treating the skin disability with systemic Prednisone, the dermatologist prescribed another topical corticosteroid (Clobetasol Propionate ointment) for short term use and advised the Veteran to switch to the topical immunosuppressive medication (Protopic), once the rash improved for better control of the skin disability. The Veteran received a third VA skin examination in April 2014. At the time, the Veteran had a flare up of rash on both forearms that, upon examination, affected 0 percent of exposed areas and only 2 percent of total body area. The VA examiner diagnosed lichen simplex chronicus, which was treated with a systemic corticosteroid (Prednisone) for six weeks or more, but not constantly, in the past 12-months. The skin disability was also treated with constant or near constant use of antihistamines (Benadryl), and topical corticosteroids (Halobetasol ointment) during the past 12 months. During a March 2015 VA examination, the VA examiner assessed lichen simplex on the left abdomen and scrotum (while on tacrolimus) that covered 0 percent of exposed area and 1.5 percent (300 sq. cm) of total body surface area; however, the VA examiner assessed that during flare ups the total body area could go up to 6 to 9 percent. Additionally, the VA examiner noted treatment with systemic corticosteroids (Prednisone), topical corticosteroids (Clobetasol) and antihistamines (Benadryl) for 6 weeks or less, as well as constant or near constant use of Tacrolimus (Protopic) ointment in the past 12 months. In a letter dated October 2015, Dr. Eagan reported that the Veteran has been a patient at the pulmonary clinic for several years. Dr. Eagan noted that the Veteran required rescue and controller inhalers for his airway disease, as well as intermittent Prednisone therapy during periods of exacerbation to regain control. In an April 2017 letter, Dr. Eagan, for the first time, noted that the Veteran was prescribed Prednisone in a near-constant or constant manner to treat a skin condition, asthma, and other health issues. Pharmacy records reflect eight prescriptions for Prednisone tablets from October 2015 to May 2017, with 3 to 12 day courses of Prednisone prescribed approximately every two to four months. For the initial rating period from March 17, 2014, the weight of the lay and medical shows that the skin disability total body area affected approximated 9 percent, including during flare up, and did not more nearly approximate 40 percent of total body area affected. With regard to the use of systemic therapy such as corticosteroids or other immunosuppressive drugs for the service-connected skin disability, Dr. Eagan's April 2017 letter that Prednisone therapy has been prescribed for the service-connected skin disability, as well as asthma and other health conditions, appears inconsistent with the October 2015 letter, and statements made for the purpose of providing treatment during pulmonary examinations in July 2012 an March 2014, which indicate that Prednisone was prescribed for non-service-connected asthma, despite incidental benefit to the service-connected skin disability. Even if the oral Prednisone therapy also had been prescribed for the service-connected skin disability, and notwithstanding the Veteran's and the wife's testimony that Prednisone therapy has been constant or near-constant, the pharmacy records dated October 2015 to May 2015 only reflect eight 3 to 12 days courses of Prednisone that were prescribed approximately every two to four months, which more nearly approximates systemic therapy required for six weeks or more, but not constantly, during any 12-month period (30 percent). As for the contention that the constant or near constant use of the topical immunosuppressive drug Protopic (Tacrolimus) should also qualify as systemic therapy to warrant a 60 percent rating, the Federal Circuit has held that a topical corticosteroid or immunosuppressive drug does not rise to the level of "systemic therapy" required under Diagnostic Code 7806. Johnson, 862 F.3d 1351; see also Dorland's Illustrated Medical Dictionary 1653, 1722 (28th ed. 1994) (defining "systemic" as "pertaining to or affecting the body as a whole," whereas "topical" is defined as "pertaining to a particular surface area, as a topical anti-inffective applied to a certain area of the skin and affecting only the area to which it is applied"). Although the record indicates that Dr. Gretch wrote a June 2015 prescription for Protopic which indicates that the medication can be absorbed systemically, this statement is given no weight, as a statement that a medication "can be" absorbed systemically is vague and does not indicate that the Veteran was specifically instructed to apply the medication to his entire body for treatment during each application. Moreover, this statement is outweighed by dermatology notes which reflect that the Veteran was instructed to apply the Protopic ointment to the affected area of the skin, and the Veteran's testimony that he applies the ointment to the affected areas of the skin, noting that applying Protopic to the affected area of the skin affects him faster than taking oral systemic prednisone therapy. See See June 2014 private treatment record; November 2017 Board hearing transcript, at 5. Therefore, the Board does not consider that Veteran's use of a topical immunosuppressive (Protopic) to the affected area of the skin to be "systemic therapy" for VA purposes. Based on the foregoing, the Board finds that, during the initial rating period on appeal from March 17, 2014, the service-connected skin disability manifested as a rash that approximated 9 percent total body area, including during flare ups; constant or near constant use of topical immunosuppressive drugs (Protopic) during any- 12-month period; and systemic therapy with corticosteroids (Prednisone) for six weeks or more, but not constantly, during any 12-month period so as to warrant a 30 percent rating under Diagnostic Code 7806. The skin disability did not manifest more than 40 percent of the entire body or more than 40 percent of exposed areas affected or require constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during any 12 month period to meet the requirements for a higher rating of 60 percent under Diagnostic Code 7806. 38 C.F.R. § 4.118. Because the preponderance of the evidence is against finding that the evidence met or more nearly approximated the criteria for a higher 60 percent disability rating for the initial rating period from March 17, 2014, the appeal must be denied, and the benefit of the doubt doctrine does not apply. See 38 U.S.C § 5107; 38 C.F.R. §§ 4.3, 4.7. A disability under Diagnostic Code 7806 may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (DCs 7801-7805), or based on impairment of function. See 38 C.F.R. § 4.118. The Board finds that, while the record reflects that the Veteran had a rash that has variably affected the arms, face, chest, stomach, and legs, etc., for the entire initial rating period on appeal, from October 21, 2008, forward, the predominant skin disability most closely approximates a rating based on dermatitis and eczema under Diagnostic Code 7806, and is appropriately rated based on total affected body area (between 5 percent and 20 percent), and durational use of systemic therapy (six weeks or more, but not constant). Because disabilities under Diagnostic Code 7806 are to be rated either as dermatitis "or" based on as a disfigurement of the head, face, or neck, "or" scars "depending on the predominant disability," the Board finds that the Veteran may not receive separate ratings in addition to the 10 percent rating assigned from October 21, 2008 to March 17, 2014, and the 30 percent rating assigned from March 17, 2014, under Diagnostic Code 7806, for the same disability. See 38 C.F.R. § 4.118. Additionally, the Veteran is not shown to have benign neoplasms on the skin, or impairment of function due to the skin disability. See July 2009, June 2012, April 2014, and March 2015 VA examination reports. Accordingly, the Board finds that the skin disability symptoms have not been of the severity indicated for a 30 percent rating for the initial rating period from October 21, 2008 to March 17, 2014, or for a 60 percent rating from March 17, 2014. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118. Extraschedular Referral Consideration The Board has considered whether referral for extraschedular consideration would have been warranted for the service-connected skin disability for any part of the initial rating period on appeal. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2017). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. Turning to the first prong of Thun, the evidence in the instant appeal does not establish such an exceptional disability picture as to render the schedular rating criteria inadequate. Lichen simplex chronicus has primarily been manifested by a rash characterized by itching, ulcer formation, and general irritation on the face, arms, legs, stomach, and chest, etc, affecting no more than 9 percent total body area at any given time. Further, the skin disability has manifest as constant or near constant use of topical corticosteroids and immunosuppressive drugs (Ultravate, Protopic), and use of systemic therapy with corticosteroids (Prednisone) for more than six weeks, but not constantly, during any 12 month period. The schedular rating criteria, including Diagnostic Code 7806 and the alternative evaluations under Diagnostic Codes 7800 through 7805, specifically provide for disability ratings based on skin conditions and residual scarring affecting the body. Diagnostic Code 7806 also takes into account side effects of systemic therapy. In sum, these ratings consider disfigurement, scars, longevity, types of treatment, pain, residuals of outbreaks, and the percentages of the entire body and exposed areas affected by a particular skin disorder. Comparing the Veteran's disability level and symptomatology of the lichen simplex chronicus to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. As there are no additional expressly or reasonably raised issues presented on the record, and absent any exceptional factors associated with lichen simplex chronicus, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Lastly, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). The record indicates that the Veteran reported that he is disabled due to a nonservice-connected back condition. See July 2010 private treatment record. Because neither the Veteran nor the evidence suggests unemployability due to the service-connected lichen simplex chronicus, the only disability for which the Veteran is service-connected, the Board concludes that a Rice claim for entitlement to a TDIU has not been raised by the record. ORDER An initial disability rating of 10 percent, but no higher, for the service-connected lichen simplex chronicus, for the initial rating period from October 21, 2008 to March 17, 2014, is granted; a rating in excess of 30 percent for the period from March 17, 2014 is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs