Citation Nr: 1804644 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 09-27 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a bilateral foot disability, to include pes planus. 2. Entitlement to an initial compensable disability rating for pseudofolliculitis barbae (PFB). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. J. Wells-Green, Counsel INTRODUCTION The Veteran served on active duty from May 1973 to May 1976. These matters are before the Board of Veterans' Appeals (Board) on appeal of June 2008 and March 2016 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2010, the Veteran testified at a Decision Review Officer (DRO) hearing at the RO. A transcript of the hearing is of record. In June 2013, January 2016 and January 2017, the Board remanded the case for further development. FINDINGS OF FACT 1. The Veteran's bilateral pes planus pre-existed military service and did not chronically worsen therein; any current bilateral foot disability other than pes planus did not have its onset in service and has not been etiologically linked to the Veteran's service or any incident therein. 2. Throughout the appeal period, the Veteran's PFB has been manifest by scars on the face and neck that exhibit two characteristics of disfigurement; there is no evidence that 40 percent of the exposed areas or of the whole body is affected, or of constant or near-constant systemic therapy required during any 12-month period. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral foot condition, to include pes planus, have not been met. 38 U.S.C. §§ 101, 1110, 1153, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2017). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 30 percent, but no higher, rating for PFB have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.14, 4.118, Diagnostic Codes 7800, 7806, 7813 (2008 & 2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. § 3.159 (2017). Neither the Veteran nor his representative has raised any issues with the duty to notify. 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"). VA has complied with its duty to assist. 38 U.S.C. § 5103A. VA has obtained, to the extent possible, all relevant evidence identified by the Veteran and necessary for an equitable resolution of the issues on appeal, including obtaining service treatment records, VA and private treatment records. The Veteran was also afforded a DRO hearing, and as noted above, a transcript of the hearing is of record. Pursuant to the Board's June 2013 remand directives, VA secured military personnel records and medical records for the Veteran during his reserve service. Pursuant to the Board's January 2016 remand directives, the Veteran was provided with VA examinations with regard to his claims for service connection for a bilateral foot condition, to include pes planus, and for a skin disorder, including PFB, in February 2016. In compliance with the Board's January 2017 remand directives, an addendum opinion regarding the Veteran's claim for service connection for a bilateral foot disability was provided in February 2017. The Veteran contends that such examinations are inadequate as the examiners did not thoroughly or "fairly" consider the severity of his disabilities. However, the Board finds that the examiners completed all necessary testing, examined the Veteran, reviewed his claims file, and provided pertinent information to allow the Board to make an informed decision regarding these issues. With regard to the Veteran's bilateral foot disability, the February 2016 VA examiner provided diagnoses and opinions that were supported by appropriate discussion of the relevant evidence and well-supported rationales. In the February 2017 addendum, the examiner also specifically addressed the inquiries posed by the Board in its remand directives, addressing whether the Veteran's pre-existing bilateral pes planus was aggravated by service. Regarding the claim for an increased initial disability rating for the Veteran's service-connected PFB, the February 2016 VA examiner provided pertinent information and evaluation of the severity of his PFB in accordance with the pertinent rating criteria. Therefore, the February 2016 examinations and February 2017 addendum opinion, in aggregate are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that there has been substantial compliance with the June 2013, January 2016 and February 2017 remand directives pertaining to the issues adjudicated herein, and that any minor deviation from the instructions will not result in prejudice to the Veteran. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of the adjudication of these particular claims. Hence, the Board may address the merits of the appeal seeking service connection for a bilateral foot disability and for an initial compensable disability rating for PFB without prejudice to the Veteran. II. Legal Criteria, Factual Background and Analysis Service Connection The Veteran contends that he is entitled to service connection for a bilateral foot disability. He asserts that he injured his feet in service when he would drop mail bags weighing as much as 70 pounds on his feet. He also believes that an inservice back injury caused his foot disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). A Veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In such claims, a veteran must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). "If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.'" Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all of the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C. § 1154(a). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's May 1973 pre-induction examination notes that he had bilateral first degree pes planus that was not considered disqualifying. No other abnormalities were noted. Service treatment records show he was treated for corns versus callouses on the dorsum of the 5th digits of both feet and for Athletes feet in August 1973. In January 1975, the Veteran was given metatarsal supports for callouses on both feet. Although the Veteran reported a history of foot trouble in November 1975, the accompanying annual examination report shows that clinical evaluation of the feet was normal. There are no subsequent complaints, findings, treatment or diagnoses during the Veteran's active duty service. Post-service VA and private treatment records show no treatment for complaints associated with pes planus. A January 2002 private treatment record shows the Veteran complained of left leg pain and had a history of deep vein thrombosis (DVT). A September 2003 private treatment record indicates that the Veteran was diagnosed with new onset diabetes mellitus, type II (DM II) and DVT that was stable. An October 2005 private treatment record indicates the toes on the Veteran's left foot were swollen and that he experienced pain off and on. The examiner suspected the pain was either neuropathy and/or was secondary to his long nails. During his September 2010 DRO hearing, the Veteran testified that he sustained injuries to his legs and feet in service working in the mail room when mail bags, weighing as much as 70 pounds, fell on his feet. He testified that his boots did not have steel toes. He also testified that he injured his back playing football in service and that his back disability also affected his feet. The Veteran testified that he did not seek treatment for his injuries in service because it was discouraged by his commanding officers. The Veteran admitted that his bilateral leg, ankle and foot disabilities were secondary to his diagnosed DM II. An August 2011 VA examination to evaluate the Veteran's bilateral ankles shows that physical examination of the bilateral feet revealed no signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. It was noted that he required a cane, corrective shoes and compression hose to ambulate due to back pain, DM II and bilateral ankle pain. Subsequent VA and private treatment records show ongoing intermittent complaints of leg and foot swelling and pain associated with DVT and diabetic neuropathy. An October 2011 VA treatment record notes that the Veteran had decreased sensation on the bottom of both feet. In July 2013, the Veteran's sister and his brother-in-law submitted written statements regarding his bilateral foot and other associated disabilities. His sister stated that the Veteran had been healthy and active prior to his active duty service. She stated that since his release from service he complained about pain in his back, shoulder and feet that had worsened as the years progressed. The Veteran's brother-in-law stated that the Veteran appeared in good health when they first met in July 1976, shortly after the Veteran's discharge from service. However, as time progressed, the Veteran confided in his brother-in-law about the pain in his back, shoulders, legs and feet. The brother-in-law noted that the Veteran's duties in service were to operate military vehicles in rugged terrain and strenuous physical labor loading and unloading heavy equipment from the vehicles. The Veteran also told him that he had injured his lower extremities on two occasions while performing military physical fitness exercises while a reservist on off duty time. An April 2015 VA diabetic education treatment record indicates that the loss of sensation in the feet led to callouses, that led to a break down in the feet and ulcers. The Veteran underwent VA examination of his bilateral feet in February 2016. He denied having any treatment for a foot condition in service and gave a history of feeling vibrations in his feet while riding in Army vehicles traveling over rough terrain in 1981. He stated he began having foot problems in 2003 that became really noticeable in 2005. He stated that he sometimes felt numbness in his feet, that the skin of his feet sometimes peeled and he was unable to wear sandals because he might stub his toes. He denied foot pain at the time of the examination, but did endorse having pain and swelling in both feet with use. He also had pain with weight-bearing, disturbance of locomotion and interference with standing in both feet. Physical examination revealed characteristic callouses in both feet, without pain on manipulation of the feet or extreme tenderness of plantar surfaces of the feet. There was no objective evidence of marked deformity or marked pronation of either foot. The VA examiner opined that the Veteran's current bilateral foot disability was less likely than not incurred in or caused by any inservice injury, or any other event or illness in service. The examiner noted that the Veteran's diagnosed pes planus pre-existed his active duty service. The examiner opined that the Veteran's symptoms of foot numbness more accurately described peripheral neuropathy which was most likely caused by his diagnosed DM II, a nonservice-connected disability. The examiner further opined that the Veteran's current bilateral foot disability was not a continuation of his complaints regarding corns and tinea pedis in service. The February 2016 VA examiner, in a February 2017 addendum, opined that there was clear and unmistakable evidence that bilateral pes planus was not aggravated beyond its natural progression by any inservice event, injury or illness. In support of this opinion, the examiner noted that there was no current complaint of foot pain that could be clearly attributed to the Veteran's diagnosed pes planus and that his complaints of foot numbness and peeling skin were attributed to his diagnosed DM II, and not to his service or any incident therein. As outlined above, the Veteran's May 1973 pre-induction examination revealed first degree pes planus that was not considered disqualifying. Therefore, the presumption of soundness does not attach in this case. See 38 C.F.R. § 3.304(b). After reviewing all of the evidence of record, the Board finds that there is no evidence demonstrating that the Veteran's pre-existing bilateral pes planus underwent a chronic increase in severity (i.e., underwent a permanent increase in the underlying pathology beyond the natural progression) during his military service. Although the service treatment records document treatment for foot corns versus callouses in August 1973 and for callouses in January 1975, the remainder of the service treatment records is silent as to any complaints of or treatment for bilateral pes planus. Moreover, while the Veteran gave a history of foot trouble in a November 1975 medical history report, the accompanying annual examination shows that clinical evaluation of the feet was normal. There were no subsequent complaints, findings, treatment or diagnoses associated with bilateral pes planus. While the Veteran, his sister, and his brother-in-law, can competently report on his observable symptoms, any opinions regarding progression, aggravation, or etiology of such symptoms requires medical expertise that they have not demonstrated. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). As such, the Board assigns no probative weight to the Veteran's, his sister's, or his brother-in-law's assertions. Nor has the Veteran submitted any medical opinion that his bilateral pes planus permanently worsened beyond the natural progression during service. In reaching a determination, the Board has afforded the greatest probative value to the February 2016 VA examiner's opinion, in the February 2017 addendum, that the Veteran's pre-existing bilateral pes planus was not aggravated beyond its natural progression during service. The opinion is persuasive as the rationale for the opinion is based upon accurate facts and sound reasoning, and the opinion is consistent with the contemporaneous evidence. This evidence outweighs the Veteran's lay opinion on the matter given the medical complexities to assess the natural progression of the disability. To the extent that the Veteran experienced an exacerbation of his bilateral pes planus disability during service, an intermittent or temporary flare-up during service of a pre-existing injury or disease does not constitute aggravation pursuant to 38 U.S.C. § 1153 unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Without some objective evidence demonstrating a worsening of the underlying pathology of the Veteran's pes planus in service, the Board concludes that the evidence does not support a finding of aggravation. Therefore, service connection for a bilateral foot disability, based on aggravation of pre-existing bilateral pes planus is not warranted. Moreover, regarding any current foot disability other than pes planus, a preponderance of the medical evidence of record is against a linkage between the Veteran's current bilateral foot disability and his service, or any incident therein. Again, while he is competent to comment on his symptoms since service, the Veteran, as a layperson, is not competent to provide the necessary etiological link to either his service or any incident therein. There is no medical evidence of record indicating any foot disability until 2003, 27 years after the Veteran's discharge from service, and there is no competent evidence linking any such disability to his service or any incident therein. In fact, the February 2016 VA examiner provided a persuasive expert opinion that the Veteran's current bilateral foot symptoms are caused by or attributed to his nonservice-connected DM II, specifically finding that his current symptoms, including foot numbness, were not a continuation of the complaints noted during service. In sum, the preponderance of the evidence is against the claim of service connection for a bilateral foot disability, to include pes planus; there is no doubt to be resolved; and service connection for a bilateral foot disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Initial Disability Rating The Veteran contends he is entitled to a higher initial disability rating for painful scars on his face and neck associated with PFB. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). A March 2016 rating decision granted service connection for the Veteran's diagnosed PFB and evaluated the disability as noncompensably disabling under the criteria found at 38 C.F.R § 4.118, hyphenated Diagnostic Codes 7813-7806 for dermatophytosis or eczema, effective from November 28, 2007, the date the Veteran submitted his claim. During the pendency of this appeal, some of the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended, effective October 23, 2008. The regulatory changes apply to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the revised rating criteria. The Veteran's claim for service connection for a skin disorder was received by VA prior to October 23, 2008. Although the Veteran has not requested such review, the record reflects the Agency of Original Jurisdiction has adjudicated the claim under the revised rating criteria. Therefore, to ensure there is no prejudice to the Veteran, the Board will consider the rating criteria effective both prior to and from October 23, 2008. Diagnostic Code 7813 provides that dermatophytosis or eczema should be evaluated on the basis of disfigurement of the head, face, or neck (Diagnostic Code 7800); scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805); or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. Under Diagnostic Code 7806 a noncompensable rating is assigned when the disorder covers less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and no more than topical therapy is required during the past 12 month period. A 10 percent rating requires that 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 are affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires more than 40 percent of the entire body, or more than 40 percent of exposed areas are affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. In Johnson v. Shulkin, 862 F.3d 1351 ( Fed. Cir. 2017), the United States Court of Appeals for the Federal Circuit (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." 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." Under Diagnostic Code 7800 both prior to and from October 23, 2008, a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. Id. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. Id. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Id. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. Post-October 23, 2008, Diagnostic Code 7800 includes the following notes: VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under Diagnostic Code 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. Under the criteria in effect prior to October 23, 2008, Diagnostic Code 7801 pertained to scars, other than head, face, or neck that were deep or caused limited motion. Under the criteria in effect since October 23, 2008, Diagnostic Code 7801 pertains to burn scars or scars not of the head, face, or neck that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801. The record does not reflect that any of the Veteran's scarring is deep or the result of burns; therefore, this Diagnostic Code will not be further discussed. Under the criteria in effect both prior to and since October 23, 2008, Diagnostic Code 7802 pertains to superficial scars, and burn scars or scars due to other causes, not of the head, face, or neck. Both versions of the Diagnostic Code explain that a superficial scar is one that is not associated with underlying soft tissue damage. Id. at Note 2 (2008); Id. at Note 1 (2017). Under the criteria in effect prior to October 23, 2008, Diagnostic Code 7803 provided for a 10 percent rating for unstable, superficial scars. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). Note (1) defined an unstable scar as one where, for any reason, there is frequent loss of covering of the skin over the scar. The current version of the Schedule does not include Diagnostic Code 7803. Under the criteria in effect prior to October 23, 2008, Diagnostic Code 7804 provides for a 10 percent rating for superficial scars that are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Under the criteria in effect since October 23, 2008, Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful; a 20 percent rating is warranted for three or four scars that are unstable or painful; and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note 1. If one or more scars are both unstable and painful, VA is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note 2. Additionally, scars that are evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804 when applicable. Id. at Note 3. Prior to and from October 23, 2008, Diagnostic Code 7805 has remained essentially similar and has provided that other scars should be evaluated based on limitation of function or disabling effects of the affected part. VA and private treatment records show treatment for intermittent complaints of skin rashes, variously diagnosed as contact dermatitis, xerosis, eczema and PFB. A February 2016 VA examination report indicates that the Veteran's PFB and eczema were as likely as not etiologically related to the Veteran's service. The examiner opined that the Veteran's diagnosed xerosis was not etiologically related to his service. Although the examiner found that the Veteran's PFB did not cause scarring and disfigurement and that there were no lesions, the examiner noted that the eczema was hyperpigmented. The examiner further noted that the Veteran's service-connected skin disorder was less than 5 percent of both his exposed body area and total body affected. It was revealed there were no systemic manifestations and the examiner noted that the Veteran took topical corticosteroids 6 weeks or more, but not constantly in the last 12 months. He also took other topical medications 6 weeks or more, but not constantly in the last 12 months. The examiner noted the medications the Veteran took were Eucerin cream, Fluocinide, and triamcinolone. In his May 2016 notice of disagreement, the Veteran contended that the February 2016 VA examiner did not adequately consider all the topical medications he used to treat his skin disorder or the associated pain, which he rated as 8/10. He specifically indicated that the examiner did not consider that he took Fluocinide cream and Triamcinolone ointment. He noted that he used these medications for frequent flare-ups, but they did very little. A February 2017 private evaluation of the Veteran's PFB includes 2 photographs of his face and neck. The examiner found that the Veteran's face and neck were covered by elevated, hyper-pigmented scars in an area greater than 6 square inches. The examiner indicated that the photographs demonstrated this and that the hyperpigmentation and the elevation of the scars associated with PFB are characteristic of disfigurement of the face and neck. With resolution of doubt in the Veteran's favor, the Board finds that the medical and lay evidence supports that the Veteran has had, throughout the course of the appeal, scarring that is hyperpigmented in an area exceeding 6 square centimeters, and elevated on palpation, 2 of the 8 characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The Board finds that the evidence is at least in equipoise, and a disability rating of 30 percent for scars of the face and neck associated with PFB is warranted. The evidence does not show that the Veteran's scarring more nearly approximates the criteria for a 50 percent rating under Diagnostic Code 7800. The record does not reflect that scarring caused by PFB caused visible or palpable tissue loss. There also is no evidence of gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes, ears, cheeks, lips). PFB has not been shown to manifest in four or five characteristics of disfigurement. Therefore, the Veteran is not entitled to a higher 50 percent rating for PFB under Diagnostic Code 7800. The evidence does not reflect that the Veteran's service-connected skin condition has resulted in five or more scars that are unstable or painful and at least one scar that is both unstable and painful; therefore, an increased 40 percent rating under the Diagnostic Code 7804 criteria, effective since October 23, 2008 is not available. The other pertinent scar criteria effective prior to and/or from October 23, 2008 do not provide for a rating in excess of 30 percent, and need not be further discussed. Additionally, there is no evidence the scarring from PFB causes any disabling effects not considered by the ratings provided under 7800 to 7804; therefore, the condition is not entitled to any further separate ratings pursuant to Diagnostic Code 7805. Likewise, the Veteran's PFB disability does not warrant a disability rating in excess of 30 percent at any time during the pendency of the appeal under the rating criteria for Diagnostic Code 7806. During the entire appeal period, the Veteran's PFB disorder has not been shown to affect more than 40 percent of the entire body, or more than 40 percent of exposed areas affected. A preponderance of the evidence is against a finding that the service-connected skin condition has required constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the 12-month periods. The evidence shows that the Veteran treats his skin disorder with symptoms of itching and pain with topical corticosteroids or other topical medications intermittently. The February 2016 VA examiner noted that the Veteran used these topical medications 6 weeks or more in a 12-month period, but not constantly. Although the Veteran felt the February 2016 examiner did not address his use of medication, the examiner did note the medications the Veteran reported in his May 2016 contentions and the Veteran has not alleged that there was any error regarding the frequency of his use of the topical medications. Moreover, the February 2016 examiner found no evidence of systemic manifestations. At no point during the pendency of the appeal have the criteria for an initial disability rating in excess of 30 percent been met or approximated under any of the applicable rating criteria. Accordingly, and resolving all reasonable doubt in the Veteran's favor, a 30 percent evaluation, but no greater, is warranted for PFB. See 38 C.F.R. § 4.3. ORDER Service connection for a bilateral foot disability, to include pes planus, is denied. A 30 percent rating, but no higher, for PFB is granted, subject to the regulations governing the payment of monetary awards. ____________________________________________ M. SORISIO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs