Citation Nr: 1805381 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 10-26 920 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for esophageal dysmotility disorder. 2. Entitlement to an initial rating in excess of 10 percent for a right foot hallux valgus, status post surgery. 3. Entitlement to an initial rating in excess of 10 percent for a left foot hallux valgus, status post surgery. 4. Entitlement to an initial rating in excess of 10 percent for a right knee disability. 5. Entitlement to an initial rating in excess of 10 percent for a left knee disability. 6. Entitlement to an initial rating in excess of 30 percent for migraine headaches. 7. Entitlement to an initial separate compensable rating for asthma (currently included in the Veteran's obstructive sleep apnea rating). 8. Entitlement to an initial rating in excess of 30 percent for scarring status-post surgeries of the right foot. 9. Entitlement to an initial rating in excess of 20 percent for scarring status-post surgeries of the left foot. 10. Entitlement to an initial rating in excess of 30 percent for depressive disorder. 11. Entitlement to an initial rating in excess of 10 percent for right wrist carpal tunnel syndrome (CTS). 12. Entitlement to an initial rating in excess of 10 percent for left wrist CTS. 13. Entitlement to an initial rating in excess of 30 percent for recurrent urticaria (claimed as eczema). 14. Entitlement to an initial rating in excess of 10 percent for psoriasis. 15. Entitlement to an initial compensable rating for alopecia. 16. Entitlement to an initial rating in excess of 10 percent for scar, status post caesarian section. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J.L. Ivey, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1978 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in April 2016. The Board previously remanded the Veteran's claims in June 2016. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's esophageal dysmotility disorder has been manifested by dysphagia, pyrosis and regurgitation accompanied by substernal pain, that is reflective of a considerable impairment of health. 2. The Veteran is in receipt of the maximum schedular rating available for right hallux valgus. 3. The Veteran is in receipt of the maximum schedular rating available for left hallux valgus. 4. A rating in excess of 30 percent for right foot scars is not warranted under applicable VA regulations. 5. A rating in excess of 20 percent for left foot scars is not warranted under applicable VA regulations. 6. A rating in excess of 10 percent for C-section scars is not warranted under applicable VA regulations. 7. Separate evaluations may not be awarded for asthma and obstructive sleep apnea. 8. The Veteran's eczema has covered 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas during the entire appeal period. 9. The Veteran's urticaria manifests with recurrent episodes occurring at least four times during the previous 12 months. 10. The Veteran's psoriasis has covered between five and 20 percent of her entire body or between five and 20 percent of exposed areas during the entire appeal period; as of July 20, 2016, the disability manifested with gross distortion of the forehead, and three characteristics of disfigurement. 11. The Veteran's alopecia has affected less than 20 percent of the scalp. 12. For the period prior to August 1, 2009 and from June 7, 2011 to the present, the Veteran's depressive disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 13. For the period from August 1, 2009 to June 6, 2011, the Veteran's depressive disorder was manifested by occupational and social impairment with deficiencies in most areas. 14. The Veteran's right knee disability has been manifested by noncompensable loss of motion, pain, and slight instability throughout the appeal period. 15. The Veteran's left knee disability has been manifested by noncompensable loss of motion, pain, and slight instability throughout the appeal period. 16. The Veteran's right wrist CTS has been manifested by mild incomplete paresthesia of the median nerve throughout the appeal period. 17. The Veteran's left wrist CTS has been manifested by mild incomplete paresthesia of the median nerve throughout the appeal period. 18. Affording the Veteran the benefit of the doubt, her headache disability has been manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating for esophageal dysmotility disorder are met for the entire appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code (DC) 7346 (2017). 2. An initial rating in excess of 10 percent for a right foot hallux valgus, status post surgery is denied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5280 (2017). 3. An initial rating in excess of 10 percent for a left foot hallux valgus, status post surgery is denied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5280 (2017). 4. The criteria for a rating in excess of 30 percent for right foot scars are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7804 (2017). 5. The criteria for a rating in excess of 20 percent for left foot scars are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7804 (2017). 6. The criteria for a rating in excess of 10 percent for C-section scars are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7804 (2017). 7. The criteria for a separate compensable rating for asthma are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.96(a). 8. The criteria for a rating in excess of 30 percent for eczema are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7806. 9. The criteria for a separate 10 percent rating for urticaria are met for the entire appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7825. 10. The criteria for a rating in excess of 10 percent for psoriasis are not met prior to July 20, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7816. 11. The criteria for a 30 percent rating for psoriasis are met from July 20, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7800. 12. The criteria for a separate compensable rating for alopecia are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.118, DC 7830. 13. The criteria for a rating in excess of 30 percent for depressive disorder are not met for the period prior to August 1, 2009 or for the period from June 7, 2011 to the present. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.130, DC 9434. 14. The criteria for a 70 percent rating, but no greater, are met for depressive disorder for the period from August 1, 2009 to June 6, 2011. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.130, DC 9434. 15. The criteria for a rating in excess of 10 percent for a right knee disability based on loss of motion are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a DC 5024. 16. The criteria for a rating in excess of 10 percent for a left knee disability based on loss of motion are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a DC 5024. 17. The criteria for a separate 10 percent rating for right knee instability are met for the entire appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a DC 5257. 18. The criteria for a separate 10 percent rating for left knee instability are met for the entire appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a DC 5257. 19. The criteria for a rating in excess of 10 percent for right wrist CTS are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 38 C.F.R. §§ 4.7, 4.124a, DC 8515. 20. The criteria for a rating in excess of 10 percent for left wrist CTS are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, DC 8515. 21. The criteria for a 50 percent rating for migraine headaches are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles for Rating Disabilities Disability ratings are determined by applying a schedule of ratings (Rating Schedule) that is based on average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of a veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). With an 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." Fenderson v. West, 12 Vet. App. 119 (1999). Rating Criteria, Facts & Analysis - Esophageal Dysmotility Through her representative, the Veteran asserts that she is entitled to a higher rating for service connected esophageal dysmotility (originally claimed as heartburn). October 2017 appellate brief; see also August 2006 notice of disagreement. This disability is currently rated at 10 percent under 38 C.F.R. § 4.114, DC 7339-7346. DC 7339 is for rating post-operative ventral hernias. DC 7346 is for rating hiatal hernia and residuals. Considering the evidence which does not show that the Veteran is status-post ventral hernia surgery but does reveal symptoms consistent with hiatal hernia, the Board finds that a rating by analogy under DC 7346 is appropriate. The rating criteria are below: 7346 Hernia hiatal: Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health 60 Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health 30 With two or more of the symptoms for the 30 percent evaluation of less severity 10 The Veteran received a VA examination for her heartburn condition in August 2006. The provider reported that the condition was manifested by dysphagia, heartburn, epigastric pain, scapular pain, arm pain, reflux, and regurgitation of stomach contents; she denied any impact on body weight or on her overall health. She stated that her symptoms caused difficulty swallowing at times and otherwise suggested that symptoms of reflux occurred "constantly" and were treated by Rolaids. The Veteran reported that the condition caused functional impairment because she needed to lie down until the symptoms passed. The provider gave a diagnosis of gastroesophageal reflux disorder (GERD) and stated that subjectiv4e factors included reflux and regurgitation symptoms. Objective factors included the use of antacids. The Veteran received an upper GI study with air contrast in conjunction with the August 2006 VA examination. The study revealed no evidence of reflux or hiatal hernia or any other abnormality besides mild esophageal dysmotility. In her June 2008 notice of disagreement, the Veteran reported persistent recurrent epigastric distress with constant regurgitation. She sometimes threw-up food and burped (with a burning sensation) after every meal, and heartburn with every meal. She also reported that the problem caused arm and shoulder pain - sometimes severe - and that she took Gas-X chewables daily. VA treatment notes from 2015 and 2016 reflect the Veteran continued to complain of symptoms of dysphagia and GERD; she was prescribed a few different proton-pump inhibitors to alleviate symptoms. See, e.g., August 2015 and April 2016 VA treatment notes. The Veteran received another VA examination with regard to her dysphagia symptoms on July 2016; the primary diagnosis was esophageal dysmotility disorder. Symptoms reported included epigastric distress, heartburn, regurgitation, pain in substernal area, and sleep disturbance due to reflux. She reported treatment with Prilosec daily and frequent Alka Seltzer. The provider indicated the following symptoms were present: persistently recurrent epigastric distress; pyrosis; reflux; regurgitation; substernal pain; sleep disturbance caused by reflex occurring four or more times per year and lasting less than one day; periodic nausea occurring four or more times a year and lasting less than one day; and periodic vomiting occurring four or more times a year and lasting less than one day. With regard to functional impact, the Veteran reported that she was retired and that she was functional with medications. She also reported that she would have severe epigastric pain without medications which would impact her ability to focus on her job, when she was working. For the entire appeal period the Board finds that a 30 percent rating is warranted. The Veteran has asserted throughout the appeal period that she has symptoms of dysphagia, pyrosis and regurgitation accompanied by substernal pain, which was reflective of a considerable impairment of health. Although it is apparent that the Veteran's GERD improved with prescription medication, the Board is prohibited from considering the ameliorative effects of medication when, as here, such effects are not contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56 (2012). The Veteran has not met the criteria for a 60 percent rating at any point during the appeal period. In this regard, the Board notes that the evidence does not show that the Veteran experienced weight loss due and hematemesis or melena with moderate anemia, or any other symptom combinations productive of severe impairment of health due to esophageal dysmotility. The Board observes that the Veteran has reported periodic vomiting along with pain; however these symptoms are not also accompanied by material weight loss and hematemesis as noted under the regulatory criteria. As such, the preponderance of the evidence fails to show the Veteran's esophageal dysmotility symptoms approximated a 60 percent rating during the period on appeal. Accordingly, for reasons outlined above, a 30 percent rating, but no higher, for esophageal dysmotility is warranted for the entire appeal period. Rating Criteria, Facts & Analysis - Hallux Valgus Under DC 5280, unilateral hallux valgus will be rated at a maximum 10 percent disabling when it requires surgical operation with resection of the metatarsal head or if it is severe in nature, which would be equivalent to amputation of the great toe. See 38 C.F.R. § 4.71a, DC 5280. The Veteran is in receipt of maximum 10 percent ratings for right and left hallux valgus over the entire appeal period. No other DCs may be considered in assessing the rating assigned to her hallux valgus. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (when a condition is specifically listed in the rating schedule, it may not be rated by analogy and should be rated under the diagnostic code that specifically pertains to it). Rating Criteria, Facts & Analysis - Scars Through her representative, the Veteran asserts that she is entitled to a higher rating for service connected right and left foot scars, status-post multiple surgeries and her abdominal C-section scar. See October 2017 appellate brief; see also August 2006 notice of disagreement. The Veteran is currently in receipt of three separate ratings under 38 C.F.R. § 4.118, DC 7804. Although there are additional diagnostic codes for scars, the most appropriate scar code for the Veteran's feet is 7804 for painful or unstable scars. The other codes are not appropriate because the service-connected scars are not on the Veteran's face, head, or neck and they are not disfiguring. Below are the rating criteria for DC 7804: 7804 Scar(s), unstable or painful: Rating Five or more scars that are unstable or painful 30 Three or four scars that are unstable or painful 20 One or two scars that are unstable or painful 10 Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable As noted, the Veteran is currently in receipt of three separate ratings under DC 7804. Her right foot scars are rated at 30 percent; her left foot scars are rated at 20 percent; and her C-section scar is rated at 10 percent. The Board finds that the Veteran is currently in receipt of a greater combined benefit than is permissible under the code, and while the Board will not disturb this favorable rating, she is not entitled to an increase. The Board observes that the VA scar regulations were amended in 2008. As the appeal period begins in 2005, the prior regulations were consulted and do not provide for a higher combined rating or higher individual ratings for the Veteran's service connected scars. In sum, the Board finds that ratings in excess of 30 percent, 20 percent, and 10 percent are not warranted considering the evidentiary record and the applicable VA regulations. Asthma Through her representative, the Veteran asserts that she is entitled to a separate compensable rating for service-connected asthma, which is currently included with her rating for obstructive sleep apnea. See October 2017 appellate brief; see also August 2006 notice of disagreement. However, as both asthma and obstructive sleep apnea are both necessarily manifested by lung or pleural involvement, separate ratings are prohibited by 38 C.F.R. § 4.96(a). Rating Criteria, Facts & Analysis - Skin Conditions Through her representative, the Veteran asserts that she is entitled to a rating in excess of 30 percent for urticaria (claimed as eczema) and a rating in excess of 10 percent for psoriasis. See October 2017 appellate brief; see also August 2006 notice of disagreement. She was also recently assigned a separate noncompensable evaluation for alopecia for the entire appeal period. The Veteran's skin conditions are rated under 38 C.F.R. § 4.118, DC 7825 (urticarial, claimed as eczema); DC 7816 (psoriasis); and DC 7831 (alopecia). The rating criterion for most skin ratings is below: Condition Rating 7806 Dermatitis or eczema. 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 60 20 to 40 percent of the entire body or 20 to 40 percent 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 30 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 10 Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period 0 Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 7816 Psoriasis: 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 60 20 to 40 percent of the entire body or 20 to 40 percent 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 30 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 10 Less than 5 percent of the entire body or exposed areas affected, and; no more than topical therapy required during the past 12-month period 0 Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 7825 Urticaria: Recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy 60 Recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control 30 Recurrent episodes occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics 10 7830 Scarring alopecia: Affecting more than 40 percent of the scalp 20 Affecting 20 to 40 percent of the scalp 10 Affecting less than 20 percent of the scalp 0 7831 Alopecia areata: With loss of all body hair 10 With loss of hair limited to scalp and face 0 The Veteran has been afforded two VA skin examinations during the appeal period. In the August 2006 examination, she reported eczema since 1981 manifested by itching, shedding, and crusting. She stated symptoms occurred constantly especially involving areas exposed to the sun, including the head, face, hands, neck, chest, legs, buttocks, back, feet, behind ears, and ear lobe. She reported that, over the previous 12 months, she had used topical corticosteroids on a constant basis. She denied any side effects from treatment. In regard to her psoriasis, she reported symptoms of itching, shedding, crusting, and loss of hair. Symptoms occurred intermittently, sometimes as often as twice a month, with each episode lasting about a week. She reported a total of 20 attacks within the previous year and she had been continuously using sulfur shampoo for treatment for the previous year. She denied any side effects and any functional impairment from either condition. On physical examination, the provider noted there were no burn scars present, and no scars on the face. The examiner did note a skin condition on the scalp's frontal hair line characterized by exfoliation. There was no ulceration, crusting, tissue loss, induration, inflexibility, hypo or hyperpigmentation, abnormal texture, or impact on motion. The skin lesion was 1 percent of exposed skin area and was approximately 0.5 percent of the total body area. In her June 2008 notice of disagreement, the Veteran stated that she had peeling behind her ear; on her face and her feet and that she had discolored skin related to the condition. She also reported eczema on virtually her entire body, usually with a few areas impacted at a time. The Veteran also reported psoriasis on her scalp, which caused scabs and ultimately hair loss; she stated that she was bald in some spots. In March 2009 the Veteran had a VA dermatology consult. She complained of eczema and/or psoriasis on her arms and scalp with hair loss; she was using hydrocortisone cream and selenium sulfide shampoo. On physical examination there was diffuse scaling on the bilateral frontal alopecia retro auricular area and mild scaling and hyperpigmentation on the arms. The assessment was seborrheic dermatitis and eczema. She was prescribed Luxiq foam, Nizoral shampoo and told to use unscented dove soap and unscented detergents. In May 2009, the Veteran presented with multiple stressors complaining and increased hair loss. She had been using the Luxiq foam and Nizoral shampoo and she had noticed some regrowth. She asked for help dealing with stressors. Physical examination revealed generalized decreased hair density with bi-frontal alopecia with sparse regrowth. The assessment was alopecia, likely stress related. She was told to avoid hair chemicals and a psychiatric consult was recommended to help with stress-coping mechanisms. In February 2013 the Veteran had a follow-up with VA dermatology for eczema and seborrheic dermatitis. She stated that she still had dry areas on the face and body. She was using hydrocortisone cream to the face and body but felt that it was becoming less effective. On physical examination there was no scaling on the scalp and a faintly hyper-pigmented patch at the right antecubital fossa. There were no other lesions noted on the abdomen, back or lower legs. The assessment was seborrheic dermatitis, well-controlled clinically but not well-controlled per patient and eczema, currently well-controlled, almost absent. A new cream treatment was recommended along with the previous recommendations. In July 2016, the Veteran had another VA skin examination. The provider noted the presence of eczema, psoriasis, urticaria, and alopecia - and that at least one of the skin conditions caused scarring or disfigurement. Specifically, the examiner noted discoloration on the face, disappeared eyebrows, and thinning hair on scalp such that it was balding in patches. Treatment included constant use of topical corticosteroids. The veteran reported four or more episodes of non-debilitating urticaria that caused itching of the scalp and face with resulting scratching and welts. These episodes were manifested by moderate to severe rash and responded to treatment with antihistamines or sympathomimetics. On physical examination, the Veteran's eczema covered 20 to 40 percent of her total body area and between five and 20 percent of exposed body area. The condition was present on the face, neck, or hands. The appearance and location was described as: facial cheeks, ears, scalp, arms, torso, calves are dry peel and hyper-pigmented in healed areas. Psoriasis was present on between five and 20 percent of total body area and exposed body area. The condition was present on the face, neck, or hands. The appearance and location was described as: scalp and face. The examiner also noted the presence of scarring alopecia affecting less than 20 percent of the scalp. The Veteran's urticaria (claimed as eczema) is currently rated at 30 percent for the entire appeal period under 38 C.F.R. § 4.118, DC 7825 (urticaria). The Board finds that the Veteran's symptoms more closely approximate the 30 percent rating for eczema under DC 7806 as she has consistently reported eczema covering a significant part of her body. Moreover, the July 2016 VA examiner indicated the Veteran had eczema covering 20 to 40 percent of her total body area, which corresponds with a 30 percent rating for eczema. The Board observes that the Veteran also has urticaria, which is manifested by recurrent non-debilitating episodes occurring at least four times during the previous year, treated with medicated shampoo and other topical medications. The increased rating for urticaria was awarded in a March 2017 rating decision and the grant was based on the RO's finding that she was treating the condition with intermittent systemic immunosuppressive therapy due to her medicated shampoo. Nizoral shampoo is a topical anti-fungal agent and Luxiq cream is a topical corticosteroid. Neither of them are systemic immunosuppressive therapy drugs. The Board finds that the RO's determination regarding systemic immunosuppressive therapy was erroneous as neither drug is an immunosuppressive. Further, they were used for topical treatment in the affected areas. See, e.g., Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Moreover, the evidence suggests that the Veteran's urticaria episodes (while undoubtedly quite bothersome) were not debilitating. See July 2016 VA examination report. As such, the Board finds that a separate 10 percent rating for urticaria is appropriate. The Board's findings with regard to the Veteran's urticaria and eczema ratings are ultimately favorable to the Veteran as they result in a higher combined rating than her previous combined rating of 30 percent, as she will now have a 30 percent rating for eczema and a 10 percent rating for urticaria for the entire appeal period. With regard to the Veteran's psoriasis, the Board finds that the currently assigned rating under DC 7816 remains appropriate. The Veteran's psoriasis has affected between five and 20 percent of her entire body and total exposed body area during the appeal period, requiring no more than topical therapy. Further, her alopecia affects less than 20 percent of her scalp, resulting in a noncompensable rating. The Board notes, however, that the Veteran's psoriasis and eczema also results in scarring of the face. See July 2016 VA examination report. The examiner noted that the Veteran had scaring on the scalp and eyebrow hair loss related to psoriasis and hyper-pigmented areas on the face due to eczema. The examiner noted one painful scar on the face when the Veteran reported that her nose and cheeks were painful when the skin rubbed off, when a scab area was thickened, when she washed her face, and when skin layers came off. The examiner noted that there was scarring of the scalp measuring 38 by 36 cm and scarring of the face measuring 8 by 20 cm. The examiner further noted that there was elevation, depression, adherence to underlying tissue, or missing underlying tissue present; however he did not indicate to which scar these manifestations were attributable, leading the Board to find this was in error. The examiner also noted hyperpigmentation related the facial scar and abnormal texture attributable to both scars (on the scalp and face). Specifically, the examiner noted that the scalp scar was atrophic and scaly; the facial scar was atrophy, shiny, and scaly. The total approximate area of hyper-pigmented areas of the face was 160 square centimeters; the total approximate area of the face and scalp with abnormal texture was 160 square centimeters. There was no area of missing underlying soft tissue or indurated and inflexible areas. The examiner additionally noted that there was gross distortion of asymmetry of facial features or palpable tissue loss at the nose (due to eczema) and forehead (due to psoriasis). Specifically, the examiner noted loss of eyebrows that are shiny, depressed areas and the Veteran's nose was nearly raw due to peeled off skin. The nose was red in color and the Veteran reported that at times the nose had scaly layers that unevenly came off. The rating criteria for disfigurement of the head, face, or neck are noted below: Condition Rating 7800 Burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck: With visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement 80 With visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement 50 With 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, lips), or; with two or three characteristics of disfigurement 30 With one characteristic of disfigurement 10 Note (1):The 8 characteristics of disfigurement, for purposes of evaluation under §4.118, are: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2): Rate tissue loss of the auricle under DC 6207 (loss of auricle) and anatomical loss of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss of one eye), as appropriate. Note (3): Take into consideration unretouched color photographs when evaluating under these criteria. Note (4): Separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) 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 §4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code. Note (5): The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Regarding psoriasis, there is gross distortion of the forehead, and three characteristics of disfigurement (scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch wide at widest part; skin texture abnormal). With regard to eczema, there is gross distortion of the nose and three characteristics of disfigurement (scar at least one-quarter inch wide at widest part; skin hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal. This corresponds to a 30 percent rating under DC 7800. Thus, it is not advantageous to change the diagnostic code assigned to her eczema; however, changing her psoriasis to DC 7800 allows for an increase to 30 percent disabling as of the date of her examination, or from July 20, 2016. The Board notes that the Veteran reported her facial scars were sometimes painful. As discussed in the section above regarding the Veteran's painful scars, which are rated under 38 C.F.R. § 4.118, DC 7804, she is not entitled to a higher rating for painful scars. Rating Criteria, Facts & Analysis - Psychiatric Disability Through her representative, the Veteran asserts that she is entitled to a rating in excess of 30 percent for depressive disorder. See October 2017 appellate brief. The Veteran's depressive disorder is rated under 38 C.F.R. § 4.130, DC 9434. Under this code, a 30 percent rating is warranted where the disorder is manifested by occupational 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). A 50 percent rating is warranted where the disorder is manifested by 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 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. 38 C.F.R. § 130, DC 9434. A 70 percent rating is warranted where the disorder is manifested by 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 that is 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; and an inability to establish and maintain effective relationships. 38 C.F.R. § 130, DC 9434. The criteria for a 100 percent rating are 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. Ratings of psychiatric disabilities shall be assigned based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Further, ratings are assigned according to the manifestation of particular symptoms. However, the various symptoms listed after the terms "occupational and social impairment with deficiencies in most areas" and "total occupational and social impairment" in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (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). A GAF of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends). American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (1994) (DSM-IV). A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication (speech is at times illogical, obscure, or irrelevant), or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood, (a depressed man that avoids friends, neglects family, and is unable to work; a child that frequently beats up younger children, is defiant at home, and is failing at school). Id. A GAF score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score of 51 to 60 is indicative of moderate symptoms (flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (few friends, conflicts with peers or co-workers). Id. Military hospital treatment notes dated August 2006 and March 2007reflect the Veteran denied depression and anhedonia the previous two weeks. In an August 2006 VA general medical examination, the Veteran was alert and oriented, her behavior was normal, affect was appropriate, comprehension was normal, memory was intact and there were no signs of tension. In a VA psychiatric examination in August 2006, the Veteran reported a history of chronic sleep impairment and a recent history of memory loss and depression - with symptoms occurring on a near-constant basis. She reported that symptoms had a minimal impact on daily functioning; however she stated she had too much time to think about having to give up active duty in the military. In regard to memory loss, she stated that she had some functional impact in that she needed to write things down in order to remember them. She was not receiving any treatment for a psychiatric condition and had not had any psychotherapy in the previous year. She denied any adjustment problems during military service and she denied any significant medical problems since leaving service and reported a good relationship with her coworkers and supervisor in her job at that time. The Veteran reported that she missed attending military functions and had experienced major social changes since separation from active duty. She reported that her mental condition was also related to physical disabilities (such as her bilateral foot problems) which prevented her from being able to exercise as much as she used to. On mental status examination, orientation was within normal limits; appearance and hygiene were appropriate; behavior was appropriate; affect and mood were normal; communication, speech, and concentration were within normal limits; panic attacks were absent; and there was no suspiciousness present. The examiner stated there were no delusions, hallucinations or obsessional rituals observed or a history thereof reported. Thought processes were appropriate; judgment was not impaired; abstract thinking was normal; memory was mildly impaired, manifested by forgetting names, directions and recent events. Suicidal and homicidal ideations were absent. The diagnostic impression was depression; GAF was 75. The examiner noted the Veteran had no difficulties with activities of daily living due to mental function; she was able to establish and maintain work/school and social relationships. She had no difficulty understanding commands and appeared to pose no threat to herself or others. A depression screen administered at the VA in March 2009 was positive and suggestive of severe depression. She went into the VA as a walk-in in April 2010 reporting migraines and trouble at work, which she said made her feel angry and sad. The assessment was significant depression triggered by job-related stress. In April 2010, the Veteran received a depression screen which was positive; she had scored a 25 on the PHQ-9 which was indicative of severe depression and she was referred for evaluation. Symptoms endorsed included sad mood, loss of interest, disrupted sleep, loss of appetite, low-self esteem, and difficulty with concentration, psychomotor retardation, and passive suicidal ideation - all secondary to significant work stress which began in approximately August 2009. She denied any current suicidal or homicidal ideation. She reported a good relationship with two siblings and her daughter, reporting she spoke to her brother on the phone almost daily; however, she reported she did not have time for friends. Mental status examination was notable for impaired concentration, short term memory loss; thought processes including anxiety-based ruminations, social withdrawal, sleep disturbance, poor appetite, loss of energy, severe anxiety, anger problems related to occupational stressors, labile affect, anxious and depressed mood, and paranoid ideations without delusional content. Specifically, the Veteran stated, "I have my own illusions. I just watch people, they are all sneaky, back-biting. People I don't speak to anymore. Walter Reed is a corrupted place." Nevertheless, the provider stated the Veteran had capacity for reality testing. The diagnostic impression was depressive disorder; GAF was 52. A May 2010 VA mental health note reflects the Veteran was coping relatively well with her legal problems at work. She was talking calmly, logically, and reflected well on her current problems. She denied any thoughts of harm to herself or others. She was motivated and future oriented. Mental status examination was unremarkable. Mood was pleasant and affect was broad and bright except for when she talked about her current situation at work, which caused her to be tearful. GAF was 60. In June 2010, the Veteran was referred to VA mental health for evaluation of depression due to serious legal problems at work. She was started on two psychotropic medications with noticeable benefits and no side effects. Initially she reported that her work stress had become consuming and had taken a toll on her emotional function, her relationship with her daughter, and her ability to enjoy life. She also felt that her other medical conditions were exacerbated by stress. The Veteran reported she felt she had "mood swings," withdraws, feels amotivated, and was tearful at times during the first session. She also noted being close to two siblings and also with a few friends. She reported improvement in her mood and stated that the medications helped her deal with stress at work. She talked calmly, logically, and reflected well on her current problems. She enjoyed a recent trip with her family and reported that the relationship with her family and daughter were improved. She denied have any thoughts of harming herself or others; she was motivated and future-oriented. Mental status examination was unremarkable; mood was pleasant and affect was bright and calm. The diagnostic impression was adjustment disorder with mixed depression and anxiety. GAF was 60. A July 2010 VA treatment note is substantially similar. A December 2010 VA mental health note reflects the Veteran was having trouble with serious legal problems at work. She was taking some medications that caused noticeable improvement in her mood. Despite work-related stress, she felt calm content and in control of her emotions. She was looking for a new job and had enrolled in college. Her relationship with her family and daughter were improved and she denied any thoughts of harm to self or others. Mental status examination was unremarkable. Her mood was pleasant with broad and bright affect. GAF was 60. A June 2011 VA treatment note reflects the Veteran had recently been started on two new psychotropic medications, from which she had noticed significant benefits. She denied any side effects and reportedly felt good, calm, content, and in control. She was enrolled in college working on a master's degree. She had no thoughts of harming herself or others and she was motivated and future-oriented. Mental status examination was unremarkable. Her mood was pleasant and her affect was broad and bright. GAF was 75. Two July 2011 VA mental health note reflect the Veteran was having some of her last therapy sessions; she had been seen for adjustment disorder with mixed anxiety and depression. The provider indicated they had been working together intermittently since June 2010 and that the Veteran had made good use of therapy. The Veteran reported feeling hopeful about her future and feeling more at peace with herself and the stressful situation she was dealing with in her professional life. A March 2013 VA mental health note reflects the Veteran came in for a follow-up; she had not been in treatment since 2011. She requested a referral for individual therapy and reported noticeable benefits on her current psychotropic medications. The Veteran reported that she felt good, calm, content, and in control; she was enrolled in college courses to finish her third master's degree. She denied have thoughts of harming herself or others and appeared motivated and future-oriented. Mental status examination was unremarkable. Mood was pleasant and affect was broad and bright. GAF was 75. An October 2013 VA mental health note reflects the Veteran had a follow-up visit, asking to have her medications refilled. She reported that she felt good, calm, content, and in control. She denied have any thoughts of harming herself or others. She was motivated and future-oriented. Mental status examination was unremarkable; her mood was pleasant and affect was broad and bright. Treatment goals were to maintain symptom remission. The diagnostic impression was adjustment disorder with mixed depression and anxiety; GAF was 75. An August 2015 PHQ-2 depression screen was negative. The Veteran had another VA psychiatric examination in July 2016. She reported chronic sleep problems but attributed them to sleep apnea; she also reported decreased motivation and interest in doing things. The Veteran reported to the examiner that she was "well-liked" by others, but that she was not interested in romantic relationships and was focused on caring for her only daughter. Symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner noted that the Veteran was open and engaging during the examination; she gave appropriate eye contact; mood was dysthymic with congruent mood; thought processes were circumstantial and hard to redirect at time. She denied any active or past suicidal or homicidal ideation. The examiner stated that the Veteran's depressive disorder was (at that time) manifested by 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. The Veteran is service connected for depression and rated at 30 percent for the disability for the entire appeal period. Given the evidence discussed above, the Board finds that a 70 percent rating is warranted from August 1, 2009 to June 7, 2011. The date August 1, 2009 is assigned because of the April 2010 VA psychiatric evaluation in which the Veteran reported onset of severe psychiatric symptoms (such as passive suicidal ideation, difficulty with concentration, and psychomotor retardation) in approximately August 2009 secondary to stress at work. Prior to April 2010, the only comprehensive psychiatric evaluation of record is the August 2006 VA examination report, which reflects the Veteran's symptoms were significantly milder. At that time, she complained of mild memory loss, chronic sleep impairment, and depression; however, she stated that symptoms had a minimal impact on her daily functioning. She reported good relationships at work and in her personal life. Further, the examiner indicated the Veteran was able to establish and maintain work/school and social relationships and that she had no difficulty understanding commands. Her mild symptoms at that time were predominantly related to physical disabilities and losing the comradery of active duty. The April 2010 VA psychiatric evaluation is the next comprehensive psychiatric evaluation of record. During this evaluation, she reported significant symptoms secondary to work stress which began in approximately August 2009. Of note, she reported passive suicidal ideation, psychomotor retardation, and paranoid ideations without delusional content. These symptoms correspond with the 70 percent rating under VA regulations. The Board notes that the Veteran continued to report positive family relationships and that these severe symptoms were related to legal troubles at work. GAF was 52. Thereafter, VA psychiatric treatment notes reflect the Veteran experienced some improvement and symptoms and was coping relatively well with her legal problems at work. Her mood was generally pleasant and affect consistent with mood, except for when she talked about her situation at work. She enrolled in college courses and was able to successfully work towards a master's degree during this time. Her GAF remained at 60 until June 2011. Given this evidence, the Board finds that a 70 percent rating is warranted for this period due to passive suicidal ideation and paranoid ideations without delusional content. A higher rating of 100 percent is not shown by the record as the evidence does not reflect the Veteran's psychiatric disability was manifested by complete occupational and social impairment. A June 7, 2011 VA psychiatric note reflects the Veteran's psychiatric symptoms were very much improved. She was taking medications which were quite effective without side-effects and her legal problems at work had resolved. Mental status examination was unremarkable. She was feeling hopeful about her future, was motivated and future-oriented; mood was pleasant and affect was broad and bright. She denied any thoughts of harming herself or others. She continued to report positive family relationships and engagement in educational pursuits. From this date onward, the Veteran's GAF was 75. By August 2015, a VA depression screen was negative. The July 2016 VA examiner indicated that the Veteran's psychiatric disability was manifested by 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. The examiner's conclusion is supported by the evidentiary record, which reflects that the Veteran's psychiatric status had improved considerably. She had been actively engaged with educational pursuits, maintained positive relationships, and was generally functioning quite well. Based on this evidence, the Board finds that a 30 percent rating is appropriate from June 7, 2011 to the present. During the period from August 2009 to June 2011, the Veteran experienced significant psychological strain due to work-related stress, which ultimately resolved. Her psychological symptoms improved significantly with the resolution of the situation. She successfully engaged in educational pursuits and maintained positive relationships. Moreover, this conclusion is supported by the evidentiary record and especially the July 2016 VA psychiatric examination. In sum, the Board finds that the currently assigned 30 percent rating is appropriate from the date of claim until August 1, 2009 and from June 7, 2011 to the present. During the period from August 1, 2009 to June 7, 2011 a 70 percent rating is appropriate due to more severe symptoms based on situational stress, including passive suicidal ideation and paranoid ideation without delusional content. Under VA regulations, separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999). In the present case, the above-defined staged ratings are necessary based on the facts found in the present case. Rating Criteria, Facts & Analysis - Right and Left Knees Through her representative, the Veteran asserts that she is entitled to a higher rating for service connected right and left knee disabilities. See October 2017 appellate brief. The Veteran is currently in receipt of a 10 percent rating for the right and left knees under 38 C.F.R. § 4.71a, DC 5024 for tenosynovitis. This diagnostic code provides that the disability should actually be rated on limitation of motion of the affected parts, as degenerative arthritis, except for gout. DC 5003 rates degenerative arthritis and instructs to rate based on limitation of motion, with a 10 percent rating for application when limitation of motion of the joint or joints involved is noncompensable. 38 C.F.R. § 4.71a, DC 5003. The rating criteria for knee and leg disabilities is noted below: The Knee and Leg Rating 5256 Knee, ankylosis of: Extremely unfavorable, in flexion at an angle of 45° or more 60 In flexion between 20° and 45° 50 In flexion between 10° and 20° 40 Favorable angle in full extension, or in slight flexion between 0° and 10° 30 5257 Knee, other impairment of: Recurrent subluxation or lateral instability: Severe 30 Moderate 20 Slight 10 5258 Cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint 20 5259 Cartilage, semilunar, removal of, symptomatic 10 5260 Leg, limitation of flexion of: Flexion limited to 15° 30 Flexion limited to 30° 20 Flexion limited to 45° 10 Flexion limited to 60° 0 5261 Leg, limitation of extension of: Extension limited to 45° 50 Extension limited to 30° 40 Extension limited to 20° 30 Extension limited to 15° 20 Extension limited to 10° 10 Extension limited to 5° 0 5262 Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace 40 Malunion of: With marked knee or ankle disability 30 With moderate knee or ankle disability 20 With slight knee or ankle disability 10 5263 Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) 10 When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran has had two VA examinations during the appeal period for the knees. In the August 2006 VA knees examination, she reported that the disabilities were manifested by pain, swelling, weakness, stiffness, lack of endurance, locking, fatigability, giving way, and pain. She reported that pain was an eight out of ten but that she could function without medication. Treatment included elevation and Tylenol. On physical examination, the provider noted range of motion of the right knee from zero to 120 degrees with pain at 110 degrees; range of motion of the left knee was from zero to 110 degrees with pain at 110 degrees. The examiner noted that there was functional impact in both knees due to pain, but not due to fatigueability, weakness, lack of endurance, or incoordination. All stability tests were within normal limits bilaterally. The Veteran was afforded a second VA knees examination in July 2016; the examiner reviewed the claims file, interviewed the Veteran, and examined her. The Veteran reported that she used to be an avid athlete and drill sergeant while in the service, but had recently experienced decreased mobility due to pain and swelling. Current symptoms included pain of seven-to-eight out of ten to ten out of ten when aggravated, instability, and swelling lasting from 24 to 48 hours. She reported that the symptoms were aggravated by cold weather, walking, standing, and climbing stairs. Treatment included ice therapy, elevation, and rest; she also reported daily use of a cane to assist with ambulation outdoors. The Veteran denied periods of flare-up. The initial range of motion measurements were as follows: right knee flexion from zero to 90 degrees and extension from 90 to zero degrees with pain noted in flexion, causing functional loss. The left knee flexion was from zero to 100 degrees; extension was from 100 to zero degrees with pain noted in flexion, causing functional loss. There was also objective evidence of localized tenderness or pain on palpation at the medial and lateral areas of the both patella. Examination of both knees further revealed evidence with pain on weight bearing and objective evidence of crepitus. The Veteran was able to perform three repeated motions on both knees and there was no further loss of range of motion thereafter. Muscle strength was fully intact with no atrophy. There was no ankylosis, no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability testing was negative and there was no current or history of a meniscus condition. The Veteran reported regular use of a knee braces and a cane for ambulation. In regard to function impact, the Veteran reported she lost zero to one week a year of work time due to her knees. She also reported difficulty with prolonged sitting, standing, walking, and climbing stairs. X-rays did not reveal any degenerative changes. Given the above findings, and even when considering noted functional loss due to pain, the currently assigned 10 percent ratings in each knee are appropriate, as range of motion findings considering such functional loss are nowhere near a compensable rating for loss of flexion or extension in either knee. However, separate 10 percent ratings for slight instability are warranted throughout the appeal period, as despite normal stability testing on examination the Veteran has competently reported stability issues in relation to her knees, with the most recent examiner noting use of a brace and cane as a result of the bilateral knee disabilities. Rating Criteria, Facts & Analysis - Right and Left Wrists Through her representative, the Veteran asserts that she is entitled to a higher rating for service connected right and left wrist carpal tunnel disabilities. See October 2017 appellate brief. The Veteran is currently in receipt of a 10 percent rating for each wrist under 38 C.F.R. § 4.124a, DC 8515 for carpal tunnel syndrome, rated as incomplete paralysis of the median nerve. The rating criteria for median nerve impairment is noted below; a veteran's dominant hand side is deemed the "major" side, while the non-dominant side is "minor." Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. As demonstrated by the medical evidence of record, the Veteran is right-hand dominant for VA rating purposes. 38 C.F.R. § 4.69. See August 2016 VA peripheral nerves examination report. Diagnostic Code 8515 provides that mild incomplete paralysis of the median nerve is rated 10 percent disabling (major or minor); moderate impairment is rated 20 percent (minor) or 30 percent (major) disabling; and severe impairment of the median nerve is 40 percent (minor) or 50 percent (major) disabling. Complete paralysis of the median nerve warrants a 60 percent (minor) or 70 percent (major) evaluation with the hand inclined to the ulnar side with the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand (ape hand); incomplete and defective pronation of the hand with the absence of flexion of the index finger, feeble flexion of the middle finger, inability to make a fist, and index and middle fingers that remain extended; inability to flex the distal phalanx of the thumb with defective opposition and abduction of the thumb at right angles to the palm; weakened flexion of the wrist; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. The words "mild," "moderate" and "severe" are not defined in the rating schedule. In applying the schedular criteria for rating peripheral nerve disabilities, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Prior to the appeal period, the Veteran was formally diagnosed with mild right medial neuropathy (right carpal tunnel) by EMG in July 2004. That test did not reveal any evidence of left median neuropathy. The Veteran received a VA examination in August 2006. The Veteran reported a progressive history of painful wrists beginning during service in the 1990s. She reported the following symptoms: weakness and pain when carrying something as simple as a purse, lack of endurance, difficulty carrying a load or handling objects, and joint locking in a particular position for a period of time. She reported increased pain occurring seven times a week, with each episode lasting for two hours, with pain traveling throughout the hands. Pain was characterized as burning, aching, and cramping at a nine out of ten. The Veteran reported that she abstained from using the hands during a painful event. She also stated that the wrists condition did not cause incapacitation. Functional impairment included inability to use hands "as usual" and restricted activities. Physical examination of the wrists revealed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding. Range of motion of both wrists was normal, with dorsiflexion to 70 degrees; palmar flexion to 80 degrees, radial deviation to 20 degrees; and ulnar deviation to 45 degrees. The examiner indicated that neither wrist was additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repeated use. The August 2006 examiner also physically examined the Veteran's hands and fingers. She was able to tie shoelaces, fasten buttons, and pick up a piece of paper and tear it without difficulty. Right and left hand strength were both within normal limits. Contemporaneous x-rays of the bilateral wrists and hands were normal. In September 2015, the Veteran reported chronic cervico-shoulder pain that radiated to her left hand. A few weeks later, she was afforded another EMG to assess her left hand/wrist pain; the test revealed left carpal tunnel syndrome of mild severity and she was fitted with a wrist brace. The right wrist was not retested at this time and she was not examined for cervical radiculopathy at her request. In her second bilateral wrist examination in August 2016, she reported symptoms of bilateral hand spasms, pain in the palms, burning sensation in the fingertips, and numb fingertips, with symptoms worse on the left. She also reported decreased strength on the left. The examiner indicated the Veteran had the following symptoms attributable to her bilateral carpal tunnel syndrome: mild intermittent pain; mild paresthesias and/or dysesthesias; and mild numbness of the bilateral upper extremities. Muscle strength was fully intact in the bilateral upper extremities, including elbow flexion and extension, wrist flexion and extension, grip, and pinch. Reflexes were normal; and sensory examination was normal except for decreased sensation to light touch in the hands and fingers. Phalen's sign was positive bilaterally and Tinel's sign was negative bilaterally. In regard to severity, the examiner noted that the Veteran had incomplete median nerve paralysis of mild severity in both the right and left wrist. She was using a left wrist brace. In regard to functional impact, she reported losing zero to one week of time of work when she was working due to her wrist problem. She also reported increased difficulty with working on a computer for prolonged periods. The Board finds that the currently assigned 10 percent rating for each wrist remains appropriate. In each evaluation, each conducted by a medical professional, the severity of her bilateral carpal tunnel condition has been characterized as mild. Moreover muscle strength was fully intact and reflexes have been normal, which also suggests the condition is of mild severity. In the present case, the Veteran's objective symptoms are wholly sensory. As such, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for each wrist. Rating Criteria, Facts & Analysis - Headaches Through her representative, the Veteran asserts that she is entitled to a rating in excess of 30 percent for migraine headaches. See October 2017 appellate brief; see also August 2006 notice of disagreement. The Veteran's headaches are rated under 38 C.F.R. § 4.124a, DC 8100; the rating criteria is below: 8100 Migraine: Rating With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability 50 With characteristic prostrating attacks occurring on an average once a month over last several months 30 With characteristic prostrating attacks averaging one in 2 months over last several months 10 With less frequent attacks 0 The rating criteria do not define "prostrating," and neither has the Court of Appeals for Veterans Claims (Court). Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." Nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). In August 2006, the Veteran sought treatment for a history of migraine headaches, recently occurring at least three days a week. She was taking Tylenol as needed and last saw a neurologist in 2003. She reported that the headache was recurrent, sharp or stabbing at the vertex; worse with noise; and not worse when moving eyes or head or body position or bending over. The pain was relieved by lying down, by sleep, by reducing stimuli, and by medication. The episodes lasted a few hours and were not accompanied by nausea, vomiting, diarrhea, rhinorrhea, watery or red eyes, or sinus pain. The diagnostic impression was migraine headaches. The Veteran received a VA examination for her headaches in August 2006; she reported recurring migraine headaches, manifested by tightness around the head, pounding and throbbing pain, and light sensitivity. When the attacks occurred, she reported she was able to go to work but needed medication to do so. She stated that attacks averaged about three times a week and lasted about two hours. She reported the condition caused functional impairment in that she needed to either work quietly at her desk, or stop everything and be left alone. She was taking Neurontin and Midrin for the headaches. The examiner stated that the Veteran's condition was manifested by subjective factors such as recurrent throbbing headaches accompanied by light sensitivity; the objective factor was use of Midrin for treatment. In December 2006, records reflect the Veteran sought treatment in the Emergency Room for chronic migraines with increase in severity for two months secondary to stress. She requested a work note and a refill of migraine medication. Midrin was refilled and the Veteran was told to follow up with her neurologist. In her June 2008 notice of disagreement, the Veteran stated that she had daily headaches, that she was taking prescription medications, and that they were sometimes so severe that she threw-up. She reported prostrating attacks averaging once per week from retirement until recently in 2008. An April 2010 VA primary care note reflects the Veteran reported increased headaches, pain rated at a nine out of ten, due to job stress. VA treatment notes suggest she was prescribed Fiorinal from April to October 2010; there is no medical documentation of her being prescribed Midrin or Neurontin after the December 2006 treatment note discussed above. The Veteran had a second VA headache examination in July 2016, which included diagnoses of migraines and chronic tension headaches. At this time she reported sensitivity to light and sound, nausea and vomiting, and changes in vision. She also reported migraines once or twice a week lasting less than one day, primarily on the right side and a daily tension headache. The examiner stated that the Veteran experienced characteristic prostrating attacks of migraine headaches about once a month but that she did not experience very frequent prostrating and prolonged attacks of migraine or non-migraine pain. In regard to functional impact, the Veteran reported that she had lost about one to two weeks a year of work time due to migraine pain when she was working. She also reported that she was unable to concentrate to perform her duties and needed to be in complete darkness with no noise for eight to 12 hours. Affording the Veteran the benefit of the doubt, and without considering the ameliorative effects of medication, the Board finds that the maximum 50 percent rating is warranted for the entire appeal period. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). ORDER Entitlement to a rating of 30 percent, but no greater, is granted for esophageal dysmotility disorder for the entire appeal period. Entitlement to an initial rating in excess of 10 percent for a right foot hallux valgus, status post surgery, is denied. Entitlement to an initial rating in excess of 10 percent for a left foot hallux valgus, status post surgery, is denied. Entitlement to a rating in excess of 30 percent for right foot scars is denied. Entitlement to a rating in excess of 20 percent for left foot scars is denied. (ORDER CONTINUED) Entitlement to a rating in excess of 10 percent for C-section scars is denied. Entitlement to a separate compensable rating for asthma is denied. Entitlement to a rating in excess of 30 percent for eczema is denied. Entitlement to a separate 10 percent rating, but no greater, is granted for urticaria for the entire appeal period. Entitlement to a rating in excess of 10 percent for psoriasis is denied prior to July 20, 2016. A 30 percent rating, but no greater, for psoriasis is granted from July 20, 2016. Entitlement to a compensable rating for alopecia is denied. Entitlement to a rating in excess of 30 percent for depressive disorder is denied for the period prior to August 1, 2009 and beginning with the period since June 7, 2011. For the period from August 1, 2009 to June 6, 2011 a rating of 70 percent, but no greater, is granted for depressive disorder. Entitlement to a rating in excess of 10 percent for a right knee disability based on loss of motion is denied. Entitlement to a rating in excess of 10 percent for a left knee disability based on loss of motion is denied. A separate 10 percent rating for right knee instability is granted for the entire appeal period. (ORDER CONTINUED) A separate 10 percent rating for left knee instability is granted for the entire appeal period. Entitlement to a rating in excess of 10 percent for right wrist CTS is denied. Entitlement to a rating in excess of 10 percent for left wrist CTS is denied. Entitlement to a 50 percent rating for migraine headaches is granted for the entire appeal period. ______________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs