Citation Nr: 1806152 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 12-01 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hepatitis with liver damage. 2. Entitlement to service connection for gout, to include as secondary to service-connected diabetes mellitus, type II. 3. Entitlement to service connection for a skin disorder, to include lichen planus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active service from May 1969 to January 1971 and he had one year of overseas service in Korea. This matter comes before the Board of Veterans' Appeals (Board) from decisions of a the Department of Veterans Affairs (VA) Regional Office (RO) in June 2010, which denied service connection for gout, and September 2010 which denied reopening of a claim for service connection for hepatitis (previously denied in February 1971), and June 2011 which denied service connection for hearing loss and lichen planus. Of note, the June 2010 rating decision also denied service connection for diabetes mellitus, type II, but service connection was subsequently granted by a December 2011 rating decision. In April 2011 the Veteran withdrew multiple other claims for service connection. The June 2011 rating decision also denied service connection for posttraumatic stress disorder (PTSD) but the July 2011 Notice of Disagreement (NOD), while contesting the denials of service connection for a skin condition and hearing loss only in the left ear, did not contest the denial of service connection for PTSD. In an August 2016 decision the Board denied service connection for hearing loss of the left ear, and it was found that there was new and material evidence to reopen the claim for service connection for hepatitis with liver damage. Upon reopening, the Board remanded the claim for service connection for hepatitis with liver damage, as well as claims for service connection for gout and for a skin disorder for further development. Following a February 2017 Supplemental Statement of the Case (SSOC), the Veteran submitted evidence in March 2017 with a waiver of initial RO consideration. In addition to the paper claim file there are paperless claims electronic files, Veteran's Benefits Management System (VBMS) and Virtual VA. All of these have been reviewed in this case. FINDINGS OF FACT 1. Hepatitis with liver damage is not shown. 2. Gout, to include as secondary to service-connected diabetes mellitus, type II, is not shown. 3. A chronic skin disorder, to include lichen planus, first manifested many years after service and is unrelated to any inservice event, including herbicide exposure, and is not proximately due to or aggravated by service-connected diabetes. CONCLUSIONS OF LAW 1. The criteria for service-connection for hepatitis with liver damage. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for gout, to include as secondary to service-connected diabetes mellitus, type II, are not met. 38 U.S.C.A. §§ 1110, 1112, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for a skin disorder, to include lichen planus, are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA imposes on VA to provide notice of how to substantiate a claim and to assist in evidentiary development. VA's duty to notify was satisfied by letters in May, August, and November 2010 as well as April 2011. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As to the duty to assist, the Veterans service personnel records and service treatment records (STRs) are on file, as are his VA treatment records, including VA outpatient treatment (VAOPT) records, and private clinical records. The Veteran declined the opportunity to testify in support of his claims. In compliance with the Board remand, by RO letter in August 2016 he was requested to either submit evidence as to his claims or provide information which would allow VA do obtain such evidence. The Veteran was afforded VA examinations to obtain medical opinions as to his claimed disabilities. The adequacy of the examinations and medical opinions obtained has not been challenged. As to this, even in light of the duty to independently consider issues suggested by the evidence of record, under Comer v. Peake, 552 F.3d 1362, 1368 (Fed.Cir. 2009), "the Board is entitled to assume the competence of a VA examiner unless the competence is challenged. Rizzo [v. Shinseki,] 580 F.3d at 1290-91. The argument that a VA medical examiner's opinion is inadequate is sufficiently close to the argument raised in Rizzo that it should be treated the same." Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); see also Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); Hilkert v. West, 12 Vet. App. 145, 151 (1999). In light of the foregoing, the Board concludes that there has been full VCAA compliance. Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed.Cir. 2007). Principles of Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. § 3.303; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A rebuttable presumption of service connection exists for chronic diseases, specifically listed at 38 C.F.R. § 3.309(a) (and not merely diseases which are "medically chronic"), including an endocrinopathy, and arthritis [including gout as form of arthritis], if the chronicity is either shown as such in service which requires sufficient combination of manifestations for disease identification and sufficient observation to establish chronicity (as opposed to isolated findings or a mere diagnosis including the word 'chronic'), or manifests to 10 percent or more within one year of service discharge (under § 3.307). If not shown as chronic during service or if a diagnosis of chronicity is legitimately questioned, continuity of symptomatology after service is required, 38 C.F.R. § 3.303(b), but the use of continuity of symptoms is limited to only those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. The presumption may be rebutted by affirmative evidence of intercurrent injury or disease which is a recognized cause of a chronic disability. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed.Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). For a chronic disease to be shown during service or in a presumptive period means that it is "well diagnosed beyond question" or "beyond legitimate question." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the unique and readily identifiable features of a medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994); and 38 C.F.R. § 3.159(a)(2). However, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). See 38 C.F.R. § 3.159(a)(1). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Hepatitis with Liver Damage The Veteran's STRs reveal that in October 1970 he sustained a stab wound of the lower right quadrant of the abdomen. When seen the next day at a dispensary the wound was described as being satisfactory. In December 1970 the Veteran was seen for what was felt to be a urinary tract infection (UTI). Later that month the impression was infectious hepatitis versus mononucleosis. He was admitted for hospitalization on December 9, 1970 due to viral hepatitis while in Korea. After 14 days, he was evacuated to the continental United States. A January 14, 1971, physical profile reflects that the Veteran was medically qualified for duty. In the Veteran's March 2011 statement he reported that he developed hepatitis in Korea and was shipped to Ft. Campbell where he was hospitalized for a long time. He later had his second case in which physicians had told him that he had liver damage and he was advised to quit drinking. Records of the Vanderbilt Medical Group include a January 2008 CT scan which showed diffuse fatty infiltration of the liver. There was also a clinical notation in November 2008 which is not clearly legible but which could be interpreted as being "Hep C." A February 2010 VAOPT record indicates that the Veteran had previously had a positive test for Hepatitis C in about 2010 but the exact date was not known. The Veteran reported that his Hepatitis C was stable and had been diagnosed by sources outside VA. An April 2010 VAOPT record indicated that the Veteran's medical problems included Hepatitis, type unknown, which had occurred when he was in Korea. However, a Hepatitis C test was not reactive. In April 2011 the Veteran withdrew multiple claims for service connection which he filed in November 2010, including "alcohol problems" and "drugs problems" [sic]. An August 2011 VAOPT record shows that he was Hepatitis C negative. An August 2014 VAOPT record reflects that his personal medical history included having liver problems secondary to Hepatitis. It was also reported that he had been discharged medically secondary to hepatitis infection contracted in Korea. April and September 2015 VAOPT records noted that the Veteran reported having a history of hepatitis with "two flares" but it was now clear. He did not know what type of hepatitis he had had in the past. It was also noted that a review of his chart in 2013 had been negative for Hepatitis C. In a September 2016 letter from a licensed practical nurse of the gastroenterology department of Vanderbilt University Medical Center it was reported that as to the Veteran's question regarding his rash, it had been reported that he had tested negative for Hepatitis C. Only Hepatitis C could be connected to Lichen Planus. No liver disease was found that could cause his Lichen Planus. On VA examination in September 2016 the Veteran's electronic records were reviewed. The examiner reported that the diagnosis was Hepatitis A. It was noted that the Veteran had had hepatitis while in Korea in 1970. This was before hepatitis B testing was available and he had probably had Hepatitis A. He did not currently have signs or symptoms attributable to chronic or infectious liver diseases. He had not been diagnosed with hepatitis C, did not have any incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) due to the liver conditions during the past 12 months. Also, he did not have signs or symptoms attributable to cirrhosis of the liver, biliary cirrhosis or cirrhotic phase of sclerosing cholangitis. The relevant clinical studies, having been performed in 2016, were listed. It was opined that there was no evidence of liver disease. The Veteran submitted evidence in March 2017 with a waiver of initial RO consideration. This consisted of the results of a November 2016 urinalysis, and medical information obtained from various Internet sources some of which addresses nonalcoholic fatty liver, called NAFL, and nonalcoholic steatohepatitis, called NASH, in both of which there is a build-up of fat in the liver but only in NASH is the liver inflamed. Analysis While acknowledging that the Veteran had hepatitis during service, and that he does have complaints which he refers to his liver, his lay testimony alone is insufficient to establish that he also now has or has ever had a chronic disease of the liver, or chronic disabling residuals of inservice hepatitis. The Board also acknowledges that the Veteran reported that he had been advised by a physician to quit drinking because his inservice hepatitis had damaged his liver. It is also acknowledged that VA records reflect a personal medical history of liver damage due to hepatitis; however, this history was never clinically confirmed and, so, it can only be concluded that this medical history of putative liver damage could only have been predicated upon a history related by the Veteran. In sum, the Veteran's statements as to his belief that he has chronic residual disability of the liver due to inservice hepatitis are, in substance, actually a medical opinion in the guise of lay evidence and, as such, are not competent because the Veteran does not have the education, training or expertise to render a medical opinion. 38 C.F.R. § 3.159(a)(1) and (2); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994); and Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir. 2009). Competent medical evidence is required to establish that the Veteran has a chronic disability which is not capable of diagnosis by a layperson. Here, both the September 2016 letter from a private nurse and the opinion of a VA examiner in September 2016 opined that the Veteran did not have any liver disease. The VA examiner stated that the Veteran did not have any signs or symptoms of liver disease and rendered this opinion after reviewing multiple relevant clinical studies. Service connection cannot be granted "[i]n the absence of proof of a present disability." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement is satisfied when the claimant has a disability at the time the claim is filed or during the pendency of the appeal even though the disability may resolve prior to adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Here, however, there is no competent evidence that the Veteran has ever had liver damage or liver disease, much less liver damage due to inservice hepatitis. The more recently submitted evidence consisting of no more than some results of a urinalysis and medical information from the Internet is not shown to have any particular relevance and does not have any corroborating effect in demonstrating that the Veteran has ever had liver damage or liver disease, much less liver damage due to inservice hepatitis. Accordingly, the preponderance of the evidence is against the claim for service connection for hepatitis with liver damage. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Gout The STRs are negative for gout and show that a November 1970 examination for separation found no pertinent abnormality. An April 2010 VAOPT was noted that the Veteran had pain in the right great toe which might be due to gout. An October 2010 VAOPT record shows that the Veteran prescribed Colchicine for gout. An August 2011 VAOPT record shows that the Veteran had had diabetes for 5 years. A July 2012 VAOPT record reflects that the Veteran denied having gout. However, a February 2012 VAOPT record indicated that the Veteran had a history of gout in his foot, with a history of flare-ups. On VA examination in September 2016 the Veteran's electronic records were reviewed. The examiner reported that there was a very vague diagnosis of gout some years ago. However, all available uric acid values were normal and the Veteran related no history of acute gout. Rather, the Veteran reported that some years ago a doctor had told him he had gout because his feet were swollen. He did not provide any other information. After a physical examination the examiner opined that it was less likely than not (less than 50% probability) that gout was proximately due to or the result of the Veteran's service-connected diabetes. The rationale was that, first there was no clear evidence for gout. Secondly, gout was a metabolic order which was not caused by diabetes. Subsequently, in November 2016 the case was referred for another medical opinion. That opining physician extensively reviewed the record, quoting numerous clinical entries, including two studies in April 2010 which had revealed a borderline and an elevated level of uric acid. The opining physician agreed with the September 2016 VA examiner that the Veteran was not currently diagnosed with gout or being treated for gout, and, thus, it was less likely than not (less than 50 percent probability) proximately due to or the result of or aggravated by the Veteran's service-connected diabetes mellitus, type II. In setting forth a rationale it was stated that in the Veteran's April 26, 2010, VA Agent Orange examination the Veteran was noted to have served two years in the U.S. Army with one of those years spent in Korea during the time frame that Agent Orange had been sprayed in that area. His problems were noted to include diabetes on medication, with right big toe pain with possible gout. Uric acid level was 7.6. On 10/29/2010 the Veteran was seen in the General Emergency Room for bilateral foot pain, and the assessment was gout. He was started on Colchicine and Indocin. In a Primary Care Urgent Care Note dated 2/3/2012 the Veteran walked-in with months of right hip pain and one week of right knee pain. Right knee was hot and swollen. A history of gout in the foot was reported. The Veteran's primary complaint was that his right knee had been swollen and hurting for about 10 days. On examination the right knee had extended fully without tenderness on manipulation of the patella. The knee was described as subtly warm and edematous. The assessment was right knee arthralgia, gout, diabetes mellitus and right hip pain. The treatment plan was to replace ibuprofen with Indocin. He was again seen in the General Emergency Room on 7/6/2012 for right hip and knee pain for approximately 6 months. The Veteran was documented to have denied gout. Imaging was noted to support a finding of arthritis of the right knee. The November 2016 opining physician observed that at the time of the September 2016 VA examination that opining physician had concluded that the Veteran did not have a current diagnosis of gout. That examiner had assessed that all available uric acid values are normal and the Veteran did not provide a history of gout. The examiner did record the Veteran's provided history that: "a doctor some years ago told him he had gout because his feet were swollen." That examiner recorded that physical examination of the feet was entirely normal. That examiner opined that as to the relationship of gout to diabetes, the claimed condition of gout was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected diabetes mellitus, type II, and the rationale was that: "First, there is no clear evidence for gout. Secondly, gout is a metabolic order which is not caused by diabetes." Citing to multiple medical sources, the November 2016 opining physician stated that in summary, a careful review of the Veteran's serum uric acid values, with 7.0 on 2/3/3012 and 7.6 on 4/23/2010, were both in the normal range, but as noted in the lab results: "Uric Acid levels above 7.0 mg/dL may fall within the normal reference range but are associated with development of gout, with sustained higher levels significantly increasing risk." A review of the literature showed a strong association between gout and diabetes mellitus type II, but with gout as a risk factor for diabetes mellitus, type II, "NOT" the other way around. Again citing to medical sources, it was stated that the etiology of gout was that it was not due to diabetes itself, but to the diabetic comorbid conditions, Also and interestingly, worse control of diabetes, based upon A1C values, lowered [not increased the] risk of gout. Additionally, while the Veteran has been diagnosed and treated for gout since leaving military service, with no current diagnosis of gout and there being no evidence of permanent worsening of his gout beyond normal progression, there was no basis for aggravation. Analysis Initially, the Board must note that it was only many years after the Veteran's active service that he had symptoms which had led to a belief that he might have gout, and that he was treated with medication for suspected gout. Thus, there is some credibility to the histories which the Veteran has related of having been told he had gout. However, the evidence is clear that he did not continue such treatment. The Board also acknowledges the Veteran's uric acid level readings. However, these were reviewed by two separate VA physicians. The September 2016 VA physician conducted a physical examination and both physicians, i.e., in September and in November 2016, reviewed the entire evidentiary record. Each concluded that the Veteran did not have gout. Most fairly and reasonably construed, the opinions are to the effect that the earlier diagnosis of gout was in error and that, in fact, the Veteran had never actually had gout. This apparently must have been the conclusion of prior treating clinicians inasmuch as the Veteran did not continued to take the medication for gout which he had been prescribed when he had symptoms which were apparently not inconsistent with gout. As noted, competent medical evidence is required to establish that the Veteran has a chronic disability which is not capable of diagnosis by a layperson. Here, both the September and the November 2016 VA opining physicians concluded that the Veteran did not have gout and, reasonably interpreted, that he had never had gout. Significantly, the November 2016 physician specifically note that the Veteran's service-connected diabetes was not a risk factor for gout; rather, it was the other way around, i.e., gout was a risk factor for diabetes, which in this case has been service-connected on the basis of herbicide exposure. Moreover, while it is not contended that gout is due to inservice herbicide exposure, even if there were such a contention the outcome would be the same in light of the unrebutted medical opinions that the Veteran does not now have, and never has had, gout. Accordingly, the preponderance of the evidence is against the claim for service connection for gout. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Skin Disorder The Veteran essentially contends that he has a chronic skin disorder which is due to either his service-connected diabetes or to liver damage from hepatitis, for which service connection is sought. The STRs show that in July 1979 the Veteran complained of irritation of his face after shaving. The impression was a shaving rash. In March 1970 he had dry skin, for which he was given mineral oil. Also, a laceration of the right side of his lip was sutured. The STRs show that a November 1970 examination for separation found no pertinent abnormality. Record of Skin Solutions Dermatology and Skin Cancer Surgery reflect that the Veteran was treated in 2007 and 2008 for lichen planus. When initially evaluated at a VA audiology clinic in April 2010 the Veteran reported a possible hearing loss, worse left ear, of gradual onset beginning perhaps 3 to 4 years ago, which had now progressed and did not fluctuate. He stated that an infection in his left ear had cleared with medical treatment and he had not noticed any sequelae other that the possible left ear hearing loss. His history was positive for the diabetes mellitus of adult onset about 1 year ago. VA electronic medical records (CAPRI records) show that in August 2010 the assessments included seborrheic dermatitis of the outer ears. An August 2011 VAOPT record shows that he reported that he had had lichen planus for more than 3 years. It was initially treated as "some other skin disorder" and, reportedly, a biopsy 2 years ago showed that it was lichen planus. He had previously been treated with Kenalog. On examination he had hyperpigmented thin plaques on both lower legs. The diagnosis was lichen planus. In April 2015 it was reported that the Veteran had a history of diabetes and hypertrophic lichen planus (with a biopsy in May 2013 having been consistent with such) for approximately 10 years. On examination he had hyperpigmented plaque of the upper and lower extremities. The assessment was hypertrophic lichen planus. When evaluated for hearing loss in May 2015 the impressions included mild seborrheic dermatitis of the external canals and conchal bowls. In November 2015 it was noted that the Veteran's past medical history included folliculitis and lichen planus. VA treatment records show that the Veteran was followed-up in January 2016 for hypertrophic lichen planus. At that time it was noted that he had a history of diabetes mellitus, type II, and hypertrophic lichen planus. Of note, at previous visits the Veteran had been noted to have hypopigmentation. His topical and intra-lesional steroids were stopped and he was changed to an ointment. He stated that this had controlled his affected areas and they were not getting worse but he still had some refractory plaques on the leg. On examination he had hyperpigmented plaques on the upper and lower extremities. The assessment was hypertrophic lichen planus. In the Veteran's VA Form 9 he reported that he had frequent breakouts of lichen planus which his physicians had attributed to his service-connected diabetes. Records of Skin Solutions show that in August 2007 the Veteran was seen for lichen planus and for "[p]ruritic, pruritus." Also in that month there was an assessment of lichen planus, primary. In September 2007 the Veteran was treated for lichen planus. It was noted that he had elevated glucose "on injectable Kenalog." Records in November 2007 as well as February and May 2008 show that he had lichen planus of both legs. In a September 2016 letter from a licensed practical nurse of the gastroenterology department of Vanderbilt University Medical Center it was reported that as to the Veteran's question regarding his rash, it had been reported that he had tested negative for Hepatitis C. Only Hepatitis C could be connected to Lichen Planus. No liver disease was found that could cause his Lichen Planus. On VA examination in September 2016 the Veteran's electronic records were reviewed. It was noted that the Veteran had developed rash involving exposed areas of arms and legs. Lichen planus had been diagnosed in 2000. On examination he had lichen planus on the extensor surfaces of forearms and legs, involving less than 20% of the surface area exposed or unexposed. It was opined that the Veteran's skin condition was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that there was nothing to suggest that lichen planus has any relationship to service. Also, it was opined that the lichen planus was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected diabetes. The rationale was that there was no nexus between diabetes and lichen planus. VA treatment records show that a skin punch biopsy in November 2016, at which time it was noted that he had a history of type II diabetes, and hypertrophic lichen planus for approximately 10 years, with a biopsy in May 2013 having been consistent with the latter. On examination he had skin involvement of his arms and legs. The assessments were flare-ups of hypertrophic lichen planus, and dermatitis, not otherwise specified; photo-distributed. An addendum in December 2016 was that overall the findings were of a subacute/chronic spongiotic dermatitis, but differential diagnoses included photo-allergic dermatitis versus allergic drug reaction. Clinical correlation was needed. Subsequently, in November 2016 the case was referred for another medical opinion. That opining physician extensively reviewed the record. The examiner stated that in her opinion the Veteran was a credible witness. It was also understood by the examiner that the Veteran was competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology, and reports of injuries. Therefore, the Veteran's lay statements were considered in formulating her medical opinion. Currently, the Veteran asserted that his claimed skin disorder, to include Lichen Planus, was related to military service and/or aggravated by his service connected Diabetes Mellitus, Type II. It was noted, citing to a medical text, that Lichen Planus was a common skin condition described as "multiple flat-topped, violaceous papules and plaques." In 2013, the Veteran was diagnosed with Lichen Planus on skin biopsy. In review of the active duty records, the medical notes were negative for any clinical presentations, complaints, diagnosis, treatment, injury and/or events related to Lichen Planus. Furthermore, the 14 November 1970 and 19 January 1971 separation examinations were also negative for complaints, diagnosis, treatment, injury and/or events related to Lichen Planus and/or other chronic skin conditions, to include areas of the extensor surfaces of the forearms and legs. On the other hand, on 06 July 1970, the Veteran presented with complains of irritation of the face after shaving. The diagnosis was shaving rash. The rash was conservatively treated with 1% Hydrocortisone Cream. Again citing to a medical text, it was reported that current dermatological literature indicated that facial skin rashes were as least as likely as not related to a local facial folliculitis because "[h]air follicles serve as portals for a number of bacteria, although S. aureus [was] the most common cause of localized folliculitis. Sebaceous glands empty into hair follicles and ducts." Therefore, it was as least as likely as not that the active duty skin condition, shaving rash, was acute, self-limited and transient as well as independent and separate from his 2013 diagnosis of Lichen Planus because of the difference in clinical appearance and dermatological pathology. Specifically, the current VA dermatological examination was negative for dermatologically-based clinical evidence of shaving rash and/or residuals of folliculitis. Thus, it was less likely than not that the Veteran's claimed skin condition, Lichen Planus, was related to and/or aggravated by his military service. For the same reasons, it was less likely than not that the Veteran's in-service skin condition related to a chronic condition because it was an acute, self-limited and transient condition that resolved with conservative treatment. Also, the Veteran was service connected for Diabetes Mellitus, Type II, following his exposure to Agent Orange while stationed in Korea. However, current dermatologic and internal medical literature lacked sufficient dermatologically-based, clinical evidence to support aggravation and/or nexus between Diabetes Mellitus, Type II and Lichen Planus. Therefore, it was less likely than not that the Veteran's claimed multiple flat-topped papules and plaques on his forearms and legs related to secondary manifestations of Diabetes Mellitus, Type II because Lichen Planus was etiologically and pathophysiologically independent and separate from Diabetes Mellitus, Type II. For these same reasons, it was less likely than not that any skin disorder, to include Lichen Planus, was permanently worsened beyond natural progress (aggravated) by service connected Diabetes Mellitus. Further, the 01 September 2016 VA skin examination, e-folder, and Tennessee Valley VA Medical Center medical notes were reviewed with care and consideration. The September 2016 examiner found Lichen Planus of the extensor surfaces of forearms and legs, with an estimated 20% surface area exposed and unexposed. The pathology of disease was confirmed on a 2013 skin biopsy. No other skin-type lesions, to include benign and/or malignant neoplasms and/or metastases, were diagnosed and/or observed. Furthermore, the 40 year gap in the Lichen Planus diagnosis (in 2013) coupled with the lack of any active duty, dermatologically-based clinical evidence clearly demonstrated that it was less likely than not that the Veteran's claimed skin condition, to include Lichen Planus and/or past dermatologic history of skin conditions, were related to and/or aggravated by his military service. In sum, it was concluded that these medical conclusions were based on a comprehensive review of the VBMS e folder, medical evidence from the clinical file, lay statements, CAPRI and current medical literature. Analysis Initially, the Board notes that the conclusion of the November 2016 opining physician was that the Veteran's inservice transient facial skin symptoms were acute manifestations of folliculitis which had resolved without chronic residual disability. This medical opinion is unrebutted, as is the opinion that the Veteran's current lichen planus had its' onset many years after active service and is likewise unrelated to the Veteran's military service. The Veteran is competent to report a contemporaneous medical diagnosis and to describe symptoms which support a later diagnosis by a medical professional. Jandreau, Id. However, his report that physicians had attributed his lichen planus to his service-connected diabetes is unsupported by clinical evidence and, rather, is rebutted by the VA medical opinions obtained in September and November 2016. Moreover, the September 2016 letter of a private nurse only concluded that his lichen planus was not related to any hepatitis or liver disease, and did not address the actual etiology of the lichen planus. In order for the Board to adjudicate the claim it need not be determined what the actual etiology of the lichen planus may be. Rather, the determinative matter is the relationship of the lichen planus to the Veteran's military service or to any service-connected disorder, in this case his service-connected diabetes. These matters were properly and thoroughly addressed in the September and November 2016 VA medical opinions. Each, independently, concluded that there was no relationship of any kind between the Veteran's military service or his service-connected diabetes and his claimed lichen planus. Based upon the education, training, and knowledge of the VA opining physicians the Board concludes that these opinions are of greater probative value than the Veteran's mere and uncorroborated report that other physicians have attributed his lichen planus to his service-connected diabetes, particularly in light of the statement of a private nurse which did not set forth any putative etiology of the lichen planus. For these reasons and bases, the Board finds that the preponderance of the evidence is against the claim for service connection for a skin disorder, including lichen planus. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). ORDER Service connection for hepatitis with liver damage; gout; and a skin disorder, to include lichen planus, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs