Citation Nr: 18140294 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 14-37 136 DATE: October 2, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure, is reopened. The claim of entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure is denied. FINDINGS OF FACT 1. A May 2002 rating decision denied entitlement to service connection for a skin condition. The Veteran did not appeal the RO determination or present new evidence within one year following the rating decision. As such, this decision is final. 2. Evidence has been received since the May 2002 rating decision that relates to an unestablished fact necessary to substantiate the claim and that raises a reasonable possibility of substantiating the claim of service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure. 3. The Veteran’s current skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, was not incurred in or aggravated by active duty service. CONCLUSIONS OF LAW 1. The May 2002 rating decision is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2018). 2. New and material evidence has been received since the May 2002 denial of service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure. 38 U.S.C. §§ 1131, 5103, 5108 (2012); 38 C.F.R. §§ 3.156, 3.303 (2018). 3. The criteria for establishing entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from August 1959 to August 1962. The Veteran filed his Substantive Appeal regarding these issues on appeal in September 2014, and requested a videoconference hearing before a Veterans Law Judge (VLJ). A hearing was conducted before the undersigned in July 2017. A transcript of the proceedings has been associated with the claims file. The Board notes that the Veteran submitted a Substantive Appeal following a separate SOC issued in August 2017, and requested a videoconference hearing with a VLJ. These issues included: entitlement to an increased evaluation for poikiloderma of civatte, and tinea pedis and tinea manum, as well as claims to reopen service connection for a back disorder, a gastrointestinal disorder, an eye disorder, and a dental disorder. In April 2018, the Veteran testified on those issues before VLJ Millikan. A transcript of those proceedings has been associated with the claims file, and those issues will be addressed in a separate decision. New and Material Evidence 1. New and material evidence having been received, the claim of entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure, is reopened Generally, if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. “New” evidence is defined as existing evidence not previously submitted to agency decision makers. “Material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold to reopen a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In May 2002, the RO denied the Veteran’s service connection claim, initially claimed as eczema of the neck, due to a lack of a nexus between service and the present disability. In that decision, the RO stated that, while the Veteran was diagnosed with seborrheic keratosis, there was no evidence that the condition was related to military service. Evidence received since the rating decision in May 2002 includes two private medical opinions relating the Veteran’s present skin disability to active duty service. In August 2013, a private physician wrote that the Veteran’s actinic damage was worsened by military service. That same month, a private physician reported that the Veteran’s diagnosis of actinic damage “may have been worsened by his time in the military due to his excessive amount of sun exposure.” The bar to reopening a claim for new and material evidence is low, and the Veteran’s evidence of a possible relationship between his present skin disability and his active duty service meets that threshold. The credibility of this evidence is also presumed for the purposes of reopening a claim. Therefore, such evidence is new and material, and the claim for service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure, is reopened. Service Connection 2. The claim of entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure The Veteran claims entitlement to service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure (hereinafter, “a skin disorder”). Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110. A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (“nexus”) between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303 (2016); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran’s enlistment examination in August 1959 did not note a skin condition upon entry. Military personnel records indicate an assignment to a Nuclear Survival Company (6470) in February 1960. The Veteran’s separation examination in July 1962 is silent with respect to skin conditions. In March 1977, the Veteran’s private dermatology records indicate suspected actinic keratosis. In an October 1994 VA examination, the examiner assessed an eruption on the Veteran’s central chest and neck. The Veteran reported that he experienced occasional papules on his chest, and used cream on the area without improvement. He stated that, while in the service in 1960, he was stationed at Fort Huachuca in Arizona, where he developed the eruption on the central aspect of the chest. Topical treatment was given at the time for irritation. The Veteran reported the eruption was exacerbated by exposure to the sun. When exposed, he experienced burning and discomfort, which also occurred when the area was moist with sweat. The examiner noted that the Veteran’s hands were slightly hyperkeratotic and minimally scaled. His chest demonstrated broken irregular macules and telangiectasia in a V distribution. The Veteran’s neck was also brown with telangiectasia and irregular brown macules. The examiner diagnosed the Veteran with actinic dermatosis of the chest due to sun exposure. VA Medical Center (VAMC) records indicate a history of treatment for multiple skin conditions. In September 2009, the Veteran experienced multiple keratotic papules on his back, face, scalp, and arms. A private Disability Benefits Questionnaire (DBQ) was submitted in August 2010 that diagnosed the Veteran with actinic keratosis and seborrheic keratosis in 2011. In September 2012, a private physician submitted a statement reporting that the Veteran was in contact with caustic chemicals, including gasoline, cutting oils, acetone, and cleaning fluids, as well as potentially exposed to radiation in service. The physician stated that such chemicals and radiation can cause a skin condition. In a statement submitted in August 2013, the Veteran’s private dermatologist stated that the Veteran has actinic damage that was worsened by his military service. In an addendum later that month, the dermatologist stated: “after reviewing the patient’s service records as well as speaking to the patient, it is my opinion that his diagnosis of Actinic Damage may have been worsened by his time in Military Service due to his excessive amount [of] sun exposure.” In a September 2014 VA examination, the Veteran reported painful seborrheic keratosis. The examiner noted that the Veteran had Fitzpatrick Type 3 skin. At the time of the examination, the Veteran did not have actinic keratoses or evidence of skin cancer on his face, trunk or arms, but he did have pink telangiectatic skin on the upper chest likely from actinic damage in the V of the neck. The examiner noted many seborrheic keratoses on the face and trunk with some hypopigmented scars from treatment. The examiner relayed the history provided by the Veteran, and considered his description of his in-service sun exposure. The examiner concluded that the Veteran’s history did not support excessive sun exposure. Further, the examiner stated that his seborrheic keratoses had no relationship to actinic damage, and attributed his condition to age, rather than service. In a March 2016 VA examination, the examiner concluded that seborrheic keratosis was not associated with sun and/or chemical or radiation exposure. Unfortunately, no rationale was provided. In a subsequent May 2016 addendum, the examiner stated that it was less likely than not that any of the skin conditions reported were associated or caused by the Veteran’s in-service exposure to chemicals or radiations as the conditions are common dermatologic conditions and not associated with radiation or chemical exposure. In a subsequent October 2016 addendum, the examiner stated that seborrheic dermatitis and seborrheic keratosis were two separate diagnostic entities. Additionally, neither of those conditions was mentioned in the Veteran’s service treatment records, to the examiner’s knowledge. Seborrheic dermatitis may start at a younger age, but seborrheic keratoses usually starts at a later age. As the examiner could not ascertain whether any of these conditions were present during the Veteran’s service, and the conditions generally start in later in life, he concluded that it was less likely that these conditions began or first manifested during the Veteran’s period of military service. In a July 2017 hearing, the Veteran reported first experiencing lesions and blisters on his skin while serving in Arizona in the Nuclear Survival Company. He stated that their work revolved around nuclear testing, and his labor was primarily outdoors. He reported experiencing blisters while working outside, which he received medication to calm the itching sensation. When he served in Germany, he used a number of chemicals, including diesel fuel and tetrachloride. On one occasion, the Veteran was sprayed with these chemicals, which caused a rash on his arms and face. The field medic assisted in cleaning it off, but the chemical caused blisters on his skin. The Veteran reported reviewing his medical files after discharge and finding the notations of these treatments absent from documentation. He stated that, at the time of his service, they did not enter such things into the files. The Veteran stated that these dermatological issues continued after discharge, and he experienced frequent itching on his back, neck and chest, which required topical treatment. The Veteran’s representative also reported that his Fitzgerald Type 3 skin caused increased sun sensitivity. In March 2018, a specialist’s opinion was obtained regarding the nature and etiology of any non-service connected skin conditions with which the Veteran was presently diagnosed. The dermatologist reviewed the entire record, including both medical and lay evidence. First, she determined that the Veteran’s present diagnoses were as follows: seborrheic keratosis, poikiloderma of civatte, dermatitis and seborrheic dermatitis of the face, folliculitis of the back, tinea manum, tinea pedis, pruritus, and actinic damage, also known as chronic sun damage. The dermatologist concluded that it was not likely or probable that the Veteran’s non-service connected diagnosis of seborrheic keratosis was related to radiation, chemical or sun exposure. Seborrheic keratoses are common, acquired, benign growths that occur in a variety of skin types, including Fitzpatrick Skin type III. These occur over time and with increasing age, and occur in sun-exposed and non-sun exposed skin. They are not related to chemical exposures or radiation. Therefore, it was not likely that this diagnosis was related to the Veteran’s active duty service. As the Veteran was already service-connected for poikiloderma of civatte, tinea manum and tinea pedis, the dermatologist did not address these conditions. The dermatologist further concluded that the folliculitis of the back was not likely and not probably related to radiation, chemicals, or sun exposure. Folliculitis is inflammation of the hair follicle and occurs in many individuals for many reasons, including sweating. The Veteran’s folliculitis appeared later in his records and was not probably or likely related to military service. Dermatitis and seborrheic dermatitis of the face is also a common skin condition not related to chemicals, radiation or sun exposure, and occurs in many individuals. As such, these diagnoses were not likely or probably related to his military service. The pruritus diagnosed was nonspecific, and the dermatologist could not relate the condition to any military service or exposure directly. The dermatologist reported that actinic damage is actually a term for chronic sun damage, which is expected in an older individual with Fitzpatrick skin type III. According to the dermatologist, this actinic damage more likely reflected what is to be expected in the course of daily existence in an elderly individual, and was not as likely incurred or related to the short duration of exposure to radiation, chemicals or the sun in service. Additionally, the Veteran had no documented skin cancers or poor outcomes from chronic sun exposure. The dermatologist reviewed both the Veteran’s military and civilian records. She noted the statement from the family practitioner that chemical and radiation cause skin conditions. The dermatologist pointed out that this statement was overly vague and did not pertain to the Veteran specifically. The dermatologist also concluded that there was no clear and unmistakable evidence that any skin disorder preexisted military service. Fitzpatrick Type III skin is a classification/grading scale of a patient’s tendency toward burning and tanning. It is not a condition in and of itself, but instead a description of a patient’s inherent skin tendencies toward burning and tanning. Type III skin sometimes burns in the sun and sometimes tans with some risk for skin cancer. A person cannot change skin types, and no experience or exposure can change this inherent grading scale, which is influenced by genetics and melanin. Fitzpatrick skin types range from 1 to 6. Thus, Fitzpatrick skin type III has preexisted military service as it is simply a description of the Veteran’s tendency to burn or tan. The Veteran has no documented skin cancers and only benign and precancerous skin lesions on a review on his records; therefore there was no documented inherent worsening or aggravation of his skin type during active duty service. Additionally, there was no clear or unmistakable evidence that the Veteran’s other diagnoses were worsened beyond the natural progression of disease by active duty service. The opinion was rendered after review of the Veteran’s records, which did not include any of the above conditions until more recently in his medical history. Thus, based on available medical records during military service and both civilian and VA medical records, there does not appear to be any preexisting skin disorder aggravated by active duty service. After a thorough review of the medical and lay evidence of record, the Board finds that the preponderance of the evidence of record weighs against entitlement to service connection for a separate skin disorder. At the outset, the Board notes that the Veteran has a present diagnosis of a skin disorder, to include seborrheic keratosis and actinic dermatosis/actinic damage. This satisfies the first requirement for service connection. The two outstanding elements, in-service incurrence and a nexus, must be resolved in the affirmative to grant service connection. With respect to these elements, the Board finds that the private medical opinions of record provided conclusory medical opinions that are insufficient to sustain a grant of service connection. The September 2012 private opinion simply reports that exposure to certain chemicals and radiation can cause a skin condition. The August 2013 opinion and addendum summarily state that the Veteran’s actinic damage “may have been worsened” by his active duty service due to sun exposure. No rationale is provided, nor is detail afforded to distinguish in-service sun exposure and post-service sun exposure. While these statements seek to establish an in-service incurrence and nexus with active duty service, they are conclusory, at best, and cannot establish the necessary service connection elements. Accordingly, these statements must be afforded significantly diminished probative weight. While the VA examinations of record have not provided complete opinions independently, the March 2018 specialist’s opinion offers the most comprehensive etiological opinion regarding the Veteran’s various skin diagnoses. A dermatologist with experience and education in the field reviewed the Veteran’s entire file, and considered both medical and lay evidence of record in reaching her conclusions. The examiner provided sufficient reasoning to deny a nexus between the Veteran’s skin diagnoses and active duty service, including his exposures to chemicals, radiation and the sun. She also adequately supported her conclusion that he did not have a preexisting skin condition that was worsened by virtue of his military service. Instead, the examiner stressed the Veteran’s age and the natural development of these conditions as dominant factors in developing these skin conditions. The Board recognizes that the Veteran believes his diagnosed skin disorders manifested as a result of active duty service, including exposures to chemicals, radiation and the sun. While the Veteran is competent to provide testimony to establish the occurrence of medical symptoms, he is not medically qualified to prove a matter requiring medical expertise. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The etiology of skin disorders is a complex medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not asserted any specialized medical training that would support his conclusion regarding the etiology of his skin disorders. Instead, competent medical evidence of record determined that the etiology of the Veteran’s skin disorders is unrelated to his service, including his in-service exposures. Instead, the March 2018 opinion of record placed greater weight on the Veteran’s age and natural development of these conditions through the aging process. Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran’s skin disorders are related to his military service, the Board ultimately affords this competent medical evidence of record greater probative weight than the lay opinion. Accordingly, the preponderance of the evidence of record weighs against a nexus between the Veteran’s skin diagnoses and active duty service. As such, the benefit of the doubt rule is not for application. The Board finds that service connection for a skin disorder, other than tinea pedis, tinea manum, and poikiloderma of civatte, to include as a result of exposure to ionizing radiation, chemical exposure, or sun exposure is not warranted. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel