Citation Nr: 18143520 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 17-17 488 DATE: October 19, 2018 ORDER Entitlement to service connection for a skin condition is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a skin condition due to an in-service event, injury, or disease, to include sun exposure or herbicide agent exposure in Vietnam. CONCLUSION OF LAW The criteria for entitlement to service connection for a skin condition have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from June 1954 to August 1974, including service in Vietnam. He is in receipt of a Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals on appeal from a July 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the appeal in August 2017; there has been substantial compliance with the remand directives. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900 (c) (2017). 38 U.S.C. § 7107 (a)(2) (2014). Entitlement to service connection for skin conditions The Veteran asserts that his current skin conditions are related to herbicide agents, such as Agent Orange. See April 2018 Decision Review Officer Hearing; see also December 2014 claim. Alternatively, the Veteran asserts that his skin conditions are related to in-service sun exposure, with the greatest exposure occurring during service in Vietnam. See September 2018 correspondence. In his September 2018 correspondence, the Veteran asserted that his sun exposure prior to service was minimal because he never went to the beach and lived in the city. He did not recall excessive sun exposure during his first in-service duty station in Alaska, and reported that when he conducted search and rescue in New Jersey, his skin was mostly covered. He asserts that it was his 14-month tour in Vietnam where he had the most unprotected sun exposure. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). Service connection may be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017). Actinic keratosis, dermatitis, and actinic porokeratosis are not chronic diseases for which presumptive service connection is permitted. Service connection also may be established on a presumptive basis for certain diseases resulting from exposure to an herbicide agent, such as Agent Orange, if a Veteran served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, absent affirmative evidence to establish that the Veteran was not exposed to such herbicide agent during that service. See 38 C.F.R. §§ 3.307 (a)(6)(iii). If a Veteran is presumably exposed to an herbicide agent, then there is a presumption of service connection for certain enumerated diseases. 38 U.S.C. § 1116 (2012); 38 C.F.R. §§ 3.307 (a) and 3.309(e) (2017). In this case, the Veteran is presumed to have been exposed to an herbicide agent during service because he has verified service in the Republic of Vietnam during the period specified. However, actinic keratosis, dermatitis, and actinic porokeratosis are not enumerated diseases for which presumptive service connection is permissible. Notwithstanding presumptive service connection, a claimant is not precluded from establishing service connection if proof of direct causation is provided. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). To establish direct service connection, VA generally requires, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service treatment records show the Veteran was diagnosed with dermatitis, related to poison ivy exposure, in August 1961. The Veteran also received a diagnosis of dermatitis in September 1970. At his separation examination in August 1974, the only skin abnormality noted was surgical scars. Consistent with the medical record, the Veteran reports the onset of his skin conditions was in 2004. Treatment records show current diagnoses of dermatitis, actinic keratosis, and disseminated actinic porokeratosis. As there is evidence of a skin condition in service and at present, the question for the Board is whether the Veteran has a current skin disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. In January 2015, the Veteran’s treating dermatologist completed a Disability Benefit Questionnaire (DBQ) for Skin Diseases, and noted prior similar diagnoses, but did not offer an etiological opinion. At his July 2015 VA examination, the Veteran was diagnosed with actinic keratosis and porokeratosis with generalized history of rash, itching, and irritation since 2004. The examiner opined that current diagnoses are less likely than not related to the in-service dermatitis and exposure to poison ivy in 1961. The examiner did not include comment on the Veteran’s reported sun exposure, and presumed exposure to herbicide agents, in Vietnam. The Veteran underwent a private examination in February 2016. At that examination, the Veteran reported no skin condition prior to 2004. The Veteran related his condition to Agent Orange exposure or significant in-service sun exposure in Vietnam. The Veteran denied significant sun exposure in occupational history after service as he worked for the state police and his uniform covered a majority of his skin surface. The clinician noted current findings of actinic keratosis and porokeratosis. As to etiology, the clinician opined that it is unlikely that herbicide agent exposure was the cause of the skin condition. The clinician reasoned that herbicide agent and dioxin related skin conditions would present as acne-like eruption, or chloracne, and within a year of exposure. However, the clinician noted that sun exposure is known to be major contributing factor for actinic keratosis. The clinician explained that actinic keratosis is prevalent among Caucasian adults with fair skin and cumulative sun exposure is the main risk factor. Regarding disseminated superficial actinic porokeratosis, the clinician opined that the main pathway leading to this condition remains unknown but the currently accepted theory is that it is an interplay between genetic factors and other contributing factors such as ultraviolet radiation and immunosuppression, such as with those taking medication or having a hematologic disorder. Ultimately the clinician opined that it is more likely than not that unprotected skin exposure during service in Vietnam contributed to the Veteran’s skin conditions. The Board obtained an addendum opinion in January 2018 to supplement the July 2015 VA opinion, and specifically to have consideration of the Veteran’s reported sun exposure in Vietnam. This examiner reviewed the medical records and examiner opined that the current actinic keratosis and porokeratosis did not have onset in service and are not otherwise related to service, including as a result of herbicide agent or sun exposure in Vietnam. The examiner explained that this conclusion was reached, in part, due to the late onset of both conditions, which were many decades after service. The examiner acknowledged that sun exposure has a role in the causation of actinic keratosis and porokeratosis; however, the late onset of these conditions in the Veteran’s case strongly favors the cause of skin conditions being a natural progression of cumulative lifetime exposure to sunlight beginning in childhood, rather than intense exposure during his 14-month tour in Vietnam. The examiner noted that the Veteran was found to have porokeratosis in 2004, 32 years after service. He was found to have disseminated superficial actinic porokeratosis (DSAP) in 2008, at the age of 74. The examiner explained that if in-service exposure to either herbicide agents or sun were significant factors, an earlier onset would have been expected- not a late onset. The examiner further noted that there was no indication in the Veteran’s service treatment records that he was ever treated for sunburn or other acute skin condition apart from one episode of poison ivy (a form of contact dermatitis unrelated to sun exposure and the subsequent development of actinic keratosis and porokeratosis). The examiner also discussed the February 2016 findings of the private clinician and noted that the opinion did not consider the Veteran’s sun exposure prior to service. The examiner concluded that the current skin conditions are most likely related to cumulative sun exposure prior to service and the natural aging process. Based on review of the evidence and after weighing the competing nexus opinions, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s skin conditions began during service or are otherwise related to an in-service injury, event, or disease. Both VA examiners opined that in-service dermatitis is not related to the current skin conditions. In addition, both the private and VA addendum opinion establish that the Veteran’s skin conditions are not related to herbicide agent exposure. Collectively, the rationales are persuasive because they were based on an accurate medical history and contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As to the etiological link between the Veteran’s skin conditions and in-service sun exposure, the medical opinions differ. The private opinion favors an etiological link and the January 2018 VA opinion does not. Both opinions are competent, as they were rendered by physicians with clinical expertise, and probative, because the rationales were based on the Veteran’s clinical history and contain clear conclusions and supporting data. Id. However, the Board finds the VA opinion the most persuasive of the two. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The VA addendum opinion is more comprehensive than the private opinion as it reflects consideration of factors not addressed by the private opinion- specifically, the latency of the development of these conditions (noting that the late onset strongly opposes a causal connection); the effect of the Veteran’s cumulative lifetime sun exposure (including normal sun exposure prior to service); the lack of evidence of sunburns or other skin conditions in service (excluding contact dermatitis); and the effect of the natural aging process. As the VA addendum opinion is more comprehensive than the private opinion, it is more persuasive on the matter of causal nexus, and outweighs the private opinion. While the Veteran believes his skin conditions are related to in-service sun and/or herbicide agent exposure, he is not competent to provide a nexus opinion on this matter. This is a medically-complex question that requires medical expertise and he is not shown to possess such expertise. Thus, his lay contentions are not competent evidence by which causation may be established. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). (Continued on the next page)   Given that the preponderance of the competent and probative evidence does not support a nexus between the Veteran’s skin conditions and his military service, the claim must be denied. 38 U.S.C. §5107 (b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Vuong, Associate Counsel