Citation Nr: 18147149 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 13-24 794 DATE: November 2, 2018 ORDER Entitlement to a rating in excess of 10 percent for tinea pedis is denied. FINDING OF FACT At no point during this appeals period has the Veteran’s tinea pedis covered at least 20 percent of his entire body or at least 20 percent of his exposed areas; nor is there any 12-month period during which the Veteran has required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of at least six weeks. CONCLUSION OF LAW The criteria for entitlement to a rating in excess of 10 percent for tinea pedis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.27, 4.118, Diagnostic Code 7820-7806. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1967 to April 1969. This matter comes before the Board on appeal from a January 2013 Regional Office (RO) rating decision. In October 2013, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Entitlement to a rating in excess of 10 percent for tinea pedis The Veteran has claimed entitlement to a rating in excess of 10 percent for tinea pedis. This disability has been rated under 38 C.F.R. § 4.118, Diagnostic Code 7820-7806. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. In the case at hand, Diagnostic Code 7820 applies to infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic diseases). It directs that the disability be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. In the case at hand, the Veteran’s tinea pedis has been rated by analogy as dermatitis or eczema pursuant to Diagnostic Code 7806. Under Diagnostic Code 7806, a 0 percent (noncompensable) rating is warranted for dermatitis or eczema affecting less than 5 percent of the entire body or affecting less than 5 percent of the exposed areas, and requiring no more than topical therapy during the past 12-month period. A 10 percent rating is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body or affecting at least 5 percent, but less than 20 percent, of the exposed areas; or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema affecting 20 percent to 40 percent of the entire body or affecting 20 percent to 40 percent of the exposed areas; or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum, 60 percent rating is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or affecting more than 40 percent of the exposed areas; or requiring constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. Diagnostic Code 7806 “draws a clear distinction between ‘systemic therapy’ and ‘topical therapy’ as the operative terms of the diagnostic code.” Johnson v. Shulkin, 862 F.3d 1351, 1354 (2017). Specifically, “systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a particular surface area, [such] as a topical antiinfective applied to a certain area of the skin and affecting only the area to which it is applied.” Id. at 1355. Although a topical treatment could meet the definition of “systemic therapy” if it were administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical treatments amount to systemic therapy. Id. The Veteran contends that his rash has become more widespread. (See Board hearing transcript, pages 3-4). He has reported that it affects his entire foot, including between his toes and on the sides, bottoms, and tops of his feet. (See Board hearing transcript, page 9). He testified that his feet itch and burn, and that sometimes a vein will pop up from his feet. (See Board hearing transcript, pages 4, 13). Both the November 2012 and the October 2015 VA examination reports reflect that the Veteran’s rash affects less than 5 percent of his total body area and no exposed areas. The VA and private medical treatment records from the appeals period do not contradict these estimates, and the Board notes that the assertion that the rash has become more widespread does not contradict the finding that it still covers less than 5 percent of his skin. In order to receive an increased rating based on the area affected, the rash must cover at least 20 percent of either the Veteran’s total body or of his exposed areas. Because neither criteria is satisfied in this case, entitlement to a rating in excess of 10 percent cannot be assigned based on the percentage of the Veteran’s skin that is affected. In terms of treatment, records reflect that the Veteran regularly applies Ketoconazole cream, which has been prescribed by a VA treatment provider. (See October 2015 VA skin diseases examination report.) They also reflect that he regularly uses Lamisil. (See October 2017 VA Podiatry Follow-Up Visit.) The Veteran does not contend, and the record does not reflect, that his use of cream should be considered systemic, rather than topical, therapy as defined above. Therefore, the use of this cream does not justify the assignment of a rating in excess of 10 percent. The Board will next consider whether the Veteran may receive a rating in excess of 10 percent based on the use of systemic therapy. The Veteran has claimed the use of systemic therapy in both pill and injection form. With respect to pills, the Veteran testified that, in addition to using different ointments and salves, he “sometimes takes the pills, too.” He testified that, “after a certain length of time, like maybe two months, it does good.” (See Board hearing transcript, pages 5-6.) Review of the Veteran’s medical records reflects that, in January 2013, his private podiatrist noted that the Veteran “has never been on an oral antifungal medication in the past.” The podiatrist prescribed Griseofulvin Microsize 500mg for two weeks. He noted that, “[i]f after 2 weeks it shows signs of improvement, I will keep him on it for 1 month.” The claims file does not contain a record of the follow-up appointment. Nor does the claims file contain any additional VA or private treatment records reflecting that the Veteran has received more than two weeks of Griseofulvin Microsize 500mg, or that he has been prescribed any other oral medication to treat his tinea pedis. (The Board notes that, in July 2015, VA sent the Veteran a letter requesting that he either submit any pertinent treatment records or complete an authorization form permitting VA to obtain such records on his behalf. He did not submit any additional medical records, and he has not authorized VA to obtain any such records on his behalf. Therefore, any evidence that may be helpful to the Veteran’s claim that may be contained in such records has not been associated with the claims file.) At his Board hearing, the Veteran’s accredited representative noted that his private treatment records recommended that the Veteran use a multivitamin, and the Veteran noted that use of a multivitamin was recommended in addition to the use of the topical cream. (See Board hearing transcript, page 7.) The January 2013 private medical record reflects that the Veteran takes a Centrum chewable tablet daily. The Veteran specifically noted that “[t]hey’re supposed to go hand-in-hand – one work[s] the outside, one work[s] the inside.” (See Board hearing transcript, page 7.) Multivitamins are not considered immunosuppressive drugs, and they therefore cannot be classified as a type of “systemic therapy such as corticosteroids or other immunosuppressive drugs.” The Board therefore finds that the Veteran’s use of a daily multivitamin does not justify the assignment of a rating in excess of 10 percent. In addition, the Veteran testified at his Board hearing that he received an injection in his arm from a City Clinic doctor. (See Board hearing transcript, pages 4, 10.) An October 2004 letter from a private physician notes that he has treated the Veteran with TMC (Triamcinolone) injections. At his October 2015 VA examination, the Veteran reported that he last saw his civilian dermatologist in the warm months of 2014 (possibly summer), at which time he received a Triamcinolone injection. Even though this treatment was not corroborated by the medical evidence of record, the Board will accept this report as a competent and credible estimation of the Veteran’s receipt of systemic therapy in 2014. Thus, the record reflects that the Veteran received two weeks of systemic medication in January 2013 and that he received a single injection in 2014. In order to receive a rating in excess of 10 percent, the Veteran must have been administered systemic therapy for a total duration of six weeks or more during a 12-month period. The Veteran’s use of Griseofulvin Microsize 500mg for two weeks in January 2013 and/or his receipt of a Triamcinolone injection in 2014 does not satisfy this requirement. In short, at no point during the appeals period has the Veteran’s tinea pedis covered at least 20 percent of his entire body or his exposed areas. Nor is there any 12-month period during which the Veteran has required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of at least six weeks. Therefore, the criteria for entitlement to a rating in excess of 10 percent for tinea pedis is not met at any point during this appeals period. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. BETHANY L. BUCK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel