Citation Nr: 18151214 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 16-40 593A DATE: November 20, 2018 ORDER Entitlement to a disability rating higher than 30 percent for allergic rhinitis, is denied. Entitlement to a disability rating higher than 50 percent for chronic sinusitis is denied. Entitlement to a disability rating higher than 30 percent for asthmatic bronchitis is denied. Entitlement to a disability rating higher than 10 percent for hypersensitive reaction with hives (hives) is denied. FINDINGS OF FACT 1. The Veteran is receiving maximum schedular rating for allergic rhinitis. 2. The Veteran is receiving maximum schedular rating for sinusitis. 3. The Veteran’s asthmatic bronchitis has been managed by daily inhalational bronchodilator therapy and anti-inflammatory medication, and no objective indication of monthly visits to a physician for required care of exacerbations, or at least three courses of systemic corticosteroids yearly. Pulmonary function test (PFT) findings show Forced Expiatory Volume in one second (FEV-1) of 82 percent predicted, FEV-1 to Forced Vital Capacity (FVC) ratio (FEV-1/FVC) of 84 percent and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method DLCO (SB) of 76 percent predicted. 4. The Veteran’s hypersensitive reaction hives affect less than five percent of the entire body and less than five percent of exposed areas and has not involved treatment from corticosteroids or other immunosuppressive drugs approximating systemic therapy and does not cause disfigurement, scars, or extensive lesions. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 30 percent for allergic rhinitis are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.97, Diagnostic Code (DC) 6522. 2. The criteria for a disability rating greater than 50 percent for chronic sinusitis are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.97, DC 6513. 3. The criteria for a disability rating greater than 30 percent for asthmatic bronchitis are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.97, DC 6600. 4. The criteria for a disability rating greater than 10 percent for hypersensitive reaction with hives are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.118, DC 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from May 1988 to May 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) located in White River Junction, Vermont. As originally developed, the Veteran’s appeal included the additional issue of entitlement to TDIU, which was later granted in a January 2018 rating decision. He has not initiated an appeal with respect to the effective date assigned and has provided no additional argument. The Board notes that the Veteran was previously represented by Attorney Keith D. Snyder during the course of this appeal. See VA Form 21-22, Appointment of Individual as Claimant’s Representative dated August 1, 2014. In a February 2018 letter, shortly after certification of the Veteran’s appeal to the Board, Mr. Snyder attempted to withdraw his services as the Veteran’s representative. A copy of this letter was also sent to the Veteran. The Board notes that the decision to withdraw from representation after certification of an appeal is not a unilateral choice to be exercised at the discretion of the representative. Once an appeal has been certified to the Board, a representative may not withdraw without showing good cause through a written motion. 38 C.F.R. § 20.608. Here, the attorney submitted a withdrawal after certification of the appeal to the Board, and did not provide good cause reasons for doing so. Mr. Snyder has not made an appropriate motion to withdraw representation, as prescribed by 38 C.F.R. § 20.608, and the Veteran has not appointed a new representative. Thus, the attorney remains the appointed representative for the purposes of deciding this appeal. Increased Rating The Veteran is seeking higher disability ratings for his service-connected allergic rhinitis, chronic sinusitis, asthmatic bronchitis and hives. Disability ratings are determined by comparing a veteran’s present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary in order to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. allergic rhinitis The Veteran’s allergic rhinitis is currently rated as 30 percent disabling under DC 6522. Under this diagnostic code, a 10 percent disability rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of the nasal passages on both sides or complete obstruction on one side. A maximum 30 percent disability rating is warranted for allergic or vasomotor rhinitis with polyps. 38 C.F.R. § 4.97. The current 30 percent evaluation is based on findings from a May 2013 VA examination report. Although the Veteran reported a history of seasonal nasal rhinitis secondary to environmental allergies, the examiner noted he did not presently have a diagnosis of allergic rhinitis. However, a CT (computerized tomography) scan of the maxillofacial or sinuses showed the Veteran did have nasal polyps. Because the Veteran is in receipt of the maximum possible schedular rating for allergic rhinitis, a higher rating is not warranted for the appeal period. The Board has also considered the applicability of alternative diagnostic codes for rating the Veteran’s disability. However, because allergic rhinitis has its own code, DC 6522, rating by analogy under other codes is not permissible. Thus, higher ratings under another code provision are not appropriate. See Copeland v. McDonald, 27 Vet. App. 333, 338 (2015) (when a condition is specifically listed in the Schedule, it may not be rated by analogy). Accordingly, the preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). 2. sinusitis The Veteran’s sinusitis is currently rated as 50 percent disabling under DC 6513. The General Rating Formula for Sinusitis is used to evaluate disabilities assigned DCs 6510 through 6514, a noncompensable rating is assigned for sinusitis detected by X-ray only. A 10 percent evaluation is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. The current 50 percent rating is based on findings from VA examination reports in December 2012 and May 2013. The Veteran reported that despite multiple sinus surgeries and the use of intranasal steroids, he still has chronic sinusitis with little relief of symptoms and that he will need recurrent surgeries for polyps every 5 years. The examiner noted the Veteran had recent sinus surgery in July 2011 and previous sinus surgeries in 1994 and 1999 for nasal polyps which were initially diagnosed in 1993. Sinus CT scan showed findings consistent with prominent chronic pansinusitis and nasal polyps. Currently the Veteran reported near constant sinusitis, sinus pain, and tenderness and purulent discharge or crusting. The examiner noted the Veteran had seven or more non-incapacitating episodes of sinusitis in the past 12 months, but no incapacitating episodes requiring a prolonged course of antibiotics. A CT scan of the maxillofacial or sinuses showed prominent chronic pansinusitis. Also of record is a January 2017, Sinusitis/Rhinitis Disability DBQ. The Veteran reported nasal polyps and near constant sinusitis, have caused increased nasal congestion, headaches, sinus pain, and tenderness, despite treatment with intranasal steroids. The examiner noted the Veteran had seven or more non-incapacitating episodes of sinusitis in the past 12 months, but no incapacitating episodes requiring a prolonged course of antibiotics. The examiner also noted the Veteran’s history of sinus surgeries in 1994, 1999, 2011 and 2015. Sinus CT scan showed long standing and extensive inflammatory change in the paranasal sinuses and extensive soft tissue thickening. A 2016 endoscopy showed widely patent nasal airways. The frontal sinuses appeared to be occluded bilaterally with hyperplastic tissue on the right and polypoid on the left. Maxillary, ethmoid, and sphenoid sinuses were all widely patent bilaterally with only mild edema. Because the Veteran is in receipt of the maximum possible schedular rating for sinusitis, a higher rating is not warranted for the appeal period. The Board has also considered the applicability of alternative diagnostic codes for rating the Veteran’s disability. However, because maxillary sinusitis has its own code, DC 6513, rating by analogy under other codes is not permissible. Thus, higher ratings under another code provision are not appropriate. See Copeland supra. Accordingly, the preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). 3. asthmatic bronchitis The Veteran’s asthmatic bronchitis is currently assigned a 30 percent disability rating under DC 6600. Under this diagnostic code, bronchitis is rated at 30 percent for FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. Assignment of a 60 percent evaluation is warranted where there is FEV-1 of 40 to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). For assignment of a 100 percent evaluation, there must be FEV-1 of less than 40 percent of predicted value, or; FEV-1/FVC of less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97. VA is required to rate a disability under DC 6600 using PFTs except in certain circumstances. 38 C.F.R. § 4.96(d)(1). Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). However, if the post-bronchodilator results are poorer than the pre-bronchodilator results, then the pre-bronchodilator results are used for rating purposes. 38 C.F.R. § 4.96(d)(5). Under DC 6602, bronchial asthma is rated at 30 percent for FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70-percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 60 percent evaluation is warranted where there is FEV-1 of 40 to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation, is warranted for FEV-1 of less than 40 percent of predicted value, or; FEV-1/FVC of less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 38 C.F.R. § 4.97. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. When examined by VA in December 2012, the Veteran reported a history of asthma since 1994 that was initially treated with a nebulizer, prednisone, albuterol inhaler and inhaled steroids. Currently his respiratory condition requires chronic low dose (maintenance) corticosteroids, daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. He does not require the use of oral bronchodilators, antibiotics, or outpatient oxygen therapy and there have been no asthma attacks or visits for exacerbations of asthma within past 12 months. The Veteran was currently employed as s a yacht broker and reported that his asthma affects his ability to work because he is constantly awakened by severe wheezing and has to get up to take his rescue inhaler. He also reported having to sleep on an incline to help with his breathing. He stated that he would not be able to do major physical labor, heavy lifting, warehouse work, or routine walking up and down stairs as he becomes short of breath and dizzy with moderate to high level physical activity. PFT revealed the Veteran’s pre-bronchodilator findings showed FEV-1 was 82 percent of the predicted value, and the ratio of FEV-1/ FVC was 84 percent, and DLCO (SB) was 76 percent predicted. The examiner stated the FEV-1/FVC test result most accurately reflected the Veteran’s level of disability. The examiner stated post-bronchodilator testing was not completed because spirometry revealed a very mild obstructive ventilatory defect and there was a significant response to bronchodilation as defined by ATS (American Thoracic Society) criteria. A May 2013 VA examination report shows the Veteran reported little change in his symptoms since his evaluation in December 2012 except for complaints of large volumes of expectorant every morning from his lungs and nasal passages. Clinical findings on evaluation were also essentially unchanged with no significant problems noted. See May 2013 Respiratory Conditions DBQ. Also of record is a January 2017, Respiratory Conditions DBQ, where the Veteran reported his asthma required intermittent courses or bursts of systemic (oral or parenteral) corticosteroids with only one course in the 12 months. He continued to require daily inhaled bronchodilators and anti-inflammatory medications, but no antibiotics, or outpatient oxygen therapy. He had not had any asthma attacks or physician visits for required care of exacerbations in the past 12 months. VA and private outpatient treatment records dated 2015 to 2018 show an improvement in the Veteran’s asthma, with an indication that it was stable and well controlled. See VA outpatient treatment records from Burlington Lakeside VA Clinic dated in December 2017. The Veteran reported that his asthma had been “very good” without the need for rescue inhaler. See clinical records from G. Landrigan, M.D. at University of Vermont Medical Center. Based upon a review of the evidence of record, the Board finds that the criteria for a rating greater than 30 percent for the Veteran’s asthmatic bronchitis are not met under DC 6600 or DC 6602. The PFT results currently of record do not show FEV-1 levels at 40-55 percent predicted or FEV-1/FVC at 40-55 percent or DLCO (SB) of 40-55 percent predicted or maximum oxygen consumption with limits as required for a 60 percent evaluation. Instead these testing results show FEV-1 and FEV-1/FVC values that are higher than the ranges required for the currently assigned 30 percent disability rating for bronchial asthma (FEV-1 of 56-70 percent predicted or FEV-1/FVC of 56-70 percent). Moreover, the evidence does not reflect PFT measurements that fall within the prescribed ranges for even a compensable disability rating of 10 percent (FEV-1 of 71-80 percent predicted or FEV-1/FVC of 71-80 percent). Accordingly, the Veteran’s PFT testing results alone do not warrant an increased disability rating under DC 6600 or DC 6602. With respect to medication, the record documents the Veteran’s daily use of multiple medications, including an Albuterol inhaler, and other inhaled corticosteroids such as Mometasone. However, there is no medical evidence that he requires intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. The Board notes that DC 6602 distinguishes between “inhalational” therapy and “systemic” therapy. Specifically, if no more than “inhalational” therapy is required, a 10 or 30 percent disability rating is assigned. If treatment requires “systemic” therapy, higher ratings are assigned depending on frequency of use. Accordingly, the Board finds that the Veteran’s impairment due to asthmatic bronchitis is more consistent with a 30 percent disability rating and that the level of disability necessary to support the assignment of the next higher evaluation of 60 percent is absent. A preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). 4. hypersensitive reaction with hives The Veteran’s hives disability is currently assigned a 10 percent disability rating under DC 7806. The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective August 13, 2018. See 83 Fed. Reg. 32,592 (July 13, 2018). “VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied.” 83 Fed. Reg. 32,592 (July 13, 2018). Because the Veteran’s claim was pending prior to August 13, 2018, the Board will consider both the old and new criteria and apply the more favorable. Under the new schedule, “systemic therapy” refers to treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin. 38 C.F.R. § 4.118(a). “Topical therapy” refers to treatment that is administered through the skin. Id. Two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of the skin are involved. 38 C.F.R. § 4.118(b). Only the highest evaluation shall be used if two or more skin conditions involve the same area of skin. Id. Prior to August 2018, DC 7806 provided a 10 percent rating for involvement of 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. A 30 percent rating is assigned for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, 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. A 60 percent disability rating is assigned for 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. Alternatively, rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. Effective August 13, 2018, dermatitis or eczema are evaluated under the General Rating Formula for the Skin. A 10 percent rating is provided for at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is provided for at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is provided for at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118. Alternatively, dermatitis or eczema can be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. The General Rating Formula for the Skin does not apply to DC 7824. Id. The pertinent evidence in this case consists primarily of clinical findings from VA examinations in 2012, 2013, and 2017. During VA examination in December 2012, the Veteran reported that he began having rashes that start as a warm sensation then become red and swollen, disappearing after about 15 minutes. There were no known precipitating factors, but it could be triggered randomly during hot or cold weather and the Veteran was able to reproduce the rash by rubbing his skin with a pen. He has been on and off antihistamines for years and has also tried Atarax and Benadryl, which have not helped. He showers daily using Dove soap and uses Gold Bond powder for relief of symptoms. The Veteran reported four or more non-debilitating episodes of urticaria, which he described as raised pruritic red wheals on the extremities or torso, that can last up to 7 days. They are temporarily relieved with cold therapy and zinc powder. The Veteran had not been treated with oral or topical medications in the past 12 months. On examination there was no current involvement of any body surface or exposed area. Additionally, the examiner indicated that the Veteran’s skin condition did not cause scarring or disfigurement of the head, face or neck. He did not have any systemic manifestations. The Veteran reports the dermatographism and pruritus affect his ability to sleep, which in turn can be disruptive to a regular work schedule. The clinical impression was atopic dermatitis and severe dermatographism. A May 2013 VA examination report shows the Veteran reported little change in his symptoms since his evaluation in December 2012. He continued to have significant scratching, particularly at nighttime which interfered with his sleep. The Veteran continued to report four or more non-debilitating episodes of urticaria, which he described almost monthly episodes of large patches of warmth, redness, swelling and pruritus, lasting 30 minutes to 2-1/2 months and which do not respond to topical steroids or antihistamine therapy. The Veteran continued to use gold bond powder and ice for relief. Referencing an April 2013 outpatient treatment record, the examiner noted the Veteran had been evaluated for a flare up of contact dermatitis on the right inner thigh and posterior neck that was pruritic, but with no breakdown or discharge. The Veteran tried treating the symptoms with olive oil, gold bond powder, baby powder, and an herbal cream with little relief. He was prescribed the topical corticosteroid, Triamcinolone, for less than 6 weeks. The examiner continued the diagnoses of dermatographism and atopic dermatitis noting that less than 5 percent of the body surface area was involved and less than 5 percent of the exposed body surface area was involved. Additionally, the examiner indicated that the Veteran’s skin condition did not cause scarring or disfigurement of the head, face or neck. Also of record is a January 2017, Skin Diseases DBQ. The examiner continued the diagnoses of atopic dermatitis and dermatographism. His medications over the last 12 months included antihistamines (Hydroxyzine and Loratadine), but do not otherwise include any prescribed systemic therapy. Examination revealed a hive that was warm and red to palpate noted on right knee and right trunk. The body surface area involved was less than 5 percent and the exposed body surface area involved was less than 5 percent. The remaining evidence documents several medical visits for treatment of intermittent active recurrences of a pruritic rash on the groin, trunk, and lower extremities the since the VA 2017 examination. The lists of active medications and prescriptions do not include any prescribed systemic therapy. Based on the evidence, the Veteran’s current disability picture resulting from his service-connected hives does not meet or approximate the requirements for a higher disability rating. The evidence shows that he has a recurrent skin condition, diagnosed as atopic dermatitis and dermatographism which, is primarily manifested by itching and swelling that requires constant or near-constant treatment with antihistamines and topical creams to suppress his symptoms. Beyond that there is no evidence that large portions of his anatomy are involved as it affects less than 5 percent of the entire body or exposed areas. Accordingly, a 30 percent disability rating is not warranted for hives under the old or new criteria pertaining to the skin. Further, while the Veteran was prescribed a topical corticosteroid for treatment of his skin condition, it was applied only to the inner thigh and posterior neck, therefore it is not consistent with systemic therapy as it was not administrated on a large scale. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (The Federal Circuit held that systemic therapy means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied, and that nothing in Diagnostic Code 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects “only the area to which it is applied” to count as a systemic therapy under that code.). Nor does the evidence show that the Veteran’s hives are predominantly manifested by scarring or by disfigurement to warrant a higher disability rating under any other diagnostic codes available under 38 C.F.R. § 4.118 for assessing scars, as these codes require a showing of symptomatology not present in the Veteran’s case. There are no medical findings of disfigurement of the head, face, or neck. There is also no evidence of tender, deep, unstable or painful scars, limitation of motion due to scars, or scars covering an area of 144 square inches. Thus, diagnostic codes for rating these manifestations are not for application. See 38 C.F.R. § 4.118 DCs 7800, 7801, 7802, 7803, 7804, 7805. (Continued on the next page)   Accordingly, the Board finds that the Veteran’s impairment due to his predominant skin disability, hypersensitive reaction with hives, most closely approximates a 10 percent disability rating under DC 7806, and that the level of disability necessary to support the assignment of the next higher evaluation of 30 percent is absent. A preponderance of the evidence is against the claim, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.R. Bryant