Citation Nr: 18152442 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 09-39 601 DATE: November 21, 2018 ORDER Service connection for dermatitis and related pruritus is granted. VETERAN’S CONTENTIONS The Veteran contends that he developed a skin disorder in service and that this disorder has continued to the present. Additionally, the Veteran contends that this skin disorder may have been caused by exposure to herbicide agents during his service in the Republic of Vietnam. FINDINGS OF FACT 1. The Veteran served on active duty from May 1962 to May 1969, including service in the Republic of Vietnam. 2. The Veteran’s service treatment records (STRs) indicate that he was treated for several skin disorders in service. Specifically, in April 1963 he was diagnosed with pityriasis rosea. In November 1967, a clinician documented that the Veteran had a pruritic rash on his waist for the past month. A December 1967 STR indicated that the rash was pruritic and lichenified with an unknown etiology. Lastly, in September 1968, the Veteran was diagnosed with tinea crucia. 3. The Veteran filed his claim for service connection for a skin disorder in February 2009. Since the filing of the claim, Department of Veterans Affairs (VA) treatment records have provided the following diagnoses related to the claim for a skin disorder: contact dermatitis and other eczema, unspecified cause, February 2009; lichen simplex chronicus, May 2009; palmar dermatitis, April 2010; xerosis, May 2011; psoriasis, February 2013; sunburn to feet, September 2013; cellulitis and abscess of foot, September 2013; atopic dermatitis, unspecified, August 2016; squamous cell carcinoma in situ, December 2016; actinic keratosis, May 2017; and seborrheic keratosis, May 2018. Additionally, the Veteran has received diagnoses of prurigo nodularis and basal cell carcinoma. 4. The Veteran was afforded VA examinations regarding his claim in February 2011 and April 2016. However, these examinations were found to be inadequate by the Board of Veterans’ Appeals (Board) in June 2014 and January 2017 remands, respectively. 5. VA provided the Veteran with another VA examination in May 2017. However, the etiological opinion provided in this examination report is also inadequate for adjudicative purposes as the examiner incorrectly stated that the Veteran did not complain of or receive treatment for any skin disorders in service. 6. Thereafter, in June 2018, the Board requested that a dermatologist from the Veterans Health Administration (VHA) review the Veteran’s entire claims file, identify all current skin conditions other than prurigo nodularis or basal cell carcinoma diagnosed by medical professionals since the filing of the claim, and, for every condition identified, provide an etiological opinion. 7. In July 2018, Dr. Khavari from the VA Palo Alto Healthcare System fulfilled the Board’s request. Dr. Khavari first identified all skin diagnoses the Veteran had received since 2009. He then noted that in 1967 while in service, the Veteran developed a rash which Dr. Khavari stated was consistent with a diagnosis of dermatitis, especially atopic dermatitis. Dr. Khavari then summarized the Veteran’s history since service and commented that dermatitis, including atopic dermatitis, can have an onset early in life and persist all the way through life. Additionally, he commented that many patients with chronic dermatitis could develop severe pruritus that can manifest as prurigo nodularis and lichen simplex chronicus. He then stated that the Veteran’s record was consistent with this and, accordingly, it was at least as likely as not that the Veteran’s chronic dermatitis and pruritus condition began during service. The other conditions, however, were self-limited in nature and not related to service, including to the dermatitis. CONCLUSION OF LAW The criteria for service connection for dermatitis and related pruritus are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSION This matter comes before the Board on appeal from an August 2009 rating decision of the VA Regional Office (RO) in Nashville, Tennessee. Jurisdiction of the Veteran’s claims file currently resides with the Roanoke, Virginia RO. Service Connection for Dermatitis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §1110; 38 C.F.R. § 3.303. Regulations also provide that service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). As indicated above, after reviewing the evidence of record, the Board finds that the Veteran is entitled to service connection for dermatitis. Accordingly, the Board grants the Veteran’s appeal. In support of this determination, the Board relies primarily upon the July 2018 opinion of Dr. Khavari. The Board finds this opinion to be adequate for adjudicative purposes and supportive of a conclusion that the Veteran’s dermatitis first arose in service and continued to the present. As mentioned in the Findings of Fact section, additional etiological opinions from VA examiners in February 2011, April 2016, and May 2017 are of record. But, each of these opinions has been found to be inadequate for adjudicative purposes. Accordingly, Dr. Khavari’s opinion is the only competent, adequate medical opinion associated with the Veteran’s claims file. To the extent that Dr. Khavari indicated that chronic dermatitis is often associated severe pruritus that can manifest as prurigo nodularis and lichen simplex chronicus, and the Veteran was diagnosed with these conditions during the appeal period, service connection is also warranted for those conditions. The Board notes that Dr. Khavari also provided comments on other recorded diagnoses, which he listed as xerosis, psoriasis, sunburn to the feet, cellulitis and abscess to the feet, squamous cell carcinoma, and actinic keratosis, and seborrheic keratosis. The Board finds that service connection is not warranted for these additional listed diagnoses. With respect to xerosis, Dr. Khavari indicated that this condition occurred with age and that it is a central feature of dermatitis. Accordingly, the Board finds xerosis to be analogous to a symptom encompassed by the grant of service connection for dermatitis and an additional grant of service connection is not warranted as it is encompassed by the grant of dermatitis. Next, in regard to psoriasis, Dr. Khavari indicated that this appeared to be a single notation error by a physician’s assistant and was not supported by a physical examination or histologic findings. The Board finds Dr. Khavari’s statement to be probative as it appears that the Veteran does not currently have psoriasis, and additionally, there is no etiological connection between a notation of psoriasis and service. Regarding the diagnoses of sunburn to the feet and cellulitis and abscess of the foot, as Dr. Khavari correctly indicted, these diagnoses were uniquely linked to a single event of excessive sun exposure in September 2013. As these diagnoses occurred many years after service and are etiologically related to an event in 2013, service connection is not warranted. Lastly, regarding squamous cell carcinoma, actinic keratosis, and seborrheic keratosis, Dr. Khavari stated that these conditions were associated with sun exposure. He then speculated that they could be related to sun exposure in Vietnam, but provided a generic rationale regarding sun exposure by veterans in Vietnam. The Board finds that service connection for these conditions is also not warranted as these conditions were not noted in service, the Veteran did not necessarily claim these conditions (as he filed for a condition associated with a rash that existed continuously ever since service), they are clinically distinct from dermatitis and pruritus, and they developed long after service discharge with no etiological connection to service. As such, the Board’s grant of service connection is limited to dermatitis and its related pruritus. (Signature on Next Page) S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N.S. Pettine, Associate Counsel