Citation Nr: 18158553 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 09-13 420 DATE: December 18, 2018 ORDER Entitlement to service connection for a skin condition is denied. Entitlement to service connection for tingling in the hands and feet is denied. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran’s skin condition was not due to her active duty service. 2. The preponderance of the evidence reflects that the Veteran’s tingling in her hands and feet was not due to her active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin condition have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2018). 2. The criteria for service connection for a hand and feet tingling condition have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In November 2012, the Veteran testified at a Board hearing in Washington, D.C. before the undersigned Veterans Law Judge, and a copy of the transcript is of record. In July 2014, the Board remanded the case for a VA examination and in January 2017, remanded the case for a VA addendum opinion. In its January 2017 remand, the Board found the December 2014 VA examination inadequate with regard to etiology because the examiner did not consider the Veteran’s lay contentions. However, the February 2017 VA addendum opinion obtained on remand is adequate as the examiner reviewed the claims file, examined the Veteran, considered the Veteran’s lay statements, and provided detailed findings. Accordingly, the Board’s duty to assist has been fulfilled. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes the issue of service connection for a bilateral eye condition was remanded, and was subsequently granted by the RO in in June 2017. The Veteran has not filed a notice of disagreement (NOD) with regard to any appealable determination regarding this issue. Therefore, this matter is no longer before the Board. See 38 C.F.R. §§ 20.200, 20.201, 20.302 (2018); Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Neither the Veteran nor her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2018); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, VA is authorized to compensate any Persian Gulf Veteran with a chronic disability resulting from an undiagnosed illness, or combination of undiagnosed illnesses, which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C. § 1117 (2012). The Veteran is a Persian Gulf Veteran. 38 C.F.R. § 3.317(d)(2) (2018). To grant service connection for a claimed disability, a Persian Gulf Veteran must exhibit objective indications of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. The claimed disability must be characterized by symptomatology that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317 (2018). The law currently defines a qualifying chronic disability as that which results from an undiagnosed illness, a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (such as CFS, fibromyalgia, and irritable bowel syndrome), or any diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 U.S.C. § 1117 (2012). Signs or symptoms that may be manifestations of an undiagnosed illness or a chronic multisymptom illness include: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs and symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the upper or lower respiratory system; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 U.S.C. § 1117 (2012). For a disability to be presumed to have been incurred in service, the disability must have become manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (2018). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the evidence in light of the entirety of the record. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2018). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Skin Disorder The Veteran complained of lesions on her legs and itching in March 1993. The evidence of record also contains the Veteran’s treatment records documenting the Veteran’s complaints of itchy skin and use of topical cream treatment. Further, at the November 2012 Board hearing, the Veteran and her family members testified that prior to going into the military the Veteran had no medical problems. They testified when the Veteran returned she complained her skin was itching and she was always scratching her skin. The Veteran stated her skin condition began after she was given an anthrax vaccination before going to Saudi Arabia. The Veteran underwent a VA examination in December 2014. The examiner noted the Veteran’s complaints of pruritus associated with dry skin over her lower legs, arms, and back. At the examination, the VA examiner noted there were no visible findings on the Veteran’s arms or back but there was some mild flaking skin on both anterior tibiae. The examiner diagnosed the Veteran with xerosis, which is a known clinical diagnosis. The Board found the negative etiology opinion for this examination inadequate, and therefore it will not be discussed, as it is not probative. The VA examiner provided an addendum opinion in February 2017. The examiner noted there was no evidence of a skin disorder documented in her medical records. The VA examiner similarly noted the Veteran’s complaints began in the late 1990s, years after service. The examiner also concluded there was no objective evidence of a chronic disability, as noted by the prior VA examinations and that the Veteran did not have any undiagnosed illness. In February 2018, a VA dermatologist determined that it was unlikely the Veteran’s pruritus was due to her service. The dermatologist noted her complaints began in November 1995, after her discharge from service. He stated the Veteran’s nummular eczema was common in the fall and winter and exacerbated by dry conditions. Additionally, the dermatologist stated that her skin conditions, nummular eczema and atopic dermatitis, were unrelated to Gulf War Syndrome or the anthrax vaccination. The Board affords the VA examinations and specialist opinion higher probative weight than the lay statements from the Veteran and her relatives. The Board finds the lay statements of record are competent as they relate to descriptions of her skin symptoms such as noting the Veteran’s continual itching of her skin. While the Board acknowledges as lay people, the Veteran and her family are competent to report conditions capable of lay observation; they are not able to render etiological opinions. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Determining the etiology of the Veteran’s skin condition requires medical inquiry into biological processes and pathology. Such internal physical processes are not readily observable and are not within the competence of the Veteran or her family, who in this case have not been shown by the evidence of record to have medical training or skills. As a result, their opinions are not competent evidence. Consequently, the findings of the VA examiner and VA dermatologist outweigh the lay evidence. The preponderance of the probative evidence of record weighs against the claim of service connection for a skin condition on a direct basis. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018). Furthermore, the examiner noted the Veteran’s skin condition, xerosis, is a diagnosed illness; thus, presumptive service connection is not warranted. 38 C.F.R. § 3.317. 2. Hands and Feet Tingling The evidence of records contains the Veteran’s complaints of pain in her legs and feet from December 1991. Since that complaint, the evidence of record contains the Veteran’s continued complaints of tingling and numbness in her hands and feet. At the Board hearing, the Veteran and her relatives also stated the Veteran did not have these issues pre-service. The Veteran stated the tingling and numbness are not precipitated by a specific event. The Veteran received a VA examination in December 2014. The examiner noted the Veteran received several neurological examinations with negative EMG findings. The VA examiner diagnosed the Veteran with peripheral sensory neuropathy associated with history of B12 deficiencies in setting of excess alcohol intake. The examiner noted the Veteran’s low B12 levels and excess alcohol intake were documented in her medical records. The VA examiner opined the Veteran’s current disability was not related to service as the complaints began many years after service, and the examiner related the Veteran’s condition to a B12 deficiency. The addendum opinion submitted by the VA examiner in February 2017 stated the same conclusion as the December 2014 opinion. The February 2018 specialist’s opinion also addressed the Veteran’s service connection claim for her hand and feet tingling. Similarly, the specialist noted the onset of her condition was in the 2000s, years after discharge from service. The specialist also noted despite the Veteran’s excess alcohol usage in combination with her B12 deficiency, there was no evidence of polyneuropathy during service. The specialist also considered her in-service lumbar puncture, but concluded that injury was non-traumatic and did not produce her current symptoms. The Board concludes the December 2014 VA examination and February 2017 VA addendum opinion provided more probative weight than the lay statements of record. Like the Veteran’s contentions concerning her skin disability, the Board considers the Veteran and her relatives lay contentions that her issues all started when she came back from service. However, as previously noted the Veteran and her relatives in this case lack the requisite knowledge to provide an etiological opinion. Conversely, the VA examiner has the requisite medical training. Furthermore, in coming to an opinion, the VA examiner considered both the lay contentions and medical evidence of record. The VA examiner provided an etiological opinion of the Veteran’s condition, which the Board finds persuasive. The Board also affords the February 2018 opinion high probative value. The specialize considered the Veteran’s B-12 deficiency and lumbar puncture injury when coming to his conclusion the Veteran’s disability was not related to service. The February 2018 opinion is afforded more probative weight than the lay contentions of record. The preponderance of the evidence is against the Veteran’s claim for service connection for tingling hands and feet. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018). Additionally, the Board finds the Veteran’s disability is not due to an undiagnosed illness, as the VA examiner diagnosed her with peripheral sensory neuropathy, so presumptive service connection is not warranted. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Brunot, Associate Counsel