Citation Nr: 1807726 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 12-03 982 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a skin condition, variously diagnosed. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Hoover, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1967 to October 1969 including service in Vietnam as a light weapons infantryman. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2011 by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied a reopening of the Veteran's claim for atopic dermatitis. A Notice of Disagreement was received in June 2011. In December 2011, a Statement of the Case was issued, and, in February 2012, the Veteran filed his substantive appeal (via a VA Form 9). In October 2016, the Board reopened and remanded the claim on appeal for additional development and the case now returns for further appellate review. The Board also recharacterized the claim as a claim for service connection for a skin disorder in order to encompass the Veteran's various skin diagnoses. In January 2013, the Veteran testified before a decision review officer (DRO) at a hearing. A transcript of the hearing is of record. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Therefore, any future consideration of the Veteran's claim should take into account the existence of the electronic record. FINDINGS OF FACT The Veteran's skin disorder as variously diagnosed is not attributable to his military service. CONCLUSION OF LAW The criteria for the establishment of service connection for a skin disorder, variously diagnosed, are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. LEGAL CRITERIA Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110 (West 2014); 38 C.F.R. 3.303(a) (2017). Establishing service connection requires competent, credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus, or link, between the current disability and in-service disease or injury. See, e.g., Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may be established on a presumptive basis for certain chronic diseases, if such diseases are shown to have been manifested to a compensable degree within one year from the date of separation from service. 38 U.S.C. § 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Where the Veteran asserts entitlement to service connection for a chronic disease and there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period under after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). The skin conditions as variously diagnosed in this case are not included in the list of chronic diseases under 38 C.F.R. § 3.309(a). For disabilities that are not service-connected under 38 C.F.R. § 3.303(b), the avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker v. Shinseki, 708 F.3d at 1338-39. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 C.F.R. § 3.303(d). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or, whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. II. BACKGROUND The Veteran contends that he has a current skin condition which can be attributed to his military service, including his service in Vietnam. In a January 2013 hearing before the RO, the Veteran testified that while in Vietnam, he was consistently in water above his knees in the deltas and canals and that his skin always stayed wet. He testified that he went to sick call for his skin conditions while in service, and was provided topical medication in the form of a powder. The Veteran also testified that he was seen by a private provider within one year of leaving the service, but that his records have since been destroyed. Upon induction examination in August 1967, the Veteran's skin was noted as clinically normal. Service treatment records show that in June 1968 the Veteran received treatment for intertrigo and a rash on the groin area and feet; the impressions were of "mild emersion feet" and "intertrigo groin." The Veteran was placed on light duty for 48 hours and treated with topical medication. On the Veteran's August 1969 separation examination, the Veteran's skin was evaluated as clinically normal. When the Veteran presented for a routine VA Agent Orange registry examination in June 2004, he related that once a year he gets a rash on the groin, thighs, and arms, for which he uses topical lotions. Physical examination revealed scaling and hyperkeratosis on the hands especially, but also on the soles. The impressions included a skin rash. At that time, a dermatology consult was planned, noting that the Veteran had provided a history of a 15 year winter exacerbation of skin problems with marked hyperkeratosis and scaling on examination of the feet, hands, and forearms. A dermatology consult was performed in September 2004. At that time, the Veteran related complaints of a long standing itchy rash affecting, the arms, feet, and scrotum areas. It was noted that the Veteran worked as a barber; that his hands were in chemicals and water all day; and that he used Dial and Ivory soap at work. Objective findings included xerosis, lichenfication on the hands and forearms, mild onychondystrophy with loss of cuticle on the left 4th finger, and lichenfication of the scrotum. Also, there was scaling on the plantar surfaces of the feet and no significant onychondystrophy of the toenails. The assessments were of atopic dermatitis and tinea pedis. VA conducted an examination of the Veteran in July 2008, during which the examiner noted that the Veteran reported that he has been experiencing a rash breaking out since the early 1970s. The Veteran related that the rash occurs every 3 to 4 months and goes away within two months of using a topical medication, that the condition is intermittent and not constant or progressive, and that he experiences symptoms of pruritus and redness. Upon physical examination, the Veteran presented with hyperpigmentation and lichenification on both forearms, with the skin scaling on the left forearm with no current arethmia. The examiner noted no current evidence of dermatitis or tinea on the genital area, but that there were 7 to 8 hypopigmented spots on the scrotal sac that could have come from previous outbreaks. The examiner noted no areas of hyperpigmentation or lichenification indicative of chronic skin exacerbations, and that the skin on the distal half of both feet was scaly, with white macerations present between every toe. The examiner diagnosed the Veteran with bilateral tinea pedis per examination. An addendum opinion to the July 2008 examination was submitted in September 2008, when the claims file was available for review by the examiner. The examiner opined that due to lack of evidence of treatment until many years after service, the claimed skin condition of the feet, hands, and groin was less likely than not related to the Veteran's military service. In November 2009, the Veteran received treatment at the VA Medical Center for diffuse mild erythema for both hands with scaling and dispigmenationin to dorsal fingers diagnosed as eczema/dermatitis and treatment for both feet with mild scaling diagnosed as tinea pedis. A September 2010 dermatology note states that the Veteran presented with eczema and contact dermatitis, and had a longstanding rash on the hands and feet. There was also treatment to the scrotum with hyperpigmentation with lichenification and central areas of depigmentation/scarring with diagnoses including pruritus scrota and lichen simplex chronicus. The Veteran submitted buddy statements in October 2011 from his spouse and brother stating that the Veteran was seen itching and with a rash ever since service which was not present prior to service. A Disability Benefits Questionnaire was submitted by a VA examiner in February 2013, which noted diagnoses of tinea pedis and lichenification. The examiner opined that the skin conditions were less likely than not incurred in service because although he was treated for a skin condition in the military, the examining physician marked the Veteran's skin as "normal" upon separation. The examiner submitted an addendum opinion in May 2013, which stated that the "normal" marking on the separation examinations indicates that the Veteran's skin condition was cured and that tinea pedis can recur in otherwise healthy individuals each time as an independent infection depending on exposures to moist atmospheric conditions or may be related to immunologic disorders. The examiner further noted that lichenification and atopic dermatitis documented in the VA medical records had no relation to the tinea pedis infections, and that atopic dermatitis is related to some type of allergy, and lichenification of skin can occur when skin is scratched over for a long period of time. A disability benefits questionnaire was completed by a March 2017 VA examination during which the examiner opined that the Veteran's skin conditions were less likely than not related to his military service. The Veteran was not provided a physical examination. The examiner noted that the medical records and lay testimony form the Veteran's family were reviewed. The examiner opined that the Veteran had a normal physical exam at separation with no skin lesions, rash, intertrigo, tinea, dermatitis, lichenified skin, or eczema, and therefore any tinea, dermatitis, or lichenified skin he may have developed post-service is less likely than not related to or caused by military service. ANALYSIS The evidence of record shows that the Veteran has been diagnosed with a skin disorder, variously diagnosed as tinea pedis, atopic dermatitis, eczema, lichen simplex chronicus, and pruritus scrota. See July 2008 VA examination & VA treatment records September 2004, November 2009, and September 2010. While the March 2017 VA examiner comments that the Veteran does not have a diagnosis, the Board observes that this same VA examiner did not conduct a physical examination of the Veteran, and did not notate the Veteran's post service diagnoses. As such, the Board finds that the first element of service connection, a current disability, is established. Shedden v. Principi, 381 F.3d at 1167. Next, the Veteran must have endured an in-service injury or event. In this regard, the service treatment records show that in June 1968 the Veteran received treatment for intertrigo and a rash on the groin area and feet, with impressions of mild emersion feet and intertrigo groin. As such, there is evidence of a skin ailment in service, thereby establishing the second element of service connection. Id. The mere fact that the Veteran received treatment for a skin ailment in service, however, does not necessarily mean that any current skin disorder, which the Veteran now has, is a result thereof. In this regard, there is no medical evidence of a nexus between the in-service skin ailment and any current skin disorder, as variously diagnosed. In fact, the medical nexus opinions of record are negative opinions which were offered by VA examiners in July 2008, February 2013, and March 2017. Although the record contains the Veteran's January 2013 testimony indicating that his current skin condition can be attributed to his military service, it is of particular significance that the service treatment records that date subsequent to the June 1968 entry do not indicate that a skin ailment persisted beyond that single treatment session. A skin condition or any related symptoms were not noted in the service treatment records dated between July 1968 and January 1969. In fact, when the Veteran reported his medical history for separation, in August 1969, he specifically denied having a skin disease or any other symptoms which could be related to a skin condition at that time. Also, there was no indication on the August 1969 separation examination of a skin problem. A clinical evaluation was conducted, but a skin condition or symptoms attributable to any incident of service were not present, and the evaluation of the skin yielded normal findings. In the same way, the January 2008 reply from the private treatment provider, who the Veteran purports to have received treatment for his skin problems within a year after service, reflects that such provider did not have the Veteran as a patient in its records. Weighing the Veteran's earlier statements as reflected in his medical records against his later contention that he has current skin condition of service origin, the Board attaches more credibility and probative value to the earlier documents because they reflect what the Veteran was experiencing at that time. Also, this assessment is strengthen by the Veteran's statement to the VA examiner in June 2004 that he has had a history of a 15 year winter exacerbation of skin problems, thereby casting even more doubt on the Veteran's consistency and credibility concerning the later contention. The fact that the Veteran did not report any skin problems at service discharge, or until many years after service, strongly suggests that they were not present at that time. Thus, the amount of time that lapsed between military service and the first post-service treatment can be considered as evidence against the claim. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Based on the Veteran's statement regarding a more recent onset of skin problems and the lack of service treatment records reporting any complaints at service discharge, the VA examiners in July 2008, February 2013, and March 2017 determined that the Veteran's current skin condition was less likely than not caused by or related to his military service. The VA examiners were justified in relying on the statements made by the Veteran at discharge that he had no skin disease, and at the June 2004 VA examination that his current skin condition did not appear until the late 1980s, because those statements were consistent with the Veteran's earlier lay and medical evidence of record. Therefore, the claim fails to satisfy the medical nexus requirement. In sum, the Veteran's opinion is outweighed by the findings to the contrary by the VA examiners, medical professionals who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). As such, as the preponderance of the evidence is against the claim, service connection for a skin condition as variously diagnosed is not warranted. The appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a skin condition, variously diagnosed, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs