Citation Nr: 1808622 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 12-29 569 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a chronic skin disability, to include psoriasis, to include as an undiagnosed illness related to service in Southwest Asia and as secondary to service-connected disabilities. ATTORNEY FOR THE BOARD B. G. LeMoine, Associate Attorney INTRODUCTION The Veteran served on active duty from October 1981 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was previously remanded by the Board in February 2015, June 2016 and July 2017. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board for review. FINDINGS OF FACT 1. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a chronic skin disability, to include psoriasis, etiologically related to an in-service injury, event or disease to include as an undiagnosed illness related to service in Southwest Asia. 2. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a chronic skin disability, to include psoriasis, proximately due to, or chronically aggravated by, his service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for a chronic skin disability, to include psoriasis, to include as an undiagnosed illness related to service in Southwest Asia, and as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duty to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Analysis The Veteran contends that he has psoriasis that is directly related to his active service or secondary to his service-connected disabilities. Specifically, the Veteran contends that his skin condition began in approximately 1992 during his active military service. See September 2016 VA examination. To establish service connection for a disability on a direct-incurrent basis, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). See also 38 C.F.R. § 3.303. The evidence of record shows that the Veteran has a current diagnosis of psoriasis. See, e.g., December 2008 VA examination. Therefore, there is evidence of a current disability. As to an in-service event, injury or disease, the Veteran's service treatment records reveal that he was treated for tinea corporis during active service. Accordingly, there is also evidence of an in-service injury in the form of tinea corporis, and the issue remaining for consideration as to direct service connection is whether the Veteran's current psoriasis is etiologically related to the in-service injury. With respect to a nexus between the current disability and in-service injury, the only competent medical opinions of record are the September 2016 VA examination and the August 2017 VA addendum opinion. The September 2016 VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted the Veteran's diagnosis of a skin condition. The Veteran stated that his skin condition started in 1992 when he first noticed dry skin on his knees and elbows. The Veteran further stated that he has gone through different stages of worsening symptoms, such as dryness, but has not had an infection. He stated that he uses topical creams but does not see a dermatologist. Upon examination, the VA examiner noted psoriasis over less than five percent of the Veteran's total body area. The VA examiner opined that the Veteran's psoriasis is less likely than not etiologically related to his active service, to include service in Southwest Asia. As rationale, the September 2016 VA examiner stated that the claimed condition is a disease with a clear and specific etiology and therefore is not an undiagnosed illness and not medically unexplained. Additionally, the VA examiner stated that the Veteran's service treatment records are silent for evaluation of, diagnosis of, or treatment for, psoriasis. Additionally, the Veteran's post-service treatment records do not reflect a diagnosis of psoriasis until 2008. As the September 2016 VA examiner did not discuss the Veteran's treatment for tinea corporis during service, the Veteran was provided an addendum opinion in August 2017. The August 2017 VA examiner reviewed the Veteran's record including the in-service treatment for tinea corporis. The VA examiner opined that it is less likely than not that the Veteran's psoriasis had its onset in active service or is otherwise causally connected to his active service. As rationale, the VA examiner stated that the Veteran's complaints of an in-service skin condition relate to tenia corporis, not psoriasis. The VA examiner noted that tenia corporis is not a bacterial infection but a superficial skin fungus infection that is totally unrelated to psoriasis. Additionally, the VA examiner noted that the Veteran's in-service tenia corporis was limited to the trunk of his body and his psoriasis starts on the Veteran's knees and elbows then spreads to other portions of his body. The only evidence indicating an association between the current psoriasis and active duty are the Veteran's own assertions. The Veteran has stated that his current skin condition began in-service. It is well established that a layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a) (1). In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). However, as the origin or cause of psoriasis is not a simple question that can be determined based on personal observation by a lay person, the Veteran's lay testimony is not competent to establish medical etiology or nexus. Id. As such, the Board finds the question of whether the Veteran's current psoriasis had its onset during active duty does not lie within the range of common experience or common knowledge but requires special experience or special knowledge. It is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to the etiology of psoriasis. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As such, the lay statements provided by the Veteran are not competent evidence as to whether the Veteran's current psoriasis had its onset during service or is otherwise etiologically related to active service. Moreover, such a finding is not supported by the record. Specifically, the August 2017 VA examiner noted that the Veteran was treated for tenia corporis during service. The VA examiner further noted that tenia corporis is a superficial skin fungus infection that is totally unrelated to psoriasis. The Board also considered whether the Veteran's current psoriasis is secondary to his service-connected adjustment disorder. A disability which is proximately due to, or chronically aggravated by, a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). With respect to whether the Veteran's psoriasis is proximately due to, or chronically aggravated by his service-connected adjustment disorder, the only competent medical opinion of record is the August 2017 VA addendum opinion. The August 2017 VA examiner reviewed the record and opined that it is less likely than not that the Veteran's service-connected adjustment disorder caused or aggravated his psoriasis. As rationale, the VA examiner stated that stress is sometimes mentioned as a risk factor for causing psoriasis. However, the likelihood of stress causing psoriasis does not rise to a probability of greater than 50 percent. Therefore, the VA examiner stated that the Veteran's service-connected adjustment disorder is unlikely to be a factor in causing or aggravating his psoriasis. The Board accepts the August 2017 VA examiner's opinion as the most probative evidence of record. The August 2017 VA examiner's opinion indicates that it is less likely than not that the Veteran's psoriasis is caused by, proximately due to or chronically aggravated by the service-connected adjustment disorder. The VA examiner explained that it is less than 50 percent likely that stress would cause or aggravate psoriasis. Additionally, the record does not reflect, and the Veteran has not asserted, that his psoriasis is proximately due to, or chronically aggravated by his service-connected ulcerative colitis, to include any stress related to having such disability. Nevertheless, even if it is conceded there is stress related to having such disability, as noted above, the VA examiner explained that it is less than 50 percent likely that stress would cause or aggravate psoriasis. In summary, the most probative evidence of record does not support a finding that it is at least as likely as not that there is a causal relationship between the Veteran's current psoriasis and his active military service, to include his service in Southwest Asia, nor is the Veteran's psoriasis at issue proximately due to, or chronically aggravated by service-connected disability. Further, as noted above by the VA examiner, psoriasis is a known clinical diagnosis, and not an undiagnosed illness. In light of the above, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. The claim therefore must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). ORDER Entitlement to service connection for a chronic skin disability, to include psoriasis, to include as an undiagnosed illness related to service in Southwest Asia, and as secondary to service-connected disabilities, is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs