Citation Nr: 1815198 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 14-23 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to an initial disability rating greater than 10 percent for skin disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. J. Tang, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1955 to October 1957. This case is before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision (with notice in January 2013) by a Regional Office (RO) of the Department of Veterans Affairs (VA), which granted service connection for skin disability and assigned an initial disability rating. This appeal stems from an application to reopen a previously denied claim for service connection for skin disability, which was received by VA in October 2006, and the Board had reopened the claim for service connection in May 2012. Records in the Virtual VA paperless claims processing system and Veterans Benefits Management System have been reviewed, to include the transcript of the April 2017 Board hearing presided over by the undersigned Veterans Law Judge. In August 2017, the Board remanded the claim for further development, and the case is again before the Board for further appellate proceedings. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran's claim for increased compensation for the skin disability turns on how much of the Veteran's body is affected by the skin disability when it is active during the appeal period; on the nature, frequency, and duration of any oral medications taken to treat the skin disability during the appeal period; and, on the symptoms attributable to the Veteran's skin disability and fever during the appeal period. Throughout the appeal period, the Veteran has recurrently reported that his skin disability covers "everything" or affects "all over the body." The Veteran submitted photographs in March 2011 to show his active skin disability. Also, the Veteran testified at the August 2017 Board hearing that his skin disability affects his butt, back, arms, shoulders. He also continues to state that "everything" is covered by the skin disability. The Veteran also referenced photographs that he had submitted on the day of his Board hearing in August 2017. The Board notes that there is also lay and medical evidence during the appeal period that indicates that the Veteran's skin disability affects his face intermittently. For instance, in the June 2012 VA examination, the Veteran reported that he gets blotches on his face and abdomen. The Veteran has been afforded multiple VA examinations during the appeal period, to include in November 2017, per the Board's August 2017 remand directives. However, based on the Veteran's lay statements as to the areas impacted by his skin disability, and based on the photographs submitted, it appears that the VA examinations have not been performed at any point when his skin disability is at its most active. In the last VA examination in November 2017, though the skin disability was active on some noted parts of the Veteran's body, it appears that the VA examiner did not find it active on other reportedly impacted parts of the body. No medical opinion has been obtained as to the area of the body impacted as reflected in the photographs submitted by the Veteran and as reflected in the Veteran's competent lay statements as to the areas affected when the skin disability is active. Further, the Board is not competent to attest as to the percentage of the body that is affected based on the photographs and lay statements. Next, though the Veteran has been afforded multiple VA examinations, no VA examiner has noted the Veteran's history of oral medications for treatment of his skin disability during the appeal period. For instance, in the VA dermatology treatment records dating in July 2013 noted that the Veteran is prescribed ivermecton and Zyrtec. In a May 2013 VA dermatology note, the Veteran is noted as being changed from oral antihistamines to Zyrtec. In a January 2013 VA dermatology note, it is noted that the Veteran has taken 2 tabs of ivermectin thus far. In a June 2014 Form 9, the Veteran reported that he takes pills to treat his skin disability. Next, the Board notes that though the medical evidence shows that the Veteran's rash is preceded by fever, it is unclear which symptoms, if any, may be attributed to such fever. For instance, the Veteran subjective reported in the August 2017 Board hearing that when he gets a fever, he "gets the chills." Based on these facts, remand is warranted to obtain an addendum VA medical opinion to determine the area of the body affected by the skin disability during active periods; to determine the frequency and duration during the appeal period in which the Veteran was being treated with oral medications; and, to determine which of the Veteran's reported symptoms, if any, may be attributed to his fever. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Please obtain updated VA treatment records. 2. After completing the above directive, obtain a VA medical opinion from the physician who conducted the November 2017 VA examination (or suitable substitute) to determine the nature and severity of the Veteran's skin disability. Make the claims file available to the examiner for review of the case. If, but only if, the examiner believes that an additional examination is necessary, then the Veteran should be scheduled for such an examination (and to the extent possible, such examination should be conducted at a time that the Veteran is experiencing a flare-up of his skin disability). The examiner is also asked to address the nature, severity, and all symptoms of the Veteran's skin disability at all times during the entire appeal period (October 2006 to present). In so doing, please specifically address the following: a. Comment on the approximate percentage of the entire body, and the percentage of exposed areas, affected by the skin disability at any point during the entire appeal period, specifically to include when the skin disability is active. The examiner's attention is specifically invited to the photographs submitted in March 2011 and in August 2017, as well as the Veteran's competent lay statements regarding affected areas. b. Comment on the time period and frequency of any oral or systemic therapy for treatment of skin symptoms at any point during the entire appeal period. For instance, the VA examiner's attention is invited to the following: The VA dermatology treatment records dating in July 2013 noted that the Veteran is prescribed ivermectin and Zyrtec; a May 2013 VA dermatology note, in which the Veteran is noted as being changed from oral antihistamines to Zyrtec; the January 2013 VA dermatology note which noted that the Veteran has taken 2 tabs of ivermectin thus far; the June 2014 Form 9, in which the Veteran reported that he takes pills to treat his skin disability. c. Comment on the Veteran's symptoms that are attributable to the Veteran's fever associated with the skin disability. For instance, the VA examiner's attention is invited to the Veteran's report in the August 2017 Board hearing that when he gets a fever, he "gets the chills." For purposes of the above opinions, the examiner's attention is invited to the following evidence: (i) The Veteran's statements throughout the appeal period that his skin disability affects his entire body, to include his face. For instance, in a January 2007 RO hearing, the Veteran stated that his skin condition has been the same since service. He testified that he has big blotches of skin rash, redness, and bumps all over his body. (ii) The August 2017 Board hearing testimony that his skin disability affects his butt, back, arms, shoulders. (iii) The June 2012 VA examination, in which the Veteran reported that he gets blotches on his face and abdomen, and the June 2012 examiner noted rash on the right flank with itching and burning. (iv) The October 2009 VA primary care note, showing that the Veteran presented with skin complaints. On examination, the Veteran was noted as having fine macular rash, lesion in hip flexural areas, but not intertriginous. It is noted that he has redden macules that are intensely pruritic and primarily truckal. It is noted that the rash is becoming less responsive to topical triamcinolone. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 3. Thereafter, complete any other development deemed warranted by AOJ. Then, readjudicate the claim on appeal, and furnish the Veteran and his representative a supplemental statement of the case if a matter is not resolved to the Veteran's satisfaction. Provide an opportunity to respond before the claim is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).