Citation Nr: 1817142 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 13-04 720 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a skin disability. 2. Entitlement to service connection for hypertension, to include as due to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD T. Harper, Associate Counsel INTRODUCTION The Veteran had active military service from January 1974 to September 1976. These matters come before the Board of Veterans' Appeals (Board) from May 2014 and July 2015 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Lincoln, Nebraska. The Veteran waived a hearing on these issues before the Board in his November 2015 and March 2016 substantive appeals. The issue(s) of service connection for hypertension as secondary to the service-connected PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran is not currently diagnosed with chloracne. 2. Dermatographism, a skin disability, did not clearly and unmistakably exist before entry into active service. 3. The Veteran is currently diagnosed with dermatographism the symptoms of which first had their onset during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for chloracne are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for dermatographism are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Pertinent Service Connection Laws and Regulations and Analysis for a Skin Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Only chronic diseases listed under 38 C.F.R. § 3.309(a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. (2013). Establishing service connection generally requires (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 evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Additionally, Veterans are presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that the injury or disease in question existed prior to service and was not aggravated by such service. 38 U.S.C. § 1111. Only such conditions as are recorded in entrance examination reports are to be considered as "noted." 38 C.F.R. § 3.304(b); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, 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 a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Turning to the claim for service connection for a skin disorder, the Veteran originally contended that he "might have chloracne." The Veteran described the skin disability as one that caused welts on his skin where he was scratched. See February 2015 statement. He indicated he had not often sought treatment for this condition, and he just dealt with it without medical intervention. As an initial matter, the Veteran has not been diagnosed with chloracne. The July 2015 VA examiner reported that the Veteran has "minimal [possibly] chloracne like lesions about the humorouses but not typical of chloracne disease." The examiner did not diagnose the Veteran with chloracne during that examination and found that it would be mere speculation to determine whether chloracne was actually present. There is no diagnosis in the VA or private treatment records of chloracne. Thus, the Board denies the claim for service connection for chloracne as the Veteran does not have a current diagnosis of chloracne of record. Brammer, 3 Vet. App. at 225 (1992). However, as reflected below, the Veteran is diagnosed with dermatographism. The Veteran and his representative assert that the dermatographism had its onset in, or is otherwise related to, active service. Neither the Veteran's Report of Medical Examination nor the Report of Medical History at entrance indicates there was any preexisting skin disability, to include dermatographism, rashes, or welts. In a November 1974 service treatment record, the Veteran reported that any blows or hard contact to the skin caused welts. The military physician noted the Veteran "has been this way nearly all his life." The physician's assessment was that the welts were dermography. The Veteran's August 1976 Report of Medical History at separation reflects that he denied ever having had a skin disease, and his skin was normal in the Report of Medical Examination for discharge. A post-service VA medical certificate dated July 1978 shows that the Veteran had a rash on his back and stomach for three days. Upon examination, it was described as discrete raised non-erythematous plaques over back and chest. The rash was non-pruritic. The assessment was that the rash was probably a hypersensitivity to Darvon. The Veteran complained of a rash on the back of his neck and behind his ears in a December 1997 private treatment record, which was assessed to be "possibly secondary to his interferon medication" for hepatitis C. The Veteran stopped taking the medication, and a January 1998 private treatment record indicates the rash resolved. However in October 1998, the Veteran again had a "little bit of a rash that looks like it could be fungal around his neck." He was treated with Lamisil cream. A May 2002 private treatment record reflects that the Veteran had a rash. The physician considered that the rash could be a result of the interferon treatment, but the Veteran thought he had this same type of rash on and off before. The Veteran was afforded a VA examination in July 2015 for a skin disability. The July 2015 VA examiner diagnosed the Veteran with dermatographism. The examiner noted the Veteran reported to the military physician in service that he experienced this condition all of his life; however, the Veteran did not recall that to be true, nor did he recall telling the military physician that information. He confirmed, however, that he had experienced this type of skin reaction for many years. The examiner concluded that because the Veteran disagreed that he had a skin disability his entire life, it would be mere speculation to provide an opinion on whether this disease preexisted service. A January 2016 VA record reflects complaints of a non-erythematous rash on the palm of one hand composed of discrete spongiform like papules extending over the radial half of his palm. He was referred to dermatology because the Veteran's VA primary care physician felt it potentially could be related to the treatment for hepatitis C. The Veteran's VA primary care physician again reported that the Veteran may have had a skin rash related to ribavirin/Haravoni treatment in February 2016 and encouraged him to see a dermatologist. A VA dermatologist evaluated the rash on the Veteran's left hand in March 2016. The left hand had blisters, itching, and peeling skin. The VA dermatologist determined the rash was dyshidrotic eczema. VA obtained an addendum opinion regarding the etiology of the dermatographism in July 2017. The examiner concluded that it is completely unknown if the currently diagnosed dermatographism is related to service. The examiner indicated that not much is known about this skin disease. Some suggestions have been made regarding the etiology of dermatographism, to include being triggered by an allergen although no causative allergens had yet been found. Triggers for this condition can include contact with extreme temperatures, simple variation in temperature, taking a bath, mild pressure from being seated for a long period, clothing, clapping of the hands, using tools, frenetic kissing, vigorously drying with a towel, rubbing skin on bed sheets, underlying infection, intake of certain medications like penicillin, or wearing jewelry. Additional risk factors for developing this condition include "nervous factors." Episodes of itchiness and subsequent scratching, resulting in the "writings" on the skin that are associated with dermatographism, occurred at regular intervals in people who have frequent bouts of emotional agitation, excessive stress, and anxiety. Hereditary factors have also been associated with dermatographism. The July 2017 examiner further indicated that whether dermatographism was a congenital disease or defect was completely unknown. The examiner also concluded that he could not prove nor disprove that the Veteran experienced this condition before service. Although the STRs report that the Veteran said he had this all his life, the Veteran denied saying such a thing during the July 2017 VA examination. The examiner noted that there were no additional corroborating clinical or other evidence to suggest whether the Veteran did or did not experience symptoms of dermatographism before service. However, the examiner ultimately concluded that the dermatographism was "likely present" before entrance into military service. At the outset, the Board finds that, on the service entrance examination, a diagnosis or symptoms of skin disorder was not "noted" at entry; therefore, the presumption of soundness attaches and requires clear and unmistakable evidence that the disease or injury existed prior to service and that the disease or injury was not aggravated by service to rebut this presumption. 38 U.S.C. § 1111; 38 C.F.R. § 3.304; Wagner; Horn. Moreover, after reviewing all evidence of record, both lay and medical, the Board finds that the evidence is not clear and unmistakable that the dermatographism existed before active service. The only indication that it may have existed before service is the one reference made by the medical professional who examined the Veteran during service in November 1974. The reference that the Veteran may have had the skin condition all of his life is not supported by any objective evidence, let alone any clear and unmistakable evidence. Moreover, the Veteran competently and credibly denies having symptoms of dermatographism before service. Notably, there is no contemporaneous clinical evidence or recorded history to corroborate or disprove the existence of a preexisting skin disability. See Miller, 11 Vet. App. at 348. The Board emphasizes that a lay report of the Veteran's medical history of the pre-service existence of dermatographism does not constitute a notation of a preexisting disorder. 38 C.F.R. § 3.304 (b)(1). Accordingly, the Board finds that the dermatographism did not clearly and unmistakably exist before service. When the presumption of soundness is not rebutted, the case converts to one for direct service connection. See Wagner at 1096. As to direct service connection, the Veteran is currently diagnosed with dermatographism, and such skin disability was first diagnosed during service. The Board's attempt to secure an etiology opinion in this case was frustrated by the fact that the nature and etiology of the Veteran's dermatographism is essentially unknown. The medical professionals in this case were unable to state with sufficient probability whether the disease is hereditary, a congenital defect, or a congenital disease. What is clear is that this skin disability was not noted upon service entrance, it was first diagnosed during service, and is currently diagnosed. Again, the symptoms that served as the basis for the diagnosis in service are the same symptoms that serve as the basis of the current diagnosis, and there is no evidence of an intervening injury. Based on this body of evidence, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the evidence is at least in equipoise as to whether the Veteran's currently diagnosed dermatographism had its onset during service. Under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for dermatographism is established. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for chloracne is denied. Service connection for dermatographism is granted. REMAND A remand of the service connection claim for hypertension is necessary to obtain an additional VA medical opinion and any outstanding medical records. The Veteran contends that his currently diagnosed hypertension is proximately caused or aggravated by his service-connected PTSD. The current evidence of record includes a June 2013 statement from Dr. G.P., the Veteran's private primary care physician. Dr. G.P. wrote that the Veteran's PTSD with depression and anxiety "will cause the hypertension and high blood pressure. I am treating [the Veteran] for." The Board previously found this opinion to be inadequate in the June 2016 remand because no rationale was provided to support the conclusion. Subsequently, the Veteran's representative, in correspondence dated February 2017, enclosed an April 2016 DBQ from Dr. G.P. with a medical opinion regarding the relationship between the service-connected PTSD and hypertension. However, the April 2016 DBQ from Dr. G.P. is not associated with the claims file. A copy of this DBQ should be obtained and associated with the claims file. The Veteran was afforded a VA examination in November 2013. The examiner, a physician's assistant, concluded that it was less likely than not that the Veteran's hypertension was proximately due to, or the result of, the service-connected PTSD. The examiner reviewed the medical literature and found that there was no documentation that listed hypertension as sequelae of PTSD. The examiner listed a number of risk factors for developing hypertension, to include race, diagnosis of hypertension in parents, excess sodium intake, excess alcohol consumption, obesity and weight gain, physical inactivity, dyslipidemia, vitamin D deficiency, and certain personality traits such as hostile attitudes, time urgency impatience, and depression. The examiner identified the Veteran's risk factors as history of smoking, obesity, hyperlipidemia, and his race. However, the examiner did not identify or discuss the Veteran's PTSD-related depression and anxiety as risk factors for this Veteran. The examiner ultimately concluded that the Veteran's non-service related risk factors were more likely the cause of the hypertension. The claims file also includes a VA opinion from May 2014. The examiner's opinion was that the hypertension, which clearly and unmistakably pre-existed service, was less likely than not aggravated beyond its natural progression by his service-connected PTSD. The examiner's rationale was the Veteran's hypertension was controlled with just one anti-hypertensive medication and that the veteran has multiple risk factors that would contribute to uncontrolled hypertension such as his history of smoking, his obesity, and his race. There examiner noted there was no evidence PTSD aggravates hypertension. This opinion is also not adequate as it is based on factual inaccuracies. There is no evidence that the Veteran experienced hypertension before or during service, and the Veteran's only theory of service connection in on a secondary basis. Additionally, the examiner's rationale was unclear. The clinician's statement that "there is no evidence PTSD aggravates hypertension" could be related to PTSD and hypertension generally or with regard to this specific Veteran. Further, the examiner did not consider all of the Veteran's contentions, to include that his hypertension is caused by the prescribed PTSD medications. The Board remanded the claim to obtain an addendum opinion to address these issues. Subsequently, an additional VA medical opinion was obtained in July 2017. The VA examiner concluded it was less likely than not that the Veteran's service-connected PTSD proximately caused or aggravated the hypertension. First, the examiner clarified that both the medical literature generally and the evidence in this case did not support the contention that PTSD proximately caused or aggravated hypertension. The examiner also reviewed the medical literature submitted by the Veteran. Nonetheless, the examiner gave a negative opinion because the medical literature did not indicate by "clear medical fact" and/or "clear causation" that PTSD proximately caused or aggravated hypertension. Additionally, the examiner discussed two specific PTSD medications prescribed to the Veteran in relation to whether hypertension was a potential side effect of the treatment prescribed for the PTSD. First, the examiner noted that hypertension is not a reported side effect of Escitalopram. Second, the examiner noted that hypertension is a reported side effect of Wellbutrin, but minimized the finding when the examiner noted that only 1 percent to 10 percent of people taking Wellbutrin experienced hypertension as a side effect. The Veteran's representative, in the October 2017 response to the September 2017 SSOC, contends that hypertension is a "common side effect" of Wellbutrin and indicates that the examiner did not acknowledge that fact or discuss it in his rationale. A more thorough discussion of hypertension as a "common" side effect of the Wellbutrin should be provided. Additionally, the examiner went on to discuss that the Veteran had multiple risk factors for developing hypertension, to include a history of smoking, obesity, and race as previously identified in the May 2014 VA examination, regardless of the prescribed medications for PTSD. The July 2017 VA opinion is inadequate as the rationale is based solely on the absence of "clear" evidence of causation between the service-connected PTSD and the hypertension, suggesting the examiner used a much higher evidentiary standard than required when evaluating the evidence. In addition, further discussion is required regarding the hypertension as a side effect of Wellbutrin. Further discussion is also needed regarding the Veteran's service-connected PTSD with depression and anxiety and its relationship with the hypertension. As depression was initially identified as a risk factor for hypertension generally in the November 2013 VA examination, the examiner should discuss how this Veteran's PTSD with depression and anxiety is or is not a risk factor for developing hypertension in the larger context of the Veteran's other non-service connected risk factors to determine the etiology of the hypertension. The Veteran's representative also indicates, in the October 2017 letter, that he has not yet received a copy of the July 2017 VA addendum medical opinion for hypertension. There is no indication in the claims file that a response was sent to the representative regarding this request. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding pertinent VA treatment records and associate them with the claims file. 2. Provide a copy of the July 2017 VA addendum medical opinion to the Veteran's representative, if this action has not already been undertaken. See October 2017 correspondence. 3. Obtain a copy of the April 2016 disability benefit questionnaire and/or medical opinion completed by Dr. G.P. and associate with the claims file. 4. Then, obtain an addendum VA medical opinion on the etiology of the Veteran's hypertension. Whether a new examination is required is left to the discretion of the examiner. A thorough review of the claims file should be undertaken. After reviewing the claims file, the examiner is asked to address the following: (a) Discuss the Veteran's PTSD-related depression in relation to the other general risk factors for developing hypertension as identified in the November 2013 VA examination, and in the July 2017 VA examination by reference. If the examiner concludes that this Veteran's PTSD-related depression is not a risk factor for developing hypertension for this Veteran, discuss why not. (b) Clarify whether the Veteran's hypertension is proximately due to, or aggravated by the medications prescribed to treat his PTSD, including Wellbutrin. **In doing so, specifically discuss the contention that hypertension is a "common side effect" of Wellbutrin, as indicated by the 1 percent to 10 percent statistic quoted by the July 2017 VA examiner. See October 2017 response to the September 2017 SSOC. The legal standard by which to evaluate the medical evidence, and to form your medical opinion, should be "at least as likely as not" (50% or greater) that the service-connected PTSD with depression and anxiety (and/or prescribed medications) proximately caused or aggravated the hypertension. A thorough rational must be provided for each conclusion. 5. Thereafter, the remaining issue on appeal should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate time period within which to respond. The appellant has the right to submit additional evidence and argument on the matter or matters 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. §§ 5109B, 7112 (2012). ______________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs