Citation Nr: 1817573 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 14-15 985A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to a rating in excess of 10 percent for tinea versicolor and tinea cruris. ATTORNEY FOR THE BOARD E. Jones III, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from June 1990 to May 1999. He was awarded the Air Force Achievement Medal with one device, in addition to other decorations. This matter is before the Board of Veterans' Appeals (Board) on appeal of a July 2012 rating decision of the Reno, Nevada, Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction over the case has since transferred to the St. Paul, Minnesota, RO. The St. Paul RO continued the Veteran's 10 percent rating for tinea versicolor and tinea cruris in a May 2013 rating decision. FINDINGS OF FACT 1. Prior to May 30, 2012, the Veteran's tinea versicolor and tinea cruris affected less than 20 percent of his body and less than 20 percent of exposed areas. 2. Beginning May 30, 2012, tinea versicolor and tinea cruris were treated with systemic therapies including oral antifungal, antibiotic, and antihistamine medications. CONCLUSIONS OF LAW 1. For the period of appeal prior to May 30, 2012, the criteria for a rating in excess of 10 percent for tinea versicolor and tinea cruris have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Code 7813-7806 (2017). 2. For the period of appeal beginning May 30, 2012, the criteria for a rating of 60 percent for tinea versicolor and tinea cruris have been met. This is the maximum schedular rating for these conditions. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Code 7813-7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran's skin disabilities are currently rated 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7813-7806. He contends that a rating of 30 percent or higher is appropriate for his skin disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's skin disabilities are rated under Diagnostic Code 7806 for dermatitis or eczema. (Diagnostic Code 7813 pertains, in relevant part, to tinea cruris, and refers to the criteria of Diagnostic Code 7806.) Pursuant to Diagnostic Code 7806, a 10 percent rating is assigned when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas is affected, or; when intermittent systemic therapy such as corticosteroids or immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent rating is assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 60 percent rating is assigned where there more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. Id. Regarding skin disabilities, the U.S. Court of Appeals for Veterans Claims (Court) held that topical use of corticosteroids constitutes systemic therapy under this diagnostic code. Johnson v. McDonald, 27 Vet. App. 497 (2016). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit), however, subsequently reversed that decision by the Court. Johnson v. Shulkin, 862 F. 3d 1351 (Fed. Cir. 2017). In reversing, the Federal Circuit agreed with the Secretary that the Court erred when it "read DC 7806 as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of 'systemic therapy.'" The Federal Circuit noted that DC 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code." The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical antiinfective applied to a certain area of the skin and affecting only the area to which it is applied." Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Board notes that the Veteran has been diagnosed with several skin disorders, only two of which are currently service connected. Where a veteran is diagnosed with multiple disorders, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam). In this case, the Board is unable to differentiate the symptomatology of tinea versicolor and tinea cruris from other skin disorders such as dermatitis. This is because medical providers and even one VA examiner do not differentiate the symptoms of the Veteran's various skin disabilities. As such, the Board has attributed all disability symptomatology and functional impairment to the now service-connected tinea versicolor and tinea cruris. After careful review of the evidence, the Board finds that prior to May 30, 2012, a rating in excess of 10 percent under Diagnostic Code 7813-7806 is not warranted because the Veteran's skin disabilities did not affect more than 20 percent of his body or exposed areas, and he was not prescribed systemic therapy for these conditions. Since May 30, 2012, he has been prescribed systemic therapy for his skin conditions and a 60 percent rating is therefore warranted. At a VA examination in April 2011, the examiner diagnosed tinea cruris and tinea versicolor that were controlled with use of topical creams. The examiner noted that these conditions affected less than 20 percent of the Veteran's total body surface, and zero percent of his exposed skin surface. With regard to topical medication use prior to May 30, 2012, the Veteran was prescribed topical corticosteroids such as triamcinolone cream. There is no indication in the record that the topical creams were administered on a large enough scale that they affected his body as a whole and therefore amounted to systemic therapy. With regard to systemic medication use, VA treatment notes show that on May 30, 2012, the Veteran was prescribed fluconazole, an oral antifungal medication, for two weeks, for tinea cruris. Beginning in June 2012, he was prescribed doxycycline, an oral antibiotic, for inflammatory dermatitis, to be taken twice per day on an ongoing basis. In February 2013, his prescription was switched from doxycycline to minocycline, another oral antibiotic to be taken daily. An April 2014 VA treatment record shows that the Veteran was prescribed oral antibiotics for a rash, and private treatment notes in February 2016 showed that the Veteran's eczematous dermatitis was treated with daily antihistamine. Under the principles set forth in Johnson, 862 F. 3d 1351, the Veteran's oral antifungal, antibiotic, and antihistamine medications are systemic therapy because they are "treatment pertaining to or affecting the body as a whole." Because the Veteran took these medications on a constant or near-constant basis for over 12 months, he is entitled to a 60 percent rating under Diagnostic Codes 7813-7806 from May 30, 2012. There is no evidence that the Veteran has stopped taking systemic therapy. The Board finds that no higher or alternative rating under a different diagnostic code can be applied. Diagnostic Codes 7800, 7801, and 7802 do not apply because the Veteran does not have burn scars. Diagnostic Codes 7804 and 7805 do not apply because the Veteran does not have unstable or painful scars. Finally, the Veteran does not have diagnoses or symptoms that more closely approximate those necessary for a separate rating under Diagnostic Codes 7807 to 7811 or 7815 to 7833. The Board therefore finds that all of the Veteran's symptoms are accounted for under Diagnostic Code 7813-7806. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER For the period on appeal prior to May 30, 2012, a rating in excess of 10 percent for the Veteran's skin disability is denied. For the period on appeal beginning May 30, 2012, a rating of 60 percent is granted under Diagnostic Code 7813-7806. ____________________________________________ LAURA E. COLLINS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs