Citation Nr: 18100705 Decision Date: 04/19/18 Archive Date: 04/19/18 DOCKET NO. 11-23 203 DATE: April 19, 2018 ISSUES DECIDED: 2 ISSUES REMANDED: 0 ORDER Entitlement to service connection for a skin disorder, to include dermatitis, is denied. Entitlement to an initial rating greater than 70 percent for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a skin disorder, to include dermatitis, due to a disease or injury in service, to include specific in-service event, injury, or disease. 2. The Veteran’s service-connected PTSD is manifested by symptoms such as constricted affect, mood normal, psychomotor activity demonstrated by leg shaking, delusions, paranoid ideation, nightmares, auditory hallucinations, poor insight, self-isolation, sleep disturbance, repressed anger, panic attacks twice a month, and difficulty having close relationships. However his appearance and hygiene were always appropriate and there was no evidence of suicidal or homicidal ideation, poor impulse control, poor judgment, obsessive or inappropriate behavior. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a skin disorder, to include dermatitis, have not been satisfied. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309 (2017). 2. The criteria for entitlement to an initial rating greater than 70 percent for posttraumatic stress disorder (PTSD) have not been satisfied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1965 through March 1988. In March 2015, the Veteran appeared before the undersigned Veterans Law Judge in a Travel Board hearing. A transcript has been associated with the claims file. In an August 2017 decision, the Board remanded the above-listed issues for further development. That development having been completed to the extent possible, the matter is again before the Board for appellate review. 1. Entitlement to service connection for a skin disorder, to include dermatitis The Veteran contends that his skin disorder is etiologically related to his active duty service. Specifically, he argues that he was diagnosed with a skin disorder while in service, which has continued ever since. Initially, the Board notes that the Veteran has not been diagnosed with chloracne, another acneform disease consistent with chloracne, or any other disability entitled to presumptive service connection for diseases associated with exposure to certain herbicide agents. 38 C.F.R. § 3.309(e). A February 2016 VA medical addendum opinion noted that actinic keratosis is not a presumptive condition due to Agent Orange exposure. Accordingly, service connection cannot be granted as presumptively associated with in-service exposure to herbicides or Agent Orange. As there is no medical evidence to the contrary, the Board finds that service connection cannot be granted for this claim as related to Agent Orange exposure. The Veteran can still establish service-connection on a direct basis. 38 C.F.R. § 3.303. There is no credible medical or lay evidence establishing an etiological link between the Veteran’s current skin disorders and his in-service skin condition. On the contrary, the overwhelming weight of the evidence establishes that the Veteran’s skin disorders are a completely distinct skin condition from what he experienced in service. Service treatment records reflect that the Veteran sought service connection for skin disorders several times while on active duty service. He reported having a skin rash in November 1973 and was diagnosed with contact dermatitis. On his August 1975 report of medical history for his reenlistment examination, he reported a rash on his scalp. In November 1975 he reported having a rash on the top of his head that sometimes extended to his face. Post-service treatment records show that the Veteran sought treatment for a facial rash in April 1988, approximately one month after separation from active duty. He presented with purple-red plaques covering his face and was diagnosed with possible erysipelas. In May 1988, he again presented with a facial rash. The physician diagnosed him with leukocytoclastic vasculitis and noted that it was very unusual for that condition to erupt only on the face. In June 1988, the Veteran went for a follow-up for his skin condition, which had nearly resolved by that time. The physician noted that leukocytoclastic vasculitis was not similar in pathology to the skin disorder the Veteran had, and neither did polymorphic light eruption. The physician concluded that the Veteran’s skin disorder could not be given a label at that time. The Veteran next sought treatment for a skin disorder in February 2007. He presented with several scaly, pink papules on his face, and a pink, firm, scaly papule on his right upper malar. He also had a pink, slightly shiny papule on his left clavicle. He was diagnosed with benign seborrheic keratoses, benign nevi (moles), and benign hemangiomas likely genetic. In August and November 2007, he was treated for actinic keratosis. In April 2008, the Veteran sought follow-up treatment for his skin disorder. The dermatologist noted that he had a history of extensive actinic damage, non-melanoma skin cancer, and numerous scaly spots. He was diagnosed with benign hemangiomas, lentigines, benign seborrheic keratoses, and actinic keratosis. The Veteran continued to seek treatment for a skin disorder, variously diagnosed as lentigines, hemangiomas, seborrheic keratoses, and actinic keratosis from February 2007 through February 2015. A June 2011 VA treatment record noted the Veteran had verruca on his left forearm. In February 2016, the Veteran was afforded a VA examination to determine the etiology of his skin disorder. However, as the August 2017 Board remand found the February 2016 nexus opinion to be inadequate, it will not be discussed. In February 2018, the RO obtained an independent medical opinion. The examiner noted that contact dermatitis is an inflammatory skin process caused by an exogenous agent or agents that directly or indirectly injure the skin. The examiner conducted a thorough review of the Veteran’s service treatment records and concluded that the skin condition diagnosed as contact dermatitis in 1973 and 1975 while on active duty service was an inflammatory skin presentation that was acute, self-limited, transient, and resolved over time, as the Veteran’s service treatment records did not document any skin disorders after November 1975. The examiner then discussed each of the Veteran’s currently diagnosed skin disorders. She noted that erysipelas is an acute bacterial infection of the epidermis and upper dermis tissues. Current dermatology and infectious disease literature agreed that Staphylococcus infection is an acute, aggressively spreading intracellular infection of the squamous epithelium with vesicle formation arising from cutaneous inoculation of extrinsic bacteria or normal flora. These eruptions within the epidermal and upper dermal tissue are characterized by an abrupt onset of fiery-red swelling on the face or extremities. A review of the claims file showed the Veteran was diagnosed with erysipelas following a vacation to Santa Domingo, and opined it was at least as likely as not that the Veteran’s 1988 infectious event on his face was an acute, transient, and self-limited bacterial exposure related to his trip taken after separation from active duty. For those reasons, she opined it was less likely than not that his 1988 erysipelas infection was related to or aggravated by his active duty service because his service treatment records lacked sufficient objective infectious disease-based clinical evidence related to erysipelas type infection. As for the Veteran’s other diagnoses, the examiner explained that seborrheic keratosis is a benign skin tumor and a form of localized hyperpigmentation as a result of epidermal alteration, and it develops from the proliferation of epidermal cells. Clinically, seborrheic keratosis presented as oval or round plaques with adherent greasy scale, pigmentation ranging from black to tan, and most often have a velvety to finely verrucous surface and appear to be “stuck on.” In comparison, a verruca is a cutaneous neoplasm caused by Papillomaviruses. Verruca presents as sessile and dome-shaped with hyperkeratotic surface features. Actinic keratosis consists of non-melanoma skin lesions described as hyperkeratotic erythematous papules and patches on sun-exposed skin. The examiner opined that it was less likely than not that the Veteran’s seborrheic keratosis, verruca, and actinic keratosis were etiologically related to his active duty service because there was no evidence of Papillomavirus, benign skin growth actinic keratosis, or benign skin tumor and hyperpigmentation as a result of epidermal alteration. Additionally, the Veteran’s post-service treatment records showed no treatment for, or diagnosis of, contact dermatitis. The Board finds the February 2018 independent medical opinion to be of great probative value because the examiner conducted an extensive review of the claims file and opined that the symptoms noted in the Veteran’s service treatment records were inconsistent with his current diagnosed skin disorders. She thoroughly explained the medical principles supporting her opinions, with citation to the factual record. The Board finds there is no competent, credible, or persuasive medical evidence of record to refute the February 2018 independent medical opinion. While the Board recognizes the Veteran’s assertions that his skin disorder is related to service and is competent to testify as to his observable symptoms, the Veteran is not competent to conclude that any condition he has now is connected to his service. Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case, skin conditions, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). While a skin condition is observable, the etiology of the various skin conditions in this case require specialized training and medical diagnostic testing. The Veteran has had many different skin conditions, and a lay person is not competent to diagnose among them or to provide an etiology. Therefore, the Board finds that the Veteran’s statements of record cannot be accepted as competent evidence sufficient to establish service connection for his disabilities. In light of the extensive medical evidence, the Board finds the Veteran’s skin disorders, to include contact dermatitis, are not etiologically linked to his in-service skin condition. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule does not apply and service connection for a skin disorder, to include contact dermatitis is denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Entitlement to an initial rating greater than 70 percent for posttraumatic stress disorder (PTSD) The Veteran contends that his service-connected PTSD warrants a disability rating greater than 70 percent. After a full review of the record, the Board finds that an increased, 100 percent, disability rating for the Veteran’s service-connected PTSD is not warranted. The Veteran was afforded a VA examination to assess the severity of his PTSD in August 2010. He reported that he only socialized with family, and although he argued with his wife frequently, she was supportive and understanding. He also reported that he maintained employment because his boss and other coworkers were veterans who understood his situation and he was given light duty on days he was in a particularly bad mood. The examiner noted that trauma and combat experience had contributed to a constant paranoia about other people and feelings that no one understood what he had been through. Mental status examination reflected the Veteran was appropriately dressed, had a good mood with restricted affect, his speech was unremarkable, he demonstrated psychomotor activity in the form of his leg shaking throughout the examination, he was cooperative and attentive, oriented, and his attention was intact. His thought processes were unremarkable, but he presented with paranoid ideation, paranoid delusions, and auditory hallucinations that were not persistent. His judgment was fair, behavior appropriate, impulse control was good, he demonstrated no obsessive or ritualistic behavior, endorsed no suicidal or homicidal ideation, but his insight was poor and he experienced sleep impairment. The examiner observed that he had repressed anger that he was able to keep under control, but had difficulty with close relationships. The examiner noted the Veteran had frequent nightmares, minimal flashbacks, avoidance behaviors, detachment, sleep impairment, irritability, hypervigilance, exaggerated startle response, and difficulty concentrating. The examiner noted that the Veteran had great capacity to cope with his symptoms as he avoided outbursts or triggers, maintained a 41 year long marriage, and had a long work history. The Veteran sought mental health treatment from January 2010 through June 2010. Mental status examination consistently noted that the Veteran’s mood was stable with congruent affect, his speech was normal, appearance within normal limits, he demonstrated no psychomotor activity, his thought processes were logical, organized, coherent, and goal directed, he endorsed no suicidal or homicidal ideation, showed no signs of disturbances of perception, and his insight, judgment, and problem solving capacity were normal. In January 2010, he had an abnormal thought process of guilt, but that was not noted during his subsequent mental health evaluations. The Veteran returned to mental health treatment in August 2012. He reported that he kept busy and slept better, his mood was stable, and he was not in distress. The Veteran and psychologist agreed that he did not need psychological services at that time, but was told to follow up on an as needed basis. In February 2016, the Veteran was afforded another VA examination to assess the severity of his PTSD. The examiner opined that the Veteran’s symptoms resulted in occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. He reported that he had not sought mental health treatment for several years; however he still got upset easily, that he stayed busy to avoid depression, and still had problems sleeping. Mental status examination reflected that the Veteran’s mood was euthymic with congruent affect, he conversed spontaneously, his thought processes were logical to the course of conversation, there was no evidence of a psychotic process, and his thought content was free of suicidal or homicidal ideation. During his May 2015 Board hearing, the Veteran testified that he was still working, and was generally able to get along with his coworkers, although he primarily worked alone. There is no evidence the Veteran’s symptoms have resulted in total occupational and social impairment. He has not shown symptoms comparable to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name to warrant a higher, 100 percent, disability rating. On the contrary, the evidence of record reflects that the Veteran is able to maintain relationships with his family, and generally gets along with coworkers and is able to work, albeit alone at times. Further, he never demonstrated inappropriate behavior, persistent hallucinations or delusions, disorientation, or memory loss. The Board notes that the Veteran’s current symptoms are not severe enough to warrant the 70 percent rating he is currently assigned. However, the Board will not disturb his disability rating. As such, entitlement to an increased rating greater than 70 percent for service-connected PTSD is not warranted.   In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel