Citation Nr: 1808879 Decision Date: 02/12/18 Archive Date: 02/23/18 DOCKET NO. 08-19 105 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for actinic keratosis and squamous cell carcinoma, including as due to exposure to herbicides. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD R. R. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In April 2012, December 2013, and July 2014, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for additional evidentiary development. FINDING OF FACT The Veteran's current actinic keratosis and squamous cell carcinoma are shown to be etiologically related to his active service. CONCLUSION OF LAW Service connection for actinic keratosis and squamous cell carcinoma is established. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Based upon the favorable outcome in this case, a discussion of VA's duties to notify and assist is not warranted at this time. To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113(b) (2012); 38 C.F.R. § 3.303(d). The Veteran contends that his actinic keratosis and squamous cell carcinoma were caused by in-service sun exposure while he was stationed in the Republic of Vietnam (Vietnam). The Veteran conceded that his service treatment records are silent for treatment for skin cancer. He elaborated that his physicians told him skin cancer could take up to 20 years to develop after his initial sun exposure. See 2008 VA Form 9. The Veteran's personnel records document his service in Vietnam. In August 2005, the Veteran was first afforded a VA examination skin examination. The VA examiner diagnosed active solar keratosis with progression to basal and squamous cell carcinoma; post numerous basal cell carcinomas with residual scars; and, post numerous squamous cell carcinomas with residuals of scars. However, the VA examiner did not provide any etiological opinions. The Veteran was afforded a VA skin examination in May 2012. The VA examiner diagnosed malignant melanoma, basal cell carcinoma, and actinic keratosis. He opined that the Veteran's diagnosed skin conditions were less likely than not incurred in active service. He elaborated that the Veteran's claims file did not document sunburns and his military separation examination was negative for skin conditions. In March 2014, the Veteran underwent a VA skin examination. The VA examiner diagnosed basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. Records from 1981 indicated diagnoses for actinic chelitis and actinic keratosis. She concurred with the May 2012 VA opinion. The Veteran reported multiple sunburns throughout his life. There was no evidence of treatment for sunburns in the Veteran's service treatment records and his separation examination was normal. The VA examiner highlighted that multiple years of repeated sunburns is known to be associated with actinic keratosis, basal cell carcinoma, and squamous cell skin cancer. There was no evidence of continuity of a skin condition from discharge to the time of the Veteran's initial treatment for basal cell carcinoma. The VA examiner concluded that it was less likely than not that the Veteran's skin conditions were incurred during his active service. In August 2014, the Veteran was afforded a VA skin examination. The VA examiner diagnosed actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. The VA examiner conceded that the Veteran was exposed to Agent Orange and the sun exposure without sunscreen while he was in Vietnam. The Veteran also had sun exposure prior to his active service and after his active service. He had no treatment for sun exposure during active service and there was no evidence of skin conditions at his separation examination. The Veteran was first diagnosed with skin cancer in 1975, but he was released from active duty in 1968. There was no evidence that Agent Orange causes skin cancer. The VA examiner found that the Veteran's skin conditions were less likely than not related to his active service. In July 2017, the Board obtained an expert medical opinion regarding the etiology of the Veteran's actinic keratosis and squamous cell carcinoma. Dr. N.K. reported that the Veteran had a life long history of sun exposure beginning in childhood and throughout his active service with a history of superimposed sunburns. His most intensive sun exposure was during his active service while he worked as a lifeguard on China Beach in Vietnam. There was photographic documentation of severe sunburn on his right ear. She also explained that there was a link between Agent Blue and skin cancer. Dr. N.K. found that it was at least as likely as not that all the skin lesions the Veteran developed, including actinic keratosis, actinic ceilitis, basal cell carcinoma, squamous cell carcinoma, and melanoma, were related to cumulative sun exposure. The Veteran's intensive sun exposure during his active service contributed to this exposure and was therefore ultimately related to his active military service. The Board finds that the July 2017 expert medical opinion is more probative than the negative VA opinions of record. Dr. N.K. is an expert in dermatology. She is the chief of dermatology at her institution. Therefore, her positive opinion is very probative. See 38 U.S.C. §§ 1110, 1131. Based upon the forgoing, service connection for actinic keratosis and squamous cell carcinoma is granted. ORDER Service connection for actinic keratosis and squamous cell carcinoma is granted. ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs