Citation Nr: 18120671 Decision Date: 07/24/18 Archive Date: 07/24/18 DOCKET NO. 08-18 754 DATE: July 24, 2018 ORDER From March 22, 2005 to March 27, 2006, entitlement to a 60 percent disability rating for lichen planus, but no higher, is granted. From March 28, 2006 to May 28, 2013, entitlement to a disability rating in excess of 30 percent for lichen planus is denied. From May 29, 2013 to April 26, 2016, entitlement to a 60 percent disability rating for lichen planus, but no higher, is granted. On and after April 27, 2016, entitlement to a disability rating in excess of 60 percent for lichen planus is denied. Entitlement to service connection for obstructive sleep apnea is granted as secondary to service-connected depressive disorder and right and left knee tibial plateau stress fracture. REMANDED Entitlement to service connection for a liver disorder, to include as secondary to service-connected depressive disorder, right and left knee tibial plateau stress fracture, and/or lichen planus, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected depressive disorder, right and left knee tibial plateau stress fracture, and/or lichen planus, is remanded. FINDINGS OF FACT 1. From March 22, 2005 to March 27, 2006, the Veteran’s lichen planus required treatment with constant or near constant use of systemic medications; but was not manifested by scars that caused limitation of function or scars that were manifested by visible or palpable tissue loss or gross distortion or asymmetry of three or more features or paired sets of features or six or more characteristics of disfigurement. 2. From March 28, 2006 to May 28, 2013, the Veteran’s lichen planus did not affect more than 40 percent of the entire body or exposed areas affected; require constant or near constant use of system medications or intensive light therapy during a 12 month period; and was not manifested by scars that were deep, scars that caused limitation of function, or scars that had visible or palpable tissue loss or gross distortion or asymmetry of two features or paired sets of features or four or five characteristics of disfigurement. 3. On and after May 29, 2013, the Veteran’s lichen planus required treatment with constant or near constant use of systemic medications; but was not manifested by scars that caused limitation of function or scars that were manifested by visible or palpable tissue loss or gross distortion or asymmetry of three or more features or paired sets of features or six or more characteristics of disfigurement. 4. The Veteran’s obesity was an intermediate step between his obstructive sleep apnea and his service-connected depressive disorder and right and left knee tibial plateau stress fracture. CONCLUSIONS OF LAW 1. From March 22, 2005 to March 27, 2006, the criteria for entitlement to a 60 percent disability rating have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7822. 2. From March 28, 2006 to May 28, 2013, the criteria for entitlement to a disability rating in excess of 30 percent have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7822. 3. From May 29, 2013 to April 26, 2016, the criteria for entitlement to a 60 percent disability rating have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7822. 4. On and after April 27, 2016, the criteria for entitlement to a disability rating in excess of 60 percent have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7822. 5. The criteria to establish entitlement to service connection for obstructive sleep apnea as secondary to service-connected depressive disorder and right and left knee tibial plateau stress fracture have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from May 2002 to November 2002. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in July 2006 and March 2009. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2018. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. The July 2006 rating decision denied entitlement to a disability rating in excess of 30 percent for lichen planus. The Board notes that 60 percent is the highest schedular rating assigned for the disability under the applicable diagnostic code. See 38 C.F.R. § 4.118, Diagnostic Code 7822. However, the Veteran's increased rating claim remains before the Board for the period prior to April 27, 2016, and to determine whether a higher rating is available based on disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, 7805) for both periods. AB v. Brown, 6 Vet. App. 35 (1993). I. Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Entitlement to a disability rating in excess of 30 percent for lichen planus prior to April 27, 2016, and in excess of 60 percent on and after April 27, 2016. 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. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran’s entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary in order for a rating to accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). When, as here, the Veteran is requesting a higher rating for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509 (2007) ("The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim."). The Board notes that the Veteran's increased rating claim was received on March 22, 2006. Therefore, the period for consideration on appeal began on March 22, 2005, one year prior to the date of receipt of his increased rating claim. 38 C.F.R. § 3.400(o)(2). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990). As discussed above, the Veteran’s lichen planus was originally assigned a 30 percent disability pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7899-7806. Hyphenated diagnostic codes, including a diagnostic code ending in the digits "99," are used when there is no specifically applicable diagnostic code and the disability is rated by analogy. 38 C.F.R. § 4.27. Diagnostic Code 7806 provides the rating criteria for dermatitis or eczema. When the September 2016 DRO decision granted the 60 percent disability on and after April 27, 2014, the Diagnostic Code was changed to 7822 for papulosquamous disorders not listed elsewhere (including lichen planus). The Board notes that 38 C.F.R. § 4.118 was amended during the pendency of this appeal. 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7805). The effective date of the revisions is October 23, 2008, and the revised criteria apply to all applications for benefits received by VA on or after that date, unless the appellant specifically requests consideration under the new criteria. As the Veteran's increased rating claim was received before October 23, 2008, and he has not requested review under the amended criteria, the Board will only consider the rating criteria in effect prior to that date. Under Diagnostic Code 7806, a rating of 30 percent is assigned with 20 to 40 percent of the entire body or exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constant, during the past 12-month period. A rating of 60 percent is assigned with more than 40 percent of the entire body or exposed areas affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Diagnostic Code 7822 similarly provides for a 30 percent rating if 20 to 40 percent of the entire body or exposed areas affected; or, systemic therapy or intensive light therapy required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A rating of 60 percent is assigned with more than 40 percent of the entire body or exposed areas affected; or, constant or near-constant systemic medications or intensive light therapy required during the past 12-month period. Both Diagnostic Codes 7806 and 7822 provide for rating the disability under the included criteria or as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Prior to the beginning of the appeal period in March 2005, a February 24, 2005 VA dermatology record stated that the Veteran had been initially diagnosed with vesicular lichen planus through a November 2003 punch biopsy. His symptoms first occurred in 2002. The Veteran was initially prescribed Protopic and econazole for 2 months, but his condition did not improve. At the time of the visit, the rash had spread throughout the scalp, the bilateral shins, and torso. The lesions were pruritic and had a burning sensation that was chronic and sporadic. In the heat and with sweating, the lesions swelled and became blister-like. The examination revealed multiple hyperpigmented and raised lesions on the base of the scalp, interior forearms, shoulders, axilla, lateral torso, and the small of his back. They had a purple color and were symmetrical on both sides. A plan was made to treat the lichen planus with 40 milligrams of Accutane taken every morning with a meal, 80 milligrams of Accutane taken every evening with a meal, and 50 milligrams of Atarax taken three times a day as the occasion required. The Board notes that Atrax is an antihistamine. See Atarax Tablet, WebMD (July 18, 2018), https://www.webmd.com/drugs/2/drug-5511/atarax-oral/details. During a March 2005 VA examination of the Veteran’s skin, the examiner discussed the Veteran’s medical history. The examiner noted that after lichen planus was diagnosed with a November 2003 skin biopsy, the Veteran was treated with steroid creams that had not been helpful. He had also been placed on two months of Protopic and econazole with poor results. The Veteran had also tried a regimen of 40 milligrams of Accutane in the morning with meals, and 80 milligrams at night accompanied by Atarax. The examiner stated the Veteran had the Accutane dosage reduced to 40 milligrams due to his belief that the medications was interfering with his liver function. His current medications included baclofen, naproxen sodium, and 40 milligrams of isotretinoin. The Board notes that isotretinoin, a type of retinoid, is the generic name for Accutane. See Accutane, RxList (July 18, 2017), https://www.rxlist.com/accutane-drug.htm. The diagnosis was lichen planus. The examiner indicated that the Veteran’s current treatment plan consisted of antihistamines and retinoids. It was possible he would require photochemotherapy with ultraviolet light. After physically examining the Veteran, the examiner stated that he had a clear facial complexion. The examiner noted that a papular rash was present on the left scalp at the occipital region just above the ear pushing diagonally across to the temple. The Veteran also had scattered violaceous papules without erythematous bases measuring from 0.2 to 1.2 centimeters to the back of the neck, back, axilla, and anterior chest. The lesions in the anterior chest and abdomen were very sparsely populated with approximately 10 lesions in this entire area. The Veteran’s forearms, soles of feet, and buttocks were spared of any evidence of lesions. In addition, there were no particular lesions in the fingers, pads, and palms. However, the genitalia had a coalescence of multiple lesions in the scrotum, foreskin, and on the glans penis. The Veteran’s thighs also had a few lesions. The anterior skins had hypopigmented areas where the lesions once were. In March 2006, a VA treatment record reported that the Veteran had lichen planus and diffuse pruritus. Later that month on March 28, 2006, a record noted the Veteran’s chief complaint was a groin rash for two weeks. Since the previous day, the Veteran had also experienced general body itching and burning with some hot and cold flashes during periods of intense itching. His active outpatient medication list included calcipotriene 0.005 percent ointment with directions to apply a thin layer to the specified area(s) twice a day. The Veteran was also advised to have cloth or hand towel at work to decrease the amount of sweat contacting and remaining on dry skin. The Board notes that calcipotriene ointment is a topical form of vitamin D. See Calcipotriene Ointment, Drugs.com (July 18, 2018), https://www.drugs.com/pro/calcipotriene-ointment.html. Accutane and Atarax were not included on the list. In April 2006, a record reported that the Veteran had not tolerated treatment with Accutane and Atarax. He complained of having erythematous lesions all over as well as itchy skin. The Veteran was found to have small, papular, and raised erythematous lesions on the arms, torso, and legs. The assessment and plan stated that the Veteran would use premazol cream as needed to treat his lichen planus. The Board notes that premazol is a type of antifungal medicine. See Gyno Premazol 2% Uses, Generic Drugs (July 18, 2018), https://www.ndrugs.com/?s=gyno%20premazol%202%25. In June 2006, a VA treatment record noted that in light of the Veteran’s lichen planus, a colonoscopy was performed to rule out an internal malignancy. The impression from this procedure stated that the results were essentially normal. In August 2006, a VA treatment record indicated that the Veteran still had lichen planus and diffuse pruritus. His active outpatient medication list included hydrocortisone 2.5 percent/pramoxine 1 percent lotion with instructions to apply sparingly to specified area(s) every day as necessary. The Board notes that hydrocortisone is a steroid and pramoxine is an anesthetic. See Analpram HC; Generic Name: hydrocortisone acetate 2.5% pramoxine hcl 1%, RxList (July 18, 2018), https://www.rxlist.com/analpram-hc-drug/patient-images-side-effects.htm#whatis. In October 2006, a VA treatment record noted that the Veteran had been experiencing mostly frontal headaches for weeks. He had a history of allergies and had not been taking any allergy medicine. He also related that he was under a lot of stress and not getting enough rest. The record noted that he would begin taking loratadine. In addition, the Veteran would be put on hydroxyzine to improve his sleep pattern. The Board notes that hydroxyzine the generic name for Atarax. See Atarax Tablet, WebMD (July 18, 2018), https://www.webmd.com/drugs/2/drug-5511/atarax-oral/details. In November 2006, the Veteran reported chronic itching of his skin and rash. Upon observation, a rash was present over the arm with no apparent pathology. The assessment was skin rash and itch. In January 2007, the Veteran reported during a mental health appointment that he had scaling on his skin that he had not been able to get effectively treated. In April 2007, the previously noted hydrocortisone cream was still listed as an active outpatient medication. In August 2007, the Veteran underwent another VA examination that included findings related to his skin disability. The examiner stated that the Veteran reported not receiving any treatment for the disability during the past two years. The Veteran continued to experience skin lesions that worsened with exercise, heat, and sweat. The examiner noted that the Veteran could also experience generalized pruritus with sweating. The physical examination revealed several slightly hypopigmented-like lesions on his left mid-shin the measured approximately 1 by 2 centimeters. He also had a slightly darker skin lesion over the right lateral malleolus as well as the left lateral foot. On his left deltoid, left triceps, mid-back, and upper back, he had some very fine, scattered, pale macular-type lesions. At the base of his scalp, he had excoriations. The examiner noted that the Veteran did not report having any current genital lesions. In May 2008, a VA treatment record stated that no rash was present on the Veteran’s skin. The Veteran’s hydrocortisone cream and loratadine were no longer included in the active outpatient medication list. In April 2009, hydroxyzine was not listed as an active medication. In May 2009, the examiner Veteran’s active outpatient medication list included flunisolide 0.025 percent, a corticosteroid that was meant to be inhaled nasally. However, the record noted that this medication was used to treat a nasal allergy. Loratadine was added back to the list in September 2009, but the record stated that it was still a treatment for allergies. In November 2009, a physical examination of the Veteran’s skin at VA showed that no lesions were present. In August 2010, a VA treatment record reported an examination of the Veteran’s skin did not show any lesions. In January 2010, a VA outpatient medication list noted that the Veteran should apply a moderate amount of ammonium lactate 12 percent cream topically once every day for dry skin. The Board notes that ammonium lactate topical is combination of lactic acid and ammonium hydroxide. See Ammonium Lactate Topical, Everyday Health (July 16, 2018), https://www.everydayhealth.com/drugs/ammonium-lactate-topical. Later in January 2011, the medication list also included triamcinolone acetonide 0.1 percent cream with instructions to apply a small amount to the specified areas twice a day as needed. The Board notes that this cream is a type of corticosteroid. See Triamcinolone Acetonide Cream, WebMD (July 16, 2018), https://www.webmd.com/drugs/2/drug-1456/triamcinolone-acetonide-topical/details. At that time, the record stated that the Veteran’s skin did not have any lesions. In March 2012, the same VA examiner who conducted the previous examination of the Veteran from March 2005 completed an additional VA examination concerning the Veteran’s lichen planus disability. The examiner reported that the Veteran had not been treated with oral or topical medications in the past 12 months for any skin condition. During that time period, there had also been no other treatments or procedures for exfoliative dermatitis of papulosquamous disorders. In addition, the Veteran had not experienced any debilitating or non-debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. There was also no benign or malignant neoplasm related to the Veteran’s lichen planus. The examiner repeated much of the past medical history that was documented in the March 2005 VA examination report. He noted that after the Veteran had his Accutane dosage reduced to 40 milligrams due to his belief that the medication was interfering with his liver function, he stopped the medication completely due to this theory. The Veteran was currently on no prescribed medication. The examiner stated that since the March 2005 VA examination, the Veteran had not attended a single dermatology appointment in May 2005. The record did not contain any subsequent evidence of active skin problems. Although the examiner initially stated that the Veteran’s skin problems were not active at the time of the examination, the examiner also remarked that the current examination revealed a 0.75 centimeter lesion on the left forearm, and several scattered lesions measuring 0.05 by 0.05 centimeters to the sacrum. No other active lesions were identified. The examiner noted that the Veteran’s papulosquamous disorder affected less than 5 percent of his total body area. Following the examination, a March 2012 VA outpatient medication list no longer included the ammonium lactate or triamcinolone acetonide. In May 2012, the Veteran reported that he had been itchy all over since he received a testosterone shot a few weeks ago. The assessment stated that he was at risk for decreased quality of life related to itching/scratching causing skin breakdown. The plan reflected that the Veteran was advised to wear loose clothing, use baby powder on his chest and back, take cool shower, and use non-pore clogging lotion on his skin every day as needed. The plan also noted that he should follow up with mental health. In August 2012, a physical examination of the Veteran’s extremities revealed that no rash, lesions, or wounds were present. A subsequent May 29, 2013 VA treatment record stated that the Veteran complained of a possible allergic reaction, stating that his skin was on fire and he had been itching since the previous night. The Veteran also reported mild shortness of breath during the night. The Veteran was referred to the emergency department, and an associated record stated that the Veteran had experienced all over itching for 2 days. He was noted to have a history of eczema, but no hives or overt rash. There was also no new medication, foods, or symptoms; and the Veteran was not taking anything for the complaint. The Veteran was assessed to have pruritus. The record indicated that the Veteran was instructed to monitor his symptoms, take Benadryl as needed, and call if he experienced persistent or worsening symptoms. The antihistamine medication of diphenhydramine, or Benadryl, HCL 25 milligram capsule was included in a separate active medication list with an expiration date of May 30, 2014. The record stated that the Veteran should take one capsule by mouth every four hours as needed. The only other noted antihistamine was loratadine, but the record stated that it was used to treat congestion. On July 25, 2013, the Veteran complained of itching all over his body and most of his back. The record noted that the Veteran had been treating the issue with antihistamines. The record indicated that he had previously been treated with triamcinolone, Premasol, Protopic, Accutane, and Atarax. However, the Veteran was currently taking diphenhydramine and nothing else. The record noted that he was describing severe pruritus. An examination of his skin showed flat-topped papules on the occipital area of the head, back, and bilateral shoulders. The assessment was lichen planus. The record stated that the Veteran would start using triamcinolone cream twice a day for 7 days to the affected areas. He was referred to dermatology for other treatment possibilities, including steroid sparing agents. On August 26, 2013, a VA treatment record noted that the Veteran had a past history of lichen planus on his lower extremities. He was currently experiencing multiple problems, including pruritus, scaling, and photosensitivity. The record stated that an objective examination did not show and definitive lesions. Some postinflammatory hypopigmentation was present in areas of previous lichen planus. The assessment and plan noted that a sensitivity to hydrochlorothiazide. The Veteran wanted permission to discontinue hydrochlorothiazide/lisinopril to see if his pruritus improved. The Board notes that hydrochlorothiazide, a thiazide diuretic, and lisinopril, an angiotensin converting enzyme (ACE) inhibitor, are medications used to treat high blood pressure. See Lisinopril and Hydrochlorothiazide (Oral Route), Mayo Clinic (July 17, 2018), https://www.mayoclinic.org/drugs-supplements/lisinopril-and-hydrochlorothiazide-oral-route/description/drg-20069073. His primary care doctor noted in an addendum on that date that they would discuss replace his hydrochlorothiazide/lisinopril with another antihypertensive agent. During a visit with his primary care doctor the next day on August 26, 2013, the record noted that the Veteran was still applying the triamcinolone ointment, but as needed. An examination for the Veteran’s skin revealed flat-tipped papules on the left side of his chest just inferior to the areola. The inactive outpatient medication list included triamcinolone acetonide 0.1 percent cream, with a note to apply a small amount ot the specified areas twice a day for a rash. The status of the medication was expired. However, the assessment and plan noted that for lichen planus, the Veteran should continue to apply the triamcinolone cream twice a day for 7 days to the affected areas. He was again referred to dermatology for other treatment possibilities, including steroid sparing agents. On November 4, 2013, the active medication list included diphenhydramine, but not the triamcinolone cream. In examining his skin, flat topped papules were noted on his back. The assessment stated that his lichen planus was followed by dermatology. On December 23, 2013, a VA treatment record stated that the Veteran’s skin was intact with no flare of his lichen planus. On May 13, 2014, the Veteran reported having flares of his lichen planus despite stopping the hydrochlorothiazide medication. He had been treated with Accutane and Premasol before. His last visit to dermatology was in August 2013. During the visit, the Veteran had flat-topped papules on the shoulder, back, and cervical area of neck. The assessment stated that the Veteran should start using clobetasol for 7 days for the flare. On May 15, 2014, a VA active outpatient medication list still noted diphenhydramine. In addition, a pending outpatient medication list included clobetasol propionate 0.05 percent ointment with directions to apply a small amount to specified areas twice a day. The Board notes that this ointment is a type of corticosteroid. See Clobetasol, Topical Cream, Healthline (July 17, 2018), https://www.healthline.com/health/clobetasol-topical-cream#about. By June 20, 2014, the ointment was listed as having an expired status in an inactive outpatient medication list. On September 29, 2014, the Veteran reported that he was still having flares of lichen planus, but it was noted that no lesion or flare was present during the visit. The assessment noted that he should continue using Clobetasol and return when he was having a flare so a photograph could be sent to dermatology. Clobetasol was included under the pending outpatient medication list; and diphenhydramine was still listed under the active outpatient medications. Subsequent treatment records included both medications under the active outpatient medication list. In January 2015, a VA treatment record noted that the Veteran continued to complain of flare ups of his lichen planus. However, there were no lesions or flares upon physical examination of the Veteran’s skin. The record stated that the Veteran should continue using Clobetasol for his lichen planus. In March 2015, a VA treatment record stated that the Veteran’s active problem list included melasma, indicating that this entry was documented in August 2013. In April 2014, it was noted that the Veteran’s skin did not have any rash. Later on June 22, 2015, the Veteran reported during a psychiatric treatment visit that he experienced difficulty sleeping with symptoms of sweating and itching at night. The same day, the Veteran requested a dermatology consultation for his lichen planus. The record stated that the Veteran would be scheduled for an appointment with dermatology. In July 2015, the Veteran reported experiencing flares of his lichen planus that were precipitated by more sweating. The flares occurred on his bilateral feet, between his thighs, on his low back, on the back of his neck, and along the skin folds. The symptoms were mildly relieved by over the counter lotion. The record did not identify any specific lotion used by the Veteran. The physical examination showed that the Veteran’s skin had scaly lichen planus scattered on the back of his neck, mid-back, and soles of the bilateral feet. The record stated that he should continue to use Clobetasol. Diphenhydramine was noted to have an expired status under the inactive medication list, but Clobetasol remained with the other active outpatient medications. A dermatology outpatient referral was made with Dr. S. for management of his lichen planus as he continued to experience small, scaly, and flat papules on severe areas of his body despite Clobetasol treatment. In August 2015, a VA podiatry consultation noted that the Veteran’s skin had diffuse hyperkeratosis on the dorsal proximal interphalangeal joint lesser digits, specifically the 2nd, 3rd, and 4th. In August 2015, the Veteran presented to the dermatology clinic for an evaluation of a skin rash which had been persisting for many years despite treatment. He reported experiencing the rash on his back, chest, and arms. He denied having any mucosal lesions in the mouth or genital area. The Veteran described the rash as itchy and noted that it worsened with sweating. If he excoriated or picked at the rash, it bled. The steroid cream the Veteran had been using had not helped, and it might have worsened the rash. A waist-up examination revealed a flat, macular rash with a pinkish purple color on the low back, shoulders, and torso. There were no lesions on the oral cavity. The assessment was lichen planus versus other. A punch biopsy was taken from a macule on the left shoulder. An addendum from another VA doctor, Dr. S., noted that he agreed with the assessment and plan. He noted that the assessment was lichen planus versus subacute spongiotic versus psoriasis versus other. The treatment was pending pathology of the biopsy. A September 1, 2015 addendum stated that the Veteran should be informed his rash did appear like lichen planus. The diagnosis was lichenoid dermatitis. Although this disability could be secondary to medication, it is often unknown why it happened. The doctor stated that he was going to send the Veteran an additional topical to use, but did not state what specific medication would be sent. However, a September 1, 2015 pharmacy medication renewal request included diphenhydramine and stated that the medication should be mailed to the Veteran. A subsequent September 3, 2015 active outpatient medication list included diphenhydramine and Clobetasol. Notably, the instructions for diphenhydramine HCL 25 milligram capsule had changed from using every 4 hours as needed to using every 6 hours as needed for pruritus The list also noted betamethasone valerate 0.1 percent cream with directions to apply a thin layer to the specified area(s) twice a day as needed for skin inflammation. Another active medication was urea 20 percent topical cream with directions to apply a thin layer to the specified area(s), specifically callused areas, twice a day to soften skin. The Board notes that topical betamethasone valerate is a corticosteroid. See Betamethasone Valerate (Topical Application Route), Mayo Clinic (July 18, 2018), https://www.mayoclinic.org/drugs-supplements/betamethasone-valerate-topical-application-route/description/drg-20073730. On October 27, 2015, the Veteran returned to the dermatology clinic at VA for a follow up of his rash. He reported experiencing no improvement in itching and eruption despite suing the betamethasone ointment. During the visit, his skin had areas of scarring, scratching on the upper outer arms bilaterally, upper back, chest, and hairline. The assessment was lichenoid dermatitis, non-resolving. The record stated that the Veteran would try a short course of oral steroids (30 milligrams in the first week, 20 milligrams in the second week, and 10 milligrams in the third week. In addition, his steroid cream would be changed to triamcinolone. In December 2015, the active medication list documented diphenhydramine, urea 20 percent topical cream, and triamcinolone acetonide 0.1 percent cream with directions to apply a small amount to the specified area(s), specifically areas of itching, twice a day as needed for a rash. The inactive outpatient medication list included prednisone 20 milligram tablets with instructs to take one and one half tablet (30 milligram) by mouth once every day for 7 days, then take one tabled once every day for 7 days, then take one-half tablet once every day for 7 days for inflammation. A December 15, 2015 VA treatment record also noted under the physical examination of the Veteran’s skin that a chronic rash was present on his arms (lichen planus). However, by February 2016, a VA treatment record stated that the Veteran denied having any rashes. In addition, no lesions were present in the physical examination of the Veteran’s skin. During an April 27, 2016 VA examination of the Veteran’s skin, the examiner stated that the Veteran reported having hypopigmented lesions in his bilateral upper extremities, lower extremities, trunk, back, head, and in the genital region. He also reported that he experienced intermittent flares of pruritus, and his associated excoriations left superficial scars that faded with time. The examination showed multiple small hypopigmented lesions with excoriations in all stages of healing. The genitourinary examination revealed hypopigmented lesions on the glans penis, but none on the scrotum. The papulosquamous disorder affected 5 to 20 percent of the total body area, and less than 5 percent of the exposed area. The examiner marked that the Veteran’s skin condition caused scarring. The scarring was located in the left parietal scalp region and described as excoriated. The area was superficial, stable, well-healed, and non-tender. The examiner also indicated that no disfigurement was present, noting that a disfigurement was not applicable. The examiner noted that the scar measured 10.4 by 0.5 centimeters. A photograph was not taken as the scar was not visible due to the Veteran’s hair. No other findings regarding scars were reported. After reviewing the foregoing evidence, the Board finds that the Veteran should be awarded a 60 percent disability rating from March 22, 2005 to March 27, 2006. Prior to March 28, 2006, the record reflects that the Veteran’s lichen planus required constant or near constant treatment with systemic therapy over at least a 12 month period. The above evidence shows that the Veteran was prescribed a treatment regimen of systemic medication in the form Accutane and Atarax as early as February 2006. Both of these treatments are considered systemic as they are oral medications that affect the body as a whole. See Johnson v. Shulkin, 862 F. 3d 1351, 1355 (Fed. Cir. 2017) (“systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a periarticular surface area, as a topical antiinfective applied to a certain area of the skin and affecting only the area to which it is applied.’) (quoting Dorland’s Illustrated Medical Dictionary, 1865, 1911, 1940 (32d ed. 2012)). Consequently, a 60 percent disability rating is warranted under Diagnostic Code 7822. As previously noted, 60 percent is the maximum available rating under this diagnostic code. From March 28, 2006 to May 28, 2013, the Board does not find that a disability rating in excess of 30 percent is warranted. The March 28, 2006 VA active medication list indicated that he no longer took Accutane or Atarax for his lichen planus, and the subsequent April 2006 record confirmed that the Veteran had been unable to tolerate these treatments. Although the March 2005 VA examiner indicated that some form of light therapy might be appropriate for the Veteran, the record does not show that he received any such therapy during this period. In addition, the Board does not find that the Veteran was treated with any constant or near constant systemic medications over a 12 month period. The Veteran used a topical form of vitamin D on March 28, 2006, an antifungal cream in April 2006, and he was noted to be using hydrocortisone 2.5 percent/pramoxine in August 2006. However, the instructions for these medications stated that they were only to be used as needed and/or applied to specified areas. The hydrocortisone instructions added that the Veteran was meant to apply the lotion sparingly. The fact that the treatment was limited to the affected areas suggests that it was a type of topical therapy that only affected the area to which it was applied. There is no indication from the record that these treatments were administered on a large enough scale to affect the body as a whole. Although the Veteran resumed taking Atarax in October 2006, the record stated that the medication was for his sleep pattern rather than a treatment for lichen planus. By May 2008, the Veteran’s hydrocortisone cream was no longer included in the active outpatient medication list. No other relevant medication was noted until the ammonium lactate 12 percent cream in August 2010. Only a moderate amount was intended to be applied, and there is no evidence to suggest that this cream had a systemic effect on the entire body as a whole. In addition, although the Veteran was prescribed another topical corticosteroid in January 2011, the instructions again stated that only a small amount should be applied to specified areas. For the reasons stated above, the Board does not find that this treatment constituted systemic therapy. In addition, the record does not indicate that this medication was used constantly or near constantly over a 12 month period as the March 2012 VA examiner reported that the Veteran had not used any oral or topical medications, or any other treatments or procedures, in the past 12 months for his skin disability. The Board also finds that the Veteran’s lichen planus did not affect more than 40 percent of his entire body to warrant a 60 percent rating. In April 2006, small, papular, and raised erythematous lesions on the arms, torso, and legs. However, the Board does not find that this report provides sufficient information to conclude that the lesions affected more than 40 percent of the Veteran’s body or exposed areas affected. Later in November 2006, a rash was only noted to be present over his arm; and in August 2007, on areas of his left mid-shin, right ankle, left foot, the deltoid of triceps of the left arm, and scattered lesions in the mid and upper back. The record indicated that excoriations rather than active lesions were present on the base of his scalp. Although different areas of the body were affected, this report also fails to suggest that the affected areas comprised more than 40 percent of the Veteran’s body. By August 2007, no rash was present; and no lesions were observed in November 2009, August 2010, January 2011. The March 2012 VA examiner similarly found that the Veteran’s skin disability affected less than 5 percent of his total body area. In addition, no rash, lesions, or wounds were found in August 2012. The Board acknowledges the Veteran’s May 2014 statement noting that he experiences flares of his lichen planus depending on the weather and his level of outside activity. The Veteran asserted that he has never been symptom free from his lichen planus. However, even after affording the Veteran the benefit of the doubt to find him credible in his contention that his symptoms have been present throughout the appeal period, the findings in the VA treatment records suggest that they did not affect more than 40 percent of the entire body or the exposed areas affected. There are no other findings from this period to indicate that the Veteran’s lichen planus affected the proportion of the body contemplated by a 60 percent rating. From May 29, 2013 to April 26, 2017, the Board finds that the Veteran should be awarded a 60 percent rating. During this period, the Veteran was prescribed an oral antihistamine in the form of diphenhydramine. The diphenhydramine was also consistently included on the active outpatient medication lists in the VA treatment records during this period, suggesting that the Veteran used it on near constant or constant basis over a period of at least 12 months. See VA treatment records dated in July, August, November, and December of 2015; May, June, September, October, November, and December of 2014; January, March, April, and June; July; September; October, and December of 2015; January, February, and April of 2016. The Board notes that on July 13, 2015 diphenhydramine was noted to be an active outpatient medication. However, a July 16, 2015 VA treatment record stated that it had an expired status; and the next record showing a renewal of diphenhydramine was dated on September 1, 2015. Given that the gap in time between these records is less than two months, the Board does not find that the Veteran discontinued his use of diphenhydramine during this period. Similar to the above conclusions concerning Atarax, the Board finds that this oral antihistamine is a type of systemic medication that affects the body as a whole. As such, a 60 percent disability rating is appropriate during this period under Diagnostic Code 7822. On and after April 27, 2016, the Veteran is already in receipt of the maximum available rating for Diagnostic Code 7806 of 60 percent. For each period on appeal, the Board has also considered whether a higher or separate evaluation is warranted for the Veteran’s scars related to his lichen planus disability. However, Diagnostic Code 7806 and 7822 instruct to rate the skin disability under the provided criteria "[o]r rate as disfigurement of the head, face, or neck . . . or scars . . . depending upon the predominant disability." The regulation’s use of the disjunctive establishes that separated ratings are not possible under the criteria for rating dermatitis, disfigurement, and scarring. In addition, a higher rating is not warranted under the criteria for disfigurement or scars. The Board first notes that the evidence does not suggest that the Veteran had any scars that were deep, i.e., associated with soft-tissue damage. See 38 C.F.R. § 4.118, Diagnostic Code 7801, Note 1 (2008). Consequently, the rating criteria under Diagnostic Code 7801 for scars other than the head, face, or neck, that are deep or that cause limited motion, are not for application. Prior to October 23, 2008, Diagnostic Code 7800 rated disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The eight characteristics of disfigurement, for purposes of evaluation under 38 C.F.R. § 4.118, included the following: 1) Scar 5 or more inches (13 or more cm.) in length; 2) Scar at least one-quarter inch (0.6 cm.) wide at widest part, 3) Surface contour of scar elevated or depressed on palpation, 4) Scar adherent to underlying tissue, 5) Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.), 6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.), 7) Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.), and 8) Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Id., Note 2. Additionally, consideration must be given to unretouched color photographs when evaluating under Diagnostic Code 7800. Id., Note 3. Under Diagnostic Code 7800, a 10 percent disability rating was warranted for disfigurement of the head, face, or neck with one characteristic of disfigurement; a 30 percent disability rating was warranted for disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement; a 50 percent disability rating was warranted for disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement; and a maximum schedular 80 percent disability rating was warranted for disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Id. The pre-amended Diagnostic Code 7802 provided that for scars that were superficial, did not cause limited motion, and not located on the head, face, or neck, a 10 percent rating is warranted for an area or areas of 144 square inches (929 square centimeters) or greater. Note (1) provided that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2) stated that a superficial scar is one not associated with underlying soft tissue damage. Under the regulations in effect prior to October 23, 2008, Diagnostic Code 7803 awarded a 10 percent rating for superficial unstable scars. Note (1) to Diagnostic Code 7803 provided that an unstable scar was one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provided that a superficial scar was one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2008). The pre-amended Diagnostic Code 7804 provided a 10 percent rating for superficial scars that were painful on examination. This was the maximum rating provided under the old version of Diagnostic Code 7804. Note (1) provided that a superficial scar was one not associated with underlying soft tissue damage. Note (2) provides that a 10 percent rating was to be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. Diagnostic Code 7804 also directed the rater to see 38 C.F.R. § 4.68 (amputation rule). Id. Diagnostic Code 7805 provided that other scars were to be rated on limitation of function of affected part. Id. Regarding Diagnostic Code 7800, the Board finds that the Veteran did not meet the criteria for even a 50 percent rating during any period on appeal. The Board has considered all the evidence of record, including the photographs associated with the March 2005 VA examination. However, the record does not suggest that the Veteran’s head, face, or neck had any visible or palpable tissue loss and gross distortion or symmetry of any features or paired sets of features. The Veteran’s features in the 2005 photographs appear to be symmetrical, undistorted, and without any visible tissue loss, and the findings from the March 2005, March 2012, and April 2016 VA examinations do not suggest otherwise. In addition, the Veteran did not have four or more characteristics of disfigurement in the head, face, or neck. The only available head, face, or neck scar measurements from the April 2016 VA examination were less than the minimum width and/or length required to be considered a characteristic of disfigurement. Furthermore, the April 2016 VA examiner did not make any findings regarding an elevated or depressed scar contour, an adherent quality of the scar, a texture abnormality, missing soft tissue, indurated and inflexible skin. In addition, although the record contains some findings that the Veteran’s skin was hypopigmented due to his lesions, the record does not indicate that the area exceeded six square inches. Even if the area did have such a measurement, the record has not established the presence of the 3 or more other characteristics of disfigurement that are required for higher ratings. The Board also notes that a rating higher rating is not available under Diagnostic Codes 7803 or 7804 as the maximum allowable rating is 10 percent. The record also fails to suggest that the Veteran’s scars were unstable or painful. In addition, a rating higher than 10 percent is not provided by Diagnostic Code 7802 unless such a rating could be obtained with the combined evaluation of separate qualifying scars. However, the Board does not find that the records contain findings to suggest that the Veteran had multiple areas of superficial scarring that measured at least 144 square inches (929 square centimeters). The records from the periods on appeal mentioned scarring and scratching in the upper outer arms bilaterally, upper back, and chest in October 2015; and the April 2016 VA examiner noted that the Veteran had excoriations related to intermittent flares of pruritus that faded with time. The record did not suggest that the scars were painful. In addition, April 2016 examiner indicated that the current excoriations were in different stages of healing, but he did not suggest that any past scars had become unstable. There is also no indication that any superficial scarring related to excoriations had an area or areas of at least 144 square inches (929 square centimeters). Moreover, neither the Veteran nor the medical evidence have indicated that he experienced any limitation of function during the current appeal period to warrant consideration of Diagnostic Code 7805. As such, the record does not show that the Veteran's scars were of the severity and/or size to warrant a higher rating during any of the periods on appeal under the rating criteria pertaining to scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). In light of the above discussion, the Board finds that a 60 percent rating, but no higher, is warranted from March 22, 2005 to March 27, 2006; a rating higher than 30 percent rating is not warranted from March 28, 2006 to May 28, 2013; a 60 percent rating, but no higher, is warranted from May 29, 2013 to April 26, 2016; and a rating higher than 60 percent is not warranted on after April 27, 2016. Although the Veteran is entitled to the benefit of the doubt where evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to service connection for sleep apnea and a liver disorder, to include as secondary to service-connected depressive disorder and/or bilateral knee tibial plateau stress fracture. Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 247, 431 (2006). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). The Board notes that obesity is not a disease or disability for which service connection may be granted. See VAOPGCPREC 1-2017 (holding the "longstanding policy of [VA], that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis, is consistent with title 38, United States Code" and "[o]besity per se is not a 'disability' for purposes of 38 C.F.R. § 3.310 "). However, service connection may be granted under 38 C.F.R. § 3.310(a) if obesity was an "intermediate step" between a service-connected disability and a current disorder. See VAOPGCPREC 1-2017. In order for secondary service connection to be granted under theory, the record must demonstrate that: (1) the service-connected disability caused the veteran to become obese; (2) the obesity as a result of the service-connected disability was a substantial factor in causing the claimed disorder; and (3) the claimed disorder would not have occurred but for obesity caused by the service-connected disability. In this case, the record has raised the theory that the Veteran’s obesity was an intermediate step between his claimed sleep apnea and liver disorder and his service-connected depressive disorder and/or bilateral knee tibial plateau stress fracture. Regarding the first question of whether a service-connected disability caused the Veteran to become obese, different opinions have been provided to support the theory that the Veteran’s service-connected depressive disorder and pain from his bilateral knee tibial plateau stress fracture caused him to become obese. In April 2013, Dr. N. stated that the Veteran in terms of the Veteran’s service-connected depressive disorder, he was severely depressed with low motivation, anhedonia, and very low energy and inactivity. Dr. N. opined that it was more likely than not that the Veteran’s depression, low energy, poor sleep, and inactivity contributed to his continued weight gain. In a May 2013 statement, Dr. Q. reported that the Veteran was overweight, and observed that this state might be due to a lack of exercise caused by chronic pain. She also noted that the Veteran had a long-standing diagnosis of back pain. The Board notes that the Veteran is not service-connected for a back disorder. See February 2015 rating decision. He is, however, service-connected for a right and left knee tibial plateau stress fracture. The record additionally indicates that since service, the Veteran has experienced difficulty engaging in certain exercises as a result of his bilateral knee pain from the tibial plateau stress fractures. See September 2002 Medical Board. The record also contains evidence to support Dr. N.’s finding that the Veteran’s depressive disorder played a role in causing his obesity. The record reflects that the Veteran was not obese before he experienced problems during service with bilateral tibial plateau stress fractures. When the Veteran enlisted into his period of active duty, his weight of 260 pounds and corresponding body fat percentage was found to be in compliance with Army standards. See Body Fat Content Worksheet dated in March 2002 and May 2002. Close to the time that a September 2002 Medical Board was conducted concerning the Veteran’s bilateral tibial plateau stress fractures, the Veteran’s weight was even lower at 233 pounds. See October 2002 service examination. After service, a January 2003 VA treatment record noted that the Veteran’s weight had been 219.9 pounds in November 2002, 252 pounds in December 2002, and it was 259 pounds at the time of the visit. It was noted that he had chronic bilateral knee pain and walked with the assistance of a cane. In February 2003, his weight had increased to 261 pounds. The Veteran was assessed to be overweight and a diet consultation was recommended. The same record noted that pain was present in both legs. In April 2003, the Veteran received nutrition counseling and reported that his weight had been increasing since he sustained a bilateral knee injury. During a subsequent July 2003 VA examination of the Veteran’s knees, he reported that he tended to walk with a cane. In addition, too much walking led to severe knee pain. The examiner also noted that the Veteran appeared distraught over his chronic pain, and he might want to begin using an antidepressant. At that time, the Veteran’s weight was 234 pounds. During a March 2005 VA examination of the Veteran’s skin, his weight was noted to be 283 pounds, and his documented diagnoses included bilateral knee pain and obesity. During a psychiatric consultation from this date, the Veteran reported that he had depression that was an 8 out of 10, he felt anhedonic and anergic, and he was experiencing an increased appetite with a 15 pound weight gain. The assessment was major depressive disorder that was chronic and moderately severe as well as dysthymia. While undergoing a subsequent September 2007 VA examination related his psychiatric functioning, the Veteran reported experiencing anhedonia and depression since 2002. The examiner noted that the Veteran’s present weight was 298 pounds, his highest weight over the last year. His lowest weight had been 287 pounds. In July 2015, a VA resident note stated that the Veteran had experienced a weight gain of 20 pounds in the past 2 months due to a lack of exercise and dietary indiscretion that was secondary to depression/PTSD. The Veteran continued to take antidepressants. Based on the foregoing, the Board finds that Dr. N.’s opinion identifying depressive disorder as a cause of the Veteran’s obesity is highly probative as it was supported by a rationale that is consistent with the evidence of record. The Board acknowledges that Dr. Q. did not specifically identify the Veteran’s bilateral knee problems as the cause of his obesity in her opinion, and she phrased the opinion with slightly speculative language. However, her opinion indicating that the Veteran’s obesity could be attributable to chronic pain is supported by the records showing that the Veteran gained weight after experiencing pain from bilateral knee problems during service. Consequently, the Board finds that the Veteran became obese as a result of his depressive disorder symptoms and pain associated with his bilateral knee tibial plateau stress fracture. The Board must next determine whether the Veteran’s obesity was a substantial factor in causing his claimed obstructive sleep apnea; and whether the disorder would not have occurred but for the obesity. The record reflects that the Veteran began to report symptoms of the current disorder in 2007. In September 2007, a VA treatment record noted that the Veteran wanted to have a sleep study performed. He felt as though he had an obstruction, could not sleep at night, and felt very tired and asleep during the day. The record noted that he had prominent bilateral tonsilla. The assessment was “obesity with ? sleep apnea.” In June 2008, the Veteran was provided with a sleep study through VA. The test result stated that he had moderate obstructive sleep apnea. Under the options for treatment, the record noted that the importance of weight loss should be discussed if indicated. Another VA treatment record from this month stated that the Veteran’s significantly enlarged tonsils could be contributing to his sleep apnea. In July 2008, a VA treatment record noted that the Veteran had moderate obstructive sleep apnea documented by a sleep study with anatomical obstruction at the level of the nose, palate, and base of tongue. He also had a clinical history that was suspicious for chronic rhinosinusitis, and a flexible fiberoptic laryngoscopy demonstrated bilateral nasal polyposis. The record indicated that operative management might be need for his sinusitis and obstructive sleep apnea under the same anesthesia event. In October 2008, a plan was made to schedule a septoplasty, turbinated reduction, uvulopalatoplasty, tonsillectomy, and radiofrequency to tongue base. A February 2009 VA treatment record later summarized that the Veteran discussed having a septoplasty and inferior turbinate reduction, but he did not want surgery at the base of tongue, palate, or uvula due to apprehension regarding the effect of the procedures on his singing voice. In his April 2013 opinion, Dr. N. also opined that the Veteran’s weight gain could worsen his sleep apnea. In another April 2013 statement submitted on the Veteran’s behalf, Dr. B. noted that sleep apnea is related to weight gain as well as upper airway and nasal passage problems. Although Dr. N.’s opinion addressed the aggravation prong of secondary service connection under 38 C.F.R. § 3.310(b), the Board finds that Dr. B.’s opinion that sleep apnea is related to weight gain addresses 38 C.F.R. § 3.310(a). Dr. B.’s opinion provides great probative value as it was based on his understanding of sleep apnea as a medical professional. The opinion also addresses the theory from the VA treatment records that the Veteran’s enlarged tonsils could be contributing to his sleep apnea. Dr. B.’s opinion indicates that both anatomical factors and obesity play a causative role in the development of sleep apnea. In April 2016, a VA medical opinion was provided in conjunction with an examination of the Veteran’s obstructive sleep apnea. The examiner gave a negative opinion concerning whether the Veteran’s diagnosed obstructive sleep apnea was caused or aggravated by any of his service-connected disabilities, to include depressive disorder, lichen planus, and bilateral knee tibial plateau stress fracture. The examiner explained that a review of the medical records revealed that there was insufficient evidence to establish a nexus between the sleep apnea and service-connected disabilities. The examiner also noted that the examination and the Veteran’s medical records suggested that his obstructive sleep apnea was of moderate severity, indicating that the Veteran’s sleep apnea had not been increased due to his service-connected disabilities. There was insufficient evidence to confirm aggravation to his service-connected disabilities. The examiner also stated that statistics showed that obstructive sleep apnea was more common in males, smokes, overweight or obese persons, and those with narrowed oropharynx and large neck habitus. The Board finds that this opinion has minimal probative value as the examiner did not address the relevant questions concerning whether obesity was an intermediate step between the claimed sleep apnea and any service-connected disability. Moreover, the examiner’s observation regarding the prevalence of sleep apnea in obese individuals only supports Dr. B.’s opinion. In light of the above evidence, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran’s obesity was a substantial factor in causing the obstructive sleep apnea, and the sleep apnea would not have occurred but for the obesity. As such, the necessary factors for the Veteran’s obesity to be considered an intermediate step between his obstructive sleep apnea and his service-connected depressive disorder and bilateral knee tibial plateau stress fracture have been satisfied. Consequently, entitlement to service connection for sleep apnea is granted as secondary to the service-connected depressive disorder and bilateral knee tibial plateau stress fracture. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. REASONS FOR REMAND 1. Entitlement to service connection for a liver disorder, to include as secondary to service-connected depressive disorder, right and left knee tibial plateau stress fracture, and/or lichen planus, is remanded. The record reflects that the Veteran was provided with a VA examination concerning his service connection claim for a liver disorder in August 2007. The examiner noted that the Veteran had abnormal liver function tests, abnormal liver enzymes, and that a recent liver biopsy had been consistent with fatty liver. However, the Board notes that these results are laboratory findings. A laboratory finding is an indication of an injury or disease which could result in disability, rather than a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440; 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). However, a previous March 2006 VA liver MRI noted in the impression that the Veteran had abnormal liver function tests and stated that he likely had nonalcoholic fatty liver disease. It is unclear from the July 2008 VA examination or the other evidence of record whether the Veteran ever received a conclusive diagnosis for this disorder. The August 2007 VA examiner also noted that the Veteran had no recent evaluation of his liver enzymes, but apparently did not conduct any such evaluation during the examination. Thus, it is unclear whether the examiner exhausted reasonable efforts of further testing and research that could lead to a more definite opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). The Board consequently finds that the Veteran should be provided with an additional VA examination upon remand to determine if any liver disorder is present. In addition, the Veteran has asserted that his liver disorder is secondary to his obesity caused by service-connected disabilities. See April 2018 Board Hearing Transcript, page 6. As the negative opinion provided by the July 2008 VA examiner did not address this theory, it should be considered in a medical opinion for any liver disorder that is diagnosed upon remand. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected depressive disorder, right and left knee tibial plateau stress fracture, and/or lichen planus, is remanded. Regarding the Veteran’s service connection claim for erectile dysfunction, the Veteran has not yet been afforded a VA examination. The record indicates that the Veteran currently has erectile dysfunction as the Veteran stated that his doctor tried to prescribe him Viagra as he knew the Veteran had the disorder. See April 2018 Board Hearing Transcript, page 7. The Veteran is competent to relay what a doctor has told him. See Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran has asserted that his erectile dysfunction is secondary to his service-connected lichen planus depressive disorder, and orthopedic disabilities, to include the medications used to treat the disabilities. See August 2006 Notice of Disagreement; April 2018 Board Hearing Transcript, page 6. He indicated that this disorder was related to the drowsiness he experienced from the medications. In light of this evidence, the Board finds that a VA examination and medical opinion must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that when the medical evidence is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his liver disorder and erectile dysfunction. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the VA Central California Health Care System dated since May 2016. 2. After the preceding development in paragraph 1 is completed, schedule a VA examination to determine the nature and etiology of any liver disorder that may be present. Any and all studies, tests, and evaluations deemed necessary should be performed. The examiner should review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. First, the examiner should clearly identify all current liver disorders. In identifying the current diagnoses, the examiner should address the impression from a March 2006 VA liver MRI that the Veteran had abnormal liver function tests and likely had nonalcoholic fatty liver disease. For the each identified disorder, the examiner should opine as to the following questions: (a) Whether it is at least as likely as not (50 percent probability or more) that the disorder was either caused by or aggravated by any of the following service-connected disabilities, to include medications used to treat the disabilities: (1) his service-connected depressive disorder; (2) his service-connected bilateral knee tibial plateau stress fracture; and/or (3) his service-connected lichen planus. (b) In addition, the examiner should address whether the Veteran’s obesity was a substantial factor in causing the disorder. If so, the examiner should provide an opinion as to whether the disorder would not have occurred but for the obesity. 3. After the preceding development in paragraph 1 is completed, schedule a VA examination in relation to the Veteran’s service connection claim for erectile dysfunction. Any and all studies, tests, and evaluations deemed necessary should be performed. The examiner should review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether the Veteran currently has erectile dysfunction. If so, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (50 percent probability or more) that the disorder was either caused by or aggravated by any of the following service-connected disabilities, to include medications used to treat the disabilities: (1) his service-connected depressive disorder; (2) his service-connected bilateral knee tibial plateau stress fracture; and/or (3) his service-connected lichen planus. (b) In addition, the examiner should address whether the Veteran’s obesity was a substantial factor in causing the disorder. If so, the examiner should provide an opinion as to whether the disorder would not have occurred but for the obesity. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel