Citation Nr: 20002232 Decision Date: 01/10/20 Archive Date: 01/09/20 DOCKET NO. 19-09 014 DATE: January 10, 2020 ORDER A compensable rating for right hand residuals of cellulitis and erysipelas is denied. VETERAN’S CONTENTIONS The Veteran contends that he is entitled to an increased, compensable rating for a service-connected right hand disability because his right “hand bothers [him] daily” and because he is “very handicap[p]ed” due to his disability. He further contends that a higher rating is warranted based on recurrent infections and symptoms including pain, numbness, and limited motion. FINDING OF FACT The Veteran does not have current residuals of his service-connected right hand cellulitis and erysipelas, and his current right hand signs and symptoms are not related to the service-connected residuals of cellulitis and erysipelas. CONCLUSION OF LAW The criteria for a compensable rating for right hand residuals of cellulitis and erysipelas are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7820. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1945 to July 1946. This matter is before the Board following his appeal of a February 2018 rating decision. The Board previously remanded this matter in May 2019 for a new examination, which was provided in October 2019. The Veteran seeks a compensable rating for his service-connected right hand disability. Unfortunately, following a review of the record, the Board finds that a higher rating is not warranted at any time throughout the pendency of the appeal. In this regard, VA examiners in June 2009, January 2011, June 2013, and August 2019 found that the Veteran does not have residuals of the service-related erysipelas or cellulitis, and that his current right hand issues are related to other nonservice-connected causes, including arthritis, aging, hemochromatosis, and/or chronic venous insufficiency. Specifically, the June 2009 VA examiner assessed chronic dermatitis that was diagnosed after and not related to service, and noted that erysipelas is an infection that is usually treated with antibiotics and clears, and is self-limited. The VA examiner also noted that the Veteran’s range of motion problems were due to arthritis related to hemochromatosis. In January 2011, a different VA examiner observed the Veteran’s skin and orthopedic issues affecting his right hand. The examiner also noted his history of skin grafting on the dorsum of the right hand for chronic hyperkeratosis, acanthosis, and chronic inflammation; history of lichen planus; and hemochromatosis with secondary moderately-severe osteoarthritis. However, the examiner explained that osteoarthritis has “absolutely nothing to do with an erysipelas infection,” and that there was “no current objective medical evidence” that the Veteran’s “current symptomatology of the right hand is due to erysipelas.” Then, in June 2013, following another VA examination, a third examiner opined that, while the Veteran was diagnosed with erysipelas while on active duty, it was an acute event that was treated and resolved without residuals. He further described in detail the conditions of erysipelas and cellulitis, and found that the Veteran’s more recent episodes of cellulitis had no association with the erysipelas many years ago. In an addendum, the June 2013 examiner opined that it was also less likely than not that the Veteran’s right thumb condition of suspected calcium pyrophosphate deposition disease (CPPD) secondary to hemochromatosis, lichen planus, and chronic dermatitis had their onset during military service. He noted, with detailed explanation, that it was possible that the symptoms the Veteran believed to be related to recurrent cellulitis were actually manifestations of chronic joint disease from CPPD, with flare ups. Similarly, in August 2019, a fourth VA examiner described the Veteran’s current skin and orthopedic right hand symptoms, but found that there was “no residual of [in service] erysipelas or cellulitis.” Instead, he opined that the Veteran’s current skin condition of symmetrical stasis dermatitis (inflammation of the skin of the lower legs) was caused by venous insufficiency. He noted that stasis dermatitis and erysipelas/cellulitis were unrelated conditions, with the former being caused by chronic venous insufficiency, and the latter being infectious in nature, and cured by antibiotic. The examiner also noted that some skin findings are age-related, noting that aging skin is thin, and bruises and tears easily. Regarding orthopedic symptoms affecting the right hand, the examiner found that the Veteran had poorly functioning hands due to debilitating and severe symmetrical arthritis of the hands secondary to hemochromatosis. The foregoing evidence overwhelming indicates that the Veteran does not have current residuals of his service-connected residuals of cellulitis and erysipelas, and that his current right hand signs and symptoms are related to other nonservice-connected causes. Indeed, the clinical evidence also shows additional diagnoses related to the right hand including carpal tunnel syndrome, peripheral venous insufficiency, neuropathy, and chondrocalcinosis due to pyrophosphate crystals involving the hands. The Board is cognizant that in December 2018, an examiner found current diagnoses to include eczema, noted as diagnosed in 2018, and erysipelas and cellulitis, both noted as diagnosed on December 19, 2018, the date of the examination. The examiner further noted a change in diagnosis from erysipelas/cellulitis “to a progression of eczema,” and treatment of the Veteran’s condition to be constant or near constant use of corticosteroids or immunosuppressives. She also found that the Veteran’s skin disability impacted his ability to work due to loss of fine motor skills “due to numbness as well as infectious process.” However, the examiner expressly noted that she did not review any records in connection with the examination, and she did not support her conclusions with any rationale. In this regard, she did not support the current diagnoses offered with the results of any diagnostic testing, such as blood testing, skin biopsies, or any other tests indicative of an infectious process. Neither did she explain the change in diagnosis based on her finding that eczema was a progression of cellulitis/erysipelas. Such an explanation is particularly necessary here, as prior examiners have noted erysipelas to be an acute and self-limiting condition that resolves with antibiotics, and have found the Veteran’s current symptoms to be unrelated to his service-connected erysipelas or cellulitis. Given the foregoing, the Board finds the December 2018 examination to be inadequate and not probative of the severity of the Veteran’s service-connected right hand disability. The Board similarly finds no probative value in references to erysipelas in the VA treatment notes, such as in October 2012, October 2015, and April 2016, as they appear to be based on the Veteran’s self-reported history. In this regard, in October 2012, when the Veteran was diagnosed with possible cellulitis, he reported that he had been started on antibiotics by a private physician and it was noted that “[t]hey said it was erysipelas as well.” Then, in October 2015, a VA provider noted the Veteran’s history of a skin graft “done many yrs ago secondary to erysipelas (per pt).” However, VA examiners have addressed the 2012 treatment for possible or presumed cellulitis, as well as the history of skin grafts, and found based on a review of records that they were unrelated to his service-connected cellulitis and erysipelas. To the extent that a private physician indicated in a March 2018 statement that the Veteran had experienced chronic infections affecting his right hand since the 1940s and “still ha[d] problems with his hands going back a number of years…” the Board again finds the statement to be of no probative value as to the severity of the Veteran’s service-connected disability. In this regard, the physician, himself, attributed no right hand symptoms, complaints, or disability to the Veteran’s service or service-connected disability, but rather recorded the Veteran’s belief that his right hand symptoms and recurrent infections were due to service. There is also no indication that the examiner was aware of or reviewed the Veteran’s medical history or treatment records. In contrast, the Board finds the opinions of the four other VA examiners to carry great probative weight, as they are internally consistent, cumulatively supported by detailed rationale, and based on review of the Veteran’s medical records and history with reference to relevant clinical evidence. Significantly, those examinations, including two dated in August 2019, after the March 2018 statement and December 2018 examination, show that the Veteran does not have any current residuals of his service-connected right hand erysipelas and cellulitis to warrant compensable rating. In sum, the Board finds that the Veteran is not entitled to a compensable rating as his current right hand signs and symptoms, including pain, limited motion, numbness, and skin problems are not (1) residuals of erysipelas, or (2) symptoms of a disability otherwise related to service-connected erysipelas. Because the Veteran’s current right hand disability is attributable to nonservice-connected causes – including hemochromatosis, CPPD, arthritis, and chronic venous insufficiency, among others – the Board must not attribute their effects to his service-connected cellulitis and erysipelas. Cf. Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service-connected condition from a non-service-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt on any issue be resolved in the Veteran’s favor, and that such signs and symptoms be attributed to the service-connected condition). As such, the Board finds that a compensable rating for service-connected residuals of erysipelas and cellulitis is not warranted. The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 49 (1990). S. C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Fagan The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.