Citation Nr: 20021909 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 16-15 040 DATE: March 27, 2020 ORDER Entitlement to an initial evaluation in excess of 30 percent for hidradenitis suppurativa with residual scarring is denied. FINDING OF FACT The Veteran’s hidradenitis suppurativa with residual scarring is manifested by total affected area less than 929 square centimeters consisting less than 40 percent of the total body area or exposed area and required topical treatment by corticosteroids or retinoids and by antibiotics. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for hidradenitis suppurativa, other than pseudofolliculitis barbae and scalp abscesses with residual scarring, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7820 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1978 to June 1982. The Board previously remanded the issue for further development in March 2018. The case has now been returned to the Board for appellate review. It is noted that the Veteran has a separate 60 percent rating assigned for pseudofolliculitis barbae of the scalp with residuals scarring that is not otherwise at issue in this appeal. Entitlement to an initial evaluation in excess of 30 percent for hidradenitis suppurativa with residual scarring. Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The Veteran seeks entitlement to an initial rating in excess of 30 percent for hidradenitis suppurativa. The applicable rating period is from April 15, 2011, the effective date for the award of service connection for that disability, as determined in the March 2018 Board decision, through the present. See 38 C.F.R. § 3.400. The Veteran’s service-connected hidradenitis suppurativa is rated under 38 C.F.R. § 4.118, Diagnostic Code 7820-7804. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. See 38 C.F.R. § 4.27. The Board notes that the Veteran is also service-connected for pseudofolliculitis barbae and scalp abscesses with residual scarring, evaluated at a 60 percent disabling under Diagnostic Code 7800-7820. Therefore, the Board considers the disability picture for hidradenitis suppurative, not evaluated by pseudofolliculitis barbae and scalp abscesses with residual scarring. 38 C.F.R. § 4.14. VA published a final rule amending its regulations on skin disabilities, effective August 13, 2018. The amendment, in pertinent part, added a General Rating Formula for the Skin for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended Diagnostic Codes 7801,7802,7817,7819,7825, 7826, 7827,7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Claims pending prior to the effective date are to be considered under both old and new rating criteria, and whichever criteria are more favorable to the Veteran will be applied. Under the rating criteria prior to August 13, 2018, Diagnostic Code 7820 pertained to infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal and parasitic diseases), to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7820 (2017). Under the scar regulations in effect prior to and since August 13, 2018, Diagnostic Code 7800 provides ratings for scars of the head, face, and neck. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar 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 warrants a 30 percent rating. A scar 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 warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion 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 warrants an 80 percent rating. 38 C.F.R. § 4.118 (2018). Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. Under the scar regulations in effect prior to August 13, 2018, Diagnostic Code 7801 provided ratings for scars, other than the head, face, or neck, that were deep or that caused limited motion. Scars that were deep or that caused limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) were rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) were rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) were rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) were rated as 40 percent disabling. Note (1) to Diagnostic Code 7801 provided that a deep scar was one associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2017). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are associated with underlying soft tissue damage. Scars that are associated with underlying soft tissue damage in an area or areas exceeding 6 square inches (39 sq. cm.) are rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated as 40 percent disabling. 38 C.F.R. § 4.118 (2018). Under the scar regulations in effect prior to August 13, 2018, Diagnostic Code 7802 provided ratings for scars, other than the head, face, or neck, that were superficial or that did not cause limited motion. Superficial scars that did not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, were rated as 10 percent disabling. Note (1) to Diagnostic Code 7802 provided that a superficial scar was one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2017). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are not associated with underlying soft tissue damage. A scar that is not associated with underlying soft tissue damage in an area or areas of 144 square inches (929 sq. cm.) or greater is rated as 10 percent disabling. 38 C.F.R. § 4.118 (2018). Under the scar regulations in effect prior to August 13, 2018, Diagnostic Code 7804 provided a 10 percent rating for superficial unstable scars. Diagnostic Code 7804 provided that one or two scars that were unstable or painful were rated as 10 percent disabling. Three or more scars that were unstable or painful were rated as 20 percent disabling. Five or more scars that were unstable or painful were rated as 30 percent disabling. Note (1) to Diagnostic Code 7804 provided that an unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118 (2017). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7804 provides a 10 percent rating for a scar that is unstable or painful. Diagnostic Code 7804 provided that one or two scars that are unstable or painful are rated as 10 percent disabling. Three or more scars that are unstable or painful are rated as 20 percent disabling. Five or more scars that are unstable or painful are rated as 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118 (2018). Under the scar regulations in effect prior to August 13, 2018, Diagnostic Code 7805 provided that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118 (2017). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7805 provides that any other scars and other disabling effects of scars should be evaluated even if not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118 (2018). Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Under the new regulations, effective August 2018, Diagnostic Code 7820 is rated under a General Rating Formula for Skin, under which a 10 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating will be assigned if the disability meets at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Alternatively, the disability can be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7820 (2018). Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118 (a). Turning to the medical record, at an August 2011 VA scar examination, the Veteran was found to have hidradenitis suppurativa, abscesses of his scalp, and pseudofolliculitis barbae. The Veteran had 12 scars at the examination, identified as Scar A through Scar L. Scar A is located in the area of left groin. Scar B is located in the right axilla. Scar C is located in the left axilla. Scar D is located in the right inguinal area. Scars E, F, G, H, I, J, and K are all located on the Veteran’s scalp, and Scar L is a scar resulting from pseudofolliculitis barbae. Since the Veteran’s scalp abscesses and pseudofolliculitis barbae are considered under a separate rating, the Board focuses on Scars A, B, C, and D for determining the rating on appeal. The measurements of the scars are as follows: Scar A with 20 cm x 3 cm; Scar B with 10 cm x 1 cm; Scar C with 14 cm x 14 cm, and Scar D with 6 cm x 3 cm, with total scar area of 284 square centimeters. The examiner noted that none of the scars were painful to examination. There was skin breakdown as well as drainage to Scar D in the right inguinal area. Scars A and D were superficial, and Scars B and C were deep. There was no limitation of range of motion caused by any of the scars. Inflammation was noted to Scar D in the right. Scars B and D had adherence to underlying soft tissue. Surface contour of Scars A, B, C, and D are raised. Scars A, B, C, and D have abnormal skin texture. Coloration of Scar A was a combination of both hyperpigmentation and hypopigmentation. Scar B, C, and D were hyperpigmented. The skin to Scar B and C was inflexible and indurated. There was no underlying soft tissue loss to any of the scars. At an August 2011 VA skin diseases examination, the Veteran was diagnosed with hidradenitis suppurativa, categorized as an infectious skins condition, scalp abscesses, and pseudofolliculitis barbae. The examiner noted that his skin conditions were treated with more than 6 weeks or more, but not constant use of minocycline, an oral medication and tretinoin cream, a topical medication. The Veteran did not have other treatment or procedure in the past 12 months for exfoliative dermatitis or papulosquamous disorders. However, the examiner noted that the Veteran had history of multiple I & D procedures for hidradenitis suppurative, most recently 4 years ago, lasting less than 6 weeks in duration. The infection of the skin was noted to cover 5 to 20 percent of both the total body area and exposed area. A December 2011 VA treatment record indicates that the Veteran’s long-standing open wound in the axillary and right groin area from hidradenitis was drained, and an oral medication of doxycycline was stated. During the followup visit in the same month, the Veteran presented with chronic draining lesions in the right inguinal region and left hemi-scrotum. The clinician noted that both axillae had had surgical extirpation and were now disease-free, but still had chronic draining sinuses in the right groin and left hemiscrotum. The right groin was noted to have surgical I&D scars that had never healed and remained open with persistent drainage. He had been on multiple courses of antibiotics. In March 2012, the Veteran underwent right groin excision of hidradenitis. The Veteran was instructed to remove the packing a day after the excision and then take showers regularly like normal, and then cover the wound with a dry gauze after cleaning or shower twice daily. He was to be seen in the clinic weekly until good wound healing. It was noted that the left hemiscrotal area had healed. An April 2012 VA treatment record reports that the right groin wound was granulating nicely with only a superficial wound opening. The clinician noted that since he had already had the axillary disease excised, the only remaining area of intermittent minor drainage was in his right upper inner thigh area. He was prescribed for Bactrim for 12 days. He was to return to the clinic as necessary only for recurrent infection or discharge. A May 2012 VA treatment record indicates that the scars from hidradenitis excision were well healed. An October 2012 VA skin diseases examination reflects a diagnosis of hidradenitis suppurativa and pseudofolliculitis barbae and evaluated the Veteran’s pseudofolliculitis barbae and scalp abscesses. Pertinent to hidradenitis, it was noted that the Veteran took doxycycline for 6 weeks or more, but not constantly in the past 12 months for his hidradenitis and clobetasol for scalp. It also noted that he took clindamycin for pseudofolliculitis barbae and hidradenitis for 6 weeks or more, but not constant. A January 2013 VA skin diseases examination noted constant or new constant use of clobetasol for scalp and a chronic constant use of a topical medication treatment for hidradenitis suppurativa on active left scrotal drainage, though the name of the medication was not ascertained. The examiner noted that hidradenitis suppurativa was active in the left scrotal drainage, consisting of less than 5 percent of the total body area with no exposed area. Due to recent surgeries, the diagnosis was modified to hidradenitis suppurativa with surgical removal of sweat glands and residual scarring. A January 2013 VA scars examination noted scars in bilateral axilla due to hidradenitis suppurativa. The scar in the right axilla was linear with the size 10 cm x 4 cm, and the scar in the left also linear with size 16 cm x 1 cm. Functional impact notes was that draining groin lesion compromised opportunity or ability to have sexual relations. The examiner noted that the measurements for chronic active left scrotal drainage were not taken. A September 2013 VA treatment record indicates that the Veteran had a sore in his groin which started draining yellow-blood-streaked pus intermittently. He noted that he resumed taking doxycycline upon receiving it in the mail and that made the sore look smaller than it had been. Triamcinolone ointment was prescribed upon the Veteran’s request. He was taking doxycycline and Bactroban to open sores. Prednisone was prescribed as well. An August 2014 VA treatment record indicates that the Veteran received intralesional Kenalog (ILK) in the left inguinal region with active cyst and minocycline was started. A February 2015 VA treatment record indicates that the Veteran reported a flare of sores in the left inguinal area. He received ILK in the left inguinal area and Bactrim for 7 days was prescribed. An August 2016 VA treatment record indicates that the Veteran had ILK for 2 lesions in the left groin area. A January 2017 VA treatment record indicates that he had ILK for 1 lesion in the left groin area. A February 2017 VA treatment record reflects that the Veteran sought emergency care for focal abscess in the left thigh and drainage from left groin. He was given doxycycline. A July 2017 VA treatment record indicates that the Veteran complained about a single painful cystic boil in the left groin fold. He received ILK for the lesion. A January 2018 VA treatment record indicates that the Veteran received ILK for the recurrent abscess in the left thigh. A March 2018 VA treatment record indicates that the clinician commented that the use of mild to moderately immunosuppressives or TNF alpha inhibitors would not be wise given the comorbidities. Intralesional triamcinolone, using clindamycin swabs daily to groin and triamcinolone cream to the groin every other day was recommended. Surgical debulking or the use of injectable Humira therapy in the future was suggested. A January 2019 VA scars/disfigurement examination reports that the Veteran has a tender scar in the inguinal/groin area, but the scar was not unstable or had frequent loss of covering of skin over the scar. The scar in the right axilla measured 16 cm x 2 cm, and the scar in the left axilla measured 13.5 cm x 16 cm. There was a 13 cm x 9 cm stable nontender hyperpigmented scar from a previous skin graft procedure in the anterolateral aspect of the left thigh. There was a 10 cm x 4.5 cm stable non tender hyperpigmented scar from a previous skin graft procedure in the anterolateral aspect of the left thigh, lateral and inferior to the above scar. There were diffuse scars of the groin/inguinal area with 11 cm x 3 cm on the right and 11 cm x 3 cm on the left. Both scars were tender to palpation. In summary, the examiner provided that the scar in the right upper extremity had approximately 32 square centimeters; the scar in the left upper extremity had approximately 216 square centimeters; the scar in the left lower extremity had approximately 162 square centimeters; and the scar in the anterior trunk had approximately 66 square centimeter. All scars were without underlying tissue damage. The current medications included clobetasol ointment twice a day, hydrocortisone cream twice a day (for groin when cysts are active), mupirocin ointment twice a day (as needed for open sore), tretinoin cream at bedtime (to hair bumps), and clindamycin swab, twice a day (to cystic lesions as directed). The examiner stated that his scars were stable and not actively draining. A November 2019 VA treatment record indicates that he complained about right axillary abscesses. An I&D procedure was conducted. Bactrim and Naprosyn were prescribed. The Veteran was instructed to remove the packing the next day. In a followup visit in the same month, prescription for clindamycin, minocycline, and doxycycline, tretinoin, and hydrocortisone creams was stopped. First, the Board notes that a rating in excess of 30 percent is not available under Diagnostic Codes 7802, 7804 both before August 2018 and after August 2018. The Board notes that for the entire appeal period, the Veteran’s scars associated with hidradenitis suppurativa (not covered under pseudofolliculitis barbae and scalp abscesses) are not located in the head, face, or neck. Thus, Diagnostic Code 7800 is not applicable for the disability at issue for the entire appeal period. The medical evidence demonstrates that in August 2011, the Veteran had deep scars of total area 206 square centimeters in August 2011 and scars of total area 477 square centimeters in January 2019, less than 929 square centimeters required for a rating of 40 percent under Diagnostic Code 7801 both prior to and after August 2018. The scars were not associated with underlying soft tissue damages. The Board now considers pre-August 2018 Diagnostic Code 7806 and post-August 2018 Diagnostic Code 7820, rated under a General Rating Formula for Skin. The Board finds that for the entire appeal period, the Veteran’s skin disability has not affected more than 40 percent of the entire body or more than 40 percent of exposed areas affected and that the Veteran’s characteristic lesions for the disability at issue on this appeal did not involve more than 40 percent of the entire body or more than 40 percent of exposed areas affected. Moreover, the medical evidence shows that for the entire appeal period, the treatment for the Veteran’s skin condition at issue did not involve constant or near-constant systemic therapy such as corticosteroids, phototherapy, retinoids, biologics, or photochemotherapy, PUVA or other immunosuppressive drugs in any 12-month period. Indeed, the Veteran’s regular treatment consisted of application of topical creams such as hydrocortisone. During the period when he was treated for active lesions and abscesses and after excision of abscesses, the record indicates that he took antibiotics, primarily doxycycline or Bactrim. For the period between August 2014 and January 2018, the medical evidence shows that he received ILK injection, a topical therapy, in the groin area every 6 months. In March 2018, a treatment consisting of application of intralesional triamcinolone (corticosteroid) applied every other day by a swab topically to the active lesion in the left groin was started, while the clinician noted that the use of mild to moderately immunosuppressives would not be wise given the comorbidities. Surgical debulking or the use of injectable Humira therapy in the future was suggested. However, medical records subsequent to this visit do not indicate that injectable Humira therapy was initiated. Based on the above, the Board finds that for the entire appeal period, the Veteran’s treatment consisted of topical application of drugs intended to impact the affected skin area and antibiotics to suppress bacterial infection. Antibiotics are not classified as corticosteroid or other immunosuppressive drugs. See, e.g., Antibiotics, Medline Plus, https://medlineplus.gov/antibiotics.html; Steroids, Medline Plus, https://medlineplus.gov/steroids.html. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim of a rating in excess of 30 percent for hidradenitis suppurativa, other than pseudofolliculitis barbae and scalp abscesses with residual scarring, at any time during the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board has also considered whether the Veteran is entitled to an extraschedular rating for hidradenitis suppurativa, not covered by pseudofolliculitis barbae and scalp abscesses. To determine whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. 38 C.F.R. § 3.321 (b)(1) (2017); Thun v. Peake, 22 Vet. App. 111 (2008). The evidence demonstrates that although he underwent excision procedures during the appeal period, no hospitalization due to his skin disability resulted and that functional impairment to daily life is difficulty in sexual relationships and discomfort in “moving around too much.” See, e.g., September 2017 Board Hearing Transcript. As the Veteran’s difficulty in sexual relationships or discomfort when moving is not contemplated by the diagnostic criteria, the Board finds these symptoms meets the first element of Thun. However, the evidence does not show that there are other indicia of an exceptional disability picture. For example, the evidence associated with the Veteran’s claims file does not document hospitalization for the skin disability. Nor has the Veteran stated that his skin disability interferes with his employment by causing him to miss work or quit his employment. The Veteran is in receipt of Social Security benefits due to his bladder and bowel problems. See October 2007 Social Security Administration Disability Report. Accordingly, the Veteran’s above-mentioned symptoms do not rise to the level of marked interference with employment and does not create an exceptional disability picture. Thus, the second element of Thun is not met. Thus, referral for an extraschedular rating for hidradenitis suppurativa is not warranted. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, Associate Counsel 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.