Citation Nr: 20043714 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 15-26 013 DATE: June 29, 2020 ORDER 1. Entitlement to service connection for a skin disability, to include onychomycosis dermatophytosis and candida albicans, is denied. REMANDED 2. Entitlement to service connection for a stomach disorder is remanded. FINDING OF FACT A current chronic skin disability, to include onychomycosis dermatophytosis and candida albicans, was not manifested during the Veteran’s service, and there is no competent probative evidence that such disability may be related to his service or the acute skin complaints that were treated and resolved therein, or to have been caused or aggravated by a service-connected disability. CONCLUSION OF LAW Service connection for a skin disability, to include onychomycosis dermatophytosis and candida albicans, is not warranted. 38 U.S.C. § § 1110, 1131, 5107(b); 38 C.F.R. § §§ 3.102, 3.303, 3.304 REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from September 1972 to March 1982. These matters are before the Board of Veterans’ Appeals (Board) on appeal of an April 2014 Department of Veterans Affairs (VA) rating decision. In August 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In March 2019, the Board remanded these matters for further development and remanded the matter of entitlement to service connection for swelling of both feet for issuance of a statement of the case (SOC). [A SOC addressing service connection for swelling of the feet was issued on April 16, 2020. On June 5, 2020, VA received a (timely) VA Form 9 on the matter requesting a Board videoconference hearing. Accordingly, the matter of service connection for swelling of the feet is not before the Board at this time; it will be decided by the Veterans Law Judge who conducts the hearing in the matter.] Additional evidence (VA outpatient treatment records was received in the record subsequent to the April 2019 supplemental SOC. The records do not contain information material to the claim of service connection for a skin disability (they show the current diagnoses of the claimed skin disability but do not discuss etiology, and are cumulative, but not new, evidence). Therefore, waiver of Agency of Original Jurisdiction (AOJ) initial consideration of the evidence (or return of the record to the AOJ for that purpose) is not required. 1. Entitlement to service connection for a skin disability is denied. Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the disease or injury in service and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Secondary service connection is warranted for a disability which is caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. To substantiate a claim of secondary service connection there must be evidence of: (1) a disability for which service connection is sought; (2) a disability that is already service connected; and (3) the already service connected disability caused or aggravated the disability for which service connection is sought. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). The determination as to whether these requirements are met is based on analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran’s service treatment records (STRs) show that in May 1974 he was seen for complaints of a rash on his neck; neurodermatitis was assessed. In July 1978, May 1979, August 1979, February 1980, he was seen for complaints of a groin rash. On retention examination (conducted in August 1980 with the nest one due in 1985), his skin, feet, and genitourinary system were normal on clinical examination. In a corresponding report of medical history, he denied having skin disease, venereal disease or foot problems. His STRs are silent for complaints, findings, treatment, or diagnosis pertaining to onychomycosis/a foot skin disability. The STRs do not include a service separation examination report. His service personnel records include a document indicating that at separation he was found physically qualified for re-enlistment in the next 3 months). In the instant claim seeking service connection for a skin disability, the Veteran identified the disability as a “serious body rash” that began while he was serving at Camp Casey, Korea, in 1974. In January 2014 he was asked to submit (or identify and authorize VA to obtain on his behalf) any records of postservice private treatment he has received for a skin disability (and other disabilities for which service connection was sought). He did not respond to the request (and it is assumed that no such private records exist, or that any existing do not support the claim). A May 2014 VA treatment record notes an assessment of dermatophytosis. At a September 2014 DRO hearing, the Veteran identified the skin disorder (claimed as “jungle rot” as a “body rash”. At the August 2018 Board hearing, the Veteran testified his groin rash has come and gone since his separation from service. On October 2019 VA skin diseases examination (received pursuant to the March 2019 Board remand), onychomycosis dermatophytosis of his toenails and candida albicans of the groin were diagnosed. The Veteran reported the groin rash was manifested in service, that he received a diagnosis of diabetes in 2000 (and has been on insulin for 3 to 4 years, during which time the groin rash seemed to improve). He also reported that his onychomycosis of the toenails of both feet worsened following his separation from service, and that he uses over-the-counter medication to treat his feet when the condition flared up. The examiner opined that the onychomycosis dermatophytosis and candida albicans were less likely related to service. The examiner explained that the groin rash during service was more likely than not caused by sexual promiscuity, as evidenced by repeat complaints of groin skin complications after sexual encounters, lab testing, and the medication prescribed [and thus were acute, and resolved with the then treatment], and that there are no medical record supporting the allegation of ongoing groin skin rashes since service. The examiner further explained that the current candida albicans of the groin is secondary to/a complication of the Veteran’s diabetes mellitus [which is not service connected]. Additionally, the examiner explained that there were no active duty STRs supporting that the Veteran had onychomycosis during service, and that he reported that the condition started following service with an Athlete’s foot infection. At the outset, the Board finds there has been substantial compliance with its March 2019 remand directives pertaining to the matter of the skin disability (the examiner provided adequate explanation for the [negative] opinion provided, i.e., indicating that the currently diagnosed skin disabilities are unrelated to skin complaints that were manifested and treated in service). See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). It is not in dispute that the Veteran has current chronic skin disabilities (first diagnosed decades following his separation from active duty service), currently diagnosed as onychomycosis of toenails and candida albicans of groin. The record also shows he was seen for various skin complaints (as noted above) during service. Accordingly the critical question remaining is whether there is competent evidence of a nexus between his service and current onychomycosis dermatophytosis and candida albicans. The etiology of the current diagnosed chronic skin disabilities (absent, as here, clinical evidence of manifestation in service and continuing presence since) is a medical question, it requires competent medical evidence). See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir.2007). The only competent (medical) evidence in the record regarding a nexus between the Veteran’s current onychomycosis dermatophytosis and candida albicans and his service is in the opinion of the October 2019 VA examiner. The examiner clearly opined that the Veteran’s current candida albicans of the groin is a complication of his [non-service-connected] diabetes mellitus and that groin rash complaints noted and treated in service were acute infections that resolved with treatment. The examiner also opined that his onychomycosis dermatophytosis is not related to service, noting there is no [contemporaneous] evidence of foot/toe rash complaints during service (an observation that is consistent with what was found on close review of the Veteran’s STRs and is supported by the Veteran’s own report, on at least one occasion that his foot skin complaints have been present since a postservice “athlete’s foot” infection). The VA examiner is a medical professional, and is competent to offer his opinion, and the opinion reflects a familiarity with the Veteran’s entire record and includes rationale that cites to supporting factual data, and for the candida infection identifies an alternate likely known etiology in the non-service-connected diabetes. The opinion is probative evidence in the matter, and without competent (medical) evidence to the contrary, is persuasive. The Veteran’s own assertions that his onychomycosis dermatophytosis and candida albicans are related to his skin complaints in service are not competent evidence in the matter. He is a layperson, and his (unsupported by medical opinion or treatise/text evidence) opinion has no probative evidence the medical question of the etiology of the currently diagnosed skin disability. Considering the foregoing, the board finds that the preponderance of the evidence is against this claim, and that the appeal in the matter must be denied. Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 2. Entitlement to service connection for a stomach disorder. The March 2019 Board remand noted the Veteran was seen for complaints of stomach pain numerous times in service (including after his last periodic physical examination, significant since there is no service separation examination), and ordered an examination to ascertain the nature and likely etiology of any current stomach disability. On October 2019 VA “Gallbladder and Pancreas Condition” examination, the examiner noted that this was the incorrect disability benefits questionnaire (DBQ) to address the claim for “stomach disorder of nausea, vomiting, and diarrhea”, as it is inadequate. There is no indication of follow-up, and the examination report is not responsive to the Board’s remand directives. Corrective action is necessary. See Stegall v. West, 22 Vet. App. 268 (1998). The matter is REMANDED for the following: Arrange for the Veteran to be examined by an appropriate clinician to ascertain the nature and likely etiology of his claimed stomach disability. The record must be reviewed by the examiner. The examiner should respond to (including rationale): (a.) Identify (by diagnosis) each stomach disability entity found/shown by the record during the pendency of the instant claim. (b.) Identify the likely etiology for each stomach disability entity diagnosed. Specifically, is it at least as likely as not (a 50 percent or better probability) that it is etiologically related to the Veteran’s service, and his stomach pain complaints noted and treated therein? (c.) If a diagnosed stomach disability is found to be unrelated to service, identify the etiology considered more likely; explain why that is so. . GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.