Citation Nr: 21000015 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 14-21 487 DATE: January 4, 2021 ORDER Entitlement to service connection for a skin condition is denied. FINDINGS OF FACT 1. The weight of the medical and other evidence of record is against a finding that the Veteran has a diagnosis of dermatitis, urticaria, Pityrosporum folliculitis, post-inflammatory hyperpigmentation (PIH), or dermatofibromas, also claimed as rash on skin, that had its onset in service or is otherwise related to a disease or injury during his military service. 2. Dermatitis, urticaria, Pityrosporum folliculitis, post-inflammatory hyperpigmentation (PIH), or dermatofibromas, also claimed as rash on skin, was not manifest to a compensable degree within one year of his separation from active service and is not otherwise related to service. CONCLUSION OF LAW The criteria for a skin condition have not been met. 38 U.S.C. §§ 1110, 1111, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.317, 4.3, 4.118. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served in the U.S. Navy from October 1988 to October 1992, which includes service in the Southwest Asia Theater. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in August 2017. A copy of the transcript from this hearing is associated with the claims file. This issue was previously remanded in February 2018 and January 2020 for further development. The appeal has been returned to the Board for further action. Following the February 2020 remand, the Veteran executed VA Form 20-0995, Supplemental Claim Application, for consideration of service connection for migraine headaches in the Appeals Modernization Act (AMA) system. See February 2020 VA Form 20-0995 and August 2020 Deferred Rating Decision. Since the issue of migraine headaches is no longer on appeal, that issue is not before the Board for consideration. 1. Service connection for a skin condition The Veteran seeks service connection for a skin condition, which he indicates is related to service, to include exposure to chemicals, burn pits, and asbestos. In general, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.317, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a)(1)). Although the credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, it is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the 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 claims, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lay evidence can be sufficient on its own to establish any element of a claim. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran contends that his skin disorder began during and is the result of his service during the Persian Gulf War. See June 2011 VA Form 21-526EZ, Veteran’s Application for Compensation. In addition, the Veteran asserts that his exposure to jet fuel, asbestos, and cleaning products and solvents aboard ship in the Navy were responsible for rashes on his skin. See August 2017 Board hearing transcript. Contemporaneous medical evidence has greater probative value than the Veteran’s reports of history. See Curry v. Brown, 7 Vet. App. 59 (1994). In October 1991, the Veteran requested a “shave chit due to facial bumps / irritation,” noted on his “beard region.” He was diagnosed with pseudofolliculitis barbae (ingrown hairs). Electric clippers were issued to the Veteran, and he was instructed to, “[U]se electric clippers to shave with.” See October 1991 Chronological Record of Medical Care. The Veteran was treated for acne on his face in January 1992. He was prescribed Retin A cream and Fostex medicated soap. See January 1992 Chronological Record of Medical Care. When the Veteran separated from service, his Report of Medical Examination reflected a “Normal” clinical evaluation regarding “Skin, Lymphatics.” See September 1992 Report of Medical Examination. A Report of Medical History at separation, completed by the Veteran, asked, “Have you ever or have you now – Skin diseases,” to which the Veteran responded “No.” In addition, the Veteran responded to “Present Health and Medications Currently Used: 1) Good Health; 2) No Medications.” The Veteran listed his occupation as “Airman.” See September 1992 Report of Medical History. Service personnel records and Board testimony from the Veteran document his duties in aviation support. See July 1990 Performance Evaluation and August 2017 Board hearing transcript. A February 1993 VA medical examination pursuant to a claim for compensation noted that the Veteran’s skin was “unremarkable.” See February 1993 VA examination report. A May 2000 Gwinnett treatment note stated, “[B]reaking out over body since Friday.” The Veteran was diagnosed with “varicella zoster.” See May 2000 Gwinnett treatment note. In October 2001, the Veteran was diagnosed with “Dermatophytosis.” See October 2001 Gwinnett treatment note. A July 2007 Kaiser treatment note documented, “[H]ere for evaluation of itchy rash on back for past 6 (months). No (treatment)…No other areas affected. Also has some dark spots on face.” The Veteran was diagnosed with “acne” and “asteatosis cutis.” See July 2007 Kaiser Permanente treatment note. The Veteran presented with “a chronic rash on his upper back present for several years” in February 2010. The Veteran stated that he was diagnosed previously with “eczema.” See February 2010 VA treatment note. A November 2012 VA Tele-dermatology note also noted a complaint of “rash on his back” from the Veteran, who stated it was “present for several years.” See November 2012 VA Tele-dermatology note. In January 2013, the Veteran presented with “neck, back studded with erythematous pinpoint pustules on background of hyperpigmentation – Similar singular pustule on left forearm – LE clear – Face, chest clear.” See January 2013 VA treatment note. A subsequent treatment note of January 2013 shows a diagnosis of “Pityrosporum folliculitis” after a biopsy. The Veteran was advised to, “[A]void predisposing factors as the yeast tends to overgrow in hot, humid, sweaty environments.” The Veteran was also diagnosed with “Acne, face – [m]ainly comedonal” and was prescribed “tretinoin 0.025% cream.” See January 2013 VA Dermatology Progress note. The Veteran was employed as a physical education teacher and football coach for ten years. See August 2013 VA Dermatology note and January 2020 VA examination opinion. By March 2013, the Pityrosporum folliculitis was “resolved with ketoconazole PO.” See March 2013 VA Dermatology Progress note. The folliculitis returned in August 2013, and the Veteran was again advised to “[A]void predisposing factors as the yeast tends to overgrow in hot, humid, sweaty environments.” He was prescribed ketoconazole PO. The Veteran continued to present with comedonal acne on his face and was advised to continue using tretinoin 0.025% cream. See August 2013 VA Dermatology treatment note. In a July 2015 Tele-dermatology consult, the Veteran reported, “Scattered excoriated papules on upper shoulder; perifollicular papules and pustules w/ hyperpigmented patch on back.” The examiner was not sure if the symptoms were indicative of acne or folliculitis, but benzoyl peroxide / erythromycin gel was prescribed for the Veteran. See July 2015 VA Tele-dermatology Consult note. A February 2016 treatment note included the observation, “[O]verall vet [sic] is very suspicious that his rash is a result of combat exposure.” The examiner noted that the “clinical history, appearance, and histology” supported the Pityrosporum folliculitis diagnosis and provided the Veteran with his pathology report. The Veteran was reported to be “incredulous regarding his diagnosis.” Also noted at the examination was “post-inflammatory hyperpigmentation (PIH),” for which the Veteran was advised to use “sun protection,” including limiting his exposure. See February 2016 VA Dermatology note. The Veteran was afforded a VA Gulf War examination in May 2016. A report of medical history regarding “Skin and scars” was not completed by the Veteran. The examiner found no diagnosed illnesses for which no etiology was established. There was no report from the Veteran of any additional signs or symptoms not addressed in the report of medical history. A physical exam for the Veteran was “normal,” and no functional impact was reported by the Veteran for any signs or symptoms of an “undiagnosed illness” or “diagnosed medically unexplained chronic multi-symptom illness.” See May 2016 VA Gulf War General Medical Examination report. A VA Allergy Clinic note from June 2016 recorded, “[H]ives (urticaria) starting in April (2016). No previous history…generalized…Zyrtec 10mg daily, helps completely…Chronic spontaneous urticaria – no identifiable trigger.” See June 2016 VA Allergy Clinic note. In July 2016, the Veteran was diagnosed with “eczematous dermatitis,” while the Pityrosporum folliculitis was thought to be “resolved at this time.” Post-inflammatory Hyperpigmentation (PIH) was addressed with instructions to use “sun protection,” including limiting his exposure. See July 2016 VA Dermatology note. An August 2017 VA treatment note recorded, “[P]ersistent itch on back…is most likely break through itch from chronic urticaria given (history) revealed today – reviewed etiology, natural (history), and treatment options with Vet.” See August 2017 VA Dermatology note. Chronic urticaria labs were negative. See October 2017 VA Dermatology note. The examiner continued to encourage “sun protection” for PIH. “Few inflammatory (folliculitis) pustules” were noted on the Veteran’s back. See August and October 2017 VA Dermatology notes. A dermatofibroma on the Veteran’s “central chest” was noted at the October 2017 VA Dermatology visit. See October 2017 VA Dermatology note. A VA skin diseases examination was conducted in May 2018. The Veteran was diagnosed with Dermatitis, Folliculitis, and Urticaria (hives). The examiner noted previous diagnoses of, “Pityrosporum folliculitis (established by skin biopsy) with postinflammatory hyperpigmentation and chronic urticaria (hives).” Dermatitis was visible on less than 20 percent of the Veteran’s total body area. The examiner noted, “Multiple hyperpigmented macules and papules on back, posterior neck and bilateral upper shoulder regions - several inflammatory follicular pustules on back - few hyperpigmented macular lesions on upper chest - Bilateral lower extremities with several Hypopigmented macules - small area of maceration noted at edges of lips - No acute urticarial lesions noted on exam.” A chronic urticaria panel was negative. Finally, no other pertinent physical findings or conditions, including signs or symptoms of acne, were made. See May 2018 VA examination report. The Veteran told the May 2018 examiner that he was a “football coach” and reported “worsening of his skin lesions with heat exposure,” which consisted of “outbreaks” of urticaria (hives) 4 or more times in the last 12 months. See May 2018 VA skin diseases examination report. With regard to symptoms of an undiagnosed illness, as defined by 38 C.F.R. § 3.317, the May 2018 examiner pointed to the previous diagnoses of folliculitis and chronic urticaria as evidence that the Veteran’s skin condition symptoms are not undiagnosed and have a partial, if not clear, etiology. The examiner reviewed articles supplied by the Veteran and concluded, “[M]edical literature does not support a direct etiological link between exposures to burn pits, aircraft cleaning chemicals, zinc oxide and asbestos and the diagnosed skin conditions. The folliculitis has been attributed to Pityrosporum which is a fungal infection.” See May 2018 VA skin diseases examination report. The May 2018 VA examiner opined that is was, “[L]ess likely as not that the Veteran’s skin condition was incurred in or caused by an in-service event (i.e. chemicals, burn pits, asbestos).” The examination report highlighted the in-service complaints and treatment for pseudofolliculitis barbae and acne, the “normal” separation evaluation, and the lack of self-reported skin diseases from the Veteran when he separated from service in 1992. The report also mentioned the February 1993 VA medical examination pursuant to a claim for compensation. The examination report noted skin for the Veteran as “unremarkable.” See May 2018 VA skin diseases examination report. The Veteran was afforded an additional VA examination in January 2020. He was diagnosed with “Pityrosporum folliculitis resolved with PIH and Dermatofibromas.” The examiner noted that acne, urticaria, and eczematous dermatitis were “resolved skin conditions.” No scarring, neoplasms, or other pertinent physical findings or conditions, including signs or symptoms of acne, were present during the examination. There was no reported functional impact, nor were any debilitating episodes reported by the Veteran. The examiner concluded, “After extensive (Medical Records) review, including Veteran’s article submission regarding contact dermatitis and infectious diseases...It is less likely as not that this Veteran’s (1) pityrosporum folliculitis with postinflammatory pigmentation (PIH) and (2) dermatofibromas were incurred or caused by service, including exposure to chemicals, asbestos, jet fuel, or burn pits.” See January 2020 VA examination report. The rationale provided by the January 2020 examiner included: “1. medical literature has not shown any skin disorder as a result of burn pit exposure; 2. Contact dermatitis can be caused by chemicals, including jet fuel exposure, but this is often an acute reaction. This Veteran did not have contact dermatitis in the service; 3. Asbestos exposure could lead to asbestos fibers being lodged in the skin causing callus / corns (Veteran was never seen for skin disorder caused by asbestos exposure); 4. Veteran checked “no” for skin disease during his separation exam in 1992 and separation exam was normal for any skin disease; 5. Gen med exam in Feb 1993 (less than 1 year after military separation) was negative for any skin disease; 6. Veteran’s current skin condition (in the back) occurred “past 6 months,” documented in July 2007, 15 years after his military discharge; (7) Dermatofibromas (benign skin growth) first appeared in 2017, decades since his military discharge.” See January 2020 VA examination report. Presumptive service connection can satisfy both the elements of an in-service event and a nexus to military service. Chronic diseases listed under 38 C.F.R. § 3.309(a) that manifest either during active service or to a compensable degree within the applicable time limits of 38 C.F.R. § 3.307(a) are sufficient to establish in-service incurrence or aggravation. If a chronic disease enumerated in 38 C.F.R. § 3.309(a) does not manifest in-service or within the applicable time limits, service connection may be granted based on continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Skin diagnoses for the Veteran do not appear in the list of presumptive diseases enumerated in 38 C.F.R. § 3.309. Further, a diagnosis of “chronic urticaria” was ruled out through testing. See October 2017 VA Dermatology note. No skin conditions were noted for the Veteran at separation in September 1992 or at the February 1993 VA examination. See September 1992 Reports of Medical Examination and Medical History and February 1993 VA examination report. In November 2012, the Veteran stated that he had a “rash…present for several years.” See November 2012 VA Tele-dermatology Note. A January 2013 biopsy confirmed a diagnosis of “Pityrosporum Folliculitis,” a yeast-based, “fungal infection.” Given the Veteran’s employment as a high school football coach, he was advised to avoid sun exposure, because yeast grows in “hot, humid, sweaty environments.” See January 2013 VA Dermatology Progress Note. Because the Veteran is not able to demonstrate a chronic disease diagnosis or continuity of symptomatology from service to present, presumptive service connection for a chronic condition is not warranted. Presumptive service connection can also be granted for those diseases listed under 38 C.F.R. § 3.317. Despite the fact that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, the medical evidence of record does not show that the Veteran’s skin condition cannot be attributed to any known clinical diagnosis. The Veteran’s skin conditions have been clinically diagnosed as Dermatitis, Urticaria, Pityrosporum folliculitis, PIH, and Dermatofibromas, which excludes the possibility of a skin rash as a symptom of an undiagnosed illness. The medical evidence of record indicates that these diagnoses have an etiology, so there is no reason to consider his skin rash as a symptom of a medically unexplained, chronic, multi-symptom illness. Regarding direct service connection, the Veteran has been provided with diagnoses that include Dermatitis, Urticaria, Pityrosporum folliculitis, PIH, and Dermatofibromas, so there is evidence of a current skin disability. Regarding an in-service event, the Veteran asserts in-service exposure to chemicals, burn pits, and asbestos while serving in the Navy and Southwest Asia, causing his skin disorders. The Veteran’s service personnel records confirm that he served in the Southwest Asia Theater of operations during the Persian Gulf War. Alternatively, the Veteran complained of and was treated in-service for pseudofolliculitis barbae and acne. See October 1991 and January 1992 Chronological Records of Medical Care. While the Board does not doubt that the Veteran truly believes his skin conditions to be causally related to his active service in the Navy and Southwest Asia, determining the relationship of a skin condition to service is a complex medical question that requires medical knowledge and expertise. Although the Veteran is competent to report that a skin condition occurred during his military service, he has not been shown to possess the requisite medical training or knowledge to medically attribute his current skin condition to service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board must still weigh the Veteran’s lay statements against the medical evidence of record. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency [“a legal concept determining whether testimony may be heard and considered”] and credibility [“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”]). Factors to consider regarding the credibility of lay evidence are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In making a credibility determination, the Board notes that the Veteran was “incredulous regarding his diagnosis (See February 2016 VA Dermatology note),” but he does not possess the medical expertise required to dispute the lab pathology report or to apply his own diagnosis to the facts presented. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, the Veteran’s statements have been inconsistent with the other evidence of record (see February 2010 VA Treatment note and January 2020 VA examination report [“I have been diagnosed with eczema”]), his description of the onset of his skin condition has been inconsistent (see June 2011 Application for Compensation [“Claiming a Disability Related to an Environmental Hazard Exposure During the Gulf War…rash on skin”] and August 2017 Board hearing transcript [“I was on the flight deck, and then also the grease when we got to clean”]), and the condition for which the Veteran sought treatment in July 2007 was present for “6 months (see July 2007 Kaiser Permanente treatment note),” and occurred fifteen years after service. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996); see also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The Veteran’s character is well-documented in his service personnel records (see August 1989 Special Counseling Report and October 1992 Administrative Board Hearing transcript), further calling into question the credibility of his lay statements. Despite the conditions documented in the October 1991 and January 1992 Chronological Records of Medical Care, direct service connection for a skin condition fails regarding a nexus between a current diagnosis and any in-service event or injury. The fungal infection (Pityrosporum Folliculitis) was “resolved” at the January 2020 VA examination, which happens to coincide with the Veteran’s unemployment as a high school football coach, where he was exposed to the “hot, humid, sweaty environment” thought to be its source. See January 2013 VA Dermatology Progress note and January 2020 VA examination report. While the Veteran’s Pityrosporum Folliculitis was resolved, according to the March 2013 VA Dermatology Progress note, an August 2013 VA Dermatology treatment note documented its return. The Veteran was educated again to avoid “hot, humid, sweaty environments,” but the Veteran was still employed as a physical education teacher and football coach. See August 2013 VA Dermatology treatment note. All in all, the Veteran was prescribed to avoid “exposure” and /or “hot, humid, sweaty environments” a total of 6 times while seeking treatment for skin conditions. See January 2013 VA Dermatology Progress note, August 2013 VA Dermatology note, February 2016 VA Dermatology note, July 2016 VA Dermatology note, August 2017 VA Dermatology note, and October 2017 VA Dermatology note. At each one of the skin-related treatment visits, the Veteran was employed as a physical education teacher and football coach. Assuming arguendo that the Veteran was misdiagnosed in-service and did in fact experience a skin condition, e.g., contact dermatitis, due to chemical, solvent, and jet fuel exposure, the Veteran is still missing a nexus between the in-service event and his current diagnoses. Direct service connection fails, because any reaction “caused by chemicals, including jet fuel exposure,” manifesting as contact dermatitis “is often an acute reaction,” as opined by the January 2020 VA examiner. See January 2020 VA examination report. In the May 2018 VA examination, the only outbreaks reported by the Veteran was hives (urticaria), not dermatitis, and the Veteran specifically mentioned that the hives were worse “with heat exposure.” The VA examiner noted that the Veteran was still employed as a high school football coach at the time and that the October 2017 chronic urticaria labs were negative. See May 2018 VA examination report. The May 2018 and January 2020 opinions are found to carry significant probative weight, as the reports indicate that the reviewing physicians conducted a thorough review of the relevant evidence of record, to include the lay assertions and articles on skin conditions and solvents presented by the Veteran. The examiners indicated that there is insufficient evidence to demonstrate a causal relationship between service and the development of a fungal-based dermatological infection 15 years after service. The medical opinions provided in May 2018 and January 2020 are found to be consistent with one another and the evidence of record. Notations of complaint or treatment for a chronic skin disorder are absent from the Veteran’s service treatment records and do not appear until 2007. See Veteran service treatment records and July 2007 Kaiser Permanente treatment records. Chronic urticaria lab testing was negative. See October 2017 VA Dermatology note. At the time of his separation in 1992, the Veteran was evaluated, and his skin was determined to be “normal.” The Veteran reported on his medical history at separation and specifically denied having any skin disease, past or present, stating that he was in “good health” and “(without) medication.” See September 1992 Reports of Medical Examination and Medical History. Less than 6 months after separation from service, the Veteran was again evaluated, pursuant to a claim for VA disability benefits. His skin was noted as “unremarkable.” See February 1993 VA medical examination report. The Veteran reported in July 2007 that he had an “itchy rash on back for past 6 (months).” See July 2007 Kaiser Permanente treatment note. A January 2013 biopsy confirmed the diagnosis of Pityrosporum folliculitis, a fungal infection. See January 2013 VA Dermatology Progress note. The etiology of the Veteran’s skin conditions is opined to come from sources not attributable to jet fuel, chemicals, solvents, asbestos, and burn pits. Even so, the resulting contact dermatitis is “often an acute reaction.” See May 2018 and January 2020 VA medical examination reports. In conclusion, although the Veteran is conceded to have served in Southwest Asia during the Persian Gulf War and to have been exposed to various environmental hazards during Naval service, the evidence of record does not demonstrate that the Veteran’s skin conditions, having a clear etiology, represents an undiagnosed illness or a sign or symptom of a medically unexplained chronic multi-symptom illness, as initially claimed by the Veteran in June 2011. Service connection on a presumptive basis under 38 C.F.R. §§ 3.309 and 3.317 must be denied. Also, while the Veteran has met the first two elements for direct service connection, a current diagnosis and an in-service event, illness, or injury, a preponderance of the evidence weighs against a finding that the Veteran’s current skin condition arose during or is etiologically related to his active military service. It is important to point out that the Board does not find that the Veteran’s lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson, 581 F.3d at 1313, quoting Buchanan, 451 F.3d at 1337 (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.”). The Veteran’s statements are lacking in credibility due to the inconsistencies, internal and with the evidence of record, and due to the delay in seeking treatment. Service connection on a direct basis must therefore be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as a preponderance of the evidence is against the Veteran’s claim of entitlement to service connection, that doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Small, Attorney Advisor 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.