Citation Nr: 21001978 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 09-18 121 DATE: January 12, 2021 ORDER Entitlement to service connection for acne vulgaris with residual scarring is granted. FINDING OF FACT Acne vulgaris with residual scarring is attributable to service. CONCLUSION OF LAW The criteria for entitlement to service connection for acne vulgaris with residual scarring have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty in the United States Army from September 1987 to September 1995. The Board acknowledges that a December 2020 FOIA / Privacy Request response from VA provided the requested February 2020 VA examination reports. As these examination reports are unrelated to the claim at issue, the Board does not find that any delay in adjudicating the claim is required. 1. Entitlement to service connection for acne The Veteran contends that he has a skin disability due to his service, specifically due to the extended use of facial camouflage paint and exposure to chemical gas. He points to in-service treatment for skin problems and contends that his problems during the appellate time period are related to those in-service problems. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110. There is a one year presumption for chloracne or other acneform disease consistent with chloracne. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran’s service treatment records include a July 1987 Report of Medical Examination prior to entrance into service that showed a normal skin examination. In a contemporaneous Report of Medical History, the Veteran denied a history of skin diseases. In September 1987, the Veteran had blackheads and blemishes on the face, with a diagnosis of acne / possible early impetigo. In October 1987, the Veteran had a diagnosis of acne vulgaris involving only the face with papules, a scar, a cyst, and other issues. In August 1991, the Veteran had a noted long history of acne with past treatment and current pustules on the face and with no involvement involving the chest / back. The assessment was severe acne vulgaris that were predominantly nodules. A June 1995 Report of Medical Examination prior to separation included a normal skin examination. In a Report of Medical History, the Veteran denied a history of skin diseases. After service, during a September 2002 VA treatment visit his skin was negative. There was no rash or prominent lesions on examination. In March 2006, the Veteran had no rash or prominent lesions on examinations. In March 2015, the Veteran was seen for facial acne and acne scars. The Veteran reported a history of acne that started flaring during his active service. He believed that the oil in the camouflage paint clogged his pores and made his acne flare. The Veteran had been treated for the acne in service, but had no recent treatment. On examination, the Veteran had a few inflamed erythematous papules and cysts, diffuse pitted scars, and rolling box scars on the bilateral cheeks and chin. The diagnosis was inflammatory acne and acne scarring. In an August 2015 statement accompanying his notice of disagreement, the Veteran discussed how during service he had worn camouflage paint for numerous days while in the field from 2 weeks to 30 days. The paint caused more sensitivity to his skin that caused recurrent acne breakouts while in service. In addition, on multiple occasions he was exposed to chemical gas that also promoted sensitivity to his skin that caused recurrent acne breakouts. From 1995 to present, he continued to suffer from the same symptoms as in service, to include acne, black heads, inflammatory lesions on the face, and facial scarring. The Veteran had “holes” in his face from the continued acne. He had been treating the acne with over-the-counter medication, with little success. An October 2015 statement from a fellow service member stated, “During out time in the field, we were put in the elements to conceal ourselves by wearing face camouflage paint for long periods of time. It was days where we had to wear the camouflage paint for more than twenty four hours a day. We returned from our field exercises and back in Garrison I would notice [the Veteran] would have acne bumps all on his face and also razor bumps from shaving the hair that grew while we were in the field. I could also see the scaring from the acne that had accumulated over time and as his squad leader I would recommend to him to seek medical help for this problem. Camouflage paint is not good for use with someone with very sensitive facial skin like [the Veteran].” In addition, during the four years they served together the service member witnessed the Veteran’s “face go from bad to worse” which the service member attributed to the conditions in the field that caused acne breakouts and residual scarring. An October 2015 statement from another fellow service member reiterated that the Veteran had acne on the face and neck during service and that the Veteran had acne flare-ups after returning from field training exercises that required the use of camouflage face paint. The service member indicated that he had seen the Veteran on multiple occasions since 2013 and that the Veteran’s acne was “still the same on his face and neck and I have also noticed quite a bit of scaring.” Yet another October 2015 from another fellow service member noted service with the Veteran in 1989 and 1990 and stated that he witnessed the Veteran on “many different occasions come [and] go to sick call for his acne problems because of the camouflage that was used while in the field. On some occasions we [were] told that we needed to keep it on because we were in training in the event we were going to be called up for war. This behavior is hard when a person is dealing with sensitive skin issues.” The service member continued contact with the Veteran and “I would see that he was still suffering with his acne that he had suffered with while we were stationed together in the military. I would see him buy ointments for the acne and scars. His face had gotten worse over time from the scarring due to the severe acne that he had.” In December 2019, the Veteran was diagnosed with integumentary acne that was attributed to the use of camouflage paint during service. In January 2020, the Veteran sought treatment for acne. He reported that he used to break out a lot using camouflage paint during service that resulted in bad scarring. The VA treatment professional assessed acne with acne scarring. The Veteran had scattered crateriform and icepick scars over the cheeks and temples and hyperpigmented macules and papules over the neck and submandibular areas. In May 2020, the Veteran was treated for moderately controlled acne on the cheeks and around the temples. A January 2020 VA contract examination report is of record. The Veteran had a diagnosis of scarring of the bilateral cheeks. The Veteran also had resolved acne. There were hyperpigmented spots on the chin, but no active infection. He had been treated with medication for the past 12 months. Following examination, the examiner concluded that the Veteran’s acne and related scarring was less likely than not incurred in or caused by service. The rationale noted that there was no acne seen on the face at the time of examination and that medical records were silent for recurrent treatment of acne complaints or treatment. There was treatment for acne noted many years after separation from service beginning in 2015. In support of his claim and in response to the findings in the January 2020 VA contract examination report, the Veteran submitted documentation of ongoing treatment for facial acne from November 2019 to October 2020. During a November 2020 Board hearing, the Veteran discussed how before service he had not been prone to acne. He first complained about acne during basic training. He continued to have problems in service and after service. The Veteran received ongoing treatment for acne during service “with little or no positive results.” He was diagnosed with blemishes, blackheads, possible early impetigo, numerous lesions on the face, and acne. The Veteran argued that his skin problems were due to the use of camouflage paint on his face and exposure to chemicals due to simulated gas attacks. As an initial matter, the Board notes that there is some question as to whether the Veteran’s acne preexisted his entrance into active service. The Veteran has made somewhat inconsistent statements in this regard, alternately arguing that he had no issues with acne prior to service and also indicating that he experienced some childhood acne, but not to the degree that he experienced during service. In medical history questionnaires at enlistment and at discharge, the Veteran denied any skin disorders. Given that the Veteran had a normal skin examination prior to entrance into service, he will be presumed to have entered service in sound condition with respect to his skin. 38 U.S.C. § 1111. Given the inconsistent evidence as to preexisting acne, the Board does not find clear and unmistakable evidence of a preexisting acne disability. 38 C.F.R. § 3.306. The Board notes that the Veteran can attest to factual matters of which he has first-hand knowledge, such as subjective complaints of skin lesions and scarring, and his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Moreover, in light of the physically observable nature of such disabilities as skin lesions or rashes the Veteran, as a layperson, may be competent to identify a skin abnormality. See Falzone v. Brown, 8 Vet. App. 398, 403 (1995); McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (Veteran alleged skin disorder of boils, blotches, rash, soreness, and itching since service; Court implied that this may be the type of condition lending itself to lay observation and satisfy the nexus requirement). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. at 303. In this case, affording the Veteran the benefit of the doubt the Board concludes that the evidence is at least in relative equipoise as to whether his acne vulgaris with residual scarring onset during or is caused by his active duty. In reaching that conclusion, the Board finds it significant that there are multiple in-service complaints of ongoing skin problems and that those complaints have continued after service. Although there are not medical records documenting ongoing problems, both the Veteran and fellow service members have attested to the Veteran having ongoing problems with acne following service, including scarring. These notations support the Veteran’s contentions that he had ongoing problems and are of significant probative weight. The Board recognizes that the Veteran had a normal examination of the skin at the time of separation from service and the January 2020 VA examination report provided a negative opinion as to any relationship between the acne and service. The Board finds the rationale of the January 2020 VA examination report somewhat problematic, given that the examiner based the opinion entirely on the absence of any current acne and the lack of medical records documenting ongoing treatment for acne. As discussed above, however, both shortly before and after the examination the Veteran was treated for acne and there is significant lay evidence documenting ongoing problems with acne. There is insufficient medical evidence discounting this lay evidence and, as noted above, the Veteran and his fellow service members are competent to discuss physically observable symptoms such as facial acne and associated scarring. (continued next page) In summary, the Board affords significant probative weight to the lay statements of the Veteran and his fellow service members of ongoing skin problems from service, coupled with the in-service treatment for skin problems. As such, the evidence is at least in equipoise such that entitlement to service connection for acne vulgaris with residual scarring is warranted and the Board concludes that this determination is a complete grant of benefits as to the Veteran’s reported skin symptomatology since service. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. J. Houbeck, 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.