Citation Nr: 21003035 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 13-32 751 DATE: January 19, 2021 ORDER Entitlement to a rating in excess of 10 percent for the Veteran’s service-connected skin tags due to characteristic disfigurement is denied. Entitlement to a separate rating of 20 percent for the Veteran’s painful scars from his service-connected skin tags is granted, subject to regulations governing payment of monetary awards. FINDINGS OF FACT 1. The Veteran’s service-connected skin tags do not result in tissue loss, disfigurement or gross distortion of his features, scars that are deep and nonlinear, measuring at least 6 square inches or 39 square cm; superficial non-linear scars on his left leg and trunk area measuring at least a surface area of 144 square inches (929 sq. cm); and the Veteran is not diagnosed with any other skin conditions such as dermatitis or eczema. 2. The probative medical evidence shows that the Veteran has 3 painful scars from his service-connected skin tags. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for skin tag scars have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7802. 2. The criteria for a separate disability rating for painful scars have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1976 to November 1981 and from January 1985 to December 1990. This matter is on appeal from an April 2012 rating decision and has been remanded in January 2016 and in October 2018. The Veteran is currently seeking a rating in excess of 10 percent for his service-connected skin tags. By way of history, he was granted service connection at a noncompensable rating effective December 20, 1990. After filing a claim for increased rating on November 8, 2011, he was assigned a 10 percent. The Veteran’s disability has been rated under pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7819-7800. The disability has been rated under 38 C.F.R. § 4.118, Diagnostic Code 7819, benign skin neoplasms. This code states that such conditions are to be rated as disfigurement of the head, face, or neck, under Diagnostic Code 7800; scars, under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805; or impairment of function. 38 C.F.R. § 4.118, Diagnostic Code 7819. During the pendency of the appeal, the rating criteria for evaluating a skin disorder under 38 C.F.R. § 4.118 was amended effective August 13, 2018. 83 Fed. Reg. 32593 (July 13, 2018). These amendments revised certain diagnostic codes to state that disabilities evaluated under these Diagnostic Codes should be evaluated under the General Rating Formula for the Skin. However, the Board notes that criteria under Diagnostic Code 7800 were not amended. 38 C.F.R. § 4.118. Diagnostic Code 7800 provides compensation for disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. A 10 percent rating is appropriate for a skin disorder with one characteristic of disfigurement of the head, face, or neck. Id. A 30 percent rating is appropriate for a skin disorder of the head, face, or neck 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. Id. A 50 percent rating is appropriate for a skin disorder of the head, face, or neck 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. Id. An 80 percent rating is appropriate for a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry 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. Id. Under Diagnostic Code 7801, scars that are associated with underlying tissue damage are assigned a 10 percent rating for scars other than the head, face, or neck with an area exceeding 6 square inches (39 square centimeters), a 20 percent rating is assigned with an area exceeding 12 square inches (77 square centimeters), a 30 percent rating is assigned for scars with an area exceeding 72 square inches (465 square centimeters), and a 40 percent rating is assigned for scars exceeding 144 square inches (929 square centimeters). Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118. A 10 percent evaluation is appropriate for scars of 144 square inches (929 sq. cm.) or greater in area. Id. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damages. Id. Note (2) provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or the trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.118. Under Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful, a 20 percent rating is assigned for three or four scars that are unstable or painful, and a 30 percent rating is assigned for five or more scars that are unstable or painful. Under Diagnostic Code 7805, any disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 are evaluated under an appropriate Diagnostic Code. In his February 2012 statement, the Veteran indicated that his skin tags reappear even after their removal three times from his face, neck and buttocks. At his April 2012 VA examination, the Veteran reported that he developed skin tags on his neck, armpit, and buttocks and that they had increased in size, despite their removal for the third time. It was reported that he had some scarring of the head, face, or neck from skin tags but had no systemic manifestations. He had not been treated with oral or topical medications in the past 12 months for any skin condition. As to the Veteran’s visible skin conditions, no indication was given as to the approximate total body area and approximate total exposed body area (face, neck, and hands) affected on current examination. As to any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the skin, he had numerous skin tags under the left eye, on his neck, in the axilla, bilaterally. There was no evidence of benign or malignant skin neoplasms. His skin condition was not shown to impact his ability to work. A November 2012 VA outpatient treatment record shows that the Veteran had a skin tag on the right side of his neck and that he requested that it be removed. It was to be removed by use of liquid nitrogen spray. At the September 2015 Board hearing the Veteran testified that he had originally had treatment by VA for skin tags by laser treatment, having had skin tags burned off. Thereafter, for about six (6) months the skin tags had not recurred, but they had subsequently recurred and he again had had them removed. However, they were now recurring once again in the last 3 or 4 months. The skin tags were on the inside areas of his legs, hands, neck, and armpits which were new areas in which the skin tags had not previously occurred. They now seemed to reappear every 3 or 4 months. Page 3 of the transcript. After filing a claim for an increased rating for his skin tags, he had been granted a 10 percent rating on the basis that they caused disfigurement; however, they had now spread to other areas of his body, i.e., his neck, arms, legs, and the armpits. The skin tags in these areas caused irritation and discomfort when clothing rubbed against them. When the matter came to the Board January 2016, it was remanded to afford the Veteran a new VA examination. Based on his February 2016 VA examination, he reported that his skin condition caused scarring of the head, face, or neck. He had two scars from skin tag removal on the left anterior thigh, measuring at 0.2 cm by 0.2 cm and another scar at 0.3 cm by 0.2 cm (hypo-pigmented, flat and nontender). He did not have any benign or malignant skin neoplasms. He had not been treated with oral or topical medication in the last 12 months for his skin condition. He does not have any debilitating episodes in the last 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epiderma necrolysis. He also did not have any non-debilitating episodes of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months. The examiner noted 5 skin tags: left angle of the mouth measuring at 0.2 cm, left axilla at 0.2 cm, right axilla at 0.1 cm, right groin at 0.2 cm, and right neck at 0.1 cm. Overall, the skin condition covered less than 5 percent of the exposed area and less than 5 percent of the total area. The VA examiner stated that the following about the characteristic for the cited scars: there are no features of disfigurement to the skin tags or to the two small scars on the anterior thigh. There is no evidence of visible or palpable tissue loss or either gross distortion or asymmetry of 1 feature or paired set of features. There is no scar measuring at five or more inches in length (13 or more cm). There is no scar measuring at least 1/4 of an inch wide at the widest part (0.6). There is no surface contour of the scar elevated or depressed on palpation. No scar was adherent to underlying tissue. No skin texture was abnormal (irregular, atrophic, shiny, scaly, etc.) in the area exceeding 6 square inches (39 sq. cm). There was no underlying soft tissue missing in an area exceeding 6 square inches (39 sq. cm). There was no skin indurated nor inflexible in an area exceeding 6 square inches (39 sq. cm). Additionally, the lesions on the face under the eyes are not skin tags, but rather dermatosis papulose nigra (DPN). There are numerous (7 on the left, 5 on the right) flat topped ovoid hyperpigmented papules ranging in size from 0.2 to 0.4 cm and spread over an area of 3 by 4 cm on each side. The dermatosis papulose nigra on the face is a distinct condition from the skin tags. It is not related to or aggravated by the service-connected skin tag condition. Although the examiner from April 2012 included these under skin tags, these are distinct and unrelated condition. There are no scars or disfigurement due to DPN. VA treatment records in May 2017 showed that the Veteran had a history of skin erythema on the back with worsening symptoms, and a skin lump swelling and with pain over the back area. However, it was unclear whether such reporting was related to the Veteran’s service-connected skin tags. The Veteran underwent another skin evaluation in August 2018. Based on his Disability Benefits Questionnaire, the examining physician found that the Veteran’s current service-connected condition does not cause scarring or disfigurement of his head, face, and neck. However, it was noted that the Veteran has a benign or malignant skin neoplasm, a finding contrary to previous reports. It was noted that the Veteran had them removed from his right buttock. He did not provide the dates of his surgery. He also reported having ongoing therapeutic treatment. The Veteran did not have any systemic manifestations due to skin diseases such as fever, weight loss or hypoproteinemia associated with skin condition such as erythroderma. The Veteran reported taking antihistamines at a near/constant rate. While the physician indicated that the Veteran is also taking systemic corticosteroids or other immunosuppressive medication, he also answered ‘none,’ when asked to list the types of medication. The Veteran was also reportedly taking topical corticosteroids (trichloracid and imiquinoa) for his neck, lip, hand, back, inside thigh, and arm. He has not had any treatment or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorder. He has experienced 4 or more debilitating episodes in the past 12 months, indicating that such episodes are significant on his legs, hand, and back, and that they occurred despite on-going immunosuppressive therapy. He requires treatment with intermittent systemic immunosuppressive therapy. It was also reported that he responded to treatment with antihistamines or sympathomimetic. He also experienced 4 or more non-debilitating episodes over the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, and toxic epidermal necrolysis in the inside left thigh, left hand middle finger, under eyes, and neck. Further physical examination revealed two scars on the anterior trunk both measuring at 0.2 by 0.3 cm, and a superficial non-linear scar measuring at 7.5 cm. The total area in centimeters squared for superficial non-linear scar was 3.5 cm. The Veteran reported 1 painful scar in the head area and 1 unstable scar on the thigh, underarm, and neck. When the matter returned to the Board again in October 2018, it was remanded due to conflicting medical examinations. The Board found that the findings documented in the August 2018 evaluation were significantly inconsistent with previous examinations conducted in April 2012 and February 2016. For instance, the August 2018 VA examiner noted that the Veteran has been treated with systemic corticosteroids or other immunosuppressive medications but listed “none” when asked to specify the medication used. Additionally, the examiner indicated that the Veteran had 4 or more debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic necrolysis but also stated the debilitating episodes are caused by skin tags. The examiner also noted that the Veteran described the episodes as “I have seen same vasculitis on my legs, hand, and back.” The examiner further indicated that the Veteran had 4 or more non-debilitating episodes caused by urticaria, primary cutaneous vasculitis, erythema multiforme, and toxic epidermal necrolysis. Such reports have not been supported by previous findings. The matter was therefore remanded for a medical opinion addendum for clarification. While a DBQ was issued in September 2019, the report did not offer any clarification sought by the October 2018 remand as it primarily listed out the Veteran’s medical history while concluding that trichloracid skin peeling agent and Imiquimod are both topical for skin tag treatment and Cyclobenzaprine HCL muscle relaxant systemic oral route and Anti Inflammatory (Naproxen Meloxicam systemic oral) are not used for treatment of skin tags. Thereafter, the Veteran was physically examined by another DBQ physician in October 2020. It was noted that the Veteran had not been treated with medication in the past 12 months. He has not had any treatment or procedures other than systemic or topical medication in the last 12 months. His current multiple skin tags (which are located on the bilateral axillary areas, neck, and left upper inner thigh areas) occupy less than 5 percent of the total body area and less than 5 percent of the exposed area. He did not have any benign or malignant neoplasm or metastases. The physician added that a skin tag is a small, soft, flesh-colored benign skin growth, often on a stalk. They are probably the single most common bump on adult skin. They are harmless but can be annoying. There is no indication that they produce debilitating or non-debilitating episodes. The examiner noted the Veteran’s scars status post lesion removal. He had scars on the trunk or extremities (regions other than the head, face, or neck). He did not have any scars or disfigurement of the head, face, or neck. There are 3 painful scars of the trunk or extremities, none of which are unstable, with frequent loss of covering of skin over the scar. There were no scars due to burns. The two scars on his left leg were measured at 6 cm by 4 cm and 0.3 cm by 0.2 cm. Two scars located on the anterior trunk (right axilla) were both measured at 0.3 by 0.2. In total, the approximate total surface area of left lower extremity scar was 24 cm square and 0.72 cm square on the anterior trunk. None of the Veteran’s scars cause limitation of motion. In a final note, the physician indicated that the Veteran’s scars on the right axillar and on the left knee were status post skin tag removal. In reviewing the record, the Board finds that while a rating in excess of 10 percent for disfigurement is not supported, a separate rating of 20 percent is warranted for painful scars under diagnostic code 7804. At his most recent evaluation in October 2020, the Veteran reported 3 painful scars located on his thigh and underarm. The scars are often irritated by his clothes or when he wears deodorant. A higher rating of 30 percent, however, is not warranted as it requires a showing of at least 5 or more painful or unstable scars. The Board has also considered whether a higher or separate rating is warranted under other applicable diagnostic codes but found they are not. For example, to warrant a rating higher than 10 percent under diagnostic code 7800, the Veteran must demonstrate that the scar resulted in tissue loss and either gross distortion or asymmetry of at least one feature, such as the nose, chin, forehead eyes, cheeks or lips. This has not been shown. This various examinations in April 2012, February 2016, August 2018, and October 2020 all found no evidence of either tissue loss, disfigurement or gross distortion of his features. Since the evidence does not show that the Veteran’s scars are deep and nonlinear, measuring at least 6 square inches or 39 square cm, a separate compensable rating is not warranted under diagnostic code 7801. While diagnostic code 7802 may provide a separate rating, the Veteran is not entitled to a separate disability rating under this code since his superficial non-linear scars on his left leg and trunk area measured far less than a surface area of 144 square inches (929 sq. cm). Other than his service-connected skin tags and their removal, the Veteran is not currently service connected for any other skin conditions such as dermatitis or eczema. Accordingly, a separate rating of 20 percent is warranted for the Veteran’s painful scars. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Yeh, 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.