Citation Nr: 21004690 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 17-43 985 DATE: January 27, 2021 ORDER Entitlement to service connection for a skin disorder, including idiopathic urticaria, is granted. FINDING OF FACT It is just as likely as not the Veteran’s skin disorder incepted during his service or is related or attributable to his service. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the criteria are met for entitlement to service connection for a skin disorder, including especially idiopathic urticaria. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1990 to November 1992. This appeal to the Board of Veterans’ Appeals (Board) is from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). More recently in support of this claim, the Veteran testified during a virtual hearing in December 2020 before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. Since the RO last considered the Veteran’s claim, he submitted additional evidence and, during his recent hearing before this Board, he affirmed on the record that he wants the Board to go ahead and consider it, rather than having the RO consider it in the first instance. 38 C.F.R. § 20.1304. As also indicated during the recent hearing, the Veteran has received diagnoses of various skin disorders, so not just of idiopathic urticaria. Therefore, the Board has recharacterized his claim more broadly to include all diagnosed skin disorders, inclusive of, but not limited to, idiopathic urticaria. Clemons v. Shinseki, 23 Vet. App. 1 (2009), cf. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Entitlement to service connection for a skin disorder, including, but not limited to, idiopathic urticaria The Veteran contends that his skin condition – regardless of specific diagnosis, onset during his service and has persisted during the many years since. While testify during his recent virtual hearing before this Board, the Veteran said he had multiple complaints of skin-related problems or issues during his service, including after receiving a vaccination (immunization) in anticipation of going overseas for Operation Desert Shield/Desert Storm. But he explained that initial reaction subsided after 24-48 hours and that he had other eruptions on his skin after his experiences in Operation Desert Shield/Desert Storm that were unrelated to that vaccination reaction but more so attributable to what occurred while overseas.   He says those other skin issues persisted for the remainder of his service, continuing until even now, despite, as an example, taking over-the-counter medication and seeing doctors during the years since service. He explained that he did not initially know about VA healthcare and, in any event, did not (at least initially after service) have ability to get treated, per se, but even since enrolling in the VA healthcare system his VA doctors also have observed the same type eruptions he had while in service. He said he saw private doctors prior to 2003 (so before enrolling in the VA healthcare system), but he conceded those records are no longer available. The Veteran’s representative additionally argued that service connection also is possibly alternatively warranted on the premise the skin condition may be additionally secondary to the service-connected acquired psychiatric disorder, inclusive of posttraumatic stress disorder (PTSD), since times of increased stress cause worsening of skin condition, so aggravate it. 38 C.F.R. § 3.310(a) and (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or an injury; and (3) a causal relationship (“nexus”) between the current disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In deciding a claim, VA adjudicators must consider all relevant lay and medical evidence and, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1. Vet. App. 49, 55 (1990).   There is no disputing the Veteran has a current skin disability, including owing to urticaria and candida. Additionally, his service treatment records (STRs) confirm he received treatment for a skin rash while in service. See July 1990 STR note. Furthermore, he served in Southwest Asia and received notification that he may have been exposed to nerve agents. See July 1997 Correspondence. Consequently, resolution of this appeal turns on whether the skin rash he had in service is the same skin condition he is now experiencing and has during the several years since conclusion of his service. To try and establish this required correlation (“nexus”), the Veteran provided a private clinical assessment showing urticaria and candida were diagnosed and treated in August 2003. A November 2013 VA dermatology note shows the Veteran reported a history of intermittent rash on his trunk and extremities since his service in Desert Storm in the 1990s. He indicated that he took over-the-counter medications to try and manage his symptoms. He provided photographs showing the extent of his skin irritation. A June 2015 VA examiner opined that it is less likely than not the Veteran’s diagnosed skin condition is related to a specific exposure event experienced by him during his service in Southwest Asia. This VA examiner reasoned that a dermatology examination in November 2013, so in the interim, had diagnosed urticaria (hives) that were “idiopathic”, and the Veteran had no subsequent visits for complaints of urticaria. This VA examiner surmised that, considering the available evidence and research on Gulf War exposure issues, there is no conclusive evidence that would support the claim that hives initially diagnosed in 2012 or 2013 (by record) are due to any exposures or chemical that the Veteran came into contact with during his 1991-1992 deployment time period. This VA examiner explained that the Veteran’s hives are not due to any events during his deployment or after his deployment to Southwest Asia.   A January 2016 VA examiner also opined that it is less likely than not the newly diagnosed skin condition in 2012-2013 is related to treatment while in service or a specific exposure event experienced by the Veteran during his service in Southwest Asia. This VA examiner reasoned that the Veteran’s STRs show that, in December 1990, a box was checked with a question mark regarding hives or skin rash; however, there was no clinical evaluation or description that accompanies this question marked box. This VA examiner also noted that, just 5 days into his enlistment, the Veteran had documentation of allergic dermatitis with symptoms of blotchy rash plaques, no crusting, no flaking, and did not appear fungal. This VA examiner observed that that allergic reaction occurred in the United States and did not occur in Southwest Asia. This VA examiner also noted that the additional records provided are dated in 2003, which diagnosed the Veteran with a fungal condition that is totally unrelated to the one-time entry in the STR previously discussed. This VA examiner explained that urticaria is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus. This VA examiner concluded that, considering the available evidence, the now fairly new diagnosed idiopathic urticaria clearly is not due to any event or treatment in service. To try and refute or at least reconcile those VA examiners’ unfavorable opinions, the Veteran testified during his recent hearing that he has been a registered nurse for ten years – both in private and public settings and including in an intensive care unit (ICU). He added that he has multiple experiences of treating people with various skin conditions. For example, he noted he treated a rash as a result of a Rocky Mountain Fever and numerous other skin conditions – irrespective of whether they are the primary issue or part of the complex problems that the patients are having. Regarding the initial allergic reaction listed in his STRs, the Veteran explained that, prior to reporting to Desert Storm, he received some vaccinations and had a skin reaction that was just a regular side effect of the vaccination and that went away after only about two days. He related that a skin reaction is a common thing and it happens sometime after immunization and it generally goes away in 24 to 48 hours. The Veteran also related that the skin irritation he experienced during Desert Storm was different than the reaction he had had after the immunization shot received before that, in anticipation of going overseas. He clarified that he did not have any issues until after he had the exposure to the smoke and irritants burnings in the desert. He described the rashes he experienced in service as growing in various and irregular shapes. They were very itchy, then they blistered, and then they started to bleed. He said they were very different than the type of reaction that you may have after getting a vaccination. Regarding the delay in seeking medical care for his ongoing skin issue, the Veteran explained that, once he separated from service, he treated most of his symptoms with over-the-counter medication. Furthermore, since he was a soldier just leaving service, he did not have a stable job and insurance to be able to go to a doctor. However, he maintained that he did seek treatment earlier than 2003, although, as already mentioned, he conceded those private medical records are no longer available so cannot now be obtained. When considering all evidence relevant to this claim, so both the lay and medical evidence, the Board finds that it is at least in relative balance concerning whether the Veteran's skin disease originated during his service. Although he was formally diagnosed with chronic urticaria in November 2003, he has provided competent lay evidence attesting that he had similar symptoms earlier, prior to his discharge from service, and continuously since his service. As a registered nurse, he has some level of medical competence, especially considering he has treated people with skin conditions. See 38 C.F.R. § 3.159(a)(1) and (a)(2). Therefore, he is competent to report the symptoms associated with his skin disease, including their time of onset, and to provide probative comment regarding their etiology in relation to his time in service. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). To the extent that the grant of service connection in this case is based primarily on lay evidence, consider that “nothing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself.” Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In sum, it is as likely as not the Veteran’s current skin disorder dates back to his service or is otherwise related or attributable to his service. And, in this circumstance, his claim is granted rather than denied by resolving this reasonable doubt in his favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Hamm, 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.