Citation Nr: 21061316 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 14-06 909 DATE: October 1, 2021 ORDER Entitlement to service connection for a scalp disorder, to include dissecting folliculitis with scarring alopecia, is granted. FINDINGS OF FACT 1. The Veteran has a current diagnosis of dissecting folliculitis with scarring alopecia. 2. The Veteran had active service in the Southwest Asia theater of operations during the Persian Gulf War. 3. The Veteran's dissecting folliculitis is a medically unexplained chronic multisymptom illness of unknown etiology. 4. The Veteran's scarring alopecia is proximately due to dissecting folliculitis. CONCLUSION OF LAW The criteria for entitlement to service connection for a scalp disorder, to include dissecting folliculitis with scarring alopecia, are met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1118, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Army from September 1990 to April 1991, including service in Southwest Asia (Saudi Arabia), with additional National Guard service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In February 2015, the Veteran testified at a Board hearing before the undersigned. In October 2015, June 2018, and April 2021, the Board remanded this matter for additional development. The Veteran asserts that his scalp condition is related to his service in the Persian Gulf War. Initially, the Board observes that the July 2021 medical opinion is inadequate. In this regard, and as discussed below, the examiner stated that the etiology of the Veteran's dissecting folliculitis is known, but then relied on contradictory medical text evidence. See McCray v. Wilkie, 31 Vet. App. 243 (2019). However, and as explained below, remand to correct this deficiency is unnecessary as the present record warrants a full grant of the benefit sought on appeal. Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is "medically unexplained," that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant's case. Id. at 391. Here, the Veteran had active service in Saudi Arabia from November 1990 to April 1991. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The Veteran's scalp condition has been diagnosed as dissecting folliculitis with secondary scarring alopecia. See, e.g., October 8, 2010 VA Dermatology Note; October 2020 VA examination report. Thus, the evidence shows that the primary condition is dissecting folliculitis that has resulted in scarring alopecia. Accordingly, if service connection for dissecting folliculitis is warranted, then secondary service connection for scarring alopecia is also warranted. The Veteran's dissecting folliculitis has been documented in treatment records since February 2002. See February 4, 2002 Dr. M.R. Treatment Note. Thus, it has existed for at least six months and it is considered chronic under the regulatory definition. Moreover, the condition has manifested to a degree of 10 percent or more because it has resulted in painful scarring, among other symptoms, which warrants at least a 10 percent rating under 38 C.F.R. § 4.118, DC 7804. The evidence of record is not in accord as to whether the etiology of the Veteran's dissecting folliculitis is known. The October 8, 2010 VA dermatologist diagnosed dissecting folliculitis with scarring alopecia and noted that the disease has manifested with symptoms including tender nodules of the scalp with purulent discharge and hair loss. The dermatologist stated that "because [the] cause of dissecting folliculitis is unknown, it is possible that this may be associated with Gulf War Syndrome." See October 8, 2010 VA Dermatology Note. A December 2013 VA Gulf War examiner opined that the Veteran's skin diseases, including folliculitis of the scalp, had a clear and specific etiology and diagnosis. See December 2013 VA Gulf War Examination Report. However, the examiner did not state the etiology of the Veteran's dissecting folliculitis. A July 2021 VA-contracted examiner, a physician with a listed specialty of "General Practice, Obstetrics and Gynecology" opined that dissecting folliculitis is a diagnosable condition with at least a partially explained etiology. However, the examiner did not state the etiology of the Veteran's dissecting folliculitis. Notably, the examiner stated that the evidence he reviewed included an article on dissecting folliculitis found at https://www.uptodate.com/contents/dissecting-cellulitis-of-the-scalp (last accessed October 1, 2021). The section of that article on "Pathogenesis" states that "[t]he etiology of [dissecting cellulitis of the scalp] is unknown" and that a defect in follicular keratinization leading to obstruction of the follicle is "suspected to contribute to the development of [dissecting cellulitis of the scalp]." A medical dictionary defines dissecting cellulitis of the scalp as "perifolliculitis capitis abscedens et suffodiens." Dorland's Illustrated Medical Dictionary, 31st ed. (2007), 330. That dictionary defines dissecting folliculitis as "perifolliculitis capitis abscedens et suffodiens." Dorland's, 735. Thus, dissecting cellulitis of the scalp and dissecting folliculitis are two terms that refer to the same condition. Here, the most probative evidence of record shows that the etiology of the Veteran's dissecting folliculitis is unknown. The VA dermatologist specializes in dermatology and thus his statement that dissecting folliculitis is of unknown etiology is highly probative. While the dermatologist did not explicitly state that the etiology of the Veteran's dissecting folliculitis is unknown, his statement that the Veteran's dissecting folliculitis "may be Gulf War syndrome" is consistent with his finding that the Veteran's dissecting folliculitis is of unknown etiology. Critically, no opinion of record states the etiology of the Veteran's dissecting folliculitis, and the July 2021 examiner's opinion is contradicted by the medical text evidence that he cited, which explicitly states that the etiology of dissecting folliculitis is "unknown," although a possible etiology is suspected. See McCray v. Wilkie, 31 Vet. App. 243 (2019). Additionally, the December 2013 and July 2021 opinions were supplied by examiners who do not specialize in dermatology, and the Board finds their opinions less probative than the opinion of the October 2010 VA dermatologist, a specialist in skin diseases. The Board acknowledges that no examiner has opined that the etiology of the Veteran's dissecting folliculitis is unknown. However, the Board has remanded this matter three times in an attempt to obtain an adequate medical opinion from an examiner. In light of these unsuccessful attempts and the present balance of evidence in favor of the claim, the Board finds that further development in this matter is unnecessary. Indeed, given the medical text evidence cited by the July 2021 examiner that the etiology of dissecting folliculitis is unknown, the Board cannot see how, upon remand, the examiner could reach any conclusion other than determining that the etiology of the Veteran's dissecting folliculitis is unknown. See Andrews v. McDonough, 34 Vet. App. 216 (2021). As there is no affirmative evidence to the contrary (see 38 C.F.R. § 3.317(a)(7)(i)-(iii)), the Veteran's dissecting folliculitis is considered a MUCMI and presumptive service connection is warranted. Secondary service connection is warranted for scarring alopecia. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, 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.