Citation Nr: 21061693 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 17-24 703 DATE: October 5, 2021 REMANDED Entitlement to service connection for a skin condition, to include as due to exposure to herbicide agents, is remanded. INTRODUCTION The Veteran served on active duty in the United States Army from January 1969 to November 1970. He was awarded the Combat Infantry Badge and a Bronze Star for his service in the Republic of Vietnam. In December 2019, the Board remanded this case for further development. This case has since been returned for additional appellate review. REASONS FOR REMAND While added delay is unfortunate, the Board finds further development is required before the Veteran's claim is decided. Initially, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In its December 2019 decision, the Board found a September 2016 medical opinion deficient because the examiner failed to consider whether the Veteran's skin condition was related to his exposure to herbicide agents. Additionally, the examiner failed to discuss the Veteran's relevant service treatment records. The Board also explained that even though the Veteran's claimed skin condition is not included as a presumptive disorder under 38 C.F.R. § 3.309(e), direct service connection may be established by evidence demonstrating that the disease was in fact incurred during the service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In February 2020, the RO obtained an additional VA skin condition examination and medical opinion. Following the examination, the examiner concluded the Veteran's discoid lupus erythematosus was less likely than not incurred in service, to include his exposure to herbicides. In support of this conclusion, the examiner indicated the Institute of Medicine has not identified an association between Agent Orange exposure and discoid lupus erythematosus. In Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009), the Court for Veteran Appeals (Court) held that "[t]o permit the denial of service connection for a disease on the basis that it is not likely there is any nexus to service solely because the statistical analysis does not support presumptive service connection, would, in effect, permit the denial of direct service connection simply because there is no presumptive service connection." Although general articles, such as statistical data and medical treatise evidence can be a factor to consider, the examiner must also discuss facts relevant to the veteran's condition and circumstances. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018); Polovick, 23 Vet. App. at 54. In this respect, the VA examiner must consider and expressly discuss the facts, medical principles, and scientific literature relevant to the specific claim at hand. As such, the Board finds a remand is necessary in order to obtain an addendum medical opinion. Additionally, following the February 2020 VA skin condition examination and medical opinion, the Veteran's representative asserted a new theory of entitlement. Specifically, in an August 2021 brief the Veteran's representative indicated the Veteran's skin condition may have been caused or aggravated by local trauma. In support of this theory, the Veteran's representative provided a link to a medical article discussing the relationship between the presence of discoid lupus erythematosus and local trauma. The Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran is service connected for a left arm shrapnel wound disability. The Veteran was in a firefight in 1969 in the Republic of Vietnam and was hit by shrapnel in the left forearm. He has residual fragments in the forearm muscle with occasional pain in the muscle. The Veteran reported his skin condition started in 1978, approximately 8 years after his release from service. The September 2016 and February 2020 VA skin condition examinations identified the presence of erythematous on the Veteran's left hand and wrist. Based on the foregoing, a remand is necessary to obtain a medical opinion addressing entitlement to service connection for the Veteran's skin condition disability secondary to his service-connected left arm shrapnel wound. Accordingly, this case is REMANDED for the following actions: 1. Afford the Veteran a VA examination by a Dermatologist with sufficient expertise to address the etiology of the Veteran's claimed skin condition disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether any diagnosed skin condition disability at least as likely as not (a 50 percent probability or greater): a) originated during his period of active service or is otherwise etiologically related to his active service, to specifically include as a result of his exposure to herbicide agents. The examiner is asked to consider and expressly discuss the facts, medical principles, and scientific literature relevant to this case. In particular, the examiner should consider any risk factors the Veteran may have had for the development of discoid lupus erythematosus, as well as the current scientific literature and studies. b) was caused by his service-connected left shrapnel wound disability; or c) was worsened to any degree by his service-connected left shrapnel wound disability. The examiner must provide a complete rationale for all proffered opinions. In this regard, the examiner must discuss and consider the Veteran's competent lay statements and the medical article offered in the August 2021 brief. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nestander, Jessica S. 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.