Citation Nr: 21063265 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-31 531 DATE: October 13, 2021 ORDER Entitlement to service connection for left knee strain is granted. Entitlement to an initial compensable disability rating for pseudofolliculitis barbae, also claimed as skin condition is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's left knee disability is caused by his service-connected lumbar disability. 2. The preponderance of the evidence shows the Veteran's pseudofolliculitis barbae has not manifested in at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected by the skin disability, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period is required. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee strain have been met. 38 U.S.C. §§ 1110,1131; 38 C.F.R. § 3.303, 3.304, 3.310. 2. The criteria for an initial compensable disability rating for pseudofolliculitis barbae, also claimed as skin condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7815. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2009 to November 2009 and from February 2013 to December 2013. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded these issues in March 2019 for further development, including issuing a Statement of the Case (SOC) addressing the issue of entitlement to an initial evaluation for posttraumatic stress disorder greater than 30 percent prior to May 2, 2017, and greater than 70 percent thereafter. The RO issued a SOC in May 2019. The Veteran failed to perfect his appeal for increased initial disability ratings for PTSD. As such, that issue is not before the Board. The Board finds there has been substantial compliance with the March 2019 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters are properly before the Board for adjudication. 1. Entitlement to service connection for left knee strain is granted. The Veteran contends service connection is warranted for a left knee strain. Specifically, he believes his left knee disability was aggravated and/or caused by a service-connected back disability. Service connection may be established on a secondary basis for a disability that is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may be established for a disorder that is caused or aggravated by a service-connected disability. Id. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 44748 (1995). To establish secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 511 (1998). The Veteran's left knee disability is well documented, and a February 2015 rating decision granted service connection for his lumbar strain, effective December 2013. Wallin elements (1) and (2) are met. Turning to element (3), a nexus dated January 2019, G.U., APRN, MN, FPN, LNC, provided a thorough and well supported private medical opinion indicating the Veteran's service-connected lumbar disability aggravated his left knee strain. She based her opinion on a review of the medical record and lay statements. G.U. explained the Veteran's lumbar disability caused an antalgic gait pattern and limping. She stated that a review of relevant medical literature shows gait and biomechanical changes hastened the development and progression of the left knee disability. G.U. also stated medical literature has linked knee pain to the biomechanical changes and alterations in antalgic gait patterns, abnormal forces in the lower extremity joints, and shifting of the normal center of gravity due to pain and painful motion. This asymmetry results in increased wear and tear in the knee joints with hastened degenerative changes. The Board acknowledges the record contains a negative October 2019 VA examination opinion. However, that report does not discuss whether the Veteran's service-connected lumbar disability aggravated his left knee. As such, the October 2018 VA report is inadequate because it fails to address the aggravation factor. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Board afford greater probative weight to G.U.'s medical report. The Veteran has satisfied Wallin element (3). In view of the totality of the evidence, the Board finds the medical evidence is at least in relative equipoise regarding this issue. When the evidence is in relative equipoise, the benefit of the doubt doctrine provides that such reasonable doubt will be resolved in favor of the Veteran. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to an initial compensable disability rating for pseudofolliculitis barbae, also claimed as skin condition is denied. The Veteran's skin disability is rated under Diagnostic Code 7815 for bullous disorders which instructs the rater to rate the disability under the General Rating Formula for the Skin unless the disability at issue involves complications and residuals of mucosal involvement. The Veteran's disability involves his jaw, chin, and neck area. 38 C.F.R. § 4.118, DC 7815. Disability ratings are based on VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The Veteran's entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found are warranted, a practice of assigning ratings referred to as staging the ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present. 38 C.F.R. § 4.2. If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the Veteran shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). During the pendency of the appeal, the rating criteria for evaluating was amended in August 2018 so that it more clearly reflects VA's policies concerning the evaluation of skin disorders, specifically, 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805 7806, 7813, 7815-7817, 7820-7822, and 7824-7829. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to August 7, 2018 and both the old and new rating criteria from August 7, 2018, and the criteria that is more favorable to the Veteran will be applied. Prior to the August 7, 2018 amendment, Diagnostic Code 7815 assigned a 10 percent disability rating where the skin disability affected at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas, or; there was evidence of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Under the new criteria, Diagnostic Code 7815 is evaluated under the General Rating Formula for the which assigns a 10 percent disability rating where at least one of the following is shown: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 38 C.F.R. § 4.118, DC 7815 (2021). The Board also notes 38 C.F.R. § 4.118 was amended to include subsection (a) which defined systemic therapy as any treatment that is administered through any route other than through the skin. 4.118(a) also defined topical therapy as treatment administered through the skin. The Veteran contends his service-connected pseudofolliculitis barbae should be granted a compensable disability rating. Specifically, the Veteran submitted a private medical report showing a 50 percent disability rating is warranted under Diagnostic code 7800 for burn scars, scars, or other disfigurements of the head, face, or neck. A February 2015 VA examiner stated the Veteran's disability did not cause scarring or disfigurement of the head, face, or neck. The skin disability did not cause systemic manifestations and only required intermittent topical treatment for six or more weeks. Specifically, the Veteran was prescribed Retin A, a retinoid, for treatment of his skin condition. The examiner noted the disability occupied less than five percent of his total exposed and nonexposed body surface, with evidence of a few hyperpigmented macules and papules on the inferior and anterior cheeks. The examiner stated the Veteran did not have treatments or procedures other than topical medication in the past 12 months for his skin condition. An April 2017 VA examiner noted the skin disability did not cause scarring or disfigurement of the head, face, neck, nor was there evidence of systemic manifestations. The 2017 examiner stated the Veteran required intermittent topical corticosteroid treatment for six or more weeks to treat razor bumps. No systemic corticosteroids or other immunosuppressive medications were used for treatment of his condition. The examiner noted the disability occupied less than five percent of his total and exposed body area. There was evidence of raised and hyperpigmented razor bumps to inferior cheeks and anterior neck. The examiner stated the Veteran did not have any treatments or procedures other than topical medication in the past 12 months for his skin condition. An October 2019 report explained the topical steroid only treats the Veteran's skin condition, and is not systemic because it does not affect the body as a whole. The VA examiner found no credible medical evidence suggesting topical corticosteroid use has systemic affects. The Veteran underwent a VA examination in October 2020. The examiner stated the Veteran required topical steroid treatment for acute exacerbations of pseudofolliculitis barbae, as needed, for a total duration of less than six weeks in the past 12-month period. The examiner stated the Veteran did not have any treatments or procedures other than topical medication in the past 12 months for his skin condition. The examiner noted the disability occupied less than five percent of his total and exposed body area. There was evidence of small, red, raised bumps along the shaving line consistent with the diagnosis. The Board has carefully reviewed the evidence of record and finds that a compensable disability rating is not warranted under the either the old or new rating criteria for his service-connected pseudofolliculitis barbae. The preponderance of the evidence shows the Veteran's skin disability did not affect at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas, or; required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. As such, a compensable disability rating is not warranted under the former Diagnostic Code. The revised rating criteria assigns a 10 percent disability rating where the evidence shows characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. The 2015 VA examination report shows the Veteran was prescribed topical retinoid treatment. However, § 4.118(a) defines topical therapy as treatment administered through the skin and systemic therapy as any treatment that is administered through any route other than through the skin. As such, the Veteran does not meet the requirements under the amended rating criteria and a compensable disability rating is not warranted. The Board also considered G.U.'s private medical opinion dated January 2019. She opined that the Veteran's skin disability warrants a 50 percent disability rating under Diagnostic Code 7800 because his disability disfigured his entire bearded area and exhibit five distinct characteristics of disfigurement. G.U. based her opinion on review of photographs from January 2019. The Board finds the VA examination reports of 2015, 2017, 2019, and 2020 more probative. The 2015, 2017, and 2020 VA examiners reviewed the Veteran's medical record, considered lay statements, and conducted an in-person examination. They found no evidence the skin condition on appeal caused scarring or disfigurement of the head, face, or neck. Moreover, treatment records do not show the Veteran suffered from scarring or disfigurement of the face or neck due to pseudofolliculitis barbae. G.U. believes the January 2019 photographs of the bumps on the Veteran's neck and cheeks are evidence of disfigurement. The Board disagrees. Razor burn, the common term for pseudofolliculitis barbae, is a disfigurement and does not warrant a disability rating under Diagnostic Code 7800 which clearly states that the characteristics of disfigurement are scars five or more inches longer, scars at least one-quarter inch wide, elevated surface contour of scar or depressed on palpation, scar adherent to underlying issue, hypo or hyperpigmented skin area exceeding six square inches, abnormal skin texture, missing underlying soft tissue exceeding six square inches, or indurated and inflexible skin exceeding six square inches. The evidence shows the Veteran's face and neck erupted after beginning to shave. The Board finds G.U.'s application of Diagnostic Code 7800 misplaced and is an inaccurate assessment of the Veteran's disability. Therefore, the Board the in-person VA examinations to be more probative. The Veteran is competent to provide evidence concerning his service-connected skin disability and treatment received. However, the preponderance of the evidence is against a finding that the Veteran's pseudofolliculitis barbae at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected by the skin disability, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period is required. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has considered other diagnostic codes and finds that the preponderance of the evidence substantiates that the Veteran is not entitled to a compensable rating under any other codes not already discussed. Accordingly, the Board finds that the claim of entitlement to an initial compensable disability rating for pseudofolliculitis barbae is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against assigning a compensable rating, that doctrine is not applicable. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, 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.