Citation Nr: 21063651 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 16-02 757 DATE: October 15, 2021 ORDER Entitlement to an increased 20 percent disability rating, but no higher, for service-connected partial amputation of distal right first toe with right foot Morton's neuroma (a right great toe disability), from June 4, 2013, forward is granted. Entitlement to a disability rating in excess of 10 percent for a service-connected right great toe disability prior to June 4, 2013 is denied. Entitlement to a separate compensable rating for a scar, status post partial amputation of distal right 1st toe with Morton's neuroma, prior to May 8, 2013, is denied. Entitlement to an initial 10 percent rating, but no higher, for service-connected psoriasis with seborrheic dermatitis prior to May 8, 2013 is granted. Entitlement to a disability rating in excess of 30 percent rating for service-connected psoriasis with seborrheic dermatitis from May 8, 2013, forward is denied. Entitlement to a separate compensable rating for disfigurement of the scalp and face associated with psoriasis, prior to May 8, 2013, is denied. Entitlement to a disability rating in excess of 10 percent for disfigurement of the scalp and face associated with psoriasis from May 8, 2013, forward is denied. FINDINGS OF FACT 1. The probative medical evidence of record reflects that the symptoms of the Veteran's right great toe disability resulted in moderately severe disability from June 4, 2013. 2. Prior to June 4, 2013, the Veteran's right great toe disability did not manifest amputation of the great toe with removal of the metatarsal head or moderately severe disability. 3. Prior to May 8, 2013, the Veteran's right toe scar was not painful, unstable, or of an area of 39 square centimeters or more. 4. Prior to May 8, 2013, the Veteran's psoriasis required intermittent topical corticosteroids for a duration of less than 6 weeks during the previous 12 months. 5. From May 8, 2013, the Veteran's psoriasis did not affect 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy. 6. Prior to May 8, 2013, the Veteran's psoriasis seborrheic dermatitis did not cause a characteristic disfigurement of the head, face, or neck for VA purposes. 7. From May 8, 2013, the Veteran's psoriasis with seborrheic dermatitis caused two or three characteristics of disfigurement of the head, face, or neck for VA purposes. CONCLUSIONS OF LAW 1. The criteria for a 20 percent disability rating, but no higher, for the Veteran's service-connected right great toe disability from June 4, 2013 have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, Diagnostic Codes 5171, 5284. 2. The criteria for a disability rating in excess of 10 percent for the Veteran's service-connected right great toe disability prior to June 4, 2013 have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, Diagnostic Codes 5171, 5284. 3. Prior to May 8, 2013, the criteria for a separate compensable rating for a scar, status post partial amputation of distal right 1st toe with Morton's neuroma, have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7805. 4. The criteria for an initial 10 percent rating prior to May 8, 2013 for service-connected psoriasis with seborrheic dermatitis have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7816. 5. The criteria for a rating in excess of 30 percent for service-connected psoriasis with seborrheic dermatitis from May 8, 2013 have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7816-7806. 6. The criteria for a separate rating for disfigurement of the scalp and face associated with psoriasis prior to May 8, 2013, and a disability evaluation in excess of 10 percent for disfigurement of the scalp and face associated with psoriasis from May 8, 2013 have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7800. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1979 to June 1983, from August 1986 to October 1995, and from March 1999 to December 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from several rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). It was previously before the Board in April 2020, where it was remanded for additional development. It has since returned for further appellate review. The Veteran testified before the undersigned Veterans Law Judge in November 2019, a transcript of which is of record. Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. By way of background, in August 2012, the RO reinstated an award of service connection for psoriasis and assigned a noncompensable disability rating under Diagnostic Code 7816, effective January 1, 2010. The Veteran submitted a notice of disagreement (NOD) in September 2012, and the RO issued a statement of the case (SSOC) in March 2013. In May 2013, within one year of the August 2012 rating decision, the Veteran submitted additional relevant evidence, including medical treatment records dated in October 2012 and February 2013. As the Board noted in its previous remand, since the RO did not issue a supplemental statement of the case (SSOC), the August 2012 rating decision did not become final and is on appeal. See 38 C.F.R. §§ 19.31, 20.302(b)(2). In a February 2014 rating decision, the RO assigned a 30 percent rating for the Veteran's psoriasis, effective May 8, 2013. The RO also awarded a separate 10 percent rating for disfigurement scalp and face associated with psoriasis under Diagnostic Code 7800, effective May 8, 2013. The Veteran maintains that the separate rating for disfigurement should be higher and should be effective January 1, 2010. See Statement in Support of Claim, dated March 3, 2015; VA Form 9, dated January 16, 2016; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (the assignments of separate ratings under several diagnostic codes is permitted for separate and distinct manifestations from the same injury, provided none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). In a March 2014 rating decision, the RO granted service connection for partial amputation of distal right first toe with right foot Morton's neuroma (previously rated as amputation of distal aspect of first and second distal phalanges under Diagnostic Code 5199-5282) with an evaluation of 10 percent under Diagnostic Code 5171; partial amputation of distal right second toe with Morton's right foot neuroma (previously rated as amputation of distal aspect of first and second distal phalanges under Diagnostic Code 5199-5282) with a noncompensable (0 percent) evaluation under Diagnostic Code 5173; and a scar, status post amputation of distal right 1st toe with Morton's neuroma, with an evaluation of 10 percent, each effective May 8, 2013. In a November 2015, the RO assigned earlier effective dates of January 1, 2010, for the 10 and 0 percent ratings under Diagnostic Codes 5171 and 5173 for the Veteran's first and second toes, respectively. The Veteran perfected an appeal of the 10 percent rating assigned for partial amputation of distal right first toe with right foot Morton's neuroma, as well as the matter of whether a separate 10 percent rating is warranted for the scar, status post amputation of distal right first toe with Morton's neuroma, from January 1, 2010 to May 7, 2013. See VA Form 9, dated January 16, 2016. In April 2020, the Board remanded the Veteran's claims for additional VA examinations, as he has that his disabilities have worsened. See November 2019 Hearing Transcript. The examinations were provided in November 2020. Based on the results of the examinations, the Veteran's ratings were continued in a November 2020 SSOC. 1. A disability rating in excess of 10 percent for a right great toe disability The Veteran's service-connected right toe disability is currently rated as 10 percent disabling from January 1, 2010, the day following the Veteran's final period of active service, under 38 C.F.R. § 4.71a, Diagnostic Code 5171 for amputation of the great toe. A 10 percent rating is warranted for a great toe amputation without metatarsal involvement. A maximum, 30 percent rating is warranted for a great toe amputation with removal of the metatarsal head. The Veteran's service treatment records (STRs) prior to his December 31, 2009 discharge note complaints of foot pain relating to a partial toe amputation of the right great toe and adjacent toe that occurred in 2005. In January 2009, the Veteran reporting a burning sensation in the right foot and asked for referral for an "EMG type study." In May 2009, the Veteran reported chronic right foot pain on a level of 4-6 on a scale of 0-10. During a September 2010 VA knee examination, the Veteran noted no complaints regarding any symptoms related to his right foot, and he was noted to walk with a normal gait. The examiner noted that the Veteran's right great toe was slightly shorter than the left due to his in-service injury. While examination of the Veteran's feet noted abnormal weight bearing, there were no signs of symptoms of shoe wear pattern or breakdown, and the Veteran was not noted to require any assistive device for ambulation. No scar was identified on the Veteran's right foot. Although the Veteran filed his original service connection claim in 2010, within one year of his separation from service, VA examinations specifically for his right great toe disability claim were not afforded until October 2012, specifically a VA amputations examination and a VA foot conditions examination. Examination of the Veteran's right foot revealed a previous amputation of the distal aspect of the first and second phalanges (i.e., the right great toe and the adjacent toe). The skin over the right first and second digits had healed so that there was no apparent residual scar that was noticeable. On June 4, 2013, the Veteran reported to his private physician, Dr. M.D., that he was experiencing "chronic foot problems." He stated that he has had ongoing pain since his in-service injury. Physical examination revealed slight sensitivity at the bases of the second, third and fourth toes of the right foot. There was no restricted range of motion. Dr. M.D. diagnosed the Veteran with [n]euritis/neuroma like symptoms second and third right interspace," and "[p]ossible complex regional pain syndrome secondary to crush injury." After this evaluation, the Veteran began treatment with corticosteroid injections. A follow-up examination in September 2013 noted that the Veteran's "second and third interspace" remained sensitive in the right foot. Additional VA foot and amputations examinations were afforded in March 2014. The Veteran reported that his condition began when car lift crushed right foot, causing partial amputation of the tips of the right first and second toes, and that his residuals have worsened. He reported that he developed post-traumatic neuromas in the right foot second and third inter-toe web spaces and increased pain, tingling, and numbness. Physical examination revealed an antalgic gait due to right foot pain. While a scar was also noted as associated with the Veteran's toe amputation, it was not painful and/or unstable, and was only of a total area of 1.0 cm by 0.3 cm square centimeters. The examiner opined that the Veteran's neuroma was secondary to his in-service injury, explaining that the crush injury on the right forefoot will cause post-traumatic scarring and inflammation. This tissue build-up will result in impingement of the interdigital nerves between the toe joints, predisposing to the development of a post-traumatic neuroma. The examiner further opined that the functional impact of the Veteran's right foot condition is impaired ambulation. A May 2015 private treatment record notes decreased range of motion in the right hindfoot subtalar, with tenderness on palpation of the ball of the foot. The Veteran's gait was noted to be antalgic in supinated posture in order to avoid full contact with the ball of the foot. Pursuant to the Board's previous remand, additional VA foot conditions and amputations examinations were afforded in November 2020. After interview and examination, the examiner noted that the in-service amputation occurred at the distal portion of the toe, and it was promptly and successfully re-attached. Over time, he also developed severe right foot Morton's neuroma. Examination of the right foot noted moderately severe pain under right forefoot with ambulation and marked tenderness under the plantar right forefoot between the first and second metatarsal heads and the second and third metatarsal heads. Specifically, as to the Veteran's amputation, inspection of the toe did not reveal any scars, which the examiner noted likely disappeared over time. There was mild tenderness on the distal toe. The examiner opined that the overall severity of the right foot Morton's neuroma status post-surgery was moderately severe. As to specific functional impairment, the examiner state that "there will be impairment of physical activities of employment such as being unable to walk longer than 30 min without pain; unable to stand for longer than [one hour] without pain; cannot run for longer than [one third of a] mile without pain; unable to climb any distance without pain; and unable to carry things heavier than 20 [pounds] without pain." The Veteran's remaining medical treatment records are not in significant conflict with the above. Based on the foregoing, the Board does not find that a higher rating is available under Diagnostic Code 5171 for amputation of the great toe at any point during the appeal period, as the medical evidence of record does not reflect that the amputation resulted in removal of the metatarsal head. Consequently, the overall evidence of record does not show symptomatology warranting a rating in excess of 10 percent for the right great to disability. 38 C.F.R. § 4.71. However, the Board may nevertheless consider whether a higher disability rating is warranted for the right great toe disability under a different diagnostic code. A higher rating is not warranted under Diagnostic Code 5279 for anterior metatarsalgia (i.e., the Veteran's Morton's disease), however, as that code only provides a maximum 10 percent rating. Diagnostic Code 5284 for other foot injuries is also available. Under Diagnostic Code 5284, a 10 percent evaluation is available for a moderate disability, a 20 percent evaluation is warranted for a moderately severe disability, and a maximum 30 percent disability rating is warranted for severe disability. 38 C.F.R. § 4.71a. The words "moderate," "moderately severe," and "severe" are not defined by Diagnostic Code 5284. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decision is "equitable and just." 38 C.F.R. § 4.6. VA's General Counsel has determined that Diagnostic Code 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion. VAOPGCPREC 9-98. Here, the Veteran's symptoms manifest a level that more closely approximates moderately severe symptoms from June 4, 2013, the date his Morton's neuroma and its associated symptoms was diagnosed. At this time the Veteran reported chronic pain in the ball of his right foot, and a physical examination noted tenderness in the second and third interspaces of the right foot, and very little sensitivity on the first or fourth interspaces. As noted above, the Veteran began injection treatments at this time. A May 2015 private treatment record notes decreased range of motion in the right hindfoot subtalar, tenderness on palpation of the ball of the foot, and the Veteran presenting with an antalgic gait in order to avoid full contact with the ball of the foot. Upon VA examination in March 2014, the Veteran's gait was noted to be antalgic due to his foot pain. In November 2020, a VA examiner noted that, despite 2014 surgery on the Veteran's right foot, examination demonstrated marked tenderness under the plantar right forefoot between the first and second metatarsal heads and the second and third metatarsal heads. The examiner opined that the overall severity of the right foot disability was moderately severe. As such, the Board resolves all doubt in the Veteran's favor in finding that a higher 20 percent rating is warranted from June 4, 2013, the earliest date of his Morton's neuroma diagnosis that was determined to be secondary to his right great toe disability. Prior to June 4, 2013, however, the record does not reflect a level of impairment that more closely approximates moderately-severe symptoms. Although limited, the Veteran was able to walk, and objective evidence did not indicate any additional symptoms beyond pain. At no time during the period on appeal does the objective medical evidence of record reflect a severe level of disability to warrant an even higher, 30 percent rating. Thus, entitlement to an increased, 20 percent rating, but no higher, for the Veteran's right great toe disability from June 4, 2013, is granted. 2. A separate compensable percent rating for a right great toe scar prior to May 8, 2013 The Veteran has been awarded a 10 percent rating for a scar associated with his in-service toe amputation with Morton's neuroma under Diagnostic Code 7804, as of May 8, 2013. He asserts that a separate, compensable rating is warranted for his toe scar prior to that date. Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. The Schedule of ratings for the skin were amended effective August 13, 2018. See 83 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the old version of the diagnostic codes only (old code); however, for the period beginning August 13, 2018 the Board will consider both the old and amended version (amended code) of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Diagnostic Code 7800 deals with scars and disfigurement of the head, face, or neck and, while not revised by the recent regulatory amendments, is not relevant to the current claim. Diagnostic Code 7801 provides for a 10 percent disability evaluation for a scar that is not of the head, face, or neck, that is deep and nonlinear (old code) or associated with underlying soft tissue damage (amended code), and that has an area of at least 6 square inches (39 sq. cm.). Higher ratings are available if larger areas are affected. Under the old code, a "deep scar" is defined as one associated with underlying soft tissue damage. The old and amended codes also differ regarding instructions for totalling the area affected when there is more than one qualifying scar. Diagnostic Code 7802 provides for a 10 percent disability evaluation for a scar not of the head, face, or neck, that is superficial and nonlinear (old code) or not associated with underlying soft tissue damage (amended code) and which covers an area of at least 144 square inches (929 sq. cm.) or more. No higher ratings are available under either version of this code. Under the old code, a "superficial scar" is defined as one not associated with underlying soft tissue damage. The old and amended codes also differ regarding instructions for totalling the area affected when there is more than one qualifying scar. Diagnostic Code 7804 provides for a 10 percent disability evaluation for one or two scars that are unstable or painful. A 20 percent disability evaluation is assigned where there are three or four scars that are unstable or painful. A 30 percent disability evaluation is assigned where there are five or more scars that are unstable or painful. An unstable scar is one where there is frequent loss of skin covering over the scar. If one or more scars are both unstable and painful 10 percent is added to the evaluation. Under the new and amended codes, pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of Diagnostic Codes 7800 to 7804. Turning to the evidence, while an October 2012 VA examination noted that the skin over the right first and second digits had healed so that there was no apparent residual scar that was noticeable, a March 2014 VA amputation examination does note a visible 1-centimeter by 0.3-centimeter scar on the great toe. Additionally, a May 2015 private treatment record notes non-tender "[m]ature scars" over the "dorsum of feet" consistent with neuroma excision, nontender. Based on the foregoing, while the Veteran's right toe scar was apparently present prior to May 8, 2013, it was not shown to be painful, unstable, or to have a total area equal to or greater than 39 square centimeters. Rather, the scar measures only 1-centimeter by 0.3-centimeter. Therefore, it is not of a severity to warrant a separate, compensable rating based on the rating criteria for scars prior to May 8, 2013. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. 3. An initial compensable rating prior to May 8, 2013, and in excess of 30 percent thereafter, for psoriasis with seborrheic dermatitis The Veteran was awarded service-connected for psoriasis with seborrheic dermatitis in an August 2012 rating decision and was assigned an initial noncompensable rating. In February 2014, the disability rating was increased to 30 percent. The Veteran asserts that higher ratings are warranted. Again, the Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. Prior to August 13, 2018, the Board will consider the old version of the diagnostic codes only (old code); however, for the period beginning August 13, 2018 the Board will consider both the old and amended version (amended code) of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Prior to August 13, 2018, the Veteran's skin disability was rated under Diagnostic Code 7816 for psoriasis, which was to be evaluated under the General Rating Formula for the Skin. 38 C.F.R. § 4.118. Under Diagnostic Code 7816, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for 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 affected, or; 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. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7816. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: 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. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is psoriasis. The Board finds that the preponderance of the evidence is in favor of an initial 10 percent rating under the pre-August 13, 2018 regulations for the period on appeal prior to May 8, 2013. While the Veteran's psoriasis did not more nearly approximate 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 affected, the record reflects the use of topical systemic therapy for a total duration of less than six weeks during the past 12-month period. Notably, a VA examination was afforded to the Veteran in February 2012, where psoriasis was diagnosed. While a physical examination indicated that the Veteran's psoriasis affected less than 5 percent of the total body area and total exposed area, he reported the use of topical corticosteroids for a duration of less than 6 weeks during the past 12 months. Additionally, the Veteran provided a private medical treatment record from Dr. J.S. dated October 2012. While the Veteran's psoriasis was now noted to affect the scalp and face, it was again noted to only affect "4 to 5% [body surface area]." He was instructed to continue using topical corticosteroids as needed. As the Veteran was treating his trunk, extremities, and face and scalp with topical corticosteroid, the Board finds that the treatment affected the body as a whole for the purposes of the pre-August 13, 2018 regulations as they pertain to systemic therapy. A 30 percent rating is not warranted, however. While the Board acknowledges that the Veteran responded to a March 2013 Statement of the Case that continued his initial 0 percent rating by providing the aforementioned records form Dr. J.S., as noted above these records do not indicate that the Veteran's psoriasis affected 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7816. For the period on appeal from May 8, 2013, the evidence is against a rating in excess of 30 percent under either the pre- or post-August 13, 2018 regulations. The record does not reflect that the Veteran's psoriasis affects more than 40 percent of the entire body or more than 40 percent of exposed areas affected or requires constant or near-constant systemic therapy. Private medical treatment records from December 2013 indicate that the Veteran's psoriasis covered 5 to 10 percent of the body and that topical medication was continued. Records provided by Dr. R.H. dated January 2015 note "recalcitrant, red and scaly skin rash of moderate to severe severity on the face, eyebrows, lips, ear, scalp and neck for weeks, which is aggravated by stress." A skin biopsy now indicated seborrheic dermatitis, and the Veteran's condition was noted to now involve at least 5 percent but less than 20 percent of the entire body, requiring intermittent systemic therapy. A short course of the systemic corticosteroid Prednisone was prescribed for 14 days. Subsequent treatment records form Dr. R.H. continue to show the Veteran being treated to skin rashes on the head, trunk, and extremity, aggravated by stress. Treatment records dated between late 2015 and late 2019 note treatment with topical creams/gels and a shampoo. A VA examination afforded most recently in November 2020 note consistent treatment with topical creams and shampoo. Physical examination indicated that the Veteran's psoriasis covered less than 5 percent of the total body area, and that his dermatitis covered between 5 percent but less than 20 percent of the total body area, and 20 to 40 percent of the total exposed area. Again, effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin. While the Board acknowledges the Veteran's constant use of topical creams during this particular period on appeal for which he is in receipt of a 30 percent rating, this treatment is not considered systemic, and the record does not reflect that Prednisone, and oral therapy, was prescribed for the duration necessary for the next higher rating. Additionally, the Veteran's skin condition does not cover 40 percent or more of his total body or the total area affected. See 38 C.F.R. § 4.118, Diagnostic Code 7816. In conclusion, while the Board finds the evidence in favor of a 10 percent rating, but no higher, prior to May 8, 2013, a rating in excess of 30 percent is not warranted for the period thereafter. 4. A separate rating for disfigurement of the scalp and face associated with psoriasis prior to May 8, 2013; a rating in excess of 10 percent for disfigurement of the scalp and face associated with psoriasis from May 8, 2013 The Board also notes that the Veteran is in receipt of a separate 10 percent rating under Diagnostic Code 7800 for disfigurement of the scalp associated with his psoriasis from May 8, 2013. He asserts that a separate rating should be afforded for the period prior, and that a higher rating is warranted for the period thereafter. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar 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 warrants a 30 percent rating. A scar 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 warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion 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 warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. While VA amended the criteria for rating skin disabilities effective from August 13, 2018, Diagnostic Code 7800 was not changed by these amendments. Here, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7800. While January 2014 and November 2020 VA scars examination note a number of "erythematous macules with exfoliation," neither examination indicates visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or two or three characteristics of disfigurement. As to the Veteran's contention that this separate compensable rating is warranted prior to May 8, 2013, the available medical records, to include his initial VA examination in 2012, are absent at least one characteristic of disfigurement under Diagnostic Code 7800, such as scarring or a skin condition in an area exceeding six square inches. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's disfigurement of the scalp is not deep and non-linear, is not associated with underlying soft tissue damage, is not unstable or painful, and does not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. In sum, as the evidence is against a finding that a separate rating prior to May 8, 2013, or a rating in excess of 10 percent, thereafter, is warranted under Diagnostic Code 7800, these claims must be denied. As to all of the increased ratings claims addressed above, the Board is sympathetic to the Veteran's lay statements that his disabilities are worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disability have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.