Citation Nr: 21063965 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 14-21 744 DATE: October 18, 2021 ORDER Entitlement to service connection for a skin disorder, to include porphyria cutanea tarda as due to herbicide agent exposure, is denied. FINDING OF FACT The Veteran's skin disorder did not originate in service or until years after service and is not otherwise etiologically related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from April 1968 to March 1972. This issue comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Veteran testified at a hearing before a Veterans Law Judge of the Board who is no longer active. A transcript of the hearing is associated with the record. In September 2021 correspondence, the Veteran was given the opportunity to request another hearing and was notified that if he did not provide a response in 30 days, it would be assumed that he did not want another hearing. The Veteran did not respond to the letter; therefore, the Board will proceed with adjudication of the Veteran's claims. This case was previously before the Board in August 2018. The Veteran's claim was remanded for additional development. The case is now again before the Board for further appellate action. Entitlement to service connection for a skin disorder, to include porphyria cutanea tarda as due to herbicide agent exposure, is denied. The Veteran contends that he has a skin disorder that was caused by his active service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when: (1) the weight of the evidence supports the claim, or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). VA regulations provide that if a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease (including atherosclerotic cardiovascular disease, which includes coronary artery disease). 38 C.F.R. § 3.309(e). A veteran, who during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 39 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Turning to the evidence, the Veteran's DD Form 214 indicates that he served in Vietnam during his active service from April 1968 to March 1972. A January 1970 service treatment record reported that the Veteran had a ganglionectomy to remove a left wrist ganglion. Other than the left wrist ganglion removed in January 1970, a review of the Veteran's service medical records does not reflect any complaints, findings, or treatment for any conditions related to a skin disorder, A February 1972 report of medical history documented the Veteran's negative response to whether he ever had a skin disease. A February 1972 separation medical examination reported the Veteran's skin was normal. A November 1984 VA examination reported that the Veteran lost part of his lung due to cancer and that he was losing his temper easily. Otherwise, the Veteran reported not having any medical problems since his last examination in July 1984. The Veteran was provided a VA examination for residuals of his right lung squamous cell carcinoma in May 1994. A review of the Veteran's systems did not report any skin disorders. His extremities were reported as normal. A January 2009 VA physician outpatient note reported that a review of the Veteran's skin indicated it was blistering. He was diagnosed with a skin rash. An April 2010 VA Agent Orange program note reported that the Veteran complained of chronic rashes on forearms (due to sun exposure) and in his groin. He denied suspicious lesions, pruritis, bruising, or swelling. An examination of the Veteran's skin found it to be warm and dry without rashes or suspicious lesions. An August 2010 VA surgery note reported that, for at least 20 years, the Veteran's skin blisters and itches when he is out in the sun. His lesions eventually heal but leave him scarred. A physical examination from the waist up shows multiple actinic keratosis type lesions over his bilateral forearms. His back, face, and ears do not exhibit any flaking or skin changes, though there is a large amount of freckling and hypopigmentation. The plan was to excise some skin on the right forearm and perform cryosurgery on the remaining actinic keratoses. An August 2010 VA pathology report indicated that the pathology results of the skin lesion excision determined that the lesions were prurigo nodularis. In April 2014, the Veteran submitted a VA Form 9 in which he expressed that he had irritation of his skin disorder every day. He stated his biopsy was negative because it was not inflamed at the time. A July 2014 private dermatology consult reported that teledermatology imaging found the Veteran to have hypertrophic pink plaque with scale. The diagnosis was hypertrophic actinic keratosis vs. squamous cell carcinoma in situ. An April 2015 VA outpatient note reported that the Veteran retired in December 2014 and was now working outside "a lot." No skin complaints were noted. An October 2015 VA outpatient note reported that the Veteran's skin was clear. The Veteran reported he was doing well and working outside. In August 2016, the Veteran's wife submitted a VA Form 21-4138, Statement in Support of Claim, in which she reported "[d]uring 1974 and 1975, years of dating and the first year of marriage, I do not recall the blisters, sores or what seems to be a fever after being outside. In the years that have followed it had been evident, sometimes mild and often severe, depending on the length of time spent in the sun." The Veteran's marriage certificate shows that he was married to his wife on December 26, 1975. A June 2018 VA outpatient note reported that the Veteran denied rashes or suspicious skin lesions but reported a sensitivity to sun exposure. The examining physician reported the Veteran's skin was warm and dry with good turgor. The Veteran was provided a VA skin diseases examination in October 2019. The Veteran reported that he developed skin lesions, to include blisters, during the summer of 1972. He denied having the skin condition during service. He reported it developed within 3 to 4 months after separation from service. The Veteran described his skin condition as red, itchy, blistering lesions that he gets while exposed to the sun. He stated that the blisters are followed by crusting, and eventually scarring. He reported the skin lesions appear on his bilateral arms, hands, and neck, face, and ears if he does not wear protective headgear. Alleviating factors include protective clothing and staying out of the sun. It was reported that the Veteran had not been treated with medication in the past 12 months for the skin condition. The examiner reported that the Veteran's report of scarring is at least as likely as not skin color changes due to the Veteran's skin condition. After performing the in-person examination and reviewing the Veteran's VA claims folder, the examiner opined that the Veteran's skin disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that the Veteran currently does not have a diagnosis of porphyria cutanea tarda. The Veteran's February 1972 separation examination was marked "NORMAL" on "SKIN, Lymphatics" on clinical evaluation and the Veteran marked "NO" to "SKIN DISEASES." The examiner noted that there was no available medical evidence of ongoing complaint, treatment, and/or diagnosis following separation from service of a skin condition until 2010 (38 years after separation from service). Therefore, the examiner opined that the Veteran does not have a diagnosis of porphyria cutanea tarda that is at least as likely as not incurred in or caused by herbicide exposure during service and/or that manifested itself within one year from the date of discharge from active duty service. After carefully reviewing multiple lay statements and testimony of the Veteran and his wife regarding the Veteran's skin disorder, the examiner found that there is no historical definitive diagnosis of porphyria cutanea tarda. The Veteran has assumed a diagnosis of porphyria cutanea tarda based on his reading of the description of the disorder in VA's Agent Orange Newsletter. The Veteran has attempted on several occasions to obtain a definitive diagnosis of porphyria cutanea tarda by various dermatologists who to date have not diagnosed the Veteran with porphyria cutanea tarda. The examiner explained that, in 2010, the Veteran had a skin biopsy of a skin lesion that he described as "blisters on skin area when exposed to the sun on areas that are not covered" that demonstrated to be prurigo nodularis. The Veteran was noted to have "hypertrophic pin plaque w/scale" on his bilateral forearms in 2014 that was diagnosed as actinic keratosis vs. squamous cell carcinoma in situ. Veteran had the bilateral skin lesions treated with cryotherapy and the "medical records did not show a return of the bilateral skin lesions (at least as likely as not actinic keratosis with no return of skin lesions noted in medical records)." The Veteran was evaluated by an outside VA dermatologist in November 2016 who would not make a definitive diagnosis of the Veteran's subject history of a skin condition since 1972, as the Veteran had no skin lesions at the time of the dermatology evaluation to perform a skin biopsy to make definitive diagnosis by pathology. The dermatologist noted "possible PCT by history versus something like polymorphous light eruption." The examiner concluded that there does not appear to be enough medical evidence to make a nexus for the Veteran's diagnosis of prurigo nodularis noted in his medical records 38 years after separation from service with the Veteran's subjective history of a skin condition and/or the Veteran's subjective lay evidence provided by his wife. The examiner explained that the medical evidence does not show that the Veteran's diagnosis of prurigo nodularis in 2010 and/or actinic keratosis vs squamous cell carcinoma in situ in 2014 began in or was made worse during service, manifested itself within one year from the date of discharge from active duty service, or manifested as a skin condition with persistent and recurrent symptoms showing chronic treatment following separation from service. Therefore, examiner's opinion was that the Veteran's current definitive diagnosed skin condition is less likely than not incurred in or caused by the Veteran's in-service skin condition, to include due to herbicide exposure. A June 2020 VA community care note reported the following impression: "Clinical scenario fits with PCT [porphyria cutanea tarda] vs. PMLE [polymorphous light eruption]. Can largely rule out PCT via porphyrin screen and LFT's [liver function tests]." It was noted that a biopsy could be done if the lesions present again. A new diagnosis of porphyria cutanea tarda distributed on the arms and neck was noted. A July 2020 private clinical laboratory analysis of porphyrin fractionation was completed. The interpretation concluded that one or more porphyrins were minimally elevated in a pattern not consistent with a porphyria. An August 2020 VA telephone encounter note indicated the Veteran's chronic medical conditions include porphyria cutanea tarda. The Veteran reported he had general skin sensitivity to sunlight. He was diagnosed with porphyria cutanea tarda. As previously described, the Veteran's service treatment records show no complaints, findings, or treatment for any conditions related to a skin disorder, other than the left wrist ganglion removed in January 1970. A February 1972 report of medical history documented the Veteran's negative response to whether he ever had a skin disease, and a February 1972 separation medical examination reported the Veteran's skin was normal. The first documented complaint of skin disorder was in 2009, more than 36 years after the Veteran's discharge from active service. A July 2020 private clinical laboratory concluded that one or more porphyrins were minimally elevated in a pattern not consistent with a porphyria. A lay person is competent to address etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, however, the record dates the onset of the Veteran's skin disorder to years after separation from active service and the question of causation extends beyond an immediately observable cause-and-effect relationship. As such, the Veteran is not competent to address the etiology of his claimed skin disorder. Although the Veteran contends that his skin disorder began during the summer after he was discharged from active service in March 1972, the Veteran's wife stated that she does not recall the Veteran having blisters or sores during their first year of marriage. The Veteran and his wife were married on December 26, 1975. Moreover, the earliest documented evidence of a skin disorder was in January 2009, more than 36 years after the Veteran's discharge. Consequently, the Board gives more probative weight to the October 2019 December 2019 examination report and medical opinion. After performing the in-person examination and reviewing the Veteran's VA claims folder, the examiner opined that the Veteran's skin disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that the Veteran denied having a skin disorder at his 1972 separation examination and there was no available medical evidence of ongoing complaint, treatment, or diagnosis of a skin disorder following separation from service until 2010. The examiner noted that the Veteran did not have a diagnosis of porphyria cutanea tarda at the time of the October 2019 examination. The examiner explained that the medical evidence does not show that the Veteran's diagnosis of prurigo nodularis in 2010 and/or actinic keratosis vs squamous cell carcinoma in situ in 2014 began in or was made worse during service, manifested itself within one year from the date of discharge from active duty service, or manifested as a skin condition with persistent and recurrent symptoms showing chronic treatment following separation from service. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for a skin disorder. 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 the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the Veteran's claim for a skin disorder must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore, 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.