Citation Nr: 21064178 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 15-12 982 DATE: October 19, 2021 REMANDED Entitlement to a rating in excess of 10 percent for a skin disability including tinea versicolor and guttate psoriasis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1969 to October 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA), and has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107. In January 2019, the Board remanded this matter to obtain outstanding VA treatment records and a VA examination reflecting the current severity of the Veteran's skin disorder. On remand, the agency of original jurisdiction (AOJ) successfully obtained the outstanding VA treatment records. The Veteran attended a VA examination in March 2020. Regrettably, the Board finds that an addendum medical opinion is necessary to clarify whether any of the Veteran's topically applied corticosteroid treatments (including Clobetasol ointment) may be considered a systemic therapy under applicable regulations. See 38 C.F.R. § 4.118, DC 7806 (2018); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA provides a medical opinion it must be adequate for decisional purposes). 1. Entitlement to a rating in excess of 10 percent for a skin disability The Board notes that applicable regulations for rating skin disorders have changed for claims pending on August 13, 2018, and that such regulations should be followed if they are more favorable to the Veteran. See 83 Fed. Reg. 32,592 (July 13, 2018). However, the new regulations set bright line rules for what constitutes a "topical" versus a "systemic" treatment, and define a "systemic" treatment as "therapy administered through any route other than the skin." As such, the Board will apply the old criteria as it is potentially more favorable to the Veteran. Under the General Rating Formula for the Skin at 38 C.F.R. § 4.118, DC 7806, compensable ratings are determined by whether a treatment is "topical" versus "systemic", the duration of any systemic therapy, and the area and extent of the body affected. Under the old criteria, the term "systemic therapy" did not automatically include topical steroids, and the Board must make a case-specific factual determination. Johnson v. Shulkin, 862 F.3d 1351, 1355 (Fed. Cir. 2017). In Burton v. Wilkie, 30 Vet. App. 286, 291-92 (2018), the United States Court of Appeals for Veterans Claims (Court) held that a treatment must "pertain to or affect the body as a whole" in order to be considered systemic. The Court further held that the Board "must determine whether a topical treatment operates by affecting the body as a whole in treating the veteran's skin condition." Id. at 292. As an example, the Court held that a topical steroid may affect the body as a whole by circulating through the blood stream to treat a skin disease, and found that the Board may be required to obtain a medical opinion to assist with its determination. The Veteran has asserted that his topical corticosteroids should be considered a systemic therapy under applicable regulations. See generally NOD, March 2014. At the VA examination in March 2020, the examiner checked the box to indicate that the Veteran was treated with Clobetasol ointment (classified as Corticosteroids or other immunosuppressive medications) topically for 6 weeks or more, but not constantly. She stated that the Veteran had guttate psoriasis that was affecting the hands, palm, and trunk, but did not describe any current symptoms on the trunk. Unfortunately, based on the record, the Board is left in doubt as to whether the Veteran's topical corticosteroids may be considered a "systemic" therapy for rating purposes. Applicable law forbids the Board from exercising medical judgments that are outside its legal capacity, and, as stated above, topical steroids were not automatically considered to be a systemic therapy under the prior regulatory framework. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, this matter must be remanded for an addendum medical opinion addressing whether any of the Veteran's medications during the rating period may be considered systemic treatment under 38 C.F.R. § 4.118. This matter is remanded for the following actions: 1. Secure for the record copies of complete updated clinical records of all VA and non-VA treatment the Veteran has received for the disorders on appeal. 2. Obtain an addendum medical opinion from a suitable clinician regarding the skin disorder. The clinician is asked to review the Veteran's medications for his skin disorder since 2013. For each medication identified, including Clobetasol ointment, the clinician is asked to: (1) Note the duration of the treatment (if possible); and (2) Offer an opinion as to whether the medication can be medically classified as a "systemic" therapy A complete rationale should be provided for all opinions. The examiner is asked to consider and discuss relevant lay and medical evidence, to specifically include: VA examination report in March 2020, showing treatment for topically applied Clobetasol ointment for a period of 6 weeks or more, but not constant VA treatment records, including a report of dermatology consultation in January 2017 with application of phototherapy, and listings of the Veteran's active medications since 2013 Photographs submitted by the Veteran of his skin disability symptoms on his bilateral hands MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Reed, 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.