Citation Nr: 21065004 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 14-19 962 DATE: October 22, 2021 REMANDED Entitlement to a compensable rating for tinea cruris is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1965 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In an August 2018 rating decision, the Board denied the Veteran's claim for a compensable rating for tinea cruris. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In September 2018, pursuant to a Joint Motion for Remand (JMR), the Court vacated the August 2018 decision and remanded the matter to the Board for action consistent with the Joint Motion. The Board remanded the issue in March 2020, April 2021, and June 2021 for additional development. Unfortunately, there has not been substantial compliance with the prior remand. Therefore, another remand is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to a compensable rating for tinea cruris The June 2021 remand directed the RO to obtain a new examination to determine the severity of the Veteran's service-connected skin condition. A new examination was obtained in July 2021. However, it is unclear whether the examiner considered all the relevant evidence of record. Therefore, remand is needed for an addendum opinion to help determine the severity of the Veteran's condition. The June 2021 remand specified that if the Veteran's flare-up periods are short in duration, the examiner should attempt to provide an assessment of the percent of the entire body areas affected and percent of exposed body areas affected by the Veteran's rash, based upon the Veteran's reports; and provide an estimate of the percent of the total body area that the skin conditions noted in the VA treatment records affected, including tinea cruris, erythrasma, hypopigmentation or hyperpigmentation, as well as any other rashes, plaques, lesions, or papules. The July 2021 VA examiner diagnosed the Veteran with dermatophytosis and intertriginous dermatitis. The examiner found that an estimate of the percent of body area that the skin conditions on the Veteran's arms, back, and chest, were each zero percent. The examiner described the Veteran's tinea cruris as residual hyperpigmented areas and hypopigmented regions in the bilateral groin areas. With respect to intertriginous dermatitis, the examiner described residual hyperpigmented areas and residual hypopigmented areas between the right and left gluteus muscles as well as the intertriginous areas between the medial thighs and intertriginous areas of the lower abdomen. The examiner also specified that the Veteran does not have erythrasma. As noted in the prior remands, VA treatment records indicate involvement of the Veteran's arms, back, and chest, in addition to the groin area, gluteus, and abdomen. An April 2010 treatment note documented a slightly hyperpigmented patch on the right arm and left abdomen. Erythematous hyperpigmented plaques of the intergluteal cleft were also noted. The clinician noted that it was likely that tinea cruris had spread. It was noted that the disease on the abdomen and arm had the appearance of resolving. In his July 2011 notice of disagreement, the Veteran indicated he was including medical evidence stating his condition covered five to 10 percent of his body, including groin, buttocks, hips, abdomen, and both arms. While it is unclear to what medical evidence the Veteran is referring, as such evidence does not appear in the record, his lay statements must be considered and suggest that he experienced symptoms on both arms. In a dermatology note from March 2012, the Veteran reported having a recurrent rash at groin, gluteal cleft, sometimes under the breasts, and never in armpits. A skin biopsy was done in April 2012, and the Veteran was assessed with chronic intertriginous rash with biopsy suggestive of erythrasma. A dermatology progress note from May 2012 noted hyperpigmented patches to bilateral axillae. A May 2012 VA opinion indicated the Veteran's biopsy report from April 2012 was consistent with erythrasma, and that the Veteran only had one diagnosis and it was erythrasma. A July 2020 dermatology telephone note indicated the Veteran stated he had a rash similar to what he had the year before; but it was on his arms, back, and left chest and seemed to be spreading. An addendum opinion is warranted to determine the severity of the Veteran's service-connected skin condition during the period on appeal. The July 2021 VA examiner provided no response to the disability benefits questionnaire question of whether the Veteran previously had a skin condition that is now completely resolved and no longer requires treatment of any type. However, he indicated that the Veteran does not have erythrasma, but did not discuss the history of this condition that is noted in the file. Additionally, it is unclear whether the examiner considered the Veteran's records, which included complaints as recent as July 2020, of a rash on his arms, back, and left chest, when estimating the percent of body area that the skin conditions affect. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from a qualified clinician to assist in determining the current severity of the Veteran's skin condition, including during flare-ups. The examiner may conduct any further clinical examination if the evidence is not sufficient to fully respond to the inquiries. All clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: The examiner must provide an opinion as to the severity and symptomatology of the Veteran's skin disability during flare-ups. Specifically, the examiner must provide an opinion as to the total body area and exposed area covered by the Veteran's condition during a flare-up. The examiner must provide an analysis of the total body area and exposed area covered by the Veteran's condition during a flare-up based on the Veteran's reports. IN PARTICULAR, IF AN EXAMINATION DOES NOT TAKE PLACE DURING A FLARE-UP, THE EXAMINER IS REQUESTED TO EXPRESS AN OPINION OF THE WORST-CASE SEVERITY BASED ON THE VETERAN'S DESCRIPTION OF THE SYMPTOMS AND ANY SUPPORTING CLINICAL EVIDENCE. The examiner must review the entire record in conjunction with rendering the requested opinions. The VA examiner's attention is drawn to the following: An April 2010 treatment note documented a slightly hyperpigmented patch on the right arm and left abdomen. In his July 2011 notice of disagreement, the Veteran indicated he was including medical evidence stating his condition covered five to 10 percent of his body, including groin, buttocks, hips, abdomen, and both arms, suggesting he experienced symptoms on both arms. In a dermatology note from March 2012, the Veteran reported having a recurrent rash at groin, gluteal cleft, sometimes under the breasts, and never in armpits. A skin biopsy was done in April 2012 and the Veteran was assessed with chronic intertriginous rash with biopsy suggestive of erythrasma. A dermatology progress note from May 2012 noted hyperpigmented patches to bilateral axillae. A May 2012 VA opinion indicated the Veteran's biopsy report from April 2012 was consistent with erythrasma and that the Veteran only had one diagnosis and it was erythrasma. A July 2020 dermatology telephone note indicated the Veteran stated he had a rash similar to what he had the year before, but it was on his arms, back and left chest and seemed to be spreading. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. (Continued on the next page) 2. Readjudicate the claim. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Vemulapalli, 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.