Citation Nr: 21066241 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 16-25 525 DATE: October 29, 2021 ORDER Entitlement to increases in the (10 percent prior to February 15, 2021 and 30 percent from that date) staged ratings assigned for pseudofolliculitis barbae (PFB) is denied. FINDING OF FACT Prior to February 15, 2021, the Veteran's PFB was not shown to have involved 20 percent or more of his total body or exposed areas or to have required use of systemic therapy; from February 15, 2021, is is not shown to have involved more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or to have required constant or near constant systemic therapy. CONCLUSION OF LAW Ratings for PFB in excess of 10 percent prior to February 15, 2021, and in excess of 30 percent from that date, are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Code 7806. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from March 1977 to February 1980. This matter was initially before the Board on appeal of an August 2014 rating decision that continued a 10 percent rating for PFB. In March 2019 a videoconference hearing was held before the undersigned. In April 2019 the matter was remanded for development. An interim March 2021 rating decision increased the rating to 30 percent effective February 15, 2021. In June 2021 the matter was again remanded for additional development. At the outset, the Board finds there has been substantial compliance with the April 2019 and June 2021 remand directives. [The April 2019 VA sought a new VA examination to assess the severity of the Veteran's PFB and the June 2021 remand requested an addendum medical opinion.] Entitlement to increases in the (10 percent prior to February 15, 2021 and 30 percent from that date) staged ratings assigned for PFB is denied. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In a claim for increase, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, "staged" ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim begins one year before the claim for increase was filed. As the instant claim for increase was received on March 31, 2014, the period for consideration is from March 31, 2013 until the present. The criteria for rating skin disabilities were revised effective August 13, 2018. Since this claim was pending on August 13, 2018, the new criteria apply if they are more favorable, but the effective date for any increase under the revised criteria may not be earlier than August 13, 2018. Prior to August 13, 2018, under Code 7806, for dermatitis or eczema, a 10 percent rating was warranted when at least 5 percent, but less than 20 percent, of the entire body or of exposed areas is affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted when 20 to 40 percent of the entire body or of exposed areas is affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or with constant or near constant systemic therapy such as with corticosteroids or other immunosuppressive drugs during the past 12-month period. 38 C.F.R. § 4.118, Code 7806. From August 13, 2018, (Under the General Formula), a 10 percent rating is warranted for involvement of 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 with the need for 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 six weeks over the past 12-month period. A 30 percent rating is warranted where the area of involvement is 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or with a need for systemic therapy for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum (60 percent) rating requires involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas, or with the need for constant or near-constant systemic therapy required in the past 12-month period. 38 C.F.R. § 4.118. The diagnostic criteria also provide that the disability may alternatively be rated as scars depending on the predominant aspect of the disability. On May 2014 VA skin diseases examination, PFB was diagnosed. The Veteran reported using clindamycin gel constantly for the last twelve months for his PFB. He did not report other treatments or any procedures. The examiner noted that he did not have scarring or disfigurement of his head, face, or neck, or benign or malignant skin neoplasms, and there was no evidence of systemic manifestations due to a skin disease. A few papules were noted in the beard area, and it was noted that the skin disorder affected less than 5 percent of total body area or exposed area. The examiner indicated that Veteran did not have a PFB condition on the day of the examination and it did not impact his ability to work. An August 2014 VA treatment record notes some folliculitis on the Veteran's facial area treated with clindamycin. In a September 2014 notice of disagreement (NOD), the Veteran expressed that his beard area remained painful. A December 2014 VA treatment record shows a diagnosis of a Verruca formation on the Veteran's lower lip. A January 2015 VA treatment record indicates a diagnosis of granulomatous dermatitis on his right posterior neck during a shave biopsy. In a June 2016 VA Form 9, the Veteran expressed a belief that his condition had worsened, and indicated that his prescription cream was recalled, and he could only use over-the-counter creams now. He attached correspondence corroborating that his prescription faced recall due to potential contamination. June and August 2016 VA treatment records show little partial formations noted in the beard area that were consistent with PFB. A March 2017 VA treatment record includes a diagnosis of steroid induced dermatitis from long term use of topical steroid cream and seborrheic dermatitis. The VA dermatologist noted a diffuse erythema of the beard and nasolabial areas with a few scaling papules or plaques without pustules or vesicles. An April 2017 VA treatment record notes that the Veteran received prescriptions of Clindamycin, Tretinoin, and a moisturizer for his PFB. An August 2018 VA treatment record notes a prescription of a topical steroid for PFB. Multiple minimal follicle papules were observed in the beard area. A March 2019 VA treatment record shows diagnoses of inflamed seborrheic keratosis on the Veteran's back and seborrheic keratosis and seborrheic dermatitis on his face. Hydrocortisone was prescribed for these conditions, and minocycline was prescribed for "pimple-like lesions" on the chin and beard. A later March 2019 VA treatment record notes that the Veteran had a flare up of seborrheic dermatitis on the day of appointment. A few scattered papules were noted in the beard area. Scaling and mild erythema were seen in the beard area, nasal folds, and behind the ears. At the March 2019 Board hearing, the Veteran testified that the area beneath his neck and chin is always sore. He stated the condition does not improve and causes itching. He denied ever taking an oral prescription for PFB. He submitted a letter from his VA dermatology provider noting diagnoses of inflamed seborrheic keratosis on his back, seborrheic keratosis and seborrheic dermatitis on his face, and PFB on his chin and neck. On February 2021 VA scars/disfigurement examination, the examiner described residuals of PFB as disfigurement (abnormal texture/irregularity/hypo-hyper pigmentation and widespread itchy bumps) too numerous to count on chin, cheeks, and upper neck. The examiner noted surface contour elevated on palpation; hypopigmentation; hyperpigmentation; and abnormal irregular texture. The approximate total area of head, face and neck involvement with the hypo-hyperpigmented areas was noted to be 200 cm2. The approximate total area of head, face and neck with abnormal texture was noted as 199.997 cm2. The examiner opined that the Veteran's PFB had worsened from affecting under 5 percent to now 30 percent of the exposed area of his face and neck; that the PFB still affected less than five percent of the total body area; and that PFB did not impact on ability to work. In a March 2021 VA addendum medical opinion, the February 2021 VA examiner stated that the Veteran suffers from PFB residuals described as disfigurement (abnormal texture, irregularity, hypo-hyper pigmentation, widespread itchy bumps) too numerous to count on his chin, cheeks, and upper neck. The examiner found there is no residual scarring from PFB. A May 2021 VA treatment record shows that the Veteran was continuing to use clindamycin, desonide cream, tretinoin, and a moisturizer for PFB, and had received prescriptions for seborrheic dermatitis. The provider noted improvement in the PFB which the Veteran attributed to shaving less often. On August 2021 VA scars/disfigurement examination, the assessment was disfigurement described as post inflammatory hypopigmentation on the chin, beard, and anterior neck in areas of previous involvement of chronic PFB. The disfigurement was noted as stable post-inflammatory hypopigmentation in areas affected for decades. The Veteran had scarring and hypopigmentation on his chin/beard area/anterior neck that were too many to count. He reported the condition has gotten worse at times with residual hypopigmentation. The examiner diagnosed a second condition, seborrheic dermatitis, that the Veteran reports arises a few times a month and is treated with a selenium sulfide shampoo and desonide cream, as needed. The examiner noted the Veteran's constant usage of topical corticosteroids (tretinoin) and a topical clindamycin gel for his PFB. It was noted that his PFB affects 5 to 20 percent of exposed areas and less than 5 percent of the total body; dermatitis was found to affect less than five percent of his exposed area and body area. The examiner indicated that PFB did not impact on ability to work. The examiner opined that the Veteran's seborrheic dermatitis is less likely than not (less than 50 percent probability) proximately due to, aggravated by, or the result of his service connected PFB. The examiner stated that the seborrheic dermatitis arose ten years after he left the military, is a separate distinct condition from PFB, and the two conditions are not related. The dermatologist noted that the Veteran's dermatitis flares up, are controlled with medication, and flare ups can be treated with the same topical steroids as prescribed for his PFB. The examiner noted the Veteran's medical history and opined that his March 2017 diagnosis of steroid-induced dermatitis was in error due to his longstanding usage of topical steroids. The examiner found that his topical corticosteroid treatment does not meet the caselaw definition of systemic corticosteroids as he never received systemic therapy and cited to medical literature. At the outset, the Board notes that although the Veteran has reported intermittent and constant use of topical corticosteroids and hydrocortisone, the application of topical corticosteroids does not mean systemic therapy. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Prior to February 15, 2021, the Veteran's PFB is rated 10 percent. Upon review of the record, the Board finds that there is no evidence that at any time during that period the PFB affected at least 20 percent of his entire body or exposed areas or required systemic therapy for a total duration of six weeks or more, but not constantly, during the past 12-month period. On May 2014 VA examination, his PFB affected less than 5 percent of the total body and exposed area and there was no evidence of systemic manifestations due to skin disease. Thus, the criteria for a 30 percent under Code 7806 were not met and a rating in excess of 10 percent for dermatitis with PFB was not warranted prior to February 15, 2021. From February 15, 2021, the Veteran's PFB is rated 30 percent. Upon review of the record, the Board finds that there is no evidence that at any time during the period the PFB affected more than 40 percent of his entire body or more than 40 percent of exposed areas be affected, or required constant or near constant systemic therapy such as with corticosteroids or other immunosuppressive drugs during a past 12-month period. The Board notes the examiner's opinion that seborrheic dermatitis is not proximately due to, aggravated by, or the result of the Veteran's service connected PFB (and thus any separate and distinct symptoms and impairment from flare-ups of seborrheic dermatitis are not for consideration in rating the PFB. The August 2021 examiner reviewed the record, considered the Veteran's lay statements, and supported the opinion with rationale that cites to supporting factual data and medical literature. The August 2021 examination shows that the Veteran did not receive constant or systemic therapy with corticosteroids or immunosuppressive drugs during the period. The February 2021 VA examination, the March 2021 addendum medical opinion, the August 2021 VA examinations, and VA treatment records for the period, do not show that the PFB affected 40 percent of the entire body area or more than 40 percent of the exposed area. Thus, the criteria for a 60 percent under Code 7806 were not met and a rating in excess of 30 percent for dermatitis with PFB was not warranted from February 15, 2021. The Board also notes that the record does not show, nor has the Veteran specifically asserted, that he has had manifestations of PFB not considered in the schedular rating criteria. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lederman, Michael 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.