Citation Nr: 21066418 Decision Date: 10/30/21 Archive Date: 10/30/21 DOCKET NO. 16-34 846 DATE: October 30, 2021 ORDER Entitlement to service connection for a skin disability, to include hidradenitis suppurativa and contact dermatitis, is denied. FINDING OF FACT The preponderance of the evidence is against finding that a skin disability, to include hidradenitis suppurativa and contact dermatitis, began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a skin disability, to include hidradenitis suppurativa and contact dermatitis, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Airforce from June 1995 until her honorable discharge October 1999. The case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by the Regional Office of the Department of Veterans Affairs (VA). In October 2016, the Veteran testified before the undersigned Veteran Law Judge during a travel board hearing. In November 2018, the Board remanded the case to the Regional Office for further development. The prior remand also included a service connection claim for sleep apnea, but that claim was granted in full in a June 2020 rating decision. Specifically, in connection to the skin condition claim, the Board directed the Regional Office to schedule the Veteran for a new VA examination regarding the etiology of her skin conditions. In response, the Veteran had a VA examination in December 2019 and an addendum examination in June 2020. The claim was recently remanded in December 2020 for a new VA examination and now returns to the Board for adjudication. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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 the so-called "nexus" requirement. Holton v Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, obesity is not a disease for service connection purposes. VAOPGCPREC 1-2017 (Jan 6, 2017). Nonetheless, obesity may be an intermittent step between a service-connected disability and a current disability that may be service connected on a secondary basis. Id. at 2. To grant service connection, the adjudicators would have to resolve the following issues: (1) whether a service-connected disability caused a veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability for which a veteran is seeking service connection; and (3) whether the current disability for which a veteran is seeking service connection would not have occurred but for the obesity caused by the service-connected disability. Id. at 9-10. Furthermore, in deciding whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. 1. Entitlement to service connection for a skin disability, to include hidradenitis suppurativa and contact dermatitis. The Veteran asserts that she developed a skin disability in service and that she self-treated her skin during and after service. In her Notice of Disagreement, she asserted that she developed hidradenitis suppurativa in service and received treatment for the disability since service. The Veteran was diagnosed with hidradenitis suppurativa in her December 2019 VA examination. This diagnosis was disputed in the June 2020 VA examination and the examiner explained that hidradenitis suppurativa was not normally found on the neck. Despite this, she has been diagnosed with hidradenitis suppurativa in several other treatment records and in the most recent VA examination in July 2021. As such, she has met the first element of service connection. There are several instances in service where the Veteran had acne, pustules, papules, itching, fungal infections, and yeast infections occurring in service. See Service Treatment Records. In March 1997 she was diagnosed with contact dermatitis on the nape of her neck that was characterized by scaly and hyperpigmented skin. As such, she has met the second element of service connection. Unfortunately, there is no connection between her current skin disability and her disabilities in service. Over the course of her appeal, she has had three VA examinations, in December 2019, June 2020, and July 2021. The first VA examination noted that the Veteran did not have a skin disability at entrance and that she first complained of abcess and sores from friction caused by her uniform in a 2016 statement. The examiner also noted that the Veteran asserted that her current skin disability was misdiagnosed in service as contact dermatitis and sebopsoriasis. She was diagnosed with hidradenitis suppurativa at the December 2019 examination; however, the examiner concluded that there was no diagnosis of contact dermatitis. They provided a negative nexus opinion stating that "[the V]eteran stated to me in history today that she was seen in service during basic training in San Antonio for skin condition around neck and was treated for it[.] No record found of this skin medical care note in indexed record." This rationale was deemed inadequate, and the claim was remanded for another VA examination. The subsequent June 2020 VA examination found that the Veteran's assertions that she was misdiagnosed were not supported by the medical evidence. The examiner concluded that the in-service description of her disability did not match the symptoms of hidradenitis suppurativa, that hidradenitis suppurativa does not normally occur on the neck, and that there was no evidence that contact dermatitis was currently diagnosed or continued after service. The Board found this examination to also be inadequate as it mischaracterized the evidence and did not match with the medical evidence in the VA treatment records which diagnosed the Veteran with dermatitis after service. The Board remanded the claim as a result. The Veteran's most recent VA examination took place in July 2021. The examiner acknowledged the Veteran's assertions that she was misdiagnosed but found that the medical evidence from service only supported a diagnosis of facial acme and contact dermatitis. The examiner noted that contact dermatitis was a temporary allergic reaction that resolves within two to four weeks. They also noted that there were no reports or findings of hidradenitis suppurativa, contact dermatitis, or acne after April 1998 continuing up to 2 years post service. Bacterial vaginosis and yeast infections were also found to have not been substantiated by the medical evidence of record. The examiner addressed the Veteran's post-service diagnoses of contact dermatitis from 2004 stating that contact dermatitis is a "generalized term for conditions that cause inflammation of the skin," and that she was specifically treated for seborrheic dermatitis. They stated that "a review of Dermatology Consultations from 2005-2019 identifies a current diagnosis of [hidradenitis] suppurativa since [December] 2013 at which the Veteran ALSO had a previous history of acne, seborrheic dermatitis, [hidradenitis], and folliculitis." However, the examiner found that the contact dermatitis that the Veteran had resolved, that there was no misdiagnosis, and that her current diagnosis was for hidradenitis suppurativa. The examiner concluded that there was no evidence she had hidradenitis suppurativa in service despite her diagnoses with "acne, pustules, papules, fungal infections, yeast infections, or any other medical issue in service mentioned in her service treatment records." VA treatment records support the Veteran's current diagnosis of hidradenitis suppurativa. However, the records place its onset after her military service. She had surgery to remove abscesses on her neck caused by hidradenitis suppurativa in July 2013. This record states that she had a "two month history of right axillary lesions/masses and posterior neck mass" with prior drainage of the lesions. See July 2013 VA Treatment Records. She reported to the physician that she believed the lesions were related to menstruation as they enlarged during her period. Id. While she is competent to report when she began experiencing symptoms, she is not competent to determine what medical diagnosis those symptoms entail. Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). The VA treatment records from July 2013 to October 2013 confirm that her diagnosis was for hidradenitis suppurativa. Furthermore, the manifestation of her skin disability in service is different from that described in the VA treatment records. Her service records state that she had a scaly, hyperpigmented skin on the nape of her neck diagnosed as contact dermatitis. See March 1997 Service Treatment Records. The treatment records in 2013 describe her neck skin disability as lesions and masses that popped, drained, and reappeared. The Board finds the contemporaneous medical evidence to be more persuasive in determining the Veteran's diagnosis and whether that diagnosis is related to service. This evidence establishes that she had contact dermatitis in service which was acute and transitory. She then developed hidradenitis suppurativa after service and there is no nexus or link between that disability and her service. As such, her claim for entitlement to service connection for a skin disability, to include hidradenitis suppurativa and contact dermatitis, are denied on a direct basis. Obesity is not a compensable disability but may be an intermediate step between a service-connected disability and a current disability. In order to be awarded service connection, a Veteran must show three elements: (1) whether a service-connected disability caused a veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability for which a veteran is seeking service connection; and (3) whether the current disability for which a veteran is seeking service connection would not have occurred but for the obesity caused by the service-connected disability. She has met the first element as her numerous service-connected disabilities prevent her from exercising and dieting. She is currently service connected for depressive disorder, migraines, sleep apnea, sinusitis, degenerative joint disease of the lumbar spine, complex regional pain syndrome, and residuals of a left foot injury. See June 2020 Codesheet. Her diagnosis of hidradenitis suppurativa was found to be multifactorial; furthermore, obesity was not found to be a substantial factor in the etiology of her disability. While excess weight, stress, hormonal changes, heat or humidity may worsen symptoms, the examiner stated the exact cause of hidradenitis suppurativa is not known, but could be "connected to hormones, inherited genes and immune system problems." The disability is more common in women, may be inherited, and studies have shown a relationship between the disability and obesity. However, in order for obesity to be an "intermediate step" the Board must find that the obesity was a substantial factor in the development of the Veteran's disability and that "but for" her obesity she would not have developed the disability. The Board finds that her obesity was not a substantial factor in the development of her hidradenitis suppurativa as there are other risk factors present. There is no evidence that but for her obesity she would have developed her skin disability and as such her claim is denied. In reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Johnston, 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.