Citation Nr: 21067690 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 16-52 672 DATE: November 5, 2021 ORDER Entitlement to a compensable rating for eczema of the hand for the appeal period prior to July 26, 2021 is denied. Entitlement to a rating in excess of 10 percent for eczema of the hand for the appeal period beginning on July 26, 2021 is denied. FINDINGS OF FACT 1. For the appeal period prior to July 26, 2021, the Veteran's eczema of the hand has not affected at least five percent of the entire body or of exposed areas and did not require intermittent systematic therapy or other immunosuppressive drugs for a total duration of less than six weeks during a 12-month period. 2. For the appeal period beginning on July 26, 2021, the Veteran's eczema of the hand has been manifested by characteristic lesions involving at least five percent but less than 20 percent of the total body area, and less than five percent of his exposed body area without systemic therapy required for a total duration of six weeks or more, but not constantly, over the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for eczema of the hand for the appeal period prior to July 26, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.118, Diagnostic Code 7806. 2. The criteria for a rating in excess of 10 percent for eczema of the hands for the appeal period beginning on July 26, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1969 to January 1972. This mater comes before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision, by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the Veteran's claim for a compensable rating for eczema of the hand. He perfected a timely appeal of that decision. In December 2018 and June 2021, the Board remanded the instant matter to the RO for additional evidentiary development. Specifically, the claim was remanded to obtain outstanding treatment records and to afford the Veteran a VA examination to determine the severity of his eczema of the hand. Updated VA treatment records have been associated with the record and a VA skin examination was conducted in June 2021. The Board therefore determines that there has been substantial compliance with its previous remands. In September 2021, a Decision Review Officer's (DRO) decision increased the rating for the Veteran's service-connected eczema of the hand from zero percent to 10 percent, effective July 26, 2021. As the rating is less than the maximum available rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a compensable rating for eczema of the hand for the appeal period prior to July 26, 2021 is denied. 2. Entitlement to a rating in excess of 10 percent for eczema of the hand for the appeal period beginning on July 26, 2021 is denied. The Veteran seeks entitlement to a compensable rating for eczema of the hand for the period prior to July 26, 2021 and in excess of 10 percent thereafter. In the Veteran's October 2016 substantive appeal, the Veteran asserted that his use of hydrocortisone and triamcinolone acetonide constituted systemic therapy. The Veteran's eczema of the hand has been evaluated as noncompensable for the period prior to July 26, 2021 and 10 percent disabling thereafter, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806. Prior to August 13, 2018, a zero percent rating was warranted for eczema of the hand where there was less than five percent of the entire body affected; less than 5 percent of exposed areas affected, and no more than topical therapy required during the past 12-month period. A 10 percent rating required involvement of at least five percent, but less than 20 percent, of the entire body; at least five percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating required involvement of 20 to 40 percent of the entire body; 20 to 40 percent of exposed areas; or systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating required involvement of more than 40 percent of the entire body; involvement of more than 40 percent of exposed areas; or constant or near constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Codes 7806, 7813. During the appeal period, changes were made to 38 C.F.R. § 4.118, Diagnostic Code 7813. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). Under the post-August 2018 rating criteria, a zero percent rating is assigned when there is no more than topical therapy required over the past 12-month period and characteristic lesions involving less than five percent of the entire body affected; or characteristic lesions involving less than five percent of exposed areas affected. A 10 percent rating is assigned for characteristic lesions involving at least five percent but less than 20 percent of the entire body affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month. A 30 percent rating is assigned for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, PUVA or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118 (August 13, 2018). Prior to the August 2018 amendments, the Federal Circuit distinguished between "systemic" therapy versus "topical" therapy, holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Nevertheless, a topical corticosteroid could be administered to a large enough scale to affect the body, as a whole, thus meeting the definition of "systemic therapy. Id. With the implementation of the August 2018 amendments, systemic therapy is now defined as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118 (August 13, 2018). The Veteran's claim for an increased rating for eczema of the hands was received in October 2013. In conjunction with his claim, the Veteran was afforded a VA examination for skin diseases in March 2014. At that time, Veteran indicated that he had been followed by private dermatologists over the years for a variety of skin conditions including a recurring hand rash. The Veteran indicated that he had not had recent treatment for the hand skin condition. On examination, it was noted that none of the total body area and none of the exposed areas were affected by the Veteran's skin condition. The Veteran did not have any of the conditions listed in the examination. The examiner reported a diagnosis of hand eczema. VA progress notes dated from July 2014 to May 2019 show that the Veteran received clinical evaluation and treatment for various skin conditions, apart from eczema of the hand. A September 2016 dermatology note indicates that the Veteran was diagnosed with Rosacea for which he was prescribed Triamcinolone cream (a corticosteroid). A March 2018 progress note reflects diagnoses of seborrheic and actinic keratoses. The Veteran underwent another VA examination for skin diseases in September 2019. The pertinent diagnoses were atopic eczema and excision of basal cell cancer forehead. The Veteran indicated that he has been using the prescriptions from the VA Medical Center about five to six times a year, that he uses hydrocortisone lotion on the skin lesion for about a week to 10 days on the lesion and that he occasionally uses triamcinolone cream on lesion on the face. On examination, the examiner reported a finding of two small spots in the one arm, one spot on the left-hand dorsal area which he said has been recurring for four months. It was noted that the Veteran had skin cancer on his nose which was excised by plastic surgeon, with no visible scar. It was noted that the Veteran uses topical medicine for six weeks or more but not constant. The examiner further noted that the eczema affects less than five percent of the Veteran's total body area and less than give percent of exposed area. A July 26, 2021 VA examination reflects the Veteran's reports of having itchy, dry, scaly and flaky dermatitis to the hands, forearms and lower extremities. Records show that the Veteran being treated with Petrolatum ointment. The Veteran reported applying a moderate amount externally to his body after showering for dry skin and he reported using a topical medication constantly or near constantly. It was noted that the eczema affects between five to 20 percent of the total body area and less than give percent of the exposed area. The Veteran does not have a skin condition currently without any visible characteristic lesions at the time of the examination. Diagnoses were noted to be bilateral dorsum of hands, A/P forearms and A/P lower extremities with dry, scaly, xerotic dermatitis. The examiner indicated that the Veteran's skin condition does not cause scarring or disfigurement of the head, face or neck. The Veteran's skin condition does not impact his ability to work. For the appeal period prior to July 26, 2021, the Veteran's eczema of the hand does not warrant a compensable rating. Under the former regulations, the evidence does not show that the Veteran's eczema of the hands affected at least five percent of the entire body or at least five percent of the exposed areas affect or required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. In fact, during the September 2019 VA examination, the examiner noted that the Veteran's eczema of the hand involved less than five percent of total body and zero percent of exposed body. Under the amended regulations, the evidence does not show that the Veteran's eczema of the hand affected at least five percent of the exposed area affected nor does it show that the Veteran required intermittent systemic therapy. The evidence does not show, the Veteran has not alleged, that he required immunosuppressive drugs for a total duration of less than six weeks over the past 12-month period due to his eczema of the hand. Under these circumstances, the preponderance of the evidence is against the Veteran's claim of entitlement to a compensable rating for eczema of the hand under the old regulations or the amended regulations in effect beginning August 13, 2018 for the appeal period prior to July 26, 2021. For the appeal period beginning on July 26, 2021, the Veteran's eczema of the hand does not warrant a rating in excess of 10 percent. Under the former regulations, the evidence does not show that the Veteran's eczema of the hands affected 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas or required systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A July 2021 VA examination found that the Veteran's eczema of the hands affects between five to 20 percent of the total body area and less than five percent of the exposed area and he reported using a topical medication constantly or near constantly. Under the amended regulations, the evidence does not show the use of systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, PUVA or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, over the past 12-month period. Therefore, the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 10 percent for eczema of the hand beginning on July 26, 2021. The Board notes the Veteran's arguments that his use of topical medications constitutes systemic therapy and that a higher rating is therefore warranted. A July 2021 VA the examiner opined that it was less likely than not (less than 50 percent probability) that the skin condition other than eczema incurred in or caused by the Veteran's claimed in-service injury, event or illness or was proximately due to or the result of is service connected condition. The July 2021 VA examiner noted that the current medical literature does not support a casual nexus between the Veteran's service connected eczema and his actinic keratosis, seborrheic keratosis, keratcanthoma or squamous cell carcinoma as these conditions have distinct and separate etiologies unrelated to eczema. A July 2021 VA examination report noted that the Veteran used petrolatum ointment for xerosis and pruritis while a September 2019 VA examination report noted that he used triamcincolone cream on the lesion of the face and hydrocortisone lotion on the skin lesion for about a week to 10 days. Multiple VA treatment records, including a September 2017 and February 2018 VA treatment note, indicate that the Veteran had an active outpatient prescription medication for hydrocortisone lotion that he was to apply to the affected areas of his face as well as for triamcinolone to apply to the affected areas of the body as directed. To the extent that the Veteran has argued that his use of Triamcinolone cream and hydrocortisone lotion constitutes systemic therapy, the Board notes that he used his medication for a lesion on his face and other skin conditions which are not service connected. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). This argument is therefore without merit. The Board has considered whether a higher rating would be warranted under another diagnostic code, but the VA examiners' reports indicate that the eczema has not resulted in scarring or disfigurement which could merit a higher evaluation under a separate diagnostic code. Consequently, the Board concludes that Diagnostic Code 7806 most appropriately reflects the Veteran's service-connected eczema of the hand. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher rating. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, medical treatment records do not show that the Veteran's disability more nearly approximates the criteria in the next higher rating. Here, the observations prepared by skilled professionals are far more probative that the Veteran's own opinion. The Board has considered whether a further staged rating under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning a further staged rating is not warranted. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability (TDIU) has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's current employment status is not clear. However, the Veteran has not alleged, and the record does not establish, that he is unable to obtain and maintain employment due to his eczema of the hand. As such, the Board finds that a claim for a TDIU is not raised in connection with the instant appeal. See Rice v. Shinseki, supra. (Continued on the next page) In light of the above, the Board finds that the criteria for a compensable rating for eczema of the hand for the appeal period prior to July 26, 2021 and 10 percent thereafter have not been met. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the claim. There is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Suzie S. Gaston, 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.