Citation Nr: 21069731 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 20-10 856 DATE: November 19, 2021 ORDER Entitlement to service connection for a skin disorder is denied. FINDING OF FACT The Veteran's rosacea and squamous cell carcinoma did not begin in service and are unrelated to service, to include presumed herbicide agent exposure. CONCLUSION OF LAW The criteria for service connection for a skin disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1967 to July 1970, to include service in the Republic of Vietnam from October 1968 to July 1970, with additional service in the Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in August 2017. In May 2020, May 2021 and July 2021, the case was remanded for additional development and it now returns for further appellate review. The Board finds that there was substantial compliance with the Board's July 2021 remand instructions and further remand is unnecessary. The Veteran seeks service connection for squamous cell carcinoma [SCC] and/or rosacea. He contends that his rosacea began in service and his SCC and rosacea were caused by exposure to herbicide agents in service. His service records show that he served in the Republic of Vietnam during the requisite period. Therefore, herbicide exposure is conceded. In an August 2017 statement, the Veteran contended that he "read articles that show [SCC] is considered a 'presumptive' condition due to [herbicide agent] exposure" and that rosacea is "considered an acneform disease consistent with chloracne." In August 2018, he wrote that his SCC should be considered a soft tissue sarcoma. VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically been determined that a presumption of service connection is warranted. See 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 57586 -57589 (1996). Because SCC and rosacea are not listed under 38 C.F.R. § 3.309(e) as a disease that is associated with herbicide exposure, the presumption of service connection due to herbicide exposure is not warranted for these conditions. While chloracne is listed under § 3.309(e), the competent evidence does not demonstrate that the Veteran has a chloracne diagnosis nor that rosacea is a form of chloracne. The Veteran underwent a VA skin examination in March 2021, at which time a chloracne diagnosis was not noted. His private and VA treatment records are associated with the claims file and show diagnoses of rosacea but not chloracne. MedlinePlus defines rosacea as "a long-lasting (chronic) skin disease that affects the face" and there is no reference to chloracne in the description, causes, or other names for the condition. See U.S. Nat'l Library of Med., Rosacea, MedlinePlus, https://medlineplus.gov/genetics/condition/rosacea/. Notably, the Veteran has not submitted evidence that shows rosacea is a form of chloracne and, as a layperson, his statement is not competent evidence of such. Accordingly, presumptive service connection is not warranted for chloracne. Similarly, while soft tissue sarcoma is listed under § 3.309(e), the competent evidence does not demonstrate that the Veteran has such a diagnosis nor that his SCC is a form of soft tissue sarcoma. Soft tissues examples include muscles, tendons, fat, and blood vessels, and soft tissue sarcoma is a cancer of these soft tissues. See U.S. Nat'l Library of Med., Soft Tissue Sarcoma, MedlinePlus, https://medlineplus.gov/softtissuesarcoma.html. Squamous cell skin cancer affects the epidermis, or the top layer of skin. See U.S. Nat'l Library of Med., Squamous Cell Skin Cancer, MedlinePlus, https://medlineplus.gov/ency/article/000829.htm. The competent evidence does not suggest these two conditions are the same. Notably, the Veteran has not submitted evidence that shows SCC is a form of soft tissue sarcoma and, as a layperson, his statement is not competent evidence of such. Accordingly, presumptive service connection is not warranted for soft tissue sarcoma. The Board further considered whether service connection is warranted on a direct basis but finds that the Veteran's SCC and rosacea are not directly related to service, to include presumed herbicide agent exposure. In making this determination, the Board relied on the Veteran's service medical records, private and VA treatment records, and September 2021 VA medical opinions. The Veteran's service treatment records are associated with the claims file and contain examinations and reports of medical history from separation and his Reserves service. At his July 1970 separation examination, his skin evaluation was normal, and the Veteran noted that his condition had not changed since his last physical and he was in good condition. He underwent an examination upon enlistment to the Reserves in April 1976, at which time only a birthmark on his hip was noted. There was no notation of rosacea or a mole, and the Veteran denied skin diseases on his report of medical history. Similarly, only the hip birthmark was noted on his March 1978 examination and he again denied skin diseases on his report of medical history. Because a birthmark was noted on his examination, it is reasonable to presume that a mole or rosacea would have been noted as well if present at the time. Similarly, because the Veteran noted other conditions on his report of medical history, it is reasonable to presume that he would have noted skin diseases if he had a history of rosacea. Thus, the Board finds that the absence of conditions on his examinations and the Veteran's explicit denials of skin diseases on his reports of medical history weigh against direct service connection. After service, the Veteran contends he did not have health insurance and he did not seek skin care treatment until the 1980s. VA attempted to obtain authorization for any outstanding private treatment records in September 2020, but the Veteran did not respond. VA treatment records show that he underwent an Agent Orange examination in February 2004, at which time he reported a history of rosacea. He denied persistent rashes, new skin lesions, non-healing lesions, and a history of skin cancer, and his skin screening was grossly negative for significant abnormal findings. In August 2005, he requested a skin examination because his father was diagnosed with melanoma. The records do not show that he underwent a skin check, but he was referred for one in June 2007 after his father died from metastatic melanoma. Private records show that he underwent a physical examination in October 2006. He reported untreated rosacea but did not discuss its onset. Private records from his treating dermatologist show that he underwent a skin examination in July 2007 and rosacea and a mole on the left temple were noted. It was noted that his rosacea onset "since [v]ietnam" and mole onset "many yrs" ago. His mole was biopsied at which time a "melanocytic proliferation" was not seen. In June 2009, the mole was biopsied again, and he was diagnosed with squamous cell carcinoma. The mole was removed in July 2009 and subsequent records do not show recurrence. Following the July 2021 Board remand, VA obtained several medical opinions in September 2021. The examiner opined that the Veteran's SCC was less likely than not incurred in or related to service, to include herbicide agent exposure. In support of her conclusion, the examiner noted that the most common risk factor for SCC is UV radiation or cumulative sun exposure. She further noted that the medical evidence does not support a causal link between SCC and herbicide agent exposure. She considered his statements but again noted that the Veteran is not qualified to ascribe his condition to an etiology. She also considered the submitted article, and other medical literature, and stated that they failed to show a causal link between herbicide agent exposure and SCC. She further opined that the Veteran's rosacea was less likely than not incurred in or related to service, to include herbicide agent exposure. In support of her conclusion, the examiner noted that the Veteran's service medical examinations and statements made at separation contradicted his contentions that his symptoms began in service. Further she noted that the literature does not support a causal relationship between rosacea and herbicide agent exposure. The Board finds that these opinions are probative because the examiner considered the evidence, to include the Veteran's statements and scientific study, and provided rationales to support her conclusions. The Board considered the scientific study he submitted in March 2020 but finds that it is not probative evidence. The study was conducted under specific conditions that distinguish it from the present case. For example, the study utilized "the Tg.AC mouse" mice which is "a genetically initiated tumor promotor." Additionally, the study noted that "in mouse skin, papillomas may progress into invasive squamous cell carcinomas." (emphasis added). The study further stated that the data provides "the opportunity to compare the relative sensitivity of the tumor response in the Tg.AC mouse with the response in the traditional 2-year rodent bioassay, and to determine whether extrapolated human risks are similar." In short, the study used a mouse that is genetically more susceptible to tumors, provided data specific to mice skin, and explicitly stated that the data provides the opportunity to determine whether extrapolated human risks are similar. Thus, the study does not link SCC to herbicide agent exposure in humans and is not persuasive for the Veteran's claim. The Board also considered the Veteran's statement that his SCC and rosacea are due to Agent Orange exposure. The only evidence that links the Veteran's current skin disorders to Agent Orange exposure is his own statements. As a layperson, however, the Veteran is not competent to relate his skin condition to herbicide exposure. Finally, the Board considered the Veteran's August 2017 statement that he experienced large "zits" since Vietnam that were ultimately diagnosed as rosacea. To the extent the Veteran contends his rosacea began in Vietnam, the Board finds that his contention is not credible. His separation and Reserves examinations were negative for a skin condition and he denied skin diseases on his Reserves reports of medical history. While he contended that his rosacea onset "since [V]ietnam" at his July 2007 treatment visit, he did not report such during earlier treatment visits, like the 2004 Agent Orange examination. Because the Veteran's current contention is contradicted by his medical records and previous statements, the Board finds that the contention is not credible. The Board considered whether the July 2021 Board's Remand instructions might reasonably lead the Veteran to conclude that the Board found such contention credible but finds that they would not. See Smith v. Wilkie, 32 Vet. App. 332 (2020). Unlike in Smith, the Board did not instruct the examiner to consider the Veteran's statements credible; the Board merely instructed the examiner that the Veteran is competent to state he has experienced rosacea since service. See id. at 338-39. The Remand did not specify that the contentions were credible. Accordingly, the Board's current decision on the Veteran's credibility was not made without fair process. In sum, the totality of the evidence does not show that the Veteran's current skin disorders began in or are otherwise related to service, to include presumed herbicide agent exposure. Accordingly, service connection is not warranted, and the claim is denied. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lavan 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.