Citation Nr: 21074641 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 18-35 536 DATE: December 15, 2021 ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for a right shoulder condition, claimed to manifest as pain, is granted. Service connection for a left shoulder condition, claimed to manifest as pain, is granted. Entitlement to an initial rating in excess of 10 percent for tinea pedis is denied. REMANDED Service connection for a skin condition of the bilateral hands is remanded. Service connection for a right knee condition is remanded. Service connection for a left knee condition is remanded. Service connection for degenerative arthritis, lumbar spine with degenerative disc disease is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of PTSD at any time during or approximate to the pendency of the claim. 2. The competent medical evidence of record shows the Veteran's acquired psychiatric disorder was not incurred or aggravated in service. 3. Resolving all reasonable doubt in favor of the Veteran, a bilateral shoulder condition manifested as pain is related to service. 4. The Veteran's tinea pedis is manifested by characteristic lesions involving at least 5 percent but less than 20 percent of the entire body affected and no more than topical therapy. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303. 2. The criteria for service connection for a right shoulder condition have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.317. 3. The criteria for service connection for a left shoulder condition have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.317. 4. The criteria for an initial rating in excess of 10 percent for tinea pedis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7813. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2002 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified before the undersigned Veterans Law Judge. A transcript is of record. Additional evidence was submitted after the appeal was certified to the Board. As in this case, section 501 of the Camp Lejeune Act of 2012 provides an automatic waiver of evidence submitted by a veteran or his or her representative with or after a substantive appeal received on or after February 2, 2013. Therefore, the Board may properly consider this evidence. 1. Service connection for an acquired psychiatric disorder is denied. The Veteran seeks service connection for an acquired psychiatric disorder. He contends his acquired psychiatric disorder is related to being called in to clean up after the U.N. bombing, during which he saw several dead bodies. See August 2015 VA Form 21-0781. Alternatively, he contends his acquired psychiatric disorder is related to an incident wherein a civilian threw something at his vehicle, which caused him to fear for his life. Id. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The record reflects diagnoses of posttraumatic stress disorder (PTSD), depressive disorder, and cannabis use disorder. A June 2012 statement by the Veteran's parents indicates the Veteran has exhibited many changes in his mood and behavior since his deployment to Iraq, including mood swings and a bad temper. In July 2012, March 2014, and June 2015 statements, the Veteran's wife indicates she met him within days of him returning from the Army and he has since had anger issues and difficulty being in crowds. An August 2012 VA treatment record notes the Veteran has been seeing a clinical psychologist since the spring and is doing better since he stopped drinking alcohol and smoking marijuana. In a May 2013 VA Form 21-4138, the Veteran indicated he has noticed a change in himself since being in Iraq, including a different mood and restlessness at night. A September 2013 VA examination reflects a diagnosis of cannabis abuse in early remission. The examiner found the Veteran's symptoms do not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for PTSD, as his only related symptom was feeling distant and detached from others, including family. The examiner indicated the Veteran is not diagnosed with any other mental condition and found the Veteran's cannabis abuse in early remission was reported to have onset prior to military service. A February 2014 correspondence from the Veteran's private marriage and family therapist, J.S., indicated the Veteran was referred in March 2012 for severe PTSD symptomology. J.S. noted the Veteran encountered numerous stressors in Iraq, including witnessing military and civilian casualties. J.S. indicated his PTSD symptomatology includes extreme hypervigilance to the point of paranoia, anger, nightmares from which he awakens sweating and agitated, sleep disturbance, flashbacks, panic attacks, and depression. A June 2015 buddy statement indicates the Veteran changed during service after the U.N. bombing, including barely speaking and having nightmares. An August 2015 VA treatment record notes the Veteran reported depression since 2004 that has worsened since 2009. An October 2015 VA examination reflects a diagnosis of unspecified depressive disorder. The examiner noted the Veteran's depressive disorder is not related to service because the Veteran states his current mental health symptoms are the same symptoms that he experienced prior to military service. The examiner noted the Veteran does not have a diagnosis of PTSD. In March 2020, the Veteran testified to having nightmares and sleeplessness during service that continued after service. See March 2020 Board hearing transcript at 26-31. In compliance with the Board's May 2020 remand directives, a VA addendum opinion was obtained in August 2020. The examiner found the Veteran did not have a preexisting disorder such that no in-service aggravation was possible. The examiner noted the Veteran reported no mental health issues on his entrance examination and has no records supporting a diagnosis prior to service. The examiner found the Veteran's deployment to Iraq is sufficient evidence to support his possible traumatic stressor and his stressor is sufficient for criteria A of PTSD. The examiner further found that the Veteran's reported symptoms are consistent with PTSD and meet the full criteria. An addendum opinion was obtained in December 2020. The examiner found that the Veteran's November 2001 entry exam shows prior use of marijuana/illegal drugs and notes he tested positive for cannabis in March 1998 and October 1999. Thus, the examiner found his substance abuse issues clearly proceeded service. While he was discharged due to cannabis use, the examiner noted his December 2004 exit exam shows no psychiatric issues other than using marijuana/illegal drugs. The examiner found that there is no evidence that service exacerbated his drug use as he clearly admitted on his entry exam to testing positive twice in three years prior to service as well as using illegal drugs. The examiner further noted the relevant evidence of record and found that the August 2020 VA examiner did not take into account that the Veteran had preexisting illegal drug use noted on his entry exam nor that the symptoms of PTSD can be mimicked by cannabis and alcohol abuse. The examiner further noted that the August 2020 VA opinion relied on the Veteran's negative assessment of his 2015 examiner who did not diagnose PTSD and did not account for the fact that he also did not meet the criteria for PTSD at his 2013 VA examination. The examiner noted he has been diagnosed with a mild depression at the VA and on examination but has tested negative in VA PTSD screens. The examiner found there is no evidence he has an accurate diagnosis of PTSD, as two compensation examiners have noted he has no symptoms of the disorder. Although he presented having been through potentially traumatic events, the examiner noted the diagnosis of PTSD cannot be made without symptoms that meet criteria. Finally, the examiner opined that his unspecified depressive disorder did not preexist service but is a progression of his cannabis use disorder and his history of drinking. The examiner opined that it is less likely than not that he has any mental health diagnosis that was exacerbated by service as his symptoms have been mild and he was in early remission when the diagnosis was made. The examiner indicated that his unspecified depressive disorder is due to the biological and environmental consequences of substance abuse and is less likely than not related to or caused by service. In September 2021, the Veteran reported his PTSD symptoms started shortly before his failed drug test during service. The Veteran submitted articles about cannabis use disorder and the use of cannabis for those who struggle with PTSD. After a review of the evidentiary record, the Board finds service connection for an acquired psychiatric disorder is not warranted. The preponderance of the evidence weighs against finding that the Veteran has a diagnosis of PTSD. While the Veteran contends that he has a diagnosis of PTSD due to service, the Board finds the most competent and persuasive medical evidence demonstrates that he does not have such a current diagnosis, nor has he had one during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In reaching this finding, the Board affords the December 2020 VA examiner's opinion great probative weight, as the opinion contains a rationale for its conclusion that the Veteran does not meet the criteria for a diagnosis of PTSD. While the February 2014 private therapist indicated the Veteran had PTSD symptoms and experienced in-service stressors, the Board notes the therapist did not address the conflicting diagnoses of record. Similarly, while the August 2020 VA examiner found the Veteran has PTSD, the Board notes the examiner did not address the evidence of record indicating the Veteran tested positive for marijuana prior to service nor the evidence relating the Veteran's symptoms to his substance use and/or depressive disorder. While the Veteran believes he has a current diagnosis of PTSD, he is not competent to provide such a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not demonstrated specialized medical knowledge to provide any competent medical diagnosis. Consequently, the Board finds the probative weight of the February 2014 private medical findings and the Veteran's lay statements is outweighed by the more probative December 2020 VA opinion, which addresses the relevant evidence in a thorough, clearly reasoned opinion. Thus, the remaining question for the Board is whether the Veteran's currently diagnosed depressive disorder and cannabis use disorder onset in service or are otherwise related to service. To the extent the Veteran further asserts his depressive disorder is related to service, the preponderance of the evidence weighs against entitlement to service connection for depressive disorder. The Veteran's November 2001 entrance examination was absent notation of a psychiatric disorder. The Veteran's service treatment records are silent for a psychiatric disorder other than substance abuse disorder. His December 2004 separation report of medical examination reflects a normal clinical psychiatric evaluation. His military personnel records reflect he was discharged for drug use. The competent medical evidence of record indicates the Veteran's depressive disorder is due to his substance abuse disorder not any aspect of military service. Indeed, the December 2020 VA examiner opined that the Veteran's acquired psychiatric disorder is less likely than not related to service. While the Veteran, and his lay witness who have offered buddy statements, are competent to offer personal observations about the Veteran's symptoms and/or behavior in service, these reports are inconsistency with his contemporaneous treatment records, which do not reflect symptoms of a psychiatric disorder other than substance abuse until 2012. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Moreover, the lay evidence suggesting that the current depressive disorder is related to service is far outweighed by the probative weight of the competent medical evidence of record. Finally, with regard to the current cannabis use disorder, competent and credible evidence of record shows that there is clear and unmistakable evidence that this disorder preexisted service. A November 2001 medical prescreen of medical history report reflects the Veteran reported a history of marijuana. His November 2001 enlistment report of medical history also reflects a history of illegal drug use or prescription drug abuse. The Veteran was rejected for service due to marijuana use in March 1998 and October 1999 due to testing positive for marijuana. The December 2020 VA examiner also opined that the Veteran's severe substance abuse issue with cannabis and alcohol clearly and unmistakably preexisted service because his entrance documents indicate he tested positive twice prior to service. However, no further discussion of whether service connection for the current cannabis use disorder is required because service connection cannot be granted for a disability resulting from a veteran's abuse of alcohol and drugs. 38 U.S.C. §§ 105 (a), 1110; 38 C.F.R. §§ 3.1 (m), 3.301. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for an acquired psychiatric disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Service connection for a right shoulder condition is granted. 3. Service connection for a left shoulder condition is granted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. His DD Form 214 confirms service in Iraq from April 2003 through July 2004. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a veteran's symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service may still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. For purposes of § 3.317, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). For purposes of § 3.317(a)(1), signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: fatigue; signs or symptoms involving skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317 (b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Service connection may not be established under 38 C.F.R. § 3.317 for a chronic disability: (i) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or (ii) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or (iii) if there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). The Veteran seeks service connection for a right and left shoulder condition. Generally, the Veteran asserts that his bilateral shoulder symptoms are related to the rigors of military service. He describes having to lift weight upwards of 50 pounds in service. See, e.g., March 2020 Board hearing transcript at 13. The competent lay statements of record indicate ongoing shoulder pain since service. Id. Service treatment record do not reflect complaints or treatment related to either shoulder. Post-service medical records reveal complaints of recurrent shoulder pain. The Board remanded the appeal in May 2020 for an opinion regarding the claimed bilateral should disabilities. In compliance with the Board's remand directives, VA examinations were obtained in October 2020 and July 2021. Regarding the left shoulder, the October 2020 VA examiner found no current pathology and/or diagnosis of the left shoulder condition to render a medical opinion. Similarly, the July 2021 VA examiner indicated that the Veteran does not have a current left shoulder diagnosis. The examiners did not address the competent lay reports of left shoulder pain or the VA treatment records indicating the Veteran has reported left shoulder pain since approximately 2004. Regarding the right shoulder, the October 2020 VA examiner diagnosed a right shoulder strain. In providing a negative direct opinion, the October 2020 VA examiner noted there are no medical records showing diagnosis or treatment for the shoulder condition or any related shoulder condition while he was still in service and there are no reports to indicate that the shoulder was affected by service duty. The examiner also indicated the Veteran's right shoulder strain is a diagnosable chronic multi-symptom illness with a partially explained etiology, as a result of mechanical process of the joints overtime, wear and tear with aging, and physical training. However, the examiner noted there are no records of injuries during active duty such that it is less likely than not due to specific exposure event experienced by the Veteran during service in Southwest Asia. In contrast, however, the July 2021 examiner found no objective evidence of a current shoulder diagnosis. The examiner noted that the physical examination demonstrates pain in the neck suggesting his pain is not a shoulder joint problem. The examiner explained that given lack of documentation and exams for now, the pain demonstrated is not isolated to a shoulder condition and therefore no diagnosis is rendered. Review of the evidence demonstrates that the Veteran's current left shoulder symptoms have not been attributed to a known clinical diagnosis. Indeed, the VA examiners agree that a left shoulder clinical diagnosis is not present. The Board has not found another clinical diagnosis of record. Further, the Veteran's right shoulder condition that is manifested by pain is not shown to have both conclusive pathophysiology and etiology. As noted, the VA examiners did not reach consensus as to whether a clinical right shoulder disorder exists. The 2020 examiner determined the right shoulder condition was a chronic multi-symptom illness with a partially explained etiology; pathophysiology was not specifically addressed. The Veteran's shoulder pain symptoms have reportedly existed from at least 2003-2004. Thus, they are considered chronic under the regulatory definition. As there is no conclusive pathophysiology and etiology shown for the Veteran's claimed bilateral shoulder conditions, and consistent with the Persian Gulf War regulations, the Board resolves reasonable doubt in favor of the Veteran and awards service connection for a bilateral shoulder condition pursuant to 38 C.F.R. § 3.317. 4. Entitlement to an initial rating in excess of 10 percent for tinea pedis is denied. The Veteran seeks entitlement to an initial rating in excess of 10 percent for tinea pedis. A September 2013 rating decision granted service connection for tinea pedis with a noncompensable rating effective April 28, 2012. A May 2018 rating decision granted a 10 percent rating effective April 28, 2012. Thus, the period on appeal begins April 28, 2012. The Veteran's tinea pedis is rated under Diagnostic Code 7813 for dermatophytosis. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. 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. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7813, instructed to rate as disfigurement of the, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (7806) depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for 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 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 is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806]. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) 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 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) constant or near-constant 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 period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. In this case, a September 2013 VA examination indicates the Veteran's tinea pedis has not been treated with oral or topical medications in the past 12 months or any treatments or procedures other than systemic or topical medications. The examiner found that the characteristic lesions due to the Veteran's tinea pedis affect approximately less than 5 percent of his total body area and zero percent of his exposed body area. An August 2015 VA examination indicates the Veteran's tinea pedis has been treated with systemic corticosteroids or other immunosuppressive medications, namely hydrocortisone cream, for six weeks or more, but not constantly. He also uses triamcinolone cream constantly or near constantly. However, he has had no treatments or procedures other than systemic or topical medications in the past 12 months. The examiner found that the characteristic lesions due to the Veteran's tinea pedis affect approximately 5 percent to less than 20 percent of his total body area and zero percent of his exposed body area. The Veteran reported the condition usually flares-up in the winter and spring and starts as itchy scales and blisters on the bottom of his feet and in the web spaces of the toes. An October 2020 VA examination indicates the Veteran's tinea pedis requires use of topical antifungal medication for six weeks or more but not constantly. The examiner noted no treatments or procedures other than systemic or topical. Finally, the examiner found that the characteristic lesions due to the Veteran's tinea pedis affect approximately 10 percent of his total body area and zero percent of his exposed body area. Thus, the evidence of record demonstrates that the predominant disability is tinea pedis manifesting as blisters and severe dry, cracked skin on both feet. See, e.g., October 2020 VA examination. The Veteran's VA treatment records reflect prescriptions for bacitracin, miconazole nitrate 2 percent cream, miconazole nitrate 2 percent top powder, and triamcinolone 0.1 percent cream for infection and inflammation/rash. See February 2020 VA treatment record. A June 2018 VA treatment record indicates eczema on hands/feet and to 'resume triamcinolone cream.' In March 2020, the Veteran testified that his feet break out when he wears shoes. He reported scaly, black feet with boils that flake. He indicated they go right above the ankle and behind the knees. He reported three different topical treatments. See March 2020 Board hearing transcript at 35. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under the pre-August 13, 2018, regulations because the Veteran's tinea pedis does not more nearly approximate 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. The Board further finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under the August 13, 2018, regulations because the Veteran's tinea pedis does not more nearly approximate (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) systemic therapy required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. The Board acknowledges the August 2015 VA examination indicates the Veteran's tinea pedis has been treated with systemic corticosteroids for six weeks or more but not constantly. However, the Board notes the examiner also indicated the Veteran's hydrocortisone cream and triamcinolone cream were oral medications when the record otherwise reflects these medications were topical. For instance, an August 2012 VA treatment record indicates the Veteran should apply his hydrocortisone cream to the affected areas on his heels after bathing, and a November 2018 VA treatment record indicates he should apply his triamcinolone cream to affected areas two times a day as needed. With regard to the meaning of "systemic therapy" prior to the new definition of the term in the revised criteria, the Court in Johnson v. McDonald, 27 Vet. App. 497, 505 (2016) held that use of a topical steroid constituted "systemic therapy" within the meaning of Diagnostic Code 7806. In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit reversed this decision and determined that "constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs" under Diagnostic Code 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that "systemic therapy" means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. The Board finds that the use of topical treatment (corticosteroids applied to the skin) did not affect the body as a whole in treating the Veteran's skin condition because the skin lesions cover at most 10 percent of the total body and use of the creams has been limited to the affected areas. Burton, 30 Vet. App. 286. The record does not otherwise indicate the Veteran's use of these topical creams was a systemic therapy. Therefore, the evidence does not warrant a finding that systemic therapy was required to treat the Veteran's service-connected skin disability as this term was defined prior to August 13, 2018. Similarly, as the Veteran's treatment has consisted of topical therapy that is administered through the skin, use of these topical creams does not amount to systemic therapy as contemplated under the August 13, 2018, regulations. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include a rash, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the medical treatment records do not show that the Veteran's disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. 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. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of a rating in excess of 10 percent for tinea pedis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 5. Service connection for a skin condition of the bilateral hands is remanded. The Veteran seeks service connection for a skin condition of the bilateral hands. The May 2020 Board decision found the October 2015 VA opinion inadequate because the examiner relied on an inaccurate factual premise that there was no in-service dermatitis and failed to address the lay statements of record that support the Veteran's history of ongoing symptomatology since service. Additionally, the VA opinion did not appear to opine on whether the Veteran's currently diagnosed dermatitis is related to his active service in the Southwest theater of operations. See 38 C.F.R. § 3.317. In compliance with the Board's remand directives, a VA addendum opinion was obtained in November 2020.While the November 2020 VA examiner opined that the claimed condition was less likely than not incurred in or caused by service, the examiner indicated that there is no current pathology and/or diagnosis of the dermatitis condition to render a medical opinion. The November 2020 VA examiner did not provide a supporting rationale and failed to address the Veteran's lay statements and his diagnoses of dermatitis and/or eczema noted both during his October 2015 VA examination and his VA treatment records. See, e.g., June 2018 VA treatment record. The Board notes that the requirement of a current disability is satisfied if a disability is diagnosed at the time the claim was filed or during the pendency of the claim, even if the disability subsequently resolves during the appeal period. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, on remand, an addendum opinion must be obtained. 5. Service connection for a right knee condition is remanded. 6. Service connection for a left knee condition is remanded. The Veteran seeks service connection for a right and left knee condition. In compliance with the Board's May 2020 remand directives, VA examinations were obtained in October 2020 and July 2021. The October 2020 VA examiner found the Veteran's bilateral knee condition is a diagnosable chronic multi-symptom illness with a partially explained etiology, as a result of mechanical process of the joints overtime, wear and tear with aging, and physical training. However, the examiner opined the bilateral knee condition is less likely than not due to specific exposure event experienced by the Veteran during service in Southwest Asia because there are no records of injuries during active duty. The October 2020 VA examiner also opined that the Veteran's bilateral knee condition less likely than not had onset in service or is otherwise related to the Veteran's active service, including his reports of the general rigors of service. The examiner reasoned that there are no medical records showing diagnosis or treatment for the knee condition or any related knee condition while the Veteran was still in service or any reports to indicate that the knees were affected by service. The November 2021 VA examiner opined that the Veteran's bilateral knee condition is has a diagnosis- patellofemoral pain syndrome. The examiner opined this disability is less likely than no related to a specific exposure event experienced by the Veteran during service in Southwest Asia because the condition is caused by strenuous physical activities that put repeated stress on the knees such as squatting, jogging, and climbing stairs. The examiner further opined that the Veteran's bilateral knee condition is less likely than not due to service because his service treatment records are negative for knee complaints and there is no documentation of continuity of care or nexus. A medical opinion based solely on the absence of documentation in the treatment records or that fails to take into account lay statements is inadequate. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Additionally, in finding that the Veteran's bilateral knee condition is due to strenuous physical activities and/or physical training, the examiner did not provide an explanation for why the Veteran's reports of the rigors of service, including having to lift weight upwards of 50 pounds in addition to running in service, does not constitute strenuous activity or physical training. Thus, an addendum opinion is necessary. 7. Service connection for degenerative arthritis, lumbar spine with degenerative disc disease is remanded. The Veteran seeks service connection for lumbar spine degenerative arthritis with degenerative disc disease. The Board found the September 2013 VA opinion failed to consider the Veteran's competent lay reports of ongoing back pain since August 2002. In compliance with the Board's May 2020 remand directives, an addendum opinion was obtained in November 2020. The November 2020 VA examiner found the Veteran's lumbosacral strain is a diagnosable chronic multi-symptom illness with a partially explained etiology, as a result of mechanical process of the joints overtime, wear and tear with aging, and physical training. However, the examiner opined the condition is less likely than not due to specific exposure event experienced by the Veteran during service in Southwest Asia because there are no records of injuries during active duty. The Veteran's service treatment records contain several complaints of low back pain starting in August 2002. As the opinion appears to be based on an inaccurate factual premise, on remand, an addendum opinion must be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's currently diagnosed bilateral dermatitis of the hands is at least as likely as not related to an in-service injury, event, or disease, to include his in-service dermatitis and/or his alleged in-service exposure. A rationale is to be provided. If the requested opinions cannot be provided without resorting to speculation, the examiner should provide an explanation as to why speculation is required. 2. Schedule the Veteran for an examination to determine the nature and etiology of his claimed bilateral knee and lumbar spine conditions. The examiner is asked to provide responses to the following: A) Is the etiology of the Veteran's bilateral knee and lumbar spine conditions (1) inconclusive, (2) partially understood, or (3) fully understood? B) Is the pathophysiology of the Veteran's bilateral knee and lumbar spine conditions (1) inconclusive, (2) partially understood, or (3) fully understood? These determinations must be based on the Veteran's specific case and cannot be based on the etiology and/or pathophysiology of the disease or disability population as a whole. C) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's bilateral knee, and lumbar spine conditions were incurred in or are otherwise related to his active service? A complete rationale must be provided for all opinions expressed. In providing the requested opinions, consider the Veteran's description of his in-service activities and symptoms as well as his post-service symptoms. The Veteran asserts that his knee problems and back are related to the rigors of military service. He describes having to lift weight upwards of 50 pounds in addition to running in service. Competent lay statements of record indicate recurrent knee pain since service. The Veteran also reports ongoing back pain since onset in August 2002, which generally has been supported by buddy statements. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disabilities, this should be noted. Stated another way, do the Veteran's reports about his bilateral knee and back symptoms align with how the currently diagnosed disabilities are known to develop? Or, are the Veteran's reports generally inconsistent with medical knowledge or implausible? D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, 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.