Citation Nr: 21075677 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 13-22 459 DATE: December 21, 2021 ORDER Entitlement to service connection for skin condition diagnosed as prurigo nodularis, claimed as skin rash, is granted. Entitlement to service connection for scarring resulting from skin condition is granted. FINDINGS OF FACT 1. The Veteran has a current diagnosed skin condition to include prurigo nodularis. 2. The Veteran has experienced intermittent skin condition flare ups in the form of rashes and nodules since active service. 3. The Veteran has scarring related to a skin condition. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for skin rash have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for scarring resulting from skin condition have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1968 to April 1970 to include service in the Republic of Vietnam. 1. Entitlement to service connection for skin condition presenting as skin rash The Veteran contends that he developed a severe skin rash during active service while in the Republic of Vietnam that has persisted to the present time. After a thorough review of the evidence, the Board finds that entitlement to service connection for skin condition presenting as skin rash is warranted. Procedurally, the Board notes that the Veteran had previously submitted a claim for skin rash condition that was denied in a July 2008 rating decision. The Veteran submitted a new claim for skin rash as due to Agent Orange in October 2015. The RO denied reopening the claim in a December 2015 rating decision. The Veteran perfected an appeal to this claim with a VA Form 9 in December 2017. The Board notes that during this process, the Veteran submitted a separate claim for service connection for skin condition in August 2017 that was denied in an October 2017 rating decision and to which the Veteran submitted a notice of disagreement in December 2017. However, the first claim from October 2015 was pursued to the Board and remanded two times. As the Board is granting the appeal herein, it does not reach the determination on the substantial compliance by the RO with the most recent remand order from May 2021 as it is not prejudicial to the Veteran. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 is presumed to have been exposed to an herbicide agent if a listed chronic disease becomes manifest to a degree of 10 percent disabling or more, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases are presumed to be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service. These diseases include chloracne 38 U.S.C. § 1116(a); 38 C.F.R. § 3.309(e). The Veteran served in Vietnam during the Vietnam era and has presumed exposure to herbicide agents to include Agent Orange. The Veteran's current medical treatment records show ongoing treatment for skin conditions to include prurigo nodularis, presenting as a skin rash or nodules. Therefore, the Veteran has met the first element for entitlement to service connection, a current diagnosed condition under Shedden. The Veteran's service treatment records do not show complaints of or treatment for skin condition with the exception of treatment for perianal pruritis in October 1968. At the Veteran's March 1970 separation medical examination and medical history report, there were no notations for skin conditions. The Veteran underwent a VA medical examination in April 1971 where the examiner noted comedones on the back. In February 1973, the Veteran submitted a written statement that he had a constant rash since serving in Vietnam that had been treated with a white salve. According to a VA memo, the Veteran enrolled for treatment at Lubbock VAMC in 2007, and there are limited to no medical treatment records of other providers in the Veteran's claims file between the 1970s and mid 2000s. A February 1998 treatment record shows complaint of rash and hives on the arms. At a 2005 VA psychiatric examination, the examiner noted that the Veteran had a skin rash all over the body described as red dots and surmised that it was chloracne. VA treatment records show a continuous, although intermittent, treatment for skin condition presenting as skin rash or nodules with healed scars. In a June 2014 VA treatment note, the Veteran complained of having skin rash for 40 years since Vietnam. In July 2013, the medical provider diagnosed prurigo nodularis and noted itchy bumps on the arms and chest for years. At a follow-up appointment, the provider noted improvement with the prescribed ointment but ongoing itchy bumps particularly at nighttime. This condition continued to be noted intermittently in the Veteran's treatment records, e.g., October 2015, December 2016, and January 2018. The Veteran had a VA skin examination in December 2019 where the provider diagnosed prurigo nodularis and the Veteran reported a rash since Vietnam. The Board remanded for a more complete medical opinion than was given in this examination. The Veteran had another VA examination in March 2021 where the examiner confirmed a diagnosis of prurigo nodularis and recorded the Veteran's statement as complaining of skin rash since his time in Vietnam. The Board again remanded in May 2021 for a more complete opinion. In a September 2021 medical opinion, the examiner opined that the Veteran's various skin conditions were not at least as likely as not related to active service, "Pityriasis Rosea (PR) was diagnosed in December of 1970. PR is a mild self limited inflammatory exanthem of unknown origin. A viral etiology is most frequently suggested. This condition has no association was herbicide exposure and is self limited and mild. The patient was also diagnosed with comedones on the back in April of 1971. Comedones are commonly associated with mild acne and are not associated with herbicide exposure as a standalone entity. The patient has a subsequent diagnosis of Seborrheic Dermatitis (SD). SD is a common, chronic superficial inflammatory disease of the skin which affects 2 to 5 percent of the general population. The etiology may be related to the yeast Pityoporum ovale. Again this condition is not associated with herbicide exposure and is quite common. The patient was diagnosed with prurigo nodularis and treated as well. Prurigo nodularis is a disease with multiple itching nodules. The contributing factors to the disease that have been suggested are numerous but exclude herbicides. The diagnosis of hyperpigmentation can occur secondary to any chronic itching or rash which the patient had intermittently. Finally the diagnosis of epidermal inclusion cyst is related to the follicular epithelium and more than likely not related to any service related exposure. Lastly, the Psychologist is unqualified to make a diagnosis. They are not medical professionals and do not have the training nor expertise to offer advice regarding skin diagnoses." Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran does not have medical training and accordingly, his lay assertion in the form of a diagnosis of a skin rash or other skin condition or that its etiology is Agent Orange is not competent medical evidence. However, the Veteran is competent to report his experiences and history of skin rashes and bumps as he has done in written statements and in medical treatment records. The evidence of record documents that the Veteran was complaining of skin rash or other skin condition one year and three years post separation, and that when he then pursued medical treatment, the skin condition was also present in the late 1990s and 2000s. The Board notes that the examiner of the 2005 VA psychiatric examination was a psychologist trained in the field of mental health. Other than that provider's notation that he thought the Veteran's skin rash was chloracne, the medical evidence of record does not support that the Veteran has a diagnosis of chloracne or other skin condition subject to the Vietnam herbicide agent presumption under 38 C.F.R. §§ 3.3070, 3.309. The Board will resolve reasonable doubt in favor of the Veteran in finding that the Veteran's skin condition claimed as skin rash and diagnosed as prurigo nodularis developed coincident to service and that he has experienced visible symptoms since service separation, such as rash or nodule with scarring during the appeal period. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the appeal for entitlement to service connection for skin condition claimed as skin rash is granted. 2. Entitlement to service connection for scarring resulting from skin condition The Veteran presented a claim for entitlement to service connection for a skin condition and during examination the examiner noted that there is scarring associated with the diagnosed skin condition. Accordingly, the Board finds that entitlement to service connection for scarring due to a skin condition presenting as skin rash is warranted on a secondary basis. Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Accordingly, in order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. On the December 2019 VA examination for scarring, the examiner wrote that the Veteran has scarring due to prurigo nodularis. As the decision herein grants entitlement to service connection for skin condition diagnosed as prurigo nodularis, the Board finds that entitlement to scarring as secondary to a service-connected skin condition is warranted. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.