Citation Nr: 21075901 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 13-21 735A DATE: December 21, 2021 ORDER Entitlement to an increased rating greater than 10 percent for dermatomycosis of the hands and face is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's dermatomycosis of the hands and face covers less than 20 percent of the Veteran's body and no more than 5 percent of exposed areas and has been treated with topical therapy and the intermittent use of oral medications for less than 6 weeks in a 12-month period. 2. The evidence does not demonstrate that the Veteran's service-connected disabilities prevent him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating greater than 10 percent for dermatomycosis of the hands and face have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Codes (DC) 7806, 7813 (2021). 2. The criteria for entitlement to TDIU have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16(a) (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the U.S. Army from April 1979 to July 1985. In April 2016, the Veteran had a hearing before one of the undersigned Veterans Law Judges (VLJ). In addition, in November 2019 the Veteran had a hearing before another of the undersigned VLJs. VLJs who conduct hearings must participate in making the final determination of the claim involved. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. By law, appeals can be assigned only to an individual VLJ or to a panel of not less than three members. See 38 U.S.C. § 7102(a). Thus, when an appellant has had a personal hearing before two separate VLJs during the appeal and these hearings covered one or more common issues, a third VLJ is assigned to the panel after the second Board hearing has been held and the appeal is then ready for appellate review. In Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011), the United States Court of Appeals for Veterans Claims (Court) interpreted 38 C.F.R. § 20.707 as requiring that an appellant must be provided the opportunity for a hearing before all three VLJs involved in a panel decision. During the above-referenced November 2019 Board hearing, however, the Veteran explicitly waived his right to a hearing before the third VLJ participating in the current panel decision. Therefore, the Board finds that there is no hearing request pending at this time and the Board has complied with the requirements set forth in Arneson. See id; 38 C.F.R. § 20.700(a). As discussed in the Board's September 2017 remand, in an October 2015 rating decision the RO granted entitlement to service connection for numerous scars of the bilateral feet and numerous painful residual scars, dermatophytosis with tinea pedis with onychodystrophy and assigned separate ratings and effective dates. The Veteran has not expressed disagreement with that decision with respect to the scars and, as such, the Board will not further discuss the scars related to the skin disability in this decision. The Board denied the above claims in a January 2020 decision. The Veteran appealed that determination to the United States Court of Appeals for Veterans Claims (Court). In an April 2021 Order, the Court granted a Joint Motion for Remand (JMR) that the January 2020 Board decision be vacated and remanded the issues to the Board for reconsideration. The Board remanded the claims in August 2021. The matter again is before the Board. 1. Entitlement to an increased rating greater than 10 percent for dermatomycosis of the hands and face Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran's service-connected dermatomycosis of the hands and face is rated under the criteria contained in 38 C.F.R. § 4.118, DC 7813. DC 7813 provides rating criteria for dermatophytosis and provides that the disability is to be rated based on disfigurement of the head, face or neck, scars, or dermatitis, depending upon the predominant disability. As noted above, the Veteran is separately service connected for the scars associated with the skin disability. In addition, although the Veteran has experienced skin breakouts on the face during the appellate time period, during his November 2019 Board hearing the Veteran clarified that such incidents were extremely isolated in nature and that the predominant skin problems involved the bilateral feet. These lay reports are supported by the medical evidence of record. During the September 2021 VA examination the Veteran had scaly skin on the face and neck, but the examiner specifically did not find them to equate to scarring or disfigurement of the face, head, or neck. As such, the Board will focus its analysis on the rating criteria for dermatitis under DC 7806. The Veteran contends that he is entitled to a higher rating because he believes the current rating does not accurately reflect the severity of his disability. 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, under DC 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, DC 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 13, 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 DCs 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: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or 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: characteristic lesions involving more than 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 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: 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, 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. VA treatment records document ongoing foot examinations and advice due to his diabetes. In November 2010, the Veteran was afforded a VA contract examination. The Veteran reported that the toenail came off his big toes and he had pain under and between the toes, with blisters on the feet. The top of his big toe also itched and there was something on his head that would not go away. He also believed he had fungus on his hands. He currently was receiving no treatment for the hands. The feet got blisters on them, stayed sore all the time, had dry and flaky skin, and had a white, flaky look to the hands and palms. In the past 12 months, the Veteran reported itching and pain in the feet at all times. They ached and he had difficulty walking or standing. There were debilitating episodes. The Veteran reported that he could only walk about a half mile before his feet started to hurt and that he was unable to work because of his foot problems. The dermatophytosis affected 4 percent of the head, face, hands, and neck and 13 percent of the total body (9 percent from the feet and 4 percent from the hands). There was swelling around the feet, underneath the toenails, and between the toes. The skin was dry, shiny, and did not sweat. The Veteran was able to perform activities of daily life, but with functional limitations with physical activity due to painful feet that blistered and healed repeatedly. The Veteran could not walk or stand on his feet for long and had not been able to work since 2004 due to the foot problems. In May 2012, the Veteran complained of itching in his feet and was told to continue using the cream prescribed to him. In his November 2013 substantive appeal, the Veteran complained that VA had failed to recognize his chronic soreness, pain, and itching in his feet and between his toes. In addition, the blisters were not confined to his feet and had numerous outbreaks on his hands, head, and face. The Veteran was afforded a VA examination in December 2013. The examiner diagnosed dermatitis and dermatophytosis. The Veteran reported chronic dermatophytosis of the feet and nails and that his feet were itching all the time. He had been given Triamcinolone for itching and dermatitis secondary to dermatophytosis. The Veteran had been prescribed topical corticosteroids for less than 6 weeks in the past 12 months. There had been no other treatment in the past 12 months. There were no debilitating or non-debilitating episodes in the previous 12 months. The Veteran's diagnosed dermatitis involved less than 5 percent of his total body and less than 5 percent of his exposed body. The percentages were the same for the infections of the skin. The Veteran's skin disability did not affect his ability to work. The Veteran was afforded a VA examination in October 2015. The Veteran reported a worsening fungal toenail infection and that they had started to hurt, including when the nails rubbed against his bedsheets. The skin problems on the feet resulted in blisters that would crack and be very sore and dry with cracks between the toes. The condition started at his feet and spread to the hands, face, and head. The Veteran had been prescribed a cream for it and had helped with the blisters on the hands, face, and head, but did not help with the blisters between the toes. The Veteran had swelling in the right foot. There was no related scarring to the head, face, or neck. There were no systemic manifestations due to any skin disease, to include fever, weight loss, or hypoproteinemia associated with skin conditions such as erythroderma. The Veteran had been treated with oral or topical medications in the past 12 months, specifically the topical medication Triamcinolone for 6 weeks or more, but not constant. There were no debilitating or non-debilitating episodes in the past 12 months. The Veteran's diagnosed dermatitis involved less than 5 percent of his total body and less than 5 percent of his exposed body. The percentages were the same for the infections of the skin. The Veteran had dry scaly skin on the palmar aspect of the right hand, 2 lesions of dry scaly skin at the posterior scalp area, no lesions observed on the face, dry scaly skin on the bilateral feet in a moccasin formation, dried blisters at the medial aspect of the right foot and lateral aspect of the left foot, hypertrophic dark colored fungal toenails on all toes, and interdigital dried scaly skin between the toes of both feet. The skin condition affected the Veteran's ability to work in that when blisters came up on his feet and toes, it rubbed against his socks and shoes and caused pain. The examiner concluded that the Veteran's dermatitis was at least as likely as not proximately due to onychomycosis. In December 2015, the Veteran reported soreness on the bottom of his right foot. The Veteran was exercising minimally due to bad weather. During his April 2016 Board hearing, the Veteran discussed how working in warehouse-type jobs required so much walking and standing that if he got up during the night, he needed to hold on to something just to be able to walk due to pain in the feet. He also had problems with fungus in his toenails. During breakouts with blistering, wearing shoes at work caused rubbing on the blisters that required him to pop the blister. The flareups mostly occurred during the summer months and wearing shoes at work made the condition worse. He had to use a cream that included a steroid at all times to try to keep the skin problems under control. He would miss 2 to 3 months at a time due to the foot problems. A May 2016 letter discussed how the Veteran had been having problems with his feet for many years and that medication would work for a time, but "when he would try to work and stand on them for [a] long period of time they would get more sores and become swollen with blisters." A May 2016 letter from the Veteran's aunt noted how the Veteran had complained of waking during the night due to foot soreness that required him to rub his feet. In September 2017, the Veteran could walk up 2 flights of stairs and more than a quarter of a mile. In May 2018, the Veteran reported continued decreased activity and that he had not been using a treadmill or riding a bike. He described himself as "just lazy" and expressed interest in renewing that activity. In September 2018, the Veteran was referred to podiatry for peripheral arterial evaluation due to constant pain in the feet that was worse with walking and which was the primary limiting factor in his walking. The pain was in the plantar metatarsophalangeal area bilaterally and in the lateral right foot. There were no wounds to the feet. The assessment was peripheral artery disease with probably intermittent claudication. The Veteran was educated on a walking program for claudication and diabetic / peripheral artery disease foot care. In January 2019, the Veteran was issued a rollator walker due to pneumonia and gangrene in the toes of the right foot. Later that month, the Veteran reported that he had not been able to walk much in the previous 6 months due to a bout of pneumonia. Previously, he had walked for about 30 minutes each morning. In January 2019, the Veteran also was diagnosed with a fungal infection in the groin area and prescribed terbinafine in a cream form to be used for 14 days. He also was prescribed terbinafine to be taken orally for 14 days with no refill prescribed. The Veteran was afforded a VA examination in February 2019. The Veteran reported reoccurring fungal infections over the years. On average once per year he would develop painful blisters that took a few weeks to resolve. The blisters were more painful when walking or standing. At times in the past, the rash also involved the hands and scalp. The rash was worse with "dampness" and perhaps in hot weather. The Veteran was last employed 2 years previously in telemarketing. The Veteran also had diagnoses of diabetes mellitus, peripheral neuropathy, and peripheral vascular disease. In December 2018, he had developed ischemic gangrene on the right foot toes 2 and 3, osteomyelitis, pneumonia, and sepsis. The Veteran improved with antibiotics but developed a fungal groin rash afterwards. The ischemic gangrene was not secondary to the service-connected tinea but was due to non-service-connected diabetes mellitus, peripheral vascular disease, and peripheral neuropathy. The Veteran had been treated with medication in the past year for his skin problems, including a less than 6-week period with oral medication. He also made constant use of topical medication. On examination, the Veteran had dermatophytosis over 5 to 20 percent of the total body area and no part of the exposed body area. There was scarring and all toenails were thickened and discolored. On the right third toes there was a small area of dry gangrene at the tip and the second toe was damaged due to gangrene and not examined. The examiner specifically noted that the gangrene was unrelated to the service-connected tinea condition. The functional impact of the disability was that the Veteran indicated that when the rash flared-up and blistered it became painful to stand or walk. This occurred a few weeks per year. The examiner concluded that the service-connected skin disability would be unlikely to cause a significant adverse impact on sedentary employment. In addition to the current examination findings, based on the Veteran's reports and the medical records the examiner concluded that the rash might be expected to involve at more less than 5 percent exposed body area and 5 to 20 percent of the total body area. During a March 2019 VA whole health after visit the Veteran was encouraged to exercise, including walking. A podiatrist advised the Veteran to use clean, non-restrictive socks / stockings and well-fitting shoes. Limitations on activities were due to non-service-connected diabetes mellitus and not to the service-connected skin disability. The Veteran was prescribed topical medication for a fungal infection in the groin. During his December 2019 Board hearing, the Veteran reported that his skin disability predominantly affected his feet when it flared up with wearing socks and shoes due to sweating in hot weather. The Veteran testified that he had been given a second cream and in March 2019 had been put on pills for about 6 weeks for his skin disability during an extreme breakout. The Veteran also was directed to limit the amount of time he wore shoes and socks to keep them as dry and sweat-free as possible. He also had some powder to put on his feet. The Veteran's representative argued that an increased rating was warranted based on the increase in medications and increased steps required to treat or prevent breakouts. The Veteran believed that extraschedular consideration and TDIU was warranted for the skin condition "because of the potential hazardous to your health and the impairment from working that it's providing which leads to you being unable to work due to that disability in any field because you have to wear shoes and socks to go to work." The Veteran was unable to walk or stand for an extended period of time but could drive a car. Although the Veteran had experiences with skin problems to the face and hands, the difficulties primarily involved the feet, and he was able to use his hands during breakouts. The Veteran worked as an administrative specialist during service and had worked moving items in a warehouse environment after service. In addition, the Veteran had last worked about 2.5 years previously answering phones for a tax service. The Veteran had taken some college courses in computer science. The Veteran was able to use a computer for basic tasks. VA treatment records in 2021 document prescribed medication of diclofenac and hydrophilic, both applied topically. The Veteran was afforded a VA examination in September 2021. Symptoms included blisters on the face, eyelids, hands, and feet. The Veteran used no current medications, but in the past had used triamcinolone. In the last 12 months, the Veteran had used corticosteroids or other immunosuppressive medications, specifically triamcinolone. The route of administration was topical in nature. The total duration of use was less than 6 weeks total. On examination, the Veteran's total body area affected by the dermatomycoses was 5 to 20 percent, as well as 5 to 20 percent of the exposed body area. The Veteran had dry scaly skin on the hands, feet, face, and toenails. The Veteran had no skin conditions causing scarring, or disfigurement of the head, face, or neck. The Veteran's skin problems impacted the Veteran's ability to work in that he could not stand or walk for long periods of time. As requested by the August 2021 Board remand, the examiner considered the past prescription of terbinafine but indicated that the terbinafine was not currently being prescribed and had not been prescribed in the past 12 months. 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 dermatomycosis 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. VA examinations have consistently shown total exposed areas and total body area to be in the 5 to 20 percent range of exposure. The Board has considered the basis for the prior JMR that VA treatment records documented treatment for oral terbinafine. The parties noted that the Board failed to address evidence that the Veteran had used oral medication for greater than six weeks. The old regulations refer to oral corticosteroids or other immunosuppressive medications and terbinafine is an anti-fungal medication. The new regulations are more general and refer to 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. The parties point to outpatient records that show the medical is "active" over several months. The parties also point to the Veteran's testimony that he was "on pills...for like six weeks." The Board notes, however, that in January 2019 the Veteran was prescribed oral terbinafine for 14 days with no refills available. Although the VA treatment records continued to note oral terbinafine as an active medication, there is no lay or medical evidence to suggest that an additional refill of the Veteran's prescription of oral terbinafine was made. Moreover, the VA examiner during the period cited by the parties noted a review of the claims file, interviewed the Veteran and found that the duration of the oral medication was less than six weeks. Thus, while there was an ongoing notation of oral terbinafine in the running list of the Veteran's medications, it is speculative to suggest and there is insufficient evidence to support actual use of oral terbinafine use for 6 weeks or more in the past 12 months, as required for a higher rating under DC 7806. Similarly, the Veteran has used topical steroid medication, including topical terbinafine, at regular periods during the appellate time period. In that regard, the Federal Circuit has held 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, and that nothing in DC 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects "only the area to which it is applied" to count as a systemic therapy under the DC. However, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case and does not automatically mean systemic therapy because DC 7806 distinguishes between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit also held that under the pre-August 13, 2018, regulations 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 must thus consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the pre-August 13, 2018 version of DC 7806: a) Whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition; and b) Whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic. The Board finds the Veteran's medications regimen consistent with topical, rather systemic therapy and with intermittent oral medications but not for any period of 6 weeks or greater. The Veteran consistently has been using topical steroids throughout the appellate time period to prevent and/or resolve skin breakouts, primarily on the feet, but also to the hands, head, groin, and neck. Given that no more than 20 percent of the Veteran's total body was involved in the topical treatment, the Board does not find that the topical treatment operated by affecting the body as a whole. There is no indication that the application of the topical treatment in a specific and discrete area had any effect on other parts of the body or that the application was intended to have such an effect. Lay and medical evidence support such a conclusion, in that they indicate that the Veteran has not demonstrated any systemic manifestations of a skin disease. The Veteran's treatment records overwhelmingly indicate that he used treatment for particular surface areas of his skin rather than for his entire body. Accordingly, a higher disability rating under DC 7806 based upon treatment of the Veteran's skin condition is not warranted at any time during the appeal period. 38 C.F.R. § 4.118. The Board also 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 dermatomycosis does not more nearly approximate characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. As discussed above, the Veteran does not meet the requirements for a higher rating based on any of the above criteria. 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 and his reports regarding such symptoms are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and 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 DCs 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 DC. See 38 C.F.R. § 4.118. The Board notes that the Veteran and his representative have specifically argued that a higher rating is warranted on an extraschedular basis in light of the Veteran's difficulty with wearing shoes and socks and the consequent difficulties associated with working given those limitations. As such, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected skin disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's skin disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, DC 7806 provides a rating based on the percentage of the body or area affected by the skin disability. In this case, the Veteran's skin problems all relate to the percentage of skin that fails to meet the requirements for a higher rating. The Board acknowledges the argument that his limitation in the length of time in which he can be in shoes and socks results in the matter requiring a higher rating on an extraschedular basis. The Board disagrees. Again, the Veteran and his representative are not arguing that some greater percentage of his skin is affected by his service-connected disability, but simply that the percentage of skin already contemplated in the assigned rating results in symptoms of pain, tenderness, and the inability to wear shoes and socks for an extended period of time. The Board fails to see how such symptoms fall outside the criteria under which the Veteran is currently rated under DC 7806. That DC provides a rating based on the percent of skin affected by the disability and, again, the Veteran does not argue that a higher percentage of skin is involved, including during flareups. In addition, the medical evidence clearly demonstrates that the majority of the Veteran's ongoing problems with his feet are symptoms related to complications from his non-service-connected diabetes mellitus. As such, the Board finds that the symptoms do not fall outside those contemplated by DC 7806. Even if the Board were to consider the walking and standing limitations to warrant application of the second step criteria, these limitations have not resulted in hospitalizations. Although the Veteran may no longer be able to walk and physically move material all day in a warehouse, he is able to leave the home, drive an automobile, and perform administrative tasks in an office environment as addressed further below. The limitations do not result in a marked interference with employment using his current skills. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Because the preponderance of the evidence is against the claim for an extraschedular rating for the Veteran's skin disability, the benefit-of-the-doubt doctrine is inapplicable, and the claim on this basis must be denied. See 38 U.S.C. § 5107(b); see generally Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). In summary, for the reasons and bases set forth above, the Board concludes that an increased rating greater than 10 percent is not warranted for any time during the appeal period. 2. Entitlement to TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background, including his employment and educational history. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. For a veteran to prevail on a claim for a TDIU rating, the record must reflect some factor, which takes this case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the Board notes that the Veteran's service-connected disabilities include dermatomycoses of the hands and face with tinea pedis bilateral with onychodystrophy of the toenails, rated as 10 percent disabling; numerous painful residual scars, dermatophytosis with tinea pedis with onychodystrophy, rated as 10 percent disabling; multiple chalazia with blepharoconjunctivitis, bilateral eyes, rated as 20 percent disabling prior to June 1, 2012, and as 10 percent disabling from that date; and numerous scars, bilateral feet, rated as noncompensably disabling. The combined disability rating is 30 percent for the appellate time period, other than the period of time from November 11, 2010, to June 1, 2012, when the combined rating was 40 percent. Thus, the Board must consider whether the evidence warrants referral to the appropriate VA officials for entitlement to a total disability rating for compensation purposes based on individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b). See Bowling, 15 Vet. App. at 1. For a Veteran to prevail on a claim for entitlement to TDIU, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). As an initial matter, the Board notes that the Veteran has not argued that his bilateral eye disability affects his employability in any way. As such, the Board will limit consideration to the Veteran's scars and skin disabilities. The Board finds no evidence of record suggesting that the Veteran's case is outside the norm requiring extraschedular consideration. In reaching that conclusion, the Board acknowledges that the Veteran has not worked steadily for the vast majority of the appellate time period. The Veteran has attributed the unemployment primarily to breakouts of the skin disability involving the feet, as the condition requires that he limit the amount of time wearing shoes and socks. In addition, when wearing shoes and socks, the blistering of the feet during breakouts make standing and walking for extended periods of time extremely difficult. The Board does not dispute the Veteran's reports as to his symptoms during breakouts; however, the evidence clearly indicates that the Veteran has a history of work in telemarketing, which would not require extended standing or walking. In addition, there is no evidence or contention that the Veteran could not obtain an accommodation from his employer in such a line of work to permit him to take off his shoes and socks while on the telephone. In addition, the Veteran had experience in the military with clerical work and during his November 2019 Board hearing discussed his proficiency with certain aspects of using a computer and having taken college courses in computer science. Work environments utilizing such skills would often not require extensive standing or walking. Similarly, there is nothing to suggest that the Veteran's limitations with wearing socks and shoes could not be accommodated in such jobs. Thus, the most probative evidence of record demonstrates that the Veteran's service-connected disabilities do not preclude him from multiple areas of employment. The Board acknowledges that the Veteran's service-connected disabilities have some effect on his occupational impairment. However, the combined schedular ratings during the appellate time period recognize the industrial or commercial impairment resulting from his disabilities. Nevertheless, for the reasons and bases set forth above, the weight of evidence is against finding his service-connected disabilities are of such severity so as to preclude his participation in all forms of substantially gainful employment. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals S. HENEKS Veterans Law Judge Board of Veterans' Appeals T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. J. Houbeck, 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.